Someone Please Justify Our Rote Memorization of Biochem Pathways

[78222]

I can't see any practical purpose to learning the details of biochemical pathways. Even if I was interested in going into some field that dealt with Glygen Storage Diseases, there is no chance in hell that I would remember these pathways. And why would I need to when I can easily reference them. Sometimes I think medschool is nothing more than a big science experiment to see how much useless stuff can be crammed into a students head before he ends up in a clock tower.

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[Droopy Snoopy]

All of the above. Alas, as we did so shall you. But to be fair, I'm of the opinion that none of us really know enough to be able to decide what's useful and what's useless. Just plow through this stuff and don't spend too much energy b*tching about it.

 

[-Goose-]

I can't see any practical purpose to learning the details of biochemical pathways. Even if I was interested in going into some field that dealt with Glygen Storage Diseases, there is no chance in hell that I would remember these pathways. And why would I need to when I can easily reference them. Sometimes I think medschool is nothing more than a big science experiment to see how much useless stuff can be crammed into a students head before he ends up in a clock tower.

I completely agree.

btw, you're avatar is... crazy.

 

[i61164]

I hate biochem with every fiber of my being. It burns up precious!!!

 

[78222]

All of the above. Alas, as we did so shall you. But to be fair, I'm of the opinion that none of us really know enough to be able to decide what's useful and what's useless. Just plow through this stuff and don't spend too much energy b*tching about it.

This is actually the first thing I have bitched about having to learn. Pretty much everything else, including the ridiculous details of Gross, seemed to have some purpose. I may have hated the subject, but I understood the need to learn it. Pathways on the otherhand, which I dont find particularly hard to learn, just seem like a waste of my time and brain space. Maybe I am wrong, thats why I am hoping someone will justify my wasting a beautiful day.

 

[78222]

I completely agree.

btw, you're avatar is... crazy.

lol, I forgot about my avatar - I got a little photoshop happy oneday and um.. edited someone elses avatar

 

[sirus_virus]

This begs the question: With the explosion of scientific information available to us, at what point will medschools switch their style of learning from this whole rote memorization crap to something more usefull? It is no more like back in the day when genetics textbooks were only 25 pages, and schools need to start responding to that. Someone in an article suggested that there needs to be a switch to some type of electronic database system(like a PDA) for storage of this info, and medstudents could be trained on how to efficiently retrieve and use info from these devices. I think it is a good idea as I don't know how the hell memorizing something you are going to forget in 1 month is of any use. At this rate I will not want to be a medstudent 50 years from now.

 

[Anka]

I'm not going to try to defend rote memorization of the biochemical pathways (you really won't remember that), but to respond to those who think the PDA is the answer to everything, it turns out it is kind of useful to have a lot of random facts in your head about a lot of the basic science stuff. You just don't know what to look up unless you're already making a lot of the connections you need to make. Half remembered facts + experience are the makings of intuition, hunches, and common sense.

Anka

 

[Droopy Snoopy]

This begs the question: With the explosion of scientific information available to us, at what point will medschools switch their style of learning from this whole rote memorization crap to something more usefull? It is no more like back in the day when genetics textbooks were only 25 pages, and schools need to start responding to that. Someone in an article suggested that there needs to be a switch to some type of electronic database system(like a PDA) for storage of this info, and medstudents could be trained on how to efficiently retrieve and use info from these devices. I think it is a good idea as I don't know how the hell memorizing something you are going to forget in 1 month is of any use. At this rate I will not want to be a medstudent 50 years from now.

It's funny, at the beginning of our first chemotherapy lecture in Pharm there was a slide showing the current dean of the medical school and his classmates back in the 60s. The next slide was a list of the cancer drugs available at that time and the ones they were required to learn about. There were like 8 of them. The slide after that was the drug list we had to learn, comprising of ~80 drugs and adjuncts, and the 235 slides after that were filled with indications and contraindications, routes of administration, combo therapies, etc. Ah, progress.

 

[OncoCaP]

I can't see any practical purpose to learning the details of biochemical pathways. Even if I was interested in going into some field that dealt with Glygen Storage Diseases, there is no chance in hell that I would remember these pathways. And why would I need to when I can easily reference them. Sometimes I think medschool is nothing more than a big science experiment to see how much useless stuff can be crammed into a students head before he ends up in a clock tower.

