Gross Anatomy Education Today: The Integration of Traditional and Innovative Methodologies

Abstract

The current study surveyed first-year osteopathic medical students about dissection, multimedia dissector, split laboratories, VH (virtual human) dissector, ultrasonography, and prior experience of anatomical concepts. Students perceived cadaveric dissection, multimedia dissector, and ultrasonography laboratories as important contributors for learning anatomy. Students felt cadaveric dissection was an important factor in their medical school selection. Study results suggested students perceived integrated anatomy courses that utilized dissection and multimodal approaches to deliver anatomical information as highly effective.

Introduction

In 1896, A.T. Still stated, “You cannot have too much dissection. It will help you to verify your mental conception of the body’s structure.”¹ Today, this belief holds true in the Department of Anatomy at A.T. Still University’s Kirksville College of Osteopathic Medicine (ATSU-KCOM). Medical education has drastically changed since Dr. Still’s time, but cadaveric dissection is still perceived as an important component of medical education at this institution.

For many medical students, gross anatomy is the cornerstone of their medical knowledge. Exponential growth in knowledge and innovations in medical education have changed the landscape of the first two years of medical school, particularly in relation to the distribution of curricular hours.² Similarly, digital resources have allowed for the development of animations, videos, and 3-dimensional reconstruction, which has changed how medical schools deliver anatomical information.³ It has yet to be seen whether alternative methodologies will be as effective as hands-on cadaver dissection or whether they will fill a supplementary role. However, evidence suggests that combining traditional cadaveric laboratory and innovative methodologies elicits better educational outcomes in anatomy.^4–7

From the founding of the American School of Osteopathy in 1892 to modern-day ATSU-KCOM, cadaveric dissection has been included in the freshman curriculum. As with most medical schools, prior completion of an anatomy course is not required to matriculate. A recent study conducted at ATSU-KCOM found that premedical anatomy experience had no impact on medical anatomy grades, unless three or more anatomy courses, including at least one with human cadaveric laboratory, were taken.⁸ This finding suggests that multiple repetitions of anatomy exposure with human cadaveric dissection may help students master medical gross anatomy material. Few undergraduate institutions offer cadaver-based anatomy courses, though, so having a human cadaver dissection anatomy course as a prerequisite does not seem feasible. Further, such repetition may be best delivered through numerous modalities within the medical school curriculum.

During the first two years, ATSU-KCOM utilizes a partially integrated, systems-based curriculum. The first semester is foundational, and although the content is partially aligned, the courses run independently to deliver their fundamental material. The remaining three semesters are systems-based with integrated courses. The medical gross anatomy course is taught during the first two semesters and is designed to provide students with a detailed understanding of human anatomy along with essential embryology, radiology, and clinical correlations. The course is divided into the following sections: back, upper extremity, lower extremity, head and neck, thorax, abdomen, and pelvis. The thorax, abdomen, and pelvis sections are taught in the second semester and integrated into the cardiovascular, gastrointestinal, and renal blocks. Approximately 90 hours are spent in traditional lectures, 100 hours in cadaver dissection laboratory, 18 hours in ultrasonography laboratory (as part of a separate course), and 20 hours in case-based learning and small group discussions. In roughly half of the dissection laboratories and when all students are present for dissection, the student-to-cadaver ratio is 6:1. In the remaining 20 of 39 laboratories, the majority of the dissection is performed by a team of three students, while the other team initially attends a case discussion or an ultrasonography laboratory. After returning from the non-dissecting activities, these students join the dissecting team to finish the dissection and participate in the assessment. During these split laboratories, the faculty-to-student ratio is 1:10; this ratio is 1:20 during the whole-class laboratories. A study involving two class years of ATSU-KCOM students found no significant difference (P=.34) in student performance on lab practical identification examinations between the dissecting and non-dissecting groups.⁹ However, students who did not dissect pelvic and abdominal neurovasculature did not perform as well on those identification questions. Despite this result, evidence suggests the split laboratory model is beneficial because it provides curricular time for the delivery of much of the ultrasonography content and some clinical correlations.

In 2011, ATSU-KCOM introduced ultrasonography imaging into the gross anatomy course during the first year of medical school. A clinical ultrasonography elective course was offered to second-year students to provide them with a review of anatomy and to prepare them for clinical rotations. A recent study found that second-year students who participated in the elective course had better retention of important anatomical concepts.¹⁰

Along with the introduction of the ultrasound component, the gross anatomy course at ATSU-KCOM underwent substantial changes in 2011–2012. These changes included split laboratories, inclusion of clinical cases, and integration of electronic resources, including a multimedia dissector developed in-house, a cross-sectional VH (virtual human) Dissector for Medical Education atlas (Touch of Life Technologies, Inc.), 3-dimensional Anatomy.TV (Primal Pictures, Informa UK Ltd.), Netter’s 3D Interactive Anatomy (Elsevier), and Acland’s Video Atlas of Human Anatomy (Wolters Kluwer Health). Of these electronic resources, the multimedia dissector and the VH Dissector images are assessed using pre-laboratory quizzes that are meant to ensure adequate preparation for the cadaveric dissection laboratory. Student knowledge of the anatomical material is evaluated using block and cumulative final written examinations that emphasize the clinical application of basic science content in a board-like case presentation format and using tagged laboratory examinations, which include radiological and cross-sectional images.

