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Medical Teacher, Vol. 15, No. I, 1993 67 How we teach anatomy eficiently and effectively T. M. SCOTT, Division of Basic Medical Sciences, Faculty of Medicine, Memorial University of Newfoundland, St. John’s, Newfoundland, Canada SUMMARY An anatomy course is presented which stresses the teaching of applied anatomy using lectures, laborato y workshops and problem-solving tutorials. Laborato y workshops include the use of prosected specimens and body imaging such as CT scan and ultrasound, but do not include dissection. The problem-solving tutorials make extensive use of clinical cases and the application of anatomical knowledge. The course is taught by anatomists and practising physicians, and needs only 98 hours of curriculum time. The perj5ormance of the students and the positive attitudes of both students and faculty are enhanced by the design of the course. Introduction Medical anatomy teaching has traditionally been extensive both in terms of the amount of curriculum time consumed and in some cases demanded, and in terms of the volume of material taught and tested. In recent years the push for change in medical education has infiltrated some anatomy departments and we have seen the development of a wide range of methods of teaching anatomy. While most schools have stuck to traditional dissection based gross anatomy courses (1 99 1-92 Association of American Medical Colleges Curriculum Directory) or have modified courses including dissection (Rennie, 1987), others have gone to prosec- tion (Bulmer, Mayor & Peel, 1982). In some cases, formal courses have been replaced by provision of learning resources alone (Pallie & Carr, 1987). In few cases has there been integration of the sub-disciplines of anatomy-gross anatomy, embryology and histology. The pressure to change anatomy teaching has come from students in clinical years and the faculty who teach them, from curriculum planners, and from anatomy faculty. Students in clinical years complain that although they worked hard in their earlier anatomy courses they now see no benefit. Curriculum planners Med Teach Downloaded from informahealthcare.com by University of British Columbia on 10/29/14 For personal use only.

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Page 1: How we teach anatomy efficiently and effectively

Medical Teacher, Vol. 15, No. I, 1993 67

H o w we teach anatomy eficiently and effectively

T. M. SCOTT, Division of Basic Medical Sciences, Faculty of Medicine, Memorial University of Newfoundland, St. John’s, Newfoundland, Canada

SUMMARY An anatomy course is presented which stresses the teaching of applied anatomy using lectures, laborato y workshops and problem-solving tutorials. Laborato y workshops include the use of prosected specimens and body imaging such as CT scan and ultrasound, but do not include dissection. The problem-solving tutorials make extensive use of clinical cases and the application of anatomical knowledge. T h e course is taught by anatomists and practising physicians, and needs only 98 hours of curriculum time. The perj5ormance of the students and the positive attitudes of both students and faculty are enhanced by the design of the course.

Introduction

Medical anatomy teaching has traditionally been extensive both in terms of the amount of curriculum time consumed and in some cases demanded, and in terms of the volume of material taught and tested. In recent years the push for change in medical education has infiltrated some anatomy departments and we have seen the development of a wide range of methods of teaching anatomy. While most schools have stuck to traditional dissection based gross anatomy courses (1 99 1-92 Association of American Medical Colleges Curriculum Directory) or have modified courses including dissection (Rennie, 1987), others have gone to prosec- tion (Bulmer, Mayor & Peel, 1982). In some cases, formal courses have been replaced by provision of learning resources alone (Pallie & Carr, 1987). In few cases has there been integration of the sub-disciplines of anatomy-gross anatomy, embryology and histology.

The pressure to change anatomy teaching has come from students in clinical years and the faculty who teach them, from curriculum planners, and from anatomy faculty. Students in clinical years complain that although they worked hard in their earlier anatomy courses they now see no benefit. Curriculum planners

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68 T. M. Scott

TABLE I. The four year programme at Memorial

First Year Second Year Third Year Fourth Year

Anatomy Biochemistry Community Medicine Clinical Skills Genetics

Immunology Physiology Pharmacology

Pathology Microbiology Haematology Elective

1. Body Systems:

Cardiovascular Respiratory Renal G.I. Endocrine Neuroscience Reproduction G r o w d ~ & Development Systems Pathology

2. Clincial Skills

1. Integrated study of disease

Musculoskeletal Nephrology Psychiatry Neurology Cardiology Endocrinology Respiratory Haematology G.I. Therapeutics Dermatology Medical Ethics Community Medicine ACLS

2. Clinical Skills

3. Electives

Clerkship

Medicine Surgery ObdGyn Psychiatry Paediatrics Electives Rural family practice

are looking for both time, as the expansion in medical knowledge and technology demands attention, and greater emphasis on development of problem-solving skills. Anatomy faculty, who traditionally have large teaching loads, feel that their teaching load is inhibiting their research output, an important consideration in career development. As faculty retire it is becoming increasingly difficult to find well trained replacements. These pressures led to the proposal and implementation of the course described below.

The four-year programme

The undergraduate programme at Memorial is a four year plan as shown in table I. In the first year, course teaching is subject based with up to five courses being taught simultaneously so that Anatomy, Biochemistry, Community Medicine, Genetics and Clinical skills teaching precedes Physiology, Pharmacology and Immunology teaching which is followed by Microbiology, Pathology and Haema- tology teaching. In the second year the teaching is system based, with clinical skills teaching occurring throughout the year. This pattern is to some extent repeated in third year, followed by a clerkship organized according to discipline.

From the inauguration of the medical program in 1968 anatomy teaching had been carried out in the form of a core course, most recently delivered over a period of seven weeks, in which the students were taught by means of lectures and demonstrations using prosected specimens. The course was intensive and encour- aged rote-learning of detailed anatomical facts. There was anecdotal evidence to suggest that students rapidly lost their hard won anatomical knowledge. This method of teaching anatomy was felt by some of those involved to be ineffective and wasteful of both faculty and student time and effort. The teaching of anatomy was reviewed and a new approach proposed in which most of the teaching would

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Anatomy teaching 69

occur in a first year course with further applied anatomy being taught in each of the body systems courses in second year.

The proposed course

Development of the proposal for the new first year course was based on the following considerations:

1. Time

The time available for the teaching of anatomy should be determined by the time required to teach the anatomy necessary at appropriate times in the programme, rather than by attempting to fit or fill a predetermined time slot.

2. Subject matter

The choice of subject matter should be determined by answering the following questions:

(a) What anatomy must a student know to be a competent ‘undifferentiated’ physician?

(b) What anatomy is clinically relevant? Anatomy that is related to or explains common complaints, and anatomy that is essential to developing an understanding of the handling of vital medical situations should be stressed.

(c) What anatomy does aJirst year medical student need to know as a basis for the learning of other related subject matter?

3. Teaching methods were chosen after considering:

(a) Efficiency of teaching 56 students. (b) The desirability of promoting as much as possible the discovery of relevant

anatomy by the student without resorting to dissection. (c) The need to expose students to current forms of body imaging and their use

in medicine. The body should be presented as much as possible in the manner in which it is examined by physicians, with concentration on surface anatomy and body imaging, using CT scans, MRI and ultrasound.

(d) The application of anatomical knowledge to clinical problem solving. (e) The use of teaching methods which promote retention and recall and which

encourage the students to develop the skills of continuous self education.

4. Assessment

Assessment was developed according to the following guidelines. (a) All assessment should be in line with the teaching philosophy. That is, that

understanding rather than memorization should be tested. The testing situations should closely resemble both the teaching situation and the situation in which the student would be expected to use the understanding, either clinically or as a basis for other appropriate learning.

(b) Assessment should contribute to the learning process.

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70 T. M. Scott

(c) Assessment should allow the identification of specific weakness in such a

According to these precepts the following course was developed and was divided

Musculoskeletal; Nervous System; Thorax; Abdomen; Pelvis; Head and Neck.

In each section there were lectures, lab workshops and problem-solving tutorials (Table 11). Gross anatomy, histology and embryology were integrated in each section. Each section was assessed at its conclusion by submission of written work and, in two cases by an oral exam.

way that remediation is promoted.

into six sections:

The lectures

For each lecture an outline was developed indicating the content and wherever possible all of the terms to be used in the lecture. The lectures were 50 minutes long and delivered in an interactive fashion. During many lectures unlabelled line-drawings were completed by the students. The number of lectures was different for each section.

