This article was downloaded by: [Selcuk Universitesi] On: 27 December 2014, At: 06:59 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
Teaching and Learning in Medicine: An International Journal Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/htlm20
The Current Status of Anatomy Knowledge: Where Are We Now? Where Do We Need to Go and How Do We Get There? Kaissar Yammine
a
a
The Foot & Hand Clinic and the Center for Evidence-Based Sport and Orthopedic Research , Emirates Hospital , Dubai , United Arab Emirates Published online: 04 Apr 2014.
Click for updates To cite this article: Kaissar Yammine (2014) The Current Status of Anatomy Knowledge: Where Are We Now? Where Do We Need to Go and How Do We Get There?, Teaching and Learning in Medicine: An International Journal, 26:2, 184-188, DOI: 10.1080/10401334.2014.883985 To link to this article: http://dx.doi.org/10.1080/10401334.2014.883985
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
Teaching and Learning in Medicine, 26(2), 184–188 C 2014, Taylor & Francis Group, LLC Copyright ISSN: 1040-1334 print / 1532-8015 online DOI: 10.1080/10401334.2014.883985
LITERATURE REVIEWS The Current Status of Anatomy Knowledge: Where Are We Now? Where Do We Need to Go and How Do We Get There? Kaissar Yammine
Downloaded by [Selcuk Universitesi] at 06:59 27 December 2014
The Foot & Hand Clinic and the Center for Evidence-Based Sport and Orthopedic Research, Emirates Hospital, Dubai, United Arab Emirates
Keywords Background: Gross anatomy is no longer considered a science, as it is no longer considered a research-led discipline. Looking to the current status of anatomical teaching, there is worldwide unanimity regarding the steady decline in the provision of contact hours of this basic science in a crowded undergraduate curriculum. The same could apply at the postgraduate level for specialties where surgical anatomy is essential. The long-term consequence of this shortage of optimal anatomical knowledge is thought to have implications on patient safety. Summary: Where are we now? Anatomy has been, and is still, severely affected by a content and extent reduction policy in most medical schools. Such suboptimal anatomy education has been linked to an increase in some types of medico-legal claims. This could be due in part to the rapid rise of modern learning approaches, lack of gross anatomy teachers, and lack of structured programs. Which direction are we taking, and where do we need to go? The introduction of surface anatomy at the undergraduate level, the implementation of surgical anatomy courses at the postgraduate level, and the revival of dissection courses at both levels could be measures that change the direction of the actual status. How do we get there? (a) The implementation of a national anatomy core curriculum by local medical education societies with a requirement stating the provision of a clinically oriented surface anatomy course. (b) Making room for the time-tested dissection method to be taught in gross anatomy at both levels. (c) The development of explicit and formal teaching in surgical anatomy via postgraduate courses for the concerned specialties. (d) An evaluation of the 3D visualization technology and surgical simulation applied to anatomy teaching. Conclusions: The current suboptimal anatomy knowledge should be acknowledged, and ways to change the course should be searched for. I present my views for possible and practical solutions by introducing surface anatomy at an undergraduate level, implementing surgical anatomy courses at a postgraduate level, and returning to the dissection room at both levels.
Correspondence may be sent to Kaissar Yammine, The Foot & Hand Clinic and the Center for Evidence-Based Sport and Orthopedic Research, Emirates Hospital, Jumeirah Beach Road, Dubai 73663, UAE. E-mail: [email protected]
medical education, gross anatomy, basic science
Gross anatomy hours in the United States are now much reduced, and a similar tendency is evident in Great Britain and Canada; but an anatomist who has an unbiased view of the whole curriculum, and who realizes how little of real value was achieved by many of the thousand hours courses, will take the reduced time not as a matter for regret but as a challenge to make the best use of it. —Professor Donald Mainland (1938, pp. 289–90)1
INTRODUCTION The most important goal of medical education is, and should be, to produce excellent physicians. In its initial and newest iteration, the UK General Medical Council (GMC) report Tomorrow’s Doctors2,3 pointed out to that, to some extent, the quality of medical education that students receive would determine the quality of care the public receives. It also recommended that all medical schools in the United Kingdom should be appraised against GMC’s quality assurance recommendations for the undergraduate medical education (UGME). When comparing different modern curricula, the GMC’s commission conclusions in 2008 on the “preparedness” for practice of graduates found little difference between three major medical schools using different curricula.4 Basic medical education are prescribed under statutory frameworks securing and assuring academic standards; all preregistration medical programs in the United Kingdom are required to adhere to subject benchmark statements published by the Quality Assurance Agency for Higher Education.5 However, the evidence for achievement is missing yielding little information about the value denoted by the award.6 Gross anatomy is no longer considered a science, as it is no longer considered a research-led discipline. Looking to the current status of anatomical teaching, there is worldwide unanimity regarding the steady decline in the provision of contact hours of this basic science in a crowded undergraduate curriculum. More, the recent introduction of new approaches of learning, such as problem-based learning (PBL) and integrated learning,
184
CURRENT STATUS OF ANATOMY KNOWLEDGE
Downloaded by [Selcuk Universitesi] at 06:59 27 December 2014
is thought to further contributing to the devolution of anatomic curricula. The long-term consequence of this shortage in optimal anatomical knowledge is thought to have implications on patient safety. In addition, it is argued that the rise of minimal invasive approaches in modern surgery could have an impact on the actual surgical anatomy knowledge. Reviving the dissection room, introducing surface anatomy at the undergraduate level, having new 3D visualization and simulation technologies, and developing new surgical anatomy courses at the postgraduate level, particularly in specialties where mastering clinical anatomy is fundamental, such as surgery and radiology, could be valuable ways to address the inadequate knowledge of medical students in this field as expressed by clinicians.
