Medical BiochemistryMedical Biochemistry

Redefining (or realigning?) the Redefining (or realigning?) the Curriculum: What must they know, Curriculum: What must they know,

when when must they know it, and why?must they know it, and why?

Michael Lieberman, Ph.D.

Professor, University of Cincinnati COM

Why Medical Biochemistry?Why Medical Biochemistry?

To teach the molecular basis of To teach the molecular basis of diseasedisease

To provide a vocabulary the To provide a vocabulary the student/physician will use for the rest student/physician will use for the rest of their lifeof their life

To prepare students/physicians to To prepare students/physicians to think and to reasonthink and to reason

To torture medical studentsTo torture medical students

What is the most important goal of a What is the most important goal of a medical biochemistry course?medical biochemistry course?

1.1. To have students pass step 1 of To have students pass step 1 of the USMLE the USMLE (8, 16%)(8, 16%)

2.2. To have students prepared for To have students prepared for the 3the 3rdrd and 4 and 4thth years of the years of the curriculum curriculum (24, 48%)(24, 48%)

3.3. To have the students learn and To have the students learn and appreciate biochemistry appreciate biochemistry (15, (15, 30%)30%)

4.4. To give the students something To give the students something to complain about to complain about (3, 6%)(3, 6%)

The results of the poll taken during this presentation at the 2006 AMGDBmeeting are shown in red, after each response.

What are the goals of a medical What are the goals of a medical biochemistry course?biochemistry course?

Learning and appreciating biochemistry; if that Learning and appreciating biochemistry; if that occurs the students will do well on step 1, and occurs the students will do well on step 1, and be prepared for the later years of the curriculumbe prepared for the later years of the curriculum

At the University of Cincinnati I tell them the At the University of Cincinnati I tell them the course specific goals are the following:course specific goals are the following: To understand how large molecules are synthesized To understand how large molecules are synthesized

and function (DNA, RNA, proteins)and function (DNA, RNA, proteins) To understand how energy is stored, retrieved and To understand how energy is stored, retrieved and

generated (metabolism)generated (metabolism) To understand the future of diagnostic medicine To understand the future of diagnostic medicine

(human genetics and cancer)(human genetics and cancer) To understand biological processes at the molecular To understand biological processes at the molecular

level (thinking)level (thinking)

Institutional goals and Institutional goals and Curriculum?Curriculum?

The LCME is asking for Institutional Goals, The LCME is asking for Institutional Goals, and how the medical curriculum fits within and how the medical curriculum fits within those goalsthose goals

How does Biochemistry fit into these goals?How does Biochemistry fit into these goals? UC AttemptUC Attempt Who is assigned to make sure the goals are Who is assigned to make sure the goals are

met?met? Does understanding these goals help one Does understanding these goals help one

design a Medical Biochemistry Course?design a Medical Biochemistry Course?

What do students think of medical What do students think of medical biochemistry?biochemistry?

Student Evaluations – how do you deal with Student Evaluations – how do you deal with questions like the questions like the followingfollowing? Who administers the ? Who administers the evaluations?evaluations?

And open-ended comments such as:And open-ended comments such as: Get rid of the pointless, nit-picky information. If only one person in the Get rid of the pointless, nit-picky information. If only one person in the

history of medicine has had a disease, skip it. Demonstrate the big picture history of medicine has had a disease, skip it. Demonstrate the big picture more effectively, I was not able to pull everything together to make sense more effectively, I was not able to pull everything together to make sense from it.from it.

TOO detailed. Medical students DO NOT need to know more than 1/2 of the TOO detailed. Medical students DO NOT need to know more than 1/2 of the detail presented in this class, according to review books, etc. If we had all of detail presented in this class, according to review books, etc. If we had all of the time in the world, this class would be great, but the level this class was the time in the world, this class would be great, but the level this class was presented at required students to (over) study for this class at the expense presented at required students to (over) study for this class at the expense of others. CUT MATERIAL OUT!!! of others. CUT MATERIAL OUT!!!

