degree, generally entitled BSc or Bachelor of Medical. Science (BMSc). In a five-year medical curriculum, this is usually undertaken between the second and ...
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A structured BMSc course in clinical biochemistry intercalated in a medical curriculum C G FRASER, MARGARET C K BROWNING, D B WALSH and C R PATERSON
Department of Biochemical Medicine Ninewells Hospital and Medical School Dundee, DD1 9SY, UK Introduction In most medical schools in the United Kingdom, it appears that didactic teaching of material of immediate relevance to the practice of medicine or to the understanding of pathophysiological processes forms the major component of the course. The extent to which medical students are encouraged to think for themselves, to criticise their teachers and to question established thinking in consequence remains somewhat limited. In some medical schools, however, students are more positively encouraged to develop critical and scientific attitudes. In a few, such as St Andrews, Oxford and Cambridge, the gaining of an honours degree is an essential step in the medical course. In many schools, compulsory project work or assignments are included in the curriculum in order to provide at least some exposure to critical thought and the methodology and difficulties of scientific research. The time available to the students for performance of such assignments varies from one year down to one month and in some medical schools, such as the University of Dundee, students are expected to carry out this work without any firm provision being made in the time-table. Despite this limitation, a remarkable number of students carry out work which provides real insight into scientific methods; such studies may also lead to their inclusion as full partners in a scientific publication. In an appreciable number of medical schools following the British Commonwealth pattern, an additional opportunity for training a small number of students in scientific attitudes is provided by the availability of an intercalated degree, generally entitled BSc or Bachelor of Medical Science (BMSc). In a five-year medical curriculum, this is usually undertaken between the second and third, or third and fourth years. In this way the students can complete their one or two year honours degree having completed three or four years of tertiary education. In the University of Dundee, intercalated BMSc courses are available in a wide variety of subjects including both preclinical and paraclinical disciplines. The departments offering these courses welcome the opportunity of covering their subjects in depth and of training students in scientific methods. In addition, departments often find that successful students return to the discipline after qualification; many medical graduates holding academic posts had their first exposure to scientific thinking in an intercalated degree course. The patterns of the courses vary greatly, some having a substantial didactic component using only literature reviews to BIOCHEMICAL EDUCATION 14(3) 1986
Ninewells hospital and medical school develop critical skills and other courses consisting predominantly of original research. We now report the development of a novel intercalated degree course in clinical biochemistry and outline the ways in which the conflicting priorities inherent in such a course were resolved.
Course Philosophy It was decided at an early stage that a research project involving original work and occupying half of the course time should be vehicle for the teaching of scientific thinking and critical skills. It was felt that a research project would provide insight into the practical difficulties of analytical techniques in a way that was not achievable in a didactic course and additionally that the students would learn to deal with the difficulties inherent in assessing the published literature, in setting up and performing experimental work, in analysing numerical data and in reaching conclusions which could be justified. It was agreed that, prior to embarking upon the project work, the students should attend a short, full-time course of seminars, demonstrations and practical work to ensure competent laboratory practice and to provide insight into the basic analytical skills and techniques used in a modern clinical biochemistry laboratory. During this course, students would also be shown the difficulties inherent in the correct interpretation of numerical laboratory results. Finally, it was agreed that the course should also include a part-time component to cover the more clinical aspects of the discipline. It was felt that this component should not be exhaustive but that a number of important principles should be highlighted and some major areas of current controversy explored. As far as possible, material which would be covered in the later parts of the traditional medical course was avoided. It was agreed that the course should extend over 36 weeks beginning in October, with the only break being a two week period after the tenth week of the course. This arrangement ensured use of the maximum possible time consistent with graduation at the end of the academic year within which the course was held.
126 Course Structure
Table 2 Content o f the clinical biochemistry course
Intensive course in analytical biochemistry This component of the course occupied the first eight weeks and its content is shown in Table 1. Some use was made of an existing departmental MSc Course in Analytical Biochemistry. Tutorial teaching, demonstrations and practical sessions were all used. In addition, during this period, each student prepared an essay to provide an initial stimulus to the competent use of the library and student originated discussion with informed m e m b e r s of staff. On the first occasion the course was run the subject matter of the essay was the laboratory and clinical problems associated with the introduction of clinical biochemistry tests in wards and clinics nearer to the patient. A review of approximately 2500 words was requested.
