Dr. Evans is a senior lecturer in anatomy and member of the Medical Education Unit at the Brighton and Sussex Medical School (BSMS). His teaching experience is in comparative and functional anatomy, embryology, and developmental biology. His research focus is the mechanisms underlying cell and tissue interactions during vertebrate embryogenesis, using skeletal muscle as a model system.
Prof. Watt is the chair of human anatomy at BSMS. She is discipline leader for anatomy and leader for the reproduction and locomotion module. Her teaching expertise is in comparative and functional anatomy, neuroanatomy, embryology, and cell biology. Her research focuses on the mechanisms by which nonmuscle cells enter the myogenic lineage and on developing cell-based therapies for musculoskeletal disorders. Both Dr. Evans and Prof. Watt are licensed teachers in anatomy and members of the Higher Education Academy.
In the autumn of 1997, a government-initiated report on the long-term demand for doctors in the United Kingdom highlighted the current shortage of fully trained doctors working throughout the country (Medical Workforce Standing Advisory Committee,1997). The report indicated that the deficit in producing new U.K. doctors was already leading to a shortage of candidates for appointment to consultant posts in many specialties, a reduced level of trainees in general practice, and an increasing proportion of non-U.K. doctors. In response to the report, and taking into account the projected significant increased demand for healthcare in the next 2–3 decades, the U.K. government announced in 1998 an increase of over 2,000 new medical student places in England, an overall increase of 57%. In order to accommodate such a large increase in student numbers, several new medical schools and centers of medical education have been created, designed, for the first time, to bring medical teaching close to many of the main population centers. The first of the new schools opened its doors in the year 2000, a gap of almost 30 years since the last were established in the United Kingdom.
The Brighton and Sussex Medical School (BSMS) is one of the new medical schools and took its first intake of students in 2003. BSMS is a joint venture between the University of Brighton and the University of Sussex, working in partnership with local National Health Service (NHS) trusts to create the Brighton and Sussex University Hospitals Trust. BSMS offers a 5-year undergraduate medical program, which is aimed at “preparing new doctors to meet the challenges of U.K. healthcare in the 21st century.” Although the majority of the students are school-leavers, there are a proportion of graduate and mature students in the program, which helps to ensure open access to medicine and brings diversity to the student body. The curriculum at BSMS has been developed in close cooperation with the General Medical Council and greatly influenced by the Council's Tomorrow's Doctors documents (General Medical Council,1993,2003). The main challenges for the anatomy faculty during both the curriculum design phase and the early years of the course have been to decide how best to integrate anatomy into the new curriculum and to utilize a number of modern-day teaching modalities as well as some more traditionally based approaches to introduce anatomy to our students.
CHOOSING THE RIGHT APPROACH FOR MODERN ANATOMICAL LEARNING
BSMS uses a systems-based approach that combines both basic scientific and clinical knowledge and skills in an integrated manner. In the first phase of the course (years 1 and 2), 25% of the learning is in clinically based modules where students gain experience in primary care and community medicine. At the same time, students also study normal and abnormal functioning of the human body using a systems-based approach (Fig. 1). From the earliest stages of curriculum development, the academic and clinical faculty of BSMS took the view that one of the core elements of early medical training is anatomy. As a result, anatomy features strongly as an interwoven theme within the integrated systems modules of the curriculum. The inclusion of a stand-alone anatomy course has been deliberately avoided to ensure integration of student learning. In choosing the most effective approach for the provision of anatomical teaching and learning at BSMS, the anatomy staff have used their collective experience in conjunction with discussion and input from clinical colleagues across a range of disciplines.
Such integrated planning was used to define first how much anatomy students should know (learning outcomes); second, at what stage of their medical training this information would be best delivered; and finally, how this anatomical knowledge could be best presented. This type of debate is essential in medical curriculum design in the United Kingdom as there is no agreement, at present, on a national core curriculum (Older,2004). For each module, a development group has been set up to investigate the content, level, and sequence of information to be included. Particular consideration was made in year 1 and year 2 modules to ensure that students were well prepared for more clinically based modules to be delivered later in the course by gradually developing their knowledge and skills base. For example, in the second-year reproduction and locomotion module, clinical colleagues from obstetrics and gynecology and orthopedics, respectively, were instrumental in guiding the clinical elements of the module and ensuring they related fully to other aspects of the module, including anatomy. This approach also ensures that students will be trained to the level relevant for the related clinical rotations in years 3 and 4. In some cases, specific elements of study have been deliberately included much earlier than in more traditional courses, while other elements will be introduced at later stages within the program.