The purpose of the current study was to survey first-year osteopathic medical students to determine student perception of the benefit of dissection, multimedia dissector, split laboratories, VH Dissector, ultrasonography, and prior anatomy experience on their mastery of anatomical and radiological concepts.

Methods

The local institutional review board granted exempt status for the current study.

Participants and Data Collection

First-year osteopathic medical students from the graduating class of 2020 participated in the study at the end of their second semester. The mean age of the entire class of 172 students was 24 years (range, 21–36 years), and the male-to-female ratio was 95:77. The mean (SD) Medical College Admission Test score was 27/504 (2.98/6.8), cumulative grade point average (GPA) was 3.61 (0.22), and science GPA was 3.54 (0.26).

Students were surveyed about the importance of cadaveric dissection for medical school selection and the benefits of various components of the medical anatomy course for mastery of anatomy and radiology concepts. The seven-item survey (Figure 1) was designed specifically for the current study and was based, in part, on content from a previous study.⁸ The survey used a Likert-like scale with responses ranging from very important/beneficial to not important/beneficial. The survey items were validated in the previous study.⁸ The current survey was delivered electronically to students using the Blackboard Learning Management System (Blackboard, Inc., Washington, DC). It was available for three days and took approximately five minutes to complete. Students were sent an email requesting their participation in the survey. To facilitate optimal participation, time was allotted prior to the last two gross anatomy and ultrasonography laboratories to complete the survey at the end of second semester. Participation was voluntary, without compensation, and had no impact on course grades. The results were anonymized before being sent out for statistical analysis. Students who did not participate in the survey were excluded from the study. Survey responses from each student were matched with the student’s final grade for the medical gross anatomy course from the first semester.

Figure 1.

Survey of osteopathic medical students on the importance of cadaveric dissection for medical school selection and the benefits of various components of the medical anatomy course to their mastery of anatomy and radiology concepts.

The anatomy course grades used in the current study came from the laboratory (45% weighted) and lecture (55% weighted) scores to produce a cumulative course grade for the first semester. The laboratory score was determined from points earned from pre-laboratory quizzes, in-laboratory identification quizzes, dissection quality points, and laboratory practical examinations. The lecture score was determined from total points earned on six multiple-choice, written examinations and one cumulative final examination.

The average anatomy subscores from COMLEX I of ATSU-KCOM students before the new anatomy curriculum was implemented (years 2008–2011) and after it was implemented (years 2012–2015) were collected to evaluate the efficacy of the current anatomy curriculum after the 2011–2012 change.

Statistical Analyses

Survey question responses were numerically coded for statistical analysis. The Likert-like choices of not important/beneficial were scored as zero points, slightly important/ beneficial as one point, moderately important/beneficial as two points, important/beneficial as three points, and very important/beneficial as four points. Summary statistics reports were generated to provide frequency of responses for each question. Wilcoxon signed rank tests were used to determine whether the median response for each question was significantly different from the moderate choice (i.e., moderately important/beneficial). SAS version 9.4 (SAS Institute, Cary, NC) was used for statistical analyses, and P≤.05 was considered statistically significant.

Results

The survey participation rate was 97.1% (167 of 172 first-year osteopathic medical students). For the medical gross anatomy course, the final grade distribution was 20.4% (n=34) of students earned an A (90%–100%), 51.5% (n=86) earned a B (80%–89%), and 28.1% (n=47) earned a C (70%–79%). The average grade was 83.8% with a low of 70.4% and a high of 96.3%.

Of the 167 students who completed the survey, 141 (84.4%) indicated that the inclusion of human cadaver dissection was important or very important when making their decision about which medical school to attend. Thirteen students (7.8%) indicated inclusion of human cadaver dissection was not important or slightly important. The median response for this question was significantly higher than the moderately important response (P<.001).

Of the six survey questions asking about the benefits of various components of the medical gross anatomy course in relation to mastering anatomical or radiological concepts, the following three areas had the largest percentage of responses in the beneficial to very beneficial categories: cadaver dissection (n=150, 89.8%), multimedia dissector (n=152, 91.0%), and ultrasonography (n=151, 90.4%) (Figure 2). The median responses for these three questions were significantly higher than the moderately beneficial response (all P<.001), represented by zero in Figure 2. Cadaver dissection and ultrasonography had no responses for the not beneficial category, and the multimedia dissector had one response for not beneficial.

