Anuradha Joshi, MBBS, MSc, PhD

H.M. Patel Centre for Medical Care and Education, Gujarat, India

 

Can we make an education system which will retain smiles on the faces of our children?1
Abdul Kalam

Image by Anuradha Joshi

At a time when doctors are confronted with a veritable explosion of new facts and information, teachers in medical schools should face up to the challenge of instilling in their students the habit of learning in creative ways rather than falling back on traditional memorisation by rote learning. It is indeed time to make medical education exciting and interesting. The teachers of today should develop more effective modes of teaching to kindle in their students enthusiasm and creativity.

 

We think too much about effective methods of teaching and not enough about effective methods of learning.2 In pharmacology, my primary area of focus, students are overburdened with curricula requiring them to assimilate a great number of facts that at first sight appear dry, possibly irrelevant, and difficult to remember.3 Teachers should aim to enrich the learning environment by incorporating of a variety of teaching and learning strategies both in and out of the classroom.

Students reap several benefits when medical learning is reinforced through arts activities. First, students memorize the core concepts of a topic more quickly than through other methods. They also learn materials more mindfully, rather than mechanically—which is often the result of rote learning. Finally, the interactions between students and teachers promote critical reflective thinking, which further stimulates curiosity and enhances reasoning skills.

In my experience, there are two main areas where students have difficulty learning: memorizing specific facts, such as learning the profile of a certain antimalarial drug; and understanding broader connections between specific materials, such as comprehending the differences between anitimalarial drugs. In the following paragraphs, I describe several methods that I have found particularly effective in addressing these challenges. I have employed examples that I use when teaching pharmacology; however, these techniques can be adapted to suit a number of subjects.

 

Activities that are useful in acquiring an in-depth knowledge of a specific area include writing autobiographies and drug alerts, or constructing bead diagrams. The autobiography exercise asks students to use their knowledge of a particular area to write a creative narrative. For example, students might be asked to write an essay on a particular drug that discusses its historical aspects, pharmacokinetic and pharmacodynamic aspects, uses, adverse drug effects, and the various formulations available on the market. They should write as if the drug itself were speaking about its own features in an interesting way, thus amalgamating science with art. They could present the autobiography of drugs with an interesting history of discovery or features, such as adrenaline, heparin, or serotonin, adding some interesting phrases. The successful completion of the task depends on a great deal of creativity, intelligence, interest, knowledge, and originality. The “Autobiography of Chloroquine” below illustrates this technique.

Similarly, composing a drug alert can help students understand the safety profile of a particular drug. In my class, I ask students to prepare colourful drug alerts on particular medicines highlighting information such as black box warnings, safety warnings, and recalls, after collecting information and referring to pharmacological textbooks, journals, and web sites. In an age of rapid proliferation of new drugs and dosage forms on the market, there is a dire need to educate our community regarding the adverse effects of drugs in order to ensure their safe use in clinical practice. Activities such as this help to reinforce this information.

 

Constructing bead diagrams can solidify students’ understanding of physical structures, such as the configuration of chemical compounds and interactions, by developing their psychomotor skills. I have successfully used this method when I discuss the medicines used for diabetes mellitus. After all of the class materials have been introduced, I display the sequence of various amino acids of insulin in the respective chains. My students are then divided into two groups. One volunteer from each group is asked to construct a representation of the amino acids from beads. For example, in case of diabetes, students might be asked to construct a model of human insulin with A chains of 21 amino acids and B chains of 30 amino acids. Whoever is able to arrange the beads in proper amino acid sequence first wins.

To help students understand the broader relationships between topics, I use concept maps and collages. A concept map deepens students’ comprehension of the key points of a topic’s highlights by asking them to summarize an entire subject with a single diagram. This drawing summarizes the topic by connecting related materials with circles, boxes, and lines.4 Since students often have difficulty balancing their heavy course loads, this activity can help students understand a drug at a single glance and quickly memorize the basics. Studies have shown that the concept mapping method can be an important tool to prepare graduates for the complex healthcare environment.


Collage activity5 is a method that encourages creativity, which promotes interactive learning and helping students to make personal meaning of their existing knowledge on a topic. This can be conducted after completion of a particular topic in any of the subject of medicine. Students are instructed to collect colourful materials like paper cuttings, pictures, and diagrams from textbooks on a particular topic and then prepare an academic collage. For example, during the study of antimalarials, students could be divided into two groups: one assigned antimalarials in general (e.g. collage on uncomplicated P. falciparum malaria); the other a collage on chloroquine-sensitive malaria. The students are told to create a collage by applying their own innovative ideas. The materials needed for this exercise are pharmacology books, national guidelines for control of vector borne diseases, diagrams of the mosquito life cycle, expired tablets and capsules, and empty cover packs of medicines used in each condition.

In conclusion, there is a great difference between teaching and learning.6 Learning is not about committing a set of facts to memory, but using resources to find, evaluate, and apply information; similarly, teaching is not about telling students what we know, but rather showing students how we learn. Educators today are under pressure to prepare graduates who are able to think flexibly and critically to solve problems in a variety of clinical practice settings. Combining art and medicine is an effective way of communicating this information in a creative and stimulating way.

