Cadaver Dissection Experience for First-Time Dissectors: a Hypothetical Three-Pronged Approach for Student Preparation

Abstract

This systematic review synthesized evidence for the development of a preparatory process for first-time dissectors, geared toward improving cadaver dissection (CD) experiences. Eleven studies focused on pre-CD intervention were selected from a literature search in PubMed, the Education Resources Information Centre (ERIC), Google Scholar, PsycNET, and the Cochrane Library. A three-pronged preparatory process was formulated for first-time dissectors based on the evidence from the review. The process includes (1) background assessment; (2) pre-CD education; and (3) gradual exposure and desensitization. The preparatory process shows some hypothetical potential for decreasing negative CD-related experiences, but it still needs validation before implementation.

Introduction

Cadaveric dissection (CD) is a long-established method of teaching gross anatomy to medical students and remains relevant in today’s medical education [1–4]. Despite the growing popularity of new, technology-driven teaching resources like 3D models, interactive computer-based software, and other resources like plastinated prosections, body painting, radiological images, virtual realities, and holograms [5–9], CD remains popular in many places due to a variety of reasons that hinder the adoption of these technologies. In the past, CDs and didactic lectures were exclusively used to teach gross anatomy to preclinical medical students [10, 11]. The unique advantages conferred by CD account for its consideration as the gold standard for teaching anatomy, making it difficult to do away with [1, 12]. Some of these include the visual and tactile perspectives of 3D anatomy [1, 13] and the importance of CD for teaching students medical ethics, professionalism, and altruism [14–17]. The role of CD in the grooming of medical doctors is considered beneficial and too essential to be eradicated or replaced [12].

However, regardless of the importance and impact of CD, the students’ perceptions of CD are varied based on their experiences, good or bad [18–28]. In psychology, a frame of reference influences how a thing is perceived [29]. Students’ perception of CD can facilitate or impede learning depending on their frame of reference toward the practice. What we perceive and fail to perceive and what we think and fail to think are powerfully influenced by habits of expectation that constitute our frame of reference, that is, a set of assumptions that structure the way we interpret our experiences [30]. Considering the relevance of CD and its persistence in anatomy education, it is necessary to mitigate any deleterious issues associated with it that could alter or negatively affect the student’s learning experience.

The first CD experience is significant for every student learning anatomy because it can set the tone for students’ perceptions or subsequent experiences [31, 32]. This present article focuses on the students’ negative experiences of their first CD exposure without prejudice toward the positive experiences. It argues for the need for more optimized preparatory steps for first-time exposure to CD to improve the students’ CD experience and overall impact. The anxiety associated with being exposed to a cadaver for the first time can be a barrier to learning anatomy with CD [33], as contact with a dead human body can be a distressing and even traumatizing experience [28, 34–36]. Students need to be adequately prepared before being exposed to such stressors, particularly those who may have underlying psychological challenges or are more susceptible to adverse emotional responses [21, 37]. In this present study, we have reviewed vital publications and highlighted some of the students' emotional responses and reactions following their first CD experience. We also argued the need and effectiveness of adequate preparation and management of students’ first exposure to CD. We conceptualized an evidence-based three-step preparatory process for first-time dissectors for further validation and implementation.

First Cadaver Dissection Exposure: Students’ Experiences

Zeivots [38] described six critical points in learning when emotions are heightened for learners: initial experience, engagement with unfamiliar themes, unexpected discovery, learning adventure, real-life feel, and being on a journey. Their study highlighted the first experience as one of the learning points where emotions are significantly stimulated during experiential learning. Emotions play a crucial role in experiential learning as they enhance the overall engagement and retention of knowledge. As learners delve deeper into unfamiliar themes, they may encounter unexpected discoveries that ignite a sense of curiosity and excitement [39]. This continuous learning adventure keeps emotions alive and encourages a real-life feel to the educational journey, making the process more immersive and memorable [40]. Incorporating emotional stimulation into the learning process can greatly enhance student engagement and retention [39, 41]. This is particularly important in anatomy learning for first-time dissectors, as it allows them to fully embrace the transformative power of experiential learning [38, 42].

