A gross anatomy course and cadaveric dissection are long-standing traditions in medical education. Students learn anatomy while confronting death; they also learn how to work cooperatively within their peer group.1–3 The hours allotted to gross anatomy during the basic sciences years of medical school have decreased steadily over the past century.2,4,5 Because of this trend and the sheer quantity of information that students must attempt to learn in gross anatomy, up to 71% of residency directors report that incoming residents need at least a refresher course in gross anatomy.4
Concern about adequate anatomy preparation is most pronounced in specialties that rely more heavily on anatomic knowledge.4 Given that the trend of decreasing hours dedicated to anatomy in the basic science years shows no signs of reversing, one way by which some medical schools have addressed this dilemma is by supplementing medical students’ anatomy education during their clinical years. This approach allows those students with interest in anatomy-laden fields to reinforce their knowledge in the context of focused, clinically relevant scenarios. In this article, we present and evaluate a model for one such approach that has been adopted at the Duke University School of Medicine, in which anatomists and members of a clinical department, radiation oncology, collaboratively direct and teach an anatomy course to students and other individuals in that department.
Background and Context
Radiation oncology is one nonsurgical specialty in which knowledge of gross anatomy and of the patterns of spread of malignancies is critically important.6–8 Radiation oncologists typically need to decide which regions of the body are to be treated with radiation therapy (RT) and to design RT fields to optimally irradiate target tissues. They must simultaneously understand the relationship between the target tissues and surrounding normal structures for two reasons: to design treatment beams that minimize the radiation dose to critical normal structures near the tumor, and to understand how the surrounding anatomy dictates the patterns of cancer spread so that RT can be delivered to the likely areas of tumor extension. Routine clinical practice relies heavily on diagnostic imaging such as computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography (PET). Students and residents must typically relearn gross anatomy in the context of these medical images to correlate the three-dimensional (3D) anatomy they learned in the gross anatomy class with the anatomy observable on these two-dimensional (2D) images.
In July 2005, we developed a course entitled Oncoanatomy and integrated it into the curriculum for medical students and residents in the department of radiation oncology at the Duke University School of Medicine. The motivations for developing this course were twofold. First, as described above, radiation oncologists must understand the complex anatomy of many body regions. The detail and scope of information that students usually retain after their initial gross anatomy class is usually inadequate for this purpose.4 This course was developed to help reinforce anatomy knowledge in the clinical context of radiation oncology priorities and concerns. Second, direct visualization and palpation of human cadavers provides a unique means for understanding complex 3D and anatomic principles, and we believe that this approach is superior to computer-assisted imaging-based tools. However, because clinical work relies on image-based tools,3 oncologists must be able to translate the 2D images they see in CT, MRI, and PET scans into the reality of complex 3D anatomy. We hope that by improving their comprehension of 3D anatomic relationships, the course will help the participants more proficiently assess 2D diagnostic images.
Development of the Oncoanatomy Course
This course was collaboratively developed by members of the department of radiation oncology and the department of biological anthropology and anatomy. To familiarize themselves with the issues and objectives of radiation oncology, the anatomists, who are basic science faculty, first attended several of the radiation oncology department’s “traditional” case conferences. These 30- to 60-minute conferences are prepared by a resident or medical student with guidance from senior residents or faculty. The student uses slides and illustrations from operative specimens or intraoperative procedures to present a particular question or issue about the management of a patient he or she has seen. The literature pertinent to this question is presented and discussed in an interactive manner in which the medical staff asks the students and residents questions. Members of the radiation oncology clinical faculty also provided several educational sessions for the anatomists, addressing basic principles of oncology (e.g., cancer biology, tumor staging, treatment approaches) and the anatomic underpinnings of radiation oncology. One of the anatomists shadowed a radiation oncologist in the clinic for about 12 hours to observe firsthand how anatomic information was routinely incorporated into clinical evaluations and decisions.
