The purpose of medical schools is to train students to care for patients. This training includes the acquisition of foundational medical knowledge from courses such as gross anatomy, which has been a fundamental component of preclinical medical education for centuries. However, students may not recognize the value of gross anatomy because of its conceptual and temporal remoteness from their future clinical work. Further impacting the perception of gross anatomy has been the significant decrease in its total course hours over the last two decades1 with some evidence of a concurrent decline in retention of anatomical knowledge.2 These factors have promoted a reevaluation of how to teach medical gross anatomy.
According to the educational theory of situated cognition, knowledge acquisition and retention are located in experiences that are bound to context.3,4 For gross anatomy, many medical school programs have incorporated clinical approaches, such as pathology,5 radiology,6 or clinical vignettes,7 into the study of anatomy. Although such “cameo” appearances of clinical content may be both popular and effective, the core of the course largely remains situated in the dissection laboratory, accompanied by anatomical lectures. In contrast, we have developed a program, described here, in which the cadaver is no longer purely the substrate from which to learn anatomy but also becomes the students’ “first patient.”8,9 As such, authentic clinical context becomes embedded within the cadaver as well as in its anatomical study. In this longitudinal program called “Cadaver Rounds,” all the exercises the students perform culminate in a self-directed, final, grand rounds–style presentation. This integrated pedagogy, detailed below, is consistent with the tenets of the situated cognition theory, which holds that learning is learner centered3 and facilitated by contextually authentic tasks.4
Cadaver Rounds was conceived and initiated concurrent with institutional curriculum reform at Virginia Commonwealth University School of Medicine. The reform necessitated changes in both the structure and the duration of the anatomy course. The structure transformed from a region-based, stand-alone lecture/dissection course to an organ systems–based, integrated, flipped-classroom series that occurs over 44 weeks across the first two years of medical school. Student contact decreased 39% from 157 to 96 hours.
The ultimate objective of Cadaver Rounds is for the students (in dissection groups) to gather observations from their first patient that collectively and over time contribute to the identification of a plausible clinical condition that the cadaver-patient likely experienced during life, and then to present that information in a final, grand rounds–style format. This general process is similar to medical care and clinical reasoning (introduced and developed in other ongoing course work; see Figure 1), whereby physicians gather, review, and synthesize patient data to make a diagnosis. We detail the components of the Cadaver Rounds program below (see also Table 1).
Introduction to cadaver and computed tomography scan
Before the first dissection, each dissection group meets individually in the dissection laboratory with a faculty member who explains the safety and ethical expectations, as well as introduces the students (about six) to their first patient—their cadaver. The group then transports the cadaver-patient to the hospital Radiology Department facility where a whole-body computed tomography (CT) scan is performed.6 This CT scan is subsequently made available online for review and study, and each group receives a written report of the CT scan to help identify and understand the images. A prerecorded video (custom-made by the faculty) that explains specific important features of CT scans accompanies each anatomy dissection exercise. Scanning costs are borne by the Radiology Department as part of its teaching mission (see Table 1). Instructional videos are generated using a PC-based video editing program (Camtasia; TechSmith, Okemos, Michigan).
Coping with cadavers
Following a standard anatomy/dissection orientation lecture, students attend a separate session dedicated to the psychological effects of working with cadavers.9,10 A representative from the hospital Chaplain’s Office moderates this session, which is designed to help students adapt to the emotional and existential reactions of working with a cadaver. The presenter helps students develop techniques for coping with the emotional stress of anatomical studies and to incorporate these methods and reactions into their professional development. Because the cadaver is regarded as the students’ first patient,8,9 it also represents the first death in their career and thus defines a new relationship with death.
Cadaver physical examination
During the first laboratory session and before any dissection occurs, each dissection group conducts a modified physical exam of their cadaver based on a standard external examination for autopsies. To do this, students complete a short-answer physical exam worksheet (see Supplemental Digital Appendix 1, available at https://links.lww.com/ACADMED/A649). At this time, each student group learns of their cadaver’s age at death, presumed cause of death, hometown, and occupation. Notably, the actual medical history is not available.
Each dissection group may submit biopsies of abnormal tissue (e.g., tumors or dysmorphic organs) for histological preparation and evaluation by pathologists.5 To perform this task, the students follow an illustrated guide for sample preparation and submission. Along with a written pathology report, photomicrographs of the actual tissue are returned to the students to facilitate correlation with the anatomy. Processing and evaluation costs are borne by the Pathology Department as part of its teaching mission (see Table 1).
