184

Learning Medical School Biochemistry Through Self-

Directed Case-Oriented Study
COLIN G D MORLEY and PHYLLIS BLUMBERG
Deans Office and Department of Biochemistry
Rush Medical College
Chicago, Illinois 60612, USA
Introduction
In 1982-83, Rush Medi cal Col l ege embar ked on devel op-
ing an al t ernat i ve medi cal school curri cul um f or t he first
t wo years of precl i ni cal basic science studies, Thi s
Al t er nat i ve Cur r i cul um i nvol ves a good deal of self-
mot i vat i on and l earni ng since t he st udent s are given t he
obj ect i ves f or l earni ng but no cont ent mat eri al .
Gr oups of six st udent s meet t wi ce a week f or t wo hour s
with a specially t r ai ned ' clinician faci l i t at or' and discuss a
medi cal case desi gned t o raise basic sci ence issues at an
appr opr i at e t i me in t he curri cul um. Thi s t ype of cur-
ri cul um is called ' pr obl em based' . In pr obl em- based
medi cal educat i on, t he st udent s use a clinical case or a
pat i ent as t he st i mul us f or l earni ng t he basic science
mat eri al . Thi s met hod of l earni ng has t wo main edu-
cat i onal obj ect i ves: t he acqui si t i on of an i nt egr at ed body
of knowl edge r el at ed t o t he pat i ent and t he devel opment
of pr obl em- sol vi ng skills.
Cogni t i ve psychol ogi st s have f ound t hat how com-
pl et el y i nf or mat i on is anal yzed and connect ed with ot her
i nf or mat i on det er mi nes how l ong such i nf or mat i on is
r emember ed. The r e f or e , pr obl em- bas ed l earni ng shoul d
hel p medi cal st udent s r e me mbe r scientific facts and
enabl e t hem to appl y t he mat eri al in a clinical setting, in
t hat t he mat eri al is well or gani zed and t hey can see t he
i mmedi at e r el evance of t he mat eri al t o t hei r f ut ur e clinical
work. Ret ent i on is i ncreased with bot h active l earni ng and
t he appl i cat i on of i nf or mat i on. 2
Rush Medi cal Col l ege is not t he onl y medi cal school to
establish a pr obl em- based, smal l -group, preclinical cur-
riculum. McMast er Uni versi t y est abl i shed such a cur-
ri cul um al most t went y years ago. 3 The Uni versi t y of
Maast ri cht in t he Net her l ands 4 and t he Uni versi t y of
Newcast l e in Aust ral i a 5 have also est abl i shed pr obl em
based preclinical curri cul a f or t hei r ent i r e class. Ot her
school s such as Mi chi gan St at e Uni ver si t y, ' t he Uni versi t y
of New Mexi co 7 and Har var d Uni versi t y s use a pr obl em-
based curri cul um f or a par t of t he class.
The Al t er nat i ve Cur r i cul um at Rush was est abl i shed in
response t o a per cei ved need t o i mpr ove and add some
flexibility t o t he preclinical curri cul um. A Nor t h Amer -
ican self-study of medi cal educat i on criticized t he tra-
di t i onal preclinical curri cul um as bei ng t oo heavi l y
schedul ed, t oo fact -l aden and failing t o devel op st udent
self-study or pr obl em- sol vi ng skills. ~ The est abl i shment of
a second t rack hel ps to accommodat e di f f er ent l earni ng
styles.
Student Selection
The first active year of t he pr ogr am (1984) enr ol l ed eight
st udent s and in t he subsequent t wo years (1985-1986),
ei ght een st udent s each year have ent er ed t he pr ogr am.
St udent s must vol unt eer f or this pr ogr am onl y aft er t hey
have been accept ed to Rush, and are onl y excl uded f r om
consi der at i on if t her e is concer n based on t hei r pri or
academi c achi evement . For all t hr ee classes thus far t her e
are no significant di fferences bet ween t he Al t er nat i ve
Curri cul um st udent s and t he regul ar curri cul um st udent s
in t er ms of under gr aduat e grades or Medi cal Col l ege
Admi ssi on Test ( MCAT) , an ent r ance apt i t ude exami -
nat i on, scores. Pr ef er ence is given to st udent s who have
pr i or exper i ence which woul d suggest success in t he self-
mot i vat ed f or mat of t he pr ogr am.
