38 BIOCHEMICAL EDUCATION April 1978 Vol. 6 No. 2

CLINICALLY ORIENTED

BIOCHEMICAL PROBLEM SOLVING

EXERCISES - - PRODUCTION AND

USE IN MEDICAL BIOCHEMISTRY

JAMES BAGGOTT & JOSEPH E. TROJAK* D e p a r t m e n t of Biological C h e m i s t r y H a h n e m a n n M e d i c a l Col lege 230 N. B r o a d St ree t P h i l a d e l p h i a , Pa . 19102, U . S . A .

The techniques of analyzing clinical biochemical data in a way that will be useful in diagnosis and treatment are seldom taught. As a step toward remedying this situation a series of exercises has been developed that involves the medical s tudent in the though processes required to successfully apply biochemical information to the solution of clinical problems. This communeat ion describes the production of these exercises and their use in an introductory course in Medical Biochemistry.

Objectives The primary objective of this method is to teach by the inductive,

synthetic approach how to formulate and solve biochemical problems of clinical interest. To provide multiple examples to the student a series of exercises is required. A secondary objective is to help the student integrate the various parts of biochemistry with one another and with clinical medicine. Participation in the problem solving process obliges the student to come to terms with the manner in which modification of a single system can affect the entire organism. Finally, it has been our experience that first year medical s tudents often have difficulty reading graphic or tabular information and critically evaluating it. Since students must evaluate such data during the course of solving the problems they get valuable practice in this important skill.

Approach The principle of the method is guided student participation in

data interpretation and problem solving. Texts are prepared which present relevant clinical and biochemical data from the clinical research literature; interspersed throughout each text at closely spaced intervals is a structured series of leading questions which directs the student in applying his knowledge of biochemistry to the clinical situation and in drawing the appropriate conclusions. The student is asked to interpret or predict results, justify the experimental approach, or suggest alternate ways of attacking the problem. Thus , the reason for pursuing a line of inquiry, as well as the meaning of the results, is developed.

Each exercise opened with an introduction which gives the clinical history and any background information that may be necessary. Data are presented, sometimes in tabular or graphic form, followed by specific questions that require the student to apply his biochemical knowledge. More data are then given, followed by addition specific questions. The student is led in this fashion through a succession of steps, each of which is built upon the preceding one. As the student answers the questions in sequence the line of biochemical reasoning leading to a solution of the problem is reproduced. This method differs from a previous case-oriented approach t in that each question directs the s tudent 's attention to the appropriate information at the appropriate time, resulting in a logical development of the story. The method has elements in common with that described by Vella and Martin 2' 3.

Exercise Preparation A survey of current clinical periodical literature will yield papers

dealing with nearly any area covered by an introductory biochemistry course. Usable papers must contain sufficient data to build a story. Rare diseases are satisfactory since the major purpose of the exercise is not to teach the biochemistry of the specific disease, but to guide the student through a problem solving process

*Present address: Department of Internal Medicine, Hahnemann Medical College.

in which he applies basic biochemical information to new situations, and draws appropriate conclusions. Table I lists some of the topics used in the exercises and the major areas of biochemistry incorporated into each.

TABLE I Some Topics Developed into Clinical-Biochemical

Problem-Solving Exercises*

Areas of Biochemistry Major Source Topics Included of Data

Fructose- 1, 6- Pathways of carbohydrate 4 diphosphate metabolism, metabolic

deficiency acidosis, fatty acid metabolism, ketone body

formation

Hyperammonemia Ammonia production and s utilization, urea cycle,

enzymology, pH regulation.

Intravenous Amino acid metabolism, 6 hyperalimentation nutrition, physiological

sources and sinks for acid and base.

*Sample exercises will be provided upon request to J.B.

Exercise content should be tailored to the order and depth of individual topics in a given course. With practice preparation of a single exercise can be accomplished in about three days. Minor revisions to remove ambiguities, etc., can be expected after the first use. After that the product is quite stable, requiring revision only if new information becomes available.

Collaboration with a medical s tudent is valuable in developing the exercises. One of the authors (J.E.T.) participated in this project during a vacation period occurring near the end of his first clinical year of training. This input insured that the exercises would possess appropriate s tudent appeal as well as a clinically realistic approach to the problems.

Classroom Use of the Exercises Each exercise requires about one hour of class time. They are

best used in the conference setting with small groups of students (25 maximum). The complete set is distributed at the beginning of the term; individual exercises are scheduled so their content complements the lecture portion of the course. Students are expected to prepare answers to all questions in advance of the conference. Individuals are called upon to present their answers orally. The role of the conference leader is to confirm correct answers and, if necessary, to draw answers out of the students with appropriate hints. The leader can also bring in new ways of looking at the problem or point out interrelationships that were not directly dealt with in the exercise. In addition, specific items may be used as springboards for review of related areas. At the end of the session printed answers to the questions are distributed.

BIOCHEMICAL EDUCATION April 1978 Vol. 6 No. 2 39

Responses Survey of s tudent opinion revealed that the s tudents perceived the

exercises as clearly illustrative of the relevance of biochemistry to clinical work. They felt the exercises should be used in class, not merely for self-study. One exercise every two weeks during a thirteen-week course was not considered excessive; many students indicated that the number should be increased.