The laboratory workshops

In these sessions the students worked through units which we termed stations. For each station there was a group of specimens which might have included a CT scan, skeleton, wet prosection, plastinated specimen, and a model. Using these tools, the students worked through the problems posed at the station and wrote up their answers in the form of a lab book. The demonstrators assisted the students in terms of orientation and identification but encouraged the students to work out their own answers to the questions.

The problem-solving tutorials

These tutorials were designed to help the student to put together the information and understanding acquired from the lectures and labs, and to apply that to a clinical situation. Each tutorial consisted of three or four clinical cases. The case history was given and the students, with the help of a facilitator, worked through problems related to each case. Each student had prepared answers to the problems in advance of the tutorial and later submitted a written account.

The assessments

Following each section, students were required to submit their lab books contain- ing the lab workshop and problem-solving tutorial write-ups. On two occasions this was supplemented by an oral exam on the same material. After three sections a mid-course exam was given. A final exam was given at the completion of the six

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Anatomy teaching 71

TABLE 11. The course listing of lectures, laboratory workshops and problem. solving tutorials

Section 1. Musculoskeletal

Introduction Lab. Examination of the body The Musculoskeletal System I Cell Organelles I Connective tissue histology The musculoskeletal System I1 Histology of Epithelia Gametogenesis and Fertilization Lab. Connective Tissue, Epithelia Cell Organelles I1 Cleavage and Implantation Problem Solving Tutorial

Section 2. The nervous System

The Nervous System The Nervous System-Histology Gastrulation and Neurulation Lab. Nervous System Histology Plexuses and Somatic Innervation Morphogenesis and Organogenesis Lab. Upper Limb Innervation Lab. Lower Limb Innervation Problem-Solving Tutorial Problem Solving Tutorial

Section 3. The Thorax

The Thorax Lungs, Pleura, Trachea Respiratory System Histology Vascular System Development The Heart The Vasculature Lab. Thoracic Wall and Viscera Cardiovascular Histology Foetal Membranes and Placenta Lab. Respiratory System Histology Lymphatic System Lab. The Heart and Vasculature Cardiovascular & lymphatic histology MID-COURSE EXAM

Section 4. Abdomen

Digestive System Organogenesis Abdomen Lab. Abdomen Oesophagus, Stomach, intestine Digestive System Histology Liver, Gallbladder, Pancreas Lab. Digestive System Digestive System Histology Lab. Digestive System Histology Large Intestine Lab. Digestive System Histology Lab. Large Intestine, Post. Abd. Problem Solving Tutorial

Section 5. Pelvis

Urogenital Organogenesis Urinary System Reproductive System Lab. Urinary System and Pelvis Problem Solving Tutorial Urinary System Histology Reproductive System Histology Reproductive Systems Urogenital Histology

Section 6. The Nervous Sysrem

The Skull Cranial Nerves Head and Neck Vasculature Lab. The Skull The Trigeminal Nerve Endocrine Histology Lab. Endocrine Histology Cranial Nerves VII and IX Lab. Face Mouth and Nose The Neck Lab. Mouth, Nose and Neck Problem solving Tutorial Problem solving Tutorial FINAL EXAM

sections. These exams were composed of seven stations. At each station a case history was given. Relevant material was provided in the form of radiology (CT scan, ultrasound etc.) , wet prosection, skeleton and histology slide. The students were required to use the materials to answer questions related to the case history. The lab books were valued at 25%, and each exam 35% of the final grade. The oral exams counted for a small percentage of the grade (5%) and were used to let the students know their status with as little stress as possible.

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72 T. M. Scott

Course guide

The course objectives, lecture outlines, laboratory protocols and case histories for problem-solving tutorials were published in the form a soft-cover course guide which was given free to each student. The guide contained copies of all light and electron micrographs used in histology teaching.