WHERE ARE WE NOW? There is an increasing amount of evidence demonstrating that anatomy teaching is considered substandard by students, teachers, junior doctors, and experienced clinicians.7–11 As the body of knowledge of medical sciences is gaining ground, growing concerns are expressed about the volume of knowledge in medical curricula and the “increase in factual overload”12 due essentially to molecular biology and genetics. Another commonly given “rationale” behind this policy was that learners should be content driven and not skills based.13 It is estimated that there has been an 80% reduction in anatomy teaching hours since the introduction of problem-based medical graduate programs in Australasia.14 in addition, significant reductions in gross anatomy laboratory hours were reported from the United States.15 In 2007, the Education Committee of the Anatomical Society of Great Britain and Ireland, in a response to the effects that reductions in anatomy teaching within the undergraduate curriculum were having upon the medical profession, reached a consensus in defining a core undergraduate syllabus in anatomy in order to “attempt to establish a necessary minimum of anatomical knowledge for all future newly-qualified medical practitioners.”16 Although this action is to be highly praised, this national curriculum has not been subject to evaluation. During the last years, it has been a popular practice to reduce the number of contact hours of some basic sciences courses in the first medical years while incorporating them with clinical sciences as with PBL and the integrated curricula. Consequently, anatomy had been, and is still, severely affected by a content and extent reduction policy. The actual status of anatomical knowledge after graduation might be in part due to “the rapid rise of integrated curricula and approaches . . . [which] have given rise to concern about the level of knowledge attained by students graduating from innovative programmes . . . for anatomy in particular” (p. 20).17 Cahill et al. argued that PBL was providing home for “(funded) anatomically untrained scientists who could ‘teach’ the anatomical components of the PBL exercises instead of competent anatomists.”18 More, and according to Levine
185
et al.,19 computers are being used to “keep students busy” in the dissection laboratory by performing self-directed PBL. On the other hand, dissection and prosection are slipping into history, and some medical schools removed cadaveric dissection from their program. In the late 1990s, a survey showed that less than one third of residency program directors indicated that new residents were adequately prepared in anatomy.20 Findings from a more recent study showed that specialist trainees, in particular those pursuing surgical or radiological careers, will require more detailed knowledge of anatomy at a later stage in their training.21 Such suboptimal anatomy education has been linked to an increase in some types of medico-legal claims, and many of these were related to “damage to underlying structures” and viewed as a threat to patient safety.22,23
WHICH DIRECTION ARE WE TAKING AND WHERE DO WE NEED TO GO? Anatomy is a sequential subject in which knowledge acquired is subsequently elaborated upon. An inadequate knowledge of the structure can affect the future understanding of the function, the dysfunction, and eventually the knowledge and skills of the therapeutic modalities. I believe that some elements of the anatomy curriculum need to be emphasized, maintained, or created in order to empower our students with sufficient knowledge to provide the best quality of care and to avoid many preventable complications. At the undergraduate level, major emphasis should be placed on clinically oriented anatomy syllabus. For instance, teaching surface anatomy doesn’t constitute a component in the majority of current medical curricula.24,25 As stated by Standring, surface anatomy “was born out of the clinical need to visualize the internal landscape of the body from the outside by looking, listening, and palpating.”26 Surface anatomy is directly relevant to undertake accurate physical examinations and safe interventional procedures. An interesting recent study conducted by Roche et al. found that the knowledge of basic foot and ankle surface anatomy overall by junior Orthopaedic and Emergency clinicians was very poor.27 They concluded that clinicians “have neglected the basic art of physical examination based on a sound knowledge of human anatomy” and that “the anatomical teaching that should begin in undergraduate medicine is inadequate” (p. 138). In fact, the vast majority of the anatomy that general physicians use may be surface anatomy.28 Being able to locate structures under the skin is essential and relevant to medical students where it links lab and clinic,29–31 and to specialist doctors such as anaesthesiologists.32 Surgery residents, graduated surgeons, and interventional radiologists need accurate knowledge of skin landmarks; most of the procedures nowadays are performed percutaneous, by endoscopy or through minimally invasive incisions. More, surface and living anatomy could be taught appropriately by clinicians rather than scientists.
186
K. YAMMINE
Similarly, I believe, as do many academic clinicians, that dissection is a vital method and should be the mainframe of surgical anatomy teaching, particularly at the postgraduate level. Beahrs addressed the deficiencies in American anatomic education by noting that it was causing surgical residents to struggle with anatomy while performing surgery, and he stated:
Downloaded by [Selcuk Universitesi] at 06:59 27 December 2014
Anatomy must be learned first by dissecting cadavers. Lack of anatomic knowledge too often leads to disaster. To learn basic anatomic information by trial and error at the expense of a patient undergoing an elective or emergency operation is morally wrong. (p. 311)33
Dissection sessions could be the solution; getting familiar with the internal structure of the body and viewing the organs and their relations to one another in a real 3D environment doesn’t need, in our opinion, evidence to prove its efficacy. Reports from undergraduate education about emotional disturbances that might be caused by dissection,34–39 possible desensitisation with death,34,40 and the assumption that the appearance of a cadaver has little clinical relevance41,42 are, to my opinion, not convincing arguments against this method. On the other hand, prosection, rather than active dissection, is adopted in many anatomy departments nowadays, and is considered a better teaching method. It seems that observing dissection is considered enough due to the good results obtained in anatomy examinations;43–45 so is the case with the different methods used to teach anatomy. Acquiring and retaining anatomical knowledge to improve the outcomes of students’ examination results are not the only student benefits from a dissection session, and neither are the acquired clinical skills outcomes. How examining and palpating a gallbladder could not add to the personal experience of a student? Such experience could not be measured, and usual tests’ results should not be the ultimate goal of teaching. The value of touching or harvesting an organ transcends any test but can remain as a profound lived experience. If medical students are not given the opportunity to perform active dissection by their own hands, who else will? If gross anatomy is not a subject for research and does not contribute to universities’ ranking, shall we reduce it to an arbitrary dangerous minimum? Furthermore, and at the postgraduate level, I argue that there may be a downside to the rise of modern minimal invasive surgeries; during their postgraduate education surgery residents are no longer exposed to the same amount of “open” procedures. From personal experience and the experience of my colleagues, unlike the graduates of the old generation of surgeons, actual junior surgeons are found not to be at ease when performing surgeries requiring extensive surgical dissection. Here again, repetitive cadaveric dissection of rare surgical approaches during residency could be an effective solution. HOW DO WE GET THERE? To address this deficiency in anatomical teaching, I believe that some actions could be undertaken at both under and postgraduate levels.
