A new syllabus for medical biochemistry

A new syllabus for medical biochemistry

70 BIOCHEMICAL EDUCATION July 1979 vol 7 no 3 K DAKSHINAMURTI A NEW SYLLABUS FOR MEDICAL BIOCHEMISTRY Starting with the academic year 1978-79, an ...

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July 1979 vol 7 no 3


Starting with the academic year 1978-79, an undergraduate course in biochemistry was included a m o n g the academic prerequisites in the competition fo~ admission for first year Medicine. As with m a n y other medical schools in recent years an increasing proportion of entering first year students h a d already taken a biochemistry course. This was the first time that we had an entire class that had completed at least one biochemistry course. Thus, the biochemistry faculty faced a challenge of mounting a course which was not a repetition of undergraduate biochemistry and at the same time providing the students with adequate basic science knowledge that would prepare them for future years of medical education. It was recognized that in the later years of practice the clinician would have to draw on facts, concepts and problem analysis skills learned in basic science courses to keep up with the advances in medicine. We had to develop a new syllabus in biochemistry that would satisfy the above needs and also the Faculty Committee on Undergraduate Medical Education (CUME) on (i) course content in terms of relevance and (it) the n u m b e r of hours required within the overall context of the medical curriculum. A departmental Planning Committee charged with the development of this p r o g r a m m e drew on the expertise of all m e m b e r s of the Department and a n u m b e r of clinicians with varying degrees of basic science bias. The p r o g r a m m e that was formulated was extensively discussed, revised over a two year period and recommended for adoption by the Biochemistry Teaching Committee consisting of all staff members of the Department and student representatives and received administration approval. We discussed the pros and cons of various approaches like an 'advanced course in biochemistry' and a course in 'clinical biochemistry' and decided to prepare an outline for a course on ' H u m a n Biochemistry', one that was primarily oriented toward providing an understanding of the normal biochemical process in the h u m a n body in which the functions of the various organs and tissues are integrated. The comprehension of the principles of metabolic regulation would contribute to the students' understanding of the biochemical basis of various disease processes. We recognized that the course, to be useful to students, should bring out the relevance of biochemistry in the practice of medicine. We decided against teaching biochemistry in a strictly case oriented fashion as it would appear contrived and also as we recognized that certain areas of biochemistry are of such fundamental importance that an obvious clinical relevance was not necessary. However, we did introduce interesting clinical examples where we deemed it appropriate. Even rare diseases were used as examples to illustrate the use of biochemistry as a scientific investigatory technique. A realistic assessment of the biochemical background of entering students assured us that they had had adequate knowledge of the biochemical language and the elementary 'road m a p s ' of metabolic interconversions. In determining what biochemistry is to include, we proceeded to examine what is 'clinically relevant' biochemistry. Each of us analysed individually a n u m b e r of case histories and listed the biochemical topics associated with each. To this list was added 'basic' biochemistry of intrinsic merit without obvious clinical relevance. The detailed outline of the course prepared by the Planning Committee was extensively discussed by the Teaching Committee. All the instructors offered detailed criticisms of sections within their area of expertise. Following the adoption of the course outline specific areas were assigned to individual instructors for the preparation of lecture outlines. This was meant to reflect the individual instructor's perception of the biochemistry material to be presented based on the accepted 'course outline'. The only criterion applied for the inclusion of any material was the instructor's ability to justify the same to the teaching committee. The lecture outline for each

D e p a r t m e n t of B i o c h e m i s t r y F a c u l t y of M e d i c i n e U n i v e r s i t y of M a n i t o b a Winnipeg, Canada R3E OW3