All documentation, history information, the physical examination findings, the pathology report, and the CT scan report constitute the cadaver-patient’s “chart.” With each dissection exercise, the students are expected to keep a written log of findings (e.g., anomalies, tumors, malformations, implants) as well as photographic documentation of anomalies or pathologic tissues. Photography of the patient-cadaver is strictly regulated. Only two student volunteers are permitted to take pictures, and they must use dedicated cameras and follow stringent requirements for handling and posting the images (at a secure site on the school’s intranet).
Clinical integration of anatomy teaching
Faculty integrate the teaching of cadaver anatomy with clinical correlations throughout the course. Integration of the anatomical exercises occurs in the form of tableside faculty–student interactions, faculty-led lectures, session-specific instructional videos (using CT scans), and session-specific video clinical vignettes.7 The preparatory session prior to the final Cadaver Rounds report also offers students an opportunity to synthesize what they have learned through their dissection exercises and other observations of their cadaver-patient.
Preparatory session with anatomy and clinical faculty
Approximately one month before the final presentation, clinical and anatomy faculty meet with student groups to help the students summarize their findings, draw conclusions, propose a feasible empirically supported diagnosis, and plan their final presentation. Recruitment of clinical experts for this exercise (and the final presentation) begins several months in advance of the scheduled event. These clinical experts, all staff at Virginia Commonwealth University School of Medicine, are identified through the curriculum office. These staff have eagerly volunteered their time and expertise.
Each dissection group delivers a final, grand rounds–style presentation that addresses the objective of the program: to describe and support a plausible clinical condition that their first patient likely experienced during life. Anatomy and clinical faculty serve as evaluators, each completing a scoring rubric for the presentations (see Supplemental Digital Appendix 2, available at https://links.lww.com/ACADMED/A649). To ensure student participation, students also provide peer-to-peer evaluations. Because some medical students overlook ungraded exercises, the Cadaver Rounds score represents 7.5% of students’ anatomy course grade.
After all the presentations, the clinical experts and students attend a closing and awards ceremony during which the group(s) with the highest score receive the distinction of “Year’s Best Cadaver.” Also, one or two student volunteers deliver a personal account or subjective interpretation of the influence of their first patient. The ceremony and course conclude with a hearty round of applause expressing the gratitude of the entire class for the magnanimity of the gift the donors have given to them, to medicine, and to humanity.
Importantly, Cadaver Rounds constitutes active, self-directed student learning, which is consistent with the guidelines of the Liaison Committee on Medical Education. Furthermore, the added course time is relatively small for both students and faculty. The one-hour introductory/CT scan session occurs during the evening when the hospital scanner is available. The subjective, chaplain-led interactive session also requires just one hour. The preparatory session for Cadaver Rounds is scheduled as two hours of group- or team-based exercises. The final presentations take two hours, after which the closing ceremony extends into the lunch period. Therefore, Cadaver Rounds adds only six scheduled contact hours to the entire course. In terms of faculty time, the additional effort is comparatively minimal because each Cadaver Rounds exercise requires approximately the same amount of preparatory and involvement time as a typical anatomy dissection laboratory. Also, although faculty generation of instructional videos (CT analysis, clinical correlations) is initially time consuming (approximately 10 hours each), once that initial investment is made, the videos require no further input for their subsequent use.
Cadaver Rounds occurs concurrently with all the anatomical exercises, as illustrated in Figure 1, and, therefore, serves as a mechanism to reinforce specific anatomical features in a clinical context over an extended time frame. Furthermore, the program not only underscores the clinical relevance of anatomy but also affords students the opportunity to practice and refine their clinical reasoning skills by synthesizing their empirical observations. Additional benefits of the program include initial exposure to clinical diagnoses and experience in preparing, speaking, and presenting medical/scientific information on a public platform.
