In 1542, Vesalius inaugurated the age of science and science-based medicine by testing published anatomical information against the facts revealed by cadaveric dissection (Nuland, 1989; Anderhuber, 1996; Bouchet, 1996; Porter, 1997). The approach of Vesalius founded the initial steps of the scientific method: data collection by direct observation of the body; a provisional explanation (hypothesis) of the data; and further observational tests of the hypothesis. By placing the deceased human at the core of his investigations, Vesalius implicitly reaffirmed the patient-centered Hippocratic canon. Harvey elaborated the Vesalian paradigm by adding quantitative observations and experimental tests on nonhuman models as further refinements of the scientific/diagnostic method (Nuland, 1989).
Dissection-based anatomical analyses facilitated the following: (1) inventory and classification of bodily components, (2) the development of a vocabulary for describing the body with clarity and precision, and (3) mapping (topographical anatomy) of bodily organs and their surface projection later used in physical diagnosis (Fig. 1). In the 18th century, Morgagni elaborated the dissection method to conduct autopsies to connect symptoms with deep-seated pathology (Nuland, 1989; Porter, 1997). Thus, he created the means for attaining more precise diagnosis and nosology; he also used the autopsy as the final test of the diagnosis. Charite Hospital (Paris) physicians—Corvisart and Laennec—extrapolated Morgagni's approach into the clinical sciences by using sophisticated diagnostic instruments and methods. Thus, clinical medicine, which commenced with the dissection of the cadaver, was concluded in the autopsy room after a series of tests. The autopsy retraced many steps first learned in the anatomy laboratory.
Flexner's reform of medical education in the United States and Canada was substantially based on the wisdom of the Paris School (Flexner, 1910). In his paradigm, both the basic and clinical sectors were based on exactly the same technique, the scientific method. However, despite its exceptional contributions toward medical education in North America, uncritical application led to erosion of parts of the Flexner model. Major national and international reappraisals of this model in 1980s leveled the following criticisms against it: (1) its “emphasis on physico-chemical reductionism” (Engel, 1973), and (2) its excessive horizontal (discipline-based) and vertical (clinical sectors) compartmentation (Muller, 1984; Warren et al., 1984; G.M.C. 1987, 1988, 1993; T.E.D., 1988). Collectively, these critiques enumerated the following flaws in contemporary medical education: (1) overcrowded curriculum, “dense packed” with clinically unconnected facts; (2) overemphasis on memorization during learning; (3) insufficient exercise in critical analysis and synthesis into concepts; (4) teacher-centered, passive learning based on didactic lectures; (5) inadequate training in the application of theoretical knowledge; (6) failure to prepare the student for a life-long habit of independent inquiry; (7) lack of emphasis on communication with patients and peers; and (8) insufficient inculcation of ethical, moral, and humanistic awareness in the student.
The same critical analyses noted that the invention of the computer and its associated digital audiovisual media—biomedical informatics—and the growth of diagnostic imaging (e.g., the computer-assisted tomography [CAT scan], magnetic resonance [MR] imaging, positron emission tomography [PET], fiberoptic techniques, etc.) had reduced the necessity of excessive rote memorization and of actual dissection. The same technologies facilitated almost instantaneous horizontal and vertical integration of learning and application. These reports rejected Flexner's assumption that students should undertake patient care only after preparation in the basic sciences. All medical training, at all times, had to be integrative and patient oriented. The following changes were recommended to improve the curriculum-emphasis on (1) student-centered, problem-based learning (PBL); (2) critical analyses and conceptualization of factual information; (3) clinical application of basic knowledge; and (4) training for life-long, independent learning.
The ensuing curricular reform—the 80s Reform—was spearheaded at several universities: McMaster, New Mexico, Southern Illinois, Harvard, Miami, Cincinnati, and numerous universities in Europe. This reform, with variations, has included the following: (1) adoption of a core curriculum, i.e., a body of essential fundamental knowledge necessary for general medical practice, and (2) development of special studies modules designed to train students for specialized medical careers. Both sectors use problem-based, small-group learning centered on case studies. At all stages, the student, assisted by faculty/facilitators, integrates basic and clinical sciences. To a substantial degree, these approaches involve the use of biomedical informatics (including Web sites, high-speed networking, and Power Point presentation). Training is centered around case studies, audiovisual displays, simulated and actual patients in hospital or community centers.
A conspicuous result of this reform has been the drastic reduction in time, form, and content of gross anatomical instruction. The instructional time for gross anatomy is less than half of what it was 20 years ago (Marks and Cahill, 1988), with an average decrease in contact hours of 197 to 182 between 1971 to 1991 (Collins et al., 1994) and 190 to 165 between 1991 to 1997 (Cottam, 1999). Some universities no longer require dissection.
A conspicuous result of reform has been the drastic reduction in time, form, and content of gross anatomical instruction.
The time “lost” to the traditional basic sciences—especially gross anatomy—has been allocated to the emerging, putatively more clinically relevant disciplines of molecular and cell biology, microbiology, immunology, pharmacology, and the neurosciences (Skandalakis and Gray, 1969). Overtly, it would appear that the special target of the 80s Reform was the didactic lecture; however, according to the critique, it was the complete dissection of the body which impeded actual progress. Attenuation of cadaver-based anatomical education is a consequence of the 80s Reform. As a result, an impressive list of complaints against the use of the actual human cadaver has emerged in the past two decades (see Box 1).
1.Time ConsumingContention: Dissection is overly time-consuming activity
2.Labor Intensive/Shortage of Anatomists Contention: Dissection is labor intensive; partly due to shortage of qualifiedfaculty. Partly due to shortage of qualified faculty.
