Student Perceived Value of Anatomy Pedagogy, Part II: Clinical Practice and Assessment.

We describe student beliefs of how anatomy education influenced their preparation for standardized clinical assessments and clinical skills. We conducted three annual surveys of students of the David Geffen School of Medicine (DGSOM) at the University of California Los Angeles (UCLA) and students of the University of California, Riverside (UCR)/UCLA Thomas Haider Program in Biomedical Sciences from 2010 to 2012. Students were asked, "What specific knowledge or skills did you learn from your gross anatomy experience that helped you prepare for USMLE board exams, third-year clerkships, and physical examination skills?" All students who responded to the survey viewed anatomy as a highly valued part of the medical curriculum. Almost all students felt that anatomy knowledge in general was useful for their success with United States Medical Licensing Examination (USMLE) exams, how they perceived their physical exam skills, and how they perceived their preparation for third- or fourth-year clerkships. On the other hand, when asked about how the anatomy curriculum helped prepare students for fourth-year clerkships, there was a downward trend over a three-year period with each subsequent class. Although anatomy is a highly valued part of the medical school experience, students value integration of the anatomical and clinical sciences, as evidenced by a perceived diminishing value of anatomy pedagogy taught outside of clinical context with subsequent classes over the course of three years.

Introduction

Anatomy is a cornerstone in both medical education and the understanding of pathology in the human body; cadaveric studies have stood through time as one of the most important and relevant parts of early medical education. The current schools of thought for anatomy pedagogy include the classic dissection approach, in which students dedicate time toward the dissection of a cadaver and understanding of the structures as they do so, and prosection, in which students are able to view a previously dissected specimen and learn in a more direct and timely manner. While there are benefits and drawbacks to both approaches, it is important to understand how students perceive the value of either approach and how the anatomy experience has benefited their medical careers as a whole.

What are the tangible benefits of learning gross anatomy?

The hands-on skills that students learn in an anatomy laboratory experience, particularly for dissection, do not translate directly, or in some specialties, at all, to medical practice. However, by learning the location and function of every major structure in the human body, students begin to understand the geographical and functional interrelationships of structures. As this skill of diagnostic reasoning develops, students also make the transition from being two-dimensional, atlas reference thinkers to becoming three-dimensional, kinesthetic mental palpation thinkers. By the end of a typical gross anatomy course, students gain the ability to think about structures and functions three dimensionally. It has been argued that while this skill is certainly helpful, it may not be completely necessary for typical students finishing their first year of medical school. Certainly, those students who do not yet master the skill of three-dimensional thinking presumably perform just as well as their peers on different types of formative and summative assessments. By the time students reach their post-graduate/residency years, however, many more have become proficient in three-dimensional anatomical (and physiological) thinking for their region of specialty and interest.

Are anatomy skills translatable?

Unlike other basic science disciplines, learning anatomy is most akin to learning a language—indeed, the language of medicine. Thus, while assessing students' semantic knowledge of anatomy is straightforward, measuring skills of diagnostic reasoning and three-dimensional thinking (ie, speaking the language of anatomy) can be difficult to measure. Just as the real test for language proficiency is being able to communicate in the linguistic tongue, the real test for anatomy proficiency is the physical exam. Fitzgerald et al noted that the anatomy experience provides intangible benefits, such as confidence in clinical skills. One of the best assessment tools currently in use to measure physical exam skills is the Objective Structured Clinical Examination (OSCE).

Anatomy pedagogy styles

Dissection of the human body is the traditional pedagogical approach to teaching and learning gross anatomy. In a typical dissection course, students dissect cadavers and cadaveric specimens, and learn the anatomical structures and relationships as they uncover tissue planes from superficial to deep. This process requires a significant amount of contact time with experienced anatomy faculty and teaching assistants who help students with the dissection and learning process. In contrast, the prosection pedagogical approach involves teaching and learning from predissected cadavers and cadaveric specimens. Without the dissection component in the laboratory exercise, more time can be devoted to learning anatomy during class time.

After the publication of the Flexner Report, medical education experienced a massive paradigm shift from a non-integrated basic science and clinical science curriculum to an integrated curriculum, resulting in precipitously declining contact hours available to gross anatomy instruction and the inability to sustain a traditional dissection course. The number of gross anatomy instructional hours declined from a mean of 350 to 150 from 1955 to 2009, with the greatest drop in hours between 1955 and 1973. In response to the declining contact hours, 40 programs continued to use student anatomy dissection approach to anatomical instruction, 23 programs used a combined dissection/prosection approach, and 2 programs used a prosection-only approach.

Students of the David Geffen School of Medicine (DGSOM) at UCLA learn anatomy through prosection, but have the option after their first year of medical school to participate in the anatomy summer dissection program on a volunteer basis. In this program, students dissect cadavers and cadaveric specimens during the summer prior to their second year for the incoming first-year medical school class. Thus, by the time DGSOM students enter their second year of medical school, some will have had the opportunity to explore anatomical structures with cadaveric specimens twice. In contrast, students of the University of California, Riverside (UCR)/UCLA Thomas Haider Program in Biomedical Sciences learn anatomy through dissection during their first year of medical school only. Students in both programs combine enrollment throughout their clerkship years. Thus, students who have learned anatomy through prosection only, prosection with dissection, and dissection only merge together in the clinical years of medical school.

In this paper, we reported students' attitudes and thoughts toward the educational approach to mastering anatomy in regard to their clinical practice and success in standardized testing.

Methods

We conducted three annual online qualitative surveys of students of DGSOM at UCLA and students of the UCR/UCLA Thomas Haider Program in Biomedical Sciences from 2010 to 2012. At the end of the 2009–2010 academic year, we surveyed students from the class of 2012 (those who had just finished their second year of medical school). At the end of the 2010–2011 academic year, we resurveyed the class of 2012 and added the class of 2013. At the end of the 2011–2012 academic year, we resurveyed the classes of 2012 and 2013 and added the class of 2014. Thus, by 2012, three classes had taken the USMLE Step 1 board exam, two classes completed the third-year clerkship, and one class completed the fourth-year clerkship and the USMLE Step 2 board exam.

The Dean's office provided coded data each year, and informed the authors which data were from the same individuals from year to year.

As a part of the survey, students were asked to provide a qualitative free response to following questions: “What specific knowledge or skills did you learn from your gross anatomy experience that (1) helped you prepare for USMLE board exams, (2) prepared you for your third-year clerkships, (3) developed your physical examination skills, and (4) prepared you for your fourth-year clerkships?”

Data were classified as “positive,” “negative,” or “neutral” by authors of this study. A response was considered positive if it expressed that anatomy education had a perceived positive value on any of the aforementioned indicators.

This study was approved by the Institutional Review Board of DGSOM at UCLA in accordance with the principles of the Declaration of Helsinki.

Results

Survey demographics

In a typical class, there are 161 entering DGSOM students, and 24 entering UCR/UCLA students. This number fluctuates year to year based on the number of students entering and leaving M.D./Ph.D. programs, leaves of absence, and/or attrition. Unfortunately, when surveys were administered, we did not have access to the exact number of students in each class because of these factors. Therefore, we calculated response rates based on the number of entering students.

In 2010, the total response rate from among DGSOM and UCR/UCLA students was 59.5% (n = 110). In 2011, the total response rate from among two years of DGSOM and UCR/UCLA students was 42.2% (n = 156). In 2012, the total response rate from among three years of DGSOM and UCR/UCLA students was 17.5% (n = 97). In all, 17 students repeated the survey for three consecutive years.

Students who experienced anatomy through prosection only, prosection/dissection, or dissection only responded to the survey in approximately equal proportions with respect to the total number of students who participated in each of those experiences.

Overall responses to survey

From the total number of respondents, all students who responded to the survey viewed anatomy as a highly valued part of the medical curriculum (99% positive). Most students viewed the anatomy curriculum highly with helping them prepare for USMLE board exams (89% positive), prepare for third-year clerkships (95%), and developing physical exam skills (65% positive). No discernable difference in the qualitative responses was found between DGSOM and UCR/UCLA students, indicating that the anatomy pedagogy did not influence how students perceived their performance on any of the performance indicators. On the other hand, when asked about how the anatomy curriculum helped prepare students for fourth-year clerkships, there was a downward trend with a 92% positive response rate for 2010, 90% for 2011, and 83% for 2012. These results appear to indicate a perceived diminishing value of either anatomy pedagogy with each subsequent class.

“What specific knowledge or skills did you learn from your gross anatomy experience that helped you prepare for USMLE board exams?”

Regarding performance on Step 1 of the USMLE board examinations, student responses toward the combined pedagogy were mostly positive (89%). The student responses focused on how the curriculum aided their studies specifically in areas that were heavily tested by board examinations, such as the brachial plexus, neurovasculature of specific muscles, and interpretation of radiological imaging. Students also believed that the combined prosection–dissection approach taught with clinical context helped on a broader spectrum regarding their medical training as it is tested in the exam. For instance, students stated that “understanding anatomy helps with learning pathophysiology of disease processes,” “anatomy itself was useful; the clinical correlates of anatomy were also invaluable (eg hernias and the structure of the abdominal wall),” and “I more easily remember/understand clinical diseases emphasized in anatomy.” Another interesting thought was related to variation of anatomy and what it may entail; one student felt that “normal versus abnormal anatomy and how this relates to health versus pathology” was one of the specific areas where the anatomy curriculum was useful.

Very few students negatively viewed the role of the anatomy curriculum in their preparation for the USMLE board examinations. Those negative opinions had an underlying theme regarding the small number of anatomical questions on the board exam as compared to the number of questions about basic science or pathological processes. One student stated that there was “not much anatomy on Step 1, but it was important to know it for the few questions that did test on anatomy,” indicating that while it was not as represented as other topics, anatomy was still of use.

“What specific knowledge or skills did you learn from your gross anatomy experience that helped you prepare for physical examinations?”

When asked about their perception of how the anatomy curriculum affected their physical examination skills, only 65% of students felt positive about the contribution of anatomy. Generally, students felt that understanding the locations of specific landmarks, such as liver edges, spleen, and specific arteries, helped them better perform the corresponding portions of the physical exam. Understanding where specific organs were and being able to mentally visualize them seemed to be also important to students. One student stated, “After studying the anatomy, I always visualize internal organs while performing my physical exam. I think it was very helpful.” Likewise, students found it important to differentiate between normal anatomy and pathology, stating “you get to see so many different bodies and get a sense of what is normal.”

On the other hand, other students also found that their physical examination skills did not benefit from the combined curriculum. Some students did not feel that the cadaveric tissue had sufficient similarity to living tissue. Others did not feel that the anatomical learning experience had any translation to the clinic. “Palpating a dead body is very different than a live one,” stated one student. Another wrote, “Doing lots of physical exams improves physical exam skills.” These were two very valid points. Another student bluntly exclaimed, “[The learning experience] had nothing to do with physical examination.” This particular response points to a perceived lack of clinical correlates by some students that are presented in the anatomy curriculum and the possibility of increasing them in the cadaver lab.

“What specific knowledge or skills did you learn from your gross anatomy experience that helped you prepare for third-year clerkships?”

Students had an overwhelmingly (95%) positive opinion regarding the combined curriculum. As could be expected, the recurrent theme to the responses was specific to the surgical and obstetrics/gynecology clerkships, which are much more dependent on a deep understanding of anatomical landmarks, as well as in interpreting imaging modalities. Likewise, students felt like medicine rotations, as well as clinical thinking, were improved by the combined curriculum. When asked what skills or knowledge learned in the curriculum helped specifically in the third-year clerkship, students responded in a similar train of thought with specific areas such as, “general overview of anatomy relevant to diseases I encountered on clerkships” and “anatomical knowledge for physical exams, reading of radiological studies, and participating in surgeries or other procedures.” A large amount of students simply replied, “surgery rotations.”

The few responses that were not as positive about the anatomical learning experience showed a common thread of students feeling underprepared. One response was simply, “I did not feel adequately prepared for my surgical rotation.” Another student wrote, “I had to relearn anatomy for third-year clerkships because one always forgets but it was easier the second time.”

“What specific knowledge or skills did you learn from your gross anatomy experience that helped you prepare for fourth-year clerkships?”

While the responses for all aforementioned questions were very similar across the three annual surveys, we did note a downward trend regarding the opinions toward the relevance of the curriculum on the fourth-year clerkships. We noted a 92% positive response rate for 2010, 90% for 2011, and 83% for 2012. While the student responses were mostly positive toward the curriculum, there seems to be a shift in the specificity of its usefulness. As may be expected, the responses are heavily positive toward the role of anatomy in surgical specialties or in fields where radiological imaging is of key importance. Positive responses toward the skills learned in the anatomy laboratory included “enhanced visualization greatly assisted my ability to perform an interventional radiology clerkship, which was [the] key to being able to secure a radiology residency position” as well as “suture skills, manipulation of tissues, anatomic basis of simple procedures (spinal taps, etc.).”

The negative responses also had a common thread, namely, that the students had by then made their choices regarding specialties in the medical field into which they were going and how learning about those specific fields had greatly expanded their knowledge base. About the skills gained, one student responded, “[I gained] none. [I'm] going into psychiatry. [I] learned more from neuroanatomy that is relevant.” Another student stated, “[I gained] no specific knowledge/ skillset except that of general female anatomy (I did several sub-I's in OB/GYN).” Seemingly, as the students gain knowledge later and later in their clinical years, their mindset about the role of anatomy may change.

Discussion

Anatomy is one of the cornerstones of medical training. While the approach of cadaveric dissection has been the tried and true method of learning about the human body, recent times are proving to be evolutionary for the studies of human anatomy. New methods, including cadaveric prosection as well as digital imaging and Internet-based learning tools, have begun to change the landscape of how anatomy is taught.[6,7] By being exposed to both dissection and prosection pedagogies during their medical anatomy, students are able to gain the benefits of both approaches. For instance, the prosection approach allows students to rapidly identify and understand the location of anatomical landmarks and their relationships with the rest of the human body while minimizing the amount of time required by classical prosection. On the other hand, dissection allows students to participate actively in discovering the anatomy first hand, as compared to the relatively passive prosection approach.

Continuity across three years or more

While not all students developed continuity across multiple years, 17 students did so by answering the survey for three consecutive years. This continuity provided additional insight into the way that students may perceive the importance of the combined curriculum through their careers. We noted that as the students advanced through their medical school careers, their responses become more specific, especially those students who began taking the assessments during their first year of attendance. For instance, when asked about the role of the curriculum regarding Step 1 of the board examinations, one student responded “none,” “basic anatomy,” and “musculoskeletal and anatomically based disease” for second, third, and fourth years of medical school, respectively. Other students responded in a similar fashion.

Most of these repeat students also showed constancy in their responses. Those students who had negative or indifferent opinions toward the curriculum maintained their opinion throughout the years they took the survey. Likewise, those with positive outlooks toward the curriculum maintained that opinion as well. Most of the sequential opinions held by students did not change across the three or more years in which they took the survey, which may imply that external factors may be playing a role in the student's preference for one modality versus another, be it preparing for a specific residency/specialty choice, or a personal aversion or appreciation toward anatomy.

Anatomy integration with clinical application

The notion that may come as a surprise, and a point to be noted by the educator, is that the classical approach of anatomy dissection may be rapidly changing to a new standard of anatomy and clinical integration, and that many students value that integration. This may be seen in the downward trend of perceived importance of learning pure anatomy outside of clinical context through the past few years. This downward trend may be explained by different reasons. Students who were not interested in the surgical fields or the fields that relied heavily on imaging modalities did not seem to find importance in the anatomy curriculum. The specificity of the fields into which students have chosen to go into by the fourth and final year may dictate the level of importance they place on specific factors of the medical school curriculum, including anatomy. This may be indicative of the current state regarding the specialties many students are going into. This may also be a sign that students are less and less inclined to go into specialties that may have competitive residence acceptance requirements, long residencies, or heavy workloads, such as in the surgical field or radiology.

Yet another reason may lie in the heavy use of new and emerging technology. While anatomy was taught classically in the anatomy lab, from printed diagrams, and from books, the current generation is becoming more and more reliant on the use of electronic devices such as smart phones, tablets, and portable computers. A student can now study from three-dimensional diagrams in the clinic or wards and still gain a decent understanding of anatomical features such as locations, landmarks, and relationships, without requiring hours of dissection or direct cadaveric contact. The classroom can likewise present these new and emerging imaging modalities, allowing equal access to the material by all students without the issues created by having too many students crowded around one cadaver. The perceived lack of importance of having a dissection/prosection curriculum may lie in the increasing usage of electronic devices, which make learning more accessible, direct, and portable.

It is not surprising to the educator to read that there is an overall positive response toward the importance of anatomy in the curriculum. As important as anatomy is in not only board examinations but also the general understanding of how the human body works and reacts to pathological processes, the notion that most students would see it as a cornerstone in their careers is to be expected, regardless of the approach taken to learning. It may or may not surprise the educator that across multiple continuous yearly surveys, students held an unwavering opinion toward the curriculum, indicating that the mindset toward anatomy may be influenced early on by external effectors, such as personal interest and/or residency/specialty choice.

Limitations

Survey response rates declined over the three years of the study likely because the survey was administered through the student listserv. A natural attrition from responding to surveys over the years for the classes of 2012 and 2013 may account for this. A large drop in responses during the final year of the survey likely occurred because the survey was distributed in May of that year instead of April of that year. This would have been the time when students were transitioning to summer activities. We recognize the declining response rate as a limitation to the study.

We acknowledge that students participating in the DGSOM anatomy summer dissection program were likely students interested in the surgical specialties. However, many students expressed also interest in internal medicine, cardiology, pediatrics, and family medicine. Specialty and interest may have influenced their perception of gaining skills for standardized exams or clinical experiences, but we did not note any differences in response themes between the DGSOM and UCR/UCLA students. We also acknowledge that by virtue of class sizes between the two schools, there are more students who participated in either prosection only or prosection/dissection than there were students who participated in dissection only.

Author Contributions

Conceived and designed the experiments: JJW, PR, SDL, CB and PFW. Analyzed the data: CRG, SY, PFW and JJW. Wrote the first draft of the manuscript: CRG and JJW. Contributed to the writing of the manuscript: CRG, SY, PR, SDL, PFW, CB and JJW. Agree with manuscript results and conclusions: CRG, SY, PR, SDL, PFW, CB and JJW. Jointly developed the structure and arguments for the paper: CRG, SY, PR, SDL, PFW, CB and JJW. Made critical revisions and approved final version: CRG, SY, PR, SDL, PFW, CB and JJW. All authors reviewed and approved of the final manuscript.