The faculty

An important component of this new course was the faculty. All lectures were given by anatomists, with one anatomist having responsibility for the gross lectures in two sections. All embryology lectures were given by one embryologist and all histology lectures by one anatomist. The laboratory workshops were staffed by anatomists paired with practising clinicians, as were the problem-solving tutorials. The clinicians were drawn from family practice, general surgery, orthopaedic surgery, neurology, urology, obstetrics and gynaecology, medicine and radiology, and all contributed only in their area of expertise.

Second year anatomy teaching

In the second year of medical studies the teaching is primarily arranged around the body systems. The teaching of anatomy occurs as a set of lectures covering the gross anatomy, embryology and histology of the relevant system complemented by a laboratory workshop. In the workshop the students work their way through a protocol which requires them to examine specimens and answer questions on applied anatomy. The specimens include histology slides, radiology, wet prosected specimens, plastinated specimens, skeleton and models. The emphasis is on ensuring that a strong base knowledge has been acquired which will allow the student to profit from the rest of the systems course. Neuroanatomy is taught within the Neuroscience course by more traditional methods.

Early results

The new first-year anatomy course has been run once and appraised by both faculty and students.

The time allocated to the old course was 320 hours while the new course required 98. The time devoted to the new course by anatomy faculty was considerably less than that previously required. Formerly, individual anatomy faculty contributed up to 180 hours while in the new course the mean contribution was 62 hours. The time spent on grading papers is not included in these figures. The clinical faculty involved each gave at least two hours, but no more than eight hours, of their time.

Both anatomy and clinical faculty found the experience to be interesting and rewarding, and all approached their teaching with an enthusiasm which ran throughout the course. While clinical faculty feel uncomfortable teaching within more traditional dissection courses, they enjoyed contributing to the new course since they were required to apply only their current knowledge without recourse to reviewing extensive detailed anatomy, and with a professional anatomist ‘on-hand’.

Student comments were gathered one month after the conclusion of the course

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Anatomy teaching 73

and final exam. Each of 48 students completed two questionnaires. The first questionnaire was a standard form which is applied to the evaluation of all courses in the undergraduate curriculum. The students were asked to rank their agreement with a series of statements from 1 (strongly disagree) to 5 (strongly agree). The second evaluation contained specific questions relating to features of the new course. The following are relevant selected items from the evaluations:

(1) The course as a whole was a valuable educational experience. Mean 4.69. (2) The course content was at a level appropriate to my needs. Mean 4.5. (3) The organization of the course facilitated my learning. Mean 4.3. (4) It was clear to me what I should be learning. Mean 3.7. ( 5 ) Was there unhelpful repetition in parts of the course? Yes-1; No-47. ( 6 ) Was the radiology that was presented helpful to your understanding of

Students were asked for written comments on the following subjects: (7) Was there anything exceptionally good about this course that you think

should be continued or adopted by other courses? Positive comments were made with respect to the clinical approach, the use of problem-solving tutorials, the format of the course, the labs and written work, the oral exams.

(8) Did the clinical tutors contribute to your understanding of anatomy, enjoy- ment of the teaching session, appreciation of the problem being studied? The whole class responded positively to each of these questions.

(9) T o what extent was your understanding of anatomy altered by the problem solving tutorials? All students responded positively indicating improvement in understanding, retention, focus, learning.

anatomy? Yes-35; No-7.

Discussion

The course was considered by the students to be highly successful in that they believe they have acquired a functional knowledge of anatomy at what seemed to them a reasonable cost in time and effort. The course was delivered using three fewer anatomy faculty than had been previously available but benefited greatly from the contribution made by clinical faculty. By these measures the new course appears to be efficient.

