16
purpose or task achieved? One way of assessing the
success of small-group teaching is to issue a questionnaire;
in other words, to undertake a formal evaluation rather
than relying on hearsay. Questionnaires need careful
planning and professional advice: at the very least,
copying or modifying someone else's questionnaire, is
recommended.
Conclusions
In a recent book by Weatherall (The New Genetics and
Clinical Practice5) the author called attention to the need,
in his opinion, for a new generation of doctor who has a
foot firmly planted on both the clinical and the basic
sciences. There was, he said, a need for not only
education but also of discussion of the issues involved at
all levels. Of course, I am not talking here solely about the
education of medical people. These skills are required by
all professional scientists. The tutorial can start the
process of discussion. This is important not only as a way
of helping the understanding of concepts but also of taking
an active and informed part in discussing the issues. This is
totally different from learning something and then of
reproducing it in an examination or of learning intellectual
and technical skills that might conceivably be of use in
future professional practice. It is the start to making a
contribution in science.
To summarise, I believe that we should aim to develop,
in students, such mental skills as critical and analytical
thinking, interpretation and deduction, as well as com-
munication skills. Tutorial teaching and group discussion,
if properly organised, must be one of our major ways of
achieving these. In addition, in the sciences, there is the
need to integrate different facts, see overall patterns and
discern general principles. In this respect, too, small-
group teaching would seem to offer the enlightened
teacher outstanding opportunities. Most important of all
is that a properly run tutorial will demand active involve-
ment of all the students. Active involvement means that
knowledge must have been remembered, digested, cor-
rected, correlated, and can now be used.
It has been reported that we remember about 20% of
what we hear, about 30% of what we see, about 50% of
what we see and hear, and 90% of what we do, that is, of
what we actively participate in. Lectures and laboratory
classes obviously have their place. However, I believe that
tutorial teaching, although it is the most expensive system
in terms of staff time, has greater potential than any other
for effective teaching and for the production of a fully
developed individual by our educational systems.
References
t Mehler, A H (1983) 'Strategies in Biochemical Education' Biochem
Educ 11, 95-118
2Newble, D and Cannon, R (1983) 'A Handbook for Clinical Teachers'
MTP Press, Lancaster, UK
3Wood, A E (1981) 'Learning in Small Groups' in 'Biochemical
Education' edited by Bryce, C F A, pp 141-155, Croom-Helm, London
4Bion, W R (1968) 'Experiences in Groups', Tavistock Press, London
5Weatherall, D J (1986) 'The New Genetics and Clinical Practice'
(Second Edition), Oxford University Press, Oxford
B I O C H E M I C A L E D U C A T I O N 16(1) 1988
Biochemistry in the Medical Curriculum
N CHANDRASEKHARAN
Department of Biochemistry
Faculty of Medicine
University of Malaya
Kuala Lurnpur, Malaysia
Introduction
During the last fifty years, biochemical principles, con-
cepts and technology have become increasingly important
for the understanding of disease, clinical treatment and
medical research. Advances in biochemical sciences have
led to progress in medicine, and this is entirely recognised
by the medical profession.
However there is dissatisfaction with the teaching of
biochemistry in medical schools, especially in the pre-
clinical years. Doctors and clinical students have often
criticised the teaching of biochemistry, saying that the
bulk of biochemistry taught to them in their preclinical
course has been only of minor value to them in their
clinical studies, investigation and treatment.l-3 Biochem-
istry is considered as a hurdle by many. A general
prevalence of dislike for biochemistry has built up over
the years amongst students and this is disheartening to
teachers. It has been said that biochemistry is a difficult
subject, not only for the student, but also for the teacher
and this opinion is widespread. 4-6 The fact that many
attempts have been made to change the emphasis on
formal conventional teaching highlights the problem.
There have been many attempts at developing curricula to
make biochemistry more relevant to the study of medicine
and textbooks have been written with this objective. 7 That
those doctors who have been through a system may from
experience be able to improve that system for their
successors must be acknowledged by the teachers and
authorities in universities as part of a developing evalu-
ation of medical education.
Feedback
We must recognise the importance of inputs from
students, past and present, as well as the medical
profession in general, as their understanding will facilitate
appropriate remedial measures towards improving the
teaching of biochemistry to medical students. In order to
get feedback information on the problems associated with
the teaching of biochemistry in the preclinical years, a
questionnaire was distributed to all students towards the
end of the academic session. The areas covered included
the lectures, tutorials, practicals and general aspects of the
course. Information was also obtained through discussion
with clinical students, doctors in teaching institutions and
hospitals. Information gathered by the medical students'
society in earlier years was also utilised, s'9
The responses from students were analysed and are
discussed in the context of views expressed by other
educationists on this subject. The information presented
here gives some feedback on the success or failure of
 17

