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. 2024 Dec 22;38(2):216–221. doi: 10.1002/ca.24256

Pathology discovered in the “first patient” can be the silent teacher of self‐directed learning

Mary Leupold 1, Daniel Topping 2, R John Cork 3, Robin McGoey 4, Guenevere Rae 1,✉
PMCID: PMC11826293  PMID: 39709620

Abstract

Pathology found during cadaveric dissection has been used to model integrative teaching methods for medical students at several institutions. Recent evidence has shown that pathology found during dissection can be used in the design of self‐directed learning (SDL) activities with standards that are difficult to meet. This study presents a novel method for providing formative feedback, one of the most challenging aspects for LCME accreditation of SDL activities. Three practitioners (two board certified pathologists and one board certified family physician) reviewed and rated pathological findings during routine dissection by first year medical students in the gross anatomy laboratory in New Orleans, Louisiana. The students also rated the findings, and a comparative score was given that provided quick, individualized formative feedback with no additional faculty time burden. The inter‐rater reliability (IRR) among the clinical expert panel (n = 3) was adequate (IRR = 0.85). The students' percentage agreement with the expert panel was just under 57%. There was no significant correlation between the score on the Gift formative feedback instrument (FFI) and the students' performances in their gross anatomy course (p > 0.05). This study describes a FFI that allows for the variety of clinical presentations in cadavers dissected in the gross anatomy laboratory, while protecting faculty time that would otherwise be used for scoring individuals in large cohorts of medical students. This instrument can be used to integrate pathology and gross anatomy and provide a practical way of implementing self‐directed learning.

Keywords: autopsy, body donation, dissection, gross anatomy, medical education, pathology, self directed learning

1. INTRODUCTION

Pathology identified in gross anatomy labs has been reported in the literature with several different purposes. Individual pathologies have been reported mainly as potential learning opportunities (Alyafi et al., 2012; Geldenhuys et al., 2016; Kumar et al., 2006; Magrill, 2008; Rae, Cork, et al., 2017). Other research has focused on describing the incidence of pathology in order to raise faculty awareness of diseases that could be found more commonly in the gross anatomy laboratory (Chun et al., 2007; Geldenhuys et al., 2016; Magrill, 2008; Rae et al., 2016). Several studies have also involved surveying students to assess the benefits they experience from identifying and learning about pathology in this setting (Eisenstein et al., 2014; Fletcher et al., 2023; Hanley et al., 2023; Kumar et al., 2006; Meredith et al., 2019; Rae, Cork, et al., 2017; Robertson et al., 2024). The results of this research have shown that students can benefit in several key areas: more understanding of clinical applications of the basic sciences, of the integration and overlap between micro‐ and macro‐anatomy, and of the pathologist as a healthcare practitioner; increases in early clinical reasoning, excitement and motivation to learn, and reflection on one's own health; and an appreciation of social determinants of health. Two studies specifically highlighted how formal autopsy activities combined with the gross anatomy lab could be used as a formal Self‐Directed Learning Activity (SDL) that would satisfy the requirements of the Liaison Committee on Medical Education (LCME) (Hanley et al., 2023; Meredith et al., 2019).

MD program accreditation in a United States medical school is contingent on the school's fulfillment of each of the 12 LCME accreditation standards (LCME, 2023). These standards cover the entirety of a medical school's structure, curriculum, and operational methods. Each of them has accompanying elements describing individual components that collectively constitute the given LCME standard. The LCME does not place requirements on how these standards are fulfilled, and this openness creates freedom for interpretation and creativity in meeting each of them. Liaison Committee on Medical Education Standard 6, Competencies, Curricular Objectives, and Curricular Design is of particular interest, specifically its third element (Element 6.3), Self‐Directed and Lifelong Learning (LCME, 2023). Through this element, the LCME requires schools to incorporate self‐directed learning in the undergraduate medical education (UME) curriculum in a way that establishes the crucial habit of life‐long learning. As defined by the LCME, SDL for a medical student involves each of the following: self‐assessment of learning needs, independent identification, analysis and synthesis of relevant information, and appraisal of the credibility of information sources. These are in addition to a facilitator's assessment of and feedback to the student on his/her information‐seeking skills. The individualized feedback required to meet this standard can make it difficult to meet the standards for Element 6.3 in institutions with large class sizes.