3.Fact-Filled/Requires Excessive Rote Memory Contention: Faculty requires students to memorize excessive, (often) clinically irrelevant facts.
4.Cadaver Unavailability Contention: It is necessary to prosect due to cadaver shortage (Religious/cultural factors)
5.Undesirable Due to Postmortem Changes Contention: Cadaver anatomy is different from living anatomy. It misleads due to postmortem changes.
6.Expensive Contention: cadaver is costly to obtain, embalm, store, maintain and dispose.
7.Unaesthetic Contention: smells, looks ugly, repulsive, etc.
9.Potential Health Hazard Contention: Danger of embalming fluid and infectious diseases; stress provoking.
A.Dangers of embalming fluid components (formaldehyde, xylene)
i.Transmissable spnogiform encephalitis-(kuru)
ii.Human immunodeficiency virus
C.Psycho-Social Impact(promoting fear and anxiety)
However, if medicine is an applied science aspiring to compassionate problem solving, then this aim can only be achieved by exposing and examining the facts inside the body, i.e., those best revealed by dissection. Whereas it is uncontested that biomedical informatics and sophisticated clinically imaging have extrapolated our senses and exponentially made “precise…the observational study of structure, and mechanisms whereby structure is maintained” (Zuckerman, 1976), they have not rendered the source of that information—the cadaver/patient—obsolete. To the contrary, they only magnify our knowledge of actual structural organization and the need for better connection with the patient.
Furthermore, Engel (1977) has persuasively argued against viewing medicine exclusively in physicochemical terms, while neglecting the psychosocial dimension. All proposals for the reform of medicine concur with this view (Muller, 1984; Warren et al., 1985; T.E.D., 1988; G.M.C., 1993). Cadaver-based anatomical education is essential to achieve these objectives. The following is a discussion of why we believe cadaver-based anatomical education is still essential in medical training.
THE PRIMACY OF THE PATIENT
Eichna (1983) argued that “patient care is the purpose of medical school education. The patient comes first.” He was reiterating Peabody's (1927) dictum: “[T]he secret of the care of the patient is in caring for the patient.” Engel (1971) calls the patient “the essential unit of medicine” and its “common denominator.”
The cadaver has been referred to as “the first patient” during medical training (Kasper, 1969; Coulehan et al., 1995). The placement of the cadaver at the initiation of medical education unequivocally establishes the central objective of training—the process of transformation which will alter the scientific, psychological, and social mind-set of the student such that he/she will earn the privilege of bringing healing to the patient. Pellegrino (1974) refers to the student-cadaver encounter as a “nodal point” in medical education which—with proper education—can lead to the “compassionate detachment” that is essential in a physician. It is a process of metamorphosis during which not only does the student “learn something new, he becomes someone new” (Engel, 1971). Coulehan et al. (1995) note that medicine is unique in allowing the dismemberment of the whole body during professional training; furthermore, this is the only opportunity a physician has to empirically confirm the reality of all the organs of the body which, individually or collectively, may be implicated during illness. Furthermore, such inspection allows the empirical observations and confirmation of changes related to morbidity and mortality. Indeed, one of the objectives of medicine is the scientific study of death itself.
Medicine—the science and art of diagnosing illness, comprehending its causes(s) and pathophysiology, and instituting therapeutic care—must ultimately contend with the patient's mortality. Postponement of death is amongst the primary objectives of medicine at the preparatory and applied levels. The encounter with the cadaver unequivocally establishes the following in the trainee's mind: (1) the palpable reality of individual life, (2) the value conferred upon it by morbidity and mortality, and, therefore, (3) the awesome responsibility with which the living patient is to be approached by the physician (Pellegrino, 1976; Coulehan et al., 1995; Aziz and McKenzie, 1999).
The 80s Reform criticized the bicameral Flexner model because the basic science sector did not connect the trainee to the ultimate objective of medical education—the living patient. This newer perspective also contrasts with the concern about students' being burdened with “premature clinical responsibilities before they have gained some fluency in the basic languages” (Engel, 1969, 1971). This perspective notwithstanding, a major pedagogical improvement being undertaken currently in some programs is the extrapolation of dissection-generated knowledge to living anatomy applied to the simulated patient, connections with the actual patient, or both, undergoing the physical examination (Blecher, 1978; Rosse and Boudreaux, 1978; Pabst et al., 1986). Gross anatomy—indeed the contemporary integrated structure-function course—is especially well-suited for extrapolation to the living, because the stilled and dynamic anatomies can be used in combination to yield a deeper understanding of living anatomy. However, even in such an integrated course, it is best to begin with the cadaver whose stillness reduces complexity such that the contemplation leading to understanding can occur.
The cadaver is also an important preceptor for issues relating to death and dying. Despite the uncontested technologic elaboration and sophistication of contemporary medicine—including robotics—a particular irreducible fact remains: only a human can treat and heal another human. Because of symbolic language, evidence points to the uniquely human foreknowledge of mortality; this is a common burden we share. Death, its foreknowledge, and its associated fear unite the patient and the physician in a common bond of humanity; it is the ultimate font of true compassion. Any good physician knows that it is only through this channel that he/she can bring healing to the patient. Dissection brings the student to the closest and most comprehensive encounter with human mortality.
Dissection brings the student to the closest and most comprehensive encounter with human mortality.