The exercises were also used with a group of medical s tudents about to enter their fourth year of training. These relatively advanced students were extremely enthusiastic, frequently embarking upon lengthy discussions of specific points, drawing upon information acquired in a variety of preclinical and clinical

courses. The basic science-oriented faculty was initially somewhat uneasy

with clinically-oriented exercises. Instructor 's guides were therefore developed which contain explanations of clinical terms and peripheral details, suggestions for further discussion of related issues, and literature references to key facts and important background. These guides, along with practice in using the exercises, have dispelled all hesitation. The exercises have now been in use four yours, are well accepted by the faculty, and continue to enjoy uniformly enthusiastic student response.

ACTIVE PARTICIPATION OF MEDICAL STUDENTS IN BIOCHEMICAL EDUCATION: PROBLEMS AND SOLUTIONS

REFERENCES tMontgomery, R., Dryer, R. L., Conway, T. W., and Spector, A. A. (1977) Biochemistry. A Case-Oriented Approach, 2nd ed., C. V. Mosby, Saint Louis.

2Vella, F. and Martin, R. O. (1975) A Case-Oriented Approach to Teaching Biochemistry. Biochem. Educ. 3, 8.

aVella, F. and Martin, R. O. (1976) Alternatives to the Biochemistry Laboratory for Medical Students. Biochem. Educ. 4, 43. 4Baker, L. and Winegrad, A. I. (1971) Fasting Hypoglycemia and Metabolic Acidosis Associated with Deficiency of Hepatic Fructose- 1, 6-diphosphatase Activity. Lancet, 2, 13.

SCampbell, A. G. M. et al. (1973) Ornithine Transcarbamylase Deficiency: Neonatal Hyperammonemia in Males. N. Engl. J. Med. 288, 1.

6Heird, W. C. et al. (1972) Metabolic Acidosis After Intravenous Alimentation with Amino Acids. N. Engl. J. Med. 287,943.

HORST E. FRUNDER I n s t i t u t e of Phys io log ica l C h e m i s t r y F r i ed r i ch -Sch i l l e r Un ive r s i t y Jena , G . D . R .

There are educational problems which are common to all students and special problems which affect only medical students. First a few words on the common problems.

Too many students seem to sit through lectures, seminars and tutorials with information and exhortation washing over them and leaving only a little deposit. Too many appear to be bored and don't see the point of what they are asked to do and, later on, pushed into doing.

World wide efforts were started some time ago to cope with this state of affairs. These efforts have included such things as simply keeping the students busy or, much better, by making the curricula more realistic in content and realization. In some cases these efforts have even gone as far as providing, often unintentionally, items which merely entertain the students.

Despite this universal and considerable increase in teaching efforts, we do not see, at least in our own limited experience, an appropriately convincing return for these efforts. Two reasons may be responsible for this: 1. There is no real objective measure avail- able to confirm the results of our teaching a n d educational efforts. In my opinion MCQ assessments, as in present use, cannot do it correctly. And this generally narrows all discussions on education. Secondly, the problems we have to face originate possibly from as yet only partly explored reasons which lie far outside the scope of the universities. However, I don't wish to discuss this now. Instead I shall deal with the framework of the medical education into which the biochemist has to weave biochemistry. Here, the pecularities to be taken into account if we wish to succeed are:

t. The unparalleled breadth of the s tudent 's training from anatomical structures to the functioning of the brain, psyche and society. Real difficulties arise for the student to come to terms with this expanse of learning and to mould it into a functional body of working knowledge,

2. The patch-work quilt of loosely related topics which is only slowly, if at all, made up into a homogeneous cloth, despite many committee meetings on horizontal and vertical integra- tion. This, again, strains the s tudent 's ability to try and put all the pieces together.

3. The present primary goal of medicine, the art of healing disease, leads the student to expect a considerable improvement in his own ability to perform this function. And it makes him question all efforts which do not at first glance appear to meet this aspect of his expectations.

4. Many present examination techniques do not pay due regard to such important factors as motivation, work habits, study skills, independent thinking and working, and thus encourage. although unintentionally, the cramming of huge chunks of knowledge to be recalled for an impending examination and soon thereafter to be forgotten or, as many students frankly confess: "loosely stuck on the surface of the mind and rapidly discarded after the examination".

In the past, Keller 1, Postlethwait 2, Lightfoot 3, Jepson 4, Garla nds and many others 6 tackled serious approaches to provide incentives for active learning and self-education. I wish to report now on our own experiences with these world wide trends which we have designed and modified to suit our situation and subject.

The background for our set-up was that all young people including our students have a genuine, not to say genetically deter- mined interest in self-responsible work recognizably related to "real life", which we have tried to promote in order to improve the students ' attitude and competence.

The panacea applied to this in many medical schools is to relate biochemistry to problems of preventive and even more to clinical medicine. We don't underestimate the utility of this approach. However, envisaging the limited viewpoint and foresight of the preclinical students we refrain from exaggerations. The at tempts we made when we went along this road did not convince us, except when examples with wide clinical usefulness are intimately interwoven into basic biochemistry.

Clinical examples taught in the form of accessories was often called biochemical "belly dancing" by our students.

In our opinion biochemistry has primarily to impart to the students its own speciality, namely experimental laboratory research. When the principles of it are really understood and taken up by the students, then this should be a specific and useful