Although not possible for the first-year modules, student representatives are recruited onto each of the module development groups and ensure that the student population is able to input fully into curriculum development. By facilitating the students with the building blocks of anatomy early in their course and developing and enhancing these concepts as the program continues to develop, it is hoped that appropriate anatomical knowledge be propagated through to the Pre Registration House Officer (PRHO) phase of their training and beyond. Such an approach will also help to ensure continued professional development.
Overall, students in this program will be exposed to about 140 hr of anatomical contact teaching time over the first 2 years of the course, with approximately half of this time dedicated to dissection sessions. This will be further enhanced in the later stages of the course when students will return to the dissection suite during clinical rotations. The amount of anatomy included in each module is dependent on the system being studied, but in each case the level of detail and knowledge required is the same. We are careful that the content of each teaching session has a strong emphasis on structure and function as well as ensuring that clinical relevance of the structures being studied is appreciated. Within each module, the significance of anatomy to a specific clinical area is defined using the integrated nature of the curriculum. For example, in the heart, lungs, and blood module, the dissection and living anatomy sessions are closely linked to the other aspects of module such as heart sounds and chest physiology. In addition, the primary and secondary care visits of the clinical practice modules complement, where possible, the particular focus of the concurrent systems-based module.
In order to provide a strong emphasis on functional anatomy and its clinical relevance, a multidisciplinary approach has been taken and a variety of traditional and contemporary techniques were employed. Unlike some of the other new medical schools, BSMS has chosen cadaveric dissection as the cornerstone of its teaching. Recent studies suggest that there is a decline in the number of medical schools now using cadaveric dissection and therefore the use of such a technique, particularly in a new medical school, must be defended even more rigorously than previously (Older,2004). Although a relatively expensive approach to anatomical learning, we hold the view that dissection is among the most profound experiences of medical school. As well as laying the foundation of medical language, dissection provides a platform to help develop three-dimensional anatomical knowledge.
Dissection has been used for hundreds of years in medical teaching and unfortunately this has meant that some see this traditional approach to learning anatomy as somewhat old-fashioned and out-of-date. On the contrary, we, like many colleagues, believe that dissection provides the most powerful technique for demonstrating anatomy and affords an excellent basis for enhancing communication and teamwork skills (reviewed by Aziz et al.,2002; but also see Newell,1995; Older,2004). In addition, examination of cadaveric material provides students with an appreciation of anatomical variation, a concept that is not possible when using models or textbook illustrations (Willan and Humpherson,1999).
Although we refer to dissection as the traditional approach, the way in which we present this aspect of anatomy at BSMS is far from traditional, for we have dispensed with the tendency to deliver the minutia of detail and initially provide our students with dissection notes that are highly structured and relevant to the most clinically pertinent aspects of the region being studied. As we will illustrate later, although the learning of anatomy revolves around dissection, we feel it is imperative to use a multifaceted and integrated approach to the delivery of the subject.
The question of student attitude toward human dissection is a keenly debated area. A number of conflicting reports have been published on the emotional effect of the dissecting room experience on medical students, although it appears from many of these studies that differences in student response may be affected by a series of local factors (Bastos and Proenca,2000; McGarvey et al.,2001; Parker,2002; Houwink et al.,2004; McLachlan et al.,2004a; Mitchell et al.,2004). Despite these differing reports, it is agreed that dissection does introduce students, in most cases for the first time, to death. It is essential therefore that the dissection experience be handled in an understanding yet professional way.
At BSMS, we use the first sessions in year 1 to acquaint the students with the dissecting room environment and introduce them to dissection of the human body. The initial sessions are designed to allow students time to adapt to the surroundings of the dissecting room, become aware of the relevant health and safety issues, to raise the question of mortality and to begin to develop their skills in the art of dissection. The response from our current students has been positive and although some students were apprehensive about seeing a dead body for the first time, they felt, in general, that the approach taken made this a less intimidating experience than had been imagined and that this allowed them to adapt quickly to the surroundings of the dissecting room. It is true that, as expected, a small number of students did experience minor difficulties at the initial dissection sessions, which included headache, feeling lightheaded, and becoming very hot. However, because students were well supported by a team of anatomy faculty, demonstrators (surgical house officers), and clinicians, these symptoms were not repeated on subsequent visits to the laboratory.