Faculty Selection
Basic science facul t y are vol unt eer s or are r ecr ui t ed i nt o
t he pr ogr am because of a pr evi ous commi t ment to qual i t y
educat i on. Whi l e t her e has been little f or mal training to
serve as ' r esour ce facul t y' (see bel ow Structure of the
Program) f or this curri cul um, t he basic science facul t y
have been i nvol ved with t he pl anni ng and devel opment of
t he curri cul um and facul t y wor kshops are hel d peri od-
ically on appr opr i at e topics. Basic sci ence depar t ment s
are pai d a small bl ock grant in exchange f or t hei r facul t y' s
time.
Havi ng been ext ensi vel y i nvol ved in l ect uri ng in t he
regul ar medi cal school Bi ochemi st r y course, one of us
(CM) was i nt ri gued by t he possibility t hat t her e mi ght be a
bet t er way t o t rai n st udent s in Bi ochemi st r y. CM t her e-
f or e vol unt eer ed to be a ' f oundi ng facul t y member ' for
t he Al t er nat i ve Curri cul um and was given t he responsi-
bility of designing t he appr oach to Bi ochemi st r y for the
Fall quar t er of each year.
Format for Teaching Biochemistry in the Alternative
Curriculum
Structure of the Program In many pr obl em- based cur-
ricula st udent s st udy all r el evant disciplines in ever y case
pr obl em. The facul t y were concer ned about this appr oach
causing excessive t i me demands on st udent s t hr oughout
t hei r preclinical years. Al so, in or der for facul t y to fulfill
ot her responsi bi l i t i es such as t eachi ng in the regul ar
curri cul um or carryi ng out r esear ch, it was deci ded t hat
specific disciplines woul d be emphasi zed at vari ous poi nt s
in t he curri cul um. St udent s t her ef or e concent r at e on
di sci pl i ne-rel at ed bl ocks for a quar t er . Some of t hese
blocks do, however , i nvol ve mor e t han one discipline.
The pr esent weekl y schedul e also allows for a number of
rest ri ct ed ( nor mal l y t wo hour ) ' r esour ce facul t y sessions"
in which basic science facul t y use t he t i me f or overvi ews,
clarifying expect at i ons, pacing, answeri ng quest i ons t hat
devel op f r om cases, ext endi ng and suppl ement i ng in-
f or mat i on, expl ai ni ng difficulties, and using t he t i me for
l abor at or y exper i ment s. The l at t er is t he case in some of
t he mi cr obi ol ogy sect i ons of t he curri cul um. ' Res our ce
t i me' was a novel concept t o many of t he basic science
facul t y and medi cal st udent s. At first, r esour ce time
consi st ed of formal cont act hour s for discussion (but no
BIOCHEMICAL EDUCATION 15(4) 1987
lectures) and office hours (time when faculty were in their
offices available to work with students individually). The
latter were never seriously used by the students and not
having lectures often precluded an efficient transfer of
information. Resource time evolved into a mixture of
mini-lectures and question and answer sessions.
In addition to the resource faculty sessions, the basic
scientists are expected to develop a learning guidebook
for each block. The learning guidebooks contain an
outline of topics to be covered, objectives, learning tables,
references, key words and in some cases multiple choice
learning quizzes, but no content. The purpose of the
gui debook is to ensure that the students see the breadth of
topics to be covered and to direct study to content
underemphasized in the cases. A current re-evaluation of
the gui debook will lead to a more condensed outline form.
Organization of Content The Administration had de-
cided that the program for the first year should include
Biochemistry, Immunology and Microbiology in the first
quarter (about 14 weeks). The faculty in these disciplines
therefore investigated the possibility of integrating these
closely related subjects into a whole quarter long cur-
riculum.
From the outset it proved very difficult to integrate the
diverse subject material in a logical fashion. Certainly one
can place a section on immunoglobulin structure in the
biochemistry of proteins but where does one fit microbial
pathogenic mechanisms within a biochemical framework?
