Narratives as Active Learning Strategy to Emphasise the Clinical Relevance of Enzymology in Medicine

Maya Roche¹, K Indira Adiga², Akshatha Ganesh Nayak³, Ronald Aloysius Roche⁴

¹ Professor, Department of Biochemistry, Melaka Manipal Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India.
² Professor, Department of Biochemistry, Melaka Manipal Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India.
³ Senior Grade Lecturer, Department of Biochemistry, Melaka Manipal Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India.
⁴ Professor, Department of Microbiology, Malabar Medical College, Kerala University of Health Sciences, Calicut, Kerala, India.

NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR: Dr. Maya Roche, Professor, Department of Biochemistry, Melaka Manipal Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India.
E-mail: maya.roche@manipal.edu

Introduction

Student learning is dictated by the learning environment rather than the inherent qualities of the learner. Mode of curriculum delivery heavily influences the learning environment and pushes the learner towards rote learning or meaningful learning. In every curriculum, there are areas which are perceived by students as unappetising and demanding. In biochemistry, enzymology is not a favourite among students since it entails learning kinetics and related equations and graphs. However, enzymology is important in the medical curriculum because of its clinical relevance in the diagnosis, prognosis and treatment of diseases. The present study employs an active learning strategy using a themed narrative and case scenarios to make the learning experience more interesting and meaningful.

Aim

The objective of this study was to revise and integrate the core concepts in ‘enzymology’ and to bring home the clinical relevance of enzymology in medicine. In addition, the study would also facilitate active learning, thus promoting knowledge retention.

Materials and Methods

A narrative on enzymology with specific numbered blanks, to be filled in by students was designed. Five case scenarios containing pictures and text, highlighting the clinical aspects of enzymology were constructed and validated. MBBS students (n=82) of the first year were asked to fill in the gaps in the narrative. Case scenarios were narrated to the students using PowerPoint slides containing pictures and text. Students responded to specific questions relating to the case scenarios. The marks obtained in both the activities were tabulated and students’ opinion on the activity based on predefined indicators was assessed using a questionnaire.

Results

Students (43%) scored distinction marks (>75%) in the narrative on enzymology. They opined that it helped them to recall and integrate (81%) and retain knowledge (88%). They also felt that case scenarios were clinically relevant (82%) and helped to bridge the gap between theory and actual practice of enzymology in medicine (85%).

Conclusion

Narratives and case scenarios can be used effectively to improve learning by medical students, especially when the subject matter is not easy to comprehend and is perceived as challenging.

Introduction

The way a student approaches learning is not determined by the inherent qualities of the learner. On the contrary, an acquired trait or strategy dictated by the learning environment can influence it dramatically [1-3]. If the right kind of approach is implemented to promote student learning, one can bring about a sea change in the way a learner learns. It is well-known that undergraduate science education falls short often times in imparting core concepts to students [4,5] as also the case in medical schools in India [6]. In this context, it is important for educators to involve students with the content of the curriculum in numerous ways. Teachers should induct a holistic approach, reduce passive modes of pedagogy and create an environment for active learning [7]. Numerous active learning strategies [8-10] are in use in various curricular contexts. Many of them involve social constructivism where students learn from their peers [11].

The case in point here is Melaka Manipal Medical College (MMMC) which hosts a twinning programme in medicine with 5 semesters in the campus at Manipal, India and the subsequent five in the campus at Melaka, Malaysia. It follows an integrated curriculum where anatomy, physiology and biochemistry are taught in the first two semesters. Curriculum delivery at MMMC is predominantly passive, since it is lecture driven. However, there is a smattering of Problem-Based Learning (PBL), Case-Based Learning (CBL) and Self-Directed Learning (SDL) which contribute to the active learning component.