A faculty member and the chief resident in radiation oncology then met with the anatomists to formulate an educational program for incorporating anatomy into the radiation oncology curriculum. Together, they identified common clinical scenarios wherein gross anatomy instruction would enhance the students’ understanding of the disease process and the implications for RT field design. These clinical scenarios were ones in which understanding the 3D relationship between the tumor and adjacent normal structures demonstrates common patterns of cancer spread and the rationale for subsequent treatment planning. Some examples are shown in List 1.
Course logistics and content
The audience to whom this course is directed is the population of medical students rotating through the department of radiation oncology, who are required to attend any oncoanatomy session that meets during their rotation. Because radiation oncology is an optional clinical rotation for medical students at Duke, the number of students in any given rotation is small (usually two to four students), but most of these students are particularly interested in radiation oncology as a potential specialty. Several students have attended many oncoanatomy sessions as they were involved in longer-term activities in the radiation oncology department, such as longitudinal clinics or research projects. The residents in the department are strongly encouraged to attend, and the entire clinical faculty is also invited. The only requirement for completion of the course is attendance (e.g., there are no textbooks or tests).
The course meets monthly in a one-hour-long time slot that is dedicated to the traditional case conference during other weeks. Because there are few conflicts with patient responsibilities at this time, attendance is typically high, with 100% of the two to four medical students, 80% to 100% of the seven to nine residents, and several of the clinical faculty in the department attending. Faculty attendance to any given session is dictated primarily by the topic being covered that day, but approximately 70% of the clinical faculty in the department of radiation oncology have attended at least one session.
The topic for any given session is cancer of a particular location in the body. Each topic is selected on the basis of the available cadaveric material and prevailing interests in the department at that time. For example, once the first-year gross anatomy students had completed their dissections of the head, we were able to use the same cadavers to study the presentation and spread of cancer of the nasopharynx. Similarly, when a particularly interesting case involving a parotid gland tumor was being treated by physicians in the department, we took the opportunity to explore the anatomic considerations relevant to this treatment.
In each session, one radiation oncology resident and one anatomist prepare lectures, and two or three other anatomists prepare dissection demonstrations. In preparation for each presentation, the resident discusses with the anatomists the clinical and anatomic factors that are pertinent to understanding the behavior and treatment of the disease. These discussions normally occur about two weeks before the scheduled class session. The anatomists then supplement their knowledge using textbooks and online resources to become more familiar with the disease process. Total preparation time is approximately 5 to 20 hours for each individual, with the variation resulting from differences in the level of familiarity and complexity of the topics and variation in the extent to which detailed cadaver dissection is required for a particular demonstration.
The format for each oncoanatomy session is as follows:
- A 10- to 15-minute presentation by the anatomist on the anatomic region in question and the relevant embryology and comparative anatomy using anatomic and medical illustrations.
- A 10- to 15-minute case presentation by a radiation oncology resident. These presentations include a review of the patient’s history and diagnostic imaging, a description of the tumor staging, and a discussion of common symptoms at presentation and how they relate to the gross anatomy.
- Thirty to 40 minutes of instruction using specially prepared cadaveric specimens.
Both 10- to 15-minute presentations are informal didactic lectures that occur in a small conference room adjacent to the gross anatomy lab. After the presentations, the group moves into the anatomy lab, where the class divides into two groups of 5 to 10 individuals per group, depending on class attendance that day. The anatomists present two to four cadaver dissections to each of these groups. These dissections are more focused and extensive than is typical for a gross anatomy class, to illustrate the anatomy relevant to the disease and its patterns of spread. Each presentation lasts 10 to 15 minutes, after which the groups rotate to the next demonstration. For example, in the session addressing adenocarcinoma of the pancreas, three separate dissections were presented. One anatomist presented dissection number one, and a second anatomist presented dissections two and three.
- The stomach and bowel were removed to provide an anterior view of the pancreas in situ. The proximity of the duodenum to the pancreas was readily apparent in this view, as was the intraperitoneal location of the first and fourth parts of the duodenum versus the retroperitoneal location of the second and third parts of the duodenum.
- The stomach, duodenum, pancreas, and liver were demonstrated along with the porta hepatis and the major vessels of the area. This dissection demonstrated the close proximity of the pancreas to the duodenum, porta hepatic, and liver, illustrating the ease with which pancreatic cancer may spread to nearby organs.
- The GI tract and its associated vessels were removed and were demonstrated from the posterior view to illustrate the proximity of these vessels to the pancreas and other organs. These relationships are important because the spread of pancreatic cancer to the surrounding soft tissues and lymphatics often can explain the patient’s symptoms and determines the resectability of the cancer.
Access to cadavers
The oncoanatomy course uses the cadavers that the first-year medical students have previously dissected, thereby making further use of these valuable resources. We use these bodies during the months in which the gross anatomy class is ongoing and for a number of months after the course ends. Eventually, the cadavers are dissected beyond the point of being useful. In addition to the gross anatomy cadavers, three extra cadavers per year are set aside from Duke’s anatomical gifts program for use in the oncoanatomy course as well as in several other advanced anatomy courses.
We distributed a confidential survey to 18 individuals, all of whom had attended the conferences in the first six months they were offered (July to December 2005); our research was exempt from IRB approval. All individuals (seven medical students, seven residents, and four faculty) responded to the survey. Respondents may have attended up to six sessions. At the time when the surveys were distributed, sessions had covered cancers of the nasopharynx, pancreas, cervix, gastroesophageal region, and the superior sulcus of the lung (Pancoast tumor). Because of the medical students’ rotation schedules, most of the students had only attended one of the six sessions that had occurred at the time the survey was distributed. Most residents had attended all of the sessions, and the faculty had attended between one and four sessions.
The survey sought to assess the course both qualitatively and quantitatively. The first two questions on the survey identified the respondent’s rank (medical student / resident / faculty / other) and the session(s) that they attended. In the subsequent questions, the respondents ranked the anatomy lectures, clinical case presentations, and dissection presentations separately. They responded for each individual class session and also for the course overall. The survey questions were:
- On a scale of 1 to 10 (1 = no interest, 10 = very interested), how would you rate your interest in the following parts of the sessions? (case study, anatomy lecture, dissection)
- On a scale of 1 to 10 (1 = unsuccessful, 10 = very successful), how would you rate the quality of the following presentations? (case study, anatomy lecture, dissection)
- On a scale of 1 to 10 (1 = none, 10 = a great deal), how would you rate the amount of new knowledge that you gained in the session(s) that you attended? (case study, anatomy lecture, dissection)
- On a scale of 1 to 10 (1 = useless, 10 = very useful), how would you rate the relevance to your work of the topic(s) discussed in the oncoanatomy sessions listed below?
- Please tell us about anything that you found to be particularly useful or interesting in the session(s) you have attended.
Table 1 presents the survey results divided by the session topics, and Table 2 presents the survey results divided by the rank of the respondent. The medical students who responded to the survey had attended one session each, so the data presented in Tables 1 and 2 are the averages of the students’ responses, which refer to different individual sessions. All data in Table 2 refer to the average “overall” rating by each group, except the data for the responses by the medical students.
On average, the respondents ranked their interest in and the quality and relevance of all parts of the course 9.6 on a scale of 1 to 10. The dissection presentation was consistently ranked the highest of the three parts of the course for all sessions as well as in the overall impressions of the respondents (Table 1). The faculty ranked the relevance of the class to their work somewhat lower than did the medical students and residents (faculty: 8.6 out of 10; students and residents: 9.8 out of 10).
In this paper, we describe one approach by which anatomy knowledge may be reinforced for clinicians training in anatomy-laden fields. The course offered at Duke, oncoanatomy, marries the skills and knowledge of anatomists with questions that are specifically relevant to radiation oncology. By providing focused lectures and dissection presentations that are relevant to the treatment of particular cancers, we believe that we both strengthen the medical students’ anatomy knowledge and reinforce the rationales for the treatment of these cancers for all participants.