The initial result was a quarter with approximately 66%
Biochemistry and 33% Immunology and Microbiology,
and this tended to force the Biochemistry into the first
eight weeks of the quarter leaving insufficient time for the
Immunology/Microbiology. This arrangement was also
arrived at as a result of a deliberate attempt not to
introduce Microbiology until the later cases.
Since that time the cases have not only been rewritten
and reworked extensively but there have also been more
appropriate choices of cases.
Eventually, due to the insufficient emphasis on
Immunology/Microbiology, the quart er was reorganized.
At present Biochemistry is spread throughout the quarter
(Table 1), with Immunology and Microbiology entering
the curriculum earlier and staying in through the rest of
the quarter. A form of integration driven by the cases, not
the gui debook, has thus been achieved. The new
arrangement appears to be working well. While the cases
became integrated in terms of the disciplines, the guide-
book remains separated by discipline since it was felt that
separate guides would be more helpful for student study
(Table 2).
Preparation of Gui debooks, the choice of cases and
integration of material were thorny issues. Anot her was
evaluation of student performance.
Exams in the Program Since the emphasis of the
program is on problem solving and not the mastery of a
BIOCHEMICAL EDUCATION 15(4) 1987
185
Table 1 Cases and Biochemistry Topics (M1 Fall Quarter
1986)
Case Biochemistry* Topics
I Juvenile Diabetes General metabolism of
(4)** glucose and fats
Use of amino acids for
energy production
Ket one body production
Hormonal regulation
through insulin and
glucagon
Acid-base balance
II Gout DNA replication
(2) Nucleotide and nucleic acid
metabolism
Shunt metabolism
III Crohn's Disease TPN
( 3 )
Electrolyte balance
Nutritional requirements
(a) calories/protein,
carbohydrate and
lipid turnover
(b) vitamins/trace elements
(c) o t h e r - - BMR
IV Thalassemia
( 2 )
DNA ~ RNA ~ protein
Protein synthesis
Mutational events
Hemoglobin-structure/
function
Bilirubin metabolism
V Multiple Myeloma
( 2 )
Protein synthesis
Protein structure and
function
Chemot herapeut i c agents
and their action
Ca + + metabolism
VI AIDS
( 3 )
Growt h factors (oncogenes)
VII Viral Hepatitis
( 3 )
VIII Burn Case
( 3 )
Liver metabolism
Coagulation
Clinical chemistry
Electrolyte balance
Protein loss
Wound repair mechanisms
Connective tissue
Nutritional needs
*The s e ar e t he poi nt s t hat s houl d be di s cus s ed in e a c h case.
** (4) s hows how ma n y f aci l i t at or c oor di na t e d s es s i ons ar e on each
case.
The Mi cr obi ol ogy a nd I mmu n o l o g y t opi cs have be e n e l i mi na t e d for
pur pos e s of br evi t y,
186
Table 2 The Gui debook Outline f or Biochemistrv
Chapt e r I - - The Bas i cs
A Bi oenerget i cs
B Wat er and Aci d-Base Equi l i bri a/ and El ect rol yt es
(Case I, III and VII)
C Ami no Aci ds, Pept i des, Prot ei ns, Pl asma Prot ei ns,
(Case V)
D Hemogl obi n and Met al Bi ochemi st ry
(Case IV and V)
E Enzymol ogy and the Regul at i on of Enzymes
(Case VI)
Chapt e r II m Ene r gy as a Th e me
A Ener gy Gener at i ng Systems (Case I and II)
B Ener gy Utilizing Systems and Energy Storage
(Case I, II, IV)
C Hor monal Regul at i on of Met abol i sm (Case I)
relate to the case (Table 3). Each page of this exam is
given to the st udent s separat el y and their answers are t hen
t aken from t hem aft er the prescribed time.
Fur t her refi nement s of the format for the basic science
written exams are now being under t aken maki ng the exam
easier to t ake and grade. This is being achieved by more
clearly focusing the quest i ons, by ' clueing' st udent s to the
areas being t est ed, using more but short er cases to cover
more areas of the discipline and worki ng out model
answers for use in grading.
