RESEARCH REPORT

Current Integration of Dissection in Medical Education in Australia and New Zealand: Challenges and Successes Hope Ellen Bouwer, Krisztina Valter, Alexandra Louise Webb* Medical School, Australian National University, College of Medicine, Biology and Environment, Canberra, Australian Capital Territory, Australia

The reduced use of dissection associated with the introduction of integrated systems problem-based learning curricula, graduate-entry programs and medical school expansion is a frequent topic of discussion and debate in modern medical training. The purpose of this study was to investigate the impact of these changes to the medical education landscape, by looking at the current utilization and integration of dissection in medical schools, in Australia and New Zealand. A survey and an invitation to participate in an interview were distributed to all Australian Medical Council-accredited medical schools. Sixteen schools (76%) responded to the survey and five interviews (24%) were conducted. Dissection was a component of the medical program in 12 of the 16 schools surveyed. The opportunity for medical students to dissect human cadavers was found to be related to whether the medical school was established pre- or post-2000 (P 5 0.003) but was not significantly associated to undergraduate- or graduate-entry (P 5 0.64), program length (P 5 0.59) or the number of commencing students (P 5 0.07). The methods used for the delivery and integration of dissection varied between schools. Despite substantial changes to the delivery of anatomy in Australian and New Zealand medical schools, a variety of approaches have been adopted to ensure dissection remains an integral component of medical student education. Based on our findings, a number of recommendations were formulated to encourage the integration of dissection, regardless of the didactics of the program, to enhance the anatomical knowledge of students. Anat Sci Educ 9: C 2015 American Association of Anatomists. 161–170. V

Key words: gross anatomy education; medical education; undergraduate education; anatomical sciences; dissection in anatomy; human gross anatomy; medical school curriculum; New Zealand; Australia

INTRODUCTION The effective integration of dissection within the modern medical curriculum is recognized as a challenge. Since the year 2000, there has been widespread adoption of problembased learning (PBL), the emergence of graduate-entry programs, and unparalleled growth in the number of medical

Additional Supporting Information may be found in the online version of this article. *Correspondence to: Dr. Alexandra L. Webb; Medical School, Florey Building 54, Australian National University, Canberra, ACT 2601, Australia. E-mail: [email protected] Received 1 December 2014; Revised 5 May 2015; Accepted 16 June 2015. Published online 3 July 2015 in Wiley (wileyonlinelibrary.com). DOI 10.1002/ase.1559 C 2015 American Association of Anatomists V

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schools, and the number of commencing medical students (Medical Deans Australia and New Zealand, 2011; AMC, 2014). A trend toward the decreased utilization or even omission of dissection, together with an estimated 80% reduction in the number of hours dedicated to anatomy teaching, has coincided with these dramatic changes to medical education in Australia during the past 15 years (Parker, 2002b; Goulston and Oates, 2007; Craig et al., 2010; Ramsey-Stewart et al., 2010; Goulston and Oates, 2012). A continued decline in the utilization of dissection has been predicted despite frequent calls from anatomists, students and clinicians to make dissection available to all medical students (Parker, 2002b; Older, 2004; Chapuis et al., 2010; Farey et al., 2014). However, there is a lack of empirical data regarding the current use and integration of dissection in Australia and New Zealand since the introduction of PBL curricula and graduateentry programs in this changing medical education landscape. The rapidly expanding medical fields and knowledge, and the need to introduce subjects relevant to the development of Anat Sci Educ 9:161–170 (2016)

lifelong skills led to a reorganization of medical training and a shift towards integrated PBL curricula. This resulted in decreased time available for biomedical sciences teaching. One of the casualties of these changes was anatomy and in particular dissection (Parker, 2002b; Azer and Eizenberg, 2007; Bergman et al., 2008; Craig et al, 2010). These changes have resulted in the perception that medical students are graduating with insufficient anatomy knowledge and skills for safe and competent practice and reports that medico-legal claims associated with anatomical errors have increased (Ellis, 2002; Turney, 2007; Mitchell and Batty, 2009; Craig et al., 2010; Bergman et al., 2011; Farey et al., 2014). It has been suggested that deficiencies in anatomy knowledge and skills and/or the opportunity for acquiring more detailed anatomical knowledge and skills (Turney, 2007) could be addressed during postregistration training (Campbell and Fox, 2012; Yammine, 2014). However, concerns have been raised that postregistration anatomy courses may shift responsibility away from medical schools to teach adequate anatomy for safe clinical practice in the early clinical years as interns and junior doctors (Ramsey-Stewart et al., 2010; Farey et al., 2014). Despite these conceptual changes in many medical programs, clinicians, anatomists and students express continued interest in the use of dissection for student education (Azer and Eizenberg, 2007; Korf et al., 2008; Patel and Moxham, 2008; Ramsey-Stewart et al., 2010; Papa and Vaccarezza, 2013; Farey et al., 2014; Yammine, 2014). Dissection is believed to be important to facilitate deeper learning of anatomy (Shaffer, 2004; Patel and Moxham, 2008), specifically, understanding of the three-dimensional organization and spatial relationships of the human body (Lachman and Pawlina, 2006), and an appreciation for anatomical variations (Willan and Humpherson, 1999). In addition, it helps build skills in professional team working (Pawlina and Lachman, 2004), heuristics and tactile gnosis of tissues (Aziz et al., 2002; Korf et al., 2008). Furthermore, dissection can introduce students to the doctor–patient relationship and concepts associated with death and dying (Aziz et al., 2002). The challenge for educators therefore is to find a balanced and effective approach to include and integrate dissection in modern medical training (Bergman et al., 2011). The current utilization of dissection in the modern medical curriculum is not known. The aim of this study was to obtain a snapshot of the utilization, delivery, and integration of dissection in medical schools in Australia and New Zealand at the present time. We were hoping to find answers to some of the following questions regarding modern medical education: (1) is there a role for dissection and (2) where and how can dissection be incorporated within the curriculum?