instructional programmes and staff in biochemistry as well
as on areas of concern (Tables 1-6).
Objectives
The objectives of the biochemistry course were not clear
to the majority of students: they could not appreciate the
purpose or relevance of the bulk of the biochemistry
taught to them (Table 1).
Students enroi in the medical faculty to become doctors
and their major objective is the acquisition of skills
needed for medical practice. Our objective as teachers is
to equip medical students with an adequate biochemical
background for the study of medicine, ie to facilitate the
study and understanding of other medical disciplines. It is
a course which should also prepare medical students for
future years of medical education. 10
Many students had difficulty in coping with the first-
year medical curriculum. Of the three preclinical subjects,
biochemistry was ranked as the subject liked most by only
16% of the respondents. Students thought that biochem-
istry was taught excessively in terms of the amount of time
devoted to the subject. It is pertinent to ask whether
professional biochemists should decide what is important
for a medical student?
Universities decide how many hours shall be spent on
different subjects and they inevitably do so on the basis of
tradition and estimates of importance. Views of con-
sumers are generally not taken into account and so
curricular subject time and therefore importance can be
perpetuated in an authoritarian and empirical way.
There is intense competition for curricular time, as the
amount of subject matter to be learnt keeps growing.
Factual overload continues, for it is easier to add new
material to the course than to delete it. Some traditional
physiological chemistry topics are often deleted.1
The basic sciences like biochemistry cover such a vast
range of knowledge that it is difficult for the student to
have a profound understanding of any part. It must also
be appreciated that basic medical education is a continu-
ing process. Biochemistry is only one of the several
subjects in the medical curriculum, and other subjects
both basic and clinical are equally important, t2 There
have also been advances in other areas. We have to be
realistic in the time allocated for biochemistry as well as in
selecting what biochemistry needs to be included in the
curriculum.
One of'the major complaints of students and doctors
was the irrelevance of substantial parts of the course to
medicine (Tables 1 and 2). Often the student finds
difficulty in relating biochemistry to other disciplines such

Table 1 Students' responses to a questionnaire on the Table 2 Students' attitudes to biochemistry (at the end of the
biochemistry course in the medical curriculum biochemistry course)

Respondents Respondents
(%) (%)
A Objectives not clear 55 A Ranking amongst the three pre-clinical
subjects (Anatomy, Biochemistry and
B Difficulty in coping with the 1st year Physiology)
medical curriculum 45 1st 16
2nd 39
C Application of biochemistry (taught in 3rd 45
1st year) to clinical years:
very often 1 B Interest
quite often 4 nil 16
sometimes 50 very much 39
hardly ever 45 average 45

D Retention of biochemistry (as taught in C Knowledge

the first year) for application in clinical learnt nothing 10
years: learnt a lot 4
good 0 average 86
fair amount 9
very little 91 D Enjoyment
boring 5
E How well has the department of bio- very much 9
chemistry prepared you for the clinical average 86
years?
very well 0 E Future application
quite well 8 very useful 12
satisfactory 41 not perceived 5
poor 50 average 83