Enzymology is a vast area of biochemistry and deals with the study of enzymes, with applications in biotechnology, industry and medicine [11]. In the medical curriculum, enzymology is a clinically relevant core area dealt within the subject of Biochemistry. A medical student encounters numerous enzymes and the reactions catalyzed by them in practically every pedagogic activity in biochemistry. This is because of the ubiquitous presence of enzymes in all cellular and extracellular compartments of the body [12]. In the MBBS curriculum of medical schools in India, the topic of enzymology is largely taught en bloc, in the first few weeks of the first semester. Here, many of the general aspects of enzymes such as classification, kinetics and regulation are taught which often at times is daunting for the students. The curriculum briefly touches upon the clinical significance of enzymes with reference to diagnosis, use of enzymes per se in treating diseases, enzyme inhibition to control and cure diseases. To demonstrate the relevance of enzymology in clinical settings [13] and to facilitate the use of this knowledge in clinical practice, it was thought worthwhile to design an activity which would not only make students revise the topic, but also bring into perspective the true clinical context where knowledge of enzymes would be drawn upon by a practicing physician. It was thought that the active learning strategy discussed here would not only boost enthusiasm to learn the topic but also motivate students to learn better. The current work was done with the aim of revising and integrating the core concepts of enzymology using narratives to enhance active learning through problem solving to promote knowledge retention.

Materials and Methods

This cross-sectional study included all students of the MBBS programme (n=82) at MMMC (Manipal campus), Manipal Academy of Higher Education in the first semester of their course after they were exposed to a series of lectures on enzymology. The activity was planned as an exercise in formative assessment and was conducted during a time slot allotted for revision of course content. The details of the design of the activity were submitted to the Institutional Research Committee which approved it. Informed consent was taken from students and they were also informed in advance that the marks obtained in the activity would not contribute to their internal assessment score. This themed activity was entitled ‘Enzym Explorica’ and its design, execution and analysis of results spanned three months from June to August 2018. The activity consisted of two parts. The first part consisted of a comprehensive narrative entitled ‘I am a magician’. This had specific numbered blanks to be filled in by students. The narrative related to all aspects of enzymology such as classification, kinetics, regulation, isoenzymes, diagnostic applications and use of enzymes in treatment of diseases, taught earlier in lectures. Students were given a response sheet with numbers representing the gaps in the narrative and asked to fill in the blanks with their responses. After collecting their response sheets, the correct answers for the gaps in the narrative were discussed for knowledge consolidation. Each correct answer was awarded 1 mark. There was no negative marking. The marks obtained were tabulated, expressed as percentage and graded as follows: 75% and above-distinction, 61 to 74%-first class, 50 to 60%-second class and below 50%-fail.

For the second part of the activity, five case scenarios highlighting the clinical aspects of enzymology were designed first in the text format. These were subsequently converted into a format containing pictures and text using Power point 2013, with one slide representing a single case. Each slide contained different components of the case scenario, such as case history, clinical signs and symptoms, physical examination findings, investigations and treatment. The case scenarios also contained additional information not dealt within lectures. The faculty estimated by trial that, each case scenario would require approximately 15 minutes for presentation, followed by gathering responses from students and discussion of novel information. Hence, the faculty narrated the case scenarios in sequence by progressive disclosure of different components of each case. Following discussion of unfamiliar terminology or information, a set of specific questions on each case was given to the students and their responses collected individually.

Students’ opinion on the entire activity was assessed using a pre-validated questionnaire developed for this particular study, (validated by the faculty of Medical Education Department of the University) with 12 items on a five point Likert Scale (from strongly disagree=1 to strongly agree=5). The questionnaire consisted of two domains, cognitive skills and attributes of the activity. Agree and strongly agree responses were summated and disagree and strongly disagree were summated separately while calculating the percentage of responses for each item. Additional suggestions or comments to improve the activity were also gathered using the questionnaire.