You should only have to know diseases. everything else seems irrelevant. it You should only have to know diseases. everything else seems irrelevant. it doesn't make sense to go into so much detail about how to make purines, for doesn't make sense to go into so much detail about how to make purines, for e.g. if i wanted to know this much about biochem I would have gone to grad e.g. if i wanted to know this much about biochem I would have gone to grad school.school.

Even More EvaluationsEven More Evaluations Evaluation after the step 1 Evaluation after the step 1 examexam Post graduate Post graduate evaluationevaluation Are these results surprising?Are these results surprising?

Is Biochemistry “useless”?Is Biochemistry “useless”? Relates back to “What is the role of biochemistry in a Relates back to “What is the role of biochemistry in a

medical curriculum?”medical curriculum?” What, if anything, should be cut from a medical What, if anything, should be cut from a medical

biochemistry curriculum?biochemistry curriculum? Who else should evaluate the course? Are Who else should evaluate the course? Are

student evaluations alone sufficient? Who student evaluations alone sufficient? Who oversees changes made in the course due to oversees changes made in the course due to evaluations? Is there a useful and functional evaluations? Is there a useful and functional Office of Medical Education?Office of Medical Education?

What should the student What should the student know?know?

What does the NBME say?What does the NBME say? Biochemistry OutlineBiochemistry Outline Is this helpful? Is this helpful? Should this group develop a Should this group develop a

recommended “outline” for medical recommended “outline” for medical biochemistry and human genetics biochemistry and human genetics courses?courses?

Who should determine the content Who should determine the content of a medical biochemistry course?of a medical biochemistry course?

1.1. The course director The course director (18, 43%)(18, 43%)2.2. Each individual lecturer Each individual lecturer (2, 5%)(2, 5%)3.3. The chair of the department The chair of the department (7, (7,

17%)17%)4.4. The Dean of medical education The Dean of medical education (1, (1,

2%)2%)5.5. The first year curriculum The first year curriculum

committee committee (13, 31%)(13, 31%)6.6. The LCME The LCME (1, 2%)(1, 2%)7.7. The medical students The medical students (0, 0%)(0, 0%)

Another View From a Recent Another View From a Recent ArticleArticle

This is from the Chronicle of Higher This is from the Chronicle of Higher Education, volume 52, issue 19, page B20Education, volume 52, issue 19, page B20 Do doctors have to know all the gory details of medical Do doctors have to know all the gory details of medical

research? I have yet to find anyone who can tell me why research? I have yet to find anyone who can tell me why medical students need to know how DNA replicates medical students need to know how DNA replicates itself, for instance. The question is not whether itself, for instance. The question is not whether discovering the structure of DNA is one of the great discovering the structure of DNA is one of the great intellectual advances of the 20th century. The question intellectual advances of the 20th century. The question is whether the average physician needs to know all the is whether the average physician needs to know all the details about DNA.details about DNA.

Physicians need to regain control of medical education Physicians need to regain control of medical education from professional educators and scientists who are far from professional educators and scientists who are far removed from the practice of medicine. In medical removed from the practice of medicine. In medical school, the best teachers of anatomy are surgeons, the school, the best teachers of anatomy are surgeons, the best teachers of histology are pathologists, the best best teachers of histology are pathologists, the best teachers of pathophysiology are internists, and so on. teachers of pathophysiology are internists, and so on.

Medical Biochemistry Course Medical Biochemistry Course Content?Content?

Should there be clinical correlations?Should there be clinical correlations? If so, who teaches them?If so, who teaches them? How do you get students to attend?How do you get students to attend?

Should experiments be discussed?Should experiments be discussed? Should there be a syllabus vs a book?Should there be a syllabus vs a book?

The minimalist approach – everything they need to know is in The minimalist approach – everything they need to know is in the syllabusthe syllabus

A book presents alternative ways to learn the same materialA book presents alternative ways to learn the same material What type of web presence should the course have?What type of web presence should the course have?

