Planning an Objective and Need Based Curriculum: The Logistics with Reference to the Undergraduate Medical Education in Biochemistry

Purpose: The medical education is recently being transformed into several domains in order to adapt to the need and the value based academics which is required for the quality doctors who serve the community. Presently, the biochemistry curricula for the graduate students of medicine have been questioned by as many experts, because of their multiple lacunae. In this review, we would like to highlight the scenario which is related to the existing biochemistry curricula for graduate medical students, which have been followed in several medical schools and universities and we also hope to share our ideas for implementing objective and pragmatic curricula. Evidence based research, wherein the articles which are related to innovative teaching-learning tools are collected and the pros and cons which are related to the different methods analyzed in biochemistry point of view.

Conclusion: Rapid changes in the content of the curriculum may not be required, but a gradual introduction of the novel approach and the methods of teaching biochemistry can be adopted into the curriculum.

Currently, the undergraduate teaching curricula for medical students in several places are largely ‘Teacher centered’, with didactic lectures taking the lead because of the lesser number of teaching hours and the large number of students [1,2]. Worldwide, the curriculum is focusing more on a ‘student-centered’ approach rather than the traditional way of teaching, which is teacher centered [3]. Although, newer innovative teaching modules and curriculum designs have been adopted in various medical schools and universities, the perception of biochemistry is often considered to be vague by the medical students. This is mainly attributed to the complex chemical structures and the intriguing metabolic cycles. In order to alleviate this distress, a student-centered approach must essentially be adopted, that would focus on ‘problem solving’ rather than on ‘information gathering’ skills. To achieve this, we should implement a combination of different teaching and learning methods [4–6]. Hence, the present review was planned with a view to highlighting the problems which are prevalent in the current scenario and also to share our proposed ideas for implementing objective and pragmatic curricula, in order to make biochemistry interesting and meaningful for even an average undergraduate medical student.

The familiar misconception is that students should know biochemistry just to clear the I-MBBS course, so as to be relieved from the gate system (Medical Council of India) and also to clear the step I of USMLE. Instead, they should learn and appreciate the role of basic and clinical biochemistry in the day to day practice.

The key concepts which should be borne in mind prior to the designing and development of a curriculum include:

We should sincerely avoid giving too many details which pertain to the organic chemistry of biomolecules and its reactions [10]. Instead , we should strive to lay more emphasis on the metabolic and the nutritional roles of various biochemical reactions which are involved in health and disease e.g. Glycolysis in people with diabetes mellitus and in normal individuals. We should minimize the provision of details about the instrumentation techniques, which may not be applied by a vast majority of doctors who prefer the clinical disciplines and practice. However, the concepts on the applications of instruments and the interpretation of the laboratory results are mandatory for a clinician and they should be well addressed. We can teach the manifestation of diseases by providing the biochemical basis e.g. Cataract in galactosaemia is attributed to dulcitol.

This continues to be a grey area. The following is an example for illustrating when and how a student should be introduced to the clinical chemistry topics: What should be the level that should be taught in the pre-clinical year?

For example, regarding the inborn errors of metabolism, the basics can be taught in the first year curriculum and the details could be elaborated when they are posted in the paediatrics department. This can stimulate self-learning and enable the student to appreciate the relevance of the basic sciences. An in depth knowledge can be acquired if they choose to do post-graduation in biochemistry, internal medicine or related disciplines.

A medical student should first realize that biochemistry is being taught to enable him/her to understand the fundamentals of the treatment of diseased conditions.

For instance, the electron transport chain is being taught to make them understand the basis of mitochondrial myopathy and the effect of various poisons on the cellular respiration; and also to highlight the manner in which free radicals (highly reactive chemical species) are produced.

In metabolism, a greater importance should be given to explain to them as to what would happen if something goes wrong in a particular reaction which is involved in a metabolic pathway and why and when it goes haywire?

For instance, while teaching glycolysis, we could lay stress on the following points:

What are the major tissues where glycolysis takes place?

In which cellular organelle does glycolysis takes place?

Where and why glycolysis is regarded as important? What are the functions of glycolysis? When the body switches over from aerobic to anaerobic glycolysis, what are the consequences? We can also introduce the concept of lactic acidosis, a topic which is of great clinical interest. The next concept that is frequently ignored is INTEGRATION [11] [Table/Fig-1].

Integrated teaching affords a holistic approach, whereas the basic tenets of biochemistry should be discussed in the light of the applied and clinical subjects. A discussion on acid- base homeostasis could be viewed from the perspectives of a medical biochemist, a chemical pathologist and an internal medicine specialist. This could be horizontal as well as vertical. The major advantages of integration are that complicated things can be broken down gradually to the scenario at the molecular level and we can also reinforce the essential biochemical concepts before the students emerge as complete doctors [12], the curriculum should also help the students in solving the clinical problems [10]. Learning about metabolism and the metabolic changes in our body could be made more effective and interesting by integrating it with other modalities of teaching. A horizontal integration is made with the anatomy which pertains to the gross and the histology, as well as to the functional physiology. For example, learning about the cardiac markers of heart diseases is in the purview of the problem based tutorials. The students should have done a concurrent anatomical dissection of the thorax and they should be familiar with the anatomical relations of the heart. They should also listen to the associated lectures on cardiovascular physiology. All these inherent concepts are termed as the HYBRID CURRICULUM [13,14]. Through a vertical integration, the concepts in basic biochemistry could be integrated with other clinical disciplines, which can be facilitated by a systematic approach [15].

