Case Based Metabolic Unit (CBMU): A Model for Better Understanding of Metabolic Pathways in the Second Year Extended Modular Program Medical Students

We designed a case based metabolic unit (CBMU) which is a hybrid learning model using case based learning and interactive lectures for 2nd year EMP medical students (n:113) who firstly attended blood module (Classical model in learning metabolism) and then locomotor module (CBMU). At the end of both modules, they were evaluated through MCQ exams and the results of both exams were compared. The Majority of students (97-100%) opined that case based metabolic unit learning model was interesting, motivating, and better than the classical model in understanding metabolic pathways and making learning stick. 99% of them demanded the application of this learning model in future biochemistry courses. Improvement in student’s exam scores ensures that they grasped the knowledge by this model. In conclusion, CBMU is a useful learning tool for metabolic pathways using human cases to aid in connecting theory to practice which is positively reflected on student’s academic performance.


Title
Case based metabolic unit (CBMU): A model for better understanding of metabolic pathways in the second year extended modular program medical students

Target audience
Medical students in the first three years

Educational objectives
1-to link metabolic concepts to clinical practice 2-to build up a systematic and investigative thinking abilities of students early in their learning to be able to apply what they learned to solve real-world problems

Worked contents
Metabolic pathways relevant to locomotor module (glycogen metabolism, Fatty acid oxidation)

Estimated duration
During the whole locomotor module from 9th

Introdution
The progress of biochemistry and medicine are inseparable, and most of modern medicine would not be applied, as they are nowadays, with no understanding of the biochemical and molecular mechanism of human diseases.Thus, the significance of educating medical biochemistry is evident.Paradoxically, biochemistry for a lot of medical students is like lyrics in a foreign language, to be memorized but with no feeling.
They may not realize the importance of biochemistry until they have graduated and gone to practice.By that time, they have already forgotten what they learned, which compromises their professional competence [1][2][3].In traditional biochemistry courses students would typically endure lectures where the teacher would demonstrate numerous biochemical pathways and reactions.
A skilled medical expert needs to be capable of going further than just accumulating a huge mass of information.It is essential for future doctors to build up a systematic and investigative thinking abilities early in their learning to be able to apply what they learned to solve real-world problems [4].Integrated teaching is an important strategy for promoting effective learning and for making it easily saved by students.Many approaches are available for integrating the basic and clinical disciplines but fears are expressed that biochemistry would lose continuity in the integrated system.

EMP (extended modular program) is a new MBBS (Bachelor of Medicine, Bachelor
of Surgery) program at the faculty of medicine, Ain Shams University in Egypt, which followed an integrated curriculum.All basic science introductory courses are taught in the first year followed by their reintroduction in the next two years in an integrated system based approach comprising 8 modules (blood, locomotor, respiratory, cardiovascular, C.N.S, special sense, endocrine, GIT& liver, Genitourinary).Biochemistry course in the blood module (2 nd year 1 st module), was taught by the conventional approach to describing the concepts of the metabolic pathways as a continuous topic and at the end we draw round how a fault in this pathway would result in a disease.
Applying this classical approach, make biochemistry integration of lower impact.
While biochemistry would be a harmonizing partner in the integration, if the metabolic unit is based on clinical cases relevant to the module.The cases will be analyzed to explain what would happen if something goes wrong in a particular reaction in the metabolic pathway and why and when it goes haywire.To achieve this goal, we designed a case based metabolic unit in the locomotor module for 2 nd year EMP medical students and we evaluated the impact of this learning approach on student's perception and performance in comparison with the conventional approach of learning metabolism in another module for the same students.

Methodology
The study was conducted on EMP second year medical students.Metabolic pathways in the blood module (from 28th September 2015 to 7th November 2015) were studied by the conventional approach applying different instruction methods e.g structured lectures and small group interactive sessions.In the 2nd module, locomotor module (from 9th November 2015 to 10th January 2016), the metabolic pathways were studied by the case based metabolic unit model.
The proposed approach was approved by the medical education council of the EMP program and the ethical committee.The metabolic pathways relevant to the locomotor module were presented in the lecture classes and small group discussion (SGD) sessions with clearly defined, short clinical problems consisting of symptoms and investigative data that were related to these topics [4].
The case (Appendix A) was presented at the start of a metabolic pathway unit with the symptoms of a particular metabolic disorder of muscle, which were made very clear.
Students were asked to define, and to summarize the symptoms and the significant investigation findings of the case.Subsequently, the students were provided with the particular learning objectives (Appendix B).The lecturer was explaining the normal metabolic pathway and assisting the students through the facts and engaging them in understanding the pathway to find a possible solution to the problem and to answer all the learning objectives.Finally, the students were asked to analyze the medical problem to integrate the information and link the basics of biochemistry to the medical problem.
Students were also encouraged to ask questions during the lectures and SGD.Four clinical cases were used for this study to cover metabolic pathways integrated in the locomotor module.At the end of the module, students were requested to reply to a 9-item, 5-point Likert scale questionnaire concerning their perception of the utility of this case based metabolic unit model in learning metabolic pathways (Appendix C).The questionnaire was prepared according to standard procedures [5] and evaluated the next items: better understanding of the metabolic pathways, the significance of the cases, chances for interaction and thinking, relevance for clinical practice, unit presentation organization and preparation, with one open-ended question at the end of the questionnaire.