First, local medical education societies need to implement a national anatomy core curriculum that provides minimum requirements for accurate physical examination and imaging interpretation, and for conducting safe basic procedures at undergraduate level. One of the requirements could be the development of surface/living anatomy courses in early curricula; such courses could be integrated in all types of programs, including PBL, for they have the potential to be interactive, clinically oriented, and patient centered. Emphasis on skin landmarks should be practiced during clinical rotations, and the interpretation of the medical imaging results should be linked to the findings of the physical examination with the help of involved academic clinicians, and not only scientists, in teaching anatomy. Second, there should be room for the historically proven traditional methods such as dissection in what is left of anatomy at both levels. Accomplishments of great surgeons who have been trained by this sole method abound in the history of medicine. Indeed, dissection is subject to many external pressures such as maintaining dissecting rooms in accordance with high but costly standards, the shortage in cadavers, and the shortage of anatomy teachers, but I sincerely believe that such obstacles are surmountable. As argued by Cahill et al.,18 cadavers could be supplied currently by an altruistic donor population. In agreement with Turney,46 I also believe that those traditional methods can meet many of PBL’s purposes in developing reasoning skills, encouraging work-related skills and learning in a relevant context. A third action could be the development of postgraduate courses in anatomy to address the inadequate anatomical knowledge after graduation. Where some specialities require a thorough knowledge of anatomy, such courses will ensure that early postgraduate training programs include explicit and formal teaching in anatomy.47 I believe that surgical anatomy teaching could be best approached, at the beginning of a surgical residency, through cadaveric dissection under the supervision of senior surgeons rather than solely learned at the operation theatre. The Core Surgical Anatomy course run by the Royal College of Surgeons of England and the Royal Australasian College of Surgeons’ approved postgraduate Diploma in Surgical Anatomy48 of the Otago School of Medicine could be excellent examples to follow. Such qualifications will need resources to be properly elaborated; this could be achieved by expanding the pool of anatomists equipped to teach anatomy to postgraduate students,49,50 and by promoting the reinstatement of anatomy demonstrating posts.51,52 A fourth step could be the evaluation of the 3D visualisation technology and surgical simulation applied to anatomy teaching. Although spatial perception is demonstrated to be difficult for some learners, such method could be the closest to reality in visualizing anatomical structures when compared to noncadaveric methods.53,54 I think that such technologies should be further explored, for it could be a valuable supplement wherever severe shortage in teaching gross anatomy exists.55–63 In addition, some authors reported promising results
Downloaded by [Selcuk Universitesi] at 06:59 27 December 2014
CURRENT STATUS OF ANATOMY KNOWLEDGE
using e-learning and computer-aided methods applied to anatomy teaching.64–67 One of the actual challenges in anatomy teaching is in integrating traditional and modern methods in a modern curriculum rather than proving the superiority of one over the other or simply discarding the “old” ones. Such challenge could be facilitated through communication between clinicians, academics, and students by bringing alignment to their perspectives.17 In conclusion, one of the difficult problems that medical education is facing is the ability to evaluating teaching methods in relation to the final end-product, the quality of care delivered by medical graduates and specialist doctors. Indeed, evidence is lacking in anatomy teaching at both levels, but we already have one time-tested method, and that is dissection. It is possible that short- and long-term retained knowledge is not proven with dissection, but knowledge is only a step to the process of synthesis. In addition, the introduction of surface anatomy at the undergraduate level and the implementation of postgraduate courses in surgical anatomy could be effective methods in raising anatomy knowledge acquisition and clinically relevant understanding for a safer practice. REFERENCES 1. Mainland D. Anatomy in medical education. Nova Scotia Medical Bulletin; May 1938. 2. The Commonwealth Fund Task Force on Academic Health Centers. Training tomorrow’s doctors: The medical education mission of academic health centers. New York, NY: The Commonwealth Fund, 2002. Available at: http://www.commonwealthfund.org/. Accessed July 5, 2012. 3. General Medical Council (UK). Tomorrow’s doctors: Outcomes and standards for under-graduate medical education. London, UK: General Medical Council, 2009. Available at: http://www.gmc-uk.org/publications/ medical education publications.asp#1. Accessed July 5, 2012. 4. General Medical Council (UK). Undergraduate medical education: Reports from schools and publications. London, UK: General Medical Council, 2009. Available at: http://www.gmc-uk.org/education/undergraduate. Accessed June 2, 2012. 5. Quality Assurance Agency for higher Education. Subject Benchmark statements –medicine. 2002. Available at: http://www.qaa.ac.uk/Publications/ InformationAndGuidance/Documents/medicine.pdf. Accessed July 5, 2012. 6. Cholerton S, Jordan R. Core curriculum and student-selected components. In J Dent & R Harden (Eds.), A practical guide for medical teachers (pp. 193–4). London: Churchill Livingstone, 2009. 7. Smith JA. Can anatomy teaching make a come back? ANZ Journal of Surgery 2005;75:93. 8. Waterston SW, Stewart IJ. Survey of clinicians’ attitudes to the anatomical teaching and knowledge of medical students. Clinical Anatomy 2005;18:380–4. 9. Tibrewal S. The anatomy knowledge of surgical trainees: The trainer’sview. Annals of the Royal College of Surgeons of England 2006;88:S240–2. 10. Fitzgerald JE, White MJ, Tang SW, Maxwell-Armstrong CA, James DK. Are we teaching sufficient anatomy at medical school? The opinions of newly qualified doctors. Clinical Anatomy 2008;21:718–24. 11. Bhangu A, Boutefnouchet T, Yong X, Abrahams P, Joplin R. A threeyear prospective longitudinal cohort study of medical students’ attitudes toward anatomy teaching and their career aspirations. Anatomical Sciences Education 2010;3:184–90.
187
12. General Medical Council (UK). Tomorrow’s doctors: Recommendations on undergraduate medical education. London, UK: General Medical Council, 2003. Available at: http://www.gmc-uk.org/education/undergraduate. Accessed July 5, 2012. 13. Patel KM, Moxham BJ. Attitudes of professional anatomists to curricular change. Clinical Anatomy 2006;19:132–41. 14. Craig S, Tait N, Boers D, McAndrew D. Review of anatomy education in Australian and New Zealand medical schools. ANZ Journal of Surgery 2010;80:212–6. 15. Drake RL, McBride JM, Lachman N, Pawlina W. Medical education in the anatomical sciences: The winds of change continue to blow, Volume 2. Anatomical Sciences Education 2009:253–259. 16. McHanwell et al. (The Education Committee of the Anatomical Society of Great Britain and Ireland). A core syllabus in anatomyfor medical students - Adding commonsense to need to know. European Journal of Anatomy 2007;11(Suppl. 1):3–18. 17. Inuwa I, Taranikanti V, Al-Rawahy M, Roychoudhry S, Habbal O. “Between a rock and a hard place”: The discordant views among medical teachers about anatomy content in the undergraduate medical curriculum. Sultan Qaboos University Medical Journal 2012;12:19–24. 18. Cahill DR, Leonard RJ, Marks SC Jr. A comment on recent teaching of human anatomy in the United States. Surgical and Radiologic Anatomy 2000;22:69–71. 19. Levine MG, Stempak J, Conyers G, Walters J. Implementing and integrating computer-based activities into a problem-based gross anatomy curriculum. Clinical Anatomy 1999;12:191–212. 20. Cottam WW. Adequacy of medical school gross anatomy education as perceived by certain postgraduate residency programs and anatomy course directors. Clinical Anatomy 1999;12:55–65. 21. Dyball R. members of the Education Committee of the Anatomical Society and others. Setting a benchmark for anatomical knowledge and its assessment (A core curriculum for the teaching of anatomy to medical students), 2003. Available at: http://www.anatsoc.org.uk/linkfiles/anat-corecurric.htm. Accessed June 12, 2012. 22. Ellis H. Medico-legal litigation and its links with surgical anatomy. Surgery 2002;20:i–ii. 23. Regenbogen SE, Greenberg CC, Studdert DM, Lipsitz SR, Zinner MJ, Gawande AA. Patterns of technical error among surgical malpractice claims: An analysis of strategies to prevent injury to surgical patients. Annals of Surgery 2007;246:705–11. 24. Heylings D. Anatomy 1999–2000: The curriculum, who teaches it and how? Medical Education 2002;36:702–10. 25. Drake RL, Lowrie DJ Jr, Prewitt CM. Survey of gross anatomy, microscopic anatomy, neuroscience, and embryology courses in medical school curricula inthe United States. The Anatomical Record 2002;269:118–22. 26. Standring S. Evidence-based surface anatomy. Clinical Anatomy 2012;25:813–5. 27. Roche A, Hunter L, Pocock N, Brown D. Physical examination of the foot and ankle by orthopaedic and accident and emergency clinicians. Injury 2009;40:136–8. 28. Kotze SH, Mole CG, Greyling LM. The translucent cadaver: An evaluation of the use of full body digital X-ray images and drawings in surface anatomy education. Anatomical Sciences Education 2012;5:287–94. 29. Boon JM, Meiring JH, Richards PA. Clinical anatomy as the basis for clinical examination: Development and evaluation of an introduction to clinical examination in a problem-oriented medical curriculum. Clinical Anatomy 2002;15:45–50. 30. Aggarwal R, Brough H, Ellis H. Medical student participation in surface anatomy classes. Clinical Anatomy 2006;19:627–31. 31. Ganguly PK, Chan LK. Living anatomy in the 21st century: How far can we go? SE Asian Journal of Medical Education 2008;57:52–7. 32. Marhofer P, Willschke H, Kettner S. Current concepts andfuture trends in ultrasound-guided regional anesthesia. Current Opinion in Anaesthesiology 2010;23:632–6.