To be sure, one's knowledge of his/her mortality remains subliminal most of the time, yet it lurks about. Freud (1915a) wrote that “our own death is unimaginable…at bottom no one believes in his own death.” However, on extreme occasions, fear and loathing emerges. Cadaver dissection has been called the “sharp end” of medical education (Maguire, 1985). Even before entering the anatomy laboratory, a student, at some level, knows that the first patient that he/she will care for is a dead one (Bertman and Marks, 1985). Immediately before and during dissection, students experience considerable anxiety and stress (Bloch, 1976; Marks and Bertman, 1980; Shalev and Nathan, 1985; Gustavson, 1988). Finkelstein and Mathers (1990) and Evans and Fitzgibbon (1992) report that 5% of students experience near-incapacitating emotional stress in cadaver encounters (Penney, 1985). Marks et al. (1997) write that “dissection is a relentless, often daily exposure to a dead body.” It is during this phase that the student must develop defense mechanisms necessary for the scientific study of deep anatomy (Rieser, 1973; Bertman and Marks, 1985). However, if this defense is allowed to overdevelop, it is likely to result in detachment and indifference; eventually cynicism and avoidance during patient care might emerge (Marks and Bertman, 1980; Marks et al., 1997). If students are allowed to confront their negative reactions earlier during exposure to the cadaver, they are more likely to achieve “a flexible emotional balance.” The objective is to begin to move the learner toward care giving, which has been defined as “expert scientific knowledge combined with utmost compassion” (Gustavson, 1988) and help a student attain “detached concern” necessary for good practice (Coulehan et al., 1995). Several universities (e.g., Massachusetts, SUNY-Stony Brook, Dalhousie, Canada, and Hannover, Germany) have instituted courses/seminars in death and dying in conjunction with cadaver dissection (Marks and Bertman, 1980; Bertman and Marks, 1985; Penny, 1985; Coulehan et al., 1995; Marks et al., 1997; Tschernig et al., 2000). Marks and Bertman (1980) maintain that “the task of assisting the development of a humane, compassionate, sensitive physician should begin in the first year of medical school.”
Yet, another value of beginning medical education with dissection is the inculcation of the scientific method which is the basis of diagnostic medicine. The primacy of the scientific method in education was espoused equally by Flexner and the 80s Reform. In the 70s, medical education had become centered on data collection, memorization, and regurgitation, rather than conceptualization and hypothesis testing. Even the student's data were unoriginal—being derived from lecture notes or textbooks (Muller, 1984; Warren et al., 1985; Watson et al., 1998; Monkhouse and Farrell, 1999). The scientific method—a problem-solving process—was neither taught nor applied and was even considered irrelevant to medicine by some (Barondess, 1974).
Zuckerman (1976) called anatomy a “discipline…basic to medical education…a descriptive branch of natural history.” Even today, descriptive acuity remains a very significant part of medical testing and diagnosis. In contemporary anatomy courses, like the one developed at Hannover-Germany by Pabst and his colleagues, dissection has been linked with radiologic and clinical (including patient presentations) and living anatomy to teach students how to observe, conceptualize, and test hypotheses (Pabst et al., 1986). At all times, this program endeavors to connect the student with reality—the cadaver and the actual patient. It teaches students to develop hypotheses by direct observations and test them by further, more precise observations.
The removal or attenuation of cadaver dissection is bound to impair the student's ability to apply the scientific method during diagnosis (Aziz and McKenzie, 1999). If curricular reform intends to strengthen the application of the scientific process, then actual dissection must not be attenuated or dispensed with. Justification of anatomy programs without dissection (Jones et al., 1978) is incompatible with the essence of the 80s Reform, which is geared toward better application of the scientific method in medicine (Muller, 1984).
Justification of anatomy programs without dissection is incompatible with the essence of the 80s Reform, which is geared toward better application of the scientific method in medicine.
Learning anatomy by actual dissection is also important for the contin uation of the hard-won privilege of receiving bodies by donation. The legally sanctioned donation of human cadavers for medical training evolved over a long and difficult course, starting with the Pennsylvania Anatomy Act of 1832, and was not obligatory until after the Civil War (Bloch, 1977). Often bodies are donated by the patients themselves; it is the ultimate gift which needs continued appreciation of educators. Communities as a whole show their support of medical education by their participation in cadaver donation programs, which represent a model for the more recent programs for organ donation for transplantation and research.
APPREHENSION OF THE MULTIDIMENSIONAL BODY
A principal drawback of the traditional didactic anatomical instruction is that it engendered “A 2-dimensional view of knowledge” (Blecher, 1978; Muller, 1984; Warren et al., 1984; Pabst et al., 1986; G.M.C., 1987, 1988, 1993; Tosteson, 1990). “Two-dimensional view” refers to memorized lecture or textbook information, which is not extrapolated to the cadaver or the living patient; in this method, the student is insufficiently prepared for the application of basic knowledge to alleviate morbidity. All image-based clinical modalities (radiologic, magnetic, nuclear, or positron-based), with the exception of simulated three-dimensional (3-D) configuration such as the Visible Human Dataset (VHD), have the same limitation. The cadaver, when associated with the living patient, provides the best means of learning applied anatomy. As Moore (1998) has stressed, education on real cadavers leads to the development of a 3-D configuration of the patient's anatomy that can be called forth on demand by the physician.
Jones (1997) has argued for a better substantiation of the benefits of 3-D learning by the dissection process. For example, some view postmortem changes in the cadaver (e.g., color, consistency, texture, loss of mobility) as a drawback of dissection-based instruction, suggesting that the cadaver is less than a real representation of living anatomy (Morris and Tribe, 1976; Spitzer and Whitlock, 1998a,b). That indeed is so and in that limitation lies the mechanism by which scientific, diagnostic investigation can begin. The cadaver is none other than a human who has experienced morbidity and mortality. The embalmed body objectifies the patient to allow the observer to begin clinically relevant data collection. Furthermore, loss of motion—a time-bound process—reduces the parameters, allowing a dispassionate conceptual assessment of function (Aziz and McKenzie, 1999). Cessation of motion allows contemplation of structure and its extrapolations into normal and abnormal/morbid functions. Dissection is the essential method for effective 3-D learning (Marks, 2000). The actual cadaver is an obligatory means by which a trainee develops a clinically oriented map of deep-seated anatomy. Once achieved, this topographical map can be projected onto the living body and used meaningfully to conduct a physical examination. It can also be used to give volumetric meaning to clinical images.
