Evaluating the Anatomage Table Compared to Cadaveric Dissection as a Learning Modality for Gross Anatomy

Abstract

The purpose of this study was to compare the effectiveness and qualitative experience of learning gross anatomy of the pelvis and perineum (P/P) and musculoskeletal system (MSK) via cadaveric dissection to learning these same anatomical regions using the Anatomage table. The Anatomage table is an anatomical visualization system that projects male and female gross anatomical structures from human cadavers onto a life-sized touchscreen table. A crossover design was implemented. Four volunteer dissection groups, consisting of four students each, were randomly assigned to dissect P/P on the Anatomage table and MSK (upper and lower limb) not on the cadaver lab or vice versa. Participating students completed surveys before and after each lab, formative quizzes following each lab, and summative final practical exams on both the Anatomage table and in the cadaver lab. Results indicated that when studying on the Anatomage table, students were more excited before and after labs and perceived a greater degree of learning. The groups did not demonstrate a significant difference in P/P knowledge based on quiz results; however, the Anatomage group had a significantly higher mean score on quizzes in MSK anatomy. Finally, the practical exam results suggest that for some anatomical regions, students may perform similarly regardless of the modality on which they were instructed.

Introduction

In recent years, advancements in technology have permeated virtually all aspects of life and ushered in a new social reality. One characteristic of this phenomenon is the powerful influence of computer-based programs and various communication technologies on the manner in which individuals are capable of interacting with one another and with their surroundings [1]. These technological advancements are influencing a plethora of disciplines, including medical education. The increase of both technological resources for educational purposes and the concurrent increased demand for information requires educators to create more flexible and challenging learning environments [2]. Additionally, technological advancements allow for increased access to information for students and faculty as well as a broader range of pedagogical options [3]. Research suggests that engaging with technology during the learning process can positively impact student perceptions of academic success [4]. Millennial students have been described as particularly interested in employing technology for learning [5]. This phenomenon is true for medical students as well as for students from other disciplines [6].

Human anatomy is a fundamental element in the process of teaching and training physicians [7]. For centuries, the modality of choice for learning human anatomy has been cadaveric dissection [8, 9]. When the New World’s first school of medicine opened in Philadelphia in 1765, cadaveric dissection was the foundation of the curriculum because it was considered a state-of-the-art pedagogical medium in Europe [10]. A recent survey of gross anatomy course directors at all allopathic medical schools in the USA found that 100% of the 66 survey respondents reported having some type of cadaver experience (either dissection, prosection, or a combination of the two) [11].

It is generally accepted that knowledge of anatomy is critical for the accurate diagnosis and treatment of many diseases with which physicians are confronted during routine clinical practice [12–14]. The results of an online survey of physicians and medical students showed unanimous agreement that anatomical knowledge is a requisite for safe and competent medical practice [15]. Furthermore, a survey of dental and medical students indicated that cadaveric dissection was perceived to be beneficial to the understanding of human anatomy and anatomical variation [16]. Dissection improves teamwork and professionalism, reveals anatomical variation in situ, and exposes students to the humanity of medicine in ways that two-dimensional images and text cannot [6].

While there is consensus regarding the need for anatomy in medical education, there is a growing shift in attitude toward the desire for and expediency of dissection in medical curricula. The process of dissection, including the removal of fat and difficulty identifying structures, may be considered to be an inefficient use of valuable curricular time by some. This can be remedied with prosection, but the creation of prosected specimens is labor intensive and difficult for many programs to provide. In many parts of the world, dissection has been marginalized in medical curricula due to the difficulty in recruiting and retaining competent anatomy faculty, the shortage of cadavers, a reduction in curricular time, and the exorbitant costs associated with cadaveric embalming and maintaining dissection labs [6, 12, 17–21]. In Europe, it is becoming increasingly common for medical schools to completely lack dissection facilities [9].

The need for effective anatomy instruction in medical curricula coupled with the challenges and costs confronting administrators has created a niche for instructional alternatives and educational supplements to cadaveric dissection. The challenge for educators in this millennium is to determine the most expedient and effective teaching/learning modalities among the multitude of technological developments that have entered the market. For the most part, researchers agree that there is not one single multimedia-based anatomy instructional method that can be identified as the ideal solution for educators [22, 23]. As a result, anatomy curricula generally combine modern and traditional methodologies to complement one another [6, 24].

