Creative Education
2012. Vol.3, No.7, 1173-1176
Published Online November 2012 in SciRes (http://www.SciRP.org/journal/ce) http://dx.doi.org/10.4236/ce.2012.37174
Copyright © 2012 SciRe s . 1173
Using Clinical Case Studies to Teach Biochemistry in a Doctoral
Program: A Descriptive Paper
Marc P. McRae
National University of Health Sciences, Lombard, USA
Email: mmcrae@nuhs.edu
Received August 30th, 2 012; revised September 25th, 2012; accepted October 12th, 2012
Introduction: Biochemistry has traditionally been taught through lectures and rote memorization paying
little attention to nurturing key problem solving skills. The literature on clinical case studies utilized in
health education indicates that case studies facilitate and promote active learning, help clinical problem
solving and encourage the development of critical thinking skills. Methods: This paper describes a
method of using clinical case studies to deepen and solidify the students understanding of biochemical
facts and concepts as related to clinical medicine. Discussion: Clinical case studies can be a helpful ad-
junct for teaching the content of human biochemistry that complements the traditional approach of lecture,
textbook and laboratory. The learning issues presented to the students required them to reformulate bio-
chemical concepts in their own words, integrate diverse principles and decide what information was im-
portant and what was superfluous. Limitations include a small subset of students riding the coat tails of
their more ambitious peers, and biochemistry professors not having the confidence to take the students
through a clinical case study because they may feel like they do not have sufficient “clinical expertise”.
Conclusion: Clinical case studies are a valuable addition to the traditional methods of lecture, textbook
reading and laboratory for teaching biochemistry. More importantly clinical case studies help remind stu-
dents that what they are learning has relevance in the real world, and may help motivate students to pay
more attention to the numerous facts faced in biochemistry.
Keywords: Biochemistry; Case Studies; Chiropractic; Education; Teaching Method
Introduction
Biochemistry is a content-rich systematic course of study,
and a foundational course for future topics in basic or clinical
sciences. Biochemistry has traditionally been taught through
lectures and rote memorization paying little attention to nurtur-
ing key problem solving skills. In traditional biochemistry
courses students would typically endure 4 fifty minute class
periods of lecture per week where the instructor would illustrate
countless biochemical structures and pathways. Competent
health professionals need to be able to go beyond merely ac-
cumulating a massive body of facts. It is important for future
physicians to develop analytic and diagnostic thinking skills
early in their program of study so that they are able to correctly
apply the facts that they have learned to the solutions of rele-
vant real-world problems. It has been acknowledged that there
should be a limit on the amount of factual information that
students are required to learn, and that students should be re-
quired to be active, independent learners and problem solvers
(Wilson, Goodall, & Ambrosini, 2006).
One of the most common educational approaches which aims
to promote student centered active learning with a focus on
critical thinking and problem solving is the clinical case study
(Popil, 2010; Shanley, 2007). Active learning engages students
in the topic and allows them to develop their critical thinking
skills. This rewarding learning experience helps students see
the relevance of the topic to clinical practice and motivates
them to continue to learn (Irby, 1994). Clinical case based
learning has also been overwhelmingly preferred by medical
students when compared to other forms of instruction (Sriniva-
san, Wilkes, & Stevenson, 2007).
The potential that clinical case studies hold in the teaching of
human biochemistry has been recognized in some biochemistry
textbooks prepared for medical students. A biochemistry text-
book publication by Lieberman and Marks includes case studies
in the teaching material which provide a strong clinical corre-
late to the biochemistry taught in the text (Lieberman & Marks,
2009). However, much of this material does not appear to have
been specifically written to reinforce the student’s understand-
ing of biochemistry. Instead, the cases served primarily to illus-
trate disease states, give real world relevance, and provide mo-
tivation for learning. The goal of the case studies should have
been to enhance the student’s understanding of the key con-
cepts and mechanistic processes of biochemistry, where the
students must assemble the relevant information, identify key
concepts, and make informed assessments to solve a problem.
