Anatomy Education: Reinventing a Fading Subject

Solid knowledge of anatomy is a foundation that is expected of all medical professionals to possess. It is not surprising then that throughout history, dissections and cadavers have been synonymous with medical education. Yet, despite the value that anatomy education offers, studies suggest that traditional anatomy teaching is starting to fade away from medical courses (Ahmad et al., 2021). Anatomy is an overbearing subject that can be content-heavy, especially since it is usually presented to students in the first year of their medical degree. Additionally, the maintenance of cadavers and anatomy labs requires evermore increasing funding and trained staff, making the course more complex to be managed and delivered (Turney, 2007).

Figure 1: "The Anatomy Lesson of Dr. Nicolaes Tulp" (van Rijn, 1632).

This article will address how knowledge of anatomy is imperative for a medical professional. It will discuss how anatomy teaching needs to be reevaluated, suggest modifications that can be made to the current medical curricula, and mention technological advancements that can be used to facilitate learning.

Why is Anatomy Important?

Anatomy, which is the study of the human body, is vital in the practice of modern medicine. Prejudice against the subject area exists, with some describing anatomy education as archaic and static. But the fact remains that anatomy is utilised in all fields of medicine. Anatomical knowledge is necessary to understand radiographic images and its significance is undeniable when performing surgical manipulations on the human body. The use of anatomical knowledge is not limited to these specialised areas; anatomical terminology is used in everyday practice to communicate with colleagues, assign a diagnosis, and give doctors an understanding of how to treat their patients (Eizenberg, 2015). A survey encompassing views from medical students and doctors supports this claim as the majority of participants believed anatomy to be a ‘most essential’ component of clinical practice (Singh et al., 2022). Moreover, anatomy is a field that is constantly expanding. New anatomical structures are being discovered, with a fourth membrane that lines the human brain being recently found (subarachnoid lymphatic-like membrane) (Møllgård et al., 2023). Also, novel methods are being experimented with to create models of the human body (Ye et al., 2023).

Figure 2: 3D anatomy model (Seto, 2021).

In the early 2000s, reports began correlating the limited anatomy knowledge of medical doctors with the increasing rate of medical errors. It was suspected that a proportion of hospital deaths in the United States could be a consequence of medical professionals practising with insufficient anatomical knowledge (Papa & Vaccarezza, 2013). The problem of inadequate anatomy education persists. A recent review indicates that there is no clear guideline of how much anatomy knowledge a doctor should ideally possess, with medical students and doctors scoring anywhere between 22.5% to 82.4% correct on an anatomy knowledge test. Despite there being no evidence to suggest that those who performed worse on the tests showed a higher propensity for medical errors, the knowledge gap was highlighted as a concern (Koppes et al., 2022).

How Can Teaching be Improved?

Limitation 1: Limited Time Dedicated to Teaching Anatomy

A glaring issue of medical school curricula is that anatomy education is poorly integrated throughout the whole course and has a sparse amount of teaching hours dedicated to it. Anatomy is typically introduced to students in their first two years of medical school; with medical courses extending for as long as six years, it is clear that having little to no anatomy education in the final years of study can be problematic (Ahmad et al., 2021). A survey of 1101 Australian medical students found that among them, low confidence in their anatomy knowledge correlated with them reporting poor integration of the subject throughout their medical education. The lack of anatomy teachings was prominent in clinical years. Students who began working as junior doctors expressed that they felt inept because of the several-year gap they had gone through without receiving proper anatomy education (Farey et al., 2018). Hence, it is important that the curricula of medical schools are re-evaluated globally. Educators should aim to provide a foundation of anatomy in the first year of education and then build upon the existing knowledge in later years, exploring more complex anatomy and integrating it with clinical practice (Bergman et al., 2011).

Figure 3: Cadaver dissection delivered through Zoom (Johnson, 2022).

Yet, a major setback for anatomy education was the need to adapt teaching during the Covid-19 pandemic. Due to the closure of educational institutions, teaching had to be modified to be delivered virtually. Anatomy is traditionally a hands-on and interactive subject, with cadaver dissections and group discussions being an integral aspect of the teaching process (Ahmad et al., 2021). In a survey of medical schools in the United States, almost 20% of all medical schools claimed that they had reduced the time that was dedicated to anatomy education. Educators from these schools agreed that this change had a negative impact on anatomy education as a whole (Shin et al., 2022). Although the pandemic has been a severe hit, the time spent teaching medical students anatomy has been declining for many years. Medical schools in the Netherlands reported a reduction to 100 hours of anatomy teaching in 2010, compared to around 320 hours being dedicated in 1990. Anatomy is an extremely vast subject area. So, the time devoted to teaching anatomy needs to be modified appropriately in the coming years in order for future doctors to have a strong grasp of anatomical knowledge (Chang Chan et al., 2022).

