This document describes a pedagogical experiment conducted with undergraduate medical students at Universidade Federal do Estado do Rio de Janeiro (UNIRIO) in Brazil. The experiment uses problem-based learning to have students research and present case reports on metabolic diseases using real patient medical records. The goals are to stimulate students' interest in cell biology, biochemistry, and research skills while connecting these basic science subjects to clinical practice. Results found increased classroom participation and more students volunteering to participate, indicating this approach improved student engagement with the course material. The conclusion is that case reports enrich learning by transforming the teacher-centered method into collaborative student-teacher learning.

1. Description of a pedagogical experiment on building undergraduate
students’ clinical thinking coupled up with cellular processes and
biochemistry understanding
Letícia Vargas de Mesquita1
, Carlos Eduardo Abbud Hanna Roque2
, Carolina
Ávila de Almeida3
, Ricardo Felipe Alves Moreira4
, Cristiane Barbosa Rocha5
1
Undergraduate Medical Student at Universidade Federal do Estado do Rio de Janeiro –
UNIRIO (Brazil)
2
Undergraduate Medical Student at UNIRIO, Fellow of the Extension Department of UNIRIO
(Brazil)
3
Undergraduate Medical Student at UNIRIO (Brazil)
4
Ph.D. Associate Professor in the Public Health Department, UNIRIO (Brazil)
5
Ph.D. Associate Professor in the Biochemistry Department, UNIRIO (Brazil)
leticiavmesquita@yahoo.com, carloseduardoroque@ig.com.br
Abstract
Introduction: Traditional teaching methods have been criticized for under stimulating students’
autonomy. “Problem Based Learning” (PBL) is pointed as a promising tool to improve the development
of students’ decision making ability as well as research skills. It is useful to help students with hard
sciences-related subjects.
Aims: To trigger undergraduate health sciences students’ interest in cell biology, biochemistry and
research.
Methods: UNIRIO students from second semester and above elaborate case reports by means of
analysis of selected Gaffrée e Guinle University Hospital’s (HUGG) medical records. They receive
orientation from tutors, and must present the case in classroom to first semester students, showing the
cellular processes involved in the illnesses. The case selection contemplates patients with listed
metabolic diseases.
Results: Classroom participation increased. A crescent amount of students have volunteered to enter
the project after they pass the course, including a few who have previously failed, indicating that the
method influenced student-course relation.
Conclusion: The case report elaboration and presentation have enriched classroom experience,
modifying the traditional teacher-centred method into a dynamic collaboration between the parts.
Students are exposed to tangible connections among Biochemistry, Cell biology and Clinical Practice,
which is valuable to courses that usually bring the students to question the “real life” use of the taught
information.
This project was approved by the HUGG´s Research Ethical Committee and has funding support of
the UNIRIO´s Extension Department.
Keywords: case report, biochemistry, cell biology, health sciences.
1 Introduction
Traditional teaching methods are usually based on the model of content exposure made by a
professor or tutor, followed by individual student efforts at home/library, in order to memorize the
subjects and become prepared for further inquiry. This technique is considered non-challenging,
lacking proper stimulus for students’ autonomy and ability to find their own way of learning [1],[2].

2. Over the past years, educators have been concerned about applying teaching methodologies that
emphasize the role of students on their own knowledge acquisition. This matter resulted in worldwide
curriculum changes [3].
When it comes to medical training, case reports have long been suggested as an efficient technique to
unite practice and theory [4], inspiring also the discussions of Problem Based Learning (PBL) [5]. The
method itself was created in the environment of a medical school, as an important tool to teach
students how to make the bridge between classroom and clinical practice, through constant analysis
and discussions of hypothetical situations
On the context of PBL, case reports elaboration offers students an opportunity to direct their own
learning path, whilst exploring scientific processes implicated on complex clinical settings. Case
reports are commonly used to train decision making abilities, whereas PBL original idea is mainly to
promote scientific subjects acquisition.
Health sciences graduation students must germinate clinical reasoning, a foundation element of
diagnosis hypothesis skills, and its consequent differential and definitive diagnosis making.
By elaborating and discussing case reports, students are able to develop an interactive way of
connecting practice and theoretical content. The relevance of this method is precisely the linkage
made between basic science and medical praxis [6], thus proving to be an important learning tool all
over medical training rather used on most of the curriculum, especially on courses that bring hard
sciences contents, such as biochemistry and biophysics.
Medical Biochemistry is a branch of clinical specialties that assists the interpretation of signs and
symptoms presented by the patients, providing instruments to diagnose and solve health issues.
These investigations are involved on a large spectrum from prevention to prognostics, including
diagnosis, monitoring amid others. Biochemical tests may comprehend over a third of all laboratory
investigations of a hospital.
Best clinical and therapeutic practice is a result of constant training and knowledge of every available
tool, and the academic environment is a privileged place moment to start producing these actions.
Hence the project of conjugating theory and case report elaboration on Universidade Federal do
Estado do Rio de Janeiro´s (UNIRIO) medical biochemistry course.
2 Aims
• Guide groups of students on the preparation of case reports and lectures based on real medical
cases (assisted inwards University Hospital Gaffrée e Guinle, HUGG) exploring their clinical
biochemistry and cell biology knowledge.
• Take advantage of the hypothetical deductive method in order to encourage autonomy, creativity
and self-education skills.
• Trigger undergraduate health sciences students’ interest in cell biology, biochemistry and
research; also enrich the ability to discuss and criticize case reports of hypothetical and real
patients, stimulating their clinical thinking; research accomplishment.
• Accumulate reports to create a bank of biochemical disorders treated on HUGG through analysis
of medical records.
3 Methodology
Groups of senior UNIRIO’s students who have already taken the course “Medical Biochemistry” are
selected to voluntarily participate this program, while two students receive a scholarship. They have

