Pre-clinical and clinical biochemistry?

19 the Soviet Union was going to provide enough Biochemists for all these Institutes. We understand that in part the answer is that the Institutes will be recruiting a large number of people from other disciplines especially Chemistry and Physics. Of course, a corollary of the present situation is that we found no concern amongst the postgraduate students concerning job prospects since they knew that they would be able to choose from quite a wide variety of jobs on completion of their PhD. This, of course, is in marked contrast at least to the situation in the UK. Professor Vinogradov is not only active in his Department but is also the Secretary for Science of the USSR Biochemical Society. This is probably, from its membership, the biggest Society in the world and he explained that it organised a very large number of meetings and had other activities. The membership subscription for the Society is 3 roubles per year. He certainly expressed a hope that there would be better contacts between the biochemists in this country and overseas and since he had worked overseas he was in a very good position to encourage such links. We also had the pleasure of meeting the Senior Research Staff member of the Department, Helen Petushkova who is an Olympic horsewoman. She must surely be unique amongst the people in the Biochemistry Departments of the world. Pre-Clinical and Clinical Biochemistry? A T D GONDWE

Department of Physiological Sciences School of Medicine University of Zambia Lusaka, Zambia Introduction Biochemistry is now generally accepted as an essential component of any Medical School curriculum, because medicine is becoming more and more dependent upon biochemistry as a discipline. Typically, a medical student takes biochemistry as one of the pre-clinical subjects, along with Anatomy and Physiology. Once he has qualified for the clinical part of the course, the student has little, if any, formal contact with biochemistry thereafter. Remembering Biochemistry Our experience in the University of Zambia is that two years after our medical students have successfully completed their pre-clinical courses, they remember hardly any of the biochemistry they had learnt. Our students spend their first two years in the University studying Biology, Chemistry, Physics and Mathematics in the School of Natural Sciences, entering the School of Medicine at the beginning of their third year in the University. It is during their third year (first year in the Medical School) that they take a one-year course (90 lecture hours plus 45 hours of practicals) in biochemistry, BIOCHEMICAL EDUCATION 13(1) 1985

obtaining their medical degrees four years later. On graduation day, a very small fraction of the new crop of physicians would be able to tell you how heme biosynthesis is regulated, for example. A good number of our students realise their deficiencies when they get to the senior clinical classes. On several occasions, some of them have come back to us and asked if they would be allowed to 'audit' our lectures. Of course they would, we have told them. It is in their sixth and seventh years that many of our students appreciate how very relevant biochemistry is to their chosen profession. In their pre-clinical year, they have little trouble recognizing the relevance of physiology and anatomy to medicine. To them, these subjects are 'obviously' useful to a doctor. Biochemistry is quite something else, and the teacher of biochemistry is faced with the problem of how to fire the enthusiasm of his sceptical audience for his subject, most of whom are in a hurry to go on to the clinical courses, biochemistry or no biochemistry, where they will forget most of their biochemistry in under two years. The biochemistry teacher is then forced to wonder, and I have myself often wondered, if all the effort one puts into the teaching of this subject is wasted. So many of our medical graduates go out knowing hardly any biochemistry, and, what is worse, some of them do not care. "The nurse brings me the patient's blood bilirubin levels", a post-graduate medical student told me, "and I only have to look at the table of standard values I have in my office, to tell if the patient's bilirubin levels are abnormal, and act accordingly". The student quoted above gave me the impression that to him, his "Table of Standard Values" was all that biochemistry meant. Sadly, this negative attitude toward biochemistry is not uncommon; but what can be done about it? There can be little doubt that the way the teacher approaches biochemistry for medical students can either inspire them, leave them cold, or put them off completely. Most if not all, of our pre-clinical students find biochemistry completely new, unlike physiology and anatomy, which they will have met with, albeit at a very elementary level, in High School. The logic, and vocabulary, of biochemistry are totally new to them, and to generate enthusiasm for the subject in the students, and convince them that they need it, is a big challenge to the teacher. Before any real enthusiasm for biochemistry can be generated in the students, it is obviously essential that the teacher should himself exude enthusiasm for the subject, in the lecture room, in the practical classes, and during tutorials. In addition, the student should be shown the relevance of the subject to clinical medicine, otherwise he will easily lose interest, and forget it all in a very short time, as happens with our students. Clinical cases I believe that our students forget their biochemistry so easily after completing the pre-clinical year because the one-year course they take is completely divorced from the teaching of clinical subjects. Reference is often made to clinical cases, some of which can be seen in the clinics and

