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Table of Contents
REVIEW ARTICLE
Year : 2019  |  Volume : 68  |  Issue : 4  |  Page : 306-311

Dissecting the future: A critical review of anatomy's past, present, and future following the carnegie foundation's call for medical education reform


1 Department of Anatomy, College of Medicine, American University of Antigua, Antigua and Barbuda
2 Department of Anatomy, School of Science, College of St. Scholastica, Duluth, MN, USA

Date of Submission28-Mar-2019
Date of Acceptance14-Apr-2019
Date of Web Publication28-Feb-2020

Correspondence Address:
Dr. Sherese Joseph
The College of St. Scholastica, 1200 Kenwood Ave, Science Building, Office-S2202, Duluth, MN 55811
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JASI.JASI_23_19

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  Abstract 


By looking at anatomy's past and present, anatomists can acquire an overview of where the profession has been and where it now needs to go to meet the needs of 21st century medical education. This paper reviews past and present pedagogy and offers an alternative approach to the future of anatomy education through the use of digital dissection and more integrative didactic experiences.

Keywords: Ebers papyrus, medical education, the use of illustrations


How to cite this article:
Amiralli H, Joseph S. Dissecting the future: A critical review of anatomy's past, present, and future following the carnegie foundation's call for medical education reform. J Anat Soc India 2019;68:306-11

How to cite this URL:
Amiralli H, Joseph S. Dissecting the future: A critical review of anatomy's past, present, and future following the carnegie foundation's call for medical education reform. J Anat Soc India [serial online] 2019 [cited 2020 Apr 9];68:306-11. Available from: http://www.jasi.org.in/text.asp?2019/68/4/306/279738




  Introduction Top


In 2010, the Flexner Report had its centennial year of publication which was celebrated by the Carnegie Foundation, the original report sponsor, with its release of another call for medical education reform.[1],[2] The consequences of the Flexner report have influenced medical education for over 100 years.[3] This report introduced pedagogical rigor and quality standards to medical education. But medical associations are emphasizing that 21st century medical education requires curricular integration of the basic sciences, which includes anatomy, with clinical experiences while adding other foundational medical subjects such as physiology, behavioral sciences, genetics, biostatistics and epidemiology. How, what, and when to teach principles and concepts in anatomy education are requiring a fundamental re-evaluation of old forms of didactic lectures followed by laboratory dissections.[2],[4],[5] The field of anatomy must address new curricular and instructional strategies, the effective use of media, and the efficient use of prosections and dissections. In the student's four-year academic experience, decreasing resources in curricular time, faculty, funding, and resources will make this a challenge, but following the lead of the Carnegie Foundation, if anatomy utilizes research from the learning and cognitive sciences, as well as researches best practices of innovative anatomy programs, anatomy will retain its foundational position in the basic sciences.[2]


  Historical Review of Anatomical Teaching Top


Teaching methods

The oldest known anatomical document, the Ebers papyrus (c. 1600 BCE), began a pedagogical trend for teaching anatomy through the use of illustrations of the human body and the definition of common anatomical terms to provide a broad overview for the medical student.[6] In the second century CE, Galen, a Greek physician, further contributed to this anatomical instructional strategy when Latin versions of his texts became the standard for teaching anatomy in the Western world. These texts, concurrent with captioned illustrations, dominated pedagogical strategies in anatomy for >200 years.[7]

Teaching hours

Before Flexner's report, gross anatomy accounted for a fifth of medical school curriculum with more than 800 h of lectures and laboratories.[8] By the year 1931, anatomy teaching still averaged around 780 h. During the 19th century, anatomy was taught by surgeons but by the 1930s, and through the 1980s, anatomy typically was taught by “classically trained” anatomists.[7],[8]

Integration

Twentieth-century anatomists did not consider the integration of clinical relevance into their teaching a priority.[8] A shortage in anatomists became increasingly apparent throughout the 20th century; however, and a few innovative programs took advantage of surgical and radiological teaching faculty to reinforce student understanding of anatomical concepts with clinical medicine.[9],[10] Anatomy has also conventionally been integrated with physiology which is better called functional anatomy.