Mutyala, a postgraduate ophthalmology student who had trained mainly from lectures, textbooks, and an atlas, encountered enough serious difficulty in his surgical rotations to require relearning anatomy by dissection under the guidance of a trained anatomist (Mutyala and Cahill, 1996). In addition to lacking a touch-based topographical map of orbital anatomy, Mutyala discovered that he (1) did not have a logical method for uncovering deep-seated structures; (2) lacked a logical, rational approach to understanding anatomical organization; (3) did not have a clinically relevant 3-D map of structures; and (4) lacked knowledge regarding the dimensions, densities, and strength of various tissues—information that is crucial in surgery. He was quite surprised that after haptic experience of topographical anatomy, he was becoming less dependent on rote recall for answers to clinical problems (Mutyala and Cahill, 1996).
TOUCH-MEDIATED PERCEPTION OF THE CADAVER
Michelangelo's The Creation of Adam in the Sistine Chapel shows God bestowing life to Adam by means of haptic exchange (DeVecchi, 1992). McLuhan (1964) regards touch not as a separate sense but rather as the interplay of several senses (synaethesia): this sense is a very important means of apprehending substantial reality. Srinivasan, the head of MIT's Laboratory of Human and Machine Haptics, states that “we use our hands (touch) to explore the external world, and then we use our hands to manipulate the external world” (Wolkomir, 2000). Touch enables us to experience palpable reality; it validates lived, experience. The most tangible evidence of the actual existence of the caregiver and receiver is touch-based. This touch experience begins in the human anatomy laboratory. Actual dissection is a journey into the body and, by touch, the student develops a synaesthetic map of human structural organization. He/she experiences structural organization of the human “in depth”; later, this experience is honed during diagnosis and healing.
To be sure, 3-D virtual reality modalities such as the Visible Human Dataset (Spitzer and Whitlock, 1998a,b) and Quick Time Virtual Reality (QTVR) software (Yorick–The VR Skull; Nieder et al., 2000) present us with high-resolution virtual modalities; yet, they are not a substitute for the cadaver itself or any of its actual parts. The simulated haptic experience of the VHD is just that—a simulated, ersatz, experience. On the contrary, when connected with the actual cadaver or patient, the VHD can be very valuable for enhanced analysis. It is still necessary to use virtual reality programs with caution. Garg et al. (1999) have recently warned against the simplistic view that virtual modality is necessarily superior to the traditional one in anatomy instruction.
The simulated haptic experience of the VHD is just that—a simulated, ersatz experience. On the contrary, when connected with the actual cadaver or patient, the VHD can be very valuable for enhanced analysis.
Ellis (2000) argues that dissection facilitates “manual skills (which) are essential to almost every branch of the (medical) profession.” Dissection is a necessary exercise in the development of touch-based skills which can then be transferred to palpation, percussion, and auscultation (Lockhart, 1927; Bowsher, 1976; Pabst et al., 1986; von Lundinghausen, 1992; Utting and Willan, 1995; Moore, 1998).
Furthermore, in addition to instruction in the volumetrical, substantial aspects of the bodily structures, gross anatomy usually incorporates the fourth dimension of time, in which changes are best understood by integrating embryology with dissection-based instruction. This information is very valuable in diagnosing the developmental causes of morbidity (Pabst et al., 1986; Moore et al., 2000).
A given individual exhibits continuous variation of almost all traits when assessed as a part of a population. This variability has adaptive value and is the raw material of evolutionary/adaptive change facilitated by natural selection over many generations (Aiello and Dean, 1990).
Despite the obvious diagnostic and clinical significance of human variability (including developmental anomalies), the trend in the latter part of the 20th century has been to view the body as a fixed, idealized “type” or “norm”; the student learns the anatomy of a nonexistent “prototypic” human. Whereas older texts (Anson, 1966) included subsections describing bodily variations, contemporary ones delete this important information. This oversimplification has led to poor training, resulting in misdiagnosis and even malpractice (Gray et al., 1974; Willan and Humpherson, 1999; Wise, 2000). To prepare a student for unpredictability due to variation, it is necessary to directly observe anatomical variation and developmental anomalies by comparing many dissected cadavers (Gray et al., 1974; Skandalakis et al., 1974; Aziz and Dunlap, 1986; Beahrs, 1991; Utting and Willan, 1995; Amadio, 1996; Aziz et al., 1998; Willan and Humpherson, 1999; Wise, 2000; Ellis, 2001). The proposal of Spitzer and Whitlock (1998) to develop a computerized anthropologic database of known variations is meaningful only as an adjunct to actually observed variations.
The question of phenotypic variation has become considerably important in light of the recent findings of the Human Genome Project. The human genome recently has been shown to contain some 30,000 protein-coding genes, far less than would seem to be necessary for the observed level of anatomical complexity. Thus, an understanding of the structural and functional complexity of the body requires appreciation of higher levels of information. In other words, to appreciate the actual complexity, the human must be studied at the developmental and gross anatomical level, best revealed by the process of dissection (Claverie, 2001). Therefore, the suggestion of Besag et al. (1976) that “compulsory dissection is desirable, but not of the whole cadaver” must be reconsidered.