Limitation 2: High Cognitive Load

Human anatomy is extensive and complex. There are eleven organ systems in the body that consist of 78 organs. On top of the large volume of content, there is variation in each individual and hence, anatomy can also diverge from what is typically considered normal (Żytkowski et al., 2021). All this makes anatomy a highly demanding subject that requires effective memory retention, pattern recognition and critical thinking. For these reasons, anatomy is often criticised for being too challenging to learn in the amount of time that is dedicated to it in medical education. The problem may lie in the sheer volume of new content that is delivered to a medical student, which is filled with difficult terminology and concepts (Talip et al., 2021). Anatomy education can be evaluated from the perspective of the Cognitive Load Theory (CLT); it proposes that a person’s memory, and the ability to apply new knowledge, are limited. Cognitive load is dependent on how difficult the incoming knowledge is (intrinsic cognitive load), if there are any distractors that hinder one’s focus (extraneous cognitive load) and on the ability to learn the novel information (de Jong, 2009). Traditional anatomy education is considered to have a high intrinsic load, with large portions of relatively difficult information being delivered to students.

Figure 4: Cognitive Load Theory (Weller, n.d.).

To improve this, anatomy content should be spread out and integrated throughout the whole duration of medical education. A study was conducted to investigate the best way to teach anatomy to undergraduate physiotherapy students. The researchers proposed that it is crucial for students to revisit the anatomy knowledge they acquire in their first year of education through more dispersed anatomy teaching during the years. This way, students do not experience an overwhelming flow of information that overloads their cognitive capacity and instead can have opportunities to revisit and learn the content (Gangata & Vigurs, 2023). Intrinsic cognitive load can also be minimised by modifying how anatomy is presented to students. 18 first-year medical students in a US medical school trialled a mixed reality (MR) tool that was used in combination with anatomy traditional lectures and practicals. The MR technology involved the students wearing a headset that transposed anatomical structures from a virtual program into the real setting the student was in. The virtual structure could be repositioned and rescaled and had educational labels. A questionnaire was then given to assess the cognitive load of the students, comparing it in the context of classroom education and MR-assisted education. A statistically significant decrease in difficulty, complexity and volume of the information was recorded when students used MR technology to assist their learning. This portrayed that the intrinsic cognitive load when learning anatomy could be reduced by utilising new technologies, such as mixed reality tools (Michalski et al., 2023). Therefore, medical schools should be encouraged to experiment with new learning methods to facilitate anatomy learning for medical students.

Limitation 3: Inability to Find an Appropriate Replacement for Cadaver Teaching

Cadaver dissections and the observation of prosections is arguably the ideal method for learning anatomy. Physical dissections can equip medical students with relevant surgical skills and give them a chance to get a glimpse at the anatomical variations that exist in every human being (Leighton, 2019). As a result of the COVID-19 pandemic, many medical students missed the opportunity to learn anatomy with cadavers. To see if this had any impact on how well students understood anatomy, researchers conducted a survey with students who had worked with cadavers in person and those who were taught using a virtual anatomy lab. The survey showed that the class of students who had encountered cadavers could identify anatomical structures with a higher accuracy and were more familiar with using ultrasound imaging than students who only had a virtual learning experience (Kochhar et al., 2023). In another study, a great majority of medical students responding to a questionnaire agreed that cadaveric dissections aided their learning (87%) and that it should continue to be used for anatomy teaching (74.5%) (Asante et al., 2021). However, maintaining an anatomy lab is costly and requires qualified staff. The ethics of using donated bodies for anatomy studies also come under scrutiny, with students finding encounters with cadavers distressing (Dissabandara et al., 2015). Although it is not optimal to remove cadaver dissections from anatomy education completely, it is important that an equally valuable, but more sustainable, teaching method is incorporated into medical curricula.

Figure 5: Mixed reality technology used for anatomy teaching (Best, 2016).

As an adjunct to traditional anatomy classes that include cadaver labs and lectures, a study introduced ultrasound-assisted learning to medical students at the University of Nicosia. Ultrasound is an imaging technique that visualises anatomical structures in real-time. Students were placed into groups and had multiple practical sessions where they were asked to locate different organs that they had learnt about in their classes or saw in cadavers. After completing a set of practical sessions, the students replied to a questionnaire about their experience. Around 90% of students were satisfied with the integration of ultrasound practicals as a teaching method for anatomy, with the majority finding it very valuable for learning anatomy. Implementing this teaching method can better prepare medical students for their careers as doctors, familiarising them with a staple imaging technique early on in their education. Additionally, ultrasound teachings can help medical schools become less dependent on anatomy labs when teaching anatomy without impeding the quality of education (Kefala-Karli et al., 2021). Apart from this, virtual reality (VR) is starting to be incorporated into medical education, specifically in the teaching of anatomy. It has been utilised to stimulate the emergence of a foetus from the birth canal for midwifery students, effectively teaching female reproductive anatomy in a way that cannot be replicated with cadavers (Aasekjær et al., 2022). With further research, it will become a possibility to employ 4D printing for anatomy teaching, producing anatomy models that change over time (Kabirian et al., 2022). Overall, educators and researchers need to strive to incorporate a diverse range of tools and methods to deliver anatomy teachings to students to ensure a more holistic education of the subject.