In the studies that used autopsy projects as models for SDL, faculty‐student interactions were the primary methods for providing formative feedback to the students. Although faculty‐student interaction is the ideal way for students to receive feedback, it is not possible at all institutions owing to the time constraints. Considering that the LCME standard requires students to receive individual feedback, but the method by which the feedback is given is not restricted, we hypothesized that a novel tool can be created to give the student formative feedback quickly without large demands on faculty resources. The purpose of this study was to model a cadaver‐based SDL activity that includes a large format formative feedback instrument capable of lessening the time burden on faculty and increasing the practicality of implementation.

2. MATERIALS AND METHODS

The research protocol was approved by Louisiana State University Health Sciences Center Institutional Review Board #9140. The Autopsy project is depicted in Figure 1 and involved three phases.

FIGURE 1.

FIGURE 1

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Overview of the Cadaver‐based SDL activity (Autopsy Project). In the image above, the first phase includes data collection sessions in the gross anatomy lab. The second phase is a didactic session that allows students to research and find references and to draw conclusions. The third phase is completion of the online Gift FFI.

  • 1

    Phase I: Identifying Learning Needs (Gross Anatomy Laboratory).

Phase I included the first‐year medical students performing dissection during the gross anatomy course and documenting any anatomical variations and pathological lesions encountered. Guides (Rae et al., 2018; Rae, Mcgoey, et al., 2017) and videos were available to assist students in identifying pathology, and experts (pathologists, pathology residents) interacted with the students during laboratory sessions (three sessions in total involved pathology assistance). The faculty assisted students in identifying pathology, artifacts and anatomical variations, and the time that the pathology faculty spent interacting with each dissection tank was measured in minutes. In addition to the gross identification of lesions, students also selected tissues to be sampled and processed for histopathological examination. At the end of the course, each dissection team submitted their autopsy data sheets to faculty. Formative feedback was given on students' data collection and identification of learning needs by the anatomy faculty and by the pathology experts, verbally when they interacted with the students in the laboratory.

  • 2

    Phase II: Independent identification, analysis and synthesis of relevant information (Didactic in‐class session).

The students were given individual assignments and were asked to perform the following tasks: Identify which abnormalities found during dissection were unfamiliar to them, and research the clinical importance of each abnormality. They were instructed to find and use credible resources to complete these tasks (expert opinions, histopathology data, online resources, textbooks, journal articles). They were also asked to share their reasoning and conclusions with other students and faculty during the in‐class session.

  • 3

    Phase III: Formative feedback to students (Online).

After the students had identified their own learning needs through the data collection process of dissection and had completed the in‐class portion of the autopsy project, they were required to complete the Gift FFI. This instrument allowed them to receive feedback on their clinical reasoning skills and their ability to synthesize and analyze the clinical information they had researched. A panel of clinical experts was recruited to help design the instrument and to create the scoring rubric. The experts had the following qualifications: experience in clinical practice (over 10 years) and experience in educating medical students in the gross anatomy laboratory. They comprised two board certified pathologists and one board certified family physician, and originated from two academic institutions, Louisiana State University Health Science Center in New Orleans, Louisiana, and University of Central Florida College of Medicine in Orlando, Florida. Students were required to outline their research and list any resources used in the activity. After the learning session, the didactic class session assignment was also reviewed by an anatomy faculty member, who gave students feedback regarding their research‐seeking skills through their learning management system.

The Formative Feedback Instrument had three embedded phases:

  1. Part IIIa‐ Identifying data from a list of possible abnormalities.

The students listed all abnormal findings discovered during the autopsy activity. These data combined the clinically important with the clinically irrelevant. Abnormal anatomy (variations) and evidence of past surgeries were recorded along with the pathologies.