Research indicates that twenty-first-century medical students enjoy learning anatomy with technology and that faculty and student learning experiences can be created or improved with the help of communication and information technology [12]. One randomized control study compared learning neuroanatomy using 3D digital models of brain anatomy with Oculus Rift VR (virtual reality) technology to studying with online textbooks. No differences were found between the two groups on pre-, post-, and delayed post-interventional quizzes on learning ease, but the VR group found their learning tools to be more useful and engaging. These students were also more likely to recommend the technology to their peers [20]. A study comparing iPads with paper lab manuals and atlases in a dissection laboratory found students to be more independent and proactive in self-study and less reliant on instructors for guidance when using the iPads [18]. Another study compared supplementing traditional neuroanatomy presentation methods such as text images and graphs with a “MagicBook” that used links to students’ mobile phones to provide supplemental multimedia materials. The results demonstrated greater success and satisfaction among the experimental group that used the technology [12]. An additional study suggested that 3D models, as opposed to 2D illustrations, enabled students to focus their “cognitive resources” on the most relevant clinical anatomical relationships rather than simpler structural features [25]. Research suggests that the most effective method of teaching anatomy is multimodal, utilizing multiple varied pedagogical resources in a complementary manner [5, 18, 26].

Case Western Reserve University School of Medicine is moving to a new medical education facility that will not include an in-house dissection laboratory. Students will begin their anatomy training with an intensive dissection “boot camp” at the current School of Medicine and then transition to a multimodal curriculum at the new facility that will include imaging, living anatomy with ultrasound, and a virtual anatomy supplement to the cadaveric dissection performed in the boot camp. One of the virtual anatomy learning technologies under consideration for inclusion in the new curriculum was the Anatomage table. The Anatomage table is an anatomical visualization system that projects male and female gross anatomy constructed from actual human cadavers onto a life-size touchscreen table. Users can rotate or zoom in to view the anatomical representations and display radiologic images adjacent to cadaveric projections. The purpose of this study was to compare the effectiveness of learning gross anatomy of the pelvis and perineum (P/P) and musculoskeletal system (MSK) via cadaveric dissection to that of learning the anatomy of these same anatomical regions using the Anatomage table.

We hypothesized that, having dissected both thorax and abdomen earlier in the academic year, student study participants would be more enthusiastic about learning anatomy on the Anatomage table than via cadaveric dissection. We also predicted that practical exam results would be the same for all medical students regardless of learning modality.

Materials and Methods

The protocol for this study was given exempt status by the Institutional Review Board of Case Western Reserve University (IRB# 2015-1035).

Four dissection groups, each comprised of four first-year medical student volunteers who had previously dissected thorax and abdomen, were randomly selected to participate in this study. These students were recruited through an in-class announcement and email solicitation. Dissection groups with members who had previous anatomy experience (e.g., an anatomy course prior to or during medical school) were excluded. Informed consent was obtained from all individual participants included in the study.

A crossover design was used in which dissection groups were randomly assigned to learn anatomy on the Anatomage table during one of two curricular blocks, either pelvis or perineum (P/P) or musculoskeletal (MSK), then learn the anatomy of the other region via dissection. Two groups learned P/P through virtual dissection on the Anatomage table then in the subsequent block, learned musculoskeletal (MSK) via cadaveric dissection. The other two groups learned P/P anatomy through cadaveric dissection and, in the subsequent block, MSK anatomy on the Anatomage table (Fig. 1).

Fig. 1.

Outline of Study Design

Guides for studying anatomy using the Anatomage table were created by modifying the cadaver dissection guides written by members of the Department of Anatomy faculty at Case Western Reserve University. These guides had been used for 5 (P/P) and 10 (MSK) years in the School of Medicine curriculum by the start of our study. The Anatomage lab guides were adapted to duplicate the contents of these cadaveric dissection lab guides.

The intervention groups (Anatomage dissection) were instructed on how to use the Anatomage table and were expected to familiarize themselves with the table prior to the first lab. The control groups (cadaveric dissection) completed dissections during the same 2-hour dissection period as the remainder of their class. Our institution has only one Anatomage table, so only one intervention group was able to complete their virtual dissection during the assigned 2-hour curricular time period while their classmates dissected. The other intervention group completed their Anatomage dissections at an alternative time agreed upon by the students, faculty, and at least one teaching assistant. Both groups had access to the same learning tools: cadavers, the Anatomage table, any online resources, texts, anatomical models, etc. Other than the use of the Anatomage table, students in the intervention group had the same academic requirements as the remainder of their peers.

Cadaver and Anatomage lab groups performed the labs according to the dissection guides. Teaching assistants and faculty were available to answer questions during lab times. Teaching assistants also provided periodic evening review sessions for students on both the cadavers and the Anatomage table.

