Perceptions of Students and Teachers Regarding the Impact of Cadaver-Less Online Anatomy Education on Quality of Learning, Skills Development, Professional Identity Formation, and Economics in Medical Students

Abstract

Anatomy is one of the most important basic sciences in medical education and is the foundation for doctors to develop clinical skills. In the last few years, anatomy teaching has been transformed from hands-on practice into online modalities. In this study, we aimed to determine the perceptions of students and teachers about learning anatomy without using cadavers (cadaver-less) from a knowledge, technological, and humanistic perspective. The research was carried out in the Faculty of Medicine at Hasanuddin University, located in South Sulawesi, Indonesia, over a period from June to August 2021. A focus group discussion was extended to all medical students in their first year of study following their completion of online anatomy lessons. Furthermore, educators responsible for instructing anatomy in the initial year were sent an invitation to participate in a one-on-one interview with the principal investigator. In general, the results of the study complied with what has been known from the literature about the quality of online learning and its advantages and disadvantages. However, our discussions with students and interviews with teachers revealed that anatomy education without the use of cadavers is perceived as undesirable as it negatively impacts the identity formation of the future physician. It also takes away the opportunity for students to develop empathy for humanity.

Introduction

Anatomy is one of the most important basic sciences in medical education and is the foundation stone for doctors to develop clinical skills [1–7]. One of the most important features of anatomical education is the opportunity for medical students to learn from cadavers. In recent times, there has been a decrease in the use of cadaver dissection as educators in the field of anatomy increasingly adopt digital methods [5]. However, it is worth noting that cadaver dissection remains the most efficient approach for medical students to understand anatomy's multidimensional structure [1, 8, 9]. For individuals who learn anatomy, using human representations acts as a symbol for the patient they will treat in the future. For them, the donor serves as their first patient [10]. In the anatomy lab, interactions with peers, teachers, technicians, academics, and donors obviously assist students to improve their emotional intelligence, situational awareness, professional skills, and their own feelings of love and empathy [4, 11–17]. The use of cadaveric learning inside the anatomy laboratory offers significant educational benefits to medical students. This pedagogical approach assists in enhancing their comprehension and skill acquisition in the field of human anatomy while concurrently cultivating a more profound recognition of death and empathy [17–19].

Due to the outbreak of coronavirus disease 2019 (COVID-19), governments all over the world, including Indonesia, had to make the bitter decision to close schools. The Ministry of Education in Indonesia instructed that learning had to be carried out in an online format and prohibited face-to-face learning. This had a huge impact on medical education, especially for learning that depends on practicum, such as anatomy education, and for those schools that had no prior experience with online learning at all. This transformation has not been easy for students or educators. During the COVID-19 pandemic, which has necessitated social distancing measures and limited opportunities for traditional anatomical dissection, the incorporation of innovative technologies and instructional methods has the ability to maintain the established standards of educational quality [20]. Furthermore, a significant obstacle encountered while teaching anatomy by remote means is the absence of face-to-face teaching activities. Both teachers and students have recognized this as a noteworthy obstacle in the context of remote anatomy teaching. The lack of communication between educators and learners has the potential to negatively affect the whole educational experience [21].

The implementation of multiple teaching strategies has the capacity to adapt to different learning preferences and enhance the understanding of anatomical concepts [22, 23]. Many medical schools offer supplementary online resources from external sources to augment the conventional modes of delivering lectures and coursework to students [20]. Online education is a teaching modality that has been used in medical education for several decades now, and several studies have proven that online learning is an effective learning method compared to conventional methods and that it supports self-directed learning [24, 25]. In anatomy teaching, online learning is often used as an addition to the dissection of human cadavers but rarely as a replacement [20]. This is also the case at the Faculty of Medicine at Hasanuddin University in South Sulawesi, Indonesia. Anatomy lessons are being offered to first-year medical students during the 1st and 2nd semesters of pre-clinical education. Content is offered to the students in a blended format, with online preparation materials followed by face-to-face instruction in the dissection room. During the COVID-19 pandemic, the face to face part of the anatomy curriculum has been transformed into online learning. Table 1 shows the differences in anatomy education before and during the pandemic.

Table 1.

Learning methods before and during the COVID-19 pandemic at Hasanuddin University

Anatomy curriculum	Before pandemic	During pandemic
Preparation phase
Videos	Online	Online
Student worksheets	Online	Online
Pretest	Online	Online
Lecture + discussion	Face to face	Online
Posttest	Face to face	Online
Practicum
Student worksheets	Online	Online
Pretest online	Online	Online
Practicum	Small group rotation between cadaver prosection, mannequin, 3D software	PowerPoint slides of cadaver and atlas images online
Posttest	Face to face	Online
Assessment
Theory	MCQ online on campus	MCQ online
Practicum	Fill-in-the-blank question online in anatomy lab	MCQ online

In this study, we aimed to determine the perceptions of students and teachers about cadaver-less anatomy education from a knowledge, technological, and humanistic perspective. Therefore, we have developed the following two research questions:

• What are the perceptions of students regarding the online delivery of the anatomy curriculum during the pandemic?

• What are the perceptions of teachers regarding the online delivery of the anatomy curriculum during the pandemic?

The feedback from students and teachers might help us redesign anatomy courses for the future.

Materials and Methods

Study Design and Sample

The study was conducted in a qualitative design by emphasizing focus group discussions (FGD) with first-year medical students and individual interviews with teachers at the Faculty of Medicine at Hasanuddin University in South Sulawesi, Indonesia. The study combines two distinct methodologies: interviews with teachers to gather comprehensive insights and focus group discussions with students to foster engagement, facilitate the exchange of experiences, and promote the development of ideas through a cascading effect of dialogue [26, 27]. Our objective is to provide a supportive atmosphere where students can express their perspectives without constraint, implementing the FGD methodology.

The recruitment of respondents was conducted using purposive sampling. All 1st year medical students that attended online cadaver-less anatomy lessons in the 1st and 2nd semesters of pre-clinical education between October 2020 and March 2021 were invited to participate in the study. We gave a short explanation about our research project via an online meeting after the anatomy lecture, and students could apply to participate in the study by filling out an online informed consent form. Exclusion criteria were applied to students who possessed prior knowledge or training in anatomy through cadaveric instruction, as the objective was to investigate the experiences of those who had not previously engaged with cadavers.

Teachers in the Departments of Anatomy, Surgery, Internal Medicine, Orthopaedics and Traumatology, Radiology, and Obstetrics and Gynecology were invited via e-mail, and they could sign up and fill out an online informed consent form by email. After 10 days, we sent out one reminder to the teachers who had not responded yet. Teachers needed to have a minimum of 5 years of teaching experience in order to be included in the study. Some of the teachers who participated in the interviews were from the clinical department, and their course syllabus integrated clinical anatomy with the pathomechanisms of diseases acquired by students during the clinical clerkship phase at the hospital. These teachers are also involved as tutors in problem-based learning (PBL) discussions, where students are expected to integrate basic anatomical knowledge with pathomechanisms of disease. Before beginning the interview, the interviewer also provided a brief explanation of the anatomy learning methods taught during the preclinical phase in order to minimize personal bias. We anticipate that teachers will share their perspectives as teachers from clinical departments where studying diseases in this field necessitates an in-depth knowledge of anatomy.

A total of 36 students, representing 11% of the total of 271 students in class 2020, participated in the focus group discussions. Similarly, 12 teachers, representing 7.6% of the total of 157 teachers, were included in the interviews. There is no predetermined rule for determining the sample size. In this study, we rely on the concept of data saturation, which refers to the point at which no new information or themes emerge from the data [28, 29]. One of the systematic reviews demonstrates that saturation can be reached with a limited number of interviews (9–17 people) or focus group discussions (4–8 people), especially in studies with relatively homogeneous study populations and restricted objectives [30].

Data Collection

Focus group discussions and interviews were conducted in an online meeting due to the COVID-19 pandemic situation and using Indonesian between June 2021 and August 2021. The FGD of students was conducted in three sessions with 12 participants each and one interviewer from the Psychology Department. The FGD sessions lasted up to an hour. The interviews with teachers were conducted in 12 meetings with 1 teacher and 1 interviewer. The duration of the teacher interviews was limited to 15 min. The interview questions were developed by conducting a comprehensive analysis of the course learning survey, which was administered to all students as well as teachers upon the completion of the anatomy course. The list of questions was discussed with other researchers in order to ensure a balanced understanding and minimize potential biases during the focus group discussions and interviews. The questions were open-ended.

1. How did you perceive the online delivery of the anatomy curriculum during the pandemic?

2. What is in your opinion the advantage of online delivery of the anatomy curriculum during the pandemic?

3. What is in your opinion the disadvantage of online delivery of the anatomy curriculum during the pandemic?

4. What do you think about future doctor competency and skills if online learning totally replaces cadaver anatomy education?

FGD and interview sessions were recorded on video. Three researchers (AAN, NFW, and LIS) independently read each transcript of the recordings. Three researchers have received training in familiarization and coding, and they are at various stages of their careers and from different generations, allowing them to interpret participant responses from different points of view. The confidentiality of all data was ensured through the use of codes that were exclusively accessible to the research team.

Data Analysis

The analysis was performed using thematic framework analysis, where familiarization was achieved during transcription and three further readings were undertaken to develop themes. Thematic analysis in this study was done through several steps based on guidance by Braun and Clarke, 2006, being familiarization, coding, generating themes, reviewing themes, and defining themes [31]. In order to conduct a thematic analysis, each statement provided in the FGD and interviews was tabulated using Microsoft Excel™ spreadsheet tools. First, three researchers (AAN, NFW, and LIS) read each transcript line-by-line and coded it independently. Codes were established and allocated in order to classify data extracts by highlighting sections of each response’s text. We classified the descriptive words as follows:

1. The perception of online delivery of the anatomy curriculum during the pandemic

2. The advantage of online delivery of the anatomy curriculum during the pandemic

3. The disadvantage of online delivery of the anatomy curriculum during the pandemic

4. The impact of cadaverless anatomy education

Subsequently, we proceeded to analyze the code structures and resolve any inconsistencies in order to establish agreement on a theme framework. Each code set was discussed with other research teams (NFW, LIS, AAN, RM, and PDJ) until a consensus was reached. After the completion of the coding process, the analytical team convened meetings to engage in discussions and further refine the emergent themes. Finally, the following themes were developed after analyzing the available data and identifying patterns within student and teacher responses: quality of learning, confidence in knowledge and skills, identity formation and ethics, and economic aspects. All of the interviews and analyses were conducted in Indonesian. The mentioned statements were translated into English for the purpose of this paper. A third party who is fluent in both Indonesian and English verified the translation.

Results

Thematic analysis of the recorded interviews revealed four major topics: quality of learning, confidence in knowledge and skills, identity formation and ethics, and economical aspects.

Students’ Perceptions of Online Anatomy Education

Quality of Learning

During the discussion, students brought up two opposite viewpoints on the quality of online learning. On the one hand, they reported that online learning allows them to be more flexible in their learning. Teachers were encouraged to supply all anatomy learning materials in the form of e-learning and anatomy applications that could be accessed through electronic media so that they could access them anytime. Students also felt that the online anatomy education was well-structured and practical. Learning objectives were included in each teacher’s teaching materials so that students could get an idea of the levels of competency they had to master. Furthermore, they were pleased with the topics of the exam questions, which were relevant and did not come from specific dissection room material being taught.

Three students described the advantages of online anatomy learning during the pandemic:

• “In my opinion, the online anatomy learning is very structured, especially since the learning uses a lot of methods, not just one. Before starting an anatomy class, we have to fill in the module via the e-learning and anatomy applications. There are also videos and pictures that can be downloaded online. Despite the fact that we cannot see the original cadaver in person, I believe it is easier for us because we already understand enough of the information the teachers have provided.”

• “In my opinion, the advantage of online anatomy learning is that it is more interesting because there are many methods and platforms that we can use as learning resources. Usually studying anatomy is perceived as difficult, but with online learning, it is easier to understand, memorize the lessons, not get bored easily, and make learning more interesting.”

• “So in my opinion, the advantage of online anatomy learning is that it is easier to receive learning. In online practicum, the organ structures that are important to study have been assigned numbers so that it is easier for us to memorize them. In addition, online anatomy learning makes it easier for us to take exams. Nearly 80–90% of the images included during the exam are in accordance with the practicum material, so it is easier to answer these questions. Maybe it’s from me, ma’am. Thank You.”

On the other hand, students also expressed their dissatisfaction with online anatomy education, claiming that it degraded learning quality. They feel that without direct contact with a cadaver, they must rely on their imagination to explore the anatomical structures and organs from 2D pictures. They believe that due to restrictions in displaying a 3-dimensional view on a 2D screen, online anatomy learning cannot depict the entire organ. Students are concerned that online anatomy learning will be difficult to recall in the long term because it uses only the senses of sight and hearing (audiovisual learning) and does not engage the senses of touch and smell. They are also concerned that if they only learn online, they won’t be able to develop their human side as doctors. Empathy for fellow humans is the aspect of humanism discussed in this discussion. They claim that ethical issues can be much better addressed if cadaver learning is used and students interact directly with their teachers and other students.

Two students described the disadvantages of online anatomy learning during the pandemic:

• “So the learning method used since I was in medical school was limited to 2D cadaver images that we had to memorize. In my opinion, this is less effective because we cannot directly feel what the cadaver looks like. When we learn about arteries, veins, or nerves, we can’t feel the difference if we don’t touch them directly. I use audiovisual learning, and there must be touch to make it easier to remember, so when there are no objects that can be seen in three dimensions, it is very difficult for me.”

• “I would like to add my opinion that one of the drawbacks of studying anatomy during a pandemic is that ethics will be disturbed because cadaver learning is practicing ethics with the human body, as previously taught about medical ethics, one of which is how we cultivate the value of humanism through dissection of cadavers. So if we have never been directly taught using cadavers, how can we develop a sense of humanism within ourselves?”

Confidence in Knowledge and Skills

During the discussion, students expressed a lack of confidence in their anatomical knowledge and skills. They are concerned that future courses involving anatomical applications and direct patient contact, despite the fact that the lessons offered are quite comprehensive and informative, will be challenging due to the fact that they only received audiovisual learning. They are also worried about their clinical competencies and lack of confidence in their ability to apply skills to patients. They believe their problem-solving and clinical reasoning abilities are still poor.

Three students described the impacts of cadaverless anatomy education on knowledge and skills:

• “Maybe I’ll add the disadvantage that we easily forget lessons because teaching materials are only two dimensions and we don’t have direct contact with three-dimensional structures, in this case cadavers, so I’m afraid the memory will only shorten. It is possible that we will not remember the learning material from the first semester in the following semesters; the purpose of studying is only to be able to do the exam at that time. If learning continues without a cadaver, we are only happy at the beginning but struggle at the end.”

• “Thank you for the opportunity. In my opinion, the competence of doctors produced by online learning alone will not be the same as that of previous doctors who studied with cadavers. First, online learning makes it clear that we don't have direct contact with cadavers, so we don't feel the direct sensation of learning with cadavers. The second is that it does not develop soft skills to become a professional doctor; we need a lot of practice using cadavers accompanied by adequate theory and clinical skills.”

• “Thank you, ma’am. In my opinion, the competence and ability of doctors if replaced completely online will greatly decrease and even be fatal because if cadaverless anatomy education continues, it will be difficult to distinguish where the organs are located. We will find it difficult to distinguish which ones are normal and which ones are experiencing pathological conditions such as enlarged organs. In the future, if we become doctors and examine the patient directly, I'm afraid we are still thinking about where it is located, and even then maybe we can determine the wrong location so that the patient will consider it unprofessional.”

Identity Formation and Ethics

In the view of their parents, family, and the public in general, a doctor must have “smelled formalin” during the education process by being faced with a preserved cadaver. Students think that by learning anatomy online, they will miss their opportunity to “smell formalin,” so they feel they haven’t gotten the sensation as a medical student. In addition, they feel less able to grow their empathy as future doctors.

Two students described the impacts of cadaverless anatomy education on identity formation and ethics:

• “In my opinion, this is also one of the disadvantages of learning anatomy online without a cadaver. We never know what a cadaver smells like, the condition of a cadaver, or how it ‘smells of formalin’, so it reduces the impression of being a medical student.”

• “Thank you, ma’am. In my opinion, the disadvantages of studying anatomy without a cadaver might be seen from an ethical aspect, especially the opportunity to develop empathy as a prospective doctor, because if we use a cadaver, it’s not just learning anatomy and so on. We apply empathy when carrying out procedures before and during cadaver dissection; for example, when we want to see the anatomy of a part of the chest region, we cover other parts to maintain the privacy of the cadaver. We think of cadavers like humans, so that by itself can grow a sense of empathy.”

Economical Aspects

Because learning takes place at the student’s house, online anatomy study is cost-effective in regard to travel. Students also find it cost-effective in terms of teaching materials because learning resources are accessible for free through e-learning. They do, however, feel disadvantaged in terms of tuition fees because they have not had the opportunity to use the classroom facilities or the anatomy laboratory they had paid for.

Two students described the impacts of cadaverless anatomy education on economic aspects:

• “In my opinion, one of the advantages of studying anatomy online is that it is more economical because we don’t have to come to campus directly to see the cadaver in person. Besides that, we don’t have to buy an atlas book because it is already available in pdf format on online anatomy e-learning, which we can download for free, as well as other teaching materials that have also been given by doctors and assistants. Yes, maybe that's it, ma'am. From me, thank you.”

• “I put more emphasis on the economic aspect, ma’am. I’ve paid a lot of money but haven’t had the experience of learning to use a cadaver, ma’am. That’s from an economic perspective.”

The comments of the students are summarized in Fig. 1.

Fig. 1.

Student’s perceptions of cadaver-less anatomy education

Teacher’s Perceptions of Online Anatomy Education

Quality of Learning

Teachers feel that the creation of online anatomy teaching has improved the quality of learning. In the online environment, teachers were forced to be more creative and innovative in their development of teaching materials. In addition to providing lectures via online meeting platforms such as Zoom, teachers had to create teaching materials in the form of videos, modules, and eBooks that students could access through the e-learning website at any time and any place. This pandemic, according to teachers, presented a challenge for them to build online learning that is more adaptable, conducive, and attractive to students. Online anatomy education is thought to be more effective and efficient. However, it requires continuous exploration from the teacher to always adapt to the development of educational technology.

One teacher described the advantages of online anatomy learning during the pandemic:

“For me, as a teacher, this is a challenge. I myself like challenges. How to teach anatomy in such limited conditions. One of the advantages is that during this pandemic, we can find many creative and innovative methods of learning anatomy that we never had before. There are also various student complaints, so we also have to adapt to conditions like this, which we have never faced before.”

However, online anatomy learning also has some drawbacks that lead to a decrease in quality of learning. Teachers think that online learning lacks three-dimensional aspects; students have to rely more on their imagination and cannot see or touch the organs directly. In addition, teachers are also unable to improve students’ clinical skills. Online anatomy learning relies more on audiovisual learning, which raises the concern of long-term knowledge retention. Teachers find it difficult to evaluate students’ level of understanding when using online platforms, and for them, it is difficult to detect cheating during exams. From an ethical perspective, teachers feel that it is difficult for students to apply humanism as prospective doctors because they do not directly interact with cadavers as their first patients and do not develop emotional relationships with other students.

Two teachers described the disadvantages of online anatomy learning during the pandemic:

• “The disadvantage of online anatomy learning is that if we learn to use only pictures, the 3-dimensional aspect is lost, so we cannot fully explore the anatomical structure. If we use a cadaver, for example, on the hand, we can see the deeper structures by dissecting the muscles in the hand. And it can be done with images too, but it’s a bit complicated because we have to create multiple slides, layer by layer, so it’s less effective. Second, the human aspect is lost. He has to respect his fellow human beings because what the doctor learns is about people, not dolls or inanimate objects. Cadaver as a representative of humans when studying anatomy. Don’t let students become robots. The skills are good; the cognitive aspect is good, but the humanity aspect is lacking. Yes, the important thing is the humanity of the doctor. In addition, it is rather difficult to detect cheating during exams when using online meeting applications such as Zoom or Google Meet. Student problems also varied during online exams; for example, we suspected students of cheating during exams because the camera often turned off even though the internet signal was not good.”

• “If learning is only done online and we don't see the organs in three dimensions, it will be more difficult to understand the location of the anatomical structures, especially if only through 2D anatomical images. In my experience in residency education, even though we read books about surgical techniques and so on, it’s still a bit difficult for us to understand how surgical techniques work before we see the operation firsthand. So, let’s see the organs directly, their location, and their relationship with the surrounding organs.”

Concern in Knowledge and Skills of Students

Teachers believe that there will be no difference in student competency development as long as teachers are creative in their preparation of teaching materials, create the same conditions as offline learning, and use virtual learning to exhibit three-dimensional elements of anatomical organs. Although some teachers are optimistic about this online anatomy learning, there are still some who think that differences in knowledge may not exist, but there will be differences in competencies that require intervention and action.

Three teachers described the impacts of cadaverless anatomy education on the knowledge and skills of students:

• “There is indeed concern for clinicians if online learning of anatomy without a cadaver continues; that is, students will have fewer clinical skills. But, in my opinion, theoretical abilities and skills are almost the same. So it all depends on the students and lecturers ability to adapt to the current conditions. However, there are several points that they will not get if they are not given the opportunity to learn how to use a cadaver, such as seeing the anatomical structure in three dimensions and its human side.”

• “The disadvantages of learning anatomy online without a cadaver are that we can’t palpate or feel the cadaver directly and can’t hear a direct explanation from the anatomy teacher. Although students can also see good live images of the atlas, they cannot touch the objects. Likewise, when we do not touch the patient during a physical examination, the memory of that is not as strong as if humans touched objects directly.”

• “If competence is just for knowledge, I don’t think there is a problem, but for competencies that require action, maybe this is what the anatomy lecturer needs to think about if this pandemic is prolonged and needs to find a solution or be scheduled for a special practicum using cadavers. For example, touching the muscles refers to the competence to perform injections in the gluteus. If he has never touched how strong the gluteus muscles are, then of course he will lack confidence when carrying out these actions. So it will mainly affect competencies that require intervention or action. As for knowledge competency, I think it will still be achieved even though learning is only done online without cadavers, but when it comes to action competence, I think that needs to be considered for a solution. For example, at the preclinical or clinic level, there is an additional OSCE to further improve the skills of these students in learning anatomy because anatomy is a basic science that is very important as a doctor, so competence must be achieved.”

Identity Formation, Ethics, and Economics

Similar to students, teachers also feel that online anatomy teaching impacts the identity formation of students. From an economic point of view, teachers also feel that it is cost-effective in terms of travel costs and teaching materials.

Two teachers described the impacts of cadaverless anatomy education on identity formation, ethics, and economics:

• “In my opinion, students’ abilities will definitely be much different compared to pre-pandemic learning if online anatomy without cadavers continues. Even though learning is now actually based on clinical cases, if it is not accompanied by the use of cadavers, then the results will not be optimal. Cadaver dissection learning is much better and can hone observation skills and develop a human side, which is very important to becoming a professional doctor.”

• “The first advantage is that it is efficient in terms of time and materials because cadaver is quite expensive, and transportation costs can be reduced so that teachers can always start classes on time because there are no traffic jams. Then the most important thing is that teaching materials can be opened anytime and anywhere, so there is no need to wait for lectures and practicum time to reopen the materials they want.”

The comments of the teachers are summarized in Fig. 2.

Fig. 2.

Teacher’s perceptions of cadaver-less anatomy education

Discussion

This is the first study to investigate the impact of the COVID-19 pandemic on anatomy education in Indonesia, a developing Southeast Asian nation. We evaluated the perceptions of students as well as teachers regarding online anatomy education during a pandemic in which there was no cadaver learning and no physical student–teacher interaction. Both teachers and students see the advantages of online teaching and learning regarding flexibility in time and place and cost-effectiveness. Almost all teachers in our study believe that in the future there will be no difference between online and face-to-face students regarding both knowledge and clinical skills, as long as teachers stay creative and keep up with the latest developments in online anatomy teaching in order to recreate the conditions that existed before the COVID-19 pandemic, when students were still in the anatomy lab. Only a small number of teachers doubt the future competence of their online students, especially those who are in professions that require sufficient basic knowledge of anatomy to perform actions and interventions on patients.

The COVID-19 pandemic has encouraged teachers to create new methods and learning modalities that are more creative and innovative to adapt to current conditions, especially in processes related to cadaveric dissection because cadaveric dissection is irreplaceable, especially for medical students [32, 33]. Singal et al. even have the opinion that digital learning will ultimately replace cadaver-based learning in the future [34]. In contrast to that study, Shin et al. analyzed the impact of the COVID-19 pandemic on teaching in US Medical Schools and its implications for current development, demonstrating that cadaveric dissection is the preferred method of interactive learning. The majority of medical colleges provide online resources to supplement lectures and coursework [20]. Nowadays, there has been a significant transition in medical education, with medical institutions implementing pedagogical reforms in order to adapt to current conditions. Traditional lecture-based teaching methods will be phased out, technology will be used to enhance anatomy and laboratory experiences, and team-facilitated, active, and self-directed learning strategies will be implemented [35]. The flipped classroom is an example of anatomy learning that incorporates multimodal digital resources and has a positive impact on student experiences and learning performance [20, 36, 37]. In addition, we can incorporate novel learning modalities such as mobile technology, 3D-printed anatomical models, and virtual dissection to improve understanding of anatomical systems’ shapes and spatial connections [38–42]. These methods accurately illustrated anatomical variations and served as a valuable supplement to the instructions for complex anatomical regions.

The majority of the students turned out to be concerned and skeptical about online anatomy education and their future ability to practice medicine if online anatomy and cadaver-free learning persist. They are pretty concerned about their clinical competency in the future if students continue to learn anatomy without using cadavers. They have doubts about their future clinical ability, particularly in areas that demand anatomical knowledge, psychomotor skills, and direct patient contact. They doubt if this lack of competency can be corrected in later stages of the curriculum. They’re also concerned about the long-term memorization of anatomical knowledge because there is no physical contact with the cadaver. The concern expressed by this student aligns with other studies that have highlighted the importance of cadaver dissection in the learning and practical application of anatomical knowledge. The integration of procedure-based dissection with lectures and problem-based learning (PBL) sessions presents a pedagogically valuable strategy that combines fundamental skills with conventional teaching methods. Both methods effectively support meaningful learning and yield satisfactory performance outcomes, indicating the possibility of delivering high-quality human anatomy teaching [43].

The process of dissecting cadavers has crucial significance for the learning and practical application of anatomical information, both within laboratory settings and in real-world scenarios [44]. Cadaver dissection is an essential component of medical anatomy education, as it improves medical students’ cognitive abilities and attention span. It is essential for students pursuing in-depth, three-dimensional knowledge of anatomy. The unique learning opportunity provided by cadaver dissection, combined with the support of faculty, contributes to the long-term retention of anatomy knowledge [45, 46]. During dissection, hands-on experience, tactile handling, and peer-group discussions enhance the cognitive process of understanding and retaining three-dimensional structures [43, 45, 46]. However, the efficacy of cadaver dissection may vary depending on the individual and the educational program.

Surprisingly, according to the dialogues with students and teachers, one of the consequences of studying anatomy without a cadaver is a lower status as a future doctor. Students believe that if anatomy is taught online rather than in the cadaver directly, they will miss out on the opportunity to “smell formalin,” which is engrained in their minds because all medical students must “smell formalin” before becoming doctors. Furthermore, both students and teachers believe that online anatomy learning without a cadaver can affect students’ human side because they do not learn humanism by experiencing the cadaver itself, which is their first patient. Empathy with the body is lost. In contrast to students’ pessimism that they will struggle to develop empathy while becoming doctors if online anatomy learning without cadavers persists, teachers believe that empathy for humanity and the virtue of humanism may be developed anywhere and at any time and are not only reliant on student-cadaver interaction. Students also report a loss of engagement with teachers and peers as they lack social interaction with friends and teachers, both of which are critical for instilling the value of humanism in a future doctor.

These findings are in line with Iwanaga et al., who suggest that learning anatomy using cadavers can promote cooperation, self-reflection, interprofessional and communication skills, and ethical values in addition to teaching the structure and function of human organs [47]. The process of cadaver dissection has the potential to play a significant role in the development of a medical student’s professional identity. This is achieved through various means, including the challenge it presents in shaping one’s own identity within the medical field, the facilitation of emotional experiences and self-reflection, the cultivation of a sense of professionalism, the promotion of teamwork and communication skills, and the fostering of a sense of responsibility. The potential consequence of excluding cadaver-based learning from the study of anatomy is the loss of its crucial function in the development of qualified medical practitioners [48, 49].

The integration of advanced anatomy courses into the clinical education of medical students necessitates a collaborative effort between clinicians and academic anatomists. The application of anatomy among preclinical students can be enhanced with the integration of clinical context derived from many areas of clinical care that heavily depend on anatomical knowledge [7, 50]. The collaboration between educators in the fields of basic and clinical medical science is of the utmost priority in the development of an anatomy teaching curriculum that not only cultivates the skills necessary for producing competent physicians but also fosters a sense of humanism. The integration of traditional cadaver-based techniques with digital teaching materials, known as blended learning, is anticipated to be the preferred approach for educational institutions in the next few years.

Study Limitations

The major limitation of this study is that the perceptions of students and teachers regarding online anatomy education might be influenced by the culture in Indonesia. One of the minor limitations of the study is that some of the teachers were not directly involved with the anatomy course in the preclinical phase. In addition, only medical students and teachers from a single institution were surveyed. Therefore, qualitative research involving multiple medical institutions in Indonesia is strongly suggested.

Conclusion

Anatomy is a fundamental component of medical education, serving as the basis for the development of clinical skills. Dissection of cadavers continues to be the most effective method for medical students to comprehend the multidimensional structure of anatomy. The global pandemic of COVID-19 has compelled governments to close schools, necessitating online education. Nonetheless, the transition has been difficult for students and teachers.

Both teachers and students see the advantages of online learning regarding flexibility in time and place and cost-effectiveness. Teachers believe online anatomy teaching does not differ from face-to-face instruction as long as teachers remain creative and up-to-date. Students are skeptical about online anatomy education and concerned about long-term memorization due to the lack of physical contact with cadavers. Additionally, online anatomy learning without a cadaver may affect students’ human side, as they do not learn humanism by experiencing the cadaver itself. Students also report a loss of engagement with teachers and peers, which is critical for instilling the value of humanism in a prospective future doctor. Cadaver dissection can play a significant role in the formation of a medical student’s professional identity by fostering cooperation, self-reflection, interprofessional and communication skills, and ethical values. However, excluding cadaver-based learning from the study of anatomy could result in the loss of its vital role in the development of qualified medical professionals.

In general, the results of the study comply with what is already known from the literature about the quality of online learning and its advantages and disadvantages. However, our discussions with students and interviews with teachers revealed that anatomy education without the use of cadavers is perceived as undesirable as it negatively impacts the identity formation of the future physician. It also takes away the opportunity for students to develop empathy for humanity. Further research might be warranted to explore if this finding is region- or culture-dependent.

Author Contribution

N.F.W., L.I.S., A.A.N.: formal analysis and investigation. N.F.W., P.D.J.: conceptualization, visualization. N.F.W., A.A.N., R.M.: methodology. N.F.W., P.D.J.: writing—review and editing.

Declarations

Ethical Approval

The Faculty of Medicine Institutional Review Board granted ethical approval (IRB Application Number 250/UN.4.6.4.5.31/PP36/2020). All participants gave informed consent to participate in the study and have their data used for research purposes.

Conflict of Interest

The authors declare no competing interests.