MATERIALS AND METHODS In Australia and New Zealand, university medical schools are responsible for delivering basic medical education programs that lead to a qualification that enables general registration as a medical practitioner. Entry to medical school may be directly from secondary school (undergraduate-entry) or following the completion of an undergraduate degree (graduateentry). Previous anatomy knowledge is a prerequisite for some, but not all medical school entry (Tedman et al., 2011). Since the year 2000, nine new medical schools (post-2000) have been established in Australia (Medical Deans Australia and New Zealand, 2011), doubling the number of existing 162

(pre-2000) medical programs. Concomitantly there has been a 116% increase in the number of commencing medical students in new and existing medical schools (Medical Deans Australia and New Zealand, 2011). In 2013, there were 19 medical schools in Australia and two medical schools in New Zealand accredited by the Australian Medical Council (AMC): 5 five-year and 3 six-year undergraduate-entry, 11 four-year graduate-entry and two schools offering both undergraduate- and graduate-entry options (six-year undergraduateand five-year graduate-entry; five-year undergraduate- and four-year graduate-entry) (AMC, 2014). All anatomy departments at the 21 medical schools in Australia and New Zealand, accredited by the Australian Medical Council (AMC, 2014), were invited to participate in this study. Ethics approval was granted from the Australian National University Human Research Ethics Committee (HREC 2013/483). Informed consent was obtained from all participants.

Survey Using a systematic approach (Rickards et al., 2012) the survey was developed using a literature review and interviews with two anatomists followed by expert review and cognitive interviews with four anatomy academics, who did not participate in the study, for content and response process validity, respectively. The survey was designed to collect quantitative and qualitative data regarding medical program structure, gross anatomy teaching and the utilization, delivery and integration of dissection throughout the medical program using closed and open questions (see Supporting Information). An electronic version of the survey (fillable portable document format created using Adobe Acrobat XI Pro, version 11.0.0, (Adobe Systems, San Jose, CA) was pilot tested by three anatomy academics. The survey and participant information sheet were emailed in November 2013 to the head of each anatomy department. Two reminder emails were sent in January and March 2014. All returned surveys were de-identified. Reports published on the AMC (AMC, 2014), Medical Deans Australia and New Zealand (2015), university websites, and a PubMed search were used to obtain publically available information from universities that did not reply to the survey. Additional information regarding accredited postgraduate anatomy courses currently available in Australia and New Zealand was retrieved from the Australian Orthopaedic Association (AOA, 2015), Royal Australasian College of Surgeons (RACS, 2015) and university websites.

Interviews An invitation to volunteer to participate in a 20–30 min individual semistructured telephone interview in February–March 2014 was included in the survey. The semistructured interview (DiCicco-Bloom and Crabtree, 2006) consisted of predetermined open-ended questions that sought to clarify the utilization and integration of dissection and the impetus behind the approach at each school, with additional questions and discussion of topics as they emerged during the interview. Interviews were recorded, transcribed, and de-identified.

Analysis Quantitative data from answers to closed questions in the survey (Sections 1, 2, and 3 [Questions 1–7]) were presented Bouwer et al.