Our findings from the survey were very encouraging. Qualitatively, the comments from participants have largely been positive. The quantitative results, although based on a small sample size, were also favorable. Every assessment of participant interest and class quality received very high rankings. Unfortunately, we did not assess the students’ knowledge before and after taking the course. Given the relatively small number of students attending each session, and because each session typically included a different pair of students, the value of such an assessment would be limited. However, the consistently high attendance rates and positive qualitative feedback from participants encourage us to perceive this course as successful. Additionally, faculty who often choose not to attend the typical conferences have made special efforts to attend the oncoanatomy sessions that are relevant to their specialties; we perceive that such efforts reflect the positive reputation the course has in the department.
We recognize the potential shortcomings of the quantitative survey that was used, which was not previously tested for validity or consistency. This survey was intended not to represent a rigorous scientific study but to provide some quantitative assessment of the course. One interesting aspect of the survey results is that the dissection presentation was consistently ranked the highest of the three course components. Most students do not have the opportunity to observe anatomy in 3D after completion of their first-year gross anatomy courses unless they are pursuing a specialty that has a surgical component. Despite this, radiation oncologists must have a thorough and confident appreciation for anatomy because they must not only understand the patterns of cancer spread; they also must appreciate what healthy tissues are nearby and adjust their radiation prescriptions accordingly.6–8 The dissection presentations are a unique resource for the advanced medical students, residents, and faculty in radiation oncology because they provide observers with the opportunity to again study anatomy in 3D, which is otherwise difficult using textbooks or online resources. Additionally, by observing the anatomy in the context of clinical points relevant to their daily work, the students find the information more relevant, memorable, and interesting. As one medical student commented, “The anatomy lecture followed by dissection was very informative. It all made a lot more sense than it did first year, when I had much less clinical knowledge.” Residents who have been actively treating patients for a number of years have commented that seeing various anatomic regions in the cadavers in the context of particular cancers not only has reinforced their knowledge of anatomy, it has also underscored the rationale behind various treatment approaches.
The oncoanatomy course is not designed to convey new anatomic or clinical knowledge but, rather, to reinforce these concepts in a different and effective manner. This goal was reflected in participants rating their interest in the presentations somewhat higher than the amount of new knowledge they gained from the course. This is reinforced by the comment of one faculty member: “While I may have ‘known’ the data presented, the dissections gave me a ‘new view.’ When I (took) anatomy as a medical student I had no idea that it would be relevant to my career—so it is good to take a look at things ‘inside out’ and relearn how it is all connected.”
When we examined the results of the survey in the context of the respondents’ rank, the students, residents, and faculty seemed to have similar levels of interest in the class (Table 2). The faculty rated the sessions as being slightly less applicable to their work than did the students and residents. Presumably, this reflects the fact that faculty have specialized in areas that do not always correspond to the topics of the oncoanatomy sessions, whereas students and residents have not yet narrowed their focus. Interestingly, the faculty and residents reported that they gained slightly more new knowledge in the sessions than the students did. This may be attributable to the fact that the students had taken gross anatomy more recently than had the faculty and residents.
Benefits of advanced anatomy courses
The format in which members of the anatomy and radiation oncology faculty teach together in the same classroom has brought about some unexpected benefits. The relatively informal environment and small-group format of the dissection presentations have led to unplanned “teaching moments” that benefit members of both departments, in addition to the medical students for whom the course was originally designed. During the dissection presentations, members of the radiation oncology faculty have spontaneously contributed information based on their clinical experiences to the lessons planned by the anatomists. This information has further enabled the anatomists to see anatomy from the clinician’s perspective. Conversely, the anatomists’ expertise has allowed them to prepare and present creative dissections that demonstrate clinical concepts in ways that the radiation oncology staff would not have considered.
The oncoanatomy course has been a success. Attendees find it interesting and useful, and ongoing sessions continue to be well attended by enthusiastic audiences. The success of the course is attributable to a positive collaborative effort between members of the radiation oncology and biological anthropology and anatomy departments as well as strong support from the medical school administration. This course may be a positive model for other courses focused on supplementing gross anatomy education in other departments in which anatomic knowledge is important, such as surgery (of all types), radiology, gastroenterology, and obstetrics–gynecology.
This study was funded by the Duke University School of Medicine.
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© 2007 Association of American Medical Colleges
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