section was reviewed by a group of three consisting of the instructor charged with its preparation, another instructor knowledgeable in that general area and a third m e m b e r whose area of expertise was different. This was designed to provide a proper balance and avoid too m u c h specialization. Once the lecture outline was approved the instructors prepared the 'lecture notes' and the same scrutiny and review was applied for this as well. Since a suitable textbook was not available we have provided print 'lecture' notes which are well received by the students. Once the course content was decided upon the next step was to allocate a reasonable distribution of the assigned lecture hours. We decided that the best way of presenting biochemistry would be through a combination of didactic lectures, quarter class tutorials (T4 with about twenty-five students per group) and small group problem solving encounters (T 8 with about twelve students per group). We also use the biochemistry teaching time to initiate students in a 'Literature Search and Evaluation Project (LSEP)'. There are 109 student contact hours of biochemistry instruction in the first I year medical curriculum. These are distributed as follows: lectures, 40 hours; "1"4, 14 hours; T a, 24 hours; LSEP, 6 hours and biochemistry problem solving time, 25 hours. The list of topics in biochemistry and the time allotted for each section is given in Table 1. Each section starts with 1--3 hours of lecture followed in some instances by a T 4 (1 hour) and in all instances by a T 8 (1 hour). Attendance at lectures as well as at tutorials by the student is optional. The T4s are used in a structured or unstructured way as designed by the instructor. The main effort here is to go over concepts requiring reiteration or clarification of student's residual difficulties. No new material is introduced in these. The objectives TABLE 1

Topics Presented in Biochemistry

Lecture 1. Introduction to metabolism, methods for studying biochemical abnormalities 2. Body fluids, electrolytes, acid-base balance 3. Proteins 4. Enzymes including clinical enzymology 5. M e m b r a n e s 6. Energy metabolism 7. Molecular mechanisms of movement 8. Molecular basis of inheritance 9. Nucleotide metabolism 10. Digestion and absorption 11. Mode of action of hormones 12. Carbohydrate metabolism 13. Lipid metabolism 14. Protein metabolism 1S. Amino acid metabolism 16. Vitamins 17. Mineral metabolism 18. Metabolic integration 19. Review 20. LSEP 21. Problem solving


Problem Solving/ Ts Library




3 2 3 2 2 3 2 1 2 1 3 3 2 2 3 2 --1

1 1 1 --1 ----

1 1 1 1 1 1 2

------4 4 --

3 3

40 13 = 109 hours

1 1

1 1 2 2 --1


4 28 32


July 1979 vol 7 no 3


of the T e are: (i) to illustrate the application of biochemical information and concepts to a wide variety of problem-solving situations related to medicine, (ii) to encourage students to develop problem-solving skills both individually a n d as part of a group enterprise and (iii) to reinforce and broaden the basic material. Different formats, including 'simulated clinical problems', I all based on case history with primary data have been used. Information in the form of a case history with required data (clinical, biochemical, etc) are provided to students in written form well in advance of the T s for study and preparation. In view of faculty manpower limitations a m a x i m u m of four groups comprising half the class are engaged in T s sessions at any one time. During this time the other half of the class has free time intended to be used for preparation of biochemistry tutorials. The students are aware of the emphasis placed by the faculty on small-group discussion as a learning method. All entering medical students go through an orientation programme during their first week in medical school when they are introduced to small-group learning encounters. During this time they acquire the skills necessary to participate effectively in such classes. Most m e m b e r s of the Biochemistry faculty have attended programmes on small-group teaching organized by the Faculty of Education of this university. The list of topics offered in the Tas is given in Table 2. These tutorials offer the opportunity for active discussion and decision making by the participants. In the Tss an attempt is made to integrate into the tutorial material biochemical topics covered earlier in the course. In addition to this, we have tutorial sessions (T4s) on various aspects of metabolic integration. Topics like effects of starvation, metabolic effects of alcohol, diabetes a n d cardiac arrest offer excellent opportunities to discuss metabolic interrelationships, their integration and control. The objectives of the LSEP are: (i) learning procedures of effective literature retrieval, (ii) developing the ability to evaluate a research report in the form of articles published in a scientific journal and (iii) learning to judge what is essential for the preparation of a report on the literature search. The topics are sufficiently specific that students do not have to examine all the current literature in a whole field. The instructors also ascertain that appropriate articles are in fact available in our library holdings before assigning a topic. When the LSEP is introduced to the students they are instructed by the Medical Librarian in a highly effective method of literature search 2 and they are specifically told about what is expected of them in this project. Each group of about twelve students is assigned a topic which they search in the library. The time required for library work is also provided within the biochemistry hours. Each group presents and discusses its findings at an assigned time. The instructor who provided the topic is present at this discussion as a resource person. Each group decides on how to use its manpower in the various tasks associated with collection, evaluation and presentation of data. We have just completed our first year of this new course in biochemistry. We have tried to evaluate the students' understanding of the principles of biochemistry a n d their ability in problem solving. In addition to the usual multiple choice question format we have included short answer questions and an essay on the LSEP in the comprehensive examination administered by the Faculty. The students, in turn, have evaluated this course as part of their curriculum evaluation seminar. As a result of these two evaluations and the Biochemistry Teaching Committee's discussion we are pleased to find that our students have acquired a sound foundation of biochemical knowledge along with the ability at problem solving. The students have been appreciative of the clinically-relevant fiavour of the course. We recognize that certain sections of the course need to be improved. However we feel that our experiment has been successful to the extent that major revisions in