Dissection

The place of dissection in an anatomy curriculum has been a controversial issue for many years and remains a key point of discussion in the field.[11]

Although fundamental knowledge of the human body is key to anatomy education, using donor cadavers for dissections was challenged on moral, cultural, and religious grounds.[12] During the middle ages, dissections were performed only on executed criminals about twice a year, and the teaching professor removed himself from the actual dissection by lecturing.[7] It is important to remember that what is now considered an essential instructional strategy for the learning of human anatomy was once less favored as a teaching tool.

By the time of Vesalius in the 16th century, dissection became a more prominent strategy in the teaching of anatomy. The creation of Vesalius's text De humani corporis fabrica included beautiful woodcuts depicting various stages of human dissections.[7] The Renaissance era became the starting point for the dissection of cadavers as the central anatomy teaching experience.[13],[14] No matter how central dissection was to become in training medical doctors, social, legal, and cultural stigmas still attached themselves to this instructional practice. Through the 18th and early 19th centuries, dissection could only be performed on the cadavers of executed criminals.[15] This stigma did not provide enough cadavers for medical students and thus led to the practice of grave robbing which outraged the public even more.[15]

Evolution of dissection

In the 20th century, cadaver shortages still haunted the use of anatomy laboratory dissections in American medical schools.[16] This was brought on by an increase in medical students and a decrease in unclaimed bodies which, heretofore, had been the major resource for dissections. The decrease was a result of several factors including a public clamor in the 1930s that the poor be afforded a decent burial supported with funds from social security, a shift to more elaborate funeral practices brought on by advances in embalming, and the public's move to cremation of the deceased.[15]

For America, the golden years of anatomy teaching, particularly of gross anatomy, fell between the beginning and middle of the 19th century and involved didactic lectures and dissections, though obstacles to dissections by the public were still common.[7],[16] Like Britain, the United States saw a proliferation of private schools run by surgeons and anatomists and with the growth in students, demands for cadavers also increased. In the early 1830s, new laws were finally passed by Massachusetts to legally permit unclaimed bodies to be used for dissection.[15],[16] Despite the struggle to gain legally acquired cadavers, the anatomy laboratory experience in the first half of the 19th century became codified as a medical school professional rite of passage and group experience for medical students.[16] Anatomical dissections were memorialized in photographs of small student groups surrounding a single cadaver, a practice that increased throughout the second half of the 19th century. Some would argue that, through the early 19th century, the practice of cadaver dissection promoted discussion and self-reflection about the cognitive, affective, professional, and ethical components of teaching and learning medicine while others worried that physicians were learning to practice “heartlessness” to remove themselves emotionally from the reality that the cadaver had been a living person.[7],[16]

With the introduction of anesthesia and sterile medical techniques in the second half of the 19th century, medicine witnessed a change in the teaching of gross anatomy,[7] and anatomists strived to have anatomy counted as scientific medicine.[16] The preeminence of the study of gross anatomy became threatened as newer, experimental sciences took center stage. Gross anatomy lost center stage in the study of medicine to the newer experimental sciences of developmental biology, embryology, and histology.[16]