First-time experience is an opportunity for tutors to stimulate a superlative student experience by arousing positive emotions, and this should be explored in anatomy learning for first-time dissectors. Unfortunately, some medical students’ initial exposure to CD is accompanied by negative emotions such as anxiety, apprehension, sadness, fear, and worry [26, 33, 43–45]. In some extreme cases, signs of acute and post-traumatic stress disorder have also been recorded among a few medical students [46, 47], with students reporting symptoms like reoccurring visual images, nightmares, insomnia, and depression. While some of these emotions may seem extreme, they should not come as a surprise since exposure to a dead human body—mainly when the body still retains its human visual and tactile appeal—can be stress-inducing [28, 46, 48, 49]. Stress has been noted as a significant contributor to anxiety among medical students [50] and may explain why some students struggle with different forms of anxiety during CD. For the majority of students, these negative emotions are short-lived, with most of them overcoming their initial anxiety in a matter of weeks [26, 33, 51, 52]. Howbeit, a smaller percentage of students—about 4–10%—have been shown to experience severe and sustained adverse reactions such as anxiety, fear, guilt, recurring nightmares, insomnia, and disgust [15, 26, 51, 53–55].

It is important to note that every medical student does not experience the above-named unpleasant events during the first or subsequent exposure to CD. Evidence from the literature shows numerous cases of positive first-time CD experiences [19, 56–61], with authors reporting desirable learning emotions like excitement, interest, and curiosity [22, 62–64]. The CD was also found to strengthen the cultural and religious beliefs of students, who described their CD experience as stimulating, exciting, and informative [65]. Furthermore, the majority of medical students admit that CD is an exciting and superior way to understand the human body [22, 60, 64, 66, 67], and they consider the experience to be an essential part of becoming a medical doctor [24]. From the findings highlighted above, students’ responses to CD vary in type, duration, and intensity. These variations are linked to different factors such as past traumatic experience, previous medical experience, or anxiety level [15, 26, 45, 55, 68]. Some studies have observed that female anatomy learners experience more adverse emotional responses to CD than males [15, 21, 68]. However, other findings do not agree with the assertion [69, 70]. Notwithstanding, this calls for adopting a preparatory process and management strategy to improve students’ CD experiences, starting from their first exposure.

Several studies have been published on reducing CD-related stress and anxiety and improving students’ learning outcomes. Some of these include providing humanizing information about the donor [33], carrying out desensitizing pre-CD sessions [15, 43, 71, 72], and incorporating soothing background music into CD sessions [73–75]. Although an essential first step, the above recommendations did not account for students with peculiar experiences and backgrounds who may need more robust and personalized intervention. Also, to the best of our knowledge, no other study has synthesized evidence from the literature on the effectiveness of pre-CD interventions to develop a student-centered CD preparatory process for first-time anatomy learners. This study boasts a holistic and evidence-based approach to reducing CD-related stress and optimizing the CD experience for first-timers. The CD continues to be the students’ most preferred tool for learning practical anatomy even during the pandemic [64], despite their negative experiences and perceptions. Therefore, it is important that students’ positive experiences during CD are maintained and reinforced to improve the practical anatomy learning experience, participation, and performance, starting from the students’ first exposure. This study examines relevant literature focusing on the emotional responses and reactions of students after their initial CD encounter. In addition, it debated the necessity and efficacy of thorough preparation and management of students’ initial encounters with CD and developed a theoretical framework consisting of a three-step preparatory procedure for first-time dissectors based on empirical evidence.