Table 1. Medical Program Structure in Australian and New Zealand Medical Schools Characteristics of medical program

Number (%)

Program entry Undergraduate

6 (38%)

Graduate

9 (56%)

Both

1 (6%)

Program pedagogy Problem based

8 (50%)

Mixed methoda

7 (44%)

Case based

1 (6%)

Traditional

0 (0%)

Gross Anatomy

Gross anatomy delivery Regional based

1 (6%)

Systems based

2 (13%)

Both regional- and systems based

13 (81%)

a

Mixed-method encompasses a combination of program pedagogy which may include elements of traditional, problem-based learning and/or case-based learning; n 5 16.

as mean, standard deviation (6SD), minimum and maximum values and number of medical schools (6percentage). Chisquare was used to investigate the association between the use of dissection and pre- and post-2000 medical schools, undergraduate- and graduate-entry programs, length of program, number of commencing medical students and use of PBL (a probability level of P 5 0.05 was set as the minimum criterion). Qualitative data from answers to open questions in the survey (Sections 3 [Questions 8–12], 4 and 5) were analyzed by three independent reviewers using coding based on a grounded theory approach (Strauss and Corbin, 1990; Watling and Lingard, 2012). Any discrepancies were discussed and resolved by consensus. The numerical data from coding was used to calculate the proportion of responses (percentages). Quotations from survey and interview data are presented in italics and identified by a corresponding number S1-S16 and I1-I5, respectively. The data were analyzed using Microsoft Excel, version 14.3.1 (Microsoft Corp., Redmond, WA) and IBM SPSS Statistics, version 21 (IBM Corp., Armonk, NY).

RESULTS Participants Anatomy academics from sixteen of the 21 (76%) AMCaccredited medical schools in Australia and New Zealand responded to the survey. Of those that responded, five individuals (31%) from different medical schools volunteered to Anatomical Sciences Education

participate in an interview. All interview participants were from institutions that currently offer human dissection within the medical curriculum. Ten pre-2000 (62.5%) and six post-2000 (39.5%) medical schools responded to the survey. Nine schools offered a fouryear graduate-entry program (Tables 1 and 2). A five-year and six-year undergraduate-entry programs were available at four and two schools, respectively. One school provided both undergraduate- (6 years) and graduate- (5 years) entry options. Ten schools had less than 200 and six schools more than 200 commencing students entering the first year of the program (Table 2). All curricula utilized problem-based or case-based learning to varying extents (Table 1). The five medical schools that did not respond to the survey included two pre-2000 (40%) and three post-2000 (60%) schools that offered five-year (one school) and six-year (two schools) undergraduate-entry, four-year graduate-entry (one school) and both four-year graduate- and six-year undergraduate-entry (one school) programs. All five schools provided opportunities for medical students to dissect during their program of study.

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Gross anatomy was taught in years 1 (Y1) and 2 (Y2) at 15 schools (94%) and in Y1 only at one school (6%) (Table 2). Five of the 15 schools continued teaching anatomy in later years. Two schools (13%) continued teaching to year 3 (Y3), two schools (13%) to year 4 (Y4) and one school to year 5 (Y5) (6%). While a paucity of dissection is noted in the latter years of medical programs, interviewees expressed the value of providing opportunities for dissection for medical students in their final years with the caveat that this was a logistical challenge to accomplish: I1-“it is very important to come back and continue dissection in latter years. . .. . ..this is when (students) can concentrate on dissection from a clinical context”; I4-“revisit the laboratory, with or without the opportunity to dissect later in their course, optimally while they are studying surgery, but the logistics around that are enormous”.

Current Dissection Utilization: When, How and Why? Four of the 16 participating schools (25%) did not currently offer human cadaver dissection while 12 (75%) included dissection in their program. The utilization of dissection was associated with the recency of medical school establishment. Pre-2000 schools were significantly associated with the provision of dissection (v2(1) 5 8.89, P 5 0.003) (Fig. 1). There was no significant association between entry level (v2(2) 5 0.89, P 5 0.64), program length (v2(2) 5 1.07, P 5 0.59), number of commencing students (v2(1) 5 3.2 P 5 0.07) and the opportunity to dissect (Fig. 1). Of the ten pre-2000 schools that offered dissection, five schools delivered compulsory (i.e., mandatory course requirement) dissection, three offered optional dissection, and one school provided both (Table 3). Two schools offered dissectionbased research projects, one of which only offered dissection via this option and the other in addition to a compulsory dissection program. In comparison, the two post-2000 schools that offered dissection provided it as an optional component of the curriculum. Whole body dissection was available at 163

215 (664) [170–260]

944 (6489) [400–2150]

155 (669) [70–315] 0

192 (659) [120–280]

12 (NA) [0–12]

206 (6112) [100–530]

8 (67) [0–6]

207 (6113) [100–530]

21 (610) [0–32]

Mean (6SD) [minimum–maximum]; NA 5 not applicable.