All participants consented to answer Likert scale surveys before and after each scheduled dissection session (Table 1), as well as a written five-question multiple-choice post-lab quiz related to the anatomy content encountered in that lab.

Table 1.

Likert scale surveys before and after cadaveric dissection or Anatomage labs

Pre-lab survey questions	Post-lab survey questions
1. Please rank your degree of comfort with the material covered in this dissection. (1 = not at all comfortable, 5 = extremely comfortable)	1. After completing the dissection (lab), how much do you think you learned? (1 = absolutely nothing, 5 = an enormous amount)
2. Please rank degree of excitement you feel about conducting this dissection. (1 = not excited, 5 = extremely excited)	2. Please rank the degree of ease/difficulty you found this dissection to be. (1 = extremely easy, 5 = extremely difficult)
3. Please rank how prepared you feel to perform this dissection (1 = not prepared, 5 = extremely prepared)	3. Please rank degree of excitement you feel about returning for the next dissection. (1 = not excited, 5 = extremely excited).

Following the completion of each block (topic), all students were required to complete written and practical exams. In addition to the written exam, all study participants agreed to complete practical exams in both the cadaver lab and with the Anatomage table. Study volunteers were assured that they would receive the higher of their two practical exam scores to eliminate potential negative academic consequences related to participation in the study. Students rotated through a traditional cadaver practical exam in the dissection lab. The Anatomage practical exam was designed such that the structures students were asked to identify were equivalent in difficulty and format to those on the cadaveric practical exam. The Anatomage exam was administered as a compilation of screenshots taken from the table, projected via PowerPoint onto a screen in a lecture hall. In both practical exams, students were given 37 pairs of questions with 75 s to answer each pair. The study participants were tested initially on the modality on which they learned, then tested on the alternative format: the intervention group (Anatomage) completed the cadaver practical following the Anatomage practical exam and the control groups (cadaveric dissection) completed the Anatomage practical following completion of the cadaver practical. Both cadaver practical exams assessed structures that had been dissected to be clearly visible. Students were not permitted to touch specimens in the cadaver lab during the exam. This assessment format was replicated for both the P/P and MSK content blocks.

Students in the intervention group (Anatomage dissection) who did not meet expectations (failed the exam due to a low score) were given the opportunity to remediate using the dissection modality of their choice (either cadaveric dissection or Anatomage). Conversely, if a student in the control group (cadaveric dissection) did not meet expectations (failing the exam due to a low score), they were required to remediate with other remediating students in the cadaver lab.

Shapiro-Wilks tests were used to determine normality of the results. For results that were normally distributed, t tests were used to analyze the results of the pre- and post-lab surveys, quizzes, and practical exams. For nonparametric results, Mann-Whitney U tests were used to analyze the results.

Results

Pre-Lab Survey

The results of the pre-lab survey for both P/P and MSK comparing the combined intervention (Anatomage) and control (dissection) groups are presented in Table 2. In the pre-lab survey, the groups did not demonstrate a statistically significant difference in perceived degree of comfort or degree of preparedness. However, the Anatomage group expressed a significantly higher degree of excitement than the control group for both blocks (p < 0.01).

Table 2.

Pre-lab survey P/P and MSK

Question	Anatomage mean (n = 79)	SD Anatomage	Dissection mean (n = 78)	SD dissection	p value
Degree of comfort	2.37	± 1.12	2.27	± 1.07	0.60A
Degree of excitement	3.25	± 0.97	2.31	± 1.11	< 0.01A
Degree of preparedness	2.38	± 1.10	2.19	± 1.13	0.27A

^AMann-Whitney U tests used to analyze results

Post-Lab Survey

The results of the Post-Lab survey for P/P and MSK comparing the combined intervention (Anatomage) and control (dissection) groups are detailed in Table 3. While the groups did not demonstrate a statistically significant difference in perceived degree of difficulty in the Post-Lab survey, there were significant differences in perceived “degree of amount learned” and “excitement for next lab” (p < 0.01).

Table 3.

Post-lab surveys P/P and MSK

Question	Anatomage mean	SD Anatomage	Dissection mean	SD dissection	p value
Degree of amount learned	3.68 (n = 77)	± 0.94	2.99 (n = 77)	± 1.06	< 0.01A
Degree of difficulty	3.16 (n = 77)	± 1.06	3.27 (n = 77)	± 1.13	0.51A
Degree of excitement for next lab	3.51 (n = 70)	± 0.96	2.30 (n = 69)	± 1.09	0.01A

^AMann-Whitney U tests used to analyze results

Quizzes

The results of the post-lab quizzes for both blocks comparing the intervention (Anatomage) and control (dissection) groups are detailed in Table 4. No difference was found between the two modalities in P/P; however, in MSK, the Anatomage group had a significantly higher average quiz score than the control group (p = 0.03).