LEARNING THE LANGUAGE OF MEDICINE
Engel (1969) states that a principal aim of preclinical training is to equip the student with the languages with which to conceptualize clinical problems. Anatomical terminology, a compendium of terms which refer to bodily parts, functions, and positional relationships, is an internationally accepted and regulated vocabulary. It facilitates a commonly understood discourse about human structure in health and in disease; it is known as the Terminologia Anatomica (F.C.A.T., 1998; Whitmore, 1999). This vocabulary is used throughout clinical training and practice, especially in surgery, oncology, and radiology, when describing structure. Rosse (2001) has attempted to further define, classify, and systematize this vocabulary with a view to broadening its application in all the healthcare professions by means of the computer.
Without anatomical vocabulary, diagnosis, treatment, and healing cannot be attained. Vocabulary is essential to (1) locate, (2) name, (3) describe, (4) classify, (5) conceptualize, and (6) relate any structure(s) where morbidity originates and to relate it (them) with contiguous structures. Vocabulary is further needed to describe, with clarity and precision, the deviation from the norm due to pathophysiology. Language is further necessary to measure the therapeutic impact of treatment. Without a vocabulary, there cannot be diagnosis, treatment, and healing.
The 80s Reform was especially critical of the “emphasis on rote memorization of detailed facts” unconnected to “essential concepts and principles” in the traditional curriculum (Muller, 1984). Computers were viewed as having “the potential to decrease students' need to memorize a large body of facts and assist them in developing analytic and problem-solving skills.” Although the computer is undoubtedly a very handy device for the rapid storage and retrieval of information, it is the physician who must integrate memorized facts, i.e., perform conceptualization of these facts, to develop a diagnosis. Before making the computer the depository of the basic medical language, the trainee must first master it. Curiously, the 80s Reform singled out memorization of factual information as a serious flaw in contemporary education, rather than emphasizing failure to extrapolate memorized facts into conceptualization as the principal drawback. It is not the requirement of memorization per se that is the problem; it is the failure to insist on appropriate extrapolation from the memorized fact(s) into concepts in the traditional curriculum that was missing from the emphasis of the critique expressed in the 80s Reform. Despite the convenience of stored anatomical or medical information in the computer, it is the physician who must conceptualize. The more a physician remembers anatomical facts, the better he/she will be able to improvise on his/her feet; this is especially necessary in emergency medicine. Living memory is the ultimate source of intuition in medicine.
Despite the convenience of stored anatomical or medical information in the computer, it is the physician who must conceptualize.
An example of the critical connection of nomenclature with conceptualization is seen in the evolution of the allocation of anatomical designations in contemporary medicine. Feinstein (1970) writes that, between 1800 and 1939, “the diseases that had formerly been named as clinical entities were largely converted to names that were entities of morbid anatomy, chemistry, and microbiology. With this conceptual change in nomenclature of disease, the terms used for diagnoses became explanatory rather than merely observational, and the diagnostic process of choosing the names for a particular patient's ailment became an act of deductive reasoning, whose accuracy could often be confirmed by the pathologist or radiologist.”
Actual cadaver dissection is essential for the acquisition of anatomical language. Keller (1990) and Vermeij (1997) give convincing evidence of the haptic aspects of acquiring, maintaining, and developing language. Graney (1996) insists that the vocabulary and concepts of anatomy must be grasped “with three-dimensional relationships and the look and feel of anatomy.”
To be sure, the anatomical vocabulary could possibly be memorized by watching a program on the computer screen. Unfortunately, a student using this approach is likely—like Mutyala—to feel “never sure of myself” (Mutyala and Cahill, 1996). As to the acquisition of anatomical vocabulary by the virtual modality equipped with simulated touch (Spitzer and Whitlock, 1998a), we only say: The only touch that really matters is that between the actual physician and the actual patient.
In addition to the revolutionary clinical advances associated with conventional radiology, our ability to observe internal soft anatomy has undergone geometric progression by the clinical application of CAT scan. Within a decade, magnetic resonance imaging enormously increased our ability to observe internal anatomy with astonishing precision (C.S.A.-A.M.A., 1987, 1988a,b). Other inventions, including those which allow observation of function, e.g., PET, have followed; we have indeed entered the age of “anatomy in vivo” (Paalman, 2000). To some, these advances in diagnostic technology mean transcendence over the deceased human as a learning tool (Spitzer and Whitlock, 1998a). Rosse (1995) writes that “dissection is a destructive rather than constructive process” and that it be replaced by the cybercadaver.
However, we may also view these imaging techniques as additional sophisticated tests of hypotheses. There seems to be a growing view—even in radiology departments—that anatomy is a prerequisite for education and applications of these technologies in patient care.
Beahrs (1991), a surgeon, writes that “with new imaging technology in clinical practice, a detailed knowledge of anatomy becomes even more important. With computed digital tomography (CT scan), MR imaging, and ultrasound, cross-section anatomy must be known and anatomical relationships appreciated by the diagnostician as well as the surgeon. Endoscopic procedures require greater appreciation of anatomy viewed in a different perspective. The recent and rapid acceptance of laparoscopic cholecystectomy is an excellent example of how new technology is leading to a greater appreciation of anatomy”.
