BLDE University Journal of Health Sciences

MEDICAL EDUCATION TEACHING NOTE
Year
: 2021  |  Volume : 6  |  Issue : 1  |  Page : 90--95

The WRITE physiology: Thinking and inking


Hwee-Ming Cheng, See-Ziau Hoe 
 Department of Physiology, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia

Correspondence Address:
Prof. Hwee-Ming Cheng
Department of Physiology, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur
Malaysia

Abstract

Writing Physiology well is much more than a fine motor skill. The capacity to simplify mechanisms, use choice, meaningful words, and construct them in accurate sentences to explain an aspect of Physiology strengthens learning. Writing focuses the mind and sharpens the students' ability to define and describe Physiology. Medical faculties should not be tempted to lessen the role of writing tests even though evaluation is less time-consuming. The enjoyment of writing Physiology can be expanded to include creative activity like composing Physiology songs, rhymes, and comic dialogs.



How to cite this article:
Cheng HM, Hoe SZ. The WRITE physiology: Thinking and inking.BLDE Univ J Health Sci 2021;6:90-95


How to cite this URL:
Cheng HM, Hoe SZ. The WRITE physiology: Thinking and inking. BLDE Univ J Health Sci [serial online] 2021 [cited 2021 Jul 26 ];6:90-95
Available from: https://www.bldeujournalhs.in/text.asp?2021/6/1/90/313362


Full Text



“Reading maketh a full man; conference a ready man; and writing an exact man.”

–Francis Bacon

The days when we had a 3-h physiology essay paper, perhaps to describe and explain six questions out of ten choices are over. The medical curriculum changes and evolves with the times. The increasing number of student enrolment is also a factor in streamlining tests to give ample time for examiners to complete evaluation in a limited time.

With the availability of online platforms to prepare tests, short answer type questions (SAQ) became a common mode of assessment. And also, computer grading of multiple-choice physiology questions was also added with or without combining with SAQ.[1],[2]

With a discipline like physiology, the need to now write less during tests to answer physiology is a factor that affects how students learn. And increasingly, in a phone texting culture and multisensory-saturated generation, the need, the ability, and the interest to write well is diminishing.

Many of my teaching colleagues in the global physiology community have observed and expressed that their students do not write Physiology well. Although writing is a diminishing “digit-al” skill,[3] the purpose of this article is to make the point that writing Physiology well is not merely to recover a lost art.

Writing physiology well is founded and hinged on the students' own understanding and clarity in unlocking and explaining the intricate network of integrated physiology.

 Treasury of Words



“The teacher searched to find just the right words”

– Ecclesiastes

How many ways are there to describe and tell the story of a physiological event? Some of us may have a copy of the classic Roget's Thesaurus. Thesaurus means treasure. The use of synonyms gives color and beauty to the narrative of the mechanisms. We can teach ourselves and our students to write and express Physiology with a whole spectrum of meaningful words.

Let's consider the synonyms to describe effects, a positive effect on a target cell. And take the example of the pancreatic beta cells that secrete insulin.

“Post-prandial hyperglycemia stimulates insulin secretion.”

We could replace the word stimulates with:

Postprandial hyperglycemia increases insulin secretionPostprandial hyperglycemia triggers insulin secretionPostprandial hyperglycemia activates insulin secretionPostprandial hyperglycemia produces insulin secretionPostprandial hyperglycemia results in insulin secretion.

If another hormone, for example, incretin acts in advance to complement or supplement the action of glucose on insulin secretion, we could say:

“Incretin enhances insulin secretion.”

We could then replace the word enhances with:

Incretin potentiates insulin secretionIncretin promotes insulin secretionIncretin sensitizes beta cells to secrete insulin.

Now consider the sentence:

“During fasting, hypoglycemia inhibits insulin secretion.”

You could ask the students to think through possible synonyms for the word inhibits that could replace/substitute and convey similar shades of meaning for the insulin response. The synonyms for the word “compensation” in homeostasis can also be highlighted [Table 1].{Table 1}

Can the list extend further for negative feedback signals?

The words enhance, sensitize and potentiate have the added meaning that the signal might not be the primary stimulus, but it synergizes, complements, supplements, or primes the target cells for the actions of the primary stimulus.

Hence, in this way, we can help students spice up their physiology with this thesaurus (treasury) of meaningful words.

 Concise and Precise



When you hear the newscaster over the 5-min evening news, before broadcasting, a fair amount of time is devoted to summarizing and focusing on the important current events happening in the world. The choice of words to adequately present the current global news engagingly and within a restricted time requires rewriting, rephrasing. This is the daily repetitive skilful task of the newscaster.

