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Case notes in biochemistry — blackwell scientific software
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Microcomputer Software Review Case Notes in Biochemistry - - Blackweli Scientific Software b y A n d r e w B o o t h a n d J o n a t h a n D a n k s . Blackwell Scientific Publications, Oxford, 1989. For M S - D O S and Apple Macintosh Teaching preclinical medical students biochemistry is notoriously difficult. Most would agree on the need to teach clinically oriented biochemistry to maintain interest in the subject. The motivation of preclinical medical students is clinical medicine and if this is seen to come first interest in biochemistry will not lag far behind. One way that can be taken is the caseoriented approach to biochemistry teaching already available in some textbooks. Here the computer comes into its own as a teaching aid and well designed software can be invaluable. Case Notes in Biochemistry is a thorough going approach to patientoriented biochemistry teaching taking advantage of computeraided instruction. The software is available for MS-DOS and Apple Macintosh computers. Presently the system has four modules: Cori type I glycogen storage disease, coma, jaundice and diabetes. The glycogen storage disease module includes type Ia and type Ib disease. The coma module includes hypoglycin poisoning, insulinoma, alcohol-induced fasting hypoglycaemia and aspirin poisoning. The jaundice module includes Gilbert's syndrome, Crigler-Najjar syndrome type I, galactosaemia and glucose-6-phosphate dehydrogenase deficiency. Lastly, the diabetes module includes insulin-dependent and non insulindependent diabetes mellitus. The glycogen storage disease module has six case simulations. The other modules have four. On first looking at the modules I thought they treated too many rare clinical conditions but on working through the exercises I was surprised to see how much fundamental biochemistry could be demonstrated with the choice of cases. Case Notes in Biochemistry is designed as a set of diagnostic exercises. Each case is presented as an open problem. In each module one selects a patient and after reading the referral note asks for the case history and physical examination. These need to be requested as sound clinical practice before proceeding with any tests. A helpful glossary of clinical terminology is available at this stage. I found it useful to jot down presenting symptoms and signs as a way of avoiding a plethora of tests. On Apple Macintosh computers this can be done using the Note Pad. The software works by presenting clinical and test information on a set of cards on the computer screen. It is easy to work through the cards at any time. What I missed is a way of highlighting information on the cards to aid review of a case as one goes along. Each module provides a large variety of biochemical, haematological and clinical investigations which can be requested to make a diagnosis. Provocative tests and biopsies carry an appropriate warning of possible danger to the patient and are not permitted before a number of more routine investigations have been demanded. Hints are available as to what to investigate in step by step manner for each case. So far as I could tell the hints have an algorithmic organisation to reach a correct diagnosis. I found the hints very reasonable even though I was surprised by the hint to investigate copper metabolism in the cases in the jaundice module: so far as I know jaundice is not a symptom in Wilson's disease. Also, on examining the coma module I was surprised by the hint to test for abnormal thyroid function in two of the cases, as I saw no reason to suspect myxoedema. I do not make these observations to quibble for the hints made me think and this is the function of teaching software. In general, it is arguable how much cueing should be provided in this type of teaching software or indeed whether any cueing should be provided at all. However, teaching software is
BIOCHEMICAL EDUCATION 18(1) 1990
intended for students not for accomplished experts and I find some cueing very valuable particularly for work without an instructor or opportunity for discussion with fellow students. Perhaps the best course is that taken in Case Notes which is that of providing optional hints with a penalty for taking them. Once a hint is requested it has to be carried out correctly for the software to allow the user to proceed with the case simulation. Regular diagnosis is permitted after sufficient investigations have been requested. In each case one can choose from nine diagnoses. Succinct information is available on the conditions listed. This information is very useful to learn differential diagnosis. Unfortunately background information is not available on tests apart from normal values, I should have liked to have some information on the scope of available tests particularly the provocative tests. As the software warns the user these should not be undertaken lightly. Provision of background information would be invaluable for appreciation of the value and thoughtful use of these tests particularly as it is not usually advisable to do more than one - - the right one. On making the correct diagnosis the software presents information on treatment, a discussion of what should have been noticed and done to reach the diagnosis, and a set of questions to test the user's knowledge of the underlying biochemistry of the disease. Presentation of the principal diagnostic features at the end of the case simulations is very helpful for one can learn what should and should not have been done and see which, if any, important steps have been missed. I found the biochemistry questions at the end of the case simulations the most difficult part of the exercises. Students are expected to answer these questions. Unfortunately they have to be copied down by hand for study. Also the literature references available in the Manual are not available on-screen. Not all students have inclination to look for themselves and the software might suggest reading material. As a measure of user performance Case Notes has a scoring system. Starting with 100 points, points are gained for carrying out tests relevant to the correct diagnosis and lost for carrying out tests that endanger the patient. Naturally points are finally gained for making a correct and lost for making a wrong diagnosis. For any case simulation the record cards can be saved together with the final score for assessment purposes. The record cards are saved in a standard order and do not reflect the exact course taken to make the diagnosis though the order of blood tests, hormone and enzyme tests and urine tests requested is available on the Chemical Pathology 1, Hormones and Enzymes and Urinalysis cards as the case may be. Also no record is kept of how the final score is obtained. It should be possible for the software to keep a short sequential record of the investigations carried out, and the points gained or lost at each step, as a more informative record of what a student has done, and the total time taken! This would permit more detailed and rapid assessment of students and facilitate discussion with them. Additionally a picture can be built of how students approach the case studies. Ultimately it is collection of data on student use that allows meaningful evaluation of teaching software. This may reveal shortcomings and suggest improvements otherwise difficult to perceive. It is easy to enthuse on the value of this type of software in teaching preelinical medical students biochemistry. A sober opinion would be that such software can usefully supplement formal teaching of clinically oriented biochemistry. Although usable by beginners, I do not think much wilt be learned from massive mistakes and I find Case Notes in Biochemistry most appropriate for students with good knowledge of fundamental biochemistry and some exposure to clinical medicine. To learn biochemistry from the software it is not essential to make the correct diagnoses. To learn medical diagnostic skills and differential diagnosis of disease it is essential to make the correct diagnoses. Case Notes can be used with profit both ways. W H Bannister
Microcomputer Software Review Case Notes in Biochemistry - - Blackweli Scientific Software b y A n d r e w B o o t h a n d J o n a t h a n D a n k s . Blackwell Scientific Publications, Oxford, 1989. For M S - D O S and Apple Macintosh Teaching preclinical medical students biochemistry is notoriously difficult. Most would agree on the need to teach clinically oriented biochemistry to maintain interest in the subject. The motivation of preclinical medical students is clinical medicine and if this is seen to come first interest in biochemistry will not lag far behind. One way that can be taken is the caseoriented approach to biochemistry teaching already available in some textbooks. Here the computer comes into its own as a teaching aid and well designed software can be invaluable. Case Notes in Biochemistry is a thorough going approach to patientoriented biochemistry teaching taking advantage of computeraided instruction. The software is available for MS-DOS and Apple Macintosh computers. Presently the system has four modules: Cori type I glycogen storage disease, coma, jaundice and diabetes. The glycogen storage disease module includes type Ia and type Ib disease. The coma module includes hypoglycin poisoning, insulinoma, alcohol-induced fasting hypoglycaemia and aspirin poisoning. The jaundice module includes Gilbert's syndrome, Crigler-Najjar syndrome type I, galactosaemia and glucose-6-phosphate dehydrogenase deficiency. Lastly, the diabetes module includes insulin-dependent and non insulindependent diabetes mellitus. The glycogen storage disease module has six case simulations. The other modules have four. On first looking at the modules I thought they treated too many rare clinical conditions but on working through the exercises I was surprised to see how much fundamental biochemistry could be demonstrated with the choice of cases. Case Notes in Biochemistry is designed as a set of diagnostic exercises. Each case is presented as an open problem. In each module one selects a patient and after reading the referral note asks for the case history and physical examination. These need to be requested as sound clinical practice before proceeding with any tests. A helpful glossary of clinical terminology is available at this stage. I found it useful to jot down presenting symptoms and signs as a way of avoiding a plethora of tests. On Apple Macintosh computers this can be done using the Note Pad. The software works by presenting clinical and test information on a set of cards on the computer screen. It is easy to work through the cards at any time. What I missed is a way of highlighting information on the