Did the students learn sufficient appropriate anatomy? Many anatomy course planners have struggled with this question. Some uphold the philosophy of a preclinical curriculum divorced to a large extent from the practice of medicine (Charlton, 1991), while others see medical education as more of a continuum and try to take into account clinical relevance when considering what anatomy should be taught (Hines, 1970; Olusanya Adeyemi-Dora & Ojeifo, 1988). There is evidence that when students attempt to apply basic science knowledge learned out of clinical context students fail to establish the necessary link between the two (Balla, 1980; Patel et al. , 1988, Balla et al. , 1990). The physiology, pharmacology and pathology courses which immediately follow this new course may provide a partial answer to this question. When the students reach second year their anatomical knowledge will be supplemented by a very brief review of the applied anatomy of each system just before extensive application of their knowledge to the study of each system. In third year the students will be required to continue the application of their anatomical knowledge in the integrated study of disease. In the clerkship again they will draw on and expand their knowledge continuously. It

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74 T. M. Scott

would be useful to test the student’s anatomical knowledge at the beginning of second year, at the beginning of third year when formal anatomy teaching has been completed, and again at the end of clerkship before the licensing examinations.

Were the methods used effective? There is general agreement that medical students must learn to be problem-solvers and decision makers (Rogers et aZ., 199 1). The incorporation of case-based studies into the curriculum is believed to promote this type of learning (Barrows, 1984; Peplow, 1990). It has been suggested that the writing of reports on the cases, as carried out in this course, improves the value of the exercise (Peplow, 1991). In this course prosected specimens and radiological images replaced the traditional dissection. While the anatomical knowledge taught and tested by traditional courses may be best acquired through dissection, it can be argued that the anatomical knowledge used daily by physicians is different and may be best taught by other methods.

Just how effective the new course is will have to await further study, but the early results are promising.

Acknowlegements

Many of the lecture outlines, laboratory protocols and problem-solving tutorials were written by fellow anatomists Dr June Harris and Dr John McLean, and by surgical resident Dr Sam Chun. The embryology lecture outlines were written by Dr Sheila Virgo. Radiological images were selected and provided by Dr Eilish Walsh. Dr Roger Butler arranged and contributed to the participation by clinical faculty.

Correspondence: T. M. Scott, Division of Basic Medical Sciences, Faculty of Medicine, Memorial University of Newfoundland, St. John’s, Newfoundland, Canada AIB 3V6.

REFERENCES BALIA, J. I., BIGGS, J. B., GIBSON, M. & CHANG, A. M. (1990) The application of basic science concepts

to clinical problem-solving, Medical Education, 24, pp. 137-147. BALIA, J. I. (1980) Logical thinking and the diagnostic process, Methods of Information in Medicine, 20,

pp. 16-18. BARROWS, H. S. (1984) A specific problem-based, self-directed learning method designed to teach

medical problem-solving skills, and enhance knowledge retention and recall, in: H. G. SCHMIDT & M. L. VOLDER (Eds) Tutorials in Problem-based learning, pp. 16-32 (Assen, Van Gorcum).

BULMER, D. , MAYOR, D. & PEEL, S. (1982) The way we teach Anatomy, Medical Teacher, 4, pp. 126-130.

CHARLTON, B. G. (1991) Practical reform of preclinical education: core curriculum and science projects, Medical Teacher, 13, pp. 21-28.

HINES, D. (1970) The application of anatomy and other basic medical sciences in general practice, British Journal of Medical Education, 4, pp. 145-148.

OLUSANYA ADEYEM-DORO, H. & OJEIFO, J. (1988) What anatomy shall we teach medical and dental students in a primary health care curriculum?, Medical Educurirm, 22, pp. 407-41 1 .

PUE, W. & CARR, D . H. (1987) The McMaster Medical Education Philosophy in theory, practice and historical perspective, Medical Teacher, 9, pp. 59-71.

PATEL, V. L., GROEN, G. J. & SCOTT, H. M. (1988) Return to basic sciences after clinical experience in undergraduate medical training, Medical Education, 18, pp. 244-248.

PEPLOW, P. V. (1990) Self-directed learning in anatomy: incorporation of case-based studies into a conventional medical curriculum, Medical Education, 24, pp. 426-432.

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PEPLOW, P. V. (1991) Performance of medical students in case-based and essay components of written

RENNIE, E. (1987:~ The way we teach: Topographical anatomy, Medical Teacher, 9, pp. 293-303. ROGERS, J. C., SWEE, D. E. & ULLIAN, J. A. (1991) Teaching medical decision making and students’

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