211 (6119) [100–560] All schools (n 5 16)

Number of students in each year of the program

208 (6113) [100–530]

72 (641) [0–160] 79 (638) [30–155]

40 (60) [40–40] 6 years (n 5 2)

All schools (n 5 16)

114 (615) [103–124] 0 12 (NA) [0–12] 10 (69) [3–16] 23 (610) [16–30]

52 (615) [30–65] 5 years (n 5 5)

35 (67) [30–40]

113 (644) [70-159] NA 0 0 26 (68) [0–32]

NA NA 4 (NA) [0–4] 8 (NA) [0–8] 96 (639) [0–160] 82 (631) [50–155] 4 years (n 5 9)

Number of hours of gross anatomy teaching in each year of the program

48 (631) [20–85]

110 (669) [100–315]

Total Year 6 Year 5 Year 4 Year 3 Year 2 Year 1 Length of program

Number of Hours Gross Anatomy Teaching and Number of Medical Students per Academic Year, Categorized According to Medical School Program Length

Table 2. 164

four out of the six pre-2000 schools with compulsory dissection and was undertaken in small groups of 4–10 students. One out of the four pre-2000 schools with optional dissection offered both whole body (small group of 5 students) and staff allocated body parts (pair of students) for dissection. At the remaining pre-2000 schools, students chose (2 schools) or were allocated by staff (2 schools) a body part to dissect in small groups of 3–8 students. In comparison to pre-2000 schools, staff allocated (1 school) and student chosen (1 school) body parts were available in the optional dissection programs at the post-2000 schools in groups of 2–3 students. Dissection by individual students was available in the latter years of the program (two schools) or for research projects (two schools). During the interviews, it was evident that not all schools are able to provide compulsory and/or full body dissection due to cost, resources, limited curricular time and large student numbers. As a result, schools have overcome these limitations by providing optional dissection programs for students interested to undertake dissection as part of their anatomy education (I5-“(students) who have a real desire to learn their anatomy at a deeper level and many of them are thinking of heading towards surgery”), offer students to choose a body part of interest to dissect (I5-“many of them (students) will have a burning (interest in an) area that they want to cover”) or allocate a specific body part to students (I4-“what we do is the thorax and abdomen because we think they are the areas where perhaps the most clinically relevant and 3D anatomy is most available to the students”). Seven universities (5 pre-2000 and two post-2000 schools) included dissection in more than one year of the program and five universities (5 pre-2000) offered dissection in first year of the program. Dissection was most commonly offered in Y2 (8 schools), followed by Y1 (6 schools), Y3 (5 schools), Y4 (2 schools), and Y5 (1 school). Compulsory dissection occurred during the first three years of the program (Y1 four schools, Y2 four schools, Y3 three schools), with one 5-year undergraduate-entry program reporting compulsory dissection throughout the first three years. Optional programs were offered at different stages of the program, Y1 (2 schools), Y2 (5 schools), Y3 (2 schools), Y4 (2 schools), and Y5 (1 school). The number of hours (mean 6 SD; min–max) of compulsory dissection was greatest in Y2 (37 6 15; 27–60) compared with Y1 (19.5 6 17; 2–40) and Y3 (36 6 24; 18– 65). Optional dissection programs were typically longer in Y3 (68 6 52; 8–100) compared to Y1 (8) and Y2 (23 6 14; 8–36) but student participation (mean 6SD; min–max) was greatest in the first two years; Y2 (85 6 40; 50–120) and Y1 (62 6 53; 25–100) compared with Y3 (18 6 14; 2–30). Previous anatomy knowledge and experience was a factor considered by institutions in the timing and conduct of dissection within the curriculum: I2- “there will be a reasonable number of students who have done dissection and there will be a reasonable number who haven’t. . ..students who have not done anatomy previously, will be observers for two weeks while they do an intensive course on the upper and lower limb (before they commence dissection)”; I3-“it is very important for students to be prepared as much as possible, they need to have a background and foundation before they begin dissection. . ..this is why dissection doesn’t begin until second semester to allow students time” (in an undergraduate-entry program); I4-“anatomy is a prerequisite” (for entry into a medical program where dissection commences in year 1). Bouwer et al.

Figure 1. Based on survey responses from institutions (n 5 16), opportunities for medical students to dissect were A, not significantly associated with the entry requirements of the medical school for commencing students (v2(2) 5 0.89, P 5 0.64); B, significantly associated with whether the medical school was established before (pre2000) or after (post-2000) the year 2000 (v2(1) 5 8.89, P 5 0.003); C, not significantly associated with the length of the medical program (v2(2) 5 1.07, P 5 0.59); D, not significantly associated with the number of commencing students at the medical school (v2(1) 5 3.2 P 5 0.07).

An anatomist was involved in the supervision or teaching of dissection in all schools in combination with either clinicians (2 pre-2000 and 1 post-2000 schools) or technical staff (4 pre-2000 and 1 post-2000 schools) or students (medical and PhD students with sound anatomy knowledge) (4 pre2000 schools). The reasons for using clinicians and students, to support dissection delivered by anatomy academics, and the range of benefits provided from their input was articulated during the interviews: I2-“very important because they (clinicians) tell us what is relevant to clinical practice and what’s not”; I4-“we have a rich hierarchy of teaching. . .. . .. staff, surgical candidates, older year medical students. . .. . .. . . surgical registrars add weight and context. . ..I hear them talking about much more than just anatomy. . .how do you study, how did you manage it?..some of the students really struggling won’t come to me with what they think is a silly question, but they will go to their own peers”. Anatomical Sciences Education

