Farnsworth W Medio F Van Winkle L Mann D

196

Integrating Clinical Problem-solving Workshops and
Lectures in a Biochemistry Course
WELLS E FARNSWORTH, FRANKLIN MEDIO,
KENNETH NELSON,
DAVID MANN, DORIS
NORWELL and LON J VAN WINKLE
Chicago College of Osteopathic Medicine
Chicago, Illinois 60615, USA
Introduction
A major problem in medical education is the perceived
gap between the basic sciences and the clinical sciences.
This is intensified by an overemphasis on memorization of
facts in basic science courses. 1 In their exhaustive reviews
of strategies for biochemical education, Mehler 2 and
Wood 3 argue that the ultimate goal of teaching biochemistry should be to develop a student's problem-solving
skills. The teaching of biochemistry in medical schools has
been criticized for failing to provide students with learning
tasks that emphasize the relevance of biochemical information in solving medical problems. 2'3 The lack of clinical
applications may result in poor retention of biochemistry

and an inability to effectively utilize laboratory tests. 4
A number of programs have been developed to address
the issue of teaching the clinical aspects of biochemistry
through clinical correlations, 3'5 "wet labs ''6'7 and a combination of the two. 8 Wood 3 uses a small-group approach to
develop students' ability to think critically and communicate more effectively. At the Medical College of
Ohio, Saffran reports using live patients who are interviewed by a physician and students. The biochemist serves
as a 'facilitator' and generates a discussion of the
biochemical, anatomical and physiological aspects of the
case with the class. 5
Roon et al6 require medical students to perform
elaborate laboratory experiments designed to provide a
laboratory experience in clinical chemistry. They consider
the fundamental goals of medical education to include
"learning teamwork, colleagueship, peer review and an
ability to empathize with and understand colleagues and
patients". These experiments subtly emphasize cooperation instead of competition which may result in higher
individual learning. Garcia-Webb 7 stresses the importance of teaching attitudes and concepts not facts in a
clinical biochemistry course by showing that the analysis
of samples of body fluids can assist in patient management. Finally, Ragatz 8 has designed a series of clinical
correlation conferences. The conference periods are

variously used to (a) discuss patient laboratory data that
students have accumulated, (b) present cases from Montgomery's textbook, 9 and/or (c) listen to a clinical correlation lecture by a physician.
A major deficiency in all of these programs is that they
have not been designed to focus specifically on developing
students' problem-solving skills. Some medical schools,
such as McMasters University, Rush Medical College and
the University of New Mexico, have adopted a multidisciplinary 'Problem-Based Learning' curriculum. HowBIOCHEMICAL EDUCATION 16(4) 1988

ever, the large investment of resources and manpower has
made the implementation of such innovative curriculum
programs difficult. 1° This study reports the development
of a modified Problem-Based Learning approach to a
freshman biochemistry course at the Chicago College of
Osteopathic Medicine. The course uniquely combines
traditional lectures and clinical problem-solving workshops. This dual teaching strategy enables faculty to teach
basic biochemical concepts and principles as well as their
application to clinical cases.
The workshop's goal is twofold: (1) to develop students'
ability to solve clinical problems, and (2) to encourage
students to assume more responsibility for learning. The

workshop is designed to improve skills in (a) researching
clinical topics using the library and clinicians as resources,
(b) cooperating with peers in a group problem solving
process, (c) presenting concise oral reports, and (d) using
biochemical concepts in analyzing clinical problems.

Methods
The course is presented in the first two (11 weeks)
quarters of the Freshman year, and enrolls 100 students.
The didactic part of the course entails 5 fifty-minute
lectures each week. Seven predominately multiple-choice
examinations (C- and K-type format), given at spaced
intervals, and a final comprehensive 'mock board' exam
are used to test students on lecture material.
For the workshops, the class is divided into 8 groups (4
with 12 and 4 with 13 students); two for each faculty
member. Each group meets with the same faculty member
for two hours every week. Each year, eight 'patient cases',
have been developed. They are selected to complement
and be approximately synchronous with the subject

matter being presented in lecture (see representative
schedule Table 1), eg diabetes, sickle cell anemia,
pancreatitis. After reviewing the case, students identify
unfamiliar terms, findings and laboratory tests and
suggested diagnoses. The class categorizes the information and each pair of students selects a category to
research. Students are encouraged to use the library and
the Family Medicine residents and faculty as resources for
their research. At the next workshop, each pair makes a
brief presentation, emphasizing not only their special
findings but also the way these fit into the solution of the
diagnostic problem. Guided by the faculty facilitator, who
tries to minimize his input of 'teacher talk', the facts are
marshalled and the underlying biochemical principles are
revealed and seen to be critical components in the
detection and explanation of the disease process. The
workup of each case is concluded by the facilitator's
presentation of a careful resum6 of the foregoing proceedings and how they lead to the agreed-upon conclusions.
Students' workshop performance is evaluated using a
rating scale form that covers (a) their preparation and
presentation, (b) their class participation, and (c) their

professional growth and development. This performance
score accounts for 25% of the course grade. Two
additional 'cases' are used for the open-book final exams

