RESUMO
OBJECTIVE: (1) To integrate clinical problem solving into freshman cell and tissue biology (CTB) and (2) to enhance understanding of diabetes using CTB principles to explain the etiology, management, and development of complications in terms of cell, tissue, and organ structure and function. DESCRIPTION: First-year medical students often question the need to learn detailed basic science material. Although clinical content has increased throughout basic science courses, little attempt has been made to link clinical correlations to one another or to enhance use of basic science material in clinical problem solving. The CTB course applies pertinent cell biology concepts such as cell proliferation, differentiation, migration, adhesion, and morphogenesis to tissue and organ function. Diabetes mellitus was chosen as a theme for CTB as diabetes has devastating effects on multiple tissues, and the disease has reached epidemic proportions in the United States, affecting individuals of every age and population group. Type I diabetes, presenting as ketoacidosis in a ten-year-old boy, was introduced by generalist physicians using a "grand rounds" approach. This format challenged students on the first day of medical school to diagnose a patient's problem and to explain the clinical findings in terms of anatomic, biochemical, and physiologic changes. The role of the blood/bicarbonate buffering system was the main focus of faculty-led discussion. The patient was then presented at age 25 with many diabetic complications. This stimulated discussion of the etiology of diabetes (type I versus type II), glycation, and the use of hemoglobin (Hb) A1c to monitor blood sugar control. Compliance and other aspects of diabetes management were added to the discussion. Faculty provided scientific information as necessary, and summary materials were distributed after the sessions. The interaction of a cell biologist with two generalist physicians optimized the integration of basic science with clinical problem solving. During the two semesters of CTB, the diabetes case is frequently referenced. Insulin synthesis provides the model for protein synthesis. Glycation, advanced glycation end products (AGE), and receptors (RAGE) are discussed. Other diabetes-related topics include wound healing (epithelium), basement membrane thickening (connective tissue), insulin regulation of muscle metabolism, diabetic neuropathy (neurohistology), platelet adhesiveness, glycation and HbA1c (blood), osteoporosis and Charcot joints (skeletal system), autoimmune mechanisms (cellular immunology), atherosclerosis and high blood pressure (blood vessels), diabetic nephropathy (renal), altered hepatic and gastrointestinal function, impotence (male reproductive system), and a comparison of type I and type II diabetes (endocrine system). DISCUSSION: Students have provided very positive feedback. The initial case enhanced interest in CTB, established clinical relevance, and has motivated learning and integration of materials from different parts of CTB and other courses. Other courses are now formally linking to the theme. For example, neuroscience will revisit diabetic neuropathy and retinopathy, physiology will relate ketoacidosis to acid-base balance, a human anatomy clinical correlation is being designed for transplantation surgeons to "cure" our diabetic patient with a renal-pancreas transplant. Uses of the case for introduction to clinical medicine, aspects of medical ethics, preventive medicine, and courses in pharmacology and pathology are contemplated.
