Medical Biochemistry

0 Medical Biochemistry Redefining (or realigning?) the Curriculum: What must they know, when must they know it, and why? Michael Lieberman, Ph.D. Professor, University of Cincinnati COM

0 Why Medical Biochemistry? • To teach the molecular basis of disease • To provide a vocabulary the student/physician will use for the rest of their life • To prepare students/physicians to think and to reason • To torture medical students

0 What is the most important goal of a medical biochemistry course? • To have students pass step 1 of the USMLE (8, 16%) • To have students prepared for the 3rd and 4th years of the curriculum (24, 48%) • To have the students learn and appreciate biochemistry (15, 30%) • To give the students something to complain about (3, 6%) The results of the poll taken during this presentation at the 2006 AMGDB meeting are shown in red, after each response.

0 What are the goals of a medical biochemistry course? • Learning and appreciating biochemistry; if that occurs the students will do well on step 1, and be prepared for the later years of the curriculum • At the University of Cincinnati I tell them the course specific goals are the following: • To understand how large molecules are synthesized and function (DNA, RNA, proteins) • To understand how energy is stored, retrieved and generated (metabolism) • To understand the future of diagnostic medicine (human genetics and cancer) • To understand biological processes at the molecular level (thinking)

0 Institutional goals and Curriculum? • The LCME is asking for Institutional Goals, and how the medical curriculum fits within those goals • How does Biochemistry fit into these goals? • UC Attempt • Who is assigned to make sure the goals are met? • Does understanding these goals help one design a Medical Biochemistry Course?

0 What do students think of medical biochemistry? • Student Evaluations – how do you deal with questions like the following? Who administers the evaluations? • And open-ended comments such as: • 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 more effectively, I was not able to pull everything together to make sense from it. • 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 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 of others. CUT MATERIAL OUT!!! • 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 e.g. if i wanted to know this much about biochem I would have gone to grad school.

0 Even More Evaluations • Evaluation after the step 1 exam • Post graduate evaluation • Are these results surprising? • Is Biochemistry “useless”? • Relates back to “What is the role of biochemistry in a medical curriculum?” • What, if anything, should be cut from a medical biochemistry curriculum? • Who else should evaluate the course? Are student evaluations alone sufficient? Who oversees changes made in the course due to evaluations? Is there a useful and functional Office of Medical Education?

0 What should the student know? • What does the NBME say? • Biochemistry Outline • Is this helpful? • Should this group develop a recommended “outline” for medical biochemistry and human genetics courses?

0 Who should determine the content of a medical biochemistry course? • The course director (18, 43%) • Each individual lecturer (2, 5%) • The chair of the department (7, 17%) • The Dean of medical education (1, 2%) • The first year curriculum committee (13, 31%) • The LCME (1, 2%) • The medical students (0, 0%)

Another View From a Recent Article • This is from the Chronicle of Higher Education, volume 52, issue 19, page B20 • Do doctors have to know all the gory details of medical research? I have yet to find anyone who can tell me why medical students need to know how DNA replicates itself, for instance. The question is not whether discovering the structure of DNA is one of the great intellectual advances of the 20th century. The question is whether the average physician needs to know all the details about DNA. • Physicians need to regain control of medical education from professional educators and scientists who are far removed from the practice of medicine. In medical school, the best teachers of anatomy are surgeons, the best teachers of histology are pathologists, the best teachers of pathophysiology are internists, and so on.

0 Medical Biochemistry Course Content? • Should there be clinical correlations? • If so, who teaches them? • How do you get students to attend? • Should experiments be discussed? • Should there be a syllabus vs a book? • The minimalist approach – everything they need to know is in the syllabus • A book presents alternative ways to learn the same material • What type of web presence should the course have? • Podcasting • Video streaming • All PowerPoints and handouts available • Online office hours • Teaching aids • These topics to be further discussed Sunday by Dr. Rawitch

Should a medical biochemistry course be different than a graduate or undergraduate course? • Yes (47, 98%) • No (1, 2%)

0 What can be left out of a Medical Biochemistry Course? • The mechanism of a serine protease (3, 10%) • The mechanism of pyridoxal phosphate reactions (3, 10%) • Certain steps in metabolic pathways (0, 0%) • Protein purification techniques (19, 66%) • Non-covalent interactions (1, 3%) • Positional cloning (3, 10%)

0 How should a medical biochemistry course be different from an undergraduate or graduate course? • Mechanisms? • Techniques? • Experiments? • Clinical relevance? • Who decides?

0 Potential differences between types of courses • Amino acid metabolism • Medical - disorders • Graduate/undergraduate – pyridoxal phosphate mechanisms; generalized reaction types • Enzyme kinetics • Medical - recognize different graphs • Graduate/undergraduate - calculate graphs, calculate Km, Vmax, turnover number, Ki • Molecular Genetics • Medical – understand techniques • Graduate/undergraduate – utilize the techniques in designing and interpreting experiments

0 How should medical students be examined? • Biochemistry knowledge? • USMLE type-questions? • Small group activities? • Comprehensive exams? • Questions based on experiments? Not usually on USMLE - but on subject exam.

0 USMLE type questions • Based on a knowledge outline • Student must be able to answer question without seeing the answers • No “negative” questions (which one is NOT) • Stem must be clinically based • Questions for subject exam different than for board exam (in the past same committee wrote both)

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

0 Limitations on USMLE questions • Since the USMLE wants clinical questions, all questions have to relate to disease • How do you relate ribosome structure to disease? How do you relate enzyme mechanisms to disease? • If stick entirely with case-based questions, it limits what you can teach – does that mean that items which cannot be asked in this format should not be taught?

0 Gratuitous stems • A six-month old presents with developmental delay. The physician notes a cherry-red spot in the retina. The child is diagnosed with Tay-Sachs disease. The defective enzyme is, or the compound which accumulates is, or the type of structure affected is, or the organelle must likely affected is, which of the following? • Stems should not tell the student what is going on - they need to use their knowledge to get there

0 Should exams be learning experiences? • Return exams - or use solely as an evaluative measure? • If move to case-based questions, very difficult to write new ones each year. • Time to revive Chair Question Bank – there are a number of ways to do this

0 Biochemistry should be integrated throughout the 4-year medical curriculum • Yes (36, 75%) • No (12, 25%)

Advantages of Integration • Reinforce key biochemical concepts throughout all four years of the curriculum • Complicated cases can be broken down to the molecular level • Surgery – collagen and wound healing; cancer and regulation of cell proliferation • Internal medicine – metabolic syndrome; atherosclerosis • Pediatrics – inborn errors of metabolism; type 1 diabetes • Ob/Gyn – mechanism of action of steroid hormones • Psychiatry – synthesis and degradation of neurotransmitters • Family medicine – type 2 diabetes • Discussed further on Sunday

0 Clinical Clerkship Directors • What do they expect students to know about biochemistry in the third year? • Surgery - as rigorous as possible • Ob/Gyn - the more the better • Pediatrics - as much as possible • Family Medicine - rigorous, make them think • Internal Medicine - very basic, train students to think

0 How does biochemistry contribute to the physicians practice? • A basic understanding of the fundamental aspects of medicine at a molecular level • Thought process • Initial introduction to kinetics (drugs) • Lab results - why are these things measured (AST, ALT, lactate, cholesterol,etc) • Human Genetics and the future of medical practice

0 Action Items? • To be continued Sunday (in part 2). . . . See Dr. Rawitch’s PowerPoint presentation

Medical Biochemistry