I'm still enjoying a few months of being a pre-med, but from what I have read, the reasons for this curriculum content in biochem and other courses is more historical than due to some outright conspiracy. A long time ago (1900s), there were improvements made to medical education that led to the med ed we have today. Before that, there were many schools that were inadequately preparing medical students to become physicians (some even required no college course pre-reqs, had lecture only, and no patient contact at all). So our system was an improvement. Fast-forwarding to 2007, it now it seems there are various reforms being used (PBL, systems, etc.) but these aren't troublefree either. Med ed reform is a work in progress. A school that deviates too far from the norm risks leaving its students unprepared for the standardized STEP tests. It looks like Biochem is part of STEP 1.

I heard that a few years ago that UTMB experimented with admissions, curriculum etc. and had trouble with their STEP 1 scores at first and had to retrace their steps somewhat and make various changes to raise their STEP scores. I'm unsure how much a school can change the Biochem content without hurting STEP 1 scores. Changes or improvements are not always greeted with joy and successful outcomes. Maybe if you have memorized all this Biochem once (beyond UG), you can relearn more easily before the STEP 1 the second time and get as good a score as possible (not sure if this is true ... perhaps you could suggest a better way to prep for STEP 1 biochem). Then again, Baylor has their preclinical classroom instruction in 1.5 years and has great STEP scores, so there is hope that scores can be maintained or improved with changes.

http://jama.ama-assn.org/cgi/content/full/291/17/2139
"Medical education in the United States today is strikingly standardized and demanding. It was not always so. Prior to the widespread implementation of educational reforms, medical training was highly variable and frequently inadequate. It was not until the early decades of the 20th century that a "uniformly arduous and expensive" system of medical education was instituted nationally.

"The AMA sought to eliminate schools that failed to adopt this rigorous brand of systematized, experiential medical education. "It is to be hoped that with higher standards universally applied their number will soon be adequately reduced, and that only the fittest will survive," the editors of JAMA declared in 1901.6 In 1904, the AMA created the Council on Medical Education (CME) to promote the restructuring of US medical education.
...
"In the 1910s, state licensing boards began to force medical schools across the United States to implement heightened admission standards and stricter curriculum requirements.10 In 1912, a group of licensing boards formed the Federation of State Medical Boards, which voluntarily agreed to base its accreditation policies on academic standards determined by the AMA's CME. Consequently, the CME's decisions "came to have the force of law."11

 

[78222]

I'm still enjoying a few months of being a pre-med, but from what I have read, the reasons for this curriculum content in biochem and other courses is more historical than due to some outright conspiracy. A long time ago (1900s), there were improvements made to medical education that led to the med ed we have today. Before that, there were many schools that were inadequately preparing medical students to become physicians (some even required no college course pre-reqs, had lecture only, and no patient contact at all). So our system was an improvement. Fast-forwarding to 2007, it now it seems there are various reforms being used (PBL, systems, etc.) but these aren't troublefree either. Med ed reform is a work in progress. A school that deviates too far from the norm risks leaving its students unprepared for the standardized STEP tests. It looks like Biochem is part of STEP 1.

I heard that a few years ago that UTMB experimented with admissions, curriculum etc. and had trouble with their STEP 1 scores at first and had to retrace their steps somewhat and make various changes to raise their STEP scores. I'm unsure how much a school can change the Biochem content without hurting STEP 1 scores. Changes or improvements are not always greeted with joy and successful outcomes. Maybe once you have memorized all this Biochem once (beyond UG), you can relearn more easily before the STEP 1 the second time and get as good a score as possible (not sure if this is true ... perhaps you could suggest a better way to prep for STEP 1 biochem).

http://jama.ama-assn.org/cgi/content/full/291/17/2139
"Medical education in the United States today is strikingly standardized and demanding. It was not always so. Prior to the widespread implementation of educational reforms, medical training was highly variable and frequently inadequate. It was not until the early decades of the 20th century that a "uniformly arduous and expensive" system of medical education was instituted nationally.

