How can clinical anatomy teaching be rationalized?

Abstract

A recent article by John Farey and his colleagues on behalf of the Australian Medical Students' Association1 has rekindled the debate as to how, when and what anatomy to teach medical students. In recent years, the teaching of anatomy within the medical curriculum has undergone major changes, including a reduction in teaching hours – mainly the cadaveric dissection component – in order to accommodate emerging disciplines such as genetics and molecular biology, and an increased emphasis in public health, epidemiology and communication skills. Introduction of problem-based learning (PBL) has led to the fragmentation of anatomy teaching, which is a sequential subject that requires basic knowledge as its foundation. The consequences of these changes to recent medical graduates and postgraduate students have been highlighted in several recent publications.1, 2 The observations regarding the examination results of surgery fellowship trainees (where a high failure rate in the basic sciences occurred within the University of Sydney graduate cohort upon the drastic reduction in anatomy teaching at that school,2 a trend now reversed by a very substantial increase in anatomy teaching3) is a sentinel wake-up call for all medical schools. In the current climate, there is a need for more effective pedagogy to develop a clinical anatomy course with emphasis on understanding rather than endless memorization, which is the common belief among students.4 A core course of clinical topographical anatomy (including regional and systemic approaches), coupled with an appropriate process of assessment, should precede the students' progress to a PBL model that supports a preferred process of inquiry-based learning. Students profit most when multiple, problem-oriented modalities are integrated.5 The core anatomy course should also be vertically integrated and reinforced with PBL during the entire undergraduate curriculum. The call for a core National Anatomy Curriculum1, 6 requires critical consideration. This is already occurring, though not in Australia, but in the American Association of Clinical Anatomists7 and the Anatomical Society of Great Britain and Ireland.8 As ‘the anatomy and anatomical problems of safe clinical practice, even at a junior level, are similar everywhere’1 – there is no need to reinvent the wheel. However, there is a need to define with clarity the depth of core knowledge, skills, values and attitude required by the graduating medical students that must be possessed for safe clinical practice. This is a daunting but I believe, is attainable goal, if we, the anatomical educators, work collaboratively in a format similar to the Stanford Medicine 25.9 The continuing argument between dissection and prosection is unlikely to bring back old methods of dissection-based anatomy teaching, especially within the context of ‘time-poor, four-year graduate programs’.1 The elective Anatomy by Whole Body Dissection Course at the University of Sydney10 is commendable but unlikely to be replicated in all medical schools for the entire cohort of students. Topp11 suggested prosected cadaver materials for undergraduate teaching and presented convincing arguments in favour of this. The dissection-based anatomy teaching may suit those pursuing postgraduate training in the surgical specialties. The latter idea seems to be the reasonable approach. The teaching of anatomy by surgeons, surgical trainees and near-peer tutors has multiple benefits including the teaching of anatomy in the context.12 Near-peer teaching also provides a strategy for vertical integration and encourages deeper learning in anatomy.13 The College of Surgeons can promote the teaching of anatomy to undergraduates by trainee surgeons by formalizing this process as part of its training requirements, as suggested earlier.14 The tertiary hospitals can also contribute in this regard by following the example described by Taylor and Keay.15 After all, improved anatomical knowledge leads to safe patient care and reduces medical litigation. The concern expressed regarding the assessment of anatomy1, 6 deserves serious consideration. Assessment is known to increase students' motivation to learn anatomy,16 and anatomy assessment through integration of factual knowledge with the principles of problem-solving in different formats should be considered.17 Also, a national Annotated Multiple Choice Question bank facilitated by the Australian and New Zealand Association of Clinical Anatomists would be an important step in the right direction.6 Finally, more research is needed to provide sufficient evidence underpinning most of the claims alleged to be exerting negative influence on anatomical knowledge of medical students.18