197

Table 1 Representative Schedule: Biochemistry Department lecture schedule, First Quarter 1987-1988
Week

Date

1

8/31
8/31
9/1
9/3
9/4
9/4
9/7

9/8
9/10
9/11
9/11
9/14
9/14
9/14
9/15
9/17
9/18
9/18

9/21
9/21

Title
Lipids
Medical Decision
Making
Lipids

Amino acids
Medical Decision
Making
pH and pKa
HOLIDAY - Labor Day
Protein Structure
Enzymes
Enzymes
Bioenergetics
EXAM 1
Enzymes
Bioenergetics
Enzymes
Enzymes
Clinical Enzymology
Nutrition:
Recommended
Dietary Allowances
and Diet Planning

L( )

Speaker

40
6

Norwell
Farnsworth

40
3
6

Norwell
Mann
Farnsworth

3

Mann

3
9
9
11

Mann
Norwell
Norwell
Van Winkle

9
11
9
9
44
32

Norwell

Van Winkle
Norwell
Norwell
Mann
Van Winkle

distributed, with accompanying 'study questions', two
weeks prior to the exam. Table 2 shows the goals of the
program, presented as dimensions of cognition, and
suggested means to assess their achievement. Figure 1
shows study questions, based on "Eugenia", a case of
pancreatitis secondary to choledocholithiasis. These study
questions are developed to show the students the scope
and format of the workshop exam which is to follow. The
students are allowed to prepare for the exam individually
or in groups. They generally select a facilitator from their
group and meet just as they have been taught to do by
their faculty facilitator. For the workshop exams, students
can bring one biochemistry text, a clinical handbook, and
any hand-written or photocopied notes which they have

collected. Each must write his own exam. Figure 2 shows
the complementary questions which were used on the
workshop exam on Eugenia. The score on this case writeup exam accounts for another 25% of the course grade.
The remaining 50% comes, in the Fall Quarter, from four
hour exams on the lecture material, and in the Winter
Quarter, 25% from written hour exams and 25% from the
comprehensive 'Mock Board' exam.

Table 2 Workshop Goals
Dimension

Implementation

Knowledge

A

Synthesis

B

Clinical Enzymology
Nutrition:
Recommended
Dietary Allowances
and Diet Planning
Krebs Cycle, ETC
Carbohydrate
Structure and
Digestion
Krebs Cycle, ETC
Glycolysis

44
32

Mann
Van Winkle

13
7A

Norwell
Mann

Analysis

D

13
7B

Norwell
Mann

Comprehension

E

9/28 Krebs Cycle, ETC
9/28 Nutrition:
Recommended
Dietary Allowances
and Diet Planning
9/29 Krebs Cycle, ETC
10/1 Fatty Acid Oxidation
10/2 Fatty Acid Oxidation
10/2 Protein and Amino
Acid Metabolism

13
32

Norwell
Van Winkle
Analysis and
Synthesis

F

Comprehension
and Analysis

G

9/22
9/24

9/25
9/25

13
14
14
21

Norwell
Norwell
Norwell
Van Winkle

given at the end of each quarter. Since the emphasis is on
problem-solving, not memorization, these exam cases are

BIOCHEMICAL EDUCATION 16(4) 1988

C

Define each of the items in SMAC
and CBC and the meaning of
abnormally high and low value.
Develop a system analysis from
chief complaint and H & P data.
From B and laboratory data,
assemble a gross profile of a
patient, eg hypotonic, febrile, 38
year old female with jaundice and
hypochromic, normocytic anemia.
From C, develop and justify two
or three most likely preliminary
diagnoses and the etiology of
each.
Explain the biochemical bases of
each individual or cluster of
clinical and laboratory
atypicalities.
Identify ambiguities and
uncertainties of a case and the
supplementary data required to
resolve these. Explain how the
added data will be used.
Explain the principles and basis of
diagnostic decision-making which
are based on (a) serum enzyme
profiles, (b) CBC profiles, (c)
bilirubin-CBC variants, etc, or the
use of these in the analysis of a
specific problem.