Figure 2.

Percentage of student responses to the survey questions asking about the benefit of various components of the gross anatomy course and previous anatomy experience to their mastery of anatomical and/or radiological concepts. The ‘Moderately Beneficial’ response straddles the zero. * P<.001

The following three areas had the largest percentage of responses in the not beneficial to moderately beneficial categories: split laboratories (n=93, 55.7%), VH Dissector (n=115, 68.9%), and undergraduate anatomy course(s) (n=86, 51.5%) (Figure 2). The median responses for these three questions were not significantly different from the moderately beneficial response (all P≥.09).

Discussion

Since the turn of this century, numerous curricular changes have occurred at medical schools, which are comparable only to those that occurred a century ago when Abraham Flexner published his report.^{2, 5, 11} These changes had a major effect on the design and delivery of basic science courses. For example, courses were modified to include more clinical content and non-discipline–related competencies, such as professionalism, teamwork, and leadership.^{2, 12–14} As a result, medical institutions across the United States and Europe have reduced curricular hours dedicated to basic sciences, especially anatomy because dissection was replaced with prosection, plastic models, or digital resources.^{3, 15–17} ATSU-KCOM’s curriculum went through similar curricular modifications. Redesign of the gross anatomy course was considered since previous studies reported a lack of evidence on the efficacy of dissection versus other methods¹⁸ and suggested that cadaveric laboratory was inefficient and unnecessary in teaching anatomy.^{16, 17} However, given the wealth of evidence about the efficacy of the cadaveric laboratory, instead of getting rid of cadaveric dissection, the gross anatomy course at ATSU-KCOM was modified to include other components as well, such as ultrasonography, clinical cases, and digital resources. This change was a positive experience for faculty and students and was supported by studies showing integrated, functionally related, and clinically relevant anatomy curricula are highly efficient⁴ and allow for long-term retention of anatomical knowledge.⁶

Even though curricular hours dedicated to anatomy education have decreased at medical schools over the last 15 years, a study by Drake and McBride² found that surveyed medical schools retained a cadaveric laboratory in some form. Recent studies showed that an anatomy cadaver dissection course is the most important tool for teaching macroscopic anatomy^{7, 19} and offers a significant advantage over multimedia simulation.²⁰ Results from the current study also suggested availability of a cadaver dissection laboratory as part of undergraduate medical curriculum significantly influenced medical school selection of students, which seems to indicate the value of cadaveric dissection laboratory is recognized by prospective students. Similarly, first-year osteopathic medical students of the current study considered cadaveric dissection an important experience that helped them master anatomical concepts. This result supports data from other studies that looked at the role of cadaveric dissection in a medical surrciulum.²¹ The other two areas that students of the current study considered highly important for their anatomy education were the multimedia dissector and ultrasonography laboratory. These results support the existing literature about the efficacy of integrated anatomy courses that utilize multimodal approaches in delivering anatomical information.^{4, 6}

The introduction of split laboratories at ATSU-KCOM allowed for the inclusion of ultrasound laboratories and clinical cases in the anatomy curriculum. Although students enjoyed using ultrasonography to strengthen their knowledge of anatomy, their responses to having split laboratories were less positive, which suggested that they value their time at the dissection table but are a little short-sighted when it comes to the evaluation of the whole curriculum. Other studies showed similar results when evaluating student perception of reciprocal peer teaching; students felt that they had less hands-on experience because they only dissected half the time in a split laboratory.²² Another area assessed in the current study that did not get positive responses was the VH Dissector. The VH Dissector provides an important link between the cadaveric laboratory and imaging, but it was not regarded by students as being important. We believe this result can be attributed to first-year medical students not yet having found a relevant use for this instrument. Future research should evaluate the student perception of this component of anatomical education in students who have been exposed to clinical medicine and view anatomy mainly through the prism of radiology. Although anecdotal, former students have noted that using the VH Dissector helped them interpret radiological images during their clinical rotations in the third and fourth years.

Although positive and informational, student survey data can only provide subjective satisfaction information about the efficacy of the current anatomy curriculum, which prompted us to compare the COMLEX I anatomy subscores of ATSU-KCOM students before the new anatomy curriculum was implemented (years 2008–2011) and after it was implemented (years 2012–2015). The scores showed marked improvement, where scores from 2012–2015 were higher than those from 2008–2011 and increased by an average of 36 points. These objective data suggested that student preparation for board examinations was improved after implementation of the new anatomy curriculum, which successfully combined cadaveric dissection laboratory with modern teaching modalities, including multimedia resources and ultrasound imaging.

Biography

Jeremy J. Houser, PhD, (left), Associate Professor, and Peter Kondrashov, PhD, (right), Professor and Chair, are in the Department of Anatomy, Kirksville College of Osteopathic Medicine, A.T. Still University, Kirksville, Missouri.

Contact: jhouser@atsu.edu