Section 1
10 hours
Section 2
8 hours
Section 3
16 hours
Section 4
10 hours
Biochemistry of pathological processes Inborn errors of metabolism, complement, chemical mediators, cell injury and repair Application of chemical pathology in disease Immunological disease, anaemia, gastrointestinal and liver disease, hypoxia and myocardial infarction Endocrinology and metabolism Endocrine function tests, gut hormones, thyroid, peptide and steroid hormones, congenital disorders, hormone receptors, pregnancy, diabetes mellitus, obesity Fluid balance and the kidney Clinical fluid homeostasis, proteinuria, acid-base balance, clearance, renal disease and its treatment
Table 1 Intensive course in analytical biochemistry Section 5 Section l
9 hours
Section 2
60 hours
Section 3
30 hours
Section 4
23 hours
Introduction to the course Role of clinical biochemistry, laboratory tour, terminology, use of the library, laboratory safety Principles of analysis Spectrophotometry, fluorescence chromatography, TLC, HPLC, gel chromatography, glc, flame emission, atomic absorption, ion selective electrodes, electrophoresis lmmunoassay techniques Units and radiation safety, counting, autoradiography, antigen-antibody reactions, immunodiffusion, immunoelectrophoresis, nephelometry, immunoassay including RIA, IRMA and ELISA, data-handling and curve-fitting Clinical biochemistry data handling Statistics, standardisation, specimen collection, reference ranges, biological variation, predictive value, analysis of literature
Clinical biochemistry course This course consisted of two to three formal sessions weekly and the subject matter is listed in Table 2. The subjects chosen to some extent reflect the interests of the staff available but the initial course on the biochemistry of pathological processes was novel and arranged specifically for this course. It represented an opportunity to introduce chemical pathology and show its relationship to the general pathology studied in the second year of the medical course. No attempt was made to cover every facet of clinical biochemistry in detail but the second part of this course was more recognisable as clinical biochemistry and took the form of detailed study of specific topics which illustrated the application of basic chemical pathology to the interpretation and understanding of human disease. Specialist extra-departmental speakers were invited and, on occasion, the students prepared essays prior to a tutorial or prepared talks which they gave to their colleagues; the content of such discussions was agreed in advance with the staff m e m b e r responsible for the topic. BIOCHEMICAL
EDUCATION
14(3) 1 9 8 6
8 hours
Mineral metabolism and nutrition Calcium and phosphate metabolism, trace metals, current controversies in nutrition
Project work During the first eight weeks of the course, students were provided with a list of available projects, each of which was presented as an abstract with a few key references. Each project was expected to include the development and evaluation of an appropriate method followed by its application in a clinical investigation. Students were expected to develop a critical approach both to the literature and to the analytical methodology. It was hoped that the results obtained would merit publication. Because the time available within the course was very limited, a strict timetable was issued in order to ensure that no student would be unable to complete the work in the available time. The projects were chosen during the first eight weeks of the course. The students were expected to provide a brief summary of their own proposals at ten weeks and these were discussed by the whole group with a tutor present. The first draft of the introduction was to be presented at 19 weeks and the first draft of the methods section at 23 weeks. The full thesis was to be submitted by the 36th week. In the first course held, the projects chosen included the determination of the prevalence of macro-amylasaemia using a polyethylene glycol precipitation test, the development of an H P L C assay for 7-dehydrocholesterol in skin, the role of zinc in the assay of the measured activity of serum angiotensin-converting enzyme and a study of thyroxine binding to serum proteins. Assessment
In the ninth week, assessment was made of the practical work done throughout the preceding weeks and of the essay mentioned earlier. An examination was held con-
127 sisting of four essay questions relating to the preceding course, together with a brief practical examination of a series of written short answer questions covering practical skills and laboratory calculations. It had been planned that the final course-work examination, consisting of two three-hour papers, one with short answers and one for essay questions, would be held during the 30th week of the course to allow the maximal amount of time for the students to prepare their theses without distraction. In the event, it did not prove possible to hold this formal examination earlier than the 32nd week. Marking of examination responses was performed by the staff members who set the question and the external examiner. The projects were assessed by one internal examiner, not otherwise involved in the course, and one external examiner. In addition, supervisors were asked to submit a report. The BMSc is an honours degree and was classified in the usual manner.