198
Results
This course has been taught using this approach for the
past 3 years. Student ratings of it have been equally
excellent all three years. In the just-completed academic
year 1987-1988, 62% rated the workshops overall as
"very good", 16% "satisfactory" and 16% "excellent".
The best features of the workshops cited by students were
(a) use of practical cases, (b) opportunity to work in
groups, (c) relaxed nature of discussions, (d) emphasis on

Figure 1 Study Questions

problem-solving process instead of the 'right answer', (e)
learning how to do independent research, and (,tO integration of biochemistry and clinical medicine. From the
faculty's point of view, the most remarkable effect of the
course has been the rapid development of facility in
applying and integrating biochemical principles and both
clinical and laboratory data into their reasoning, a skill
Coughlin and Patel ~ have shown distinguishes physicians
from traditionally-trained sophomore medical students.
It is by no means clear whether the instrument of the
Osteopathic National Board of Medical Examiners

Directions: Using selected items from A, apply these to
patient through B and C, and solicit the theory through E.
Ask for item from G.

Directions: Use other dimensions from A. Ask for D and F

SI

relative the patient. Provide and ask the effects of selected
shifts in or additions to data. Ask about other G item(s).

Write a definition of each of the following items.
What do abnormally low and abnormally high levels
tell about the donor patient? NOTE: In this section,
consider each item as isolated data. There will be an
opportunity to discuss how these items fit with other
data in subsequent sections.
Hgb
MCV
RECTICS (with correction)
GLUH
Na

SII

Figure 2 Examination Questions

EXI

EBAL
TRIG
TBIL
SGPT
GLOB

Imagine yourself to be the Emergency Room physician. You have only Eugenia's history and physical.
How would you describe the patient to the house
officer who you want to admit Eugenia to the
hospital? (Hint: Use 10 words or phrases to characterize the signs and symptoms of this 52 year old
female. For example, hypotensive, febrile, 52 year
old female with jaundice and suspected presence of
x, y and z.)

Sill Select 6 items from Eugenia's chart which you think
best describe her primary signs and symptoms.
Explain the connection of each to the general
impression which you have of the patient's problem.
Suggest three disease states which you feel can be
reasonably considered. Explain your reasons for
considering each of these.

Hct
MCHC
BUN
PO4
EXII

Explain briefly the use of each of the items in the
CBC in defining the hematological state of an
individual.

SVI Briefly describe in terms understandable to a layman
the structural defects found in this patient's osteopathic examination.
B I O C H E M I C A L E D U C A T I O N 16(4) 1988

CA
CO 2

DBIL
PRO

Explain briefly how each of the following laboratory data are related to the patient's condition.
GLUH
NA
CO2

TRIG
ALK
BIL data

EXIII

List three diagnoses of Eugenia's condition and
show how the above laboratory data assist you in
choosing the most likely one of the three.

EXIV

What other data in Eugenia's chart will assist you
in making your decision in III and how? Consider
at least three items.

EXV

Discuss the biochemical principles underlying the
tests you selected in III and IV and their use in
explaining the nature of the patient's disease.

EXVI

What additional tests and/or clinical data are
required to assist in making a definitive diagnosis? Explain how they will be used and the
biochemical principles upon which they are
based.

SIV Give the biochemical basis for each of the test results
you selected in III. How does each help explain the
patient's disease state?
SV

Write an explanatory definition of each of the
following items. What do abnormally low and
abnormally high levels tell about the donor
patient? NOTE: In this section, consider the item
as isolated data. There will be a chance to discuss
how it is related to other data in a subsequent
section.

EXVII How do the following additional data about the
patient modify your diagnosis? Explain.

199
presently is a reliable measure of problem-solving skills.
Thus, it can be reported at this time only that the students
in the first two classes to experience the new combined
program did very well in the Part I exam; at least as well as
the students from the Chicago College who received the
more conventional Biochemistry curriculum.
It should be noted that, at the outset, the faculty were
wary of their ability to use the unfamiliar Socratic mode of
teaching and of their competence to deal with the clinical
material intelligently and responsibly. To solve the first
problem, a specialist in education and small-group teaching (Dr Medio) conducted practice sessions before the
start of classes and periodically monitors and critiques the
performance of each faculty member in workshops. To
assist the faculty with the clinical aspects of each case, a
physician (Dr Nelson) provided consultation by reviewing
each faculty-generated case write-up to assure adequacy
and accuracy, to eliminate unnecessary details and to
thoroughly brief the faculty on all nuances, jargon and
clinical interpretation.
Review of the workshops held during these past three
academic years reveals a number of aspects of procedure,
organization and case selection which may be helpful to
the reader. Since these have shown that, indeed, "experience is the name given to past mistakes", they are
discussed briefly in the accompanying Appendix.