20 wards of the Teaching Hospital nearby, but no attempt is made to take the biochemistry class to such clinics to look at actual cases of Kwashiorkor, diabetes, or whatever, and have clinicians discuss the cases before the students. Indeed, some of the hours reserved for practical classes could be used this way. This is one of the points brought out by Professor Alan Mehler in his excellent analysis, ~ and we, in the Division of Biochemistry in the School of Medicine of the University of Zambia, have been thinking along these lines for some time now. Contrary to what Professor Mehler says about the ineffectiveness of medically-qualified biochemistry teachers alongside PhDs we are finding our two young medical doctors (each with an MSc in biochemistry) quite effective in explaining the relevance to clinical medicine of selected topics in Biochemistry. Nevertheless, the recruitment of medicallyqualified teaching staff is certainly not the answer to the problem of making the pre-clinical students perceive the relevance of biochemistry. It is possible, as Professor Mehler suggests, to wait until the clinical years before offering biochemistry but, apart from the difficulty Professor Mehler points out, that is, the necessity to offer biochemistry early because it is an essential pre-requisite for other courses, there is also the danger that if the teaching of biochemistry is delayed, the students will have forgotten most of their Chemistry, Biology, Physics, by the time they tackle biochemistry. It is quite necessary, therefore, that biochemistry should be offered to the medical student early in this College career. But, does all the biochemistry he needs have to be offered in a lump, in the pre-clinical year? For a couple of years now, some of our biochemistry teaching staff have been exploring the possibility of offering biochemistry in two parts. Part one, consisting mainly of basic enzymology, major metabolic pathways and their regulation, would be taught during the preclinical year. Part two, covering the more applied aspects of biochemistry, such as membranes, biochemistry of specialised tissues, and endocrinology, would be offered in one of the clinical years, preferably the sixth year (our students graduate at the end of their seventh year). Such a departure from the present traditional curriculum would no doubt, present problems, not the least of which would be persuading the clinicians to accommodate basic scientists in a traditionally clinical year. But I believe the

The University Teaching Hospital, University of Zambia School of Medicine. BIOCHEMICAL EDUCATION 13(1) 1985

younger members of the clinical departments could be won over, first. Some of these young doctors would welcome biochemistry, so that they might brush up on their knowledge of the subject in preparation for the MRCP and other professional examinations. Such a halfcourse would enable our students to graduate as doctors with some knowledge of biochemistry still fairly fresh in their minds, knowledge which they would certainly need if they decided to go for a post-graduate qualification in medicine. Master of Medicine On the subject of post-graduate medical training, our School of Medicine mounted a Master of Medicine degree course about three years ago, and one of the basic science subjects required for graduation is biochemistry. The students who enrol for the course obtained their basic medical degree at least four years prior to registration for the higher degree course, which means that each candidate will have had no formal contact with biochemistry for at least eight years. If at the time of his graduation the candidate knew hardly any biochemistry, four years later, even the little knowledge that had remained will have disappeared. Indeed, that is our experience with these students. They start on the Master's degree course knowing practically no biochemistry. And they do not seem to care. It was one of them whom I have quoted above about his 'Table of Standard Values'. These candidates therefore need to be reminded about basic enzymology and metabolism, yet they find the material "boring". I get the feeling they mean the material is 'difficult'. Instead they would like us to discuss the metabolic bases of the more common diseases. How can we explain metabolic defects in a disease state without referring to enzyme action mechanisms, regulation, inhibition induction and repression, the very topics the students find "boring" (impossible?). Selection of topics for our post-graduates is therefore a thorny problem. Case Approach We are now considering trying what to us is a novel approach, the 'Case Approach', whereby hypothetical clinical cases will be described to the class. Fortunately for us, our annual intake is less than 15. Each week, a case will be presented to the class by the lecturers and will be discussed by the students, as qualified physicians, and the lecturer, the latter pointing out, and explaining, the role played by biochemistry in the aetiology, symptomatology, and treatment of the case. The clinical cases will have to be selected most carefully, preferably in consultation with senior members of the clinical departments, to ensure maximum benefit to the students, both clinically and biochemically, from each case discussion. Conclusions Our basic problem, then, is how to teach biochemistry to our undergraduate medical students in such a way that the

