Dissection in learning and teaching gross anatomy: Rebuttal to McLachlan

Authors

  • Wojciech Pawlina,

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    • Department of Anatomy, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905
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    • Dr. Pawlina is an associate professor in the Department of Anatomy and Obstetrics and Gynecology at Mayo Clinic College of Medicine (Rochester, MN). He has taught anatomy for 26 years at Copernicus Medical School (Kraków, Poland), University of Florida College of Medicine (Gainesville, FL), and Mayo Clinic College of Medicine where he has served as chair of the Gross and Developmental Anatomy and Microscopic Anatomy courses. Dr. Pawlina also chairs the Educational Affairs Committee of the American Association of Clinical Anatomists. His research area is in clinical anatomy and medical education.

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  • Nirusha Lachman

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    • Dr. Lachman is an associate professor of anatomy at the Department of Human Biology, Durban Institute of Technology in Durban (South Africa). She has taught gross anatomy for 10 years and directs several gross anatomy courses. She serves as Secretary of the Anatomical Society of Southern Africa and is chair of the ASSA Education Committee. Her research area is in cardiovascular and clinical anatomy and medical education.


The notion that anatomy as a basic medical science should remain traditional in its learning approach and classic in its content can no longer be supported due to the recent advancements in electronic media. The development of more powerful computers, video cards, and 3D gaming technology has allowed medical educators to use high-quality imaging, sophisticated training tools, and interactive computerized programs projecting cross-sectional, radiologic, and living anatomy in the classroom. What were once considered advanced imaging methods and technologies are now considered routine.

It is unlikely, therefore, that an anatomy teacher would not want to take advantage of this modern technology. There is no question that the use of such techniques and tools in anatomy education is essential to the training of a medical student. There is no question that gross anatomy must be taught in relation to clinical practice and that students must incorporate principles of living anatomy in their learning. The question is simply, Where do we draw the line?

TO DISSECT OR NOT TO DISSECT?

The issue of dissection is ongoing and has been a topic of debate by anatomists, educators, and politicians for centuries. Those who advocate retaining this traditional learning exercise cite the value of the cadaver experience. Those who see the practice as redundant defend their position by pointing to recent technological advancements. While arguments remain within the confines of debate, it is evident that denying a medical student the privilege to dissect is undeserved. As Jacobus Sylvius (1555) remarked in his Manual of Anatomy: “For my judgment is that it is much better that you should learn the manner of cutting by eye and touch than by reading and listening. For reading alone never taught anyone how to sail a ship, to lead an army, nor to compound a medicine, which is done rather by the use of one's own sight and the training of one's own hands.”

DOES ACQUISITION OF CLINICAL SKILLS EQUAL ACQUISITION OF CORE KNOWLEDGE?

In attempting to frame a modern concept of gross anatomy education, it is necessary to shift the paradigm of tradition passed down over the centuries and integrate its foundation into clinical practice. However, the acquisition of clinical skills should not be confused with the acquisition of core knowledge. While the two are interdependent, they are separate educational entities whose distinctness must be preserved. The establishment of a foundation in basic science is mandatory for the successful performance of clinical skills, not the other way around (du Toit, 2003). The trend toward minimal-access surgery and the more frequent performance of interventional procedures within limited anatomical areas further necessitate a solid understanding of anatomical relationships. Anatomical details considered minor in the past have now become critical to the success of a clinical procedure. Dissection as an integral tool in the training of clinical experts cannot be subverted, nor can an acceptable substitute be found. Dissection defines anatomy and teaches essential skills that support the development of a student across the spectrum of medical education.

DOES ANATOMY LABORATORY PROVIDE VALUABLE EXPERIENCE FOR LEARNING AND TEACHING?

Standard anatomical teaching that does not include dissection provides the student with an artificially narrow experience in which one seldom-seen ideal state is recognized as the normal model. But does this normal educational model work? Often, when we have reviewed normal anatomy with senior medical students or residents, we have found that many of them have acquired only superficial and sometimes even misleading information about the orientation and structure of the human body. Before they can understand the true anatomy of these structures, they must unlearn information that they have already been taught. Dissection provides students with the opportunity to verify their learning, trust their observations, and appreciate the concept of variability as it presents itself and not as it is presented to them.