There is a view that using dissection may desensitize students to emotional issues such as death and dying. Indeed, McLachlan et al. (2004a,2004b) argue that anatomy is about life and not death and that the use of cadaveric dissection in undergraduate teaching leads to a transfer of knowledge to an “animated corpse” rather than a real patient. Although we strongly disagree with this latter view, we are acutely aware that students must be able to demonstrate empathy and connection with patients and like all modern undergraduate medical courses, the art and significance of communication skills are high on the learning agenda in all aspects of the program. In the dissection room, we also provide students with the opportunity to develop their ability to respond to emotional events and emphasize the role of respect and compassion within the dissecting room environment. We encourage the students to view the cadavers more as donated bodies and provide them with the likely cause of death so that they are able to appreciate that their cadaver is indeed someone's relative. Students are made fully aware of the process of donation in the United Kingdom and have already become involved in the Ecumenical Service of Thanksgiving that is held on an annual basis in London, where students may meet relatives and friends of the donors. By all these routes, we avoid students taking a totally detached position that will impede participation in the process of patient-focused care and instead guide students in their initial approaches to clinical and nonclinical situations (Weeks et al.,1995; Bourguet et al.,1997).
A further argument against the use of cadavers has been the hazard to health that embalmed bodies pose to students and potential ethical and legal difficulties (McLachlan,2004). However, through the use of defined health and safety procedures, a well-established legal process for donation, and teachers and facilities being licensed under the Anatomy Act 1984, there are no such difficulties in using a cadaveric approach for undergraduate teaching and learning in the United Kingdom.
All cadaveric dissection at BSMS is carried out in an anatomy laboratory housed at the University of Sussex (Fig. 2). Although BSMS is a partnership between two universities, we are fortunate that these institutions are spatially adjacent to one another so that students do not have great distances to travel. In addition, the school has chosen to have a single cohort of students in each year (albeit divided into many small groups for a variety of learning activities), which allows the anatomy laboratory to be used as a central facility, therefore being easily accessible to all of our students. Developing such a useable resource has been more difficult to achieve for some of the other new medical schools in the United Kingdom as some of these schools have two cohorts of students based at distinctly separate geographical locations. This may have been a factor in determining their different approaches to anatomical teaching.
ENSURING A MULTIMEDIA APPROACH TO ANATOMICAL TEACHING
Although cadaveric dissection is the cornerstone of our anatomical teaching program, such an approach to learning the structure and function of the human body is best carried out, we believe, when complemented by a portfolio of other learning and teaching methods, a view supported by other medical schools in the United Kingdom and elsewhere (Reidenberg and Laitman,2002; Mitchell and Stephens,2004). To facilitate contextualization and to achieve the defined learning outcomes, students also have access to prosections, preserved specimens in jars, anatomical models, bones, radiographs, and interactive 3D images. Interactive lectures and small-group tutorial sessions are integrated into each module. However, as mentioned already, we are well aware that doctors examine living patients and that many of our students will eventually specialize in areas where they will only see internal anatomy through medical imaging; therefore, we have incorporated many aspects of living anatomy into our teaching program.
Living anatomy sessions are designed to emphasize the way in which palpation and auscultation of surface features can reveal details of deeper underlying structures. Students are fully involved in these practical sessions and are required to palpate each other in small groups to find specific landmarks. A consented peer examination approach also provides students with an understanding of what it is like to be the patient as well as the doctor and at each stage we use case-based studies to give a clinical slant to each session. Students are forewarned about their involvement in these sessions with particular reference for the need to demonstrate surface landmarks and therefore the necessity of removal of some clothing to enable them to undertake such studies. Although many are apprehensive at first, students appear happy to contribute to these sessions, and we remain conscious of the different principles and faiths of our students.
One of the most notable aspects of our living anatomy program has been to link surface identification of deep visceral structures with their ultrasonic appearance. Although ultrasound has been used as a practical teaching system previously, such a student interactive approach has not been widely utilized in undergraduate medical teaching (Teichgraber et al.,1996). In these sessions, we ask students to indicate the surface markings of certain structures (e.g., some of the abdominal viscera) on each other using makeup pencils and then with the help of the chair of medical imaging, the surface markings are compared with the actual position of the structures as identified through ultrasonography.
This fully interactive approach demonstrates the relevance of anatomical surface landmarks to the students. Such a method also provides them with an opportunity to use the ultrasonography to begin to localize and recognize deeper anatomical structures and link this to the cadaveric material. In the clinical setting, ultrasound is a widely used imaging modality and therefore the relatively early introduction to this technique allows students to develop an appreciation of the power of ultrasound when determining normal and abnormal structure. This will hopefully lead to a better interpretation of diagnostic imaging later in the course. It is hoped that future developments will include the use of ultrasonography in the dissecting room on cadaveric material. This will ensure that students can develop further the concept of ultrasonography and how it relates to normal and abnormal anatomy. Such an approach will also allow students to practice the technique of ultrasound in a nonclinical setting.