21 knowledge of the subject imparted to them will serve the students in their clinical years as a tool for solving clinical problems. Our friends at Monash University are apparently faced with the same problem] It is felt that offering all biochemistry in the preclinical year is unsatisfactory, because, first, the students have difficulty in perceiving the relevance of the subject to clinical medicine, having had no clinical exposure yet, and, second, by the time they are required to apply their biochemical knowledge to a clinical situation, most of our students do not remember any biochemistry worth talking about. It is recognised that basic Biochemistry ought to come early in the college career of a medical student, but it is felt that if the more applied aspects of the subject were offered in one of the clinical years, it would enable the students to maintain contact with the subject when they need it most. We would like to experiment with offering a basic course in the pre-clinical year, to be followed by a more applied one during one of the clinical years, parallel with clinical subjects. It is hoped that such a programme would enable the students to appreciate biochemistry better as a basic medical science, and that the subject would so stick in their minds that, even four years after graduation, they would still be able to give a logical explanation of the use of methotrexate as an anti-tumour agent.

References f Mehler, A H (1983) Biochem Educ I t , 95-118 2 Shaw, P L G (1984) Biochem Educ 12, 39-41

Using Biochemistry Chemistry

to Teach the Principles of

The 47 students registered in Chemistry 200 (for nonscience students) came from 21 different educational programmes, grouped into 9 major fields (Table 1). Just over half of the students were in the business field. The fields of Law, Education and Computers accounted for about one-third. The rest were studying Sociology, Speech Pathology, Languages or Sports. When asked what they expected from the course, the largest number of students replied "A general knowledge of the principles of chemistry." Other common reasons were to learn more about their bodies and about the environment. About one-quarter of the students did not know what they expected from the course (Table 2). The most difficult problem to solve in teaching chemistry to scientifically illiterate students is the fact that in choosing a non-science career the student has often discarded science as being of no interest. Therefore, such students often enter the required science course with a negative attitude that hinders learning.

Table 1 Fields of study of students in Chemistry 200 Field Business Education Computers Law Sociology Speech Pathology Languages Sports Total

Number 25 6 5 4 3 1 1 1 47

MURRAY SAFFRAN and DOUGLAS C NECKERS

Department of Biochemistry Medical College of Ohio Toledo, Ohio, USA and Department of Chemistry Bowling Green State University Bowling Green, Ohio, USA Introduction The impact of chemistry on the lives of individuals, nations, and the world makes the knowledge of basic principles of chemistry important, and even necessary, in the education of the future leaders of Society. Many of the leading politicians and statesmen of the World arise from the ranks of the legal profession, and a growing number of their advisors are trained in economics. Neither of these professional tracks traditionally includes chemistry, yet governments are faced with decisions on energy, the environment, nutrition and health that are rooted in the principles of chemistry. Some universities, including Bowling Green State University, therefore insist that students in the non-science disciplines be exposed to at least one course in science as a requisite for graduation. BIOCHEMICAL EDUCATION 13(1) 1985

Table 2 What do you expect from Chemistry 200? Learn chemical principles Learn about my body Don't know Learn about the environment Learn about biochemistry Course sounds interesting Learn about nutrition Total

17 11 10 7 3 1 1 47

Gaining the attention of the students We have tried to capture the attention of non-science students by letting the student's interests guide his or her pathway to the study of science. For example, a student embarking on a career in law would select a topic dealing with the patenting of a new drug, while a student in journalism would choose a topic that just appeared in the newspaper or in a news magazine dealing with the environmental problems encountered by a new industry. The choices were made at the first meeting of the class. Each student introduced himself to the group, announced his chosen field of study and suggested one or more topics