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Eleven of the 12 medical schools that offer dissection specified the intended learning outcomes of student dissection at their institution in their survey responses (Table 4): I2-“the problem with using prosected material exclusively is that students don’t get an appreciation of just how much connective tissue is in the body. . .. (dissection) gives them an appreciation of the connective tissue in the body and its relationship to other structures”; I4-’It’s about review, they actually come with the knowledge but with all the questions, the things they haven’t understood”; I4-“we do simple procedures, so for example for the first dissection, on the thorax, the first thing the students do will be to put in an intercostal drain tube. . ..and then they dissect down and see if they got it. . .. . .. . . .. . . we emphasize material that is relevant surgically but difficult to get in the lectures and workshops. . .. . ..giving them a clinical context for their anatomy helps them learn it and remember it”. Five survey 165

Table 3. Summary of Dissection Delivery in Australian and New Zealand Medical Schools Dissection

No. schools

No. hours

No. weeks

No. participating students

Compulsory

6 (38%)

136 (6119) [2–273]

17 (612.3) [1–32]

238 (6133) [120–560]

Optional

4 (38%)

50 (646) [8–116]

NA

78 (647) [12–120]

Research projecta

2 (13%)

140b

NAb

4b

2 (38%)

76 (674) [24–129]

NA

111 (647) [77–144]

Pre-2000 Medical School

Post-2000 Medical School Optional

Mean (6SD) [minimum–maximum]; No. 5 number. a Two schools offered an optional dissection-based research project. b One of the two schools reported the number of hours and number of participating students for the research project. One school provided both compulsory and optional dissection. One school offered dissection-based research projects in addition to a compulsory dissection program. Compulsory dissection was mandatory and required to be undertaken by all students. Optional dissection was calculated to be available and/or taken up by 8–71% of students per academic year; n 5 12.

ticipating as tutors during years 1 and 2 medical student dissection sessions, providing the tutors with an opportunity to revisit and strengthen their anatomical knowledge and integrate and communicate to their peers their clinical and anatomical knowledge. Three schools reported using completed student dissections as prosected specimens for teaching and encouraged students to develop a dissection report to be paired with the specimen or deliver a verbal demonstration to instruct their peers. The benefits of a system for using student dissection outputs for teaching were highlighted in one of the interviews: I1-“students learn this is something you produce not just for yourself but for someone else”. One school used examinations to assess students on their

respondents addressed how the learning outcomes progressed if dissection occurred in more than one year of the program; students advanced by dissecting different or more complex regions, increasing independence, focusing on specific areas of interest, developing surgical skills, gaining deeper anatomical knowledge and clinical relevance and preparing prosected specimens for use in anatomy teaching. Seven of the 12 schools reported distinctive aspects to the delivery of dissection within their program. One school reported reciprocal peer teaching involving students alternating between dissecting and demonstrating their dissection in a small group setting on a 2–3 week roster. Peer teaching in another school involved years 3 and 4 medical students par-

Table 4. Free Response Items to the Survey Question “What are the Intended Learning Objectives/Outcomes of Student Dissection at your Institution?” Were Coded into Six Categories

Learning outcomes Clinical application (e.g., surgery, physical examination)

Responses  S2—“consideration of common surgical procedures and their potential complications”;

Number (%) 8 (73%)

 S8—“study the pathology they find”;  S10—“develop dissection/surgical skills”;  S15—“investigate the anatomical basis to common clinical problems”.

Learning anatomy

 S12—“identify the structures and their anatomical relationships”;

7 (64%)

 S15—“gain a better understanding of three-dimensional anatomy as well as of anatomical variations”. Health and safety

 S14—“maintain laboratory equipment”.

1 (9%)

Psychosocial aspects

 S1—“explain the body donor program, including the psychosocial aspects of body donation”.

1 (9%)

Research

 S4—“dissection towards answering a research question”;

2 (18%)

 S15—“research project on anatomical variations of clinical significance”. Revision of anatomy

166

 S16—“better understanding of anatomy; a form of revision after first appreciating structure in prosection”.

3(27%)

Bouwer et al.

dissections and four schools awarded annual dissection prizes. One school introduced dissection skills by running sessions on fixed animal tissue prior to the commencement of human cadaver work. The reason for this was described in the interview: I1-“in the past we noticed there were a few limitations of dissection from the students and one is that they are not sure they can do it. . ..so one thing we do to respond to this is to organize sessions where they could use nonhuman material where they could practice and use the instruments”. The same school also used animal dissection to expose students to fresh tissue and enable them to gain an appreciation of the differences between fresh and embalmed tissue. Another school described a ‘dissection experience’ focusing primarily on psychomotor aspects and stimulating discussion on the ethical and legal aspects of body donation. One school described a ‘first patient project’ to integrate dissection with the study of pathology uncovered during dissection, including histological processing, microscopic examination and concluding with students presenting a case relevant to their cadaver at the end of the year in a grand round scenario.

