Abstract
A series of three annual surveys of David Geffen School of Medicine (DGSOM) at UCLA students and UCR/UCLA Thomas Haider Program in Biomedical Sciences students were administered from 2010 to 2012 to ascertain student perceptions of which anatomy pedagogy—prosection or dissection—was most valuable to them during the first year of preclinical medical education and for the entire medical school experience in general. Students were asked, “What value does gross anatomy education have in preclinical medical education?” We further asked the students who participated in both prosection and dissection pedagogies, “Would you have preferred an anatomy curriculum like the Summer Anatomy Dissection during your first year in medical school instead of prosection?” All students who responded to the survey viewed anatomy as a highly valued part of the medical curriculum, specifically referring to four major themes: Anatomy is (1) the basis for medical understanding, (2) part of the overall medical school experience, (3) a bridge to understanding pathology and physiology, and (4) the foundation for clinical skills. Students who participated in both prosection and dissection pedagogies surprisingly and overwhelmingly advocated for a prosection curriculum for the first year of medical school, not a dissection curriculum. Time efficiency was the dominant theme in survey responses from students who learned anatomy through prosection and then dissection. Students, regardless of whether interested in surgery/radiology or not, appreciated both pedagogies but commented that prosection was sufficient for learning basic anatomy, while dissection was a necessary experience in preparation for the anatomical medical specialties. This suggests that anatomy instruction should be integrated into the clinical years of medical education.
Introduction
The mere words gross anatomy conjure a variety of personal experiences from medical students and experienced physicians, alike. Many view their time in gross anatomy as a rite of passage and as the one experience that sets the medical profession apart from non-medical, post-baccalaureate programs. 1 Within the medical community, opinions about gross anatomy can differentiate surgical and non-surgical practitioners. 2 Apart from these anecdotal over-generalizations, gross anatomy, as a foundational medical science, has traditionally been the forum in which medical students learn the language of medicine, 1 experience their first professional relationship with a patient, 3 learn how to work with colleagues to accomplish the task of learning an inordinate amount of semantic and functional relationship information,3,4 and in many cases, face mortality for the first time. 5 By fully participating in these experiences, students consequently begin their metamorphosis from being consumers of knowledge to becoming healers and life-long learners.
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/or cadaver 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. Different schools utilize the prosection program differently. In most people's minds, prosection involves viewing dissected specimens as if they were museum pieces. At the David Geffen School of Medicine (DGSOM) at UCLA, students learning from prosected specimens are working in teams to learn anatomy through palpation of structures. Indeed, the only process not performed during class time is the dissection process to get to the structures that need to be studied. In a typical four-hour lab, prosection students spend the entire time studying anatomy instead of finding anatomy. Without the dissection component to the laboratory exercise, more time can be devoted to learning the anatomy during class time.
After the publication of the Flexner Report, 6 and later introduction to the problem-based learning paradigm,7, 8 medical education experienced a massive paradigm shift from a non-integrated basic science and clinical science curriculum to an integrated curriculum. This resulted in precipitously declining contact hours available to gross anatomy instruction and the ability 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 U.S. medical education 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. 9
DGSOM students 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 at the University of California Riverside (UCR)/UCLA Thomas Haider Program in Biomedical Sciences learn anatomy through dissection during their first year of medical school. 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 student's attitudes and thoughts toward the educational approach to mastering anatomy.
Methods
We conducted three annual online surveys of DGSOM at UCLA students and UCR/UCLA Thomas Haider Program in Biomedical Sciences students from 2010 to 2012 to assess student perceptions of anatomy instructional styles. 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.
Students were given the following instructions regarding their identity:
“Data from the survey will be used for cross-sectional and longitudinal research purposes. Your identity will be coded from the key personnel of the study (Wisco JJ, Wimmers PF) and remain so throughout your medical school career. However, in order to contact you for participation in the survey in future years, the Office of the Dean for Medical Education will necessarily need to keep a record of your identity with this survey. You will not receive any benefit from participating in the survey other than the opportunity to contribute to medical education research. You are not required or obligated to participate in this survey.”
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 part of the survey, students were asked to provide a qualitative-free response to the following question: “What value does gross anatomy education have in preclinical medical education?” We classified responses based on the anatomy pedagogy students received: prosection only, prosection/dissection, or dissection only. We further asked for a free response answer of only prosection/dissection students: “Would you have preferred an anatomy curriculum like the Summer Anatomy Dissection during your first year in medical school instead of prosection?”
Data for answers to the question, “What value does gross anatomy education have in preclinical medical education?” 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, and likewise for the other classifications. We analyzed all the data for primary themes and classified responses for whether each was provided by a prosection-only, prosection/dissection, or dissection-only student. We also indicated whether the student was a second-year (MS II), third-year (MS III), or fourth-year (MS IV) medical student, or intern (PGY 1).
Data for answers to the question, “Would you have preferred an anatomy curriculum like the Summer Anatomy Dissection during your first year in medical school instead of prosection?” were classified into whether students advocated for prosection, advocated for dissection, or were neutral. We also indicated the student year (MS II, MS III, MS IV, PGY 1) for each response.
We directly quoted representative student answers for each of the aforementioned categories.
This study was approved by the David Geffen School of Medicine at UCLA Institutional Review Board in accordance with the principles of the Declaration of Helsinki, which covered both DGSOM and UCR/UCLA students.
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). The response rate for prosection students was 61.4% (n = 51), for prosection/dissection students was 53.8% (n = 42), and for dissection students was 70.8% (n = 17).
In 2011, the total response rate from among two years of DGSOM and UCR/UCLA students was 42.2% (n = 156). The response rate for prosection students was 51.9% (n = 83), for prosection/dissection students was 37.0% (n = 60), and for dissection students was 27.1% (n = 13).
In 2012, the total response rate from among three years of DGSOM and UCR/UCLA students was 17.5% (n = 97). The response rate for prosection students was 18.2% (n = 44), for prosection/dissection students was 19.5% (n = 47), and for dissection students was 8.3% (n = 6).
In all, 35 of the 149 DGSOM/prodis students repeated the survey at least once and 17 students from among all cohorts repeated the survey three consecutive years.
Overall responses to survey
All students who responded to the survey viewed anatomy as a highly valued part of the medical curriculum (99% positive response). The anatomy pedagogy (prosection and/or dissection) influenced how students valued their anatomy experience in the medical curriculum. Dissection-only students from UCR/UCLA commented that it would have been helpful for them to receive contextual or clinical context to what they were learning. Prosection/dissection from DGSOM at UCLA overwhelmingly advocated for a first-year curriculum of prosection pedagogy, but acknowledged the importance of dissection later during the medical school education. The aforementioned sentiments from all students were given regardless of the year in school that any particular student responded to the survey.
“What value does gross anatomy education have in preclinical medical education?”
The responses to this question were overwhelmingly positive. There were a number of negative responses, but they all pertained to observations that the pedagogy was too far removed from the clinical context. Below are listed representative quotes for four major themes that we identified amongst all of the responses regarding the value of anatomy education in preclinical medical education: Anatomy is (1) the basis for medical understanding, 2) part of the overall medical school experience, 3) a bridge to understanding pathology and physiology, and 4) the foundation for clinical skills. For all responses quoted, the current year in school for each of the respondents is annotated at the end of each quote in parentheses.
Basis for Medical Understanding
Prosectors (DGSOM at UCLA)
“It is important to understand the basics of anatomy prior to working with patients. Knowing the basic anatomy of the head, neck, thorax, and abdomen provides essential information needed to understand diagnostics and therapeutics in clinical medicine. However, in my experience, an overly detailed study of anatomy (such as the tiny musculature of the head and neck, the musculature of the larynx, and much of the musculoskeletal anatomy of the extremities) results in students memorizing the material for course exams and board exams and then just forgetting it later as it is not useful in most clinical settings. I can imagine, though, that for my colleagues destined for careers in surgery and radiology—their responses would be markedly different.” (PGY 1)
Prosectors/dissectors (DGSOM at UCLA)
“Gross anatomy is essential to understanding the human body. It provides insight into the daily physical exams we perform on the wards and prepares us for future careers in both medicine and especially surgery. The prosection-based approach is simply more efficient given the time constraints and the availability of the summer dissection program is complementary to the core curriculum.” (MS III)
Dissectors (UCR/UCLA)
“Definitely helps visualize the human body but unfortunately much of it is lost on us without having clinical experience. Would potentially be better to intertwine this with some kind of surgical experience (video or shadowing) to help translate the dissection/prosection into real-life clinical applications.” (MS III)
Part of the Overall Medical School Experience
Prosectors (DGSOM at UCLA)
“Immeasurable value! It prepares you for examining patients, understanding disease processes, and taking tests. And just philosophically, it seems important for medical students to learn the whole gross structure of the body they're working with.” (MS II)
Prosectors/dissectors (DGSOM at UCLA)
“The structures are central to just about everything we learn. Knowing how it all fits together literally provides a framework into which we can organize information. Also being comfortable around a cadaver makes being comfortable around most other things much easier. Oddly enough that amount of contact with another person, albeit a deceased one, also cements the idea of human touch as being central to medicine.” (MS II)
Dissectors (UCR/UCLA)
“Helps with physical exam and imaging modalities as well as surgery but I don't think that was emphasized to its full extent even in dissection. More clinical skills training and procedural training in anatomy lab would have been helpful. Also, reviewing the anatomy before 3rd year clerkships for surgery ' OB/GYN would be useful.” (MS III)
A Bridge to Understanding Pathology and Physiology
Prosectors (DGSOM at UCLA)
“I believe it is extremely important for medical students to have an understanding of the anatomical structure and function of the body prior to starting on the wards. It helps not only with physical examination skills, but also with reading radiological studies and understanding of the surgeries you see on your surgical clerkships. Anatomy is also a very important component to the understanding of many disease processes, so it is important to have it as a foundation prior to learning all of the pathology in the second year of medical school.” (MS IV)
Prosectors/dissectors (DGSOM at UCLA)
“Gross anatomy helped me in relating the other courses to the physical location and structure of the different organ systems. It was helpful to have a strong understanding of the anatomy while we were learning about how the organ systems functioned, but being able to revisit the prosection after going through the pathology curriculum would have been useful for comparing and contrasting even after being presented with the pathological specimens.” (MS IV)
Dissectors (UCR/UCLA)
“Gross anatomy allows you to see and touch a lot of the pathology that you are learning about and helps to present all the didactic material in a different fashion. But I definitely see the benefit of gross anatomy during 4th year as well after completing my autopsy path rotation, which again helped to refresh my knowledge base in anatomy.” (MS IV)
The Foundation for Clinical Skills
Prosectors (DGSOM at UCLA)
“Gross anatomy dissections/prosections are usually the first chance we have to really see inside the human body. It is important to see, touch, feel, and interact with anatomical structures in a comfortable, learning environment before examining and cutting into real patients. I am a very hands-on learner. My knowledge of anatomical structures on the boards and in my surgical clerkships was definitely strengthened by having physically dissected and examined cadavers in anatomy lab. I think prosection can be very helpful for intricate or difficult-to-dissect structures, but I believe it would be most helpful to have prosection as a model for students to refer to when performing their own dissections.” (MS IV)
Prosectors/dissectors (DGSOM at UCLA)
“It is the basis of our physical exam. Without a decent knowledge of anatomy, you will really suffer as a clinician. I would have appreciated more re-enforcement during the clinical years in the anatomy suite, going over structures and seeing the 3D anatomy again. This would be particularly helpful as we begin to specialize, and we can concentrate on exactly what we want to see in the cadaver.” (MS IV)
Dissectors (UCR/UCLA)
“[Students] should be taught in the applied context—that is, in context of procedures, radiology, pathology, to help students make connections between anatomy, physiology, and pathophysiology. Rote memorization of structures is not helpful and typically is forgotten before they are put to use. In-depth anatomy knowledge would have been helpful in procedural skills, but the importance is not realized until much after anatomy lectures are far gone (i.e. clinical rotations).” (MS IV)
“Would you have preferred an anatomy curriculum like the Summer Anatomy Dissection during your first year in medical school instead of prosection?”
Responses to this question were mixed, but one surprising theme emerged: time efficiency. Below we list representative quotes from prosectors/dissectors (DGSOM at UCLA) about whether they advocated for prosection or dissection pedagogy during their first year of medical school. For all responses, the current year in school for each of the respondents is annotated at the end of each quote in parentheses. Only 4 students (out of 17) who advocated for dissection during the first-year curriculum provided commentary.