Methods

This section describes the selection criteria and search strategy for synthesizing evidence from pre-CD intervention studies. This present study highlights students’ reactions to CD and reviews the effectiveness of strategies used to improve students’ emotional/psychological reactions to CD upon first exposure. This study also made evidence-based recommendations on preparatory sessions that would be useful in managing students’ first exposure to CD. To synthesize evidence from pre-CD intervention studies, the following selected keywords from the objectives and title of the study—“cadaver dissection,” “anxiety,” “preparation,” “student experience,” “student perception,” and “management”—were used for an online search in PubMed, the Education Resources Information Center (ERIC), Google Scholar, PsycNET, and the Cochrane Library. These databases were purposefully chosen as they contain publications related to anatomical science and medical education. The reference lists of the studies that fit the inclusion criteria were screened for additional related articles. Only quantitative studies that utilized a defined scale of measurement to determine the effect of their reported intervention were selected for review. All the studies included either had control subjects or included the pre- and post-intervention outcomes of their cohort.

Additionally, only studies whose interventions were administered before or during students’ first exposure to CD were considered, and no review or meta-analysis was considered. Furthermore, the current investigation chose to refrain from doing a meta-analysis of the selected studies due to the significant heterogeneity observed between them. The systematic search strategy and outcomes have been described using the updated PRISMA 2020 guideline for reporting systematic reviews [76] and the PRISMA flowchart was automatically generated using the R package and Shiny app — a PRISMA 2020‐compliant online flowchart generator [77] (Fig. 1). However, the supporting literature used in this study was obtained using the non-systematic method (internet and snowball search) and was not included in the PRISMA flowchart. The search terms and themes used for the supporting literature search were similar to the systematic literature described above. The database search results included in this study were retrieved until June 27, 2022, and the publication dates of the included studies range from 2004 to 2022.

Fig. 1.

PRISMA flowchart of the search strategy

Results

Table 1 summarizes the study descriptions of the reviewed studies and the effect of pre-CD intervention in each study. Eleven (11) pre-CD intervention studies were included in this review. Most of the included studies (~ 70%) used standardized outcome measurement scales such as the Kessler Psychological Distress Scale [78], the Visual Analogue Scale (VAS), and a 6-item abbreviated form of the Spielberger State-Trait Anxiety Inventory survey (6-STAI) [71], the State-Trait Anxiety Inventory (STAI) [74, 79–81], the Beck Anxiety Inventory (BAI) [82], and Brief Symptom Inventory (BSI) [83]. About 30% of the included studies [84–86] used a newly developed self-assessment questionnaire in Likert scale measures for their outcome assessments. The interventions used in the different studies vary considerably, from the use of pre-CD anatomical demonstrations of organ systems [85] to the use of video-based interventions [71, 78–81, 83], information about processes and advantages of CD [82], student tutors [84], and education about death and dying [86]. The majority of the reviewed studies showed positive outcomes [74, 78, 79, 81, 82, 84, 85], with a significant reduction in anxiety and symptoms of mental distress. Three of the reviewed studies reported no significant effect between the intervention and control groups [71, 80, 83], while one study had an unexpected adverse outcome, with increased anxiety in the intervention group that received education about death and dying [86].

Table 1.