Our current use of living anatomy is further supported by imaging practical sessions run by the Department of Medical Imaging, where state-of-the-art software programs are used to develop clinical relevance. In both the dissection and imaging suites, staff are able to access the managed learning environment and utilize a variety of pertinent teaching material. In addition, a rapidly growing digital collection of medical images from the local University Hospitals Trust can be directly accessed via digital links with the university. Images for use can be displayed immediately as individual frames, three-dimensional data sets, or time series.
In addition to imaging sessions, students can apply their anatomical knowledge to a variety of clinical scenarios using sophisticated simulators in the Clinical Skills Laboratory (Fig. 3). For instance, in the heart, lungs, and blood module, students are able use their knowledge of chest wall palpation landmarks and also other surface markings in the cardiovascular-respiratory clinical skills sessions. During these sessions, students are encouraged to relate the function of the lung to the knowledge of lung structure they have gained in the dissection room and during imaging sessions. A fully integrated timetable ensures that sessions are delivered at appropriate stages within the modules.
WHERE DOES ANATOMICAL LEARNING FIT IN A NEW CURRICULUM—USING A HORIZONTAL AND VERTICAL APPROACH
Novel to the BSMS curriculum is the continuation of anatomical teaching beyond the initial stages of the undergraduate medical course. In the past, anatomy in U.K. medical schools has usually been confined to the preclinical years, with little focus paid to the need for continued anatomical learning, either in terms of reinforcing what has already been assimilated or developing more detailed anatomical knowledge when being introduced to more specialized clinical areas. This mode of anatomical teaching has led to frequent criticism by clinical colleagues in latter stages of the course who feel that there is a lack of relevant anatomical knowledge among the students. Our approach at BSMS is quite different and provides for vertical as well as a horizontal integration. Vertical integration within the medical curricula appears to stimulate better understanding and retention of core knowledge while avoiding superficial learning (Dahle et al.,2002). We have therefore ensured that students are provided with the amount and type of anatomical knowledge that is appropriate to both their level of learning and area of study.
In the first 2 years, the modular teaching is designed to ensure that students concentrate on the structure, function, and the relevant clinical correlates related to the major body systems. In years 3 and 4, all students return to practical anatomy sessions, where teaching will be focused toward specialist rotations. For instance, in the ear, nose, and throat (ENT) clinical rotation, students will examine in detail the anatomy associated with pharynx, larynx, and nasal and oral cavities. By providing our students with an early grounding in structural and functional morphology in the early years of the course and gradually developing this knowledge with more clinically pertinent material as they move through the program, we believe that students will develop the total conceptual framework that is required by a newly qualified doctor. Such a conceptual approach should enable students to retain factual information more easily and apply this core knowledge to their medical practice.
EVALUATION AND CONCLUSIONS
So how do we know whether our method of teaching is successful? Obviously with only two intakes of medical students to date, it is not possible to examine in detail the student attitude to the anatomical learning experience as a whole. In addition, we cannot yet quantify the success/failure of our teaching methodology over the entirety of the course. However, student feedback has already been collected through formal questionnaires at the end of each of the modules run so far. This feedback gives some insight into how the students have responded to the anatomical aspects of the course. There was a very high rate of return for the questionnaires with an average of 91% completion from the entire cohort. The students were requested to give numerical scoring (1 = poor; 5 = very good) to specified aspects of course delivery (not just for anatomy). In addition, students were also asked open-ended questions to solicit comment.
Anatomical teaching has achieved high ratings in each of the modules for which data have thus far been obtained, as can be seen in Figure 4. Where lectures/tutorial sessions could be identified as a particular anatomy component, student ratings averaged 4.53, indicating a very high level of satisfaction. Practical classes that included dissection and living anatomy were also very well received, scoring an average of 4.42 for all first- and second-year modules reviewed. The student open-ended comments reflected much of the statistical feedback, with anatomy appearing as one of the best aspects of all the systems-based modules. In many cases, students indicated that dissection is their preferred way of learning anatomy with other anatomy teaching acting as reinforcement and expansion of the knowledge gained.
The establishment of the Brighton and Sussex Medical School has given us the opportunity to develop a modern and distinctive curriculum, which includes anatomy as one of the core elements. Although we use human cadaveric dissection as the cornