From cadavers to clinical practice: the anatomy of lifelong learning

Introduction

Basic sciences are the foundation stones on which clinical knowledge and skills are built. Clinical teachers are the cement that binds and bridges these bricks of theory and practice. However, anatomy teaching is in a phase of transition. Traditional methods of teaching such as cadaver dissection are declining. Anecdotal evidence postulates that anatomy knowledge amongst medical students and graduates is deteriorating. ¹ Contemporary integrated undergraduate medical curriculums, focusing on system-based and problem-based learning, have led to the erosion of a core anatomy curriculum and time dedicated to teaching anatomy.^2,3 Anatomy is often taught by non-medical teachers and lacks a clinical context leading many to question the adequacy of current methods of assessing anatomy knowledge amongst undergraduate medical students. ²

Given these challenges, new methods of delivering anatomy teaching must be developed in addition to, but not instead of, more traditional methods such as cadaver dissection. Clinical teachers are ideally placed to develop such novel approaches. Evidence exists, which shows that an integrated approach to teaching anatomy, surgery and radiology leads to increased interest and acceptance amongst medical students. ⁴ Furthermore, it has been postulated that a clinical approach to anatomy teaching increases student confidence in their clinical skills and knowledge base by bridging the knowledge theory gap.^1,4 However, little is known about the educational needs of newly qualified doctors concerning the basic sciences as they transition from medical students to practicing clinicians responsible for their own ongoing professional development.

Aims

The aims of this study were firstly to establish foundation year doctors’ (FYD) attitudes towards anatomy in terms of perceived importance to their practice and future career, teaching methods previously exposed to and their satisfaction with these. Secondly, this study aimed to determine whether delivering a course integrating clinical anatomy, radiology and surgery would enhance FYD motivation, comprehension and confidence in both anatomy knowledge and its application to their clinical skills.

Methods

A course was designed which aimed to teach clinical anatomy by talking students through common surgeries of the abdomen and related radiology. For example, lower gastro-intestinal tract anatomy was taught through explaining small and large bowel resections. This course was free, voluntary and open to all FYD in the West of Scotland deanery. It was delivered by general surgery trainees of ST3 level and above. Teaching methods included: lectures, interactive small group tutorial and DVD demonstrations.

A pre-course questionnaire was formulated to establish anatomy teaching methods that students had been exposed to and their perceptions about the usefulness of each method. Pre- and post-course assessments were based on the anatomy competence score (ACS). The ACS incorporates multiple-choice questionnaire (MCQ), objective structured practical examination (OSPE) and objective structured clinical examination (OSCE) assessment, to assess the three domains of: theory, practical application of knowledge and clinical application of knowledge, respectively. ⁵ This also helped to establish a more holistic view of knowledge acquisition. Finally, a satisfaction questionnaire was formulated to study overall satisfaction with the course and its impact on FYD confidence in their anatomy knowledge and application to clinical skills.

A pilot study was carried out on senior medical students rotating through their general surgery attachments in a small district general hospital. This cultivated feedback from 44 students on course content and assessment tools; 86% rated the course as excellent and 93% would recommend the course. Analysis of pilot study data proved intra-rater reliability, construct validity and inter-rater agreement for the participant satisfaction questionnaire. Literature review, in conjunction with qualitative feedback from senior members of the surgical department, established content validity and reliability of course material. Qualitative feedback from students highlighted the popularity of clinically focused small group sessions. The course was therefore modified to include more clinical skills sessions, where students would translate newly acquired knowledge into simulated clinical scenarios.

Ethical considerations

All FYD participating in the course were fully informed that the course they were attending was part of a study. The purpose and aims of the study were explained in an introductory lecture and participants signed a consent declaration giving permission for their anonymous feedback and assessment scores to be used in the study.

Results

Twenty-nine FYD participated in the course; 96.55% rated anatomy as important or very important to their career and clinical practice; 55.17% rated their anatomy knowledge as average. Only 6.9% felt confident in applying their anatomy knowledge clinically despite 82.76% feeling that they applied anatomy knowledge weekly or more frequently. The most popular method of teaching was tutorials with theatre sessions, cadaver dissection and seminars rated equal second.

Satisfaction with this approach to anatomy teaching was high; 100% reported the course to be relevant, useful, advanced their knowledge and said they would recommend it to fellow FYD; 92.86% felt it improved their confidence on the subject and 58.62% felt it improved their clinical skills. The average pre- and post-course assessment score increased from 55% to 81%.

Discussion

Findings from this study corroborate existing studies which show that an integrated, clinical approach to teaching anatomy improves both acquisition of, and confidence in, anatomy knowledge.^1,4 High satisfaction levels have been reported with a clinical approach to anatomy teaching both in the prior teaching methods that students had been exposed to, and also through this course. FYD also highly value cadaver dissection as a teaching method, which reiterates existing studies championing the need to develop novel approaches to anatomy teaching in addition to, but not instead of, traditional methods of teaching.^1,3,4 FYD rated theatre sessions as very useful modes of anatomy teaching. Further work is recommended on how to maximise operating theatre time as anatomy teaching opportunities for junior doctors and also on how to support and train surgeons in achieving this.

Given that, confidence in anatomy knowledge and its application is so low amongst FYD, more work is required to explore the best ways of assessing anatomy knowledge within undergraduate and postgraduate curriculums. Future studies exploring the impact of undergraduate curriculum design on FYD confidence in anatomy may be a starting point in establishing the true impact of modern curricula and teaching styles on anatomical knowledge.^1,2 This could provide context for a subsequent exploration of educational needs during the transition from medical student to junior doctor so that ongoing educational needs in this area can be better supported.

Conclusion

A clinical, integrated approach to teaching anatomy is successful in terms of knowledge acquisition, development of FYD confidence and satisfaction. More work needs to be done exploring how best to: utilise operating theatre time as educational opportunities, assess clinical anatomy knowledge and address ongoing educational needs during transition from medical student to junior doctor.