In the Classroom
Television Medical Dramas as Case Studies in Biochemistry Julie T. Millard Department of Chemistry, Colby College, Waterville, ME 04901;
[email protected] As is true of most chemistry courses, biochemistry has a relentless pace, and students are often so busy transcribing notes that they do not think about course material during class. Breaking up lecture with short periods that require students to think about and discuss the course material can be an effective teaching tool. Case studies are an excellent means to this end ( ref 1 and references within). Many topics in biochemistry, which attracts students interested in the health sciences, can be enhanced with the use of medical case studies (2). Medical case studies help students develop a deeper understanding of the material, rather than emphasizing simple recall. Complete seasons of many television shows are now commercially available, providing the opportunity to use popular culture as a tool in biochemistry education. In this article, I describe several interesting cases from two popular medical dramas, ER and House, compiling herein all of the scenes from the first nine seasons of ER and the first four seasons of House relevant to a traditional biochemistry course. These cases can be used as problem-solving opportunities in which students use fundamental principles of biochemistry to propose the correct diagnosis. Additionally, some clips contain inaccurate biochemistry, discussion of which can also be an effective critical-analysis tool. There are several advantages of the case-study approach, including increased engagement through active learning (3) and the mental refocusing that comes with a change of pace (4). Furthermore, case studies require application and analysis skills (levels 3 and 4 of Bloom’s taxonomy; ref 5); higher-order thinking skills that are critical for future success in medicine and biomedical research (6). Showing a short scene from a television drama piques the interest of students, energizing them in preparation to apply fundamental biochemical principles to complex problems. The Cases Protein Structure and Function Collagen is often used as a model protein to illustrate structure–function relationships. An introduction to the structure of collagen can also lead into a discussion of genetic defects and their manifestations. In a clip from ER (7), Dr. John Carter suspects child abuse when a young patient is found to have several broken bones. When a follow-up X-ray shows more rib fractures than the initial X-ray taken upon arrival, Carter realizes that he caused the additional fractures during his examination. His patient suffers from osteogenesis imperfecta, a collagen defect in which cysteine or serine replaces the normal glycine. The result is instability of the mutant protein and extremely brittle bones. A presentation of this case can be followed by an in-class discussion of the molecular basis of the disease. Many biochemistry courses spend considerable time on hemoglobin, which is an excellent model for allosteric enzymes. Clips from both ER and House can be used to illustrate important aspects of hemoglobin’s activity. In the first ER clip (8), a pregnant mother wakes in the night with labor pains. As she 1216
unsuccessfully attempts to rouse her family for the trip to the hospital, she comments to herself about how cold the house is. This scene provides a gripping introduction to hemoglobin, with students asked to postulate the events that led to this situation. Many students immediately gather that the family is suffering from carbon monoxide poisoning as the result of a defective furnace but are unable to explain why the mother is unaffected. Popular answers include her increased blood volume and hemoglobin because of pregnancy, but the correct solution (tighter binding of carbon monoxide to fetal hemoglobin) is more elusive. In the second ER clip (9), Dr. Carter has a young patient suffering from respiratory distress while returning from his grandparents’ farm. Carbon monoxide poisoning is ruled out, and the correct diagnosis is made when a blood sample has the chocolate-brown appearance indicative of methemoglobinemia. In addition to introducing hemoglobinopathies, this case provides an effective problem-solving opportunity for the students to postulate the cause of the illness, which turns out to be nitrates from the farm well. In the House clip (10), a professional cyclist suffers from respiratory distress during a charity ride. Dr. House is initially uninterested in the case, attributing the problems to illegal erythropoietin (EPO) use. He becomes intrigued, however, when the patient admits to using many performance-enhancing aids, including blood doping and sleeping in a hyperbaric chamber, but vehemently denies using EPO because of its dangers. Eventually, House determines that the patient has a tumor on his thymus, leading to dramatically decreased red cell production. He had been asymptomatic because his blood doping and other actions had constituted self-treatment. While this is an interesting case, the confusion between hypobaric chambers, used to enhance athletic performance (11), and hyperbaric chambers, sometimes touted as a “fountain of youth” (12), is a biochemical flaw that undermines the plot. Enzyme Inhibition A classical example of enzyme inhibition is provided by the treatment of ethylene glycol or methanol poisoning with ethanol, which competes for the enzyme liver alcohol dehydrogenase, thereby preventing production of the toxic products oxalic acid or formaldehyde. Although this treatment has been replaced by fomepizole (4-methylpyrazole) in today’s emergency departments (13), ethanol has been used in a pinch in both ER and House. In the ER episode (14), Dr. Greene has a violent patient who appears to be under the influence of drugs or alcohol. Although both drug and alcohol tests are negative, his urine fluoresces under UV light, suggesting ethylene glycol consumption. (Antifreeze contains fluorescein as a tracer for radiator leaks.) Because the pharmacy is out of ethanol, Greene prescribes “bourbon shooters” for the patient. An interesting follow-up problem is to have students calculate the required volume of ethanol to decrease ethylene glycol turnover appropriately for this patient (see the online material).