"The AMA sought to eliminate schools that failed to adopt this rigorous brand of systematized, experiential medical education. "It is to be hoped that with higher standards universally applied their number will soon be adequately reduced, and that only the fittest will survive," the editors of JAMA declared in 1901.6 In 1904, the AMA created the Council on Medical Education (CME) to promote the restructuring of US medical education.
...
"In the 1910s, state licensing boards began to force medical schools across the United States to implement heightened admission standards and stricter curriculum requirements.10 In 1912, a group of licensing boards formed the Federation of State Medical Boards, which voluntarily agreed to base its accreditation policies on academic standards determined by the AMA's CME. Consequently, the CME's decisions "came to have the force of law."11

I dont really see what this has to do with biochem pathways. It is a good thing that we have standardization in our medical schools. The problem, as I see it, is standardizing subjects which may not be usefu in preparing us to be better physicians. A subject is not valuable to us simply by virtue of being covered on the board exams.

 

[OncoCaP]

I dont really see what this has to do with biochem pathways. It is a good thing that we have standardization in our medical schools. The problem, as I see it, is standardizing subjects which may not be usefu in preparing us to be better physicians. A subject is not valuable to us simply by virtue of being covered on the board exams.

I agree. From reading statements of various med students, a lot of medical education and training doesn't help make better physicians ... it's just warmed over from year to year and quickly forgotten. I don't think anyone is arguing that we should have no exposure to biochem, but do we really need to memorize all the details? We agree that standardized testing is beneficial (otherwise the standards at one school could be really lax whereas another school makes it unfairly hard). We should be tested over material that is more pertinent to the work of a physician, and I have heard there is some movement in that direction. On the ohter hand, I've read some papers that said that medical education today sometimes makes medical students bitter, cynical, and non-patient centered. I hope things improve in time for me (MS0), but it looks like changes of this nature (less rote memorization of material that can be easily looked up) will happen slowly, if at all.

 

[Tired Pigeon]

I'm not going to try to defend rote memorization of the biochemical pathways (you really won't remember that), but to respond to those who think the PDA is the answer to everything, it turns out it is kind of useful to have a lot of random facts in your head about a lot of the basic science stuff. You just don't know what to look up unless you're already making a lot of the connections you need to make. Half remembered facts + experience are the makings of intuition, hunches, and common sense.

Agree with the above. It seems pointless at the time, but you'll be surprised what comes back to you later, and in what context. That broad base of seemingly unrelated knowledge will be like signposts to point you in the right direction in an unusual clinical situation.

That said, I feel your pain -- nobody enjoys the rote memorization part of med school.

 

[indo]

my mentor pimps me on biochem like no other. He is an interventional cardiologist and apparently the metabolic syndrome/ diabetes stuff they've been cramming down our throats is important.

 

[DoctaJay]

It seems like second year classes are more useful, but can you understand a 2nd year class like Pharm without Biochem, or the pathways in biochem?

 

[Tired Pigeon]

It seems like second year classes are more useful, but can you understand a 2nd year class like Pharm without Biochem, or the pathways in biochem?

Another excellent point.

 

[78222]

It seems like second year classes are more useful, but can you understand a 2nd year class like Pharm without Biochem, or the pathways in biochem?

I am not saying do away with biochem. I am just saying that maybe the level of detail is a little bit ridiculous.

 

[lilnoelle]

At my school they don't ask us to know all of the steps of the pathways. Rather we are expected to know the general mechanisms and control steps involved. Our school is systems based so we learn the biochemistry in the same block as we learn the physiology, pharmacology, pathology, etc.

 

[AmoryBlaine]

Medical education is deeply flawed. It focuses on idiotic memorization of obscure factoids and never encourages clinical thinking until the 3rd year, at which point you are supposed to arrive on the floors magically able to put all this stuff together.

We all have take these stupid classes where we painstakingly learn each step of an arcane and largely pointless physical exam. This is almost always justified by some vague reference to medical mission work which will be the ONLY time in your career that a laboratory and radiology suite will not be available. So we learn about tactile fremitus, meanwhile studies show that even pulmonologists suck at examining the lungs and a CXR is about 1 million times superior.

I have seen a small study that demonstrated that 2nd year medical students with hand-held ultrasound and 10 hours of training beat the pants off of cardiologists in bedside dx of structural heart disease, but that's not going to stop your teachers from torturing you over which murmurs increase in intensity when you make that 73 year old lady squat.

I just put a paper in my personal EBM binder that shows that a simple BNP assay crushes both EM and IM trained docs in accuracy of diagnosis of CHF. The LR for "rales" was like 2 while that for an elevated BNP was 12.

I digress. Memorize your pathways and then forget them. The most important thing is to ask questions about your education, which is exactly what you are doing. The reason it seems idiotic to learn the biosynthesis of urea is that it is idiotic.

 

[AmoryBlaine]

By the way: I completely ignored biochemical pathyways when I was studying for Step1. I just decided that it was too low-yield and too painful.

So cheer up, you might never have to see them again.

 

[Anka]

Medical education is deeply flawed. It focuses on idiotic memorization of obscure factoids and never encourages clinical thinking until the 3rd year, at which point you are supposed to arrive on the floors magically able to put all this stuff together.

We all have take these stupid classes where we painstakingly learn each step of an arcane and largely pointless physical exam. This is almost always justified by some vague reference to medical mission work which will be the ONLY time in your career that a laboratory and radiology suite will not be available. So we learn about tactile fremitus, meanwhile studies show that even pulmonologists suck at examining the lungs and a CXR is about 1 million times superior.

I have seen a small study that demonstrated that 2nd year medical students with hand-held ultrasound and 10 hours of training beat the pants off of cardiologists in bedside dx of structural heart disease, but that's not going to stop your teachers from torturing you over which murmurs increase in intensity when you make that 73 year old lady squat.

I just put a paper in my personal EBM binder that shows that a simple BNP assay crushes both EM and IM trained docs in accuracy of diagnosis of CHF. The LR for "rales" was like 2 while that for an elevated BNP was 12.

I digress. Memorize your pathways and then forget them. The most important thing is to ask questions about your education, which is exactly what you are doing. The reason it seems idiotic to learn the biosynthesis of urea is that it is idiotic.

Yeah, and it's been shown that PAs can safely put in cardiac stents. But you aren't in school to be a PA. You're in school to be an MD. And the roles are different. An experienced, well-trained PA can do 90% of what a doctor can, but you still need an MD for that extra 10%, because it's the 10% that isn't rote for which your knowledge and longer training are important.

As far as listening for rales. Physical exam isn't useful when your confirming the obvious. You don't use rales clinically to "accurately diagnose" heart failure. It's useful when it comes up in someone you don't already know is in heart failure to pick up something you might otherwise have missed (i.e., to tell you to get your CXR). Unfortunately this gets lost in the medicine clerkship because when you present someone who is obviously in florid failure based on a lot of objective data other than the PE, you're still expected to present the rales you heard. My favorite was the time I was told by the attending to present only "pertinent positives", so I didn't tell them my patient with known long standing end stage liver disease listed for transplant had palmar erythema and spider telangectasias. Why? Because it's no longer pertinent... we already know why he has those things, and we have stronger evidence to back it up than the physical exam. However, it is useful to know the two are associated so when you see them together in someone who "looks healthy" you start thinking they might not be so healthy.

Anka

 

[english muffin]

I don't know how the hell memorizing something you are going to forget in 1 month is of any use.

You remember stuff for a MONTH? As SOON as I check off b,c, or d or my exam scantron, that info's gone. It takes less than a second.

I think the reason we are so overburdoned with details, at least at my school, is that every topic is taught by a different faculty member, and each of them thinks their subject (or more specifically their research) is the most important in the world. They're given an hour to lecture, and they'll cram up to 90 power point slides into that hour. The slides will be in tiny font, listing every possible detail under the sun. Many of them will just mumble their way through the material. There's often no overarching point. I'm sure the "administration" of our school would LIKE to make education be more about concepts and less about details, but until they can rein in the faculty, there's no hope.

 

[Critical Mass]

At my school they don't ask us to know all of the steps of the pathways. Rather we are expected to know the general mechanisms and control steps involved. Our school is systems based so we learn the biochemistry in the same block as we learn the physiology, pharmacology, pathology, etc.

Sounds like a good idea to me. My school is still in the dark ages.

If you have to memorize whole pathways, the school is probably not doing you justice. The control points and regulation (i.e. where drugs act) are the important parts.

 

[logos]

I am not saying do away with biochem. I am just saying that maybe the level of detail is a little bit ridiculous.

I think part of the problem is they half-ass it. Here we had to know the names of the substrates and the enzymes and their order, but didnt need to know much of anything else. They need to decide to go all or none with biochem and stick with it.