Conclusion

Anatomy is an area of study that is essential for medical doctors to excel in. It is a vanishing area of expertise, as medical curricula dedicate less time towards its teaching, eliminate valuable cadaveric experiences, and do not integrate it effectively throughout medical education. However, anatomy education can be reinvented by incorporating teachings in all years of a medical course, by increasing the teaching hours dedicated to anatomy and by using technological tools, such as mixed reality, virtual reality, and ultrasound imaging. Educators should aim to develop a standardised medical curriculum that integrates anatomy appropriately and researchers should focus on creating hyper-realistic anatomy models that can replace cadavers entirely.

Bibliographical References

Aasekjær, K., Gjesdal, B., Rosenberg, I., & Bovim, L. P. (2022). Virtual Reality (VR) in Anatomy Teaching and Learning in Higher Healthcare Education. How Can We Use Simulation to Improve Competencies in Nursing?, 117–129. https://doi.org/10.1007/978-3-031-10399-5_10

‌

Ahmad, K., Khaleeq, T., Hanif, U., & Ahmad, N. (2021). Addressing the failures of undergraduate anatomy education: Dissecting the issue and innovating a solution. Annals of Medicine and Surgery, 61, 81–84. https://doi.org/10.1016/j.amsu.2020.12.024

Asante, E. A., Maalman, R. S., Ali, M. A., Donkor, Y. O., & Korpisah, J. K. (2021). Perception and Attitude of Medical Students towards Cadaveric Dissection in Anatomical Science Education. Ethiopian Journal of Health Sciences, 31(4), 867–874. https://doi.org/10.4314/ejhs.v31i4.22

‌

Bergman, E. M., Van Der Vleuten, C. P. M., & Scherpbier, A. J. J. A. (2011). Why don’t they know enough about anatomy? A narrative review. Medical Teacher, 33(5), 403–409. https://doi.org/10.3109/0142159x.2010.536276

‌

Chang Chan, A. Y.-C., Stapper, C. P., Bleys, R. L., van Leeuwen, M., & ten Cate, O. (2022). Are We Facing the End of Gross Anatomy Teaching as We Have Known It for Centuries? Advances in Medical Education and Practice, Volume 13, 1243–1250. https://doi.org/10.2147/amep.s378149

Dissabandara, L. O., Nirthanan, S. N., Khoo, T. K., & Tedman, R. (2015). Role of cadaveric dissections in modern medical curricula: a study on student perceptions. Anatomy & Cell Biology, 48(3), 205. https://doi.org/10.5115/acb.2015.48.3.205

‌

de Jong, T. (2009). Cognitive load theory, educational research, and instructional design: some food for thought. Instructional Science, 38(2), 105–134. https://doi.org/10.1007/s11251-009-9110-0

‌‌

Eizenberg, N. (2015). Anatomy and its impact on medicine: Will it continue? Australasian Medical Journal, 373–377. https://doi.org/10.4066/amj.2015.2550

Farey, J. E., Bui, D. T., Townsend, D., Sureshkumar, P., Carr, S., & Roberts, C. (2018). Predictors of confidence in anatomy knowledge for work as a junior doctor: a national survey of Australian medical students. BMC Medical Education, 18(1). https://doi.org/10.1186/s12909-018-1280-5

Gangata, H., & Vigurs, K. (2023). Pedagogical principles used by anatomy teachers to facilitate the teaching and learning of anatomy to physiotherapy undergraduates in the United Kingdom. Clinical Anatomy. https://doi.org/10.1002/ca.24035

‌‌

Kabirian, F., Mela, P., & Heying, R. (2022). 4D Printing Applications in the Development of Smart Cardiovascular Implants. Frontiers in Bioengineering and Biotechnology, 10. https://doi.org/10.3389/fbioe.2022.873453

‌

Kefala-Karli, P., Sassis, L., Sassi, M., & Zervides, C. (2021). Introduction of ultrasound-based living anatomy into the medical curriculum: a survey on medical students’ perceptions. The Ultrasound Journal, 13(1). https://doi.org/10.1186/s13089-021-00247-1