Table 4.

Post-lab quiz results P/P and MSK

	Anatomage mean	SD Anatomage	Dissection mean	SD dissection	p value
P/P	64.1% (n = 37)	± 24.3%	62.5% (n = 32)	± 25.5%	0.91A
MSK	51.4% (n = 42)	± 27.3%	38.7% (n = 45)	± 25.7%	0.03A

^AMann-Whitney U tests used to analyze results

Practical Exam

Comparisons of the results of the exam scores for the intervention (Anatomage) and control (dissection) groups in both the P/P and MSK anatomical regions are detailed in Tables 5 and 6. Table 5 compares practical exam performance for both the Anatomage and control groups for P/P. When comparing the results of the exam completed on the Anatomage table, the Anatomage group scored significantly higher than the dissection group (p = 0.01). However, when comparing the results of the cadaver practical exam, the dissection group scored significantly higher than the Anatomage group (p = 0.04). No significant difference was found when the mean exam scores of the Anatomage and cadaver practical exams were compared (p = 0.83).

Table 5.

P/P practical exam results

	Mean Anatomage group (n = 8)	SD intervention	Mean dissection group (n = 7)	SD control	p value
Anatomage exam	77.1%	± 7.2%	64.6%	± 9.4%	0.01B
Cadaver exam	62.8%	± 7.5%	73.6%	± 10.0%	0.04B
Mean exam score	69.9%	± 6.8%	69.1%	± 7.4%	1.00A

Table 6.

MSK practical exam results

	Mean Anatomage group (n = 7)	SD intervention	Mean dissection group (n = 7)	SD control	p value
Anatomage exam	73.8%	± 8.6%	69.0%	± 11.3%	0.39B
Cadaver exam	75.9%	± 5.4%	72.6%	± 10.1%	0.47B
Mean exam score	74.9%	± 6.5%	70.8%	± 10.6%	0.41B

^AMann-Whitney U tests used to analyze results

^Bt tests used to analyze results

Table 6 compares practical exam performance for both the Anatomage and control groups for MSK. No significant difference was found on the exam completed on the Anatomage table (p = 0.39). Similarly, no significant difference was found on the MSK cadaver practical exam between the two groups (p = 0.47). There was also no significant difference in the mean scores of the Anatomage and cadaver practical exams (p = 0.41).

Discussion

The results of the pre- and post-lab surveys support the hypothesis that participants were more enthusiastic about learning anatomy on the Anatomage table than via cadaveric dissection. In other words, as indicated by other studies, students today seemed to be particularly interested in employing technology to supplement learning [5, 6]. The practical exam results indicate that, for some anatomical regions, Anatomage may yield the same results as cadaveric dissection. During the P/P block, students scored better on the modality on which they learned the material, while in MSK, no score difference was observed based on the modality with which the students were instructed.

The pre- and post-lab qualitative surveys indicated that those students who learned via the Anatomage table were more excited both before and after the labs and also believed that they learned more, as compared to the students learning via cadaveric dissection. The higher degree of excitement among members of the Anatomage group both before and after the labs was consistent across P/P and MSK sessions. It is possible that the students’ enthusiasm for the Anatomage table was related to factors other than the device itself. Perhaps students were excited due to the novelty of the Anatomage table. Prior research suggests that novelty can partially explain greater perceived effectiveness and satisfaction for three-dimensional visualization technology over two-dimensional anatomical images [9]. It is also possible that the students who volunteered to participate in this study are generally more excited by the use of technology as a learning supplement. A priori enthusiasm for this novel learning technique may have inspired students to volunteer for this study and influenced their responses to the surveys. Further research is required to determine if student enthusiasm for incorporation of new technology in anatomy instruction is durable or whether excitement wanes over time. It would also be of value to determine whether any other technological modality could elicit similar excitement or if the Anatomage table is a distinctly attractive learning tool.

The perceived amount learned was significantly higher in the Anatomage group than the cadaveric dissection group for both P/P and MSK. Perhaps, students felt more adept at working with the Anatomage table than dissecting a cadaver. However, despite perceptions, no significant difference was found in summative practical exam performance between groups. These results suggest that a student’s perceived amount learned immediately following a lab may not translate into greater long-term retention of information. At the time of data collection, students were only required to indicate the group to which they belonged; thus, there is no individual information about the relationship between the subjective factors and a student’s performance on the formative quizzes and summative practical examinations. This would be valuable to include in future studies, as it may provide insight into additional factors that contribute to a student’s ability to retain information.