Results
There was a statistically significant (p<0.007)increase in the test score of the academic performance of students in the locomotor module as compared to the blood module (Table 1 and Figure 1).

Mean values and multiple bar diagram of the student responses have been shown
in Table 2 and Figure 2.  All the students felt that the case based metabolic unit learning approach was a good tool for understanding concepts as compared to the classical approach.A majority (97 to 100%) of students rated "agree" on a 5 point Likert scale for "well organization and preparation of CBMU", "The significant relevance of the cases to the metabolic pathways of the module", "helping understanding the metabolic pathways of the module","The challenge to think and interact", "the clear & logical framework of biochemical information in the learning method and highlighting its clinical significance" and 81% felt that this model "has increased their interest in the field of biochemistry".
When the future application of this approach in learning biochemistry and other basic sciences was asked, 99% of them recommended applying this method to all biochemistry courses in all modules and 86% recommended applying it to other basic science subjects."Overall, all students agree that this approach has been effective in advancing their learning in biochemistry".
In response to the open ended question about what did they like in CBMU, mostly, all respondents wrote positive comments as: 1-Interactive method that we have an applied case we work on and analyze, we did not only have a perfect overview about the metabolic pathway in an organized simplified way but we also enjoyed the interaction and the way the lectures were organized.about the topic which I do not do often.I think this the best topic I did understand in biochemistry 3-It made the lecture easier to follow.It is more thought -provoking than the classical approach (i.e.explaining the metabolic pathway then explaining its clinical application).The lecture was more focused, and had a clear aim: understanding the biochemical principles behind the given case 4-I actually liked the CBMU generally, as an overall opinion because it helped me understand biochemistry and less effort at home and I also liked the way the lecture was presented, it has made a brilliant link between the case and the clinical information needs to be studied.

Discussion
It puzzles medical students that biochemistry is outside the perspective of medicine.
This can be solved if medical biochemistry explains how it applies to medicine, sticks with students and diminishes rote memorization.
Integrated teaching affords a holistic approach, whereas the basic tenets of biochemistry should be discussed in the light of the applied and clinical subjects.The major advantage of case based metabolic unit is that it makes biochemistry a harmonizing partner in the integration that is not completely accomplished by the classical approach.
In the CBMU learning approach, we first defined core biochemical concepts that teachers and students could review in the locomotor module.We discussed these essential ideas and medical applications of biochemistry deeply, by a series of well planed clinical cases.These patients stories are what make the acquisition of biochemistry knowledge compelling.They serve as the scaffolding on which facts and concepts can be reorganized and reinforced.CBMU seems to be a good model of learning, on the basis of the current questionnaire results.All of the EMP students sensed that the clinical cases were motivating and reflected that this approach facilitated their understanding and memorization of the metabolic pathway.The improvement in students exam scores ensures that they grasped the knowledge.They were inspired to concentrate on many biochemical concepts.Students enrolled in this module speak out that by the asset of this case-based metabolic unit, they were able to integrate biochemistry basic facts in the form of clinical cases.In support of our data on CBMU, previous reports on case based learning in biochemistry topics [4 and 6] and in health care teaching [7 -10].The significance of using interactive discussion of clinical vignettes that highlighted the biochemical basis of various diseases was discussed by Prober and Heath.[11].
Two limitations of applying this learning model: firstly, care should be considered in the case design to reinforce the student's understanding of the core concepts of biochemistry.Secondly, not all biochemistry staff will accept this learning process by taking students through a clinical case due to lack of clinical experience.
However, the feedback of students in the current study encouraged us in using case based metabolic unit as a method of learning, as it had a significant impact on the students.Another outcome is faculty training and development that improves the quality of teaching in the future.
In conclusion CBMU as a learning model of metabolic pathways in EMP integrated curriculum was perceived positively by the students and was reflected on their academic performance.They valued the introduction of clinical cases to solidify the relevance of biochemistry to clinical practice.The major advantage of case based metabolic unit is that it makes biochemistry a harmonizing partner in the integrated curriculum which is not completely accomplished by the classical teaching approach

Table 1 .
Comparison of students scores in the evaluated modules.
Figure 1.Students mean test scores in locomotor module compared to blood module.

Table 2 .
Results of student questionnaire (scale from 0 to 4) Case Based Metabolic Unit (CBMU): A Model for Better Understanding of Metabolic Pathways in the Second Year Extended Modular Program Medical Students Case Based Metabolic Unit (CBMU): A Model for Better Understanding of Metabolic Pathways in the Second Year Extended Modular Program Medical Students 2-Much more interesting that it encourages me to open the text book and read more Case Based Metabolic Unit (CBMU): A Model for Better Understanding of Metabolic Pathways in the Second Year Extended Modular Program Medical Students http://dx.doi.org/10.16923/reb.v14i3.64423/12/2016