C Heath

CG Prober

D Irby

EJ Wood

EP Brass

G Bandiera

GB Clack

KF Lee

M Srinivasan

MGV Heiden

MH Davis

MI Ebomoyi

PR NJølstad

RM Harden

S Watmough

SO Nam

TB Fulton

Mehdi Afshar

Zhiyong Han

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COMMENTARYTeaching and Learning Medical Biochemistry: Perspectivesfrom a Student and an EducatorMehdi Afshar & Zhiyong HanPublished online: 7 May 2014# The Author(s) 2014. This article is published with open access at Springerlink.comAdvancement of medicine and that of biochemistry are insep-arable, and much of modern medicine would not be practicedin the ways, as they are known today, without our understand-ing of how genetic, pathogenic and environmental factorsaffect the human body at the biochemical level. Thus, theimportance of teaching medical students biochemistry isself-evident. Ironically, many medical students and practicingphysicians consider learning biochemistry an unnecessaryburden and that biochemistry has very little relevance to theirdaily practice of medicine [1–3]. Also, many students, espe-cially those interested in fields such as primary care or psy-chiatry, also complain that there is too much anatomy in thepreclinical curricula [1]. Thus, it seems that these studentswould prefer to selectively learn subject matters that theybelieve to be relevant to the medical specialties that they wishto acquire and practice in. Such utilitarian thinking, we be-lieve, is in part responsible for the trend in medical curriculumthat devaluates basic science and emphasizes apprenticeshipexperiences with clinical faculty [4].Why do these medical students consider it unnecessary tolearn biochemistry? What can educators do to convince themthat learning biochemistry is important in their education? Wehave tried to answer these questions from the perspectives ofM.A. (Mehdi Afshar), a fourth year medical student, and Z.H.(Zhiyong Han), a medical biochemistry educator. Based on ourown experiences, we have considered and discussed four fac-tors that we think partly explain why some medical studentshave unfavorable opinions about biochemistry (Table 1). Wehope that our discussions could stimulate similar discussionsamongmedical students and biochemistry educators elsewhere.Medical Biochemistry Needs to Present New BiochemistryKnowledgeA large number of the students admitted to medical schoolsalready have undergraduate biochemistry education. But theexperiences of MA show that much of his medical biochem-istry materials are unnecessarily taught in ways and depthsimilar to those in his undergraduate biochemistry courses.We suggest that medical biochemistry should incorporate stu-dents’ previously learned knowledge with medical applica-tions and fill in the gaps with new knowledge. For example,instead of re-teaching medical students to compare and con-trast the structures of DNA and RNA and ask them to explainthe difference between bases, one could discuss the biochem-ical basis of the “omics” that are profoundly changing medicalresearch and medicine. Also, instead of re-teaching medicalstudents the glycolysis pathway and asking them to memorizeminute details of it, one could discuss the Warburg effect andwhy the glycolysis pathway serves to produce not only ATP,but more importantly molecules that are important for themetabolic requirements of cancer cells [5]. One could evendiscuss the rational for selecting certain glycolysis enzymes forthe development of anti-cancer drugs [6]. This way of teachingis very likely to get students excited because it teaches themnew knowledge and the applications of biochemistry knowl-edge to not only today’s medicine, but also future medicine.Medical Students Need to Learn Medically RelevantBiochemistryIt puzzles students that medical biochemistry is generallypresented outside the context of diseases and medicine. Forexample, medical students are still taught how to use theGibbs free energy equation to calculate the free energy andequilibrium constant of reactions. We fail to see medicalM. Afshar : Z. Han (*)Department of Biochemistry and Molecular Medicine, the GeorgeWashington University School of Medicine and Health Sciences,Room 547, Ross Hall, 2300 Eye Street NW,Washington, DC 20037, USAe-mail: zyhan@gwu.eduMed.Sci.Educ. (2014) 24:339–341DOI 10.1007/s40670-014-0004-7relevance of being able or unable to do so. Therefore, likeothers [7], we also suggest that educators need to focus onteaching medical biochemistry in ways that show medicalrelevance. To us, medically relevant biochemistry is one thatgives students just enough information to be able to under-stand the basic mechanism of why a biochemical defect resultsin a disease and potential avenues of diagnosis and treatment.We admit that this is not an easy task, because so muchbiochemistry is about chemical formula, reaction mecha-nisms, pathways, and seemingly unrelated schemes that aretoo far detached from living human body functions, such asblood flow or heart beats; furthermore, because medical stu-dents take biochemistry prior to having any medical knowl-edge and hence it is extremely difficult for them to relatebiochemistry to diseases by themselves as MA can tell fromhis personal experience. Nevertheless, it