“Nothing Operates in Isolation”: Learning Biochemistry and Physiology Through Drawing

Abstract

Mastering complex biochemistry pathways and physiological processes can be challenging for undergraduate medical students. Although drawing out the conceptual relationships in complex information can potentially support student learning, there is a lack of consensus in current literature regarding optimal strategies that effectively integrate drawing into teaching. In this paper, we report our experience incorporating drawing in multiple approaches during the delivery of first-year pre-clerkship biochemistry and physiology instructional sessions. Students’ perception of and experience with these different strategies were compared. Themes that emerged from learner feedback and their implications for future practice and research are presented.

Background

Undergraduate medical students often encounter difficulties mastering complex biochemistry pathways and physiological processes. Drawing out these conceptual relationships can promote student learning in multiple ways:

• Diagrams can effectively condense information, organize knowledge, and highlight conceptual frameworks [1–3].

• When instructors construct diagrams with narration, learners can simultaneously utilize visual and auditory working memories to expand their information processing capacities [4].

• The creation of diagrams engages learners in active learning tasks, such as identification and summarization of relevant concepts and self-questioning. When learners collaborate in drawing, they are further encouraged to elaborate their own understanding and clarify misconceptions through the negotiation of group perspectives [1–3, 5].

Despite past successes with adopting drawing to enhance students’ conceptual learning in health professions education [6–9], current literature still highlights a need to investigate strategies that effectively integrate drawing into teaching [1, 2, 10, 11]. For instance, there is a lack of consensus regarding whether a graphical presentation should be provided before, during, immediately after, or some time after the corresponding text presentation in order to enhance information retention and comprehension [12–14]. Additionally, to our knowledge, no comparison has been conducted between the outcomes of teaching biochemistry vs. physiology through drawing. Further, researchers are still exploring measures to boost the effectiveness of individual and group drawing [1, 5, 6]. In this paper, we report our experience exploring multiple instructional strategies incorporating drawing to teach biochemistry and physiology, and we compare students’ perception of and experience with these strategies.

Activity

A series of biochemistry and physiology instructional sessions was offered by one of the authors, SN, in two pre-clerkship courses: a five-week Foundations of Medicine (FOM) Course enrolling 156 learners, and a six-week Gastrointestinal System (GI) Course enrolling 155 of them five months later. The following strategies to incorporate drawing were implemented:

• Pre-recorded videos of instructor drawing demonstrations

• In-class instructor-led drawing demonstrations that were either:

  • Stand-alone reviews of recently delivered materials;
  • The integrated reviews that alternated between the other instructor’s lecturing and SN’s drawing-based summary;
  • A preview of upcoming sessions; or
  • Using drawing to teach new content

• In-class group drawing exercises contained within a problem set session. Learner triads diagramed previously taught physiology and biochemistry materials before applying the knowledge to solve clinical cases. Instructor diagrams were provided for learners to evaluate their constructs.

Tables 1 and 2 provide detail about each format. After each course, all learners were invited to participate in an online anonymous survey on a voluntary basis. Each survey included two open-ended questions soliciting learner feedback on the drawing sessions. (Survey questions are provided in the Appendix.) Theme analysis of learner responses was conducted.

Table 1.

Types of the sessions that incorporate drawings (total numbers and minutes of sessions per student)

	Preview		In-class review		In-class teaching new materials with drawing (mixed-style)	Student group drawing
	Pre-recorded videos	In-class	Stand-alone review	Integrated review
Description	Drawing provided background information for and overviews of upcoming sessions	Drawing summarized information to be covered in detail in upcoming sessions	Drawing summarized lecture content that other instructors had taught recently	Each team-taught session alternated between two teaching approaches: After the other instructor lectured on a sub-topic, SN gave a drawing-based summary of the materials that he had just taught.	In SN’s teaching of new materials, she used drawing to help explain the new concepts that she was teaching and sometimes also to summarize what she had just taught.	Learner triads were prompted to diagram previously taught physiology and biochemistry materials before applying the knowledge to solve a relevant clinical problem. Afterwards, students were given SN’s diagram and were instructed to count the number of invalid conceptual components and links on their diagram and the valid ones that were missed.
Foundations of Medicine Course Biochemistry only 11 sessions, 618 min in total	4 videos 43 min in total	1 session, 50 min	2 sessions, 180 min	2 sessions, 160 min	1 session, 185 min	0
Gastrointestinal System Course Biochemistry and/or Physiology 6 sessions, 615 min in total	0	0	0	0	Physiology*, 3 sessions, 315 min Biochemistry, 1 session, 80 min Biochemistry +Physiology, 1 session, 110 min	Biochemistry +Physiology 1 session (3 drawing exercises), 110 min

Except for the student group drawing session, drawing sessions were led by the instructor (SN) and were provided in two formats: in-class sessions and pre-recorded videos. All instructor-led drawing demonstrations were accompanied by instructor narration

All the minutes and numbers of sessions reported in the table were minutes and numbers of sessions per students

*One of the sessions was repeated due to logistical arrangements. Students were separated into two groups, and each group received the same instruction once

Table 2.

