The dual problems of clinical relevance and expanding data in basic science courses continue to vex medical school faculty and students alike. Biochemistry in a traditional curriculum may be the most prominent example, since many of the most important and basic concepts do not figure obviously in clinical practice even if they underlie other preclinical courses. (How often do surgeons use the Krebs cycle, for example?) In some clinical courses, e.g., Cardiology and Genetics, biochemical concepts are more closely related intellectually but are farther away in time, as these blocks often are not taken until the fourth year. Coupled with the problem of clinical relevance is the speed at which research information in Biochemistry and Molecular Biology is being incorporated into clinical knowledge. Physicians in training are expected to be “lifelong learners” with the capacity for incorporating information from a host of disciplines into their practice.1,2 Finally, physicians are expected to work collaboratively with each other and allied health professionals. These behaviors are not always characteristic of entering medical students.2
For the past six years our approach to dealing with these issues has been to structure collaborative learning exercises in Biochemistry which model scholarly behaviors that will be required in students’ later practice. Our first-year medical students are each required to subscribe to The New England Journal of Medicine. We chose a single journal primarily to reduce the time demand on course faculty who must read the articles along with the students. The students are assigned to groups of 5 or 6 which are responsible for analysis of 4 primary research articles over the semester. Articles analyzed must be current (published within the last 6 weeks) and with a biochemical focus or content. Usually, 1-3 articles per issue meet this last criterion; since the students are taking Physiology at the same time, articles dealing with pathophysiological mechanisms and the biochemistry of organ systems are popular.
Analysis consists of a written report from each group answering a series of questions: Which article? Who are the authors? Where was the work done? What was the objective of the study? What is the biochemical background of the problem under investigation? What were the results? What are the authors’ conclusions? What are your own reactions/conclusions? (This last answer is often the most interesting; questions of statistical significance and patient population size are frequently raised.) Final reports are usually 4-6 double-spaced pages. All students in a group sign the group report to verify their participation. Time for this exercise is made available by dropping one lecture per week during the second semester of the year-long Biochemistry course sequence.
The literature reports figure into the final Biochemistry course grade in a small but potentially important way. First, reports are graded on a scale of plus (above and beyond the call of duty), check (good), minus (deficient in some aspect) or zero (no report). The grades do not figure into the course grade formally but can be used to lift a borderline grade at course end. Conversely, zero grades can bring a course grade down. The adjustment for being in a group with consistently superior reports is usually on the order of 1-3% of the final grade. Additionally, 10-15% of the course final exam is devoted to a menu of questions based on the reports submitted over the semester.
Our expected outcomes for this work were that students would learn to read primary research papers, that they could put biochemistry in a context directly related to their interests, and that they would learn to work collaboratively, learning from, reinforcing and policing each other. These goals were apparently met. In a survey of second year students who had taken the course, 22 of 28 respondents (a response rate of one-third) agreed that the exercise improved their skills in analyzing current medical literature. Equally strong majorities agreed that they were able to relate concepts and results reported in the articles to their databases in biochemistry (24/28) and in other basic science courses (22/28). A majority agreed that the exercises helped them integrate science and medicine (16 yes, 6 no, 6 not sure). Half of the respondents agreed that the exercise helped them learn more biochemistry and that it stimulated their interest in biochemistry. Only a minority (6/28) maintained their subscriptions to NEJM through the second year. Of those who did not continue their subscriptions, several cited cost as a factor and several others indicated that they subscribed to other journals (JAMA and American Family Physician).
Information regarding other behavioral outcomes is necessarily anecdotal. In one case a group refused to let a nonparticipating student sign its report. In other cases, students have reported their efforts (successful and not) in getting their fellow group members to work harder at their assignments.
Some potential pitfalls in the exercise have been identified, mostly in the composition of the groups. Students are assigned by the course faculty to groups with the aim of roughly equalizing the level of academic background and talent. Student-selected and randomly assigned groups will vary considerably on this score. Since all individuals in the group are expected to gain the skills we expect, we wanted to avoid giving some groups an advantage coming into the assignment. One year we had a 1:1 correspondence between group members and assignments, and the students took turns writing individual reports rather than collaborating on each report; the quality of the work suffered noticeably.
In summary, we find this exercise useful in equipping medical students with some of the tools of lifelong learning and perhaps even some biochemistry. These outcomes were achieved in the context of a traditional, discipline-based curriculum. We have also used this experience as an entree into students’ using the National Library of Medicine databases during another part of the first-year Biochemistry course.3
Acknowledgements: This program was sparked by discussions one of us (FJS) had with Dr. Alan Mehler. Additionally, Dr. Douglas Randall provided some of the questions for the report format.
REFERENCES
1.Kassirer, J.P. Learning medicine — too many books, too few journals. N. Engl. J. Med. 1992, 326: 1427-1428.
2.Physicians for the Twenty-First Century. The GPEP report: Report of the Panel on the General Professional Education of the Physician and College Preparation of Medicine. Washington, D.C. Association of American Medical Colleges, 1984.
3.Proud, V.K., Schmidt, F.J., Johnson, E.D., and Mitchell, J.A. Teaching Human Genetics in Biochemistry by Computer Literature Searching. Am. J. Hum. Genet. 1989; 44: 597-604.