According to the seven-item surveys used to evaluate students’ perceptions of Cadaver Rounds in 2015–2017, the students’ experience was highly positive (see Table 2). Overall student appreciation was high for all years (average = 4.2 [standard deviation = 1.0]) on a 5-point Likert scale. Students particularly valued the self-directed nature of the exercise, the designation of the cadaver as their “first patient,” and the goals of the program. Although we did not modify the Cadaver Rounds program from year to year, student perception of the program improved across iterations. In 2015, the average score was 3.9; in 2016, the average score was 4.2; and in 2017, the average score was 4.5. This trend may be due to several factors. Perhaps, the earlier classes disliked the newness of the overall curriculum change, and/or the faculty learned to present the new program with increasingly more confidence.
Another important consideration is student performance on the anatomy subsection of the United States Medical Licensing Examination Step 1. Although anatomy subscores may not necessarily reflect the experience of Cadaver Rounds, there was the possibility that anatomy subscores could drop because of the numerous curriculum-based changes to the course. However, we have noted no differences in students’ anatomy subscores since Cadaver Rounds has been in place.
Faculty participation, assessed by annual review and discussion of the program, has been enthusiastic and supportive. One of the major benefits identified by the faculty has been that pathologies (e.g., tumors, implants) encountered in the cadavers, once regarded as an annoyance/detraction from the study of anatomy, are revalued as representing a positive, educational focus of interest.
The medical gross anatomy course at Virginia Commonwealth University School of Medicine described here takes an expanded view of cadavers. Beyond being a substrate for learning anatomy, the cadaver, as the students’ first patient, provides clinical context during the longitudinal, self-directed anatomy course and Cadaver Rounds program. Subsequent efforts will be directed toward identifying and including additional clinical exercises that can be modified and imported into the dissection laboratory, especially to supplement specific dissection topics (such as a digital rectal exam while studying the prostate). Also, instead of having only selected students provide an oral tribute to their first patient during the final ceremony, we will encourage all students to submit personal accounts of their experience with their first patient. We hope to combine all these narratives into a document accessible to the entire class and publish selected works in the online newsletter. A further step in the ongoing development of Cadaver Rounds is to partner with or assist in the implementation of this approach within other medical anatomy programs. Because Cadaver Rounds is dynamic and flexible, it can be adjusted to an existing program with only a few additional contact hours, and it can accommodate current staffing and curricular pressures.1 If adopted by other institutions where major variables (course time, content, curriculum structure—see Approach) are controlled, then directly evaluating the efficacy of Cadaver Rounds as a teaching stratagem will be possible. Ultimately, a wide-scale importation of authentic clinical features into gross anatomy dissection exercises could help bridge the divide between the preclinical and clinical components of medical training.
Acknowledgments: The authors thank Dr. Daniel Erb for review and comments on an earlier version of this report.
1. Drake RL, McBride JM, Pawlina W. An update on the status of anatomical sciences education in United States medical schools. Anat Sci Educ. 2014;7:321325.
2. Doomernik DE, van Goor H, Kooloos JGM, Ten Broek RP. Longitudinal retention of anatomical knowledge in second-year medical students. Anat Sci Educ. 2017;10:242248.
3. Schumacher DJ, Englander R, Carraccio C. Developing the master learner: Applying learning theory to the learner, the teacher, and the learning environment. Acad Med. 2013;88:16351645.
4. Burgess A, Ramsey-Stewart G. Anatomy by whole body dissection: A focus group study of students’ learning experience. Adv Med Educ Pract. 2015;6:533537.
5. Eisenstein A, Vaisman L, Johnston-Cox H, et al. Integration of basic science and clinical medicine: The innovative approach of the cadaver biopsy project at the Boston University School of Medicine. Acad Med. 2014;89:5053.
6. Lufler RS, Zumwalt AC, Romney CA, Hoagland TM. Incorporating radiology into medical gross anatomy: Does the use of cadaver CT scans improve students’ academic performance in anatomy? Anat Sci Educ. 2010;3:5663.
7. Ikah DS, Finn GM, Swamy M, White PM, McLachlan JC. Clinical vignettes improve performance in anatomy practical assessment. Anat Sci Educ. 2015;8:221229.
8. Cobb WM. The Laboratory of Anatomy and Physical Anthropology of Howard University. 1936.Washington, DC.
9. Weeks SE, Harris EE, Kinzey WG. Human gross anatomy: A crucial time to encourage respect and compassion in students. Clin Anat. 1995;8:6979.
10. Penny JC. Reactions of medical students to dissection. J Med Educ. 1985;60:5860.