When should clinical correlations by introduced?

Murray Saffran, Ph.D.

Professor, Department of Biochemistry & Molecular Biology

Medical College of Ohio
Toledo, OH 43699-0008

(+) 1-419-381-4133

The introduction of clinical dimension in the basic science years of medical school is more difficult in the first year than in the second. The second year traditionally contains the bridge courses of pathology, pharmacology, microbiology and immunology, which thrive on close connections with heir clinical counterparts of pathophysiology, therapeutics, infectious diseases, and clinical immunology. Biochemistry’s clinical connection used to be clinical chemistry, leading into laboratory medicine, but the biochemists of the USA have allowed these clinical specialties to fall into alien hands and their connection with ancestral biochemistry is no forgotten.

Most of us who teach medical school courses in biochemistry are not physicians and are not even remotely concerned with laboratory medicine (now within the purview of pathologists). How, then, can we introduce clinical material into our courses? While some genetic diseases are clear and exciting examples of biochemical principles, such diseases are rare; most clinical problems do not lend themselves to easily-understood biochemical interpretation. Several approaches are available to bring the real world of medicine into the intangible world of biochemistry. One method is to use a biochemistry test that contains “Clinical Correlations”. While this approach is better than another, the clinical correlations in dark sidebars in one such book suggest that this is secondary material, not as important as the regular test, with its many colorful illustrations. In another book the clinical correlations are printed in the same dull and visually monotonous format as the rest of the book and the cases are clustered at the end of the chapters, offering both the student and the instructor the easy alternative of ignoring them altogether. Both test so what our curricula do—they separate the basic science from the clinical matter. Is there any way of presenting biochemistry WITHIN the context of the clinical problem? Shouldn’t the case be presented first complete understanding of the underlying basic science (biochemistry) is necessary to understand the pathological findings and the rationale for treatment?

When I taught the medical biochemistry course at McGill University in the 1960’s I began the course by inviting a clinical colleague to bring a patient to the classroom [Saffran, M. (1971) “Relevance in the medical biochemistry course. J Med Educ 46:1080-1086]. The students were very surprised and anxious to be confronted with a human problem on the first day. The patient and the physician were introduced to the class and the students were instructed to interview the patient. The first questions were generally asked by member of the class with some health professional experience, “What made you see the doctor?? was a usual and excellent first question. The answer elicited the presenting signs and symptoms from the patient’s point of view. The following questions produced more details. Soon the class forgot their anxiety and entered into the spirit of the exchange. In as little as 15 minutes, the ability of the students to get more useful information from the patient was exhausted. The patient was than dismissed and the students were invited to question the physician. The class now asked more sensitive questions related to prognosis, genetics and treatment. They physicians, by the way, were instructed to answer specific questions only and not to volunteer information. The students enjoyed the interplay and began to formulate basic science questions in exploring the pathophysiology. They were told that the biochemistry would be discussed later in the course. There were murmurs of dissatisfaction, because they were eager to explore the topic further. The first lecture ended with the promissory note that more discussion of the case would follow. The class expected the second lecture to be on the underlying biochemistry, but instead we brought in another patient, accompanied by the same physician. This time the class was experienced and immediately asked pertinent questions. In a very short time they had the chief complaints, family and medial histories, treatment from the patient’s point of view, etc. After the patient left they asked the physician very pointed and intelligent questions, leading to matters in biochemistry, which, they were promised, would be discussed in the course. It was not time to take advantage of the obvious eagerness of the class to delve further into the basic science aspects of the patient’s problems.

The prior exposure of the students to a real human problem provides them with motivation to learn the associated biochemistry, overcoming one of the great barriers between instructor and students. The lecturer can refer back frequently to the patient’s history, physical and laboratory findings and even therapy to provide a continuous ti-in between biochemistry and the “real” medical. It is important to bring in new patients before the students tire of the constant references to the old ones. New patients can also be introduced at the beginning of new chapters in biochemistry.

I have consistently found that the patient first, biochemistry next approach, with its great motivational force, to be far more stimulating than the biochemistry first, clinical correlation later approach. It is much easier to interweave clinical and biochemical principles when the patient has been seen early, than to keep on promising some clinical relevance toward the end of the course.

The Forum
Vol 2 No 2
Page 5