Advocate for Prosection
“I strongly believe that it is a better use of our time to use prosections to learn the anatomy and the optional summer dissection program to give more experience to those who wanted it. This allowed students to specialize based on interest and be able to prioritize, which is extremely important in medicine. This structure gives students interested in anatomy more opportunity to really spend time in the anatomy lab while giving other students the option to focus their efforts in other places.” (MS II)
“Learning through prosections was extremely valuable to me. It removed the frustrations of dissection and enabled us to concentrate fully on learning the anatomy of the human body in a time efficient and effective way. Then, later going back and performing dissections helped to solidify that knowledge as well as helped me with procedural skills.” (MS III)
“During the summer dissection course, I realized that it was easy to get lost in perfecting the dissection, and it took some deliberate effort to use this activity as a review/learning tool. Spending time isolating the structures rather than observing them and studying them may not have been as beneficial during the actual anatomy course.” (MS IV)
“The dissection program [after the first year of medical school] is good because it allows those who are interested in anatomy… future path, rads, and surgery residents to participate while those who are less anatomically inclined can do something else with the allotted time.” (PGY 1)
Advocate for Dissection
“Yes. I believe a curriculum like the Anatomy Summer Dissection would have enhanced my educational experience in Anatomy. I think I would have learned and understood more with direct hands-on dissection experience. I had previous dissecting experience prior to coming to medical school, and that is the experience that I often draw upon because it is etched into my long-term memory.” (MS II)
“Dissection would have helped me learn the anatomy better [as I discovered] during my time in summer dissection.” (MS III)
“I think there is something to obtain the depth and relation of structures while you conduct the dissection. I feel this is lost with prosections.” (MS IV)
“The anatomy prosection curriculum was certainly one of what I perceive to be the top two weaknesses of my preclinical medical education.” (PGY 1)
Undecided or Advocated for Both Prosection and Dissection
“I think a combination of the two would be best. People that want to do medicine and not surgery tend to like having less anatomy, especially less hands on anatomy. I like the current setup with prosection during the year and elective dissection in the summer for those that want it. Adding some dissection to the first year curriculum would be another option.” (MS II)
“I thought the progression from prosection to preparing the dissection was appropriate; however I definitely feel weaker in areas of anatomy that I did not do during the Summer Dissection.” (MS III)
“I think that a mixed curriculum (dissections + prosections) would have been ideal.” (MS IV)
Discussion
Prosection followed by dissection pedagogy
We were astonished that students who learned anatomy through prosection and dissection overwhelmingly advocated for prosection pedagogy in the first year of medical school, despite the fact that they thoroughly enjoyed dissecting. We did not follow enough students long enough to determine whether they entered surgical or radiological specialties. Anecdotally, however, many students who participated in the Summer Dissection Program had either surgical or radiological specialties in mind. The dominant theme in these students' responses was that learning anatomy through prosection first, and then dissection later during their medical career, was the most efficient use of their time.
As preclinical medical curricula have become increasingly time deficient in order to fit all the basic sciences instruction, adopting a prosection, and then dissection anatomy pedagogy, should be one that all curriculum designers should consider. As mentioned earlier, only two schools in the United States currently use a prosection-only anatomy curriculum. One of those is DGSOM. To our knowledge, the other institution does not include dissection later in its preclinical medical curriculum.
In addition, vertical integration of the anatomical basic sciences into the clinical curriculum would allow students to revisit important anatomical concepts when it is most relevant. Therefore, students could learn the basic principles during the preclinical years and learn the clinically relevant details during the clinical years. DGSOM has started employing this philosophy by offering teaching in clinically relevant anatomic radiology to third- and fourth-year medical students, and third-year clerkship anatomy orientations for Ob/Gyn rotations and emergent bedside simulations using cadaveric specimens to fourth-year medical students enrolled in the Acute Care College.
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. All but one of these students showed constancy in their responses: Opinions (positive, negative, or neutral) toward the anatomy curriculum were maintained throughout each of the years of answering the survey. The one student who changed his/her mind, initially, declared that anatomy was extremely important to medical education, but by the third year responded undecided. External factors may be playing a role in any student's preference for one pedagogy versus another, be it preparing for a specific residency/specialty choice, or a personal aversion or appreciation toward anatomy. In the case of this one student, it is possible that he/she changed specialties toward a non-anatomical sciences clinical practice, but we did not gather this information.
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.
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: JJW and CRG. Contributed to the writing of the manuscript: JJW, SY, PR, SDL, PFW, CB and CRG. Agree with manuscript results and conclusions: JJW, SY, PR, SDL, PFW, CB and CRG Jointly developed the structure and arguments for the paper: JJW, SY, PR, SDL, PFW, CB and CRG. Made critical revisions and approved final version: JJW, SY, PR, SDL, PFW, CB and CRG. All authors reviewed and approved of the final manuscript.
Footnotes
Acknowledgments
The authors would like to thank the individuals who donated their bodies and tissues for the advancement of education and research. We also thank LuAnn Wilkerson, Ph.D.; Neil H. Parker, M.D.; Michelle Vermillion; Evie Kumpart; and Meredith Szumski, Ph.D., for their assistance with acquisition of the survey data.