Downloaded by [Selcuk Universitesi] at 06:59 27 December 2014
188
K. YAMMINE
33. Beahrs OH. Gross anatomy in medicine. Clinical Anatomy 1991;4: 310–2. 34. Marks SC Jr, Bertman SL. Experiences with learning about death and dying in the undergraduate anatomy curriculum. Journal of Medical Education 1980;55:48–52. 35. Finkelstein P, Mathers LH. Post-traumatic stress among medical students in the anatomy dissection laboratory. Clinical Anatomy 1990;3:219–26. 36. Druce M, Johnson MH. Human dissection and attitudes of pre-clinical students to death and bereavement. Clinical Anatomy 1994;7:42–9. 37. Nnodim JO. Pre-clinical student reactions to dissection, death, and dying. Clinical Anatomy 1996;9:175–82. 38. Dinsmore CE, Daugherty S, Zeitz HJ. Teaching and learning gross anatomy: Dissection, prosection or both of the above? Clinical Anatomy 1999;12:110–4. 39. Snelling J, Sahai A, Ellis H. Attitudes of medical and dental students to dissection. Clinical Anatomy 2003;16:165–72. 40. Marks SC, Bertman SL, Penney JC. Human anatomy: A foundation for education about death and dying inmedicine. Clinical Anatomy 1997;10:118–22. 41. Spitzer VM, Whitlock DG. The visible human data set: The anatomical platform for human simulation. The Anatomical Record 1998;253: 49–57. 42. McLachlan JC. New path for teaching anatomy: Living anatomy and medical imaging versus dissection. The Anatomical Record 2004;281(B1): 4–5. 43. Miller SA, Perrotti W, Silverthorn DU, Dalley AF, Rarey KE. From college to clinic: Reasoning over memorization is key for understanding anatomy. The Anatomical Record 2002;269:69–80. 44. Nodim JO. A controlled trial of peer-teaching in practical gross anatomy. Clinical Anatomy 1997;10:112–7. 45. Yeager VL. Learning gross anatomy: Dissection and prosection. Clinical Anatomy 1996;9:57–9. 46. Turney B. Anatomy in a modern medical curriculum. Annals of the Royal College of Surgeons of England 2007;89:104–7. 47. Standring S. New focus on anatomy for surgical trainees. ANZ Journal of Surgery 2009;79:114–7. 48. Stringer MD, Lyall P. Design, implementation, and evaluation of a postgraduate Diploma in Surgical Anatomy. Anatomical Sciences Education 2012;5:48–54. 49. Rizzolo LJ, Drake RL. Anatomists debate the value of a teaching credential. Anatomical Sciences Education 2008;1:60–67. 50. Fraher JP, Evans DJ. Training tomorrow’s anatomists today: A partnership approach. Anatomical Sciences Education 2009;2:119–125. 51. Rainsbury D, Barbour A, Mahadevan V. College launches National Anatomy Project. Annals of the Royal College of Surgeons of England 2007;89:S19. 52. Standring S, Larvin M. 2011. Anatomy teaching: The cruellest cut—A progress report. Annals of the Royal College of Surgeons of England 2011;93:S16–S18.
53. Garg A, Norman GR, Spero L, Maheshwari P. Do virtual computer models hinder anatomy learning? Academic Medicine 1999;74(10 Suppl.): S87–9. 54. Nguyen N, Nelson AJ, Wilson TD. Computer visualizations: Factors that influence spatial anatomy comprehension. Anatomical Sciences Education 2012;5:98–108. 55. Nicholson DT, Chalk C, Funnell WR, Daniel SJ. Can virtual reality improve anatomy education? A randomised controlled study of a computergenerated three-dimensional anatomical ear model. Medical Education 2006;40:1081–7. 56. Keedy AW, Durack JC, Sandhu P, Chen EM, O’Sullivan PS, Breiman RS. Comparison of traditional methods with 3D computer models in the instruction of hepatobiliary anatomy. Anatomical Sciences Education 2011;4:84–91. 57. Tam MD, Hart AR, Williams SM, Holland R, Heylings D, Leinster S. Evaluation of a computer program (“disect”) to consolidate anatomy knowledge: a randomised-controlled trial. Medical Teacher 2010;32: e138–42. 58. Ruisoto P, Juanes JA, Contador I, Mayoral P, Prats-Galino A. Experimental evidence for improved neuroimaging interpretation using three-dimensional graphic models. Anatomical Sciences Education 2012;5:132–7. 59. Moss K. Learner retention of anatomical information presented in a digital two-dimensional format versus a digital three-dimensional format. Journal of Biocommunication 2001;28(3):4–10. 60. Fritz D, Hu A, Wilson T, Ladak H, Haase P, Fung K. Long-term retention of a 3-dimensional educational computer model of the larynx: A follow-up study. Archives of Otolaryngology Head and Neck Surgery 2011;137(6):598–603. 61. Codd AM, Choudhury B. Virtual reality anatomy: Is it comparable with traditional methods in the teaching of human forearm musculoskeletal anatomy? Anatomical Sciences Education 2011;4:119–25. 62. Levinson AJ, Weaver B, Garside S, McGinn H, Norman GR. Virtual reality and brain anatomy: A randomised trial of e-learning instructional designs. Medical Education 2007;41(5):495–501. 63. Petersson H, Sinkvist D, Wang C, Smedby O. Web-based interactive 3D visualization as a tool for improved anatomy learning. Anatomical Sciences Education 2009;2:61–8. 64. Choudhury B, Gouldsborough I. The use of electronic media to develop transferable skills in science students studying anatomy. Anatomical Sciences Education 2012;5:125–31. 65. Choudhury B, Gouldsborough I, Gabriel S. Use of interactive sessions and e-learning in teaching anatomy to first-year optometry students. Anatomical Sciences Education 2010;3:39–45. 66. Svirko E, Mellanby J. Attitudes to e-learning, learning style and achievement in learning neuroanatomy by medical students. Medical Teacher 2008;30:e219–27. 67. Tam MD, Hart AR, Williams S, Heylings D, Leinster S. Is learning anatomy facilitated by computer-aided learning? A review of the literature. Medical Teacher 2009;31:e393–6.
Teaching and Learning in Medicine: An International Journal Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/htlm20
The Current Status of Anatomy Knowledge: Where Are We Now? Where Do We Need to Go and How Do We Get There? Kaissar Yammine
a
a
The Foot & Hand Clinic and the Center for Evidence-Based Sport and Orthopedic Research , Emirates Hospital , Dubai , United Arab Emirates Published online: 04 Apr 2014.
Click for updates To cite this article: Kaissar Yammine (2014) The Current Status of Anatomy Knowledge: Where Are We Now? Where Do We Need to Go and How Do We Get There?, Teaching and Learning in Medicine: An International Journal, 26:2, 184-188, DOI: 10.1080/10401334.2014.883985 To link to this article: http://dx.doi.org/10.1080/10401334.2014.883985
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
Teaching and Learning in Medicine, 26(2), 184–188 C 2014, Taylor & Francis Group, LLC Copyright ISSN: 1040-1334 print / 1532-8015 online DOI: 10.1080/10401334.2014.883985
LITERATURE REVIEWS The Current Status of Anatomy Knowledge: Where Are We Now? Where Do We Need to Go and How Do We Get There? Kaissar Yammine
Downloaded by [Selcuk Universitesi] at 06:59 27 December 2014
The Foot & Hand Clinic and the Center for Evidence-Based Sport and Orthopedic Research, Emirates Hospital, Dubai, United Arab Emirates
Keywords Background: Gross anatomy is no longer considered a science, as it is no longer considered a research-led discipline. Looking to the current status of anatomical teaching, there is worldwide unanimity regarding the steady decline in the provision of contact hours of this basic science in a crowded undergraduate curriculum. The same could apply at the postgraduate level for specialties where surgical anatomy is essential. The long-term consequence of this shortage of optimal anatomical knowledge is thought to have implications on patient safety. Summary: Where are we now? Anatomy has been, and is still, severely affected by a content and extent reduction policy in most medical schools. Such suboptimal anatomy education has been linked to an increase in some types of medico-legal claims. This could be due in part to the rapid rise of modern learning approaches, lack of gross anatomy teachers, and lack of structured programs. Which direction are we taking, and where do we need to go? The introduction of surface anatomy at the undergraduate level, the implementation of surgical anatomy courses at the postgraduate level, and the revival of dissection courses at both levels could be measures that change the direction of the actual status. How do we get there? (a) The implementation of a national anatomy core curriculum by local medical education societies with a requirement stating the provision of a clinically oriented surface anatomy course. (b) Making room for the time-tested dissection method to be taught in gross anatomy at both levels. (c) The development of explicit and formal teaching in surgical anatomy via postgraduate courses for the concerned specialties. (d) An evaluation of the 3D visualization technology and surgical simulation applied to anatomy teaching. Conclusions: The current suboptimal anatomy knowledge should be acknowledged, and ways to change the course should be searched for. I present my views for possible and practical solutions by introducing surface anatomy at an undergraduate level, implementing surgical anatomy courses at a postgraduate level, and returning to the dissection room at both levels.
Correspondence may be sent to Kaissar Yammine, The Foot & Hand Clinic and the Center for Evidence-Based Sport and Orthopedic Research, Emirates Hospital, Jumeirah Beach Road, Dubai 73663, UAE. E-mail: [email protected]
medical education, gross anatomy, basic science
Gross anatomy hours in the United States are now much reduced, and a similar tendency is evident in Great Britain and Canada; but an anatomist who has an unbiased view of the whole curriculum, and who realizes how little of real value was achieved by many of the thousand hours courses, will take the reduced time not as a matter for regret but as a challenge to make the best use of it. —Professor Donald Mainland (1938, pp. 289–90)1
INTRODUCTION The most important goal of medical education is, and should be, to produce excellent physicians. In its initial and newest iteration, the UK General Medical Council (GMC) report Tomorrow’s Doctors2,3 pointed out to that, to some extent, the quality of medical education that students receive would determine the quality of care the public receives. It also recommended that all medical schools in the United Kingdom should be appraised against GMC’s quality assurance recommendations for the undergraduate medical education (UGME). When comparing different modern curricula, the GMC’s commission conclusions in 2008 on the “preparedness” for practice of graduates found little difference between three major medical schools using different curricula.4 Basic medical education are prescribed under statutory frameworks securing and assuring academic standards; all preregistration medical programs in the United Kingdom are required to adhere to subject benchmark statements published by the Quality Assurance Agency for Higher Education.5 However, the evidence for achievement is missing yielding little information about the value denoted by the award.6 Gross anatomy is no longer considered a science, as it is no longer considered a research-led discipline. Looking to the current status of anatomical teaching, there is worldwide unanimity regarding the steady decline in the provision of contact hours of this basic science in a crowded undergraduate curriculum. More, the recent introduction of new approaches of learning, such as problem-based learning (PBL) and integrated learning,
184
CURRENT STATUS OF ANATOMY KNOWLEDGE
Downloaded by [Selcuk Universitesi] at 06:59 27 December 2014
is thought to further contributing to the devolution of anatomic curricula. The long-term consequence of this shortage in optimal anatomical knowledge is thought to have implications on patient safety. In addition, it is argued that the rise of minimal invasive approaches in modern surgery could have an impact on the actual surgical anatomy knowledge. Reviving the dissection room, introducing surface anatomy at the undergraduate level, having new 3D visualization and simulation technologies, and developing new surgical anatomy courses at the postgraduate level, particularly in specialties where mastering clinical anatomy is fundamental, such as surgery and radiology, could be valuable ways to address the inadequate knowledge of medical students in this field as expressed by clinicians.