Recently, there is a popular competition called the 3-min thesis talk. Competitors are asked to summarize their research topic and findings strictly within 3 min. Obviously, the preparation to write, choose words, and package the gist of the research data in such a limited time is mentally challenging and stimulating. It requires extracting out the essentials and only uses the necessary words to display and highlight the unique and significant research contribution. The winning presentation is naturally in writing. The student likely has a good mentor who thinks and writes well.

My own journey in writing physiology learning books has homeostatically benefitted my effectiveness in communicating physiology.[4]

Doing a good voice-over your PowerPoints, especially needed now in this Corona season, will require us to write down simply, concisely, to read what are the essential points to match and elaborate on our slides. Writing focuses our minds and our explanations.

 PowerPoint of the Pencil



“See what large letters I use as I write to you with my own hand!”

– Paul to the Galatians

I prefer the use of a pencil rather than a pen as a revision can be easily erased with a pencil eraser. For my young generation of “Type-Writers,” they have the delete button at their service.

It is slower to write with a pencil than to type-write and this is precisely the reason why for Write Physiology, your best, unhurried handwriting is preferred. Learning Physiology takes time to ruminate like the cows chewing.[5]

For teachers, writing out lecture notes to read maybe thought a recommendation only for junior lecturers. Certainly, it is helpful for younger teachers who are less experienced with the physiology contents and the dynamics of the large classroom.

However, I would also suggest for those of us who are senior teachers that carefully chosen words and summary points made during certain times in our lectures can be a great help for students to grasp the major concepts in the topic taught. Of course, these points can still be presented in our lecture slides. But to keep our slide less crowded and to train our students to also use their auditory pathway, carefully worded sentences spoken to elaborate on succinct points in the slides is a good approach.

 Write and Show and Tell



Writing to define and describe an aspect of physiology is good exercise. Writing is aimed at choosing the right words to simplify the complexity, to clarify the multiple integrations in whole-body homeostatic physiology.

Writing is actually voiceless speech translated into the written word. The formation of the words and sentences that explain Physiology well is a good mental exercise strengthening the central synaptic activity for word formation and speech.

It is good practice for students to show others what they wrote. It is a little embarrassing for the weaker students, but better students should be encouraged to be patience and helpful. Is not this a part of what is encouraged as peer-centered learning?

I quite often during tutorial ask a relatively simple question and ask the students to write their answers, which require one or two sentences. Then, I will select a few students and copy their different answers on the board. I consider it an ethical teaching principle to never criticize any answers, however inadequate. It can be quite an eye-opener for students to see their written answers display publicly! Use the different answers as a platform to teach students how to be more precise and clear in their explanation.

I could say to the students in the tutorial class:

“Try writing your explanation for what is Haldane's effect at the cells during exercise?”

The student will soon realize that her writing instrument will only move confidently when she has already understood well in your mind, the Haldane's event. Other possible physiology phenomena that could be asked in this writing exercise are:

Perfusion-limited lung oxygenationChemoreceptor hypoxic drive in pulmonary patientsSensory receptor adaptation.

 The WRITE Cause and Effect



The temporal sequence of contributing mechanisms is important for the students learning Physiology. Knowing the keywords and writing to put them together in a cause and effect manner, linking parameters in the correct sequential direction train students to think physiologically.

In endocrine physiology, students encounter tables with a list of stimulatory and inhibitory factors. Rather than memorizing multiple lists for the whole spectrum of hormones, students can be asked to write out why they think a factor have a positive or negative effect in the overall homeostasis.[6] For examples:

a. In calcium homeostasis: “What is the logic for the phosphaturic action of parathyroid hormone (PTH)?”

Here, the combined actions of PTH on bone and kidneys to raise the free ionized calcium can be elaborated.

b. In glucose homeostasis: “Why do amino acids stimulate glucagon and insulin while most factors that stimulate anabolic insulin would be expected to inhibit he catabolic glucagon?”

Here the hyperglycemic glucagon counteracts the hypoglycemic insulin in response to a high protein meal that will increase plasma insulin.

Quantitative physiology and the sense of priority among homeostatic mechanisms can be expressed by writing out to explain. For example,

“Why does hypotonic contraction occur in a person with Addison's disease?”

The explanation should hit on the concept that the volume control is given priority at the expense of osmolarity control when the primary deficiency of the mineralocorticoid aldosterone causes a critical drop in extracellular fluid and blood volume.

By writing, thinking, rewriting, as the student refined these sentences, they are making the explanation more specific, tight and a more in-depth answer to the question.[7] Ask any authors of a novel, and they will tell that a lot of rewording takes place before they are satisfied that the narrative gives the best mental picture to the readers.