cards to aid review of a case as one goes along. Each module provides a large variety of biochemical, haematological and clinical investigations which can be requested to make a diagnosis. Provocative tests and biopsies carry an appropriate warning of possible danger to the patient and are not permitted before a number of more routine investigations have been demanded. Hints are available as to what to investigate in step by step manner for each case. So far as I could tell the hints have an algorithmic organisation to reach a correct diagnosis. I found the hints very reasonable even though I was surprised by the hint to investigate copper metabolism in the cases in the jaundice module: so far as I know jaundice is not a symptom in Wilson's disease. Also, on examining the coma module I was surprised by the hint to test for abnormal thyroid function in two of the cases, as I saw no reason to suspect myxoedema. I do not make these observations to quibble for the hints made me think and this is the function of teaching software. In general, it is arguable how much cueing should be provided in this type of teaching software or indeed whether any cueing should be provided at all. However, teaching software is
BIOCHEMICAL EDUCATION 18(1) 1990
intended for students not for accomplished experts and I find some cueing very valuable particularly for work without an instructor or opportunity for discussion with fellow students. Perhaps the best course is that taken in Case Notes which is that of providing optional hints with a penalty for taking them. Once a hint is requested it has to be carried out correctly for the software to allow the user to proceed with the case simulation. Regular diagnosis is permitted after sufficient investigations have been requested. In each case one can choose from nine diagnoses. Succinct information is available on the conditions listed. This information is very useful to learn differential diagnosis. Unfortunately background information is not available on tests apart from normal values, I should have liked to have some information on the scope of available tests particularly the provocative tests. As the software warns the user these should not be undertaken lightly. Provision of background information would be invaluable for appreciation of the value and thoughtful use of these tests particularly as it is not usually advisable to do more than one - - the right one. On making the correct diagnosis the software presents information on treatment, a discussion of what should have been noticed and done to reach the diagnosis, and a set of questions to test the user's knowledge of the underlying biochemistry of the disease. Presentation of the principal diagnostic features at the end of the case simulations is very helpful for one can learn what should and should not have been done and see which, if any, important steps have been missed. I found the biochemistry questions at the end of the case simulations the most difficult part of the exercises. Students are expected to answer these questions. Unfortunately they have to be copied down by hand for study. Also the literature references available in the Manual are not available on-screen. Not all students have inclination to look for themselves and the software might suggest reading material. As a measure of user performance Case Notes has a scoring system. Starting with 100 points, points are gained for carrying out tests relevant to the correct diagnosis and lost for carrying out tests that endanger the patient. Naturally points are finally gained for making a correct and lost for making a wrong diagnosis. For any case simulation the record cards can be saved together with the final score for assessment purposes. The record cards are saved in a standard order and do not reflect the exact course taken to make the diagnosis though the order of blood tests, hormone and enzyme tests and urine tests requested is available on the Chemical Pathology 1, Hormones and Enzymes and Urinalysis cards as the case may be. Also no record is kept of how the final score is obtained. It should be possible for the software to keep a short sequential record of the investigations carried out, and the points gained or lost at each step, as a more informative record of what a student has done, and the total time taken! This would permit more detailed and rapid assessment of students and facilitate discussion with them. Additionally a picture can be built of how students approach the case studies. Ultimately it is collection of data on student use that allows meaningful evaluation of teaching software. This may reveal shortcomings and suggest improvements otherwise difficult to perceive. It is easy to enthuse on the value of this type of software in teaching preelinical medical students biochemistry. A sober opinion would be that such software can usefully supplement formal teaching of clinically oriented biochemistry. Although usable by beginners, I do not think much wilt be learned from massive mistakes and I find Case Notes in Biochemistry most appropriate for students with good knowledge of fundamental biochemistry and some exposure to clinical medicine. To learn biochemistry from the software it is not essential to make the correct diagnoses. To learn medical diagnostic skills and differential diagnosis of disease it is essential to make the correct diagnoses. Case Notes can be used with profit both ways. W H Bannister