  • 2

    Part IIIb‐ Rating the importance of each data point.

The instructions on the formative feedback instrument assessment asked the student to rate the likelihood that each data point contributed to their cadaver's cause of death, using a five‐point Likert scale (Figure 2).

FIGURE 2.

FIGURE 2

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Assigning importance to each finding. This is an example of one dissection team's scoring of data they collected during dissection. After conducting research, the student rated the probability that each datum contributed to their cadaver's cause of death.

  • 3

    Part IIIc‐ Students receive a numerical score.

The students' responses were compared to the expert panel's responses for each pathological lesion. The students received a score that reflected the percentage agreement between their choices and the expert panel's choices. For additional feedback, they were also given reference ranges of other students who had completed the Gift FFI so they could see how they compared to their peers.

GraphPad Prism 6 software (GraphPad Software, San Diego, CA) was used for all statistical analyses. The IRR (internal consistency) of an assessment was calculated using a two‐way random absolute Intra‐Class Correlation method (Mcgraw & Wong, 1996). A Pearson Correlation Coefficient was calculated for all correlations detected (demographic data, time spent interacting with experts, grade in anatomy course).

3. RESULTS

During the pilot year, 202 first year medical students participated in the study. The participants had an almost equal sex balance (100 males, 102 females). Their ethnicities were: 81.6% White/Caucasian, 7.9% Asian, 6.9% Black,1.9% Hispanic; 1.5% chose not to answer this question. Their mean age was 24.91 years ± 5.7. There were no significant correlations between the demographic variables and scores on the formative feedback assignment (p > 0.05).

For the Gift FFI, where the students rated each pathological lesion or anatomical variation, the IRR was 0.85. This value indicates good internal consistency of the Gift FFI. The data were normally distributed and there were no significant correlations between demographic variables and student performances (p > 0.05). The mean score on the Gift FFI was 57.95 ± 22.40% agreement with the clinical experts. There was no significant correlation between students' performances on the Gift FFI and their grades in the gross anatomy course (p > 0.05). The average time spent interacting with the clinical experts was 15.29 ± 11.06 min. There was no significant correlation between total time spent with the expert and performance on the Gift FFI (p > 0.05).

The feedback survey on how the students felt about the assessment revealed that 93.59% of them wanted to know how their scores compared to the expert panel's. The open‐ended question (What they would use this information for?) elicited 127 answers with the following themes: 33.07% said they were curious about how they would compare, 22.09% said they would use the information for self‐assessment, 11.8% were curious about the clinicians' opinions, 2.36% said they wanted to understand the cause of death of their first patient better, and 0.79% said they were emotionally or intellectually invested in the patient. For the question that invited students to rate the value of the assessment information on a scale of 1–10, most respondents selected “7” (20.51%), “8” (19.23%), or “6” (16.67%); Figure 3. For the question asking participants to self‐report the length of time they spent on this assignment, 22.8% chose “0–1 h”, 45.5% chose “1–2 h”, 17.3% chose “2–3 h”, 10.4% chose “3–4 h”, 1.0% chose “4–5 h”, and 3.0% chose “>5 h”.

FIGURE 3.

FIGURE 3

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Perceived value of formative feedback tool. This figure shows the percentage of students who chose each value level for the Formative Feedback tool.

4. DISCUSSION

This study enhances our previous work because it involves measuring the students' clinical reasoning after they find pathology during dissection. Our previous study measured whether students chose to report the importance of pathology, using an open‐ended essay assignment at the end of their gross anatomy course. Each essay had to be analyzed qualitatively, which was time‐consuming, and it was difficult to determine why the students chose particular content for inclusion in their essays. In the present study, the focus was on designing a custom tool that allowed a student's early clinical reasoning to be compared with experts on an online platform. This assignment also asked students to perform research and follow the steps involved in the LCME element of an SDL activity.