Examples of instructor diagrams used in teaching

Results and Discussion

The first survey asked students to compare the helpfulness of learning biochemistry through in-class drawing as a preview, an integrated review, or a stand-alone review. Among the 124 respondents, 122 (98%) found drawing helpful, highlighting these benefits:

• Integration. Realizing that “nothing operates in isolation,” learners found drawing “crucial in integrating all the different individual diseases and reactions.”

• Synthesis. Drawing “highlighted the key points” and facilitated learning of “more detailed information.”

• Visualization. Drawing assisted students to acquire “the overall big picture” of the materials and to “make mental images of the pathways.”

Among these 122 students, 48 (39% of 122), 29 (24%), and 29 favored the stand-alone review, integrated review, and preview format, respectively, and 34 (28%) did not indicate their preference. Some picked more than one format.

Specifically, 25 (20% of 122) students found the drawing-based preview gave them “a visual guide” for subsequent learning and “a framework” to “slot into” detail. Six (5%) students, however, found the preview overwhelming due to their unfamiliarity with the concepts. Both stand-alone and integrated reviews allowed learners to check their understanding and “clear up misconceptions.” Seventeen (14%) students appreciated that integrated reviews efficiently enhanced their understanding of lecture content; on the contrary, 18 (15%) found switching between lecturing and drawing difficult to follow or repetitive. While six (5%) students liked that in the integrated sessions, the drawing-based reviews occurred “immediately after the content was presented” rather than on a different day, 12 (10%) favored stand-alone reviews for having additional time to digest the materials prior to reviewing. As one explained, “the more information we understand, the more we can get out of visualizing it through drawing.”

An additional question asked learners for their preference of drawing by themselves, with peers, or following instructor demonstrations, and 127 students responded, with some picking more than one format. Fifteen (12% of 127) preferred drawing by themselves, nine (7%) with peers, and 116 (91%) following instructor demonstrations. Among these 116 students, seven (6% of 116) preferred doing some drawing prior to attending instructor demonstrations, and 36 (31%) reviewed or redrew afterwards. Students favoring instructor demonstrations reported learning from watching the instructor draw and listening to her explanations and appreciated being able to ask questions. Major benefits highlighted in learner feedback included figuring out key points, assessing their understanding, and enhancing the “efficiency” of drawing through receiving instructor guidance. Learners were concerned that drawing on their own or with peers would be more time consuming and their diagrams might not be accurate, sufficiently comprehensive, or properly laid out.

Pacing was the most frequently mentioned challenge with following instructor demonstrations, with 16 (13% of 127) students expressing concerns about missing key points when attempting to listen and draw simultaneously. While some chose to just listen and not draw or decided to do some initial drawing ahead of time, others preferred following the instructor through watching video recordings of her drawing demonstrations. This latter modality gave students the ability to rewind and pause to modify their diagrams and add additional notes.

The second survey asked students if drawing was more helpful for learning biochemistry vs. physiology. Among the 117 respondents, 52 (44% of 117) reported drawing more helpful for learning biochemistry/in the Foundations of Medicine (FOM) course, four (3%) found drawing more helpful for learning physiology/in the Gastrointestinal System (GI) course, 51 (44%) said drawing was helpful without clearly indicating a preference, nine (8%) found drawing unhelpful although two of these nine students mentioned the diagrams were useful, and one (1%) was unsure. The most frequently mentioned themes in their explanations are listed below:

• Fifteen (13% of 117) students suggested for the GI sessions that only the most challenging topics be drawn in class and the less challenging materials be supplied as ready-drawn diagrams.

• Twelve (10%) found drawing more helpful for learning the “complex” biochemistry pathways connecting “small details/processes,” which were “harder to visualize independently” and to “memorize,” whereas drawing is “helpful, but not quite as necessary” for learning the more “intuitive” and “bigger concepts” in physiology.

• Ten (9%) preferred having a drawing session after they had acquired the foundational knowledge instead of learning new content through drawing. The latter was the major format adopted in the GI course.

An additional question asked learners for comments on their collaborative drawing experience. Among the 117 respondents, 60 (51% of 117) found the drawing helpful or somewhat helpful, 33 (28%) found it unhelpful, six (5%) expressed no strong feeling either way, 15 (13%) did not attend or could not recall, and three (3%) did not provide a clear opinion.

Specifically, although 38 (32%) students were able to review relevant concepts, clarify misunderstanding, and learn from peers through group drawing, 10 (9%) reported challenges with collaborative learning, mainly keeping up with group pacing, nine (8%) were unsure about “the desired level of detail” required of their diagrams, and 13 (11%) commented negatively on the inclusion of the drawing exercise in the problem set. Since the instructor had previously drawn out some of these materials in class, some learners deemed redrawing the materials a “memorization” exercise/repetitive and preferred to focus on practicing the application of their understanding in the problem set.