The groups did not demonstrate a significant difference in P/P post-lab quizzes; however, the Anatomage group exhibited a significantly higher mean score on MSK post-lab quizzes. This may suggest that the Anatomage table may be a more effective modality for short-term retention of information for only a subset of anatomical regions; however, further study with a larger cohort is recommended. A separate study comparing virtual and cadaveric dissection found no significant difference between test results of the two student cohorts [27]. Future research should also explore how technological modalities such as the Anatomage table impact student performance across a broader range of anatomical regions. Research shows that medical students perceive differing degrees of difficulty in learning disparate anatomical regions [28]. Pelvis and perineum, for example, are generally considered to be particularly challenging due to the location in the body and vascular variability. Further research may provide insight into whether different anatomical regions vary in their proclivity to learning via cadaveric or virtual dissection.

Practical exam results for P/P indicated that students performed better on the modality on which they learned. In MSK, however, no difference was found. For MSK, students could learn on either modality and perform equally well on an exam on the other modality. This implies that for some anatomical regions, Anatomage may be a learning modality equivalent to cadaveric dissection.

It is possible that increased familiarity with Anatomage images or the modality itself played a role in student performance when assessed on the Anatomage table. The Anatomage table used in this study utilized only a single male and single female specimen. In order to prepare the dissection guide, precise screen coordinates for certain structures were noted in the lab guide. During learning sessions, students were directed to scroll to this precise set of coordinates to observe a given structure. The Anatomage practical exam consisted of screenshots of these structures. Conversely, the cadaveric exam included approximately 40 bodies distributed in two laboratories; students could not simply memorize a single configuration of a structure and expect to identify it on the exam. Anatomage has developed numerous features since this study was performed. A future study should incorporate these novel features into its design so that the table can simulate multiple male and female cadavers, as would be found in a traditional cadaver lab. Further research is also needed to assess the impact of learning modality on long-term retention of information.

This study was limited in a number of ways. In total, only 16 students participated, which limits power and external validity. We recommended a larger cohort of students be recruited for a future study, but there may be challenges to implement this. Purchase of Anatomage tables represents a sizeable upfront expense. In order to duplicate the dissection small-group experience, no more than eight students can stand around the table at once. In the present study, four students used the table during a single teaching session, which necessitated that the other four students study at an alternative time. Therefore, increasing the number of groups using a single Anatomage table presents a logistical challenge in a medical school curriculum. An alternative possibility for a more robust study would include the purchase of multiple tables. However, financial constraints might limit a program’s ability to procure enough tables for an entire class. Furthermore, any program purchasing multiple Anatomage tables may be adopting them in lieu of cadaveric dissection and may not have easy access to a cadaver lab as an experimental control.

Another possible limitation of this study may have been the timing of each anatomical section. P/P was taught and tested first; therefore, by the time the students took the MSK practical exams as new second-year students, both cohorts had more familiarity with the Anatomage table exam than when the P/P exams were completed. It is possible that increased comfort with the Anatomage table images enabled the students to perform better on the subsequent MSK exam even if they used dissection to learn MSK.

Selection bias is also present in the study. The students who volunteered to participate actively pursued an opportunity to learn anatomy outside of the dissection lab, indicating that the volunteers may have been intrinsically biased toward learning anatomy via technology. They may have not been interested in, or enjoyed, cadaveric dissection or they may have had a particular interest in learning anatomy using a novel approach. The enthusiasm and motivation of students willing to volunteer to participate in a study of this nature may have impacted their performance and the subsequent results.

Conclusions

Effectiveness of learning the anatomy of certain regions of the body employing the Anatomage table was compared to such learning via cadaveric dissection using both subjective student feedback and student performance on assessments. The Anatomage table was found to generate significantly more excitement and an increased perception of the amount learned during a given lab. These results support the notion that medical students enjoy employing technology in order to supplement learning, including in gross anatomy. The results also suggest that the Anatomage table may be a modality equivalent to cadaveric dissection for learning some anatomical regions (in this case, musculoskeletal anatomy, i.e., upper and lower limb).

Compliance with Ethical Standards

Ethical Approval

The protocol for this study was given exempt status by the Institutional Review Board of Case Western Reserve University (IRB# 2015-1035).

Informed Consent

Informed consent was obtained from all individual participants included in the study.

Conflict of Interest

The authors declare that they have no conflicts of interest.