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A case-oriented approach to teaching biochemistry
8
BIOCHEMICAL EDUCATION
described a system used in the Russell Grimwade School of Biochemistry in which the lecture and practical courses were divided separately into units. Thus students had the option of taking theory units without taking the practical units. In 1975 there would be eleven such theory units, each consisting of twelve lectures and four practical units. The practical units could be described as metabolic biochemistry: physical biochemistry: protein, nucleic acid and nucleotide synthesis and whole animal metabolism. There were some disadvantages in scheduling separate theory and practical units and students were recommended to take physical biochemistry lecture units with the physical biochemistry practical unil. In practice students majoring in biochemistry, took most of the theory' and practical units together but the system does allow greater flexibility in course structures. Dr. F. L. Bygrave (Australian National University) described the structure of their course in Biochemistry for third year science students with a division into four major units, two in each semester; molecular genetics and the biochemistry of macromolecules in the first semester and bioenergetics and perspectives in biochemistry in the second semester. The units covered a combination of lectures and practical work but the practical work encouraged students to plan their own experiments and required them to prepare their own reagents etc. Dr. Bygrave emphasized the wide range of procedures used in the assessment of the different units. In all units a combination of assessment procedures was used ranging from essays, practical reports and laboratory assessments to seminars, problems and problem papers to oral and open book examinations. This wide range of assessment procedures was felt essential so that objectives of the total course such as the development of the ability to research the literature, design experiments, communicate information to others, solve biochemical problems and apply biochemical knowledge to new situations could be assessed adequately. Dr. P. A. Sullivan (Otago University, New Zealand) described the courses used at Dunedin as more traditional. In their Advanced II - - biochemistry course in third year science the lecture and practical courses were carefully integrated. The lecture course was divided into roughly 10 major areas covered by different staff members who each arranged the pragtical course associated with
January 1975 Vol. 3 No. 1
that lecture area. The practical course was quite informal and students are given as little information as possible and are given every encouragement to plan, design and execute experiments themselves. Students undertaking the Honours course undertook additional work in which the teaching was also informal. Over the first and second term the students dealt with some twelve topics related to the lecture and practical course. They were given research papers which they studied and then presented seminars on the papers to the group. In the third term they concentrated on three topics of their own selection in a similar manner. At the conclusion of the presentations by the panel of five speakers the chairman opened a general discussion. He first emphasized the growing sophistication of instrumentation associated with biochemistry and called on Professor S. L. Leach (University of Melbourne) to discuss their experiences with computer-assisted learning exercises. These exercises had been developed by Dr. W. H. Sawyer of the Biochemistry department in conjunction with the Department of Higher Education. They formed part of the practical unit in physical biochemistry. Two exercises had been developed which involved the students, in groups of three or four, using the computer terminal, (teletype operation) in the biochemistry department. The students were thus able to simulate experiments within a few minutes which would otherwise take many hours to perform. A technical report on these exercises has now been produced by the 'Computers in Education Research Group' of the University of Melbourne. A lively discussion followed which particularly centred on the advantages and disadvantages of the self-paced instruction courses, as outlined by Professor Garland and Dr. Weaver. The Symposium gave all those present m u c h 'food for thought'. The Chairman concluded that today there is a growing emphasis on new teaching methods in biochemistry together with a growing realization that students must be given every assistance in acquiring a variety of skills such as researching literature, planning and evaluating experiments and communicating with others in both written and oral presentations as well as acquiring basic biochemical knowledge. The Symposium was followed by a further lively informal discussion over coffee.
