Anatomy education continues to present curriculum planners with interesting challenges. Whether driven by institutional goals of fewer overall contact hours for students, more integration of various disciplines, more interaction with clinical faculty, suggestions for fewer lectures and more interactive learning, technological advances, cadaver costs, or fewer teaching faculty, educational programs in anatomy are being asked to look critically at how they educate. These challenges provide exciting opportunities to reshape the instructional methods used to teach medical students this discipline.
The creation of a new medical school program at the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University (CCLCM), whose initial class entered in July 2004, presented one of these exciting opportunities to develop an innovative approach to anatomy education that I believe to be unique. The challenge was to create a human anatomy course in the context of a problem-based, organ-systems-oriented curriculum stressing small-group, interactive learning, with no lectures and no traditional tests or grades. The available class time for this program in the first year was one morning a week for 1 hour 50 minutes for approximately 30 weeks.
As the development of an educational program in anatomy moved forward, several guiding principles were always at the forefront:
- The educational program that was being developed must fit and follow the philosophical personality of the institution. Thus, it must emphasize active rather than passive learning, and foster the development of lifelong learning and problem-solving skills. Also, assessment at CCLCM is student centered, and each student is expected to attain a defined level of achievement in nine competencies.
- The new program must involve the integration of the basic sciences with clinical medicine. This type of approach allows learning to take place in an authentic context and reinforces the reasons for learning. Studies have shown that this type of integrative learning facilitates the later retrieval of useful information.1
- Medical education is a continuum. Learning should be longitudinal and reinforced on a regular basis.
- Finally, a variety of educational experiences should be used to guide student learning. Several reports indicate that this type of multiple-modality approach fosters the efficient acquisition of knowledge.2,3
What emerged from the development process, which included consultation with surgery colleagues, was an educational program in anatomy referred to as case-directed anatomy. Unique in its approach and innovative in its design, this educational program uses clinical cases to introduce anatomy concepts and facts that are reinforced using cadavers and relevant imaging. The format of this program follows a three-step process: Step 1—Preview a Clinical Case, Step 2—Acquire Basic Knowledge, and Step 3—Reinforce Knowledge in Weekly Sessions.
Step 1—Preview a Clinical Case
The first step in this educational program involves the students’ previewing a clinical case. Clinical cases for each week are posted on the medical school’s Web-based electronic curriculum at the beginning of each organ-system course. Each case has specific learning objectives and clinical questions presented to focus student learning on the anatomy relevant to the case. The following is an example of a case used during the Cardiovascular, Pulmonary and Hematology I course:
A 61-year-old woman presents with severe congestive heart failure (prolonged impairment of the ability of the heart to maintain an adequate flow of blood to the tissues). The cardiac exam reveals an irregular rhythm, and a heart murmur is heard at the right second intercostal space, the lower left sternal border, and the apex. The apical impulse is noted at the anterior axillary line in the sixth intercostal space. A chest x-ray demonstrates that the heart is enlarged. An echocardiogram reveals mildly dilated ventricles, dilated atria, severe mitral regurgitation (backflow of blood from left ventricle to left atrium due to improper functioning of mitral [bicuspid] valve), moderate aortic stenosis (a narrowing of the aortic orifice of the heart), and severe tricuspid regurgitation (backflow of blood from right ventricle to right atrium due to improper functioning of tricuspid valve). She undergoes surgery that consists of mitral valve replacement, aortic valve replacement, and tricuspid valve repair.
An example of the learning objectives and clinical questions associated with this clinical case are presented in List 1.
Step 2—Acquire Basic Knowledge
During the second step, students use textbooks and self-directed learning modules to acquire basic anatomical knowledge. The textbook used in this program is Gray’s Anatomy for Students.4 The students are given specific reading assignments that describe the anatomy relevant to the specific case for that week. The learning modules are a complete, Web-based self-study course consisting of 52 anatomy modules and 25 embryology modules.5 Each module is a short program, in outline format, that uses illustrations and clinical images to present a specific anatomy lesson. Many of the modules also contain a short video clip demonstrating, on a prosected cadaver, the aspect of anatomy discussed in that module. There are self-assessment activities in each module to assist the students as they evaluate how well they comprehend the material. Because the self-directed learning modules are available online, student accessibility is ensured at all times.
Step 3—Reinforce Knowledge in Weekly Sessions
The third step focuses on weekly sessions designed to help students reinforce their knowledge. Each session begins with the presentation and discussion of the clinical case that was used to introduce the anatomy relevant for that week. A clinician leads the interactive session. A cadaver laboratory that presents the anatomy related to the case and outlined in the learning objectives follows this short session. The laboratory consists of a number of stations around which the students rotate. The 32 students in the class are divided into five groups for the laboratory. The stations consist of prosected cadavers demonstrating relevant areas of anatomy and workstations demonstrating those areas using different types of imaging. The prosections and images are prepared and presented to the first-year students by faculty and fellows or residents in the clinical disciplines. Examples of the laboratory stations that would be used to demonstrate the appropriate anatomy for the clinical case that had been presented earlier in Step 1 are presented below.
- Median sternotomy—heart in situ
- Clamshell incision—heart and lungs in situ
- Denuded chest wall—thoracic wall structures
- Hearts—chamber anatomy
- Radiology—chest films, cardiac CTs and MRIs
Thus, learning anatomy in this format involves the use of different educational activities and a variety of interactive experiences.
How is embryology presented?
Embryology is presented using the same case-directed approach and process that is used to present anatomy. The students preview a clinical case, which is posted on the medical school Web-based electronic curriculum, that focuses on a congenital defect. The following is an example of a case used during the endocrinology and reproductive biology course related to the development of the genital system:
A 16-year-old female presents with a concern that she has not yet begun menstruating. She reports normal breast development and growth of normal pubic hair. She denies sexual activity and has no other gynecologic complaints. A physical examination confirms normal breast development and normal pubic hair (Tanner stage V). On examination she has normal external genitalia; however, the vagina is shortened and no cervix is present. An ultrasound evaluation reveals the absence of a uterus and normal ovaries bilaterally.
Each case has specific learning objectives and clinical questions that focus student learning on the embryology relevant to the case. An example of the learning objectives and clinical questions associated with this clinical case are shown in List 2.
To acquire basic knowledge related to this developmental problem, students use the self-directed learning modules that address embryology. As with the anatomy learning modules, the embryology learning modules5 use a variety of illustrations and text that cover all aspects of basic embryology. The modules also contain self-assessment activities to assist the students as they evaluate how well they comprehend the material. The students are also given reading assignments in Langman’s Medical Embryology. 6
A longitudinal program by design
Reinforcement of knowledge through repetitive exposure to information helps to solidify learning. At CCLCM, this has been accomplished by creating a truly longitudinal approach to anatomy education. Following the in-depth program in anatomy education during the first year, students have the opportunity to review and strengthen their knowledge of anatomy, using the same case-directed format, during each organ-system course in the second year. Also, second-year students are given the opportunity, on a voluntary basis, to help fellows or residents prepare the prosections for the new first-year students and for their own review of anatomy in the second year. This provides students with a dissection experience if they are interested.
During the third year, anatomy and embryology will be reinforced in the Basic Core I and II rotations. In Basic Core I, consisting of clinical work in internal medicine, family medicine, and surgery, anatomy will be reviewed using prosected cadavers in two half-day sessions. As with the preparation of the previous prosections, students will be given the opportunity to assist the fellows or residents during these dissections. In Basic Core II, consisting of clinical work in pediatrics, obstetrics–gynecology, neurosciences, and psychiatry, embryology and core neuroscience topics will be reviewed. During the students’ final year, surgery anatomy electives will be offered. These will be designed in discussions involving the medical student and the director of anatomy. Thus, the program in anatomy at CCLCM uses a longitudinal approach in which knowledge is reinforced and strengthened throughout the entire curriculum.
Presentation of material
The success of an educational approach is not only dependent on how the material is presented but also on who does the presenting. This is clearly one of the strengths of the case-directed anatomy program. Clinicians present all of the material, under the guidance of the director of anatomy, who is responsible for the course. Whether it is the clinician who presents the case or the fellow or resident who demonstrates one of the prosections, the students hear about anatomy from an individual who practices clinical medicine. The value of this approach should not be underestimated. Not once in the initial two years of this program has the question been asked, “Why do I have to know this?” Students learn anatomy because it is presented in the context of clinical situations and through the use of clinical examples. Thus, they see the importance of learning anatomy as they prepare for their future as physicians.
Prosection versus student dissection
Whether to use prosection or have students dissect cadavers is a challenging question, and there have been numerous articles written exploring the strengths and weaknesses of each approach.7–9 At CCLCM, the laboratory activity uses prosected, unembalmed cadavers to present the anatomy. There is no student dissection in the first year. Fellows or residents from various surgery disciplines prepare the prosected cadavers and then present the dissections to the students during the laboratory section of the course. To supplement the time available to see the prosected cadavers, students have the opportunity to revisit the laboratory during office hours, which occur three times a week for two hours in the afternoon. During this time, students are able to examine the dissections, and an anatomist is present to answer any questions. Thus, in the case-directed anatomy program, the opportunities to view anatomy using a cadaver exist, but the time needed to prepare a dissection has been eliminated.
However, the chance to have a dissection experience has not been eliminated. For second-year students in the program, the opportunity exists to assist the fellows or residents as they prepare the prosected cadavers for the first-year program students and also for the students in the second-year program. Thus, not only have cadavers not been eliminated in this unique approach to anatomy education, but student dissection still has a place in the training of students. This has proven to be a very valuable experience for the students who have participated (approximately 65% of the class), and, for that reason, I suggest that any institution planning a prosection-only approach should develop a plan that allows students to have a dissection experience.
Small class versus large class
Many reading this article may be saying that this program is a nice idea but that it is impossible with a large first-year class, and class size must be considered as a curricular approach is being developed. My response to this concern is that many of the activities that form the basis of this unique approach to anatomy education can be adapted to a larger class size if the larger group is viewed as multiple small groups. In this plan, several small groups would be involved in interactive sessions with a faculty member leading each group, while the other small groups would participate in whatever type of laboratory exercise had been designed.
The interactive sessions could provide a more structured approach, which in schools with large first-year classes may be necessary because many of the students in this type of program may not be comfortable with a self-directed approach. The laboratory activity would vary depending on the approach decided on by the faculty. It could be (1) prosection-only, with four or five stations that the students rotate around, or (2) student dissection, where the students work in groups, or (3) a combination of the two approaches. Whatever is decided, if a plan using multiple stations that students rotate around is to be followed, each station may need to be duplicated or triplicated depending on the number of students who can comfortably view the activity at each station.
A Promising Approach
This unique and clinically oriented approach to anatomy education was created in the context of an innovative program in medical education. At its core are the four guiding principles listed early in this article.
Is it succeeding? Initial reports suggest that it is. Students are excited about the program, and according to their PBL tutors, clinical preceptors, and physical diagnosis instructors—who provide formative comments about the students’ knowledge and application of anatomy—the students are able to demonstrate anatomical knowledge in other parts of the curriculum and in the clinical setting. One additional positive comment about this approach to anatomy education is that most of the clinical faculty, residents, and fellows participating in the program wish their anatomy courses had been like the approach we are using in this program.