Integration Five schools reported integrating dissection with other science themes (pathology, histology, imaging, surgery and other clinical sciences), seven schools reported integrating nonscience themes including medical ethics, law and social science, and one school specifically described the integration of dissection with weekly PBL topics. Three main methods of integrating dissection with other disciplines were identified from the survey responses: within the dissection class (2 schools; 12.5%), within the anatomy course (1 school; 6%), and within the medical program (4 schools; 25%), that is, alignment of related lectures, tutorials and clinical sessions with dissection. Ethics, social science, professionalism, and law were integrated with dissection using all three methods and included discussions during dissection class, conversations with visiting clinicians, alignment with relevant lectures and, most commonly, multidisciplinary tutorials conducted within ethics and health profession courses outside of the dissection laboratory class. The integration of pathology and clinical procedures within dissection classes occurred by the presence of pathologists (reported by three schools, two as a part of the program design and the other as opportunistic involvement) and surgeons/surgical registrars, respectively. The pathologists were available to review pathology uncovered during dissection in small student groups or projected on a screen to the whole class, and the surgeons instructed students on the performance of common clinical procedures, such as putting in an intercostal drain, before dissection commenced. Directed activities that required students to relate their dissection to clinical skills were additional approaches for integration during dissection classes. Within the anatomy course and medical program, medical imaging was integrated using tutorials to supplement dissection classes and prelaboratory exercises that involved the examination of images relevant to the region being dissected and one school planned to closely align lectures on skin with student removal of the skin from their cadaver during dissection sessions. It is worthwhile to note that some schools adopted a variety of methods to integrate dissection within the program. The multifaceted methods and benefits of integrating dissection within the curriculum were Anatomical Sciences Education

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emphasized during the interviews, together with the complexities and challenges associated with organizing and achieving integration: I2-“one of the difficulties is (that) dissection is regionally based and most medical curricula, certainly PBL and CBL, are systems based and. . .. . . when you make it (dissection) separate, unconnected to the rest of the program, it really doesn’t work”; I2-“It (dissection) needs to be integrated with the physiology and histology and pathology, in particular, and that’s what we are trying to do. . .. . . when the students are taking off the skin, they are doing the histology of skin and epithelial tissue and talking about wound healing in pathology. . ..so we are actually making the dissection the core for integrating some of the other disciplines”; I2“learning how to remove the skin, it’s not just for dissection, we are trying to get them to think more about . . .. . . psychosocial aspects and some legal aspects like talking about the body donor program, the anatomy and transplantation act and the psychomotor component of actually using the instruments”.

Past and Future Dissection Utilization Four schools reported an increase in the time available and opportunities for dissection in the past five years. Two schools plan to increase dissection in the next five years. Only one school reported a decrease in dissection time in the past five years. Four schools increased the clinical relevance of dissection programs in the previous five years with two additional schools planning such changes in the next five years. Furthermore, one school reported the introduction of a more integrated dissection program during the previous five years.

Current Nondissection Utilization: Why Not? All four schools (one 5-year undergraduate entry and three 4year graduate entry) currently not offering dissection are post-2000 schools with less than 200 commencing medical students. Factors influencing the omission of dissection from the program included insufficient resources (4 schools), time (4 schools), funding (1 school), and space (1 school). One school reported the provision of alternative methods including animal dissection and ultrasound to provide opportunities to experience dissection and study living human anatomy, respectively. Two of the four schools plan to introduce dissection into their program in the next five years; one of the two schools plans to offer dissection as an elective and the other school plans to continue to provide animal dissection until it is possible to provide equal access to human cadaver dissection for all students.

Postregistration Dissection Programs From the survey as well as Australian Orthopaedic Association and Royal Australasian College of Surgeons websites (AOA, 2015; RACS, 2015), it was evident that 14 accredited postregistration anatomy courses are currently delivered by universities in Australia and New Zealand (including two universities without preregistration training of medical students). Six of these courses include dissection of human cadavers. Two of the surveyed schools in the present study reported future plans to introduce a postregistration training program using dissection. 167