F. VELLA and R. O. MARTIN A CASE-ORIENTED APPROACH TO TEACHING BIOCHEMISTRY
We have recently taken the opportunity to use a case-oriented approach ~ to teaching Biochemistry, while initiating a new onesemester class of 39 lecture hours. The class was based on twelve clinical case reports selected from the medical literature because of the quality and quantity of investigative procedures which had been used, not only in arriving at a diagnosis, but also in an attempt to extend knowledge on a particular metabolic condition. The literature is replete with such case-reports. We were prompted to use this approach by two factors: (i) a decision by our department that students who were newly admitted to the College of Medicine and who had already successfully completed a two-semester class in Biochemistry should not be required to take the class in Biochemistry that forms part of the medical curriculum but should be required to take a one-semester class which contains topics not usually covered in a general biochemistry course; (it) a need that was felt to exist for a course in Biochemistry that would be useful to students majoring in various areas (including Biochemistry or Biology) who were interested in
*We have borrowed this term from the title of the book Bioa case-oriented appraach by Montgomery, Dryer, Conway and Spector, C. V. Mosby Company, (1974).
chemistry,
D e p a r t m e n t of B i o c h e m i s t r y U n i v e r s i t y of S a s k a t c h e w a n Saskatoon, Sask. Canada. exploring how biochemical knowledge is applied in the investigation and m a n a g e m e n t of h u m a n disease states and who had already successfully completed a course in general biochemistry. A course on Medical Aspects of Biochemistry was developed to satisfy these two requirements. The defined objectives were: (1) to present an integrated approach to the consideration of metabolism and some of its disorders in Man. (2) to develop an understanding of the role of nutrition, genetic endowment and regulatory mechanisms in the biochemical profiles produced by simple disturbances of metabolism. (3) to develop an understanding of the biochemical basis of some of the investigative procedures used in the elucidation of metabolic problems. The course was to be integrative (i.e. it would cover molecular, functional, regulatory, nutritional and genetic aspects in a coordinated manner), medically oriented and contain a body of knowledge most of which would be new to the majority of students in the class. It was also to be the joint responsibility of the authors, of whom one has had clinical training and the other has not. To achieve the degree of integration that was felt to be desirable, not only in the material but also in its presentation, a considerable a m o u n t of discussion was required in the planning of each presentation and both instructors were present during each of the lecture periods.
BIOCHEMICAL EDUCATION
January 1975 Vol. 3 No. 1
We were especially interested in exploring the following areas in this course: essential food constituents; vitamin deficiency and vitamin dependency i obesity; the response of the body to fasting and to starvation; regulation of purine metabolism; the role of gluconeogenesis and regulation of glucose homeostasis; metabolism of amino acids in general and of tyrosine in particular; metabolism of fatty acids and of cholesterol; metabolism of porphyrins; biosynthesis of collagen. The titles of the case-reports selected from the clinical literature were: (1) Evaluation of thiamine status during fasting for obesity. (2) Infantile convulsions associated with pyridoxine-deficiency. (3) Hyperuricemia and gout during starvation for the severe obese. (4) Xanthinuria with xanthine oxidase deficiency. (5) Lactic acidemia and hepatic fructose diphosphatase deficiency. (6) Pyruvate decarboxylase deficiency. (7) Hepatic cytosol tyrosine aminotransferase deficiency. (8) Hydroxylysine deficient collagen disease. (9) Muscle carnitine palmityltransferase deficiency. (10) Familial hypercholesterolemia. (11) Congenital erythropoietic porphyria. (12) Congenital unconjugated hyperbilirubinemia. They were rewritten for this course with the following points in mind: (1) Each report was to be concerned with one patient, except in the case of familial disorders. (2) The signs and symptoms of the condition were to be described in chronological order so that the evolution of the clinical problem in each case could be appreciated. (3) The results of all laboratory investigations were to be included (hematology. chemistry, radiology, post mortem, etc.). (4) The results of all special investigations undertaken on the patient and designed to extend established knowledge of the condition were to be incl.uded. (S) Where more than one report was published on the patient, the information present in all these papers was to be included. (b) No literature review or published discussion material was to be included. Thirty students registered for this class. There were an equal number of medical and of non-medical students. The former were a more selected group academically than the latter. Their knowledge at the beginning of the course was assessed by use of a pre-test which took the form of short answer questions concerning the biochemical basis of the tests used in a case report on transient diabetes in infancy. The same case-report and questions formed part of the final examination. The students were also asked to describe in writing their expectations of a course on Medical Aspects of Biochemistry and these were found to coincide very closely with the objectives that the planners had for the course. The majority were against being exposed to more 'detailed metabolic pathways, reaction mechanisms and molecular structures' and strongly in favour of 'learning how Biochemistry is used in investigating disease in Man'. The case-reports were handed out several days before they were to be discussed and students were advised to read them and to record questions they would like answered. Each report was reviewed and
all questions regarding terminology answered. The apparent clinical problem was then defined and the results of special investigations discussed. The necessary biochemical knowledge needed as a background for understanding the results of special investigations was reviewed. Textbooks that were found useful for this course were White, Handler and Smith's Principles of Biochemistry, Harper's Review of Physiological Chemistry and Montgomery. Dryer, Conway and Spector's Biochemistry - - A case-oriented approach. In the final examination, the medical students scored slightly higher and the range of results was narrower than that of the rest. A formal course evaluation showed that the class as a whole was enthusiastic about the course approach and content, and that the medical students had responded more positively to the course than the other students. This was attributed by us to the fact that as part of the medical curriculum, these students were exposed once weekly to a clinical tutorial or clinical demonstration experience. Besides, their motivation and interests made them a more homogeneuus group. Many of the medical students have requested that consideration be given to extending the course to two semesters. The salient points from our experience with this approach can be stated as follows: (1) Students appeared to settle down to this course in much the same time that they do in conventional cuurses. (2) During the first few case-reports to be discussed, an appreciable amount of time was spent in giving brief explanations of clinical terms and the significance of individual laboratory tests. (3) Though most of the students had some background in human physiology, they had difficulty in using this information and pertinent aspects had to be reviewed simply and briefly as required. (4) Initially students expected that they would be able to explain all aspects; of the clinical findings in a case-report in molecular terms. (5) Initially students had difficulty in interpreting tabulated results. (6) This approach made heavy demands on preparation time by the instructors, since each report was discussed jointly in great detail so as to delineate the biochemical principles and knowledge that were to be brought out in the presentation. (7) This approach demands a physiological a n d / o r clinical orientation on the part of the instructor or instructors concerned since it integrates biochemical knowledge with symptomatology, pathological investigation and therapy. Critics of this approach may suggest that it dilutes the teaching of Biochemistry. By contrast we believe that it strengthens the teaching of Biochemistry by demonstrating the application of biochemical knowledge and techniques to the solution of human problems with which students can identify easily and strongly. Our enthusiasm for the approach has not waned since we planned the course and our experience with it has been most rewarding. We are now in the process of increasing the size and scope of our pool of useful case-reports. Meanwhile we have initiated the same approach, but to a more limited extent, in teaching Biochemistry as part of the medical curriculum and to this also the students response has been positive. We feel that the approach has much to offer while essentially retaining the traditional lecture format.
Alternatives to the Lecture
revolves around a hypothetical patient with bizarre symptoms which turn out (when the problem is solved) to be due to a single genetically-determined enzyme defect. Statements of observations, assay results, etc. are distributed to members of a group, but each member is the sole possessor of a piece of the total information which he may have to deduce or abstract from the data he has. Members of a group confer, discuss and compete against rival groups in reaching an acceptable 'diagnosis'. The authors were pleased with the results of the game which led to intense intellectual activity by students who found the game entertaining and worth while. B. A. Kilby
A p u b l i c a t i o n of the E d u c a t i o n a l T e c h n i q u e s Subject G r o u p of the C h e m i c a l Society of L o n d o n . P a p e r b a c k , pp 90 (1974) f r o m the Secretary, E d u c a t i o n a l Division, C h e m i c a l Society, B u r l i n g t o n H o u s e , L o n d o n W 1 V 0BN. £1.00. This short booklet contains the text of eight papers (mainly chemically orientated) given at a conference in 1973 in the University of East Anglia. Among the papers is one by Prof. J. B. Jepson and Dr. A. D. Smith who discuss Simulated Problems in Biochemistry. This is an information game for Medical Students and
0
BIOCHEMICAL EDUCATION
described a system used in the Russell Grimwade School of Biochemistry in which the lecture and practical courses were divided separately into units. Thus students had the option of taking theory units without taking the practical units. In 1975 there would be eleven such theory units, each consisting of twelve lectures and four practical units. The practical units could be described as metabolic biochemistry: physical biochemistry: protein, nucleic acid and nucleotide synthesis and whole animal metabolism. There were some disadvantages in scheduling separate theory and practical units and students were recommended to take physical biochemistry lecture units with the physical biochemistry practical unil. In practice students majoring in biochemistry, took most of the theory' and practical units together but the system does allow greater flexibility in course structures. Dr. F. L. Bygrave (Australian National University) described the structure of their course in Biochemistry for third year science students with a division into four major units, two in each semester; molecular genetics and the biochemistry of macromolecules in the first semester and bioenergetics and perspectives in biochemistry in the second semester. The units covered a combination of lectures and practical work but the practical work encouraged students to plan their own experiments and required them to prepare their own reagents etc. Dr. Bygrave emphasized the wide range of procedures used in the assessment of the different units. In all units a combination of assessment procedures was used ranging from essays, practical reports and laboratory assessments to seminars, problems and problem papers to oral and open book examinations. This wide range of assessment procedures was felt essential so that objectives of the total course such as the development of the ability to research the literature, design experiments, communicate information to others, solve biochemical problems and apply biochemical knowledge to new situations could be assessed adequately. Dr. P. A. Sullivan (Otago University, New Zealand) described the courses used at Dunedin as more traditional. In their Advanced II - - biochemistry course in third year science the lecture and practical courses were carefully integrated. The lecture course was divided into roughly 10 major areas covered by different staff members who each arranged the pragtical course associated with
January 1975 Vol. 3 No. 1
that lecture area. The practical course was quite informal and students are given as little information as possible and are given every encouragement to plan, design and execute experiments themselves. Students undertaking the Honours course undertook additional work in which the teaching was also informal. Over the first and second term the students dealt with some twelve topics related to the lecture and practical course. They were given research papers which they studied and then presented seminars on the papers to the group. In the third term they concentrated on three topics of their own selection in a similar manner. At the conclusion of the presentations by the panel of five speakers the chairman opened a general discussion. He first emphasized the growing sophistication of instrumentation associated with biochemistry and called on Professor S. L. Leach (University of Melbourne) to discuss their experiences with computer-assisted learning exercises. These exercises had been developed by Dr. W. H. Sawyer of the Biochemistry department in conjunction with the Department of Higher Education. They formed part of the practical unit in physical biochemistry. Two exercises had been developed which involved the students, in groups of three or four, using the computer terminal, (teletype operation) in the biochemistry department. The students were thus able to simulate experiments within a few minutes which would otherwise take many hours to perform. A technical report on these exercises has now been produced by the 'Computers in Education Research Group' of the University of Melbourne. A lively discussion followed which particularly centred on the advantages and disadvantages of the self-paced instruction courses, as outlined by Professor Garland and Dr. Weaver. The Symposium gave all those present m u c h 'food for thought'. The Chairman concluded that today there is a growing emphasis on new teaching methods in biochemistry together with a growing realization that students must be given every assistance in acquiring a variety of skills such as researching literature, planning and evaluating experiments and communicating with others in both written and oral presentations as well as acquiring basic biochemical knowledge. The Symposium was followed by a further lively informal discussion over coffee.