In summary, students were positive about learning physiology and biochemistry through drawing. Consistent with current literature, drawing helped them integrate different topics and visualize difficult concepts and conceptual frameworks. Table 3 summarizes the major survey findings, and Table 4 presents tips for conducting instructor-led drawing.

Table 3.

Summary of major survey findings

Table 4.

Tips for instructor-led drawing demonstrations on paper in a large class setting

	Tips
Prior to class	□ Draw out the diagram on your own ahead of time. □ To draw out the diagram, prompt yourself to consider how to summarize and organize all the important information on one piece of paper. (Examples of prompt questions are listed in the "In class" section.) □ After finishing the diagram, review and make sure all the key ideas have been covered. □ Consider using colors and labeling to help organize and categorize the materials.
In class	□ Set up the document camera to project the drawing. □ If you also plan to project slides before or after doing some drawing, familiarize yourself with the instructions to switch between video sources for the large screen projector. Fluidity is important to the success of the session. □ Bring paper and white-out correction tape for the students. While trivial, this gesture helps to establish a personal connection with the students. □ Before you start, invite students to signal you, e.g. by tapping their microphone, to reorient the paper when you are annotating/drawing outside of the view of the document camera. □ Tell students beforehand that you will post the finished drawing after the class, which helps lower their anxiety. □ Draw slowly and provide ample explanations, giving students time to comprehend and to think about the conceptual relationships. □ Invite students to ask questions during the drawing process to clarify and resolve their misconceptions. □ During your drawing, consistently ask questions that invite students to think about how things function and what might go wrong. Answering these questions yourself also allows you to elaborate your thinking. Examples of prompt questions: ° What are the different types of products? ° Which are the important molecules and signals, and why? ° What are the important categories/ steps? ° Where can things go wrong, and what would you expect to see in such a situation? ° What are the consequences? □ For elaborate diagrams, periodically switching to a different color that you mainly use can help students identify the new information that you are adding to the paper.
After class	□ Provide video recordings of your drawing sessions for students to re-watch. □ Provide learners with your finished diagrams.

Interestingly, the acquisition of conceptual understanding was perceived both as a prerequisite for and an outcome from learning related information through visualization, which contributed to learners’ mixed opinions about how drawing should be integrated with lecturing. Learners with more prior knowledge might be able to more effectively interpret visual information and integrate the drawing and lecture content; meanwhile, learners may not benefit as much from drawing if they already possess advanced understanding of the topic. Further exploration regarding the impact of learner characteristics on the outcomes of learning through drawing is necessary, and additional investigation on effective instructional strategies that accommodate the individual differences in large class settings is still needed [13].

Consistent with our past observation, learners became less positive about drawing in the Gastrointestinal System course than they were in the Foundation of Medicine course. The higher complexity of biochemistry content and the increased emphasis on clinical application in the later curriculum seemed to account for this change of opinion.

Students were also less positive about the group drawing exercise in the Gastrointestinal System course than they were about the instructor-led drawing demonstrations in the Foundation of Medicine course. Rather than seeing the drawing exercise as preparing themselves for the clinical application of knowledge, some viewed it as a memorization test. Although we provided instructor diagrams at the end of each drawing exercise intending to engage learners in self-assessment, some students perceived this practice emphasized only one correct answer. In the future, the rationale of providing instructor diagrams for the group exercise should be explicitly stated.

Another theme that emerged from learner feedback is their emphasis on efficiency. Undergraduate medical students are constantly challenged to master daunting amounts of information in brief time periods. Whereas individual and group drawing can engage students in deeper learning, it is more time consuming than following instructor demonstrations. However, short-term efficiency cannot always foster long-term information retention [15]. Past research also suggests the necessity of providing learners guidance to conduct individual and collaborative drawing [3, 5, 6]. A future session guiding learners to adapt drawing into their self-study routine is warranted.

Appendix. Survey Questions

Survey 1

1. In the biochemistry thread, do you feel that drawing as a preview (Carbohydrate Metabolism), an integrated session (Nutrition & Amino Acid Disorders), or as a review (all other sessions) was more helpful for your learning? Please explain.

2. Do you prefer to do drawing on your own, with peers, or following instructor demonstration? Please explain.

Survey 2

1. Do you feel drawing is more helpful for your learning of biochemistry vs. physiology? Please explain.

2. Can you comment on your experience drawing in groups during the Physiology Problem set on 3/1?

Data Availability

While students’ responses to open-ended questions are not available for sharing in order to protect students, we are very willing to share the diagrams that we created. Please feel free to contact the authors.

Compliance with Ethical Standards

For this study, we used de-identified curriculum evaluation data for which formal consent from individual students is not required. Students are informed of such use of evaluation data for medical education research generally and are given the option to opt-out. Our use of de-identified evaluation data for medical education research was approved by the University of Virginia’s Group on Research in Medical Education and Institutional Review Board.

Conflict of Interest

The authors declare that they have no conflict of interest.