Results

[Table/Fig-1] shows the narrative on enzymes ‘I am a magician’. There were a total of 64 blanks which amounted to 64 marks. [Table/Fig-2] corresponds to the marks scored by the students in this activity. It was heartening to see that a good number of students scored distinctions (n=35, 43%) and first class (n=32, 39%). The questions [Table/Fig-3] related to the case scenarios https://drive.google.com/open?id=16C3MqZVITMxdSAl6RhW2mMYvYh3jCfDD on enzyme deficiency or the diagnostic or therapeutic enzymes, elicited correct responses to the extent of 72%. [Table/Fig-4] shows the questionnaire used to collect feedback on the activity. Students when asked about their exposure to developing cognitive skills through this activity felt that the study enhanced their self-learning ability (86%). They also reiterated that such activities helped them activate prior knowledge (71%) and wished that such activities be done on various other topics in Biochemistry to enhance and retain students’ knowledge (88%). Regarding attributes of the activity measuring the suitability of the content and design, students unanimously agreed that the activity as a whole was well-planned (98%), the narrative on enzymes was well-designed (91%), case scenarios were clinically relevant (82%) and helped bridge the gap between theory and actual practice of enzymology in medicine (85%). When asked for suggestions for improving the activity, some felt that for the discussion on case scenarios, students could have been divided into groups to make the session more interactive. Overall, they opined that the activity was interesting and increased their motivation to learn enzymology.

[Table/Fig-1]:

Narrative on enzymes ‘I am a magician’

I am a magician
I am a magical child born into a large family. I have innumerable brothers and sisters. Catalyzing biochemical reactions is our business. We……..1………….(increase/decrease) the rate of chemical reactions. We are……2…….. (changed/unchanged) at the end of the reaction. So we……3…… (can/can’t) be recycled. We can carry out reactions at normal body temperature at an appropriate rate. We bind to……4……and convert them to……5……….. Sometimes we can catalyze reactions in both directions, ………6……… and backward, and these are called………7………reactions. Many times we need organic molecules called………8………….. or inorganic ions called………9……. to help us in our work. When we are bound to these molecules we form a complete entity called………10…………. We are divided into six classes, depending on the kind of reactions we catalyze. These classes are listed below according to the order of classification. …………11……………….…………12…………………………13……………….…………14……………....…………15…………………………...16………………The rate at which we catalyze reactions is affected by three factors. They are…………17……….,………18…………. and……………19………….. We enhance the formation of ………20………state of the substrate by………21……activation energy. We provide catalytic groups, we stabilize the………22………state and thus increase the rate at which substrate is converted into products. In the process, we…….23…… (do/don’t) change the free energy associated with reactants or products We have a special set of amino acids in our structure which forms the active site, which has two parts the……………24……………site and the ………25………site. The substrate concentration determines how fast the reaction happens. As substrate concentration……26……….. velocity increases up to a maximum. This is called………27……….. Further increase in substrate concentration will not change the velocity of the reaction. The substrate concentration [S], at which the reaction velocity is half the maximum is called………28….….. . If we have a high……29….., then we bind with……30…….. affinity to the substrate and vice versa. When [S] is much less than Km, the velocity of the reaction is approximately proportional to substrate concentration and it is a……31……order reaction. The rate of the reaction is independent of substrate concentration when Vmax is achieved and so it is a……32….…. order reaction. The temperature of the reaction mixture affects us. In humans we are optimally active at the body temperature. Normally, we undergo………33……. at high temperatures, losing our activity. All our family members are also sensitive to the hydrogen ion concentration and undergo…………34….…. when pH is altered. Hydrogen ion concentration in the medium affects ionic states of our substrates……35…the catalysis. Under physiological conditions, activity of some of us can be regulated. Then, we are referred to as………36………enzymes. When regulation occurs very fast, within seconds or minutes (short term), our quantity is…………37…………… (changed/unchanged). Short term regulation occurs by two modes. First one is…………38…………., in which effectors bind to the allosteric sites by ………39……….. bonds and affect our activity. Second one is…………40…………, in which we are phosphorylated or dephosphorylated, thereby inter-converting us to active or inactive forms. During long term regulation of our activity, our quantity is increased by a process called………………41…………or decreased by……………42 Rate of our reactions in the body are decreased by inhibitors which are very often drugs/poisons that get introduced into system. Inhibition of our activity occurs mainly by two mechanisms…………43……………, and……44………. In the first category, inhibitor competes with our substrates for binding to the………45…….site. In the presence of this inhibitor, our Vmax is ……..46………. and the Km is ………47………In the second category, inhibitors………48…….. (compete/do not compete) with the substrate for the substrate binding site. They can even bind to me when I am bound to my substrate. Here, the Km of the reaction is………49……… (changed/unchanged), but the Vmax…………50………. Our presence in ………51…….. indicates the destruction of specific tissues. So we are estimated in different clinical conditions to help the doctors to diagnose organ damage. Following are my cousins who are estimated when damage to various organs (indicated in parenthesis) are suspected.…………52. 53…………… (Heart disease, Myocardial infarction) …………54, 55, 56…………… (Liver disease)…………57………….. (Bone disease) …………58………….. (Prostatic carcinoma)…………59, 60………….. (Acute pancreatitis) I can exist in different forms in different tissues catalyzing the same chemical reaction. In that case my different forms are called………61………When I convert creatine to creatine phosphate in the brain, heart and muscle, I am called,……62……….,……63……….,………64………… respectively. All the magical things I do, when you are awake and when you are asleep, when you feed and when you starve, keep you fit and healthy to keep a smile on your face, day after day. I am your true friend in every situation. Let’s hope our friendship is eternal and endures the test of time.