It was deci ded t hat t here woul d be a practice mi d-t erm
(not to count for grade) t hat woul d mimic the final exam
in format . Such an exam was necessary because the format
of the exams was new to the st udent s. It also helps to
overcome the usual practice of the eval uat i on driving the
curriculum.
Table 3 Example of Content Exam
Case I
Chapt e r III - - I nf or mat i on Fl ow as a Th e me
A Revi ew of Ba s i c s - - Purines, Pyri mi des and
Nucleic Acids
B DNA --~ RNA --~ Prot ei n
C Cont rol of Gene Expressi on (Cases II, IV, V)
D Met abol i c Inhi bi t ors, Ant i bi ot i cs,
Chemot her apeut i c Agent s and Cell Cycle Kinetics
(Cases IV, V)
Chapt e r IV - - Bi o c he mi c a l An a t o my
A Nut ri t i on (Cases I, III, VII)
B Macr omol ecul ar Compl exes (Case VII)
C Muscle Bi ochemi st ry (Case I)
large dat abase, it was deci ded t hat multiple-choice
Nat i onal Board t ype quest i on exams were i nappropri at e.
Various format s were tried to test pr obl em solving with-
in bi ochemi st ry. In the first year of the Al t ernat i ve Cur-
riculum the exam consisted of two parts: a recall of
i nformat i on (short and long answer), and a probl em-
solving group of quest i ons, with a section requi ri ng library
research. In practice the l at t er did not work very well.
St udent s were given two days t o arrive at the correct
answers and the result, ei t her t hrough collusion (the
st udent s were honor bound not to discuss the exami nat i on
with each ot her) or sheer coincidence in the use of
resources, the answers t ur ned in were very similar from
st udent to st udent . As a result the library section has now
been dropped.
The exam is now in a ' case f or mat ' in which st udent s are
present ed with some i nf or mat i on and are asked specific
quest i ons. Once t hey hand in t hei r answer sheets t hey are
given more i nf or mat i on about the clinical case. Fur t her
quest i ons are t hen asked, these usually being di rect ed
t oward specifics within the basic science disciplines as t hey
Page 1
(This case is wort h 55 points. Ti me Limit: 55 mi nut es)
CC is a 40 year-ol d mal e st r anded on a desert island for 40
days eat i ng onl y nut s and dri nki ng fresh rain wat er. He
was finally rescued and t aken to a Uni versi t y Hospi t al
where tests were per f or med.
Case I
Page 2
( Appr oxi mat e t i me 20 mi nut es, 20 points)
(1) Describe the changes in met abol i c pat hways t hat
occurred over the 40-day peri od. Explain the intra-
cellular regul at ory mechani sms governing these
changes. (Do not discuss hormone regulation).
Case I
Page 3
( Appr oxi mat e t i me 35 mi nut es)
Serum data: Na + 150, K + 3.1, CI- 108, C02 29,
BUN 50, Creatinine 1.2, Glucose 100, Acetone +2:
Urine data: Ketones +4, Glucose, neg, WBC, neg, RBC,
neg, Protein, neg, Cholesterol 70.
(2) Explain why acet one in serum is +2, but ket ones in
urine are +4.
(10 POINTS)
(3) Why is the chol est erol level so far below normal:
explain using your knowl edge of lipid met abol i sm.
(10 POINTS)
(4) What rel at i onshi p do the levels of bl ood urea ni t rogen
and t hat of creat i ne have to each ot her and why?
(15 POINTS)
B I OCHE MI CAL E DUCAT I ON 1 5 ( 4 ) 1 9 8 7
187
In the final exam for the quarter, students are also
evaluated for their individual problem-solving skills as
well as for content knowledge (Table 4). This assessment
emphasizes their problem solving (process) abilities and
not their mastery of content. Individual problem solving
skills are evaluated by means of a two-part examination
which simulates a group problem-solving session. The first
part is a written examination where students are given a
specific case. The students then develop a database,
formulate questions and hypotheses, and establish learn-
ing issues. The students are then required to explain their
hypotheses (ie, how they relate to the data of the case).