Erkonen et al. (1990, 1992) found that the students' ability to learn to interpret and retain knowledge of sophisticated diagnostic images improved exponentially when they were trained in actual cross-sectional anatomy. Similar results were also obtained by Jensen (1977) and Bassett and Squire (1985). More recently, De Barros et al. (2001) “demonstrated that a simple exposure to a separate course in sectional anatomy in undergraduate curriculum has a significant impact on identification of anatomical structures on CT scan.” Similarly, Nieder et al. (2000) were pleasantly surprised to find “students were using the program [Yorick–the VR skull] to interpret the real skull in their hands and not just memorizing labeled screen images and questions.” Nieder et al. (2000) point to the best application of the Spitzer and Whitlock's (1998b) VHD. When this information is used to connect actual dissection with the living patient, it can yield better clinical judgment. For example, VHD allows instant retrieval of cross-sectional anatomy, which can be compared with diagnostic images for interpretation. Having mastered the vocabulary and topography during dissection, the student can then use VHD as a convenient instrument to refresh his/her memory to interpret diagnostic tests. Thus, the VHD is an excellent device by which actual cadaver dissection can be the beginning of effective use of images in practice.
A principal instigator of the 80s Reform was the explosive growth of biomedical information unleashed by postwar technologic innovation; much of this research extended our comprehension of cellular and molecular causes and processes of morbidity. Marks and Cahill (1988) write about “the escalating discrepancy between a rapidly expanding base in science and technology and the relatively fixed time period for education of a physician.” It appears that this fact itself has resulted in the erosion of education, involving the excessive preoccupation with data at the expense of analysis and synthesis.
The availability of biomedical informatics presented a convenient means of information management. The adoption of this technology in medical education was a principal goal of 80s Reform (Muller, 1984; Warren et al., 1985; McManus, 1991; Fitzgerald, 1992; Lieber and Smith, 1997). Instantaneous access, storage, retrieval of information and hypertext on computers offered relief from excessive memorization, allowing the student (and faculty) to facilitate the acquisition of analytic and problem-solving ability. As a corollary, diagnosis—a problem-solving exercise—was felt to benefit from computer-based learning. Muller (1984) enumerated the following benefits of learning by computers: they promoted (1) independent learning, (2) computer-based decision making, (3) patient data retrieval, and (4) office management. Additional positive attributes include diagnostic imaging technologies and software-based textbooks (Conley and Sundsten, 1993; Narayan et al., 1993; Rosse, 1995; Marks, 1996; Spitzer and Whitlock, 1998a,b; Bacro et al., 2000; Nieder et al., 2000). These developments have increased the precision, speed, depth, clarity, and communication of observations; they have collectively extended the human sensorium, allowing better clinical testing and analysis. These same modalities facilitate integration of the basic and clinical sciences.
The merit of computer-associated modalities is not contested; what can be debated is their proper use in education and practice. In developing the curriculum for the year 2000 and beyond, Parry (1989) writes that the “use of computers should be seen as an aid and not a replacement for brain power in handling information and decision-taking—there was a real risk of damaging the doctor-patient relationship if computing was allowed to override medical decision-taking.” Unfortunately, there has been a tendency to get caught up in the excessive exuberance over cybernetic technology. This, in turn, has led to the devaluation of the deceased human as preceptor in medical education (Rosse, 1995; Spitzer and Whitlock, 1998a,b).
The merit of computer-associated modalities is not contested; what can be debated is their proper use in education and practice.
If we overvalue the cybercadaver over the actual cadaver, then clearly we are discounted by our own creation. The cadaver has been described as “the unseemly residue of death” (Coulehan et al., 1995) or “the blight man was born for” (Gerard Manley Hopkins). However, Freud (1915b) wrote that “transience value is scarcity value in time. Limitation in the possibility of an enjoyment raises the value of enjoyment. It was incomprehensible…that the thought of the transience of beauty should interfere with our joy in it.” Machines, however sophisticated, teach us nothing about this ephemerality of life, only humans do—in life and in death; the dissected cadaver remains the most powerful means of acquiring this wisdom. The cadaver vividly educates the trainee regarding the value of the evanescent living moment.
Jack Myer, the inventor of the computer-based program for diagnosis The Internist insisted that the proper use of his program was to “supplement the human brain” (Warren et al., 1985)—not to replace it. Several computer-based learning programs have been designed specifically to assist the student in his/her primary exercise, i.e., that of learning anatomy from the dissected cadaver (Levine et al., 1999; Neider et al., 2000). Gorlin and Zucker (1983) worried about the growing mutual rejection of patients and physicians. Regarding this alienation, they write that “high technology tends to dehumanize care.” If training gives greater value to biomedical informatics than to patients (including deceased ones), then it would be impossible to humanize medicine.
PEER GROUP LEARNING
In their systematic observations of the students' responses to dissection, Shalev and Nathan (1985) found that immediately after the encounter with the cadaver, students tended “to form groups” to cope with “acute anxiety.” The authors refer to this phenomenon as the social attachment phase. It is not surprising that this happens, because cadaver dissection is a sanctioned violation of the privacy of the body of a deceased human being. In their quest for knowledge, the students are permitted to do to the cadaver that which is strictly taboo (Coulehan et al., 1995). Bonding fosters coping with distress through social cohesion. Coulehan et al. (1995) observe that “gross anatomy is also a group process in which students must work cooperatively under difficult, emotionally charged conditions to accomplish their shared goal,” i.e., dissection facilitates “interactive class time.” It is the best place to begin to steer them toward solidarity of purpose. We have found that the dissection table is the best place for small group conference teaching. In the laboratory, it is possible to engage in truly interactive, cadaver-centered PBL or case study type of instruction. For instance, the dissected cadaver is an excellent source of seeking explanations of functional loss associated with neuromuscular disease/injury. Hypotheses can be constructed and tested on the anatomy revealed by dissection. Here too, the judicious use of the computer can help enhance anatomical learning. It is also the time to engage in discussions about the ethical use of informatics in medical education (Levine et al., 1999).