Pre-CD interventions and outcomes for first-time cadaver dissectors

S/No	Author(s)	Title	Study description	Assessment tool and scale of measurement	Intervention	Outcome
1	Albabish et al. [71]	Using a dissection-based introductory laboratory video to reduce the anxiety state of dissection- and prosection-based anatomy students prior to their first cadaver-based laboratory	A quantitative study involving 273 third-year male and female anatomy students	The Visual Analogue Scale (VAS) and 6-item abbreviated form of the Spielberger state-trait anxiety inventory survey (6-STAI)	Pre-CD dissection-based introductory video	No significant change in anxiety level
2	Bellier et al. [74]	Impact of Background Music on Medical Student Anxiety and Performance During Anatomical Dissections: A Cluster Randomized Interventional Trial	A quantitative study involving 187 male and female second-year medical students with a mean age of 20 years	State-Trait Anxiety Inventory	Standardized background music during the CD	Significant decrease in acute anxiety
3	Chaudhuri [78]	An initial preparation for human cadaveric dissection ameliorates the associated mental distress in students	A mixed-gender quantitative study involving 129 master’s students of occupational therapy with a mean age of 23.67	The Kessler Psychological Distress Scale (K10)	YouTube videos, peer-reviewed journal articles, and an oral presentation on cadaver dissection	Significantly decreased mental distress
4	Casado et al. [79]	Audiovisual material as educational innovation strategy to reduce anxiety response in students of human anatomy	A quantitative study involving 303 first-year male and female anatomy students	State-Trait Anxiety Inventory	Introductory video on human anatomy and dissection	Significantly reduced symptoms of anxiety
5	Attardi et al. [80]	YouTube-based course orientation videos delivered prior to matriculation fail to alleviate medical student anxiety about anatomy	A quantitative study involving 226 male and female first- and second-year medical students with a mean age of 23.44	State-Trait Anxiety Inventory	Short YouTube videos on the anatomy course, dissection facilities, and available study resources to dispel initial CD anxiety	No significant effect was observed
6	Belsiyal et al. [81]	Comparison of the effect of in vitro and in vivo exposure on cadaveric anxiety among first-year medical and nursing students	A quantitative study involving 127 first-year male and female medical and nursing students with a mean age of 18.08	State-Trait Anxiety Inventory	Video demonstration of cadaver dissection	Significantly reduced anxiety, although no changes were observed in the levels of disgust,
7	Javadnia et al. [82]	How to decrease the emotional impact of cadaver dissection in medical students	A quantitative study involving 68 first-year male and female medical students with a mean age of 18.5 years	Beck Anxiety Inventory (BAI)	Pre-CD mental preparation; information about the process and advantages of CD	Significantly reduced anxiety
8	Iaconisi et al. [83]	Effects of an Educational Film About Body Donors on Students’ Empathy and Anxiety Levels in Gross Anatomy	A mixed population quantitative study involving 77 (48 females and 29 males) first-year medical students	Brief Symptom Inventory (BSI)	Educational film about body donors	No significant effect was observed
9	Houwink et al. [84]	Help of Third-Year Medical Students Decreases First-Year Medical Students’ Negative Psychological Reactions on the First Day of Gross Anatomy Dissection	A quantitative study involving 99 first- and second-year male and female medical students with a mean age of 23.5 years	5-point Likert scale	The assistance of third-year medical students during CD	Significantly reduced anxiety, disgust, and physical reactions
10	Böckers et al. [85]	Reduction of mental distress in the dissection course by introducing the body donor experience through anatomical demonstrations of organ systems	A quantitative study involving 199 first-year male and female students with a mean age of 21.9 years	5-point Likert scale with a Visual Analogue Scale (VAS)	Pre-CD anatomical demonstrations of organ systems	Significantly reduced mental distress
11	González-Pinilla et al. [86]	Does education about death and dying decrease stress generated in the dissection room?	A quantitative study involving 336 male and female first-year students	Self-assessment checklist on stress symptoms	Pre-CD preparatory classes about death and dying	Significantly increased stress symptoms

Discussion

Studies in psychology have shown that the outcome of an initial or previous experience can have a substantial and lasting effect on subsequent behavior [31]. The tendency of humans to recall or reinforce initially held beliefs or information is the basis for two crucial cognitive concepts in psychology: “confirmation bias” and “primacy outcome” [87, 88]. One thing is clear in terms of confirmation bias or primacy outcomes: humans tend to recall and hold on to information based on their first, prior, or most striking experience. First-time exposure to CD can influence the subsequent learning behavior of medical students, causing them to build expectations and develop unhealthy learning behaviors based on their first CD experience [89]. Therefore, students need to be adequately prepared and assisted in ensuring an easy mental transition, especially for those students who are highly susceptible to adverse emotional reactions.

As seen in the data presented in this review, students benefit from pre-CD intervention and assistance. The majority of the studies show that students react better to CD and are less anxious during CD when prepared beforehand or assisted during their first visit. The majority of the studies (Table 1) showed reduced symptoms of anxiety and psychological distress in students that received different forms of intervention and/or assistance when compared to those that did not receive any help [74, 78, 79, 81, 82, 84, 85]. This finding supports and justifies prior recommendations on the potential benefit of preparing students psychologically before CD [69, 72].

The outcomes from six of the reviewed studies [71, 78–81, 83] showed interesting variations that should be noted. Despite having similar video-based interventions, only three studies [78, 79, 81] showed a significant decrease in anxiety and mental stress among students. Evaluation of the video interventions showed a consistent content variation between those that did cause a decrease in anxiety and those that did not. Video intervention in studies with the desired outcome (decreased anxiety and mental stress) was longer and focused almost exclusively on the dissection process [78, 79, 81], while those that failed to decrease anxiety in students were either very short or did not feature the dissection process [71, 80, 83]. For instance, the video-based intervention used by Belsiyal and coworkers [81] involves a 30-min demonstration of cadaveric dissection of the thorax and abdomen, while that used by Albabish and colleagues [71] involves a less than 3-min video showcasing the building, and laboratory space, before showing a student-centered laboratory session. Similarly, the video intervention used by Attardi and coworkers [80] entirely focused on providing information about the anatomy course, dissection facilities, and available study resources without featuring the dissection process. It is safe to argue that the varied impacts of the video-based pre-cadaver dissection student preparation observed in the selected studies are likely associated with one or more factors including the duration of the video, nature of the content, and the manner of delivery.

Evidence also showed that interventions performed at the moment of students’ first exposure to a CD effectively reduced anxiety and stress symptoms. The introduction of background music [74] and the assistance of peer teachers [84] during students’ exposure to CD significantly reduced anxiety among the students with no pre-CD preparation. It is possible that the introduction of background music [74] and peer teachers [84] made the dissection hall less airy and isolated since fear and discomfort constitute a major element of mental stress in the CD hall [63]. While pre-CD preparation helps students ease into the CD process through gradual desensitization, it is possible that the “on-site” interventions—background music and peer tutors—help improve the feel and learning atmosphere of the CD environment and, as such, enable easier and faster acclimatization. The above speculation was corroborated by medical students, who described peer teaching in the CD laboratories as creating a “positive, non-intimidating learning environment” [25].

The first dissection of a human cadaver is an essential and unforgettable milestone for any learner [20], and as such, it should be handled with maximum care. Anatomy tutors should adopt and implement effective management practices for first-time dissectors [45], as the wrong approach can worsen students’ mental preparedness. This was seen in one of the reviewed studies, where students who received a pre-CD lecture on death and dying became more anxious and showed increased stress symptoms compared to their control counterparts who did not receive any form of intervention [86]. This finding shows that the essence of the pre-CD exposure must be desensitization of the CD procedure to enable the students to have a seamless first-time experience. The activities that make up the preparatory process for the first exposure are as important as the exposure itself, as they go a long way toward determining the immediate- and long-term student experience.

Strength of Evidence

The majority of the studies included in this analysis employed validated and standardized psychological assessment scales, such as the State-Trait Anxiety Inventory (STAI), Beck Anxiety Inventory (BAI), Brief Symptom Inventory (BSI), Visual Analogue Scale (VAS), 6-item State-Trait Anxiety Inventory (6-STAI), and the Kessler Psychological Distress Scale. However, it should be noted that two of the included studies [84, 85] utilized newly developed Likert scale questionnaires which were based on interviews on student experiences. Despite the use of these validated scales, the reliance on self-reported symptoms of stress and anxiety is a potential limitation to the reliability of the results due to an increased risk of bias. The strength of the evidence presented by the reviewed studies is potentiated further by the apparently equal number of males and females across the study groups observed in all the included studies (Table 1). This is especially important due to the observed gender-based differences in the psychological impact of CD among students [15, 21, 68]. However, it is important to note that the quality assessment of the included studies was not undertaken due to the high heterogeneity observed in the selected studies.

Hypothetical Approach to Student Preparation

It is evident that a good student preparatory process for first-time dissectors is very beneficial and could determine whether a student adapts to CD easily or struggles for prolonged periods [85]. Consequently, we recommend that students’ first exposure to CD be preceded by an extensive preparatory process that includes, in strict order, (1) student background assessment; (2) pre-cadaver dissection education; and (3) gradual exposure and desensitization.

1. Student background assessment.

Student background assessment should be an essential first step toward students’ first exposure to CD. Students who participate in CD must be assessed for factors that could increase the risk of adverse stress-related reactions to CD. Factors like past or recent traumatic experiences mainly related to the death of a loved one, mental health, childhood relationships, and moral or religious beliefs can affect how an individual responds to stress [90]. These factors should be examined before the first contact with a cadaver. This assessment is critical given the significant risk and prevalence of mental health disturbances among medical students [91–93]. More so, responses to CD-related stress have been shown to be different among students with different backgrounds. Boeckers and colleagues [85] observed that students without any prior medical training needed more psychological support in the dissection hall when compared to those with a medical background. Also, González-Pinilla et al. [86] reported a higher number of stress symptoms among students that considered themselves religious when compared to their non-religious counterparts. Similarly, an evaluation of socio-demographic predictors of anxiety over cadaver dissection observed prolonged anxiety levels among non-white, non-Christian international students compared to self-identified white Christian students [33]. In another medical student cohort, it was revealed that about 37% would not touch a cadaver for moral and ethical reasons [44], and students who believed in a soul—the spiritual or immaterial part of a human being, regarded as immortal—experienced higher stress levels during dissection [23].

An assessment of students’ backgrounds will ensure that students are screened for underlying stress markers and background factors that may affect their ability to cope with stressors. The information from these assessments will also help educational administrators develop personalized interventions for students at increased risk of mental stress. It is also imperative that students are encouraged to talk about their concerns, fears, and expectations for CD.

We recommend that this assessment be done using a background self-assessment form or one-on-one counseling sessions depending on the class size, available time, and the staff strength of the department. Anatomical societies, anatomy departments, and concerned anatomists are urged to develop standardized background assessment forms that could be adapted and used globally for student background assessment in preparation for their first CD. While this assessment protocol is being developed and implemented, all the necessary ethical considerations must be taken into account while giving each student ample opportunity for a thorough assessment. Some of the critical, personalized, and common concerns identified for each student should be isolated, anonymized, and addressed during the second stage of the CD preparatory process.

It is important to note that the depth of assessment may vary for some students and may be beyond the purview of the student’s department personnel, but rather could involve coordination with medical school administration, clinicians, or counselors. This viewpoint is in conformity with the trauma-informed approach to pedagogy, which acknowledges the potential risks involved and places emphasis on ensuring the emotional well-being of students during the learning process [94]. Some other challenges are envisaged during the development or implementation of protocols for student background assessment. These include the following: what to ask the students to get all the necessary information needed to support each student better and give them an improved first-time CD experience; and how to ask the questions to show professionalism and stimulate honesty. However, early preparation against these challenges will help limit their impact on the quality of information gotten from each student. The development of protocols or modalities for student background assessment is not within the scope of this present study and should be considered by experts within each anatomy educational setting or a designated anatomical association committee.

2. Pre-cadaver dissection education.

It is ideal that after the background assessment of first-time dissectors, the next focus should be pre-CD education. Following previous recommendations on student preparation for CD [43, 72], pre-CD education should be designed to give the students detailed information on the dissection processes. The provision of more detailed information on the purpose and procedures of CD, when combined with mental preparedness through gradual exposure to CD, can significantly reduce anxiety and mental stress during CD [82]. Students should be educated on what to expect during CD, the state of the cadavers and dissecting environment, how to use basic dissection tools, and the proper use of personal protective equipment (PPE) [3]. During the pre-CD sessions, students should also be taught CD hall etiquette and standard ethics. Adherence to ethical behaviors like treating cadavers with respect and care, adequately covering the cadavers, exposing only the areas to be dissected, and keeping bags and other personal belongings (aside from the dissection manual) outside the dissection rooms must be emphasized [3]. At this stage, other important information necessary to ensure easy adaptation of students during the CD should be given to the students, and the students should be allowed to ask questions until all their concerns are cleared. All the non-sensitive socio-cultural and religious issues identified from the student background assessment can be discussed in groups or in general sessions. However, some sensitive and personalized issues raised can be discussed in private sessions with the students concerned. To give the first-time dissectors the best information and support needed at this phase, anatomy experts may also require strong collaboration with the institution’s counseling unit to execute this preparatory phase. The extent of information needed to be shared during the pre-CD sessions may vary between institutions due to regulatory, religious, socio-cultural, and regional differences. Available data show that students who had some form of pre-CD preparation had significantly decreased levels of mental distress and anxiety when compared to those who were not prepared [15, 82]. In implementing the pre-CD education sessions, experts should be aware that the quality of relevant information gotten from each student during the background assessment will determine the quality of the education sessions and its impact. This will also determine the platform to adopt for the pre-CD education sessions. Howbeit, the use of different engagement approaches, whether virtually or in person, is permissible, based on perceived implications. More importantly, the education phase of the student preparation must be done with the mindset that each step of the CD preparatory process is germane to the success and impact of the next steps.

3. Gradual exposure and desensitization.

The gradual exposure and desensitization of students should be considered the last step of their preparatory process before their first exposure to CD. It is based on the concept of counterconditioning through gradual exposure and habituation [95, 96]. The model is a highly utilized strategy that uses repeated exposure to feared cues like images, memories, and sensations to treat anxiety disorders [97, 98]. In essence, responses to fear cues are controlled and decreased due to repeated, predictable presentations of a stimulus. Although the neurobiological basis of the effectiveness of this method is still being explored, it has been asserted that the prefrontal cortex inhibits the amygdala (which is the primary site for fear conditioning) by activating inhibitory lateral nucleus interneurons or the central nucleus of the amygdala [97]. Students should be exposed to similar but less striking and stressful settings as a way to prepare them for CD [43]. The benefits of this approach have been extensively discussed in the literature, and evidence shows that it plays a significant role in reducing students’ initial anxiety in the dissection hall, by helping them mentally ease into the settings [15, 33, 43, 71]. Böckers and coworkers [85] demonstrated the effectiveness of this method by using anatomical demonstrations of organ systems in advance of the dissection course to ease students’ psychological burden. Also, gestures like allowing students to inspect the dissection hall before CD without any contact with cadavers, using mannequins and/or prosected body parts for anatomical demonstration, as well as using YouTube videos [78], and live videos to demonstrate dissection, have been suggested as part of this approach [15, 33, 43, 71]. In one of the studies [71] reviewed in this article, the use of a 3.5-min-long pre-CD video alone was not effective in reducing student’s anxiety. Hence, it is strongly recommended that the use of pre-CD video to mentally prepare students for CD should be combined with other preparatory materials for more effectiveness [78].

Implementation Challenges and the Way Forward

One of the most critical challenges of the recommendations put forward in this paper is the availability of time to execute the three-step student preparatory process within an already dwindling time for anatomy teaching [4, 99–104]. Therefore, the integration of the preparatory process into the anatomy teaching curriculum is highly recommended to ensure planning, time allocation, and a smooth transition from the preparatory program to the dissection lessons of each student cohort. Every anatomy department should work out a fitting model to ensure an effective integration of the preparatory process especially as the process has to be completed before each students’ first contact with the cadaver.