Discussion
The student evaluations of the clinical case workshops
have been positive. The opportunity to learn how principles of biochemistry can be applied to the diagnostic
process appears to create a more positive attitude towards
biochemistry. Student comments indicate that the workshops complement the lectures.
Two reasons why the course may be successful are (1)
the retention of traditional lectures to teach the basic
information, and (2) the use of simulated clinical cases in
the workshops. The workshop format exposes students to
a 'hands-on' opportunity to solve a clinical problem
longitudinally. This contrasts sharply with the one session
clinical correlation or wet lab. 5-8 The emphasis on
information gathering and synthesis appears to promote
the development of independent learning skills.
This course provides an educational experience of the
type recommended in the GPEP report. That is, one that
"requires students to be active, independent learners and
problem-solvers, rather than passive recipients of information" (ref 1: p 12). In conclusion, this study strongly
suggests that a modified problem-based learning model
that integrates lecture and small-group problem-solving
workshop can enhance the teaching of biochemistry.

Acknowledgments
The Department is indebted to Drs Phyllis Blumberg (Rush University),
Rex Montgomery (University of Iowa), Roon and Van Pilsum (University of Minnesota), Frank Vella (University of Saskatchewan) and
LuAnn Wilkerson (Harvard University) for valuable help, suggestions
and encouragement during the development of this program.

BIOCHEMICAL EDUCATION 16(4) 1988

References
aPhysicians for the Twenty-First Century. The GPEP Report (1984)

Association of American Medical Colleges, Washington, DC
2Mehler, A H (1983) Biochem Educ I1, 95-118
3Wood, E J (1982) Biochem Educ 10, 101-103
4Sandier, G (1979) Brit Med J 6, 21-24
5Saffran, M (1982) Biochem Educ 10, 98-99
6Roon, R J, Van Pilsum, J F, Harris, I, Rosenberg, P, Johnson, R,
Liew, C and Rosenthal, L (1983) Biochem Educ 11, 12-15
7Garcia-Webb, P (1985) Biochem Educ 13, 23-24
8Ragatz, B H (1984) Biochem Educ 12, 77-88
9Montgomery, R, Dryer, R L, Conway T W and Spector, A A (1983)
'Biochemistry: A Case Oriental Approach', C V Mosby, St Louis
t°Barrows, H S (1980 'Problem-Based Learning. An Approach to
Medical Education', Springer Publishing, New York
llCoughlin, L D and Patel, V L (1987) J Med Educ 62, 818-828
12Vella, F (1984) Biochem Educ 12, 119
13Berezov, T T (1985) Biochem Edue 12, 76-79
~4Fraser, C G, Browning, M C K, Walsh, D B and Paterson, C R (1986)
Biochem Educ 14, 125-127

Appendix
Cases should be selected to not only complement subject
material of concurrent didactic lectures but also to provide
a full diagnostic experience. History and physical findings
should be complete and well organized, providing a model
of this workup to the students and enough information to
permit development of a small number of preliminary
diagnoses. One must stress at every point the necessity of
justifying every hypothesis. The students must be made to
see how various data re-enforce or are in conflict with
other data: the synthetic process.
While each case is selected to illustrate a different type
of disease, all should provide practice in reasoning and
problem solving. Our students are taught to take a
systematic approach beginning with chief complaint,
presenting signs and symptoms, systems review, laboratory, and such other diagnostic procedures, eg X-ray,
IVP, CAT scans, etc as they can justify. They are made
conscious of cost-containment considerations and the
importance of risk/benefit estimates when selecting invasive or otherwise traumatic test modalities.
An early requirement is to become familiar with each
item of standard blood chemistry, CBC and urinalysis.
This involves knowing what each item is, where it comes
from, and, in general, how to interpret values outside the
normal range. To do this requires that students grasp the
rudiments of descriptive statistics, especially the mean,
normal range and standard deviation about the mean.
When students are more experienced, a case is used for
which several diagnostic tests are available. The concepts
of diagnostic sensitivity and specificity, prevalence and
incidence, and predictive value are introduced and the
students are shown how to use these to select the test
which best meets the diagnostic requirements of the case.
The mode of facilitation employed by different faculty
members may vary from a formal recitation, in which each
student reports to the teacher, to the interactive dialogue
between students. The merits of the recitation are the