TRAINING FOR THE MEDICAL SPECIALTIES
Although it has been suggested that anatomical training can be acquired in the autopsy room, critical differences exist between anatomy and pathology laboratories (Moosman, 1980; Beahrs, 1991). Skandalakis and Gray (1969) have convincingly argued against equating the pedagogic value of these facilities. Furthermore, gross anatomy is required in addition to pathology as a prerequisite in multiple medical specialties, especially the surgical ones.
In the reorganized integrated curriculum, which is now being adopted by many medical schools, including our own, gross anatomy is no longer the foundation of medical education (Drake, 1998; Giffin and Drake, 2000). The program now begins with the cell and molecular biology module. The more abstract topics are a prelude to the more concrete ones. Even a cursory examination of this approach leads one to conclude that the cell is the repository of the body. Truth is otherwise: the cell is in the body; the body is not in the cell. The body is the first entity that is confronted by the physician. Disease may begin in the cell, but it is the patient who is ill.
GROSS ANATOMY AND BIOMEDICAL INFORMATICS
Several surveys of students in advanced clinical training were undertaken in the 90s to gauge the significance of gross anatomy (and dissection) in medical training. Gross anatomy was considered essential by 94% of respondents and necessary by 6% of students in Germany (Pabst, 1995). Pabst and his colleagues wrote that “one surprising result of this survey was that not only certain specialists…graded anatomy so high in its clinical relevance…but also doctors of general medicine and pediatricians.” Seventy percent of students surveyed asked for “specialized dissection courses during later clinical phase.” The survey of Besag et al. (1976) in Great Britain showed that students desired a “well-defined basic course in anatomy in the first year” followed by a review course at the beginning of clinical training. Compulsory dissection was considered desirable “but not the whole cadaver.” A similar survey by Cottam (1999) in the United States showed that “a majority of the residency programs report that gross anatomy is either extremely important or very important to mastery of their discipline and rank it as the most important basic science.” Again, a refresher course in anatomy just before clinical training was desired by a majority of respondents.
However, between 1961 and 1975, gross anatomy programs sustained a loss of 141 hours of curricular time, leading Sinclair (1975) to write that “the amount of detail…in gross regional anatomy has now decreased below safety level.” Similar concerns have been expressed by Skandalakis et al. (1974, 1980), Moosman (1980), and Beahrs (1991). The report of Cottam (1999) noted that less than one third of residents were adequately trained in anatomy. Cahill et al. (2000) have expressed the concern that of the 80,000 avoidable deaths per year in the United States at least some ”could be attributed to anatomical incompetence.“ In light of this, it is heartening that most departments still use a traditional teaching format where ”the majority of hours were in the dissection laboratory“ (Collins et al., 1994). However, these authors also note the trend to include ”more integrated, problem-based learning and computer-assisted teaching while reducing overall content, didactic lectures, and rote memorization.“
It is ironic that those who champion catastrophic change to the alternative curriculum necessarily find regional dissection incompatible with PBL and case-based instruction. If the cadaver is essential at the core of medical training—both for its scientific, humanistic, and spiritual value—and if it is our aim to train active, caring, compassionate physicians who are committed to patient care by means of heightened communication (Muller, 1984), then abandoning well-designed cadaver-based instruction is contrary to achieving those goals.
Pellegrino (1978) writes that “compassion” and “patient” share a common origin from “patior” which means “to suffer with, to bear together, to share in another's distress … to be moved to relieve another's distress” —or put more succinctly, to share each other's mortality. Deep contemplation of the deceased facilitated by dissection begins to inculcate compassion in the trainee. Yet, the thrust of the 80s Reform has been to direct the learner to the living patient without any reference to his/her mortality. A principal objective of medicine should be to contend with that fact. To be caring, compassionate and communicative, the student must come to grips with human vulnerability, i.e., the potential of human morbidity and mortality. Equally, to steer students toward exclusive interaction with the computer and its associated inanimate modalities cannot further the essential aims of the 80s Reform (Gorlin and Zucker, 1983; Parry, 1989). To be caring, compassionate, and communicative calls for actual human interaction. This interaction must be actually applied and exercised during training.
Much regarding medical technology has changed, and yet the essential elements of good medicine remain unchanged: the human body is vulnerable to morbidity and mortality, and we have to train physicians who can rationally determine and institute cure and healing. Sophisticated technology is just this: ever more sensitive means by which to test and establish the diagnosis. The challenge remains in using rather than abusing technology. Any factor that distances the patient from the physician contributes to poor medical training and bad medicine—it constitutes abuse of technology (Gorlin and Zucker, 1983). Indeed, whenever new technology is added to patient care, compensatory means must be developed to reach the patient's humanity. Medicine still remains what it always was: a direct, open dialogue between the patient and the healer. The only interaction that truly matters is that between the patient and the physician.
Sophisticated technology is just this: ever more sensitive means by which to test and establish the diagnosis. The challenge remains in using rather than abusing technology.
Pabst and his colleagues (1986) have developed what we consider to be the most complete, innovative program of clinically oriented anatomy education. This course trains the student in the applied science of medicine—it equips the student the scientific method and the way its sequential steps of observation, hypothesis formulation, experimentation, and quantification can be used in diagnoses. Equally, by including discussions of death and dying in the course, the student learns to use the psychosocial sciences to develop a compassionated view of the patients who are also seen by the students in their living anatomy laboratory. Different formats are judiciously used, i.e., dissection, lecture, small-group discussion, case studies, living anatomy. All these components have been carefully linked to give the student a full experience of anatomy and its clinical applications. Faculty, student, the computer, and the diagnostic image are also ingredients of superior learning involving human- to-human and human-to-machine interactions. Furthermore, time-tested wisdom has been linked to future possibilities creating a learning experience that is also esthetically satisfying.
Such a program was also pioneered by Marks and his colleagues at the University of Massachusetts (Marks and Bertman, 1980). Similarly, Levine et al. (1999) and Nieder et al. (2000) show the potential of bringing the computer close to the dissected cadaver to allow the student to engage in an amplified learning experience. However, before investing in biomedical informatics, it is obligatory to consult Marks' (1996) critique of the application of medical informatics in anatomy in particular and medicine in general.
Pellegrino (1976) writes that “medicine as a discipline began under the domination of religion and myth.” Because abnormal perturbation of intracellular physicochemical processes (disease) have extracellular effects such as illness and its psychosocial and spiritual effects, medicine is closely related to religion. Human morbidity and mortality unite medicine and religion, at least its spiritual aspect. Ritual is the obligatory building material in both disciplines. Ritual is memory, communication, and therapy.
Cadaver dissection is the most important ritual at the threshold of medical training; it concretely connects the student with over 400 years of scientific medical wisdom which—by steady accretion—has earned for us the capability of diagnosing and treating illness. Crisp (1989) notes that a medical student has the unique privilege to conduct human dissection and that “it is from this that his clinical competence and confidence derives…Dissection of the human body is an initiation into the role of the doctor. After undertaking it, the person is different.” During history, cadaver dissection has helped to train a lineage of physicians to bring healing to patients. Cadaver dissection still breathes the soul into medical education; therefore, it should remain its obligatory part. The proper role of biomedical informatics is to amplify cadaver-based learning.
For over 400 years, cadaver dissection has formed the basis of Western medical education. Dissection facilitates a direct encounter with the deceased, allowing education in the scientific method and its application in diagnosis, treatment, and healing. From a scientific point of view, dissection aids the student to (1) develop a named inventory of bodily parts; (2) classify tissues into a hierarchical scheme; (3) develop a touch-based map of internal anatomy; (4) assess anatomical variability of the bodily parts; (5) project this map on the bodily surface to be used in the diagnostic physical examination; (6) precisely locate the origin, topography, and trajectory of the wound/infection; (7) develop diagnosis by using etiologic and nosologic information; (8) lay the foundation of education in other basic sciences, e.g., physiology, microbiology, pharmacology, and pathology, for which the bodily organs are the substrate. It is obligatory to acquire this information by a direct encounter between the trainee and the deceased. Cadaver-based anatomy establishes the centrality of the patient in medical education and practice.
Because medicine is more than science, the student also begins to learn it as an applied art. At the core of this education, is the deep understanding of human vulnerability due to morbidity and mortality. The objective of death and dying learning exercise in conjunction with dissection is to awaken the student's empathy and compassion not only for the dead but especially for the living patient during clinical training. The student learns that, indeed, in medicine the patient does come first (Eichna, 1983). Furthermore, these programs train the student to develop a sensitive language with which to communicate with the stricken.
Biomedical informatics, when properly used, facilitate economic, yet enhanced, anatomical education. Computer-based modalities permit a convenient and user-friendly method by which we can store, organize, maintain, retrieve, and rapidly communicate (even over great distance) vast quantities of medically relevant information necessary for diagnosis and treatment. Computer software also allows a convenient mechanism of refreshing memory, doing trial runs for surgery, and communicating with patients. The same software allows the student to correlate stationary and dynamic aspects of anatomy to develop insight regarding normal functional anatomy and its deviations during morbidity. Similarly, the newer diagnostic techniques such as CAT scan, MR imaging, and PET; endoscopic modalities; and laparoscopic procedures, require prior training in actual experience of cadaveric anatomy. Once proficient, the student can effectively use these for diagnosis and treatment.
Overreliance on virtual modalities—even those with simulated touch— can distance the physician from the patient; it can cause alienation. The proper application of biomedical informatics is to serve as a link between the physician and the patient; the medical student must, at all times, be directed toward the actual patient. Much has changed in our ability to diagnose, treat, and prevent disease; yet the central issue of medicine remains unchanged, i.e., that it is the actual human individual who experiences morbidity and mortality. The cadaver forms the link of mortality between the caregiver and receiver. In combination with the living patient, it remains the best means of training the scientific diagnostician who can bring treatment and healing to the patient. As long as actual persons suffer morbidity and mortality, the actual cadaver must remain at the core of anatomical instruction. Exclusion or reduction of cadaver-dissection in medical education is antithetical to training competent, compassionate, communicative, patient-centered physicians and other healthcare professionals.
Exclusion or reduction of cadaver-dissection in medical education is antithetical to training competent, compassionate, communicative, patient-centered physicians and other healthcare professionals.
This study is dedicated to the memory of Robert Earl Stephenson. The principal author also thanks Dr. James Pettersen (UW-Madison) for being a wise guide in early training. Stephenson (Madison, Wisconsin)—poet, friend, and mentor. We thank Ms. Alyce R. Smith, Mr. Brian Rutherford, and Ms. Gillian P. Laurence for their kind assistance in the preparation of our manuscript.
East Tennessee State University and is a Professor in the Department of Physical Therapy at Winston-Salem State University, teaching “Gross and Developmental Anatomy” and “Neurosciences”. His research program primarily consists of the neural topography of the vestibulocochlear system. Dr. Ayeni, is an Adjunct Professor at HU-COM, where he teaches “Neurosurgery”. His research program focuses on the anatomy of the posterior cranial fossa with reference to the cranial nerves. Dr. Dunn received her Ph.D. from the University of Wisconsin, Madison, and her M.D. from Georgetown University. Currently, she is the Program Director at the National Cancer Institute and an Adjunct Instructor at George Washington University. Her research program examines breast cancer genetics and prevention.