PodcastingPodcasting Video streamingVideo streaming All PowerPoints and handouts availableAll PowerPoints and handouts available Online office hoursOnline office hours Teaching aidsTeaching aids

These topics to be further discussed Sunday by Dr. RawitchThese topics to be further discussed Sunday by Dr. Rawitch

Should a medical biochemistry Should a medical biochemistry course be different than a course be different than a

graduate or undergraduate graduate or undergraduate course?course?

1.1. Yes Yes (47, 98%)(47, 98%)

2.2. No No (1, 2%)(1, 2%)

What can be left out of a What can be left out of a Medical Biochemistry Medical Biochemistry

Course?Course?1.1. The mechanism of a serine protease The mechanism of a serine protease

(3, 10%)(3, 10%)2.2. The mechanism of pyridoxal The mechanism of pyridoxal

phosphate reactions phosphate reactions (3, 10%)(3, 10%)3.3. Certain steps in metabolic pathways Certain steps in metabolic pathways

(0, 0%)(0, 0%)4.4. Protein purification techniques Protein purification techniques (19, (19,

66%)66%)5.5. Non-covalent interactions Non-covalent interactions (1, 3%)(1, 3%)6.6. Positional cloning Positional cloning (3, 10%)(3, 10%)

How should a medical biochemistry How should a medical biochemistry course be different from an course be different from an

undergraduate or graduate course?undergraduate or graduate course?

Mechanisms?Mechanisms? Techniques?Techniques? Experiments?Experiments? Clinical relevance?Clinical relevance? Who decides?Who decides?

Potential differences between Potential differences between types of coursestypes of courses

Amino acid metabolismAmino acid metabolism Medical - disordersMedical - disorders Graduate/undergraduate – pyridoxal phosphate Graduate/undergraduate – pyridoxal phosphate

mechanisms; generalized reaction typesmechanisms; generalized reaction types Enzyme kineticsEnzyme kinetics

Medical - recognize different graphsMedical - recognize different graphs Graduate/undergraduate - calculate graphs, Graduate/undergraduate - calculate graphs,

calculate Kcalculate Kmm, V, Vmaxmax, turnover number, K, turnover number, Kii

Molecular GeneticsMolecular Genetics Medical – understand techniquesMedical – understand techniques Graduate/undergraduate – utilize the techniques Graduate/undergraduate – utilize the techniques

in designing and interpreting experimentsin designing and interpreting experiments

How should medical How should medical students be examined?students be examined?

Biochemistry knowledge?Biochemistry knowledge? USMLE type-questions?USMLE type-questions? Small group activities?Small group activities? Comprehensive exams?Comprehensive exams? Questions based on experiments? Questions based on experiments?

Not usually on USMLE - but on Not usually on USMLE - but on subject exam.subject exam.

USMLE type questionsUSMLE type questions

Based on a knowledge outline Based on a knowledge outline Student must be able to answer question Student must be able to answer question

without seeing the answerswithout seeing the answers No “negative” questions (which one is NOT)No “negative” questions (which one is NOT) Stem must be clinically basedStem must be clinically based Questions for subject exam different than Questions for subject exam different than

for board exam (in the past same for board exam (in the past same committee wrote both)committee wrote both)

Examples of questionsExamples of questions

Which enzyme catalyzes the degradation Which enzyme catalyzes the degradation of muscle glycogen?of muscle glycogen?

A 12 year old boy complains of muscle A 12 year old boy complains of muscle fatigue while participating in gym class. fatigue while participating in gym class. He has more trouble with anaerobic He has more trouble with anaerobic activities, and blood analysis before and activities, and blood analysis before and after exercise indicate very little lactate after exercise indicate very little lactate production. A defect in which enzyme production. A defect in which enzyme may lead to this condition?may lead to this condition?

Limitations on USMLE Limitations on USMLE questionsquestions

Since the USMLE wants clinical questions, Since the USMLE wants clinical questions, all questions have to relate to diseaseall questions have to relate to disease

How do you relate ribosome structure to How do you relate ribosome structure to disease? How do you relate enzyme disease? How do you relate enzyme mechanisms to disease?mechanisms to disease?