Prosection versus dissection

The Anatomical Gift Act shifted the “property rights” of human bodies to the donor, but, despite increases in deeded body programs, the need for organ donation soon overshadowed the need for cadavers in medical schools.[15],[16],[17] The increasing shortage of cadavers initiated over 40 years of debate concerning the advantages and disadvantages of prosection over dissection. Dissection involves progressive identification and removal of tissue to display each structure fully, clearly, cleanly, and with understanding of the sequence of structures.[18] Prosection, with or without plastination, requires presentation of specific structures from a part of a cadaver. The plastinated specimens can be preserved for future reviews. As early as 1970, dissection was considered a time-consuming teaching technique. Other reports demonstrated prosections as instructionally more effective.[19],[20] An experimental program by Emory University using multimedia concluded there was no significant difference between using prosected specimens instead of traditional dissection. Through the end of the 90's and beginning of the 20th century, experiments with prosections, computerized tomography, and magnetic resonance imaging (MRI) provided further evidence that pedagogical techniques other than full dissection were effective in increasing student understanding of basic anatomy.[21],[22],[23],[24],[25] However, for nearly every article promoting prosection, other articles promoted the viability of dissection as an important instructional and learning strategy. Yeager described a program at the St. Louis University School of Medicine that reduced course time but retained dissection.[26] These students were performing above average on the anatomy part of the National Board Examination.[27] By the 21st century, some authors were reasserting that dissections gave students psychological and emotional training advantages as well as increasing anatomical knowledge through a spatial, three-dimensional (3D) relationship to different anatomical structures.[28],[29] Rizzoloans Stewart reported that the small-group setting of the dissection laboratory was important to a sense of group learning that echoed the small group closeness of medical students in the dissecting laboratory in the 1800s.[30] Given alternative tools for the study of anatomy, the question of what future doctors can gain from cadaver dissection has not been answered with rigorous, scientific studies.[9],[31]


  Current State of Anatomical Teaching Top


Teaching methods

In addition to the debate regarding appropriate instructional materials in anatomy, pedagogical strategies began to take on more importance. Small group and problem-solving strategies were beginning to find their place in the medical curriculum and in so doing, took up traditional anatomy lecture and laboratory time.[32],[33] Lecture format was challenged as researchers asserted that the instructional design of a lecture focused on specific learning outcomes could make a difference to learning human anatomy.[34]

Other schools of physical sciences are faced with similar challenges. Research results from the New York University College of Dentistry suggest that gross anatomy be taught in small groups and that dissection of wet cadavers be replaced by the study of plastinated specimens and cross-sectional anatomy. Utilizing these methods, the study reported a significant improvement in the scores of their students at the National Board Dental Examination Part I examination.[35]

Furthermore, changes in the conceptualization of the field of anatomy also were occurring. During the middle 20th century, the appropriate teaching of gross anatomy in the medical school curriculum resulted in the American Association of Clinical Anatomists (ACCA) examining the perception that anatomy curriculum was largely composed of content and not skills.[6],[36] Gross anatomy had always held a central position in medical education, but reforms calling for more clinical exposure and active learning experiences during the preclinical years were emerging. Learning objectives for gross anatomy courses were still valid and focused on providing medical students with adequate knowledge of structure, spatial relationships, and the clinical significance of the systems of the human body. What had been changing were the teaching methods and the time commitments required to reach these course objectives.[32]

Integration within basic sciences

By the early 20th century, medical educators favored curriculum changes and pedagogical strategies which foster critical thinking in applications of basic sciences to clinical problems instead of memorization of facts.[3],[7],[16],[37] Into this context, Abraham Flexner was hired by the Carnegie Foundation in 1910 to undertake a survey of all 155 US and Canadian medical schools. This survey led to recommendations, namely reduce the number of medical schools, intensify prerequisites for admission to medical schools, train physicians to practice scientifically and to engage in research, provide medical schools with control of clinical instruction in hospitals, and institute a rigorous regulation of medical licensure.[2],[3],[37]

The American Medical Association's Council on Medical Education in 1904 proposed the first restructuring of medical school curriculum into the now familiar “two-plus-two” curriculum consisting of 2 years in the basic and “laboratory” sciences followed by 2 years of clinical experience in teaching hospitals.[3],[37],[38] The advent of state licensing boards in the second decade of the new century caused the focus of medical education to shift from an emphasis on varying instructional strategies to lecture and didactic instructional strategies.[39]