DISCUSSION This study provides a snapshot of the utilization of dissection in medical schools across Australia and New Zealand, as well as investigates whether the increased pressures on time and resources have had an impact on dissection use, as predicted when the PBL philosophy of medical teaching was introduced. A study of Australian medical schools in 2000 reported that the majority had dispensed with compulsory anatomical dissection (Parker, 2002a,b). Three schools offered compulsory whole body and six did optional elective dissection (Parker, 2002a). Contrary to predictions that anatomy teaching, and in particular the use of dissection, will further decline, our findings show that the majority of current schools (17 out of 21) do utilize dissection in their curricula and those who do not are schools that were established more recently with limited infrastructure and resources. Half of these, however, do plan to introduce dissection in the future when the opportunity arises. In recent years, medical education literature has discussed the use of dissection only as part of anatomy education as a whole (Craig et al., 2010). This study has focused on the use of dissection, to find out whether it has a role in modern medical education and if there is, where and how it can optimally be incorporated in the curriculum. This research revealed enticing data regarding the way dissection has evolved within the curricula of Australian and New Zealand medical schools and how it is integrated and delivered to enhance the PBL philosophy. The integration of dissection in the teaching curricula is greatly varied between institutions. The wide spectrum of different approaches was unexpected and has raised new research questions regarding the basis of each school’s selection of their tactic. However, an in-depth analysis of the reasons and motivations behind these choices were beyond the scope of our original aim, and we believe that further exploration of this area is warranted. Nevertheless, by presenting the wide variety of approaches, we hope to provide inspiration for institutions planning to implement dissection into their curricula. Furthermore, we believe that by sharing these ideas, colleagues in institutions with an existing dissection program can also benefit. An interesting finding that emerged was the use of animal dissection at two institutions, implemented for different reasons. In one school, animal tissue is used to provide all students with dissection experience as human dissection is not presently available at that school. This resource has been found to be successful in institutions where there are no donor programs available for the provision of embalmed human cadavers for dissection and/or access to fresh human tissue is not possible (Musumeci et al., 2014). In the other school, human dissection is available for students and animal dissection is used as an adjunct activity to introduce dissection instruments and skills to students prior to participation in human dissection. In addition, nonfixed animal dissection is also offered to help appreciate the realistic structure, texture and strength of different tissues, especially for small anatomical structures that are often not preserved, nonidentifiable, or lose their fresh tissue properties in the embalmed human cadaver (Robinson et al., 2004; Kivell et al., 2009; Macchi et al., 2011; Musumeci et al., 2014). Dissection activities using fresh chicken appendages, porcine eyes and hearts and whole rats have been found to provide 168

students with skills in dissection heuristics and tactile gnosis of tissues and enabling the systematic exploration by sequential dissection of three-dimensional representations of the equivalent human anatomy (Robinson et al., 2004; Khalil et al., 2009; Kivell et al., 2009; Musumeci et al., 2014; Sarkis et al., 2014; Kaplan et al. 2015). Animal body parts can be easily obtained from a butcher or abattoir at low cost with minimal preparation time, concerns regarding ethics, infection transmission, and no requirements for specialized facilities or disposal (Khalil et al., 2009; Kivell et al., 2009; Musumeci et al., 2014). Furthermore, all students can participate, without a need to share specimens, can undertake multiple attempts, and be introduced to clinical skills such as surgical wound closure (Robinson et al., 2004; Khalil et al., 2009). The original question, whether dissection has a role in the modern medical curricula has been answered by our findings that the majority of Australian and New Zealand medical schools implement dissection in their teaching, as it is perceived as an important part of medical education. From an educational point of view, dissection may be considered a valuable tool in anatomy education in a variety of ways. Dissection conforms with many stages of cognitive apprenticeship, an educational theory that describes the process where students actively learn by modeling the expert who coaches them and provides a scaffold of learning strategies and teaching activities to aid their learning. Students participating in dissection can learn anatomy under the tutelage of experts (anatomists and/or clinicians) while using self-directed learning in exploring a clinically relevant region. In many schools, students also present their findings to their peers to articulate their newly acquired knowledge. In their review, Bergman et al. (2008) discussed that the retention of anatomy knowledge is best achieved by supporting active learning, providing longer exposure time, context and vertical integration of the subject. Dissection programs can be designed to provide opportunities to extend the time students spend in the classroom learning anatomy. By offering dissection at different stages of the program, dissection can provide vertical integration of the discipline. Human body dissection inherently provides clinical context, helping to acquire not only discipline knowledge but also valuable clinical and interpersonal skills. The present study highlights the diverse array of dissection programs currently available in Australian and New Zealand medical schools, which reflects the variety of medical curricula. Of the recent medical education transformations, the age of the medical school, rather than the entry requirements, length of the program or number of commencing students, was found to be the most significant factor influencing whether a medical school currently offers a dissection program or not. In the present study, all of these factors, which have been suggested to have contributed to the decline of dissection in medical education (Leung et al., 2006; Bokey et al., 2014) were identified as challenges to the effective incorporation of traditional dissection in the modern medical curricula. The results of the present study have demonstrated that a range of methods that are sympathetic to the local medical curriculum have been adopted to successfully integrate dissection into the modern medical curriculum. The complexity and time constraints associated with the creation of effective multidisciplinary integrative activities within laboratory-based dissection were evident during the interviews. It was apparent that it is not always practically possible to integrate ‘everything’ and that sometimes integrative Bouwer et al.