‌

Kochhar, S., Tasnim, T., & Gupta, A. (2023). Is cadaveric dissection essential in medical education? A qualitative survey comparing pre-and post-COVID-19 anatomy courses. Journal of Osteopathic Medicine, 123(1), 19–26. https://doi.org/10.1515/jom-2022-0016

‌

Koppes, D. M., Triepels, C. P. R., Notten, K. J. B., Smeets, C. F. A., Kruitwagen, R. F. P. M., Van Gorp, T., Scheele, F., & Van Kuijk, S. M. J. (2022). The Level of Anatomical Knowledge, Hard to Establish: a Systematic Narrative Review. Medical Science Educator, 32(2), 569–581. https://doi.org/10.1007/s40670-022-01509-w

Leighton, M. X. (2019). The Importance of Anatomy Dissection in a System‐Based Curriculum. The FASEB Journal, 33(S1). https://doi.org/10.1096/fasebj.2019.33.1_supplement.332.1

‌‌

Møllgård, K., Beinlich, F. R. M., Kusk, P., Miyakoshi, L. M., Delle, C., Plá, V., Hauglund, N. L., Esmail, T., Rasmussen, M. K., Gomolka, R. S., Mori, Y., & Nedergaard, M. (2023). A mesothelium divides the subarachnoid space into functional compartments. Science, 379(6627), 84–88. https://doi.org/10.1126/science.adc8810

‌

Michalski, C., Cowan, M., Bohinsky, J., Dickerson, R., & Plochocki, J. H. (2023). Evaluation of cognitive load for a mixed reality anatomy application. Translational Research in Anatomy, 100247. https://doi.org/10.1016/j.tria.2023.100247

‌

Shin, M., Prasad, A., Sabo, G., Macnow, A. S. R., Sheth, N. P., Cross, M. B., & Premkumar, A. (2022). Anatomy education in US Medical Schools: before, during, and beyond COVID-19. BMC Medical Education, 22(1). https://doi.org/10.1186/s12909-022-03177-1

‌

Singh, R., Yadav, N., Pandey, M., & Jones, D. G. (2022). Is inadequate anatomical knowledge on the part of physicians hazardous for successful clinical practice? Surgical and Radiologic Anatomy, 44(1), 83–92. https://doi.org/10.1007/s00276-021-02875-7

‌

Talip, S. B., Mohd Ismail, Z. I., & Hadie, S. N. H. (2021). Investigating the Benefits of Integrated Anatomy Instruction: A Cognitive Load Theory Perspective. Education in Medicine Journal, 13(3), 1–14. https://doi.org/10.21315/eimj2021.13.3.1

‌

Turney, B. (2007). Anatomy in a Modern Medical Curriculum. The Annals of the Royal College of Surgeons of England, 89(2), 104–107. https://doi.org/10.1308/003588407x168244

‌

Ye, Z., Jiang, H., Bai, S., Wang, T., Du, Y., Hou, H., Zhang, Y., & Yi, S. (2023). Meta-analyzing the efficacy of 3D printed models in anatomy education. Frontiers in Bioengineering and Biotechnology, 11. https://doi.org/10.3389/fbioe.2023.1117555

Żytkowski, A., Tubbs, R. S., Iwanaga, J., Clarke, E., Polguj, M., & Wysiadecki, G. (2021). Anatomical normality and variability: Historical perspective and methodological considerations. Translational Research in Anatomy, 23, 100105. https://doi.org/10.1016/j.tria.2020.100105

‌

Visual Sources

Figure 1: van Rijn, R.H. (1632). The Anatomy Lesson of Dr. Nicolaes Tulp [Oil on canvas]. Mauritshuis, The Hague

Figure 2: Seto, B. (2021, May 20). A modern approach to teaching anatomy. Permanente Medicine. https://permanente.org/a-modern-approach-to-teaching-anatomy/

‌

Figure 3: Johnson, C., Hyde, L. E., Cornwall, T., Ryan, M., Zealley, E., Sparey, K., Paterson, S. I., & Spear, M. (2022). Collaborative, Two-Directional Live Streaming to Deliver Hands-on Dissection Experience during the COVID-19 Lockdown. Springer EBooks, 95–112. https://doi.org/10.1007/978-3-031-17135-2_6

Figure 4: Weller, D. (n.d.). What is Cognitive Load Theory? Www.barefootteflteacher.com. Retrieved September 17, 2022, from https://www.barefootteflteacher.com/p/what-is-cognitive-load-theory

Figure 5: Best, J. (2016). HoloLens, MD: Why this medical school will teach doctors anatomy with Microsoft’s augmented reality, not c... ZDNet; ZDNet. https://www.zdnet.com/article/hololens-md-why-this-medical-school-will-teach-doctors-anatomy-with-microsofts-augmented-reality-not/

‌

‌

‌