Journal of Chemical Education • Vol. 86 No. 10 October 2009 • www.JCE.DivCHED.org • © Division of Chemical Education
In the Classroom
In the House episode (15), Clarence, a death row inmate, suffers from life-threatening seizures, tachycardia, and cyanosis. Eventually, Dr. House deduces that his patient had attempted suicide by consuming photocopier toner, which contains methanol. In typical fashion, House tricks Clarence into drinking shots with him and then informs him that the ethanol has just foiled his suicide attempt. Biochemical flaws in this episode include the time between toner consumption and treatment (a day or two) and House’s explanation of the ethanol’s effect (“It binds with that nasty formic acid rampaging through your body...”). Many students have reported seeing this episode on television before taking biochemistry and being satisfied with House’s explanation but realizing its inaccuracy during the viewing in class. Lipids A biochemical discussion of lipids often begins with the hydrophobic nature of these compounds. An interesting aspect of human fat stores is their ability to act as storage depots for nonpolar xenobiotics and toxins, which may remain harmless until fat stores are mobilized (16). An illustrative case is provided in an episode of House (17) in which a young patient is suffering from unexplained internal bleeding, hemolytic anemia and liver failure following a hospital stay after a car crash. Initially, House’s team dismisses an environmental cause because the patient has continued to deteriorate in the hospital. When House discovers that the family cat died a month earlier, his team exhumes the cat for necropsy. The diagnosis is naphthalene toxicity, originating from a large nest of termites within the walls of the boy’s bedroom. Because of the nonpolar nature of the compound, the naphthalene was released as the patient’s fat stores were mobilized during his initial hospital stay. In House’s words, “Getting away from his dad’s meatloaf is what’s killing him.” Metabolism Inhibition or mutation of key enzymes in metabolism is often disastrous. An example of a natural toxin is hypoglycin A, found in unripe ackee fruit. The compound is metabolized to methylene cyclopropyl acetic acid, which inhibits beta-oxidation of fatty acids via the acyl-CoA dehydrogenases (18). Hypoglycin A toxicity manifests as Jamaican vomiting sickness, as diagnosed by ER’s Dr. Malucci in a patient who had recently traveled to Florida, where ackee is available (19). Ironically, Malucci catches this diagnosis, missed by more accomplished doctors, because he attended medical school in the Caribbean. The relationship between fatty acid oxidation and other pathways of metabolism can be explored in a follow-up problem based on this case (see the online material). The importance of vitamins as a source of coenzymes for metabolism is dramatically demonstrated by Korsakoff ’s syndrome, a degenerative brain disorder caused by thiamine (vitamin B1) deficiency. Symptoms include profound memory impairment arising from the brain’s inability to perform the pyruvate dehydrogenase reaction. Korsakoff ’s can arise from long-term alcohol abuse or malnutrition, as shown by House’s anorexic patient with an inability to form new memories (20). Genetic defects in the urea cycle lead to protein intolerance, as illustrated by House’s coma patient who appears to recover, only to lapse into a second unexplained coma after admission
(21). High estrogen levels from an herbal supplement act as a red herring, but House eventually deduces that the patient suffers from a genetic defect in ornithine transcarbamoylase, which leads to ammonia toxicity. Both comas followed a steak dinner, one of which was smuggled into the hospital to replace the standard meal of fish sticks. ER’s Dr. Carrie Weaver poses another challenge in nitrogen metabolism by asking Dr. Carter what metabolic defect can produce a false positive for ethylene glycol (22). The correct diagnosis, methylmalonic acidemia, is also described as a medical mystery in a popular biochemistry textbook (23). In this case, a mother was convicted of poisoning her infant son when high levels of methylmalonic acid, resulting from a defect in the breakdown of isoleucine and valine, were interpreted as ethylene glycol through laboratory error. In-Class Use of Television Clips I have been using medical cases studies in my biochemistry courses for many years, writing scenarios based on the medical literature. Students have always appeared to be more engaged in these problems than in more generic ones. Two years ago, I used a short clip from ER to introduce a particular topic and was amazed at the lively discussion that ensued. Since then, I have surveyed many seasons of my favorite medical dramas and have increased my use of these clips to several per semester. Many of the ER cases are found in “stand-alone” scenes lasting