200
assured participation of all members of the class, the
opportunity for drill, and the development of each
student's speaking ability. The dialogue emphasizes
debate, resourcefulness and adequate mastery of the
material to field questions of peers. In this latter mode,
more akin to clinical rounds, the facilitator serves as
catalyst and referee and sees to it that the discussion
proceeds in an orderly and constructive manner. He must
ascertain that all participate and all understand. He is
responsible for providing encouragement and re-enforcement to each speaker during the session and, where
needed, one-on-one guidance to individual students after
the session.
One of the most important elements of every case study
is the careful resum6: the facilitator must review the
proceedings step-by-step to assure that all students clearly
see the reasoning process and comprehend the conclusions and their bases.

An Example of a Practical Biochemistry Examination
for Health Professional Students
ALLEN OTSUKA* and BARNEY KADISt

* Department of Biomedical Sciences
School of Dental Medicine
Southern Illinois University
Edwardsville, Illinois 62026, USA,
and
t Department of Basic Sciences
School of Medichte
Mercer University
Macon, Georgia 31207, USA
Introduction
In presenting a biochemistry course to dental students, we
have had noteworthy success using practical, caseoriented examinations. By making the tests relevant to
their future endeavors, we believe that the students not
only more readily accept taking such a course, but also
view the information presented as being beneficial in
understanding certain aspects of their chosen profession.
For examination purposes, we have used clinical cases
taken from the medical or dental literature, cases of
patients who presented to the clinic, or formulated cases
to suit particular goals.
A case is usually given to the students at least a week
prior to an examination so that they have ample time to
research various aspects and to familiarize themselves with
it. We have used a format of essay questions, multiple
choice questions or a combination of both in our examinations. Our approach has been to formulate questions
which (a) are derived from the data presented in the case
rather than some esoteric or theoretical concepts; or (b)
attempt to present broad principles rather than specific
details. For a final examination, we also include questions
related peripherally to the case that test the biochemical
knowledge of the students.
BIOCHEMICAL EDUCATION 16(4) 1988

The following clinical case, modified to suit our
purposes, was used in one of our final examinations. We
have excluded the patient's case history in this article but
have included fifteen of the seventy multiple-choice
questions that were used on the examination. No essay
questions were utilized for this particular final examination.

Examination Case Study
Mr PB, a 51-year-old while male, was administered an
unidentified local anesthesia for multiple extractions at a
dental clinic. During the next 24 hours he hemorrhaged
profusely from the extraction sites and was referred to the
dental service in a nearby hospital.
The patient was a well-developed, well-nourished man
who was slightly confused and disoriented but responded
to verbal commands. There was ecchymotic swelling of
the soft tissues in the submandibular area, icterus of the
sclera, protrusion of the abdomen, and enlargement of the
liver.
The patient was taken immediately to the oral surgery
operating room where an infusion of 5% dextrose in
Ringer's lactate solution was started and 5 mg of a
tranquilizer (Valium) was administered. Following local
anesthesia (6 ml of 2% lidocaine containing epinephrine
1:100 000) the extraction sites were packed with oxidized
cellulose and sutured. Except for a slight ooze, the
bleeding subsided. The patient was taken to the dental
ward in the hospital for observation.
Admission laboratory test results were:
Prothrombin time 19 s (Normal control: 11.5 s)
SGOT 120 U/I (Normal: 7-27 U/l)
Bilirubin (total) 5.4 mg/100 ml (Normal: Up to 1.0
rag/100 ml)
Blood Ammonia 97 Ixmol/1 (Normal: 12-55 ~xmol/1)
Twenty-four hours after admission, the patient became
semicomatose and disoriented as to time and place. He
did not respond to verbal commands. He remained in a
semicomatose state for 72 hours and did not become
completely oriented until the seventh day in the hospital.
Treatment consisted of a protein-free diet of 1800
calories/day, 500 mg neomycin sulfate orally four times a
day for seven days, 600 000 units procaine penicillin
intramuscularly two times a day for seven days, 5 mg folic
acid each day, 200 mg ferrous sulfate three times a day,
50 mg Aquamephyton (water solubilized Vitamin K-I)
injection intramuscularly twice a day for three days, and
an oral vitamin B complex supplement.

Sample Questions
1. Which of the following led to the patient's comatose
condition?
(a) ammonia toxicity.
(b) hepatic cirrhosis.
(c) amino acid metabolism.
(d) all of the above choices.
(e) none of the above choices.