The study of anatomy has evolved over the years, especially regarding its ethics and code of practice [105–109]. Hence, it is essential that pre-CD education should continue beyond the students’ first exposure to CD. This will ensure that students stay updated with relevant anatomy ethics and national and international regulations on the use of cadavers and continue to maintain professional conduct during CD. It is expected that experienced anatomists should be responsible for the implementation of the student preparatory program to maintain professionalism and ethical compliance. We also recommend using a low-cost measure like a self-assessment questionnaire for the assessment of student background. Additionally, the student counseling department or psychology expert could also be coopted during the preparatory process depending on the students’ needs, especially if sensitive issues arise which may require one-on-one sessions. However, if there is an inadequate number of experienced anatomy educators for the preparatory process, teaching assistants could be trained to execute the student preparatory process efficiently.

Study Limitations

This study focuses on psychological factors that contribute to students’ negative experiences during their first exposure to CD. The role, contributions, and implication of factors like dissection environment including room structure, air/window designs, and hygiene; specimen preparation technique/handling including the type of chemical used, embalming method, and putrefaction level; and teachers’ attitude and teaching competence were considered outside the scope of this study. Therefore, the recommendations made in this study were geared toward reducing students’ emotional-related disturbances in the CD laboratory by adequately preparing them mentally before their first exposure to CD.

The three-step CD preparatory process focuses on interventions that are very necessary before CD. However, it is important to note that there are other programs that may be necessary for student’s emotional support during and after the first dissection experience, to maximize the gains of the preparatory process. For example, the use of background music and peer assistance were reported to be beneficial in reducing the stress associated with CD [74, 84]. Medical educators and psychologists have made it clear that students need psychological support before, during, and/or after the CD [43, 56, 110]. Therefore, future studies should focus on beneficial recommendations for student preparation during and after first CD exposure, and also designing protocols and modalities for these preparatory processes.

The studies reviewed in this present paper focused more on gradual exposure, desensitization, and pre-CD education, as there was a dearth of studies showing evidence for background assessment for anatomy students as a strategy for an intervention prior to their first exposure to CD. Consequently, the recommendations made regarding student background assessment were based on existing and established human psychological theories and principles. However, the three-step student pre-cadaver dissection preparatory process still requires critical evaluation and validation to determine its practicability and effectiveness in different anatomy educational settings, since only a few studies are currently available to support these recommendations. More research is required to develop robust and evidence-based protocol for implementation of the three-step recommendation in specific student settings. Some of the recommendations put forward in this paper are authors’ viewpoints informed by a combination of personal implementation experience and scientific literature, and may not have captured all the global purview of the psychological issues related to first CD exposure.

Conclusion

The first contact with a cadaver can provoke stressful responses in students learning anatomy that if left unattended to may impede learning, socialization, and relationship with future patients. Given the importance of CD in anatomy education, students should be adequately prepared before their first exposure to CD to reduce bad experiences during CD, especially for the students at higher risk of being affected. A three-step student preparatory process has been postulated in this paper: (1) student background assessment, (2) pre-CD education, and (3) gradual exposure and desensitization. These recommendations were based on authors’ personalized implementation experience, proven human psychological principles, and evidence from relevant systematically selected studies on student pre-CD intervention. The three-step process shows some hypothetical potential for an outstanding first impression that will impact long-term anatomy learning and ensure that the emotional and psychological well-being of the students are not jeopardized. However, the student pre-cadaver dissection preparatory guide should be validated before implementation, with a focus on the possible complexity that could be associated with individualized student’s assessment.

Author Contribution

IAO conceived and designed the study. IAO and JAN performed the literature search and data analysis. All the authors interpreted the data and contributed to writing the first draft and the revised versions. All the authors read and approved the final manuscript.

Data Availability

All data generated or analyzed during this study are included in this published article.

Declarations

Ethics Approval

This study does not require ethical approval following the Nigerian National Health Research Ethics Committee (NHREC) guidelines.

Competing Interests

The authors declare no competing interests.