The gross anatomy laboratory is a unique learning environment where many of the learning elements are unknown to both teacher and student until discovered during dissection. This situation parallels the presentation of real patients that medical students will encounter during their clinical training; no two patients present in exactly the same way. The main difference is that in the lab there is no risk of harming a patient or from inaccurate diagnoses. Both the structural content of gross anatomy and variations in the body that result from disease and development are learned in the lab. The Gift FFI is similar to a recently‐described formative feedback tool for clinical reasoning (Waechter et al., 2022), although the instrument presented in this study is individualized to the student's data collected during dissection.

Much educational research has demonstrated how pathologies found during dissection can be used as learning opportunities beyond the gross anatomy laboratory. The cost and time demand of dissection is currently under intense scrutiny, and research has been directed toward non‐traditional non‐discipline‐specific benefits of learning from cadavers (Byram et al., 2023). Medical educators contributing to the system of health professional education could use our feedback methods to enhance the effect that donors can have on medical education and the value of the gross anatomy laboratory as a multifaceted resource. Considering that SDL activities are required by the LCME and are challenging to implement with large student cohorts, the aim of this project was to deconstruct these challenges and offer a plausible amelioration of the burdensome demand of formative feedback.

Our results show that students want to know how their early clinical skills compare to those of expert clinicians. They found this exercise valuable, and many would use this information for self‐assessment. As most of the students spent only 1–2 h on this activity, it seems as though this exercise and feedback tool could easily enhance the benefit of dissection in the gross anatomy course. The mean score of the Gift FFI was 57.95%, but the standard deviation was wide (22.40%). This could be further explored in future studies to determine whether certain pathologies are easier for first year students to interpret in terms of clinical importance. More years of data collection could reveal patterns in clinical reasoning that stem from pathological incidences in the cadaver population, which could also allow faculty to target a smaller list of pathologies for faculty development. Second year students also benefit from learning from the pathological incidences in the gross anatomy laboratory (Meng et al., 2021). Perhaps these feedback tools could be used to track longitudinal changes in clinical reasoning.

At this early point in their training, when students have had similar exposure to clinical scenarios in other environments, formative feedback on clinical reasoning could be particularly useful, enabling them to reflect on where they stand in comparison to their peers. Another benefit of having students complete this SDL early in their training is that by giving attention to pathologies and conditions that are not yet part of their formal training they can begin to organize knowledge into chunks and continue to add to it later in their training. Chunking and organizing knowledge is necessary for developing expertise in any domain (Schuwirth & Van Der Vleuten, 2011). It can motivate students more to learn pathology and histopathology and to perform better in Anatomy and Pathology (Meng et al., 2021).

One of the most useful features of this formative feedback instrument is that it can give the students feedback that compares their behavioral responses to those of expert clinicians. This “behaviorism” approach measures the student's behavior in assigning importance to a piece of patient data (Durning et al., 2013). Feasibility is a crucial element to consider for widespread implementation, so it can be a major flaw in the design of assessments (Cooke & Lemay, 2017). This formative feedback instrument's design allows for unique cadaver‐based scenarios while allowing the student to receive immediate feedback on their performance. It is currently being re‐designed for online delivery outside of the institution studied to allow access by other medical schools. This freely accessible tool could help to transform the “first patient” autopsy activity into a formal SDL learning activity.

5. LIMITATIONS OF THE STUDY

This study is limited in that the expert panel consisted of three experts whose assessments were influenced by the inherent individual biases of the individuals typically seen. The Gift FFI was also limited to the anatomical variations and lesions that were discovered during dissections over one academic year. Since its initial implementation, subsequent students have added to the catalog of lesions and variations, and this will expand further over time. Years of data collection could be needed to create a well‐rounded, complete feedback instrument.