WHERE ARE WE NOW? There is an increasing amount of evidence demonstrating that anatomy teaching is considered substandard by students, teachers, junior doctors, and experienced clinicians.7–11 As the body of knowledge of medical sciences is gaining ground, growing concerns are expressed about the volume of knowledge in medical curricula and the “increase in factual overload”12 due essentially to molecular biology and genetics. Another commonly given “rationale” behind this policy was that learners should be content driven and not skills based.13 It is estimated that there has been an 80% reduction in anatomy teaching hours since the introduction of problem-based medical graduate programs in Australasia.14 in addition, significant reductions in gross anatomy laboratory hours were reported from the United States.15 In 2007, the Education Committee of the Anatomical Society of Great Britain and Ireland, in a response to the effects that reductions in anatomy teaching within the undergraduate curriculum were having upon the medical profession, reached a consensus in defining a core undergraduate syllabus in anatomy in order to “attempt to establish a necessary minimum of anatomical knowledge for all future newly-qualified medical practitioners.”16 Although this action is to be highly praised, this national curriculum has not been subject to evaluation. During the last years, it has been a popular practice to reduce the number of contact hours of some basic sciences courses in the first medical years while incorporating them with clinical sciences as with PBL and the integrated curricula. Consequently, anatomy had been, and is still, severely affected by a content and extent reduction policy. The actual status of anatomical knowledge after graduation might be in part due to “the rapid rise of integrated curricula and approaches . . . [which] have given rise to concern about the level of knowledge attained by students graduating from innovative programmes . . . for anatomy in particular” (p. 20).17 Cahill et al. argued that PBL was providing home for “(funded) anatomically untrained scientists who could ‘teach’ the anatomical components of the PBL exercises instead of competent anatomists.”18 More, and according to Levine
185
et al.,19 computers are being used to “keep students busy” in the dissection laboratory by performing self-directed PBL. On the other hand, dissection and prosection are slipping into history, and some medical schools removed cadaveric dissection from their program. In the late 1990s, a survey showed that less than one third of residency program directors indicated that new residents were adequately prepared in anatomy.20 Findings from a more recent study showed that specialist trainees, in particular those pursuing surgical or radiological careers, will require more detailed knowledge of anatomy at a later stage in their training.21 Such suboptimal anatomy education has been linked to an increase in some types of medico-legal claims, and many of these were related to “damage to underlying structures” and viewed as a threat to patient safety.22,23
WHICH DIRECTION ARE WE TAKING AND WHERE DO WE NEED TO GO? Anatomy is a sequential subject in which knowledge acquired is subsequently elaborated upon. An inadequate knowledge of the structure can affect the future understanding of the function, the dysfunction, and eventually the knowledge and skills of the therapeutic modalities. I believe that some elements of the anatomy curriculum need to be emphasized, maintained, or created in order to empower our students with sufficient knowledge to provide the best quality of care and to avoid many preventable complications. At the undergraduate level, major emphasis should be placed on clinically oriented anatomy syllabus. For instance, teaching surface anatomy doesn’t constitute a component in the majority of current medical curricula.24,25 As stated by Standring, surface anatomy “was born out of the clinical need to visualize the internal landscape of the body from the outside by looking, listening, and palpating.”26 Surface anatomy is directly relevant to undertake accurate physical examinations and safe interventional procedures. An interesting recent study conducted by Roche et al. found that the knowledge of basic foot and ankle surface anatomy overall by junior Orthopaedic and Emergency clinicians was very poor.27 They concluded that clinicians “have neglected the basic art of physical examination based on a sound knowledge of human anatomy” and that “the anatomical teaching that should begin in undergraduate medicine is inadequate” (p. 138). In fact, the vast majority of the anatomy that general physicians use may be surface anatomy.28 Being able to locate structures under the skin is essential and relevant to medical students where it links lab and clinic,29–31 and to specialist doctors such as anaesthesiologists.32 Surgery residents, graduated surgeons, and interventional radiologists need accurate knowledge of skin landmarks; most of the procedures nowadays are performed percutaneous, by endoscopy or through minimally invasive incisions. More, surface and living anatomy could be taught appropriately by clinicians rather than scientists.
186
K. YAMMINE
Similarly, I believe, as do many academic clinicians, that dissection is a vital method and should be the mainframe of surgical anatomy teaching, particularly at the postgraduate level. Beahrs addressed the deficiencies in American anatomic education by noting that it was causing surgical residents to struggle with anatomy while performing surgery, and he stated:
Downloaded by [Selcuk Universitesi] at 06:59 27 December 2014
Anatomy must be learned first by dissecting cadavers. Lack of anatomic knowledge too often leads to disaster. To learn basic anatomic information by trial and error at the expense of a patient undergoing an elective or emergency operation is morally wrong. (p. 311)33
Dissection sessions could be the solution; getting familiar with the internal structure of the body and viewing the organs and their relations to one another in a real 3D environment doesn’t need, in our opinion, evidence to prove its efficacy. Reports from undergraduate education about emotional disturbances that might be caused by dissection,34–39 possible desensitisation with death,34,40 and the assumption that the appearance of a cadaver has little clinical relevance41,42 are, to my opinion, not convincing arguments against this method. On the other hand, prosection, rather than active dissection, is adopted in many anatomy departments nowadays, and is considered a better teaching method. It seems that observing dissection is considered enough due to the good results obtained in anatomy examinations;43–45 so is the case with the different methods used to teach anatomy. Acquiring and retaining anatomical knowledge to improve the outcomes of students’ examination results are not the only student benefits from a dissection session, and neither are the acquired clinical skills outcomes. How examining and palpating a gallbladder could not add to the personal experience of a student? Such experience could not be measured, and usual tests’ results should not be the ultimate goal of teaching. The value of touching or harvesting an organ transcends any test but can remain as a profound lived experience. If medical students are not given the opportunity to perform active dissection by their own hands, who else will? If gross anatomy is not a subject for research and does not contribute to universities’ ranking, shall we reduce it to an arbitrary dangerous minimum? Furthermore, and at the postgraduate level, I argue that there may be a downside to the rise of modern minimal invasive surgeries; during their postgraduate education surgery residents are no longer exposed to the same amount of “open” procedures. From personal experience and the experience of my colleagues, unlike the graduates of the old generation of surgeons, actual junior surgeons are found not to be at ease when performing surgeries requiring extensive surgical dissection. Here again, repetitive cadaveric dissection of rare surgical approaches during residency could be an effective solution. HOW DO WE GET THERE? To address this deficiency in anatomical teaching, I believe that some actions could be undertaken at both under and postgraduate levels.
First, local medical education societies need to implement a national anatomy core curriculum that provides minimum requirements for accurate physical examination and imaging interpretation, and for conducting safe basic procedures at undergraduate level. One of the requirements could be the development of surface/living anatomy courses in early curricula; such courses could be integrated in all types of programs, including PBL, for they have the potential to be interactive, clinically oriented, and patient centered. Emphasis on skin landmarks should be practiced during clinical rotations, and the interpretation of the medical imaging results should be linked to the findings of the physical examination with the help of involved academic clinicians, and not only scientists, in teaching anatomy. Second, there should be room for the historically proven traditional methods such as dissection in what is left of anatomy at both levels. Accomplishments of great surgeons who have been trained by this sole method abound in the history of medicine. Indeed, dissection is subject to many external pressures such as maintaining dissecting rooms in accordance with high but costly standards, the shortage in cadavers, and the shortage of anatomy teachers, but I sincerely believe that such obstacles are surmountable. As argued by Cahill et al.,18 cadavers could be supplied currently by an altruistic donor population. In agreement with Turney,46 I also believe that those traditional methods can meet many of PBL’s purposes in developing reasoning skills, encouraging work-related skills and learning in a relevant context. A third action could be the development of postgraduate courses in anatomy to address the inadequate anatomical knowledge after graduation. Where some specialities require a thorough knowledge of anatomy, such courses will ensure that early postgraduate training programs include explicit and formal teaching in anatomy.47 I believe that surgical anatomy teaching could be best approached, at the beginning of a surgical residency, through cadaveric dissection under the supervision of senior surgeons rather than solely learned at the operation theatre. The Core Surgical Anatomy course run by the Royal College of Surgeons of England and the Royal Australasian College of Surgeons’ approved postgraduate Diploma in Surgical Anatomy48 of the Otago School of Medicine could be excellent examples to follow. Such qualifications will need resources to be properly elaborated; this could be achieved by expanding the pool of anatomists equipped to teach anatomy to postgraduate students,49,50 and by promoting the reinstatement of anatomy demonstrating posts.51,52 A fourth step could be the evaluation of the 3D visualisation technology and surgical simulation applied to anatomy teaching. Although spatial perception is demonstrated to be difficult for some learners, such method could be the closest to reality in visualizing anatomical structures when compared to noncadaveric methods.53,54 I think that such technologies should be further explored, for it could be a valuable supplement wherever severe shortage in teaching gross anatomy exists.55–63 In addition, some authors reported promising results
Downloaded by [Selcuk Universitesi] at 06:59 27 December 2014
CURRENT STATUS OF ANATOMY KNOWLEDGE
using e-learning and computer-aided methods applied to anatomy teaching.64–67 One of the actual challenges in anatomy teaching is in integrating traditional and modern methods in a modern curriculum rather than proving the superiority of one over the other or simply discarding the “old” ones. Such challenge could be facilitated through communication between clinicians, academics, and students by bringing alignment to their perspectives.17 In conclusion, one of the difficult problems that medical education is facing is the ability to evaluating teaching methods in relation to the final end-product, the quality of care delivered by medical graduates and specialist doctors. Indeed, evidence is lacking in anatomy teaching at both levels, but we already have one time-tested method, and that is dissection. It is possible that short- and long-term retained knowledge is not proven with dissection, but knowledge is only a step to the process of synthesis. In addition, the introduction of surface anatomy at the undergraduate level and the implementation of postgraduate courses in surgical anatomy could be effective methods in raising anatomy knowledge acquisition and clinically relevant understanding for a safer practice. REFERENCES 1. Mainland D. Anatomy in medical education. Nova Scotia Medical Bulletin; May 1938. 2. The Commonwealth Fund Task Force on Academic Health Centers. Training tomorrow’s doctors: The medical education mission of academic health centers. New York, NY: The Commonwealth Fund, 2002. Available at: http://www.commonwealthfund.org/. Accessed July 5, 2012. 3. General Medical Council (UK). Tomorrow’s doctors: Outcomes and standards for under-graduate medical education. London, UK: General Medical Council, 2009. Available at: http://www.gmc-uk.org/publications/ medical education publications.asp#1. Accessed July 5, 2012. 4. General Medical Council (UK). Undergraduate medical education: Reports from schools and publications. London, UK: General Medical Council, 2009. Available at: http://www.gmc-uk.org/education/undergraduate. Accessed June 2, 2012. 5. Quality Assurance Agency for higher Education. Subject Benchmark statements –medicine. 2002. Available at: http://www.qaa.ac.uk/Publications/ InformationAndGuidance/Documents/medicine.pdf. Accessed July 5, 2012. 6. Cholerton S, Jordan R. Core curriculum and student-selected components. In J Dent & R Harden (Eds.), A practical guide for medical teachers (pp. 193–4). London: Churchill Livingstone, 2009. 7. Smith JA. Can anatomy teaching make a come back? ANZ Journal of Surgery 2005;75:93. 8. Waterston SW, Stewart IJ. Survey of clinicians’ attitudes to the anatomical teaching and knowledge of medical students. Clinical Anatomy 2005;18:380–4. 9. Tibrewal S. The anatomy knowledge of surgical trainees: The trainer’sview. Annals of the Royal College of Surgeons of England 2006;88:S240–2. 10. Fitzgerald JE, White MJ, Tang SW, Maxwell-Armstrong CA, James DK. Are we teaching sufficient anatomy at medical school? The opinions of newly qualified doctors. Clinical Anatomy 2008;21:718–24. 11. Bhangu A, Boutefnouchet T, Yong X, Abrahams P, Joplin R. A threeyear prospective longitudinal cohort study of medical students’ attitudes toward anatomy teaching and their career aspirations. Anatomical Sciences Education 2010;3:184–90.
187
12. General Medical Council (UK). Tomorrow’s doctors: Recommendations on undergraduate medical education. London, UK: General Medical Council, 2003. Available at: http://www.gmc-uk.org/education/undergraduate. Accessed July 5, 2012. 13. Patel KM, Moxham BJ. Attitudes of professional anatomists to curricular change. Clinical Anatomy 2006;19:132–41. 14. Craig S, Tait N, Boers D, McAndrew D. Review of anatomy education in Australian and New Zealand medical schools. ANZ Journal of Surgery 2010;80:212–6. 15. Drake RL, McBride JM, Lachman N, Pawlina W. Medical education in the anatomical sciences: The winds of change continue to blow, Volume 2. Anatomical Sciences Education 2009:253–259. 16. McHanwell et al. (The Education Committee of the Anatomical Society of Great Britain and Ireland). A core syllabus in anatomyfor medical students - Adding commonsense to need to know. European Journal of Anatomy 2007;11(Suppl. 1):3–18. 17. Inuwa I, Taranikanti V, Al-Rawahy M, Roychoudhry S, Habbal O. “Between a rock and a hard place”: The discordant views among medical teachers about anatomy content in the undergraduate medical curriculum. Sultan Qaboos University Medical Journal 2012;12:19–24. 18. Cahill DR, Leonard RJ, Marks SC Jr. A comment on recent teaching of human anatomy in the United States. Surgical and Radiologic Anatomy 2000;22:69–71. 19. Levine MG, Stempak J, Conyers G, Walters J. Implementing and integrating computer-based activities into a problem-based gross anatomy curriculum. Clinical Anatomy 1999;12:191–212. 20. Cottam WW. Adequacy of medical school gross anatomy education as perceived by certain postgraduate residency programs and anatomy course directors. Clinical Anatomy 1999;12:55–65. 21. Dyball R. members of the Education Committee of the Anatomical Society and others. Setting a benchmark for anatomical knowledge and its assessment (A core curriculum for the teaching of anatomy to medical students), 2003. Available at: http://www.anatsoc.org.uk/linkfiles/anat-corecurric.htm. Accessed June 12, 2012. 22. Ellis H. Medico-legal litigation and its links with surgical anatomy. Surgery 2002;20:i–ii. 23. Regenbogen SE, Greenberg CC, Studdert DM, Lipsitz SR, Zinner MJ, Gawande AA. Patterns of technical error among surgical malpractice claims: An analysis of strategies to prevent injury to surgical patients. Annals of Surgery 2007;246:705–11. 24. Heylings D. Anatomy 1999–2000: The curriculum, who teaches it and how? Medical Education 2002;36:702–10. 25. Drake RL, Lowrie DJ Jr, Prewitt CM. Survey of gross anatomy, microscopic anatomy, neuroscience, and embryology courses in medical school curricula inthe United States. The Anatomical Record 2002;269:118–22. 26. Standring S. Evidence-based surface anatomy. Clinical Anatomy 2012;25:813–5. 27. Roche A, Hunter L, Pocock N, Brown D. Physical examination of the foot and ankle by orthopaedic and accident and emergency clinicians. Injury 2009;40:136–8. 28. Kotze SH, Mole CG, Greyling LM. The translucent cadaver: An evaluation of the use of full body digital X-ray images and drawings in surface anatomy education. Anatomical Sciences Education 2012;5:287–94. 29. Boon JM, Meiring JH, Richards PA. Clinical anatomy as the basis for clinical examination: Development and evaluation of an introduction to clinical examination in a problem-oriented medical curriculum. Clinical Anatomy 2002;15:45–50. 30. Aggarwal R, Brough H, Ellis H. Medical student participation in surface anatomy classes. Clinical Anatomy 2006;19:627–31. 31. Ganguly PK, Chan LK. Living anatomy in the 21st century: How far can we go? SE Asian Journal of Medical Education 2008;57:52–7. 32. Marhofer P, Willschke H, Kettner S. Current concepts andfuture trends in ultrasound-guided regional anesthesia. Current Opinion in Anaesthesiology 2010;23:632–6.