  Introduction of Technology Top


Technology has yielded possibilities for teaching anatomy that did not exist before the 21st century. Excellent results in teaching basic anatomy have been quantified using such techniques as medical imaging, 3D visualization, virtual reality, and augmented reality.[40] Cadaver dissection needs enormous continuous funding and this skill is available to students only in laboratories. Alternately, digital dissection can be accessed in and out of a laboratory and consists of onetime capital investment or a small annual fee. Although many traditional anatomists would argue that cadaver dissection still has its place in medical education. However, because of shrinking budgets and the availability of computerized digital dissection programs, many institutions are reviewing the need of for expensive cadaver dissection laboratories.[41],[42] Students at our institution have digital dissection available to them on the institution website where it can be accessed at all times.


  Evolution of Anatomy Top


Teaching methods

In 1991, the faculty of the University of Texas Medical Branch designed a questionnaire and distributed it to medical schools throughout the US and Canada, collecting information on how gross anatomy was being taught. The response to the questionnaire from 20% of the schools revealed that major changes in their teaching methods had been introduced, including integrated, problem-based learning, and computer-assisted teaching. These schools also began reducing overall content, didactic lectures, and rote memorization in favor of more active learning techniques.[32] Conventionally, trained gross anatomists familiar with basic lecture and dissection in medical education found their role to be diminishing in favor of these newer instructional strategies.[32],[43]

Integration

For anatomy to have relevance in medical education, clinical anatomists need to discuss in their departments, institutions, and organizations, reforms in medical education such as curricular integration of the basic sciences with clinical sciences.[2] Just as breakthroughs in medicine and science integrated the scientific method into clinical medical training over 100 years ago, today's breakthroughs in information technology and the dissemination of medical information have challenged the anatomy curriculum and forced on it further changes, including pedagogical methodologies, content changes, and an emphasis on life-long learning in this age of evidence-based medicine.[37],[44]

Future of anatomy analysis

Beginning in 1996, the Educational Affairs Committee of the AACA developed a series of guidelines to help medical institutions ensure that their students received thorough competent training in anatomy.[6] The organization maintained that health care still relied on effective clinical diagnosis through physical examination which requires a solid anatomical base.[6] The monograph stressed the importance of learning normal variations of anatomy, 3D relationships, functional and living anatomy, and imaging technology as applied to patient care.[6]

How necessary is a strong foundation in gross anatomy for clinical training? One of AACA's Educational Affairs Committee papers describes the role of gross anatomy in clinical training as safe, efficient, and effective performance of several invasive procedures. It further emphasizes that other invasive procedures be incorporated into a clinical anatomy curriculum for students of medicine.[45]

However, the challenges of the information explosion in medicine's understanding of the biological process and technological advances in diagnostic methods and treatments are also altering strategic decisions for new curriculums in anatomy.[46] In one report comparing data sets from surveys of anatomy course directors, the total course hours for gross anatomy fell around 55% from 1955 to 2009.[8] However, the instructional design of gross anatomy courses remained largely unaffected with little change in the percentage, of course, hours devoted to lectures and laboratory experience over the past decade. Gross anatomy courses seemed to have reached a plateau around 149 h for total course hours. Over 60% of the courses still use dissections exclusively in their laboratory sections. The incidence of using an integrated approach (29%) with subject matter content had not yet overcome the instances of offering gross anatomy as a stand-alone course 71%.[8]

Some medical educators have suggested further reductions in teaching hours in anatomy. One of the major questions for today's medical educators concerns the amount of anatomical knowledge required to make medical students safe practitioners, during various stages of their medical education, including basic sciences, clinical sciences, and during the residency program. Researchers should begin to speak of anatomical teaching hours with reference to the stage of the medical student's career.

Limitations and remaining challenges

To date, the question of how much anatomy education is sufficient to produce adequately trained new physicians persists and has not been addressed with rigorous investigation. Furthermore, not adequately addressed is the related question of how much variation in numbers of anatomical training hours should students preparing for different specialties receive.