appears that moststudents can effectively learn and understand medical appli-cations of biochemistry if the applications are presented tothem in contextualized ways through uncomplicated medicalcases. For example, students could easily see the biologicalimportance and medical relevance of the Vmax and km ofglucokinase if they are shown real life cases of diabetes causedby mutations that alter the Vmax and km of glucokinase [8].Therefore, we suggest a way of teaching medical biochem-istry. To do so, medical biochemistry educators need first todefine core concepts and biochemical principles that teachersand students could review (or relearn) in a short period. Theeducator will then teach new concepts and medical applica-tions of biochemistry, in an in-depth fashion, via a series ofcarefully designed PBL (problem-based learning) or CBL(case-based learning) modules [9]. The in-depth teachingshould aim to (1) stimulate personal cognitive processes tofirst understand concepts and then connect concepts to con-struct knowledge structures, and (2) teach students to applytheir knowledge to new situations and solve new problems.This way of teaching promotes lifelong learning, open inquiry,and critical thinking capability that physicians should have[10, 11].Alternatively, medical biochemistry could be taught invarious way that integrate basic and clinical sciences that havebeen or are being adapted by medical schools worldwide[12–14]. Imagine the following scenario in an integrativecurriculum. A biochemist starts the day by teaching studentsthe biological roles of cholesterol, its synthesis, absorption,transportation, and disposition and how alterations in any ofthese processes change the laboratory values of the blood lipidtest. The pathologist then continues by teaching the diseaseprocesses that result from dysregulation of the aforementionedevents involving cholesterol. The nutritionist follows up byteaching dietary management of cholesterol-related disorders.Finally, the pharmacologist ends by discussing various treat-ment options and potential for future therapies. This integra-tive teaching allows students to see cholesterol metabolism inrelationship to diseases and medicine from different perspec-tives without any delay.Teaching of Medical Biochemistry Should Not RevolveAround Board RelevanceSome students seem to like the idea of learning just “boardexamination relevant” materials. As such, they simply wantbiochemistry to be presented to them in bullet points formatthat shows “key words connections” that are easy to recallduring board examinations. This is a bad idea. Since boardexaminations assess a physician’s minimum competencies,we should not set the bar to the height of minimum compe-tencies and limit ourselves to teaching and learning just aminimal amount of materials for passing examinations. Webelieve, for example, that it is not enough that physiciansprescribe nucleoside analog-derived drugs, such as AZT, totreat HIV/AIDs—they should be able to articulate the bio-chemistry underlining the action mechanisms of these drugs.What we do not want is to produce physicians who can passthe board examinations with knowledge deficiencies and whoare unable to critically read and understand the sciences in thearticles published in medical journals, such as the Journal ofClinical Investigation, The Lancet, or the New England Jour-nal of Medicine.We Must Minimize Rote Memorization of Materialsand Make Information StickNeedless to say, students can attest that they have to memorizea huge amount of biochemistry materials. However, rotememorization is not synonymous to learning and understand-ing of the materials and produces learning fatigue. In the era ofusing pocket devices to instantly gain access to ubiquitousinformation, we should stop asking students to memorize avast amount of details, such as the minute details in themetabolic pathways, as long as it does not reduce the qualityof educational outcome. Instead, we should teach studentshow to conceptualize metabolic pathways with an emphasisTable 1 Factors negatively affecting medical students’ interest inbiochemistry1. Medical biochemistry often repeats the materials of undergraduatebiochemistry2. Medical biochemistry is presented mostly outside the context ofmedical relevance3. There is a large portion of the material that seems irrelevant to boardexaminations4. Medical biochemistry requires too much rote memorization that doesnot last long340 Med.Sci.Educ. (2014) 24:339–341on the biological roles of metabolic pathways and their inter-connection in the context of physiology and diseases. Then,we test the students’ understanding of the metabolic pathwaysand their interconnection by assessing whether they knowwhere and what information to look for in the metabolicpathway charts when solving problems. Thus, it is best, forexample, if a student knows how to diagnose a metabolicdefect that causes methymalonic acidemia using a metabolicpathway reference. This idea was proposed by Professor Ed-ward J. Wood 23 years ago, and he suggested then that itwould be better if we stop “asking students to rememberdetailed information [of a metabolic pathway], to reproduceit accurately under stressful, time-limited [examinations] con-ditions, and in competition with their peers [15].”Equally important, biochemistry needs to be taught inways that stick with students—the stickier the better—toreduce rote memorization. There are many ways to makethings stick [16], and it requires personalities, presenta-tion styles, use of vivid and sticky examples, clarity, andeven something that shocks [16]. For example, theshocking case of a 66-year-old “man” who turns out tobe genetically a woman with Turner’s syndrome plusvirilising 21-hydroxylase deficiency should allow stu-dents to visually understand the function and biologicalsignificance of the 21-hydroxlyase in the context ofsteroid synthesis [17]. Stories like this one should grabstudents’ attention, induce students’ curiosity and inter-est, unfold medical/biochemical investigative events be-fore students, vividly relate biochemistry to medicine,and will stick!In summary, medical biochemistry needs to highlighthow biochemistry applies to medicine, minimizes rotememorization, and stick with students. The best outcomeshould be one that highlights the connection betweenmedical biochemistry and its clinical applications. Theultimate goal of medical biochemistry, in our opinion,should be to provide students with fundamental biochem-istry concepts and principles that serve as a knowledgefoundation enabling them to better study and understandthe complexities of diseases and medicine. Teaching bio-chemistry concepts and principles to students should beaimed at helping the students to become scientificallyliterate so that they will gain the ability to becomeindependent learners in the future, and be able to criti-cally read and understand biomedical literatures, partici-pate in biomedical research projects, and evaluate claimsof efficacy and safety of new therapeutic strategies. Thiswill help students become the best doctors that they canbe, and provides the best care for patients throughouttheir careers.Acknowledgments We thank Dr. Rakesh Kumar for bringing us to-gether to discuss issues concerning teaching and learning biochemistry inthe medical school. ZH thanks Drs. Mark S. Elliott and Glen A. Walkerfor many stimulating discussions about teaching medical biochemistry.Open Access This article is distributed under the terms of the CreativeCommons Attribution License which permits any use, distribution, andreproduction in any medium, provided the original author(s) and thesource are credited.References1. Clack GB (1994) Medical graduates evaluate the effectiveness oftheir education. Med Educ 28(5):418–4312. Ebomoyi MI, Agoreyo FD (2007) Preclinical students’ perceptionsof their courses and preclinical specialty choice. J Med and BiomedRes 6(1–2):47–583. Watmough S, O’Sullivan H, Taylor D (2009) Graduates from atraditional medical curriculum evaluate the effectiveness of theirmedical curriculum through interviews. BMC Med Educ 9:64–704. Brass EP (2009) Basic biomedical sciences and the future of medicaleducation: implications for internal medicine. J Gen Intern Med24(11):1251–12545. Heiden MGV, Cantley LC, Thompson CB (2009) Understanding theWarburg effect: the metabolic requirements of cell Proliferation.Science 324:1029–10336. Nam SO, Yotsumoto F, Miyata K, Shirasu N,Miyamoto S, Kuroki M(2013) Possible therapeutic targets among the molecules involved inthe Warburg effect in tumor cells. Anticancer Res 33:2855–28607. Fulton TB, Ronner P, Lindsley JE (2011)Medical biochemistry in theera of competencies: is it time for the Krebs cycle to go? Med SciEduc 29(1):29–328. NJølstad PR, Søvik O, Cuesta-Muñoz A, Bell GI et al (2001)Neonatal diabetes mellitus due to complete glucokinase deficiency.New Engl J Med 344:1588–15929. Srinivasan M, Wilkes M, Stevenson F, Nguyen T, Slavin S (2007)Comparing problem-based learning with case-based learning: effectsof a major curricular shift at two institutions. Acad Med 82:74–8210. Irby D, Cooke M, O’Brien BC (2010) Call for reform of medicaleducation by the Carnegie Foundation for the advancement of teach-ing: 1910–2020. Acad Med 85:220–22711. Prober CG, Heath C (2012) Lecture halls without lectures—a pro-posal for medical education. New Engl J Med 366:1657–165912. Davis MH, Harden RM (2003) Planning and implementing an un-dergraduate medical curriculum: the lessons learned. Med Teach 25:596–60813. Harden RM (2000) The integration ladder: a tool for curriculumplanning and evaluation. Med Educ 34:551–55714. Bandiera G, Boucher A, Neville A, Kuper A, Hodges B (2013)Integration and timing of basic and clinical sciences education.Med Teach 35:381–38715. Wood EJ (1990) Biochemistry is a difficult subject for both studentand teacher. Biochem Educ 18(4):170–17216. Heath C, Heath D (2007) Made to stick: why some ideas survive andothers die. Random House, New York17. Lee KF, Chan AOK, Fok JMC, Mak MWH, Yu KC, Lee KM, ShekCC (2013) Late presentation of simple virilising 21-hydroxylasedeficiency in a Chinese woman with Turner’s syndrome. HongKong Med J 19:268–271Med.Sci.Educ. (2014) 24:339–341 341

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Teaching and Learning Medical Biochemistry: Perspectives from a Student and an Educator

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