Resources The Department of Biochemical Medicine in Dundee is a joint University/Health Service Department and senior staff employed by both the University and the Health Service contributed extensively. In addition, staff from outwith the Department, particularly clinicians with special relevant expertise, took part from time to time. Examples of such individuals were a radiotherapist with a special interest ~in tumour markers and a clinical endocrinologist with a special interest in diabetes. Clinical Biochemists and Medical Laboratory Scientific Officers not directly involved with the course gave considerable help with the project work. Discussion The extent to which clinical biochemistry is taught in medical schools varies greatly. In the University of Dundee, the members of the Department of Biochemical Medicine contribute to undergraduate medical teaching in the second, third, fourth and fifth (final) years, through lectures, tutorials and bedside teaching. The major thrust in the limited time available is directed towards the competent interpretation of results obtained in patients. The limited time in the curriculum unfortunately does not allow significant expansion into the very necessary discussion of analytical techniques or of the principles of interpretation, except in the most elementary way. When there is severe competition for contact time in the medical curriculum, it is unlikely that the much increased amount of clinical biochemistry recommended by the International Federation of Clinical Chemistry t will be realised. Nevertheless, it seems important to us that a small number of medical undergraduates should be encouraged to consider the possibility of careers in clinical biochemistry and be provided with sufficient insight to allow a reasoned choice later. We believe that the course we have described may serve in this way much as previously prepared courses in microbiology and pathology frequently encourage students to return after qualification. BIOCHEMICAL EDUCATION 14(3) 1986
We recognised that there was a conflict between what was desirable for a 'vocational course' and what was required for an honours degree in a scientific subject. The course we have described was inevitably a compromise to some extent. On review of the first such course conducted, we now believe that the proportion of time used for formal teaching and practical work was probably too large, while that available for the project work was probably too small. Nevertheless, we feel that the pattern we devised may be of assistance to others planning the introduction of a similar intercalated degree course and the wider availability of such courses could make a real contribution to the recruitment of academically competent and well motivated medical graduates into biomedical research and clinical biochemistry.
Acknowledgements The very many members of staff of the Department of Biochemical Medicine who gave of their time are sincerely thanked, particularly Drs J D Baty, T E Isles, P E G Mitchell and J P Moody. Professors I W PercyRobb and P D Griffiths, the external and internal examiners, are thanked for their considerable efforts.
Reference 1Fraser C G, Zinder O, deCediel N, Porter C J, Schwartz M K and Worth H G J (1985) 'Guidelines (1985) for Teaching of Clinical Chemistry to Medical Students', J Clin Chem Clin Biochem 23 697-703
Reservoir Model of Metabolic Crossroads as a Teaching Tool in Enzyme Kinetics ENRIQUE CRESPO,* ALBERTO SOLS ° and ANTONIO SILLERO*
* Departamento de Bioqu#nica, Facultad de Medicina Universidad de Extremadura 06071 Badajoz, Spain and °Departarnento de Enzimologia del Instituto de Invest# gaciones, Facultad de Medicina Biom(dicas del CSIC y Departarnento de Bioquimica Universidad Aut6noma de Madrid 28029 Madrid, Spain Introduction In 1969 we developed a method to quantify the glyceraldehyde "metabolic crossroads. ''1 The method may be useful both for metabolic studies and as a pedagogic tool to teach enzyme kinetics. This last aspect of the problem has remained somewhat hidden probably due to the basic nature of the journal in which that work was originally published. The object of this article is to recall the existence of this procedure and to extend its application to allosteric enzymes. General Application A metabolic crossroads refers to the situation in which a metabolite may be transformed by more than one enzyme. Illustrative examples are the crossroads of acetylCoA, glucose-6-phosphate, pyruvate, glutamate, glycer-