Downloaded by [Selcuk Universitesi] at 06:59 27 December 2014
188
K. YAMMINE
33. Beahrs OH. Gross anatomy in medicine. Clinical Anatomy 1991;4: 310–2. 34. Marks SC Jr, Bertman SL. Experiences with learning about death and dying in the undergraduate anatomy curriculum. Journal of Medical Education 1980;55:48–52. 35. Finkelstein P, Mathers LH. Post-traumatic stress among medical students in the anatomy dissection laboratory. Clinical Anatomy 1990;3:219–26. 36. Druce M, Johnson MH. Human dissection and attitudes of pre-clinical students to death and bereavement. Clinical Anatomy 1994;7:42–9. 37. Nnodim JO. Pre-clinical student reactions to dissection, death, and dying. Clinical Anatomy 1996;9:175–82. 38. Dinsmore CE, Daugherty S, Zeitz HJ. Teaching and learning gross anatomy: Dissection, prosection or both of the above? Clinical Anatomy 1999;12:110–4. 39. Snelling J, Sahai A, Ellis H. Attitudes of medical and dental students to dissection. Clinical Anatomy 2003;16:165–72. 40. Marks SC, Bertman SL, Penney JC. Human anatomy: A foundation for education about death and dying inmedicine. Clinical Anatomy 1997;10:118–22. 41. Spitzer VM, Whitlock DG. The visible human data set: The anatomical platform for human simulation. The Anatomical Record 1998;253: 49–57. 42. McLachlan JC. New path for teaching anatomy: Living anatomy and medical imaging versus dissection. The Anatomical Record 2004;281(B1): 4–5. 43. Miller SA, Perrotti W, Silverthorn DU, Dalley AF, Rarey KE. From college to clinic: Reasoning over memorization is key for understanding anatomy. The Anatomical Record 2002;269:69–80. 44. Nodim JO. A controlled trial of peer-teaching in practical gross anatomy. Clinical Anatomy 1997;10:112–7. 45. Yeager VL. Learning gross anatomy: Dissection and prosection. Clinical Anatomy 1996;9:57–9. 46. Turney B. Anatomy in a modern medical curriculum. Annals of the Royal College of Surgeons of England 2007;89:104–7. 47. Standring S. New focus on anatomy for surgical trainees. ANZ Journal of Surgery 2009;79:114–7. 48. Stringer MD, Lyall P. Design, implementation, and evaluation of a postgraduate Diploma in Surgical Anatomy. Anatomical Sciences Education 2012;5:48–54. 49. Rizzolo LJ, Drake RL. Anatomists debate the value of a teaching credential. Anatomical Sciences Education 2008;1:60–67. 50. Fraher JP, Evans DJ. Training tomorrow’s anatomists today: A partnership approach. Anatomical Sciences Education 2009;2:119–125. 51. Rainsbury D, Barbour A, Mahadevan V. College launches National Anatomy Project. Annals of the Royal College of Surgeons of England 2007;89:S19. 52. Standring S, Larvin M. 2011. Anatomy teaching: The cruellest cut—A progress report. Annals of the Royal College of Surgeons of England 2011;93:S16–S18.
53. Garg A, Norman GR, Spero L, Maheshwari P. Do virtual computer models hinder anatomy learning? Academic Medicine 1999;74(10 Suppl.): S87–9. 54. Nguyen N, Nelson AJ, Wilson TD. Computer visualizations: Factors that influence spatial anatomy comprehension. Anatomical Sciences Education 2012;5:98–108. 55. Nicholson DT, Chalk C, Funnell WR, Daniel SJ. Can virtual reality improve anatomy education? A randomised controlled study of a computergenerated three-dimensional anatomical ear model. Medical Education 2006;40:1081–7. 56. Keedy AW, Durack JC, Sandhu P, Chen EM, O’Sullivan PS, Breiman RS. Comparison of traditional methods with 3D computer models in the instruction of hepatobiliary anatomy. Anatomical Sciences Education 2011;4:84–91. 57. Tam MD, Hart AR, Williams SM, Holland R, Heylings D, Leinster S. Evaluation of a computer program (“disect”) to consolidate anatomy knowledge: a randomised-controlled trial. Medical Teacher 2010;32: e138–42. 58. Ruisoto P, Juanes JA, Contador I, Mayoral P, Prats-Galino A. Experimental evidence for improved neuroimaging interpretation using three-dimensional graphic models. Anatomical Sciences Education 2012;5:132–7. 59. Moss K. Learner retention of anatomical information presented in a digital two-dimensional format versus a digital three-dimensional format. Journal of Biocommunication 2001;28(3):4–10. 60. Fritz D, Hu A, Wilson T, Ladak H, Haase P, Fung K. Long-term retention of a 3-dimensional educational computer model of the larynx: A follow-up study. Archives of Otolaryngology Head and Neck Surgery 2011;137(6):598–603. 61. Codd AM, Choudhury B. Virtual reality anatomy: Is it comparable with traditional methods in the teaching of human forearm musculoskeletal anatomy? Anatomical Sciences Education 2011;4:119–25. 62. Levinson AJ, Weaver B, Garside S, McGinn H, Norman GR. Virtual reality and brain anatomy: A randomised trial of e-learning instructional designs. Medical Education 2007;41(5):495–501. 63. Petersson H, Sinkvist D, Wang C, Smedby O. Web-based interactive 3D visualization as a tool for improved anatomy learning. Anatomical Sciences Education 2009;2:61–8. 64. Choudhury B, Gouldsborough I. The use of electronic media to develop transferable skills in science students studying anatomy. Anatomical Sciences Education 2012;5:125–31. 65. Choudhury B, Gouldsborough I, Gabriel S. Use of interactive sessions and e-learning in teaching anatomy to first-year optometry students. Anatomical Sciences Education 2010;3:39–45. 66. Svirko E, Mellanby J. Attitudes to e-learning, learning style and achievement in learning neuroanatomy by medical students. Medical Teacher 2008;30:e219–27. 67. Tam MD, Hart AR, Williams S, Heylings D, Leinster S. Is learning anatomy facilitated by computer-aided learning? A review of the literature. Medical Teacher 2009;31:e393–6.