Therefore the ultimate goal of the case study is to obtain a
deeper working knowledge of the material rather than simply
captivate attention with interesting clinical situations.
The use of case studies in basic sciences has been shown to
have positive effects on learning outcomes. Students involved
in a case study based course in human anatomy and physiology
indicated that their work on the case studies made the subject
material easier to learn and helped them solidify their under-
standing of anatomy and physiology (Cliff & Wright, 1996).
This was supported by a measurable improvement in student
comprehension of the subject material as evident by the statis-
tically significant improvement in student exam performance. A
substantial majority of the students therefore found case studies
M. P. MCRAE
to be beneficial to their learning and appreciation of anatomy
and physiology.
The purpose of this paper is to describe an instructional ap-
proach to using clinical case studies in a first trimester human
biochemistr y course.
The Case Study Method
Students in a first trimester biochemistry course in a chiro-
practic doctoral program were presented with four clinical cases.
Each case focused on a specific topic in biochemistry (protein,
carbohydrate, lipid and nucleic acid metabolism). For each case
a full class period (50 minutes) was used to introduce the case
and 2 additional class periods were used to discuss the directed
question learning issues. The information that was freely avail-
able at the beginning of the first session included: age, gender,
race, appearance, and chief complaint. Details needed to diag-
nose the patient had to be generated through history taking,
physical examination and diagnostic tests. Each clinical case
study was presented in a simulated doctor patient scenario
where the instructor played the role of the patient. In this sce-
nario the students first took a history, followed by a discussion
and listing of the patient’s differential diagnosis. This was fol-
lowed by the physical examination and diagnostic tests. After-
wards the differential diagnoses were addressed and the listed
conditions were ruled-in or ruled-out. Ultimately at the conclu-
sion of this exercise the patient’s diagnosis was revealed, be-
cause “searching” for the patient’s diagnosis was not the goal of
this exercise.
The real goal was the mechanistic description of the encoun-
tered signs and symptoms of the disease as related to the bio-
chemical concepts covered in lecture up to that week. At the
conclusion of the first session the students were presented with
2 to 3 directed questions which are referred to as “learning
issues”. The learning issues were of sufficient depth without
requiring excessive amounts of time or effort by the students,
and therefore the students were assigned typically one week to
complete the learning issues. The learning issues were chosen
by the instructor with the purpose of directing the students to
explore in more detail the specific issues in biochemistry as
they related to the previous weeks lectures.
With one or two of the learning issues the students were
asked to formulate a specific me chanism for a particular sign or
symptom. To answer the question, the students were asked to
formulate the molecular steps involved in the mechanism and
arrange them in a proper sequence which explained the phe-
nomena of the case in terms of underlying disease mechanisms.
This activity develops the student’s analytic outlook to the
problem instead of merely reinforcing his or her talent for fact
recall. This task also sometimes required students to associate
the mechanism of one event with the mechanisms learned in
other courses. For example, the students had to tie into their
biochemistry mechanism the concepts of osmosis, diffusion and
apoptosis as learned in physiology, or the structural proteins
used in the basement membrane of capillaries as learned in
histology.
The students were free to work together in groups outside of
class time and this was highly recommended. Students were
instructed that they should be able to successfully answer the
case questions with information obtained in the lectures, course
notes, course textbook, and supplemental material. Because the
students were free to use any source of information, they were
cautioned about the use of non-reliabl e i n t e rnet sources.
In the second session the students presented their learning
issues in a large group setting, and the instructor illustrated the
mechanisms on the write on/wipe off board at the front of the
class. This illustration was solely created based on the input and
flow of information from the students. At the conclusion of the
second session another two to three learning issues were given
to the students to be taken up the following week.