I am a magician

I am a magical child born into a large family. I have innumerable brothers and sisters. Catalyzing biochemical reactions is our business. We……..1………….(increase/decrease) the rate of chemical reactions. We are……2…….. (changed/unchanged) at the end of the reaction. So we……3…… (can/can’t) be recycled. We can carry out reactions at normal body temperature at an appropriate rate. We bind to……4……and convert them to……5……….. Sometimes we can catalyze reactions in both directions, ………6……… and backward, and these are called………7………reactions. Many times we need organic molecules called………8………….. or inorganic ions called………9……. to help us in our work. When we are bound to these molecules we form a complete entity called………10…………. We are divided into six classes, depending on the kind of reactions we catalyze. These classes are listed below according to the order of classification. …………11……………….…………12…………………………13……………….…………14……………....…………15…………………………...16………………The rate at which we catalyze reactions is affected by three factors. They are…………17……….,………18…………. and……………19………….. We enhance the formation of ………20………state of the substrate by………21……activation energy. We provide catalytic groups, we stabilize the………22………state and thus increase the rate at which substrate is converted into products. In the process, we…….23…… (do/don’t) change the free energy associated with reactants or products We have a special set of amino acids in our structure which forms the active site, which has two parts the……………24……………site and the ………25………site. The substrate concentration determines how fast the reaction happens. As substrate concentration……26……….. velocity increases up to a maximum. This is called………27……….. Further increase in substrate concentration will not change the velocity of the reaction. The substrate concentration [S], at which the reaction velocity is half the maximum is called………28….….. . If we have a high……29….., then we bind with……30…….. affinity to the substrate and vice versa. When [S] is much less than Km, the velocity of the reaction is approximately proportional to substrate concentration and it is a……31……order reaction. The rate of the reaction is independent of substrate concentration when Vmax is achieved and so it is a……32….…. order reaction. The temperature of the reaction mixture affects us. In humans we are optimally active at the body temperature. Normally, we undergo………33……. at high temperatures, losing our activity. All our family members are also sensitive to the hydrogen ion concentration and undergo…………34….…. when pH is altered. Hydrogen ion concentration in the medium affects ionic states of our substrates……35…the catalysis. Under physiological conditions, activity of some of us can be regulated. Then, we are referred to as………36………enzymes. When regulation occurs very fast, within seconds or minutes (short term), our quantity is…………37…………… (changed/unchanged). Short term regulation occurs by two modes. First one is…………38…………., in which effectors bind to the allosteric sites by ………39……….. bonds and affect our activity. Second one is…………40…………, in which we are phosphorylated or dephosphorylated, thereby inter-converting us to active or inactive forms. During long term regulation of our activity, our quantity is increased by a process called………………41…………or decreased by……………42 Rate of our reactions in the body are decreased by inhibitors which are very often drugs/poisons that get introduced into system. Inhibition of our activity occurs mainly by two mechanisms…………43……………, and……44………. In the first category, inhibitor competes with our substrates for binding to the………45…….site. In the presence of this inhibitor, our Vmax is ……..46………. and the Km is ………47………In the second category, inhibitors………48…….. (compete/do not compete) with the substrate for the substrate binding site. They can even bind to me when I am bound to my substrate. Here, the Km of the reaction is………49……… (changed/unchanged), but the Vmax…………50………. Our presence in ………51…….. indicates the destruction of specific tissues. So we are estimated in different clinical conditions to help the doctors to diagnose organ damage. Following are my cousins who are estimated when damage to various organs (indicated in parenthesis) are suspected.…………52. 53…………… (Heart disease, Myocardial infarction) …………54, 55, 56…………… (Liver disease)…………57………….. (Bone disease) …………58………….. (Prostatic carcinoma)…………59, 60………….. (Acute pancreatitis) I can exist in different forms in different tissues catalyzing the same chemical reaction. In that case my different forms are called………61………When I convert creatine to creatine phosphate in the brain, heart and muscle, I am called,……62……….,……63……….,………64………… respectively. All the magical things I do, when you are awake and when you are asleep, when you feed and when you starve, keep you fit and healthy to keep a smile on your face, day after day. I am your true friend in every situation. Let’s hope our friendship is eternal and endures the test of time.