If stick entirely with case-based questions, If stick entirely with case-based questions, it limits what you can teach – does that it limits what you can teach – does that mean that items which cannot be asked in mean that items which cannot be asked in this format should not be taught?this format should not be taught?

Gratuitous stemsGratuitous stems A six-month old presents with A six-month old presents with

developmental delay. The physician developmental delay. The physician notes a cherry-red spot in the retina. notes a cherry-red spot in the retina. The child is diagnosed with Tay-Sachs The child is diagnosed with Tay-Sachs disease. The defective enzyme is, or disease. The defective enzyme is, or the compound which accumulates is, or the compound which accumulates is, or the type of structure affected is, or the the type of structure affected is, or the organelle must likely affected is, which organelle must likely affected is, which of the following?of the following?

Stems should not tell the student what Stems should not tell the student what is going on - they need to use their is going on - they need to use their knowledge to get thereknowledge to get there

Should exams be learning Should exams be learning experiences?experiences?

Return exams - or use solely as an Return exams - or use solely as an evaluative measure?evaluative measure?

If move to case-based questions, If move to case-based questions, very difficult to write new ones each very difficult to write new ones each year.year.

Time to revive Chair Question Bank – Time to revive Chair Question Bank – there are a number of ways to do there are a number of ways to do this this

Biochemistry should be integrated throughout Biochemistry should be integrated throughout the 4-year medical curriculumthe 4-year medical curriculum

1.1. Yes Yes (36, 75%)(36, 75%)

2.2. No No (12, 25%)(12, 25%)

Advantages of IntegrationAdvantages of Integration Reinforce key biochemical concepts Reinforce key biochemical concepts

throughout all four years of the curriculum throughout all four years of the curriculum Complicated cases can be broken down to the Complicated cases can be broken down to the

molecular levelmolecular level Surgery – collagen and wound healing; cancer and Surgery – collagen and wound healing; cancer and

regulation of cell proliferationregulation of cell proliferation Internal medicine – metabolic syndrome; Internal medicine – metabolic syndrome;

atherosclerosisatherosclerosis Pediatrics – inborn errors of metabolism; type 1 Pediatrics – inborn errors of metabolism; type 1

diabetesdiabetes Ob/Gyn – mechanism of action of steroid hormonesOb/Gyn – mechanism of action of steroid hormones Psychiatry – synthesis and degradation of Psychiatry – synthesis and degradation of

neurotransmittersneurotransmitters Family medicine – type 2 diabetesFamily medicine – type 2 diabetes

Discussed further on SundayDiscussed further on Sunday

Clinical Clerkship DirectorsClinical Clerkship Directors

What do they expect students to know What do they expect students to know about biochemistry in the third year?about biochemistry in the third year? Surgery - as rigorous as possibleSurgery - as rigorous as possible Ob/Gyn - the more the betterOb/Gyn - the more the better Pediatrics - as much as possiblePediatrics - as much as possible Family Medicine - rigorous, make them Family Medicine - rigorous, make them

thinkthink Internal Medicine - very basic, train Internal Medicine - very basic, train

students to thinkstudents to think

How does biochemistry contribute How does biochemistry contribute to the physicians practice?to the physicians practice?

A basic understanding of the fundamental A basic understanding of the fundamental aspects of medicine at a molecular levelaspects of medicine at a molecular level

Thought processThought process Initial introduction to kinetics (drugs)Initial introduction to kinetics (drugs) Lab results - why are these things Lab results - why are these things

measured (AST, ALT, lactate, measured (AST, ALT, lactate, cholesterol,etc)cholesterol,etc)

Human Genetics and the future of medical Human Genetics and the future of medical practicepractice

Action Items?Action Items?

To be continued Sunday (in part To be continued Sunday (in part 2). . . . 2). . . .

See Dr. Rawitch’s PowerPoint See Dr. Rawitch’s PowerPoint presentation presentation