Another challenge for anatomy departments or instructors is to find sufficient research data that identifies which instructional practices affect student learning outcomes – a problem that is faced throughout medical education.[9],[31],[36],[44] An important question for anatomy education is how much anatomical training with cadaveric specimens is necessary for basic sciences students. This question cannot be answered without a consensus about the levels of anatomy training which should be required at different stages of a medical student's career. Perhaps, pre-clinical medical students only need to be able to identify and explain basic structures and functions and later, during clinical years, describe correlated pathological results.

Many politicians argue that the medical curriculum is already too long and costly.[47] Experimental sciences in genetics, cell and molecular biology, pharmacogenomics, epidemiology, and statistics are taking time, faculty, and money away from anatomy. Although considered an antiquated medical science at the turn on the 20th century, gross anatomy today holds a central position in medical education.[16] The question of whether it will continue to hold that position is dependent on the kind of instructional strategies, technologies, and assessments which will enable anatomy to thrive throughout the medical curriculum.

At our institution, we have made changes in the laboratory teaching that includes the study of cadaveric plastinated specimens, models, skeleton, digital resources like ADAMS online, Video Home (VH) Dissector dissector, Acland's videos, MRI, and X-rays. Guided by objectives, the laboratory studies are self-directed and facilitated by the faculty. Students are divided into six groups and exposed to two different modules. In the first half of the module, the students study the cadaveric plastinated specimens, skeleton, surface anatomy, and models. In the second module, digital resources are available to the student that includes digital dissection and studying the MRI scans and X-ray. In the second period, the gross functional anatomy is directly linked with the imaging and surface anatomy. This helps in correlating facts in their mutual relationship and leads to a better understanding of the concepts. With this in mind, the student can apply anatomical knowledge to a patient's problem. To date, the literature provides no single best teaching method but suggests that the combination of multiple teaching pedagogies is most effective.[40] Brenner et al. describe different modalities of teaching tools, which include cadaver dissection, the study of prosected specimen, didactic lectures, anatomical models, computer-based learning (ADAMS online, VHS dissector, and Acland's videos), and use of radiological anatomy (MRI's, X-rays, and ultrasounds).[48] However, there is no consensus as to the amount of material to be taught and the duration of a course which is necessary for safe and effective practice.[49]

Research-based best practices can only be answered with investigation into the following questions; is cadaveric dissection necessary in medical education and if so, in which stage of a student's career? Is learning from plastinated prosections and/or computer-based technologies adequate for basic sciences students? How many hours of anatomical education are necessary at the basic science, clinical science, and residency levels? The challenges described in this article could best be met through a multicenter study which reviews and standardizes anatomical education necessary to enable a safe and competent physician.


  Conclusion Top


There is a consensus among educators for change in the teaching of anatomy to medical students. However, the challenge is how to standardize these innovative ideas into a curriculum acceptable to all educators.

Numerous individual studies cited in this article have addressed significantly the challenges and questions facing anatomical education. However, there is no consensus regarding the resolution of these challenges. It is, therefore, incumbent on medical educators in the United States and Canada the Liaison Committee on Medical Education, the Committee on Accreditation of Canadian Medical Schools and leaders in the field of instructional design and technology to come together and standardize the following for the field of anatomy: Learning outcomes expected at various stages of a student's career, intra- and inter-subject integration of basic sciences which facilitate problem-solving in small group clinical settings, greater emphasis on evidence-based medicine in the medical curriculum, the role of digital dissection and plastinated cadaver specimens in place of cadaver dissection, and the best pedagogical practices in teaching anatomy to 21st-century medical students. This requires further evidence-based studies involving collaboration from multiple institutions to concretely establish a standardized teaching practice in anatomy which is adequate for the training of a safe physician.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Abstract
Introduction
Historical Revie...
Current State of...
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Evolution of Anatomy
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