3. weekly meetings with the professor in order to plan their actions, study better practices and discuss
possible case reports.
On an attempt to integrate pupil monitoring and extension, these students from second semester and
above elaborate case reports by means of analysis of selected Gaffrée e Guinle Hospital’s (HUGG)
medical records. They receive periodic orientation from tutors, and must present the case in classroom
to first semester students, showing the cellular processes involved on a previously chosen illness. The
case selection contemplates patients with listed metabolic diseases, and is made by the students after
they visit and explore the medical records archive. Once the case is selected, they show it to the
professor who will advise and direct their studies. They will then elaborate a case report presentation,
with the task of give junior students a view not only of the disease but also of its metabolic etiology and
biochemical components behind it. It must be included on the course content.
The project is being developed on the premises of the department of biochemistry and Gaffrée e
Guinle University Hospital. Students analyze medical records of patients seen and hospitalized in this
hospital over recent years. Case reports are being developed based on data obtained from HUGG’s
medical records, emphasizing biochemical aspects contained on the results of specific and
complementary tests, combined with findings described on scientific literature . All documentation is
accompanied by appropriate clinical laboratory results. Every data obtained from medical records is
collected respecting patients’ privacy, and their identities remain confidential, following the guidelines
of the Ethics Committee.
Case reports produced during this extension project are used in classroom. Tutored students involved
in the project send in advance the cases to freshman year students (enrolled in this course), with
questions they must try to answer. The questions usually demand a diagnostic hypothesis, laboratory
tests they could ask to help them to test their hypothesis, and typical findings and parameters of the
named disease. They have a week to prepare the answers. After this period, the tutored students
deliver lectures about the disease described on the cases accentuating the cellular and biochemical
processes of it, and check with audience possible doubts and different hypothesis, stimulating them to
rethink alternatives and differential diagnostic ways.
As a matter of illustration, a group of students delivered a lecture based on a rare case of paroxysmal
nocturnal hemoglobinuria (PNH) treated on HUGG. To show the connections between the illness itself
and its biological etiology, this group not only described the symptoms and course of the disease but
emphasized the cellular system that allowed such medical condition. They explained how its etiology
is related to a surface protein malformation, and showed the cellular paths that lead to this
characteristic and its consequent symptomatology. The subject was part of the protein metabolism
content, which was being taught on previous classes by the professor. This way they could make a
link between the topic and a possible clinical finding.
This project was approved by the HUGG´s Research Ethics Committee (n.08/10; CNS196/96) and has
funding support of the UNIRIO´s Extension Department.
4 Results
This method appears to benefit the students’ comprehension of the subjects on a broader spectrum,
for it offers them a bridge connecting what can be perceived by a freshman as “harsh content” into a
pleasant discovery of the practical side of the theme.
Classroom participation increased, signaled by the number of questions and comments after the
lectures. Students often brought up some of the discussed content on the following classes, what can
be perceived as an indicative of an appropriation of what was taught.
We have also observed that an increasing amount of students have volunteered to enter the project
after they are approved on the course, including a few who have previously failed medical
biochemistry, indicating that this method influenced student-course relation. The project started on the
first semester of 2010 with three invited students, chosen because of their merits (grades and
interest).On the first semester of 2011, we had one more student join the team, he also volunteered to
participate. On 2011, second semester, 15 new students volunteered, but two had to discontinue
participation because of their graduation. On the first semester of 2012 we had a total of 21 students,
which are still part of the team. Because of a national universities strike, we had to adjust the calendar

4. and weren’t able to accept new volunteers for the second semester of 2012, although the work was
maintained. This numbers support our hypothesis that the students became prone to join the team
after taking the course and observing the effects of their colleagues’ efforts on their own learning
processes, what leaded to an interest to volunteer and also become part of the team.
Although this result has been shown through assessments and class observation, the evaluation of
this study is still incipient, once the tools to quantify these data are still being developed. At the
moment questionnaires are being tested to make a quantitative record of students’ perception of the
subject before and after taking this course.
5 Conclusion
Case report elaboration and presentation have enriched classroom experience, modifying the
traditional teacher-centered method into a dynamic collaboration between the parts. Students are
exposed to tangible connections among Biochemistry, Cell Biology and Clinical Practice, which is
valuable to courses that usually bring the students to question the “real life” use of the taught
information. Both senior and junior students are harvesting the benefits of PBL: senior by learning
research skills, case report elaboration, practicing their oratory and lecture delivering, preparing
themselves for peers inquiry and more. Juniors benefit from being early exposed to practical content,
as well as being pushed to start building their own problem solving expertise. The interaction between
students from different levels proved to be an extra gain, for they have an opportunity to exchange
their college experience and learn how to do teamwork.
Further investigations must be made to quantify these achievements, although this practice appears to
be successful on its purposes.
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