6. CONCLUSION

The Gift FFI gives anatomy educators the opportunity to conduct an SDL activity in a cadaveric‐based gross anatomy course. The online FFI tool can easily be mass‐distributed, is high‐fidelity, and gives the students useful information about how they compare with their peers in developing early clinical reasoning skills. Using this method of formative feedback, targeted to anatomical science educators, anatomists can achieve a more effective role in clinical sciences education at their respective institutions.

FUNDING INFORMATION

Funding for this project was provided by the American Association of Anatomists Education Research Scholarship.

PATIENT CONSENT STATEMENT

Patients were not used in this study, but student participants were given an informed consent and were allowed to voluntarily not have their data used in this study.

PERMISSION TO REPRODUCE MATERIAL FROM OTHER SOURCES

None of the data or material used in this study has been previously published.

CLINICAL TRIAL REGISTRATION

This study did not include a clinical trial registration.

ACKNOWLEDGMENTS

The authors would like to express their gratitude to those who donated their bodies for the advancement of science and education. They also thank Anthony Wells and Shenell Thomas for their assistance with the anatomical services.

Leupold, M. , Topping, D. , Cork, R. J. , McGoey, R. , & Rae, G. (2025). Pathology discovered in the “first patient” can be the silent teacher of self‐directed learning. Clinical Anatomy, 38(2), 216–221. 10.1002/ca.24256

DATA AVAILABILITY STATEMENT

This kind of statement is not applicable to the type of data presented in this study.