The clinical case study process represents an opportunity for
the student to review, reinforce and gain a greater comprehend-
sion of the biochemistry covered in lecture. To keep the stu-
dents involved in the process, enough weight was placed on the
midterm and final exams in regard to the case studies so that
each student valued the importance of successfully completing
the learning issues and attending the large group classes. The
NUHS IRB committee reviewed this descriptive project and
deemed it not to fall under the IRB auspices as it is not re-
search.
Case Study Example 1
This clinical case study used a protein malnutrition case to
focus on the biochemical topics of proteins, amino acids and
enzymes.
MJ is an 81 years old white female who lived alone and was
found lying on the kitchen floor by her son. She was confused,
disoriented and had great difficulty walking because of weak-
ness. She appeared thin and frail, with significant muscle wast-
ing. Her son periodically checked in on her and brought her
groceries, but she has only been eating Saltine crackers and
drinking tea for the past couple of weeks. She stated that she
experienced difficulty swallowing and easily got heartburn after
she ate. She had lost more than 25 pounds in the past couple of
years. On physical exam she weighed 81 lbs, and her height
was 5’2”. Her temperature was 99˚F; blood pressure 105/80;
heart rate 62 with an irregular rhythm and respiratory rate of 16.
Her skin was pale and dry, with many small perfectly round
pinpoint purplish red spots on her arms, hands and legs. Her
hair was dry and thin; the temples were sunken; the tongue was
reddened with several small ulcers, and there were ulcerations
at the corner of her mouth. There was moderate pitting edema
of both feet and ankles. She was hyporeflexive and there was
decreased bilateral vibratory and position sense in the feet. A
chest exam revealed decreased breath sounds in the lower right
lobe and a chest X-ray indicated consolidation in the lower
right lobe.
This clinical case study allows for students to investigate
proteins biochemical role in both structural (i.e. collagen) and
functional (i.e. enzymes) physiology. This case study also al-
lows students to investigate the role of co-enzymes and relate
certain vitamin and mineral deficiencies to the patient’s signs
and symptoms. The learning issues posed to the students for
this case included:
What is the cause and mechanism pertaining to the bilateral
swelling of both lower extremities?
What is the cause and mechanism behind the multiple small
perfectly round pinpoint purplish red spots (petechia)?
What is the cause and mechanism related to the develop-
ment of her pneumonia?
What is the cause and mechanism of her swollen reddened
tongue and the ulcerations at the corner of her mouth?
What are the physical, psychological, social and economic
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M. P. MCRAE
factors related to anorexia of aging?
At the next 2 class sessions in a large group setting, the stu-
dents would discuss the learning issues from the previous week,
and the instructor would illustrate the mechanisms as laid out
by the students. Figure 1 is an illustration of the mechanism
behind the bilateral swelling of both feet and ankles and Figure
2 is the illustration of the mechanism describing the multiple
small peripheral extremity hemorrhages (petechia).
Note that from one class to the next the illustrations will vary,
but ultimately they would all portray the pertinent and vital
information necessary to explain the mechanism.
Case Study Example 2
This clinical case study used a diabetes case to focus on car-
bohydrate metabolism.
RW is a 54 years old male whose chief complaint is right
sided low back pain which started the day after helping a friend
move. RW is an office worker who leads a sedentary life with
hardly any regular physical activity. He states he has come to
see you because his back pain prevents him from falling asleep,
and this is especially bothersome since he is getting in and out
of bed 3 to 4 times a night to urinate. He states that his appetite
increased in recent months and that he feels thirsty much of
Figure 1.
Illustration of the mechanism behind the bilateral swelling of both feet
and ankles.
Figure 2.
Illustration of the mechanism describing the multiple small peripheral
extremity hemorrhages (petechia).
the day, in spite of drinking 5 to 8 cans of soda a day. He also
admits to drinking “more alcohol than I should” often drinking
several beers and/or cocktails a day both at lunch and in the
evenings. On physical exam he weighed 264 lbs., and his height
was 5’10”. His temperature was 98.5˚F; blood pressure 160/94;
heart rate 88 bpm and a respiratory rate of 16. Upon physical
exam it was deduced that he had a right L4/L5 facet sprain-
strain, but light touch was decreased in both feet and his uri-
nalysis was positive for glucose.