I spent about a quarter and a half of my year long biochem for majors course learning the same material, but it was much different because we needed to know so much more about each reaction. All of the additional information we went over set up a nice framework such that knowing things like the structure of intermediates or the enzyme names wasnt a big deal. Things like stereochemistry, inhibitors, kinetics, and enzyme mechanism make the whole picture more clear, but take a ton of time.

In med school, they just expected us to memorize the details, without really building a framework to understand it in. Just learn all of these meaningless words in order.

 

[Neuronix]

A school that deviates too far from the norm risks leaving its students unprepared for the standardized STEP tests. It looks like Biochem is part of STEP 1.

Penn is very weak in Biochem, at least in the sense that the course is very much an overview and summary course and you have to memorize little. They hand you a large diagram of all the pathways in the exam. We supposedly have the highest Step I average at this time.

Also, when I took Step I there was almost no biochem on it. Maybe one or two relatively easy questions. That was pretty true for everything in first year. Step I is mostly the second year stuff. Hence why again at Penn we only have 6 months of first year (alot of crap omitted) and still do fine on Step I.

I agree with Cerb's summary of the situation. As for being a physician, just because you know a statin is a HmG CoA reductase inhibitor, that doesn't mean you need to know the whole biochemical pathway. Almost no doctor knows that. Ask one how many ATP you get from a glucose and they'll wonder what an ATP is aloud at you.

Edit: And if you don't believe me, if you weren't a chem major, how much Orgo Chem do you remember? How about intro Physics? You'll remember none by third year.

 

[funkless]

There's some horrible advice on this thread.

Don't memorize by rote, but by placing each step in its place within the larger conceptual picture of pathophysiology and pharmacological therapeutics. Typically, when our bodies cease to function properly, it's due to a defect in one of these molecular pathways. Pursuantly, most of our medical therapies target these malfunctioning pathways.

In my opinion (and I'm far from humble on this one), the difference between excellent physicians and miserable cookbook docs is that the former group can explain exactly what's wrong with their patient and exactly why they're using the drugs they use. The latter group just follows a protocol without only the remotest idea why.

Cerb, PM me.

 

[SeventhSon]

In my opinion (and I'm far from humble on this one), the difference between excellent physicians and miserable cookbook docs is that the former group can explain exactly what's wrong with their patient and exactly why they're using the drugs they use. The latter group just follows a protocol without only the remotest idea why.

Cerb, PM me.

Wrong, excellent physicians are the ones who can share their feelings with their patients

 

[funkless]

Wrong, excellent physicians are the ones who can share their feelings with their patients

 

[rickthetwinkie]

Some of the earliest studies on memory(forgot the guy's name), showed that previously memorized information is recovered faster than information that was not previously remembered. While not all of the basic science is necessary(from what I've heard) to every specific type of medicine, if it is previously learned(even by rote), it is more easily recovered when studied again when it is more relevant.

Note: this isn't really a defense of the medical school curriculum. Do not take it as such.

 

[45408]

We supposedly have the highest Step I average at this time.

There are at least 10 schools currently with this honor.


When one of our anatomy profs graduated med school, Watson and Crick hadn't even discovered the double helix. I bet he had a lot less biochem to learn than we did.

 

[OncoCaP]

Some of the earliest studies on memory(forgot the guy's name), showed that previously memorized information is recovered faster than information that was not previously remembered. While not all of the basic science is necessary(from what I've heard) to every specific type of medicine, if it is previously learned(even by rote), it is more easily recovered when studied again when it is more relevant.

Note: this isn't really a defense of the medical school curriculum. Do not take it as such.

Wouldn't it make more sense to learn the concepts and memorize the stuff you are really expected to remember? To retain this stuff, we would need to "refresh" those memorized facts periodically. Are we really going to keep that biochemistry textbook on the shelf in our practice and refer back to it? In most specialties, probably not.

While biochemistry is a great foundation for pharma, etc., to me it would make more sense to study something we can reasonably be expected to remember (plus maybe a little extra for good measure) as opposed to a ton of material we will quickly forget and maybe never see again. I can see the value of studying some biochem mechanisms in detail just to teach people how to find the information, interpret it, etc., like one might later in one's career when studying up on a new disease or drug discovery. Researchers keep adding more medical knowledge (including human biochemistry knowledge) every single day. At some point, it simply isn't going to be possible to memorize it all (we are there now). Computers with search engines are really good at retaining all these kinds of details. I like the curriculums that put more emphasis on the most important aspects of biochemistry, teach students where to find the information and understand it if they need it, and let students go further if they really want to take that up as an area of personal study, research, and expertise.