REFERENCES

  1. Alyafi, M. M. , Alamodi, A. A. , Juurlink, B. H. , & Ganguly, P. (2012). How the dissection laboratory facilitates integration of learning: Presence of abdominal aortic aneurysm with a large intracardiac thrombus: A rare cadaver finding. International Journal of Angiology, 21, 77–80. [DOI] [PMC free article] [PubMed] [Google Scholar]
  2. Byram, J. N. , Van Nuland, S. E. , Harrell, K. M. , Mussell, J. C. , & Cornwall, J. (2023). Educator perspectives on non‐technical, discipline‐independent skill acquisition: An international, qualitative study. Anatomical Sciences Education, 16, 1102–1117. [DOI] [PubMed] [Google Scholar]
  3. Chun, J. , Theologou, T. , & Ellis, H. (2007). Incidence of cardiovascular disease in the dissecting room: A valuable teaching asset. Clinical Anatomy, 20, 89–92. [DOI] [PubMed] [Google Scholar]
  4. Cooke, S. , & Lemay, J. F. (2017). Transforming medical assessment: Integrating uncertainty into the evaluation of clinical reasoning in medical education. Academic Medicine, 92, 746–751. [DOI] [PubMed] [Google Scholar]
  5. Durning, S. J. , Artino, A. R., Jr. , Schuwirth, L. , & Van Der Vleuten, C. (2013). Clarifying assumptions to enhance our understanding and assessment of clinical reasoning. Academic Medicine, 88, 442–448. [DOI] [PubMed] [Google Scholar]
  6. Eisenstein, A. , Vaisman, L. , Johnston‐Cox, H. , Gallan, A. , Shaffer, K. , Vaughan, D. , O'hara, C. , & Joseph, L. (2014). Integration of basic science and clinical medicine: The innovative approach of the cadaver biopsy project at the Boston University School of Medicine. Academic Medicine, 89, 50–53. [DOI] [PubMed] [Google Scholar]
  7. Fletcher, L. , King, L. , Criswell, S. , & Herr, M. J. (2023). Pathology education project (PEP): A pilot program to spark student understanding in pathology as a career. Academic Pathology, 10, 100084. [DOI] [PMC free article] [PubMed] [Google Scholar]
  8. Geldenhuys, E. M. , Burger, E. H. , Van Helden, P. D. , Mole, C. G. , & Kotze, S. H. (2016). Optimizing the use of cadavers by integrating pathology during anatomy dissection. Anatomical Sciences Education, 9, 575–582. [DOI] [PubMed] [Google Scholar]
  9. Hanley, L. C. , Ou, J. , Ritter, D. , Chew, A. , Monteiro, K. , & Dumenco, L. (2023). Bridging anatomy, histology, and pathology: A novel curriculum component incorporating self‐directed learning for first‐year medical students. Medical Science Educator, 33, 1055–1059. [DOI] [PMC free article] [PubMed] [Google Scholar]
  10. Kumar, R. K. , Freeman, B. , Velan, G. M. , & De Permentier, P. J. (2006). Integrating histology and histopathology teaching in practical classes using virtual slides. Anatomical Record. Part B, New Anatomist, 289, 128–133. [DOI] [PubMed] [Google Scholar]
  11. LCME . (2023). Element 6.3 Self‐Directed and Life‐Long Learning. https://lcme.org/wp‐content/uploads/2023/04/Frequently‐Cited‐Elements‐6.3_8.8_9.9_11.1.pdf#:~:text=Self‐directed%20learning%20involves%20medical%20students%E2%80%99%20self‐assessment%20of%20learning
  12. Magrill, D. (2008). Intra‐abdominal pathology in the dissecting room: A study of incidence and its value in teaching. Anatomy, 2, 22–29. [Google Scholar]
  13. Mcgraw, K. O. , & Wong, S. P. (1996). Forming inferences about some intraclass correlation coefficients. Psychological Methods, 1, 30–46. [Google Scholar]
  14. Meng, J. , Love, R. , Rude, S. , & Martzen, M. R. (2021). Enhancing student learning by integrating anatomy in pathology teaching. Medical Science Educator, 31, 1283–1286. [DOI] [PMC free article] [PubMed] [Google Scholar]
  15. Meredith, M. A. , Clemo, H. R. , Mcginn, M. J. , Santen, S. A. , & Digiovanni, S. R. (2019). Cadaver rounds: A comprehensive exercise that integrates clinical context into medical gross anatomy. Academic Medicine, 94, 828–832. [DOI] [PubMed] [Google Scholar]
  16. Rae, G. , Cork, R. J. , Karpinski, A. C. , Mcgoey, R. , & Swartz, W. (2017). How the integration of pathology in the gross anatomy laboratory affects medical students. Teaching and Learning in Medicine, 29, 101–108. [DOI] [PubMed] [Google Scholar]
  17. Rae, G. , Husain, M. , Mcgoey, R. , & Swartz, W. (2016). Postmortem aortic dissection: An artifact of the embalming process. Journal of Forensic Sciences, 61(suppl 1), S246–S249. [DOI] [PubMed] [Google Scholar]
  18. Rae, G. , Mcgoey, R. R. , Donthamsetty, S. , & Newman, W. P. (2017). A new resource for integrated anatomy teaching: The Cadaver's kidney PG (pathology guide), The Cadaver's Heart Pathology Guide. HAPS Educator, 12, 25–31. [Google Scholar]
  19. Rae, G. , Mcgoey, R. R. , Donthamsetty, S. , & Newman, W. P. (2018). A new resource for integrated anatomy teaching: The Cadaver's lung PG, A Pathology Guide. HAPS Educator, 22(1), 32–39. [Google Scholar]
  20. Robertson, K. A. , Organ, J. M. , Yard, M. , & Byram, J. N. (2024). First patient project: Engaging pathology through the donor dissection experience and its role in professionalism. Anatomical Sciences Education, 17, 199–212. [DOI] [PubMed] [Google Scholar]
  21. Schuwirth, L. , & Van Der Vleuten, C. (2011). General overview of the theories used in assessment: AMEE guide No. 57. Medical Teacher, 33, 783–797. [DOI] [PubMed] [Google Scholar]
  22. Waechter, J. , Allen, J. , Lee, C. H. , & Zwaan, L. (2022). Development and pilot testing of a data‐rich clinical reasoning training and assessment tool. Academic Medicine, 97, 1484–1488. [DOI] [PubMed] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

This kind of statement is not applicable to the type of data presented in this study.

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