BIOCHEMICAL EDUCATION 16(1) 1988

18
as anatomy, physiology, pharmacology and to the func-
tioning of the body as a whole and thus the application of
these concepts to the disease process. Substantial parts of
the biochemistry course are irrelevant to the future needs
of contemporary medical practitioners and are presented
when the student is ill prepared to grasp their relevance
and significance to clinical practice. 1,3
Tutorials, practicais and exams
Some of the comments made by students are worth
consideration, even though they are not revolutionary
(Table 3). The traditional aim of supplementation and
reinforcement of didactic material is very often not
attainable. Very often there is no correlation between the
practical classes and the lecture topics. Often the equip-
ment and methods used affect the quality of results.
Dissatifaction with practical classes is nothing new. 6
Table 3 Some of the comments of students on practicals and
tutorials in biochemistry
Tutors have insufficient knowledge for conduct of prac-
ticals and tutorials
Benefits of tutorials vary with the topics and tutors
Often practicals have no correlation with lecture topics
Insufficient emphasis placed on objectives and principles
of the practicals
Unsatisfactory discussion of results
The value of many of the practicals to practising
physicians is limited. Often people who conduct these
practicals are isolated from developments in clinical
chemistry. In this connection a clinical chemistry format
may be useful, as clinical chemistry determinations and
clinical correlations may be more meaningful. There is a
global trend to reduce practical classes, with the hope that
practical class time, if reduced, will be filled by more
lectures and tutorials. A depressing tendency indeed!
For maximum benefit, participation from both students
and staff is essential at tutorials and this calls for adequate
preparation before coming to tutorial classes. 13
At present the learning of biochemistry is oriented
towards overcoming examination hurdles. Medical
students will continue to be overloaded with masses of
factual information, whilst examinations will continue to
assess merely the ability to recall specific facts, rather than
their competence to apply basic principles in problem
solution. 3.1o
The requirements for studying medicine vary consider-
ably. In some countries a basic science degree is a
prerequisite for the study of medicine and such students
have a high level of academic achievement. Textbooks
designed for such students are often also prescribed for
students with inadequate knowledge of English as well as
B I O C H E M I C A L E D U C A T I O N 16(1) 1988
lower entry qualifications. Some books require knowledge
of extensive clinical situations. 7 Books which are recom-
mended are at times not accepted and students resort to
books used by their seniors.
What biochemistry should a practising physician know?
It is appropriate to ask: are we preparing students to be
physician-scientists, or for a teaching/research oriented
career, or of course clinicians.12 Perhaps it would not be
presumptuous to say that we would like to have a better
clinician.
Any review of the teaching of biochemistry must also
take into account, in addition to the course content and
context in which it is taught, the students and most
important the teachers. Some of the suggestions made by
students for improving the biochemistry course are listed
in Tables 4 and 5, and some of the factors that may
influence students attitudes towards biochemistry are
given in Table 6. It is important to rationalise the medical
curriculum and to decide what should be taught to
undergraduates and what can be left to later years to be
taught as part of chemical pathology. 10 It is necessary to
reduce the factual load in terms of the chemical content of
the course as well as details of metabolic pathways. There
is a need for proper distribution between basic and
clinically relevant biochemistry, and to orient biochem-
istry courses towards clinical problems. 3"7'm Isolated
preclinical courses are inappropriate and if they are seen
as unrelated to what is considered, rightly or wrongly, to
be the requirements of a practising clinician. The result is
likely to be the annhilation of students' enthusiasm and
motivation for studying biochemistry and medicine and
which are essential for progress in medical education and
practice.
The need for relevance must be accepted as far as
possible and we make it clear to the students that the way
in which each topic relates to the clinical situation at the
Table 4 Students' suggestions for improving the biochem-
istry curriculum in the medical course
Reduce the quantity of 'irrelevant' material taught
Improve the quality of lectures and lecturers
Highlight relevance to the practice of medicine
Table 5 Biochemistry course content: some points for
consideration
What is the role of biochemistry in medical education and
the training of doctors?
What are the areas of biochemistry which are of relevance
to other medical disciplines and medical practice?
How should the biochemistry course be taught?