either the content or format are not considered necessary for the next year. We expect this course to evolve further based on our continuing experience with it. TABLE 2 T o p i c s Discussed in TBs 1. Protein-losing enteropathy - - the use of radioisotopic tracers administered through different routes in investigation of a metabolic abnormality. 2. 'Willie' - - the consequences of acute glomerular nephritis on acid-base and fluid balance. 3.. Sickle cell anemia - - the molecular pathology and treatments suggested. 4. Serum enzymes in various diseases - - diagnostic use of serum enzyme assays. S. Watery stools - - electrolyte changes as a result of cholera toxin

exposure and the concept that a simple molecule like GM1 ganglioside can act as a m e m b r a n e receptor. 6. Luft's Syndrome - - hyper metabolism due to uncoupling of muscle mitochondrial oxidative phosphorylation. 7. Connective

tissue diseases - - the relationship between connective tissue diseases and the pathway of collagen and glycosaminoglycan metabolism.

8. Lesch Nyhan Syndrome - including prenatal diagnosis. 9. Genetic engineering - engineering.

Twins with hyper uricemia',

the facts and fiction of genetic

10. Orotic aciduria - - genetic defect in hereditary orotic aciduria. l l. Enterokinase deficiency - - the role of enzyme activation in digestion. 12. 'Dulcina' - - the significance of reducing substances in urine, the techniques used in testing for them and the interpretation of the tests. 13.'A test of tests' - - h u m a n problems associated with hyperglycemia and the choice of techniques used in testing for it. 14. 'Where, what is it?' - - glycogen storage diseases. 15. 'Linda' - - carnitine deficiency and fatty acid oxidation. 16. 'Hyperlipoproteinemia' - - Endogenous hypertriglyceridemia; hyperchylomicronemia. 17.'Diabetes' - - laboratory findings in this disease and the underlying pathways of carbohydrate and lipid metabolism. 18. Protein metabolism - - nitrogen balance. 19.'Elsie' - - a case of homocystinuria apparently caused by Vitamin B12 deficiency. 20. 'Tropical sprue' - - megaloblastic anemia, interrelationship between folic acid a n d vitamin B12; polyglutamate conjugase. 21.'fl-hydroxy isovaleric dependency.






22. 'Mineral metabolism' - - analysis of flow routes of calcium and phosphate; techniques of determinations and interpretation of data. 23.'Lead poisoning' - - absorption, excretion and biochemical effects of an environmental toxin.

REFERENCES 1 Blanchaer, M C (1975). 'Simulated Clinical Problems in a Medical Biochemistry Course', Biochemical Education, 3, 71. 2Kerr, A M (1970). 'The Medical Library or the Problem of Solomen', U Manitoba Medical Journal, 42, 25. I

Biochemical Education is published from the Editorial Office, Department of Biochemistry, 9 Hyde Terrace, Leeds, England LS2 9LS. Annual subscription for vol 7 (1979): $8.00 or £4.00 for the four issues including postage by surface mail (printed paper rate); $10.00 or £.5.00 if sent by 2nd class airmail. Vol 1 (1973) and vol 2 (1974) available at $6.00 or £3.00 each, and vols 3 - 6 (1975-78) at $8.00 or £4.00 each, including surface postage. Please make cheques, etc, payable to Biochemical Education. © 1979. Published in January, April, July, a n d October.