Example: Acid base chemistry (conventional and modern) could form the nuclei for the integration with the critical care and other specialists, as is managed in a tertiary healthcare setup.

The modern modalities of the integration:

Design the learning objectives Identify the clinical problems Store the resource in common retrieval for study.

The learning that takes place in a setting which is external to the educational centre is community based learning and here, the student teaches the community and in the process, acquires knowledge as well. There are 2 terms: community based education and community oriented education. In community based education, the students are introduced to the community facilities, namely community hospitals and general practices. Community oriented education is carried out outside the routine hospital, which highlights the plans and the objectives [16–18].

Primarily, the student, along with other facilitators, acquires knowledge about the society, the social taboos, and the lifestyles of different people in the rural and urban population settings. In view of the ever increasing private medical colleges in India and also because of the fact that the students who join are mostly from the affluent group, they don’t have a thorough knowledge about rural settings. Hence, community based teaching is deemed essential.

For example, the topics on nutritional biochemistry could be allotted to each student, wherein they will have to educate the community (Eg.Labourers or slum dwellers, etc.) Following this, their feedback could be obtained.

Advantages:

Disadvantages:

Elective teaching programmes:

‘A teaching module which is systematically designed as a proposal with key components and mandatory skills which have to be acquired for all students’.

e.g., Duke University and Stanford University follow the elective curriculum.

Advantages:

Disadvantages:

This method refers to the outcome based teaching with a provision for a clear curriculum map, which could be distributed to the teachers and the taught. In addition, this method facilitates a transparency which pertains to the information on clear and specific objectives that would enable in deciding when, what and how they should be taught. Furthermore, the time of their assessment should be made transparent [11,20].

Disadvantages:

Interference with the continuity of the teaching programme.

Suggestion: The subjects such as molecular biology and intermediary metabolism can be dealt with in this manner.

PBL uses carefully constructed problems as a context for the students to define their learning needs and for conducting self-directed enquiries. Integrate theory-practical; apply knowledge and skills to develop a solution to label a defined problem.

It serves as a stimulus in the process of acquiring new knowledge [20,21].

Disadvantages: It demands more manpower and time and is difficult if the teacher and the student lack enthusiasm when there is a large student strength [25].

Designing and implementing a curriculum module by using PBL can be supported by other teaching methods [24, 25].

Example:

[Table/Fig-3]:

The PBL cycle

[Table/Fig-4]:

Steps in problem based learning

A 12 years old boy complains of muscle fatigue while participating in a gym class. He has more trouble with the anaerobic activities and the blood analysis prior to his exercise. This indicates very little lactate production.

Which metabolic pathway is involved in the above condition?

The defect of which enzyme may lead to this condition and why?

Comment: This problem will help the student in understanding the significance of the aerobic and the anaerobic phases of metabolism and it will also enable a meaningful learning.

The Problem Based Learning (PBL) can facilitate the students in such a way that they can correlate with their own practice. Cognitive way of problem solving skills and also promotes collaborative and cooperative learning rather than competitive learning [13].

How to develop a PBL module and to implement it?.

A student centered, active learning approach which focuses on questioning critical concepts, and problem solving. It is often associated with the idea of “involve me and I understand” [26,27].

What question do the students have?

Topics?

What will be the time frame?

What will be the scope?

Will it facilitate tie-ups with other course works and how?

Learning objectives?

Media/resource/information needs?

Group works.

Question types:

[Table/Fig-5]:

Algorithm for development and Implementation of PBL Module.

It is factual, interpretative and evaluative and it should help in inferring, interpreting, transfering and hypothesizing.

The smaller groups of students in a team interact in a class to apply the contents to simple and complex problems [28].

Pre-class: An individual learns the assigned teacher specific content, which is co-ordinated by the team leader.

In the class: The team members apply themselves in a teacher specified content to a problem solving discussion. During the class, the student receives a frequent and an immediate feedback.

Example: We suggest that organ function tests can be better taught by TBL.

Any curriculum needs evaluation periodically by a set of experts [33,34]. The feed back from the students should be meticulously evaluated, because they are the ones who are going to apply biochemistry successfully in the realms of medicine. Additionally, the services of an experienced general practioner may also be called for and included in the expert committee.

[Table/Fig-6]:

The Steps in “Team Based Learning” process

The students should be encouraged to learn on how to use other learning resources e.g. Internet is an effective way in addition to the text books and class notes. e- resources based learning is a new and an emerging arena, which has a positive impact on learning biochemistry [2].

We are listing below, a few of the websites which may be useful for the students of biochemistry [Table/Fig-7].

Rapid changes in the content of the curriculum may not be required, but the gradual addition of a novel approach and the inclusion of effective methods in teaching biochemistry could be explored in medical schools and institutes, in order to acquire skillful and thoughtful medical professionals. This in turn, largely depends on the availability of manpower and other essential resources.

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