only a couple of minutes, whereas in the House episodes, clues are scattered throughout the show. In the latter case, pertinent information can be summarized for the class before showing a few minutes of the episode, often the culminating scene, that resolves the outcome. Cases can be introduced before discussing a lecture topic to perk the class’s interest or afterwards to provide a medical context. Questions that pursue the topic in more depth can be used as the basis for in-class group discussions or posed as homework (see the online material). To be clear, I am not suggesting using video clips to teach biochemistry but rather to enhance the classroom experience. The material becomes more personal to students when familiar shows are seen in a biochemical context. When they discuss the science behind these scenes, students are improving their communication skills. Chemistry and biology majors, who populate the biochemistry courses about equally at my institution, bring different knowledge and skill sets to the classroom and can learn from each other during these discussions. Furthermore, medical cases often contain confounding information, requiring students to decide for themselves what is important and what is not. The increased drama provided by the vivid images and sounds, as well as the occasional comic relief, promotes student engagement in the classroom environment more so than a similar case presented on the printed page. Although I have no quantitative data to suggest that using television dramas is more successful than written cases based on the medical literature, student evaluations, even from chemistry majors with no intention to pursue medicine, often comment favorably about this approach. Students generally find our biochemistry course series to be the most rigorous courses that they have ever taken, and many report back from medical school and graduate school that they find themselves extremely well prepared. They often cite the difficulty of the cases studies as being key to their preparation.
© Division of Chemical Education • www.JCE.DivCHED.org • Vol. 86 No. 10 October 2009 • Journal of Chemical Education
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In the Classroom
Conclusions Although there are entire biochemistry textbooks with a medical slant (24–26), integrating an occasional medical case into a traditional course is a reasonable option for those who do not wish to go to this extreme yet have a large proportion of students interested in biomedical applications. The cases described here can also be supplemented with written in-class case studies based on the medical literature (for published books of case studies, see refs 27–29). Breaking up a lecture for small group discussions is an effective tool for refocusing students (4), increases retention of information (30, 31), and provides an opportunity for increased student participation. Furthermore, integrating real-world examples into chemistry lectures engages students and gives them a reason to invest in the material (32). With today’s students having grown up in an era of TV, computers, and video games, incorporating short video clips in the classroom is a good complement to the audiovisual attention skills that they have developed outside of the classroom (33). Response to the case-study approach has been very favorable at Colby, with students reporting that they feel empowered by the fact that their biochemical knowledge sometimes puts them one step ahead of television physicians. Acknowledgments I thank Frederick J. LaRiviere (Washington and Lee), Kevin P. Rice (Colby College), Brenda L. Fekete (Colby College), James K. Zimmerman (Clemson University, Emeritus), and Paul G. Greenwood (Colby College) for helpful comments and Erzsebet Nagy for help with viewing. Literature Cited
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Cornely, K. Biochem. Mol. Biol. Educ. 2003, 31, 173–176. Hodges, L. C. Biochem. Mol. Biol. Educ. 2005, 33, 101–104. Bobich, J. A. J. Chem. Educ. 2008, 85, 234–236. Olmsted, J. A., III. J. Chem. Educ. 1999, 76, 525–527. Taxonomy of Educational Objectives: The Classification of Educational Goals, Handbook I: Cognitive Domain; Bloom, B. S., Ed.; David McKay: New York, 1956. Zheng, A. Y.; Lawhorn, J. K; Lumley, T.; Freeman, S. Science 2008, 319, 414–415. Mack, C. Point of Origin (episode 109; episode 18 of season 5). ER, Apr 8, 1999. McCormick, N. Blood Relations (episode 216; episode 15 of season 10). ER, Feb 19, 2004. Green, W. Suffer the Little Children (episode 90; episode 21 of season 4). ER, May 7, 1998. Hess, S. Spin (episode 28; episode 6 of season 2). House, Nov 15, 2005. Rodriguez, F. A.; Casas, H.; Casas, M.; Pages, T.; Rama, R.; Ricart, A.; Ventura, J. L.; Ibanez, J.; Viscor, G. Medicine and Science in Sports and Exercise 1999, 31, 264–268. Arehart, J. L. Science News 1972, 101, 188. Casavant, M. J. Pediatrics 2001, 107, 170.