activities are better delivered outside of the dissection laboratory in parallel and with close curricular alignment. For example, one school reported practical difficulties integrating imaging and dissection within the laboratory and instead chose to create separate imaging tutorials aimed to support the dissection program. Thus indirect integration outside the laboratory may be more appropriate in some educational environments. Even in established schools, identifying the optimal methods of using and integrating dissection within the curriculum requires some trial and error. Schools are encouraged to explore new activities keeping in mind the provision of clear student objectives (Eisenstein et al., 2014) and the avoidance of pedagogical overload of students (Murakami et al., 2014). Another challenge identified was organizing collaboration between staff from multiple disciplines. A decline in the availability of clinical staff to contribute to anatomy teaching has been reported (Craig et al., 2010; Burgess and RamseyStewart, 2014, 2015). Solutions for organizing clinical input to student dissection were not explored in the present study. A sense of duty to their alumni (Burgess and Ramsey-Stewart et al., 2015) may explain the involvement of clinicians primarily in pre-2000 medical schools in the present study. The wide variation and reduction in hours dedicated to anatomy education in Australian and New Zealand medical schools is frequently associated with the increasing availability of postregistration anatomy courses (Campbell and Fox, 2012). It is widely accepted that regardless of extent, anatomy teaching in medical school is inadequate for specialist training (Briggs, 2014). The present study identified that the number of postregistration anatomy courses has nearly doubled since 2010 when Campbell and Fox (2012) described nine university-based postregistration anatomy courses. However, only four of these courses include dissection because these postregistration courses aim to extend and deepen anatomy knowledge and skills rather than simply provide a substitute for medical school anatomy education (Stringer and Lyall, 2012; Briggs, 2014).

Limitations of the Study While five of the 21 Australian and New Zealand medical schools did not respond to the survey, these schools were found to have characteristics consistent with those that responded to the survey and all offered dissection. Thus the potential for bias in the present study is limited. Results are limited to Australian and New Zealand medical schools. Further studies are required for international comparisons and to identify specific educational needs in different jurisdictions. Given the complexity of current integrated modern medical curricula, it was difficult to classify and distinguish all of the details specific to anatomy from the survey data. For example, it was not always clear if reported gross anatomy hours included integrated anatomy teaching within PBL or optional dissection programs and so should only be considered as estimates. Although the introduction of PBL is reported to have had one of the greatest impacts on current anatomy education, in the present study it was not possible to examine the effects of PBL on the use of dissection as the majority of schools reported elements of PBL within their curriculum. Anatomical Sciences Education

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CONCLUSIONS Opportunities for medical students to dissect are available in the majority of Australian and New Zealand medical schools. A variety of approaches are currently employed to optimize the effective use and integration of dissection within the modern medical curriculum. The changing paradigm of medical education requires a concerted effort by schools to optimize anatomy learning and knowledge retention for medical students. A well-integrated dissection program can help achieve this. Exploration into the ways dissection is utilized and integrated in medical schools across Australia and New Zealand, in the present study, revealed a number of key themes that are supported by current educational theories. Based on the key themes that emerged through our research, we devised a list of suggestions for the effective integration of dissection within medical programs regardless of the didactic approach of the school, which can be adapted to the local educational environment:  Dissection is a valuable resource that provides an opportunity for students to gain additional exposure to anatomy, thereby facilitating knowledge retention. Flexible delivery would allow its implementation, even in time-poor programs as a co-curricular activity, without encroaching upon teaching time.  Focused dissection opportunities, supported by expert academic and clinician input, enables learning through cognitive apprenticeship and will aid the development of valuable life-long knowledge and skills as well as providing a context for learning.  When possible, schools should aspire to the vertical integration of dissection to provide students with an opportunity to re-visit anatomical concepts. As part of the ideology of spiral learning this will encourage deep learning and application of anatomy knowledge.  Peer and team-based learning should be encouraged to help students develop skills in problem-solving, communication and reflection that are pertinent to the clinical environment. Finally, institutions with no direct access to human cadavers are encouraged to explore opportunities for sharing of facilities and resources between neighboring institutions (Strkalj and Dayal, 2014) and/or consider the introduction of animal dissection. Innovative implementation and integration of dissection can achieve synergy between this classic method and modern medical educational values.

NOTES ON CONTRIBUTORS HOPE E. BOUWER, B. Health Sci., is currently a third-year graduate-entry medical student at the Australian National University, Canberra, ACT, Australia. She is interested in a career in rural medicine and continued involvement in medical education. KRISZTINA VALTER, M.D. (Ophthalmol), Ph.D., is an associate professor of anatomy in the Medical School and leads a Retinal Cell laboratory in the John Curtin School of Medical Research at the Australian National University, College of Medicine, Biology and Environment, Canberra, ACT, Australia. She teaches anatomy in undergraduate and medical programs. Her research includes vision science and medical and science research-based education. 169

ALEXANDRA L. WEBB, B.Sc., M.Chiro., Ph.D., is a senior lecturer in the Medical School at the Australian National University, College of Medicine, Biology and Environment, Canberra, ACT, Australia. She teaches anatomy to medical and science students. Her research encompasses anatomy and its clinical application in a variety of contexts.

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