 The Write Graph: Flattening the Curve



Encourage students to Write in their own words rather than memorize and regurgitate model answers. Naturally, students are less confident of their own version of the explanation, but that is precisely the purpose of promoting writing. Students see their own initial answers and can alter and improve on the accuracy of their explanations.

Students are generally adverse to graphs and to ask them to explain and highlight salient features of Physiological importance in graphs often present a challenge.[8] Here are a few standard physiological graphs where the curves flatten out [Table 2].{Table 2}

A simple query “Why does the graph flatten out?” is a useful thinking and writing situation.

 WRITE Evaluation for Physiology



“The faintest ink is more powerful than the strongest memory.”

–Zhengxuelu

Do we also retain knowledge and deepen understanding more easily when we write intentionally?

In Universiti Malaya, for the last 7 years in the Medical Faculty and increasingly across the globe, testing has simplified to responding to single best or multiple-choice questions. These questions for the dynamic discipline of Physiology are more time consuming to prepare, but the scope of testing is however reduced since Physiology is now part of an integrated paper with Anatomy, Biochemistry, Pharmacology, so less can be covered in the assessment. Marking is obviously easier without working through some of the illegible writing of the students.

Some writing required in the SAQ were still retained for medical students until the last 7 years. Recently, for biomedical students, some online SAQ are incorporated. The plus factor compared to handwriting is that all the students' type-writing online is in an equally beautiful font!

For institutions which have a large number of students, nonwriting tests are obviously very attractive.[9],[10] Perhaps for the continual formative assessment, some form of writing for the Physiology test should still be retained.

One WRITE way that works well in my tutorial and could be employed in the end of semester evaluation are the use of “Why What's Wrong (www)” questions. A sentence is given that is physiologically incorrect, and students are asked to explain why the physiology is inaccurate. This will test students' understanding instead of factual recall. For examples:

1. Hypotonic contraction develops in a normal person on low salt diet.

In normals with normal aldosterone and ADH functions, an isotonic rather than a hypotonic contraction will result.

2. Hyperventilation is the main factor in increasing rate of oxygen (O2) delivery to cells

Increased cardiac output is the main factor as arterial oxygen content is near saturation at rest. Oxygen delivery rate (ml O2/min) is the product of cardiac output and arterial O2 content.

3. The arterial blood pressure increases during exercise when the two determinants, cardiac output and total peripheral resistance (TPR) are increased.

Cardiac output increases, but the TPR is decreased by cutaneous and skeletal muscle vasodilation. The higher blood pressure is sustained only by, the greater cardiac output.

 Don't just Write Physiology for Exams



The writing to learn Physiology can be enjoyed when the writing extends to creative works like composing a Physiology song, rhyme. The ability to write these engaging, entertaining Physiology content does require the student to have first understood the essentials of Physiology before they can convert Physiology to a song, rhyme or a Physiology comic conversation.

Here are some samples that I have done over the teaching years, a Japanese Haiku poem, a rhyme, and a song. A Physiology comic conversation created by one of my 1st-year medical student is shown in [Figure 1].{Figure 1}

Haiku (which has a 3 lines, 5-7-5 syllable structure)

Enjoy Tempura

Trigger Macula Densa

Homeostasis Na+

The Haiku can then be a springboard to talk about sodium balance control

Rhyme (Gulliver's Bladder)

When Gulliver say 'water he makes'

What he meant was glomerular filtrate

When Gulliver, a lot, must urinate

Its not an increase in secretion rate

What Gulliver excretes is the filtrate he makes,

minus the water reabsorption rate.

Gulliver's bladder adventure in Lilliput

Of nephrons, collecting ducts and Henle's loop.

The renal handling of water and the associated details can follow from this popular story.

Song (on Starling's Intrinsic Law of the Heart)

O My Starling, I Am Fainting

I've Been Standing A Long Time

Gravity Pulling, Venous Complying,

SV Falling, I'm Going Supine.

O My Starling, Sympathetic Increasing

Venoconstricting, Give Me Some Time,

Venous Returning, Cardiac Lengthening,

SV Improving, I'm Just Fine.

The original tune to be sung to was “O my Darling,” but my students wanted a more modern rhythmic beat and creatively matched it to a Justin Bieber's song.[11]

Summary

This article expresses a current concern among educators that, increasingly, due to the large student population and the priority given to standardize evaluation, writing answers in Physiology is diminishing. We need to recover and maintain Learning and Teaching physiology the WRITE way.

Physiology is a multi-organ discipline and explaining the cross-talk and mechanisms of integrated whole-body requires time to think, rethink, and process in words what we have understood.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

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