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14. Sachs, J. A. Shift in the Night (episode 43; episode 18 of season 2). ER, Apr 4, 1996. 15. Friend, R.; Lerner, G. Acceptance (episode 23; episode 1 of season 2). House, Sep 13, 2005. 16. Occupational and Environmental Health; Recognizing and Preventing Disease and Injury, 5th ed.; Levy, B. S., Wegman, D. H., Baron, S. L., Sokas, R. L., Eds.; Lippincott Williams and Wilkins: 2005; p 290. 17. Kaplow, L.; Moran, T. L. Detox (episode 11; season 1). House, Feb 15, 2005. 18. Emedicine: Excerpt from Toxicity, Plants-Ackee Fruit. http:// emedicine.medscape.com/article/1008792-overview (accessed May 2009). 19. Orman, J. Great Expectations (episode 121; episode 8 of season 6). ER, Nov 25, 1999. 20. Thompson, J. Histories (episode 10; season 1). House, Feb 8, 2005. 21. Foster, D.; Mankiewicz, J. Mob Rules (episode 15; season 1). House, Mar 22, 2005. 22. Gemmill, R. S. Things Change (episode 198; episode 19 of season 9). ER, Apr 24, 2003. 23. Nelson, D. L.; Cox, M. M. Principles of Biochemistry, 5th ed.; W. H. Freeman and Company: New York, 2008; p 700. 24. Baynes, J. W.; Dominiczak, M. H. Medical Biochemistry, 2nd ed.; Elsevier Mosby: Philadelphia, 2005. 25. Devlin, T. M. Textbook of Biochemistry with Clinical Correlations, 5th ed.; Wiley-Liss: New York, 2002. 26. Garrett, R. H.; Grisham, C. M. Principles of Biochemistry With a Human Focus; Cengage Learning: Florence, KY, 2001. 27. Glew, R. H.; Ninomiya, Y. Clinical Studies in Medical Biochemistry; Oxford University Press: New York, 1997. 28. Ludueña, R. F. Learning More Biochemistry; Wiley-Liss: New York, 1997. 29. Cornely, K. Cases in Biochemistry; John Wiley and Sons, Inc.: New York, 1999. 30. Gelula, M. H. Surg. Neurol. 1997, 47, 399–402. 31. Bobby, Z.; Koner, B. C.; Sridhar, M. G.; Nandeesha, H.; Renuka, P.; Setia, S.; Kumaran, S. S.; Asmathulla, S. Biochem. Mol. Biol. Educ. 2007, 35, 45–48. 32. Franklin, S. J.; Pienta, N. J.; Fry, M. D. J. Chem. Educ. 2005, 82, 847–850. 33. Habraken, C. L. J. Sci. Educ. Tech. 2004, 13, 89–94.
Supporting JCE Online Material
http://www.jce.divched.org/Journal/Issues/2009/Oct/abs1216.html Abstract and keywords Full text (PDF) Links to cited URL and JCE articles Supplement
Instructor notes including problems based on medical drama case studies
JCE Concept Connections for October 2009 This article is discussed in the JCE Concept Connections for this issue. See p 1223 for details.
Journal of Chemical Education • Vol. 86 No. 10 October 2009 • www.JCE.DivCHED.org • © Division of Chemical Education