This clinical case study allows for students to investigate
carbohydrate metabolism and insulin’s role in normal metabo-
lism. The learning issues posed to the students for this case
included:
What is the cause and mechanism pertaining to his hyper-
glycemia?
Which type of diabetes does he have and what is your
proof?
What is the cause and mechanism involving insulin resis-
tance?
What is the cause and mechanism related to the develop-
ment of his bilateral lower extremity peripheral neuropa-
thies?
What is the cause and mechanism for type II diabetics be-
coming insulin dependent?
What are the biochemical consequences of his alcoholism?
How will his diabetes impact your treatment plan for his
low back injury?
At the next 2 class sessions in a large group setting, the stu-
dents would discuss the learning issues from the previous week,
and the instructor would illustrate the mechanisms as laid out
by the students. Figure 3 is an illustration of the mechanism
behind the bilateral lower extremity peripheral neuropathies.
Discussion
Clinical case studies can be a helpful adjunct for teaching the
content of human biochemistry that complements the traditional
approach of lecture, textbook and laboratory. The clinical cases
studies can foster intellectual development as students consider
opposing or alternate possibilities in their approach to the solu-
tion of a problem, but such a format can also cause confusion
and cognitive frustration if students do not have the prerequisite
knowledge to handle the problem (Cliff & Wright, 1996).
Figure 3.
Illustration of the mechanism describing the bilateral lower extremity
peripheral neuropathies.
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M. P. MCRAE
Copyright © 2012 SciRe s .
1176
Therefore it is believed that the case studies must be designed
to encourage successful learning and not overly frustrate stu-
dents (Sandstrom, 2006). Although very few first trimester
students possess any significant clinical knowledge, collec-
tively as a group, the knowledge possessed by single individu-
als will collectively come together, and therefore as a group
they will adequately get through the case.
Another significant limitation involves students not follow-
ing through on the learning issues and deciding to ride the coat
tails of their more ambitious peers. As well, in the large group
session, there is the potential that a subset of students may de-
cide to hide behind the efforts made by more outgoing and
enthusiastic students. This decision on their part essentially cuts
these students off from experiencing the rewarding opportunity
the clinical case study can provide. Finally not all biochemistry
professors will have the confidence to take the students through
a clinical case study because they may feel like they do not
have sufficient “clinical expertise”. However the case study
experience can be designed to script out the clinical pathway,
and so the instructor can tailor the case to fit the level of clini-
cal experience he or she possesses.
The clinical case studies presented in the biochemistry course
will help remind students that what they are learning has rele-
vance in the real world, and may also help motivate students to
pay more attention to the numerous facts faced in biochemistry.
The learning issues presented to the students requires them to
reformulate biochemical concepts in their own words, integrate
diverse principles and decide what information was important
and what was superfluous. Clinical case studies enable students
to lea rn a wi de r sco pe of ma te ri al t han c ou ld be pr e se nt e d in t he
lecture, and learning in the context of specific cases facilitates
cognitive flexibility and improves the student’s higher order
reasoning skills (Irby, 1994). Student’s discourse during the
large group sessions also provided opportunities for connecting,
challenging and extending their knowledge. However, whether
students actually attain a more sophisticated knowledge as a
result of this experience will require further study with the next
step being to develop a study to compare students who use case
studies versus those who do not.
Conclusion
Clinical case studies are a valuable addition to the traditional
methods of lecture, textbook reading and laboratory for teach-
ing biochemistry. More importantly clinical case studies help
remind students that what they are learning has relevance in the
real world, and may help motivate students to pay more atten-
tion to the numerous facts faced in biochemistry.
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