F. VELLA and R. O. MARTIN A CASE-ORIENTED APPROACH TO TEACHING BIOCHEMISTRY
We have recently taken the opportunity to use a case-oriented approach ~ to teaching Biochemistry, while initiating a new onesemester class of 39 lecture hours. The class was based on twelve clinical case reports selected from the medical literature because of the quality and quantity of investigative procedures which had been used, not only in arriving at a diagnosis, but also in an attempt to extend knowledge on a particular metabolic condition. The literature is replete with such case-reports. We were prompted to use this approach by two factors: (i) a decision by our department that students who were newly admitted to the College of Medicine and who had already successfully completed a two-semester class in Biochemistry should not be required to take the class in Biochemistry that forms part of the medical curriculum but should be required to take a one-semester class which contains topics not usually covered in a general biochemistry course; (it) a need that was felt to exist for a course in Biochemistry that would be useful to students majoring in various areas (including Biochemistry or Biology) who were interested in
*We have borrowed this term from the title of the book Bioa case-oriented appraach by Montgomery, Dryer, Conway and Spector, C. V. Mosby Company, (1974).
chemistry,
D e p a r t m e n t of B i o c h e m i s t r y U n i v e r s i t y of S a s k a t c h e w a n Saskatoon, Sask. Canada. exploring how biochemical knowledge is applied in the investigation and m a n a g e m e n t of h u m a n disease states and who had already successfully completed a course in general biochemistry. A course on Medical Aspects of Biochemistry was developed to satisfy these two requirements. The defined objectives were: (1) to present an integrated approach to the consideration of metabolism and some of its disorders in Man. (2) to develop an understanding of the role of nutrition, genetic endowment and regulatory mechanisms in the biochemical profiles produced by simple disturbances of metabolism. (3) to develop an understanding of the biochemical basis of some of the investigative procedures used in the elucidation of metabolic problems. The course was to be integrative (i.e. it would cover molecular, functional, regulatory, nutritional and genetic aspects in a coordinated manner), medically oriented and contain a body of knowledge most of which would be new to the majority of students in the class. It was also to be the joint responsibility of the authors, of whom one has had clinical training and the other has not. To achieve the degree of integration that was felt to be desirable, not only in the material but also in its presentation, a considerable a m o u n t of discussion was required in the planning of each presentation and both instructors were present during each of the lecture periods.
BIOCHEMICAL EDUCATION
January 1975 Vol. 3 No. 1
We were especially interested in exploring the following areas in this course: essential food constituents; vitamin deficiency and vitamin dependency i obesity; the response of the body to fasting and to starvation; regulation of purine metabolism; the role of gluconeogenesis and regulation of glucose homeostasis; metabolism of amino acids in general and of tyrosine in particular; metabolism of fatty acids and of cholesterol; metabolism of porphyrins; biosynthesis of collagen. The titles of the case-reports selected from the clinical literature were: (1) Evaluation of thiamine status during fasting for obesity. (2) Infantile convulsions associated with pyridoxine-deficiency. (3) Hyperuricemia and gout during starvation for the severe obese. (4) Xanthinuria with xanthine oxidase deficiency. (5) Lactic acidemia and hepatic fructose diphosphatase deficiency. (6) Pyruvate decarboxylase deficiency. (7) Hepatic cytosol tyrosine aminotransferase deficiency. (8) Hydroxylysine deficient collagen disease. (9) Muscle carnitine palmityltransferase deficiency. (10) Familial hypercholesterolemia. (11) Congenital erythropoietic porphyria. (12) Congenital unconjugated hyperbilirubinemia. They were rewritten for this course with the following points in mind: (1) Each report was to be concerned with one patient, except in the case of familial disorders. (2) The signs and symptoms of the condition were to be described in chronological order so that the evolution of the clinical problem in each case could be appreciated. (3) The results of all laboratory investigations were to be included (hematology. chemistry, radiology, post mortem, etc.). (4) The results of all special investigations undertaken on the patient and designed to extend established knowledge of the condition were to be incl.uded. (S) Where more than one report was published on the patient, the information present in all these papers was to be included. (b) No literature review or published discussion material was to be included. Thirty students registered for this class. There were an equal number of medical and of non-medical students. The former were a more selected group academically than the latter. Their knowledge at the beginning of the course was assessed by use of a pre-test which took the form of short answer questions concerning the biochemical basis of the tests used in a case report on transient diabetes in infancy. The same case-report and questions formed part of the final examination. The students were also asked to describe in writing their expectations of a course on Medical Aspects of Biochemistry and these were found to coincide very closely with the objectives that the planners had for the course. The majority were against being exposed to more 'detailed metabolic pathways, reaction mechanisms and molecular structures' and strongly in favour of 'learning how Biochemistry is used in investigating disease in Man'. The case-reports were handed out several days before they were to be discussed and students were advised to read them and to record questions they would like answered. Each report was reviewed and