This part of the examination should take no more than
two hours. The students then have a day to study their
learning issues, refine their hypotheses and reach some
conclusions regarding the mechanisms which explain the
abnormalities presented in the cases. The students are
instructed not to speak to one another during this study
time. Since this exam concentrates more on the process by
which students solve problems than on specific content
knowledge, students may bring notes with them for this
part of the exam.
The second part of this problem solving examination is
an oral exam which should take 30-45 minutes per student
(Table 4). A facilitator (not the one who has assisted the
students through the quarter) quizzes an individual
student on the application of data to the hypotheses and
on the new knowledge obtained following study stimu-
lated by the learning issues. Students are asked to review
and refine their hypotheses. Students may be given
additional information and asked to apply the information
to their hypotheses. This exam (similar to McMaster's
triple jump type exam l) is graded according to a
predetermined criteria checklist of process points that the
students should discuss. Students are also graded on their
performance throughout the quarter in the problem
solving group sessions through peer and facilitator review
(Table 4).
In order to reassure students of their ability to answer
multiple-choice questions, a battery of National Board of
Medical Examiners (NBME) Mini Board exams are also
given to the students at the end of the quarter as learning
exams. Students must pass the NBME Part I exam before
starting their clerkships in Year 3.
Guidebooks versus Cases One of the greatest stresses
noted in students coping with the Alternative Curriculum
approach arises from the tension which develops between
what the guidebook says must be learned (See Table 2)
and what comes up in the cases (Table 5). Not all topics
are raised as learning issues during the cases. Students
also raise additional learning issues which are not devel-
oped by the basic science resource faculty (Table 5). (The
learning issues from the groups are provided to the
resource faculty prior to their sessions with the students.)
Stress arises not only because not all issues to be learned
are necessarily covered by the cases (although 90% are
covered), but also because pacing of learning is a problem
in the absence of a structured lecture schedule. It is here
that the resource sessions can help with the students'
learning pace.
Conclusions
In general, our Alternative Curriculum program has
worked well. In spite of some skepticism on the part of
faculty, the program is growing in acceptance. While the
curriculum is not perfect, major improvements have been
made during the three years since its implementation. Its
Table 4 Student Evaluation Per Quarter
Type Format Weight for Grade Example of Evaluation Duration
Content Written History of patient given. 1-2 days
Applying factual Students identify hypotheses
knowledge to cases.
50%
Physical examination given.
Students revise hypotheses.
Answer discipline specific questions
Lab, further data given.
Students revise hypotheses.
Answer discipline specific questions
Individual Written Case given with no questions. 2 Hours
Problem-solving 1st Part Students list, revise their hypotheses, l i s t (Written)
Exam relevant data and develop learning issues for
library study
Oral
2nd Part
30%
Facilitator individually discusses case with '/2 Hour
student to assess their problem-solving within (Oral)
case
Group Oral 20%*
Problem Solving
Assess student's ability to communicate, co- Throughout
operate, accept criticism, use basic science the
information, revise hypotheses, synthesize quarter
information
* = facilitator (12%), peers (6%), self (2%).
BI OCHEMI CAL EDUCATI ON 15(4) 1987
188
Table 5 Selected examples of Biochemistry Learning Issues
raised by the student groups in Case 1: IDDM
The f unct i on of all hor mones responsi bl e f or met abol i sm
of car bohydr at e
Pat hways t hat pr oduce glucose: how hor mones i nt er act
with pat hways:
Aci d/ Base - - physi ol ogi cal i mpl i cat i ons - - r espi r at or y and
met abol i c r el at i onshi p bet ween acidosis and di abet es
Ket osi s, ket one bodi es, 13-oxidation of fat t y acids
Lact i c acid f or mat i on
Rol e/ Mechani sms by which insulin st i mul at es lipid
pr ot ei n, gl ycogen synt hesi s
Hor mona l act i on via c AMP on enzyme synt hesi s
Wher e is acet yl - CoA in cell? How is it t r anspor t ed out of
cell t o liver? What is t he ef f ect of t he bui l dup of acet yl -
CoA on tissues and cells? ~(storage capaci t y)
Mechani sms of f at t y acid and ami no acid cat abol i sm
How does stress or i nfect i on i ncrease insulin r equi r ement ?