[Table/Fig-2]:

Distribution of students based on marks scored in the narrative ‘I am a magician’.

[Table/Fig-3]:

Questions on the case scenarios.

Case-1:

What is the enzyme defect in the child?

What do hematology results indicate?

What do you conclude from the results of the biochemical tests done on the blood and urine sample of the patient?

Any other disease where you see a similar clinical presentation?

Case-2:

What is the relevance of learning enzymology in this case?

Name the serum enzyme/non-enzyme markers which can be estimated in this patient.

What is the enzyme used for thrombolytic therapy in this case?

What are the lifestyle modifications the patient has to adopt?

Case-3:

Name the enzyme defect in this case?

How does hemin and glucose loading help this patient?

What is the basis for the development of clinical symptoms?

Case-4:

Name the defective enzyme.

How do serum enzyme markers help to differentiate this condition from others with jaundice?

Explain the basis for the appearance of Heinz bodies in the peripheral smear.

Why does the urine appear red in this case?

Case-5:

Why does the patient appear icteric?

Name the serum enzyme marker estimated in this case?

What is the basis of development of edema?

[Table/Fig-4]:

Student feedback on ‘Enzym Explorica’.

Items	*Strongly disagree+Disagree	*Neutral	*Agree+Strongly agree
Cognitive skills:
Narrative on enzymes helped us recall and integrate various aspects of enzymes	2	17	81
This study enhanced our self-learning ability	2	12	86
Helped us activate our prior knowledge	7	22	71
Enhanced problem-solving ability	6	16	78
Activities like this should be done on various other topics in Biochemistry to enhance and retain students’ knowledge	3	9	88
Attributes of the activity:
Activity as whole was well planned	0	2	98
Narrative on enzymes was well designed	2	7	91
The narrative covered most of the aspects of enzymology taught in class.	2	10	88
Case scenarios were well structured	1	7	92
The difficulty level of the cases were appropriate for 1st semester MBBS students	4	12	84
Case scenarios were clinically relevant	6	12	82
The activity helped bridge the gap between theory and actual practice of enzymology in medicine	5	10	85

*Indicates the percentage of students answering each statement in the questionnaire

Any other suggestions/comments:

Discussion

It is well known that active learning promotes consolidation and retention of knowledge [14-16]. In pedagogic environments where active learning is not the mainstay of curriculum delivery, it is imperative that strategies for active learning be developed and implemented. These can be in the form of narratives [17-19] and can be used as a mode of assessment [20]. In our institution, the topic of enzymology is delivered to undergraduate medical students, in a series of lectures which are dense with information. It has been noticed over the years that enzymology is not a topic that is very popular with students and therefore engaging the medical student with the course content in this critical area through pedagogic innovations holds the key for a better learning experience. The objective of the narrative ‘I am a magician’ was primarily to integrate the entire topic of enzymology as taught in the curriculum. The performance of students in this activity indicates that, they were able to bring forth facts in a comprehensive manner and were able to correlate different aspects of the topic as evidenced by the response to the questionnaire. Also, the students in this batch were novices who experienced a totally new pedagogic initiative as narratives, which probably explains the fact that only 43% of students scored distinctions. To achieve better outcomes, such an activity may have to be repeated at different time points with suitable content, as the students’ progress through the course.

The second part of the activity which was case-based consisted of case scenarios meant for training students to recognise signs and symptoms; correlate them with clinical examination and laboratory findings to diagnose the case. The cases which were designed for this activity touched upon different aspects of how the knowledge of enzymes is applied in clinical practice. In modern day evidence-based medicine, to diagnose a case correctly, the clinician relies heavily on laboratory tests, consequent to which the course of therapy is decided. This in turn determines patient outcome. The clinician is confronted with a battery of tests from which he is expected to make an intelligent choice [21]. In the developing world, where a large percentage of the population is not covered by medical insurance, every penny spent on health care by the patient counts. Hence, it is even more significant that medical students are trained appropriately to be able to order the tests relevant to the case, including the ones on the enzyme panel. It thus addressed a core competency required to be mastered by a medical student. Though the subject matter of the cases was familiar to the students, the inclusion of several new signs, symptoms and clinical findings made the cases look quite novel. The students did take a few minutes to understand the case, but they did catch the leading clues in each case and were able to give coherent answers. Though it was formative in nature, it has the potential to be converted into a purely summative form of assessment. The fact that students scored 72% marks in this part of the activity was commendable. The responses of some students as ‘neutral’ or ‘disagree’ to some of the items in the questionnaire may be attributed to the fact that they had just completed 8 weeks of the MBBS course of the first year. It was also their first experience in active learning in a subject area which is generally perceived as unappetizing. Though they had been advised to revise the content of lectures on ‘enzymology’, before their participation in ‘Enzym Explorica’, few of them had come unprepared and as such might have lost out on the reinforcement of knowledge which happens through active learning. This fact might also have contributed to some ‘disagree’ responses since some students have added general comments to that effect in the feedback. From the teacher’s side, designing a pedagogic initiative, such as ‘I am a magician’ requires a creative bent of mind. Designing case scenarios keeping in mind an appropriate level of difficulty are time consuming and challenging. However, as evidenced by previous studies, the outcome of the present study also indicates numerous benefits for the learner. These include, contextualising learning, helping students to transition into professionals [22], engaging learners actively and boosting memory leading to long term acquisition of knowledge [23-25]. Faculty’s involvement in such an endeavor gives learning a positive dimension and the thrust in this direction is definitely worth the time and the trouble.

Conclusion

The study establishes the fact that narratives are useful tools for enhancing learning in medicine. Besides engaging learners actively, they provide a context in which the learning needs to be done. The fact that students requested for more such activities, is proof that the activity made an impression on their mind. If medical schools have to impart knowledge that addresses the needs of society, they need to adopt and implement new teaching strategies. Collaboration between teachers in planning and executing the pedagogic initiatives is the foundation for engaging students in meaningful learning. With reference to the Indian context, authors strongly reiterate that medical schools should lay more emphasis on active learning, particularly by problem-solving to empower students to be better doctors.

*Indicates the percentage of students answering each statement in the questionnaireAny other suggestions/comments:

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