 

[soonereng]

Wouldn't it make more sense to learn the concepts and memorize the stuff you are really expected to remember?

While biochemistry is a great foundation for pharma, etc., to me it would make more sense to study something we can reasonably be expected to remember (plus maybe a little extra for good measure) as opposed to a ton of material we will quickly forget and maybe never see again. I can see the value of studying some biochem mechanisms in detail just to teach people how to find the information, interpret it, etc., like one might later in one's career when studying up on a new disease or drug discovery.

I agree with you OncoCaP, but you've got to quit thinking like an engineer and start thinking like a doctor: MD = Memorizing Degree.

 

[OncoCaP]

I agree with you OncoCaP, but you've got to quit thinking like an engineer and start thinking like a doctor: MD = Memorizing Degree.

I like that! MD = Memorizing Degree; that should help keep my spirits up when I'm sitting down with 1200 pages of memorization that will be partial memorization at best and haphazard at worst.

I actually love memorization as well. Biochemistry was my favorite subject as an undergrad. It just fascinated me that you can watch life with these 1000s of reactions. It's a chemical engineer's dream plant. On my bio exams I would always write a lot more more on the essay questions than was required because I would get into all the details. Now I'll get my chance to regurgitate all those little details just to fight for an average grade, let alone honor.

 

[Neuronix]

There are at least 10 schools currently with this honor.

Agreed. Since the USMLE won't release this information we get to listen to everyone else's misinformation.

 

[rickthetwinkie]

Wouldn't it make more sense to learn the concepts and memorize the stuff you are really expected to remember? To retain this stuff, we would need to "refresh" those memorized facts periodically. Are we really going to keep that biochemistry textbook on the shelf in our practice and refer back to it? In most specialties, probably not.

While biochemistry is a great foundation for pharma, etc., to me it would make more sense to study something we can reasonably be expected to remember (plus maybe a little extra for good measure) as opposed to a ton of material we will quickly forget and maybe never see again. I can see the value of studying some biochem mechanisms in detail just to teach people how to find the information, interpret it, etc., like one might later in one's career when studying up on a new disease or drug discovery. Researchers keep adding more medical knowledge (including human biochemistry knowledge) every single day. At some point, it simply isn't going to be possible to memorize it all (we are there now). Computers with search engines are really good at retaining all these kinds of details. I like the curriculums that put more emphasis on the most important aspects of biochemistry, teach students where to find the information and understand it if they need it, and let students go further if they really want to take that up as an area of personal study, research, and expertise.

I wasn't defending current medical school curricula, really, but people claim that rote memorization is useless, when it seriously isn't. It does have a role even if you "forget" the information because it's simply easier to recover information that we've previously memorized. Hence, it's called the savings method. Ideally, med school curricula should be what you say it is, but "rote memorization" will probably still be necessary in some aspects.

Don't get me wrong. I have no idea as the usefulness of memorizing much of the information the OP was describing as I'm not actually in med school as we speak.

 

[Mixtli]

Dang, I'm feeling you.

Rote memorization of biochem is really painful especially when you cram it all the day before the exam. .

 

[TRAMD]

Biochemical pathways . . . did I learn those? Seems like there was something maybe like that about 4 years ago . . . can't remember.

 

[braluk]

Done with biochem in a week. Cumulative Friday. Genetics/Cancer exam tommorrow

Perfect timing for st patty's and spring break

 

[gostudy]

If we got rid of useless information in med school some teachers would be out of a teaching job. And we know how professors LOVE to hear themselves talk. Who makes all the rules about the curriculum? Hmmm.

 

[LJDHC05]

Um...how else are you going to make diagnoses of somewhat overly emphasized congenital metabolic disorders that you may see once in your 30-40 year career. You never know what might walk in through the door of your derm practice...

the more important question is why would anyone make us study cardiovascular physio?

 

[acute2]

If we got rid of useless information in med school some teachers would be out of a teaching job.

Hahaha, right! And who knows you may want to teach Biochem someday
Seriously, it's still important, most topics if not all.

 

[anum]

at my school they expect you to know urea cycle or the others when the lecture is over the enzymes and associated disturbances,we are asked questions after the 45 min class.....thats what i call Injustice!