The case for maintaining dissection in the undergraduate medical curriculum rests on an appreciation that it involves more than routine physical investigation. If directed creatively, dissection provides the platform for the independent learning and independent thinking that underpins the development of diagnostic aptitude. Dissection can thus play many roles in the educational process.

If directed creatively, dissection provides the platform for the independent learning and independent thinking that underpins the development of diagnostic aptitude. Dissection can thus play many roles in the educational process.

DOES CADAVER EXPERIENCE PROVIDE AN OPPORTUNITY FOR PSYCHOSOCIAL DEVELOPMENT?

In addition to its academic merits, the dissection experience contributes to a student's psychosocial development. While it is true that the very nature of dissection demands a level of desensitization, it also promotes greater sensitivity to issues involving death and dying. Students also learn to respect the act of body donation. The unnatural setting of the gross anatomy laboratory is fertile ground for teaching aspects of medicine that cannot be learned in any other setting. Far from being a stressful occasion, the dissection experience should be viewed as a valuable gift that every medical professional deserves.

DO HEALTH CARE CHANGES INFLUENCE TEACHING OF ANATOMY?

The ongoing transformation of the world's health care infrastructure as well as increasing pressures from insurance and managed care institutions threatens to undermine the values and attitudes that are the foundation of medical professionalism (American Board of Internal Medicine Foundation, American College of Physicians-American Society of Internal Medicine, European Federation of Internal Medicine, 2002). Erosion of professional values in the medical community has a negative impact on the professional development of medical students and residents. In the past, medical students, residents, and physicians modeled their professional behavior on those whom they most respected in their fields (Mufson, 1997). As health care delivery and the financial and societal issues that surround it have become more complex, it has become clear that traditional methods of instilling professional values in medical students are inadequate. An intricate world and a diversified society require the establishment of formal programs to teach professionalism in medical schools as well as residency programs (Stephenson et al., 2001).

DOES ANATOMY TEACH PROFESSIONALISM?

Medical educators are responding to this changing environment by implementing innovative methods to provide such training. Currently, almost 90% of U.S. medical schools provide formal activities designed to teach medical professionalism, and some of them start from day 1 of the medical curriculum (Swick et al., 1999). Courses that have traditionally offered only pure content are now being utilized to teach professionalism. The gross anatomy course is a perfect vehicle with which many aspects of professionalism can be addressed (O'Connell and Pascoe, 2004).

For most medical students, their initial contact with professional values occurs during the first-year gross anatomy course. Students in gross anatomy courses are asked to reflect on the altruistic gift of the human body for which they are assigned to care for (Jones, 1997). Other important areas of professionalism exercised in the gross anatomy course include team-building, cooperative learning, and the development of leadership skills. These skills and competencies are essential for new physicians to function in the current health care system. In addition, ample opportunities exist to explore issues related to interprofessional respect, responsibility, confidentiality, self-policing, and interpersonal skills (Swick, 2000). In many gross anatomy laboratories, the members of a dissection group perform self- and–peer evaluations and learn how to use formative and summative evaluations effectively in order to provide constructive feedback to the gross anatomy faculty (O'Connell and Pascoe, 2004; Pawlina, 2004). In many educational institutions, the gross anatomy course is being viewed not only as a way to teach the morphology of the human body but also as the first link in a long chain of events that teach new skills and competencies to tomorrow's physicians.

In the dynamic continuum of global education, the future of gross anatomy as an inclusive component of the medical curriculum continues to be scrutinized. Will the decision to phase out dissection—a vital pedagogical component of anatomy education—be determined by curriculum committees? As this question continues to be debated, it will be important to keep in mind that clinical competency, good educational practice, and professionalism can only benefit the health care system and its consumers.

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).

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