all questions regarding terminology answered. The apparent clinical problem was then defined and the results of special investigations discussed. The necessary biochemical knowledge needed as a background for understanding the results of special investigations was reviewed. Textbooks that were found useful for this course were White, Handler and Smith's Principles of Biochemistry, Harper's Review of Physiological Chemistry and Montgomery. Dryer, Conway and Spector's Biochemistry - - A case-oriented approach. In the final examination, the medical students scored slightly higher and the range of results was narrower than that of the rest. A formal course evaluation showed that the class as a whole was enthusiastic about the course approach and content, and that the medical students had responded more positively to the course than the other students. This was attributed by us to the fact that as part of the medical curriculum, these students were exposed once weekly to a clinical tutorial or clinical demonstration experience. Besides, their motivation and interests made them a more homogeneuus group. Many of the medical students have requested that consideration be given to extending the course to two semesters. The salient points from our experience with this approach can be stated as follows: (1) Students appeared to settle down to this course in much the same time that they do in conventional cuurses. (2) During the first few case-reports to be discussed, an appreciable amount of time was spent in giving brief explanations of clinical terms and the significance of individual laboratory tests. (3) Though most of the students had some background in human physiology, they had difficulty in using this information and pertinent aspects had to be reviewed simply and briefly as required. (4) Initially students expected that they would be able to explain all aspects; of the clinical findings in a case-report in molecular terms. (5) Initially students had difficulty in interpreting tabulated results. (6) This approach made heavy demands on preparation time by the instructors, since each report was discussed jointly in great detail so as to delineate the biochemical principles and knowledge that were to be brought out in the presentation. (7) This approach demands a physiological a n d / o r clinical orientation on the part of the instructor or instructors concerned since it integrates biochemical knowledge with symptomatology, pathological investigation and therapy. Critics of this approach may suggest that it dilutes the teaching of Biochemistry. By contrast we believe that it strengthens the teaching of Biochemistry by demonstrating the application of biochemical knowledge and techniques to the solution of human problems with which students can identify easily and strongly. Our enthusiasm for the approach has not waned since we planned the course and our experience with it has been most rewarding. We are now in the process of increasing the size and scope of our pool of useful case-reports. Meanwhile we have initiated the same approach, but to a more limited extent, in teaching Biochemistry as part of the medical curriculum and to this also the students response has been positive. We feel that the approach has much to offer while essentially retaining the traditional lecture format.
Alternatives to the Lecture
revolves around a hypothetical patient with bizarre symptoms which turn out (when the problem is solved) to be due to a single genetically-determined enzyme defect. Statements of observations, assay results, etc. are distributed to members of a group, but each member is the sole possessor of a piece of the total information which he may have to deduce or abstract from the data he has. Members of a group confer, discuss and compete against rival groups in reaching an acceptable 'diagnosis'. The authors were pleased with the results of the game which led to intense intellectual activity by students who found the game entertaining and worth while. B. A. Kilby
A p u b l i c a t i o n of the E d u c a t i o n a l T e c h n i q u e s Subject G r o u p of the C h e m i c a l Society of L o n d o n . P a p e r b a c k , pp 90 (1974) f r o m the Secretary, E d u c a t i o n a l Division, C h e m i c a l Society, B u r l i n g t o n H o u s e , L o n d o n W 1 V 0BN. £1.00. This short booklet contains the text of eight papers (mainly chemically orientated) given at a conference in 1973 in the University of East Anglia. Among the papers is one by Prof. J. B. Jepson and Dr. A. D. Smith who discuss Simulated Problems in Biochemistry. This is an information game for Medical Students and
0