Pr ot ei n spari ng
Cr eat i ni ne and ki dney f unct i on
BUN and Dehydr at i on
Gl ycogeni c and Ket ogeni c Ami no Aci ds
Tr ansami nat i on and Deami nat i on
How are t he pancr eas and adr enal glands made aware of
low levels of gl ucose in cells?
Det er mi nat i on of hi er ar chy f or utilization of carbo-
hydr at es, fat t y acids and pr ot ei ns
How does ci t rat e affect gl ucose utilization in t he ket o-
acidotic st at e?
What crosses t he mi t ochondr i al me mbr a ne ?
Will gl ucose 6- phosphat e build up?
bi ochemi st r y sect i on will cont i nue t o evol ve and i mpr ove.
A measur e of its success has been t he i ncreasi ng spi l l over
into t he regul ar cur r i cul um wher e t her e is a t endency to
use smal l er gr oup sessions, f ewer l ect ures and mor e
wor kshop format s. Some concer ns have been voi ced t hat
t he Al t er nat i ve Cur r i cul um t ends t o at t ract mor e out goi ng
st udent s who have mor e conf i dence in t hemsel ves, and we
may t her eby be creat i ng a so called ' dl i t e' cot er i e of
st udent s in our medi cal school . Al so since this is a faculty-
i nt ensi ve ef f or t , facul t y r esour ces can be s quander ed if t he
st r uct ur ed t i me of t he pr ogr am is not kept t o a mi ni mum.
Whi l e t he pr ogr am is t oo new to be fully eval uat ed, t he
Al t er nat i ve Cur r i cul um st udent s seem general l y satisfied
with t he pr ogr am. The first class has ent er ed t he clinical
years and has r epor t ed vari ous benefi t s f r om part i ci pat i ng
in this pr ogr am. For exampl e, one st udent felt t hat she did
well on t he oral exam af t er t he surgery cl erkshi p because
of her t rai ni ng in t he preclinical years. Al t er nat i ve
Curri cul um st udent s have r epor t ed t hat t hey can research
mat eri al on a case easily and are not afrai d to t hi nk on
t hei r feet .
None of t he st udent s ent er i ng t he pr ogr am have want ed
to dr op out of school , a few have opt ed to r et ur n to t he
regul ar curri cul um (this is gener al l y al l owed onl y at t he
end of t he first year). Those who have t r ansf er r ed pro-
grams have ci t ed dissatisfaction f or t hemsel ves with the
l earni ng f or mat : none has criticized t he pr ogr am per se.
One obj ect i ve measur e of t he pr ogr am' s success has
been t he r ecor d of Nat i onal Boar d Part I passage by the
first gr oup t hr ough t he pr ogr am. All passed and exceeded
t he Mean Score achi eved by t he regul ar class in all
disciplines sitting in June 1986, with t he except i on of
bi ochemi st r y which was just bel ow t he class Mean. Thus,
al t hough Boar d pr epar at i on is not a goal of t he Al t er na-
tive Cur r i cul um, our st udent s are at least as well, if not
bet t er , pr epar ed t han t he st udent s in t he regul ar cur-
riculum. These dat a, however , r ef er t o onl y eight st udent s
and conf i r mat i on will r equi r e l arger groups over the
comi ng years. A r ecent st udy f r om anot her college has
f ound t hat t he Boar d scores of Al t er nat i ve Curri cul um
t ype st udent s and regul ar curri cul um st udent s do not
differ, it
Fr om t he per spect i ve of a t eachi ng bi ochemi st , t he
Al t er nat i ve Cur r i cul um offers a fine way for st udent s to
l earn and appl y such subj ect s as Bi ochemi st ry. Anot her
benefi t arises f r om t he gr eat er degr ee of per sonal satis-
fact i on exper i enced by bot h facul t y and st udent s in the
educat i onal process.
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