Table 6 Factors that may influence students' attitudes
towards biochemistry
Motivation of students towards medicine and biochem-
istry.
Perception of the relevance of biochemistry taught to the
clinical subjects and the subsequent practice of medicine.
Are students' lecture and study time overloaded?
Are students too examination oriented?
time it is taught. It is not enough to assure them that it will
be valuable later. It is difficult for students to appreciate
the value of certain material if they do not witness its
application soon thereafter.14
Role of the teaching staff
Many innovative changes have taken place in the teaching
of biochemistry. There are attempts to eliminate the sharp
division which exists between the basic sciences and the
clinical sciences. It is often assumed that we have the
perfect teachers in biochemistry and so it is adequate to
modify the curriculum - - or sometimes the students.
A good teacher is one who is interested and prepared to
work sufficiently hard to get to know his subject and its
physiological and clinical applications. Adequate recog-
nition needs to be given to good teachers, as judged by
students. It must not be forgotten that the most effective
judges of a good teacher are the students them-
selves. 1,10.15
The teacher must explain, in terms the students can
understand, the complete concepts and principles. He
must guide and direct the student to assume a greater
responsibility for his own education. As an integrator of
experiences, the teacher assumes a multidisciplinary
approach with the major functions of co-ordinating,
relating, harmonising and associating all aspects of acad-
emic life and study. Performing this role the teacher
correlates knowledge, skills and behaviour with pro-
fessional practice. Perhaps it should be realised that no
educational system works better than that which is
acceptable to both students and teachers. The main thing
is to combine good teachers with good students.
The medical profession has a strong lobbying potential
and has taken considerable interest in postgraduate
medical education. However, it has paid relatively little
attention to the undergraduate medical curriculum. It
must take an active interest and institute remedial
measures in this long neglected area of medical education
and emphasise the need for periodical review and change,
and not allow those who have no interest or stake in the
future of medical education and practice to influence
professional training.
BIOCHEMICAL EDUCATION 16(1) 1988
19
Conclusions
Anyone attempting to change the pattern of medical
education is likely to face resistance from many quarters.
Faculty and departmental staff consider such an action an
encroachment on well established practices and a poten-
tial threat to academic autonomy and existing order. Any
reforms in medical education, fundamental or not, to be
effectively applied should not only follow other successful
new models, but also fulfil local, social, cultural require-
ments and be economically feasible. Finally it must not be
forgotten that biochemical knowledge must be seen as a
means to an end in the study of medicine rather than as a
subject which is satisfying by itself.
Acknowledgement
I would like to thank the many medical students, doctors and clinical
colleagues for their comments and useful discussions, the officials of the
Medical Society for permission to make use of some of their survey
results.
References
i Neame, R L B (1984) J Med Educ 59 699-707
2Muir, G G (1968) Lancet 1:632-633
3Wills, E D (1985) Biochemical Basis of Medicine Wright, Bristol, v-vi
4Candlish, J K, (1984) Lecture Notes on Biochemistry, Blackwell
Scientific Publications, Oxford, (preface)
5perumal, R (1987) 'Problems in biochemical education', in Malaysian
Biochemical Society Newsletter, 1-5
6Vella, F (1980) Innovations in the teaching of medical biochemistry, in
Biochemical Education Bryce, C F A editor, Croom Helm, London,
81-94
7Montgomery, R A (1980) A Case oriented approach-design, imple-
mentation and results, in Biochemical Education Bryce, C F A editor,
Croom Helm, London, 69-80
8Chandrasekharan, N (1985) The biochemistry course in the medical
curriculum - - Trends and students' attitudes, Abstracts X1X Malaysia
Singapore Congress of Medicine pp 132
9The Medical Society Survey on the medical curriculum, Faculty of
Medicine, University of Malaya, Kuala Lumpur, 1979
1°General Medical Council Recommendations on basic medical edu-
cation, GMC London, 1980
H Richardson, I M (1983) Med Educ 17, 8-10
~2Dakshinamurthy, K (1980) Syllabi construction, curriculum content
and relevance in medical biochemistry, in Biochemical Education
Bryce, C F A editor, Croom Helm, London, 58-68
13Woods, A E, Learning in small groups, in Biochemical Education
Bryce C F A editor, Croom Helm, London, 141-55
14Smith, A D (1983) Med Teacher 5, 56-93
15Veiga, S M G, Miller, M D, Hammock, J (1983) Med Educ 17, 87-9
Erratum
Drawing a Porphyrin Formula
In the article with the above title by H B F Dixon which
appeared in Biochemical Education 15(4), 208, point (2)
should have read 'Draw alternate double bonds round the
porphyrin ring . . . . '. We apologise for any confusion this
omission may have caused.