 

Example: autobiography of chloroquine

Hello friends, I am Chloroquine and just want to share some facts about myself. I was born in the year 1934 at the Bayer laboratory and my father was Hans Andersang. He and his co-workers first named me as Resochin. To my utter shock, I was initially rejected by the community because of my toxic potential in avian models. But then I got recognition in 1947 and was determined to be highly effective against erythrocytic forms of sensitive strains P. vivax, P. ovale, and P. malariae, as well as the chloroquine-sensitive strains of P. falciparum. Unfortunately, I exhibit no activity against primary or latent liver stages of the parasite; however to prevent relapses from P. vivax & P. ovale infections, my very dear friend Primaquine can be administered along with me.

 

I am a weak base, and I am well absorbed from the gastrointestinal tract and rapidly from intramuscular and subcutaneous sites. My volume of distribution is very high, so I have a tendency to sequester in tissues, especially in liver, spleen, kidney, lung, melanin containing tissues, and to a lesser extent to in the brain and spinal cord. So, friends, beware of my strong tissue connections. Because of this extensive binding property, I have to be given in a loading dose of about 600mg (10mg/kg base) followed by 300mg (5mg/kg base) after 8 hours and then for next 2 days, for a total of 25mg/kg over 3 days. Following this, my friend Primaquine can be administered along with me in a dose of 15mg (0.25mg/kg daily for 14 days). After undergoing biotransformation in the liver, I am excreted by renal route.

My mechanism of action is very interesting, as I accumulate inside the highly acidic digestive vacuoles of susceptible Plasmodium due to my weak basic nature. Here I raise the vacuolar pH and thereby interfere with degradation of haemoglobin by parasitic lysosomes. I also inhibit the parasitic enzyme haem polymerase and thus protect the host’s haem from being converted to haemozoin. Simultaneously I am also able to inhibit peptide and amino acid synthesis necessary for plasmodia’s viability.  Ha! Ha! you see I can really trouble the Plasmodium to the core. Regarding my safety profile, I am safe if taken in proper doses for the recommended duration, but my safety margin is narrow. In my normal dose, I may cause gastrointestinal upset, nausea, headache, visual disturbances, and urticaria. If I am given for a prolonged time I will have the tendency to cause diplopia, confusion, convulsions, widening of the QRS interval, and T wave abnormalities. Unfortunately, I may cause in any one of the recipients a lichenoid skin eruption and bleaching of the hair; however, one need not panic, as these side effects disappear after I am withheld. During pregnancy, don't worryI can be given to mothers if they are suffering from malaria.

One should take due caution in not administering me along with drugs like mefloquine, amiodarone, and other antiarrhythmics. Also, please do not use me on those suffering from liver diseases, severe gastrointestinal damage, or neurological and haematological diseases, as I may precipitate an attack of seizures, porphyria, or psoriasis. Be aware that my high daily dose greater than 250mg per day can lead to irreversible retinopathy and ototoxicity. I am inexpensive and quite a safe if taken in proper doses for the recommended duration of time. Also, I would humbly request that all healthcare professionals not administer me too rapidly by the parenteral route, as this can be highly deleterious to patients’ cardiovascular and central nervous systems. Because this type of adverse effect is more likely to occur in children, beware of such medication errors.

Finally, I am available in the market as an oral chloroquine phosphate tablet, 250 mg=150mg base. My dear, dear recipients, remember I am quite bitter in taste (although to prevent this I am coated with sugars). Also, do take care not to chew me. Finally I am also available as 100mg (base) per 10ml oral suspension and as Parenteral chloroquine 40mg (base)/ml injection in 2 and 5ml ampule. So dear friends, here I am, your antimalarial friend, Chloroquine, and this is my story.

Reference

  1. APJ Abdul Kalam: Inspiring thoughts by APJ Abdul Kalam. India: Rajpal& Sons; 2008, p. 29.
  2. Fink Dee L: Creating significant learning experience: An integrated approach to designing college courses, San Francisco, California; Jossey Bass 2003.
  3. Achike Francis I. Information overload in the teaching of pharmacology. Journal of Clinical Pharmacology, 200; 40:177-183.
  4. Clayton LH Concept mapping: an effective, active teaching-learning method. Nurs Educ   Perspect. 2006  Jul-Aug; 27(4):197-203.
  5. Seymour RJ: Creating a collage: A meaningful interactive classroom strategy. Nurse  Education 1995 MayJune;20(3):19-21
  6. Lujan. L. Heidi and  Di Carlo.E. Stephen: Too much teaching, not enough learning: what is the solution? Adv Physiol Educ 30: 17–22, 2006.


ANURADHA JOSHI, MBBS, MSc.(Medical in Pharmacology), PhD, is an Associate Professor of Pharmacology at Pramukhswami Medical College, H.M. Patel Centre for Medical Care and Education in Gujarat, India. Her areas of interest are cognitive learning and reforms in the teaching of undergraduate pharmacology. Education is her passion, and she has worked continually to create moments of enlightenment for her students.