Dissection laboratory is vital to medical gross anatomy education

Abstract

The medical anatomy course has become a complex and complicated educational experience, in which dissection of the human body instructs not only in structure and function, but also in psychosocial areas critical to the development of the whole physician (Dyer and Thorndike, 2000; Gregory and Cole, 2002; Rizzolo, 2002). As the need to teach newer areas (such as molecular biology, cell biology, and medical genetics) has severely compressed the time spent in the dissection laboratory, and a generation of anatomists has reached retirement age without replacement (Marks, 1996; Fitzharris, 1998; Cottam, 1999; Parker, 2002), elimination of dissection is seen as one way to resolve these pressures. Can an anatomy course fulfill its objectives if it no longer includes dissection, using instead two- or three-dimensional virtual representations and computer-assisted learning programs? I would argue that it cannot. I have listed the major reasons why I believe dissection is so important to the learning of anatomy and the creation of the mature physician, gleaned from my own experiences and that of many in the field more eloquent than I, including some of the thoughts of students at the University of North Carolina School of Medicine. Student quotations are taken from e-mails sent to me in response to the Los Angeles Times article “Cutting Out the Cadaver” (Zarembo, 2004). Roman numerals refer to the student's medical school (MS) educational level. Dissection teaches the following: Patients are three-dimensional beings, changing as they age. It is in the dissection laboratory where students form their ideas and mental images of the structure of the human body at different levels over time (Marks, 2000). There is little educational research on how students learn three dimensionally, but it is clear that education on real cadavers allows them to recall this information on demand (Moore, 1998). “Although it is true that much of what we learn in our first 2 years has nothing to do with clinical medicine, dissection does …. The only way to truly know the body is to get up close and personal with it … to feel the tendons and nerves, the fascia and the vessels. There are times when I have to do a femoral stick or an a-line or a central line and I remember the anatomy not from some picture but from what I saw during my own dissection” (MS IV student). The dissection laboratory is the only place where the three-dimensional structure of the human body is reinforced by visual, auditory, and tactile pathways (Mutyala and Cahill, 1996; Aziz et al., 2002). A simulated haptic experience that can adequately replace dissection of the cadaver is not yet available and may not be for many years. “I can't figure out why technology is so often championed as a substitute rather than a supplement in anatomy when, after all, a patient is human—with smells and fluids and all the ‘dirty’ stuff …. When a baby is being delivered in my arms, pointing and clicking on a computer screen will not help me” (MS IV student). The dissection laboratory is the only place where the three-dimensional structure of the human body is reinforced by visual, auditory, and tactile pathways. A simulated haptic experience that can adequately replace dissection of the cadaver is not yet available and may not be for many years. The dissection laboratory provides an introduction to the variability of the human body and the uniqueness of each cadaver. Discussions of variability have been dropped from many of the current textbooks, and lack of this information, or even of an awareness of variability, can lead to misdiagnosis and malpractice (Willan and Humpherson, 1999). “For me, one of the most important lessons I learned in anatomy was that a vast range of structures are considered normal (or at least will never cause dysfunction)” (MS III student). Terminologica anatomica (Federative Committee on Anatomical Terminology, 1998) is the anatomical vocabulary used throughout medical training and practice, and the use of this terminology facilitates a common discourse about anatomy in both healthy and diseased patients (Whitmore, 1999; Rosse, 2001). It is in the dissection laboratory that this vocabulary is acquired and learned, not by rote memorization, but by conceptualization based on what is seen and felt. The routine performance of dissection provides students with training in spatial appreciation and orientation and in the use of instruments. Most of these are directly related to surgery, but the acquired skill in eye-hand coordination and manual dexterity is relevant in a variety of clinical settings (Moore, 1998; Newell, 1999; Ellis, 2001). The normally small dissection groups force students early on in their professional education to communicate effectively, engage in cooperative interaction, and utilize “both self-directed and directed self-learning” (Newell, 1999). This establishes the routine by which they will continue to work, as a part of a medical team in many different practice settings (Moore, 1998; Aziz et al., 2002). In addition, the bonding of the dissection team fosters coping with the distress of the laboratory (Coulehan et al., 1995) and the stress of the first year of medical school. “I feel gross anatomy was like deriving the equation instead of being handed the equation” (MS III student). “Sharing the struggle of assimilating tons of information, learning a new ‘language’ and dealing with the implications and magnitude of dissecting a human being is, in my opinion, one of the more formative experiences in the first 2 years of medical school” (MS IV student). Their first encounter with a cadaver establishes for the students the reality of a human life, connects them to their ultimate objective—the living patient—and confronts them with the tremendous responsibility they will assume in treating that patient as their physician (Coulehan et al., 1995; Aziz et al., 2002). The anatomy dissection laboratory is often where the process of professional acculturation is initiated, fostering knowledge, skills, attitudes, values, and behaviors that will enable physicians to function appropriately within their chosen discipline. “It is the only course in the first 2 years that makes explicit the privilege and challenge of being a physician, because only the anatomy lab teaches you to be intimate with the bodies of strangers” (MD graduate, class of 2004). Introduction of the concepts of humanistic care in a medical curriculum is a formidable task in the face of increasing educational technology and procedurally based patient treatment. The anatomy laboratory is where this education can begin, with attention to end-of-life issues and to opportunities for student expression of their emotions and attitudes (Rizzolo, 2002). The students' emotional responses to their cadaver and, for many, their first confrontation with death and dying present a true teaching opportunity. “Compassion and true understanding go hand in hand, and it is only with a hands on dissection (as messy and smelly and frustrating as it may get) that both may be maximized” (MS III student). Memorial services for the donors are standard ritual in many curricula (Tchernig and Pabst, 2001). Thus, the dissection laboratory plays an essential role in “initiating a balanced attitude to death and dying in trainee medical doctors” (Tchernig et al., 2000). “I never want to dissect again. But I also recognize what an amazing experience this was. Someone gave herself to me. She forced me to confront death in a very real way, a way that I will have to contend with as a future physician …. Dissection was a critical part of my development of compassion towards my future patients” (MS II student). It is interesting to note that the University of Washington discontinued full dissection in the 1970s and made the dissection laboratory an elective. Dissection returned to the curriculum 2 years later, when nearly 90% of their students signed up for the elective (Clark, 2003). Would this happen today, with the wealth of computer programs available to replace dissection? Perhaps so. A recent study at the Rush Medical School indicated that even the students who dissect little (30 h total) sense that this process is somehow important to their training (Dinsmore et al., 1999). A far better measure of the students' anatomical knowledge than the United States Medical Licensing Examination (USMLE) part 1 score is the measure of the clerkship and residency directors who subsequently train them. In a recent study, a majority of the reporting residency program directors felt that gross anatomy was either extremely important or very important to the mastery of their discipline, and 57% of them felt residents needed a refresher course in gross anatomy upon arrival (Cottam, 1999). Is this situation only going to worsen if dissection is no longer part of an anatomy course? This article is one of four invited papers that address the following question in a moderated debate format: “To what extent is dissection necessary in the learning of medical gross anatomy?” These articles were published in the November 2004 issue of The Anatomical Record Part B: The New Anatomist (Vol. 281B#1, pp 2–14). These articles can also be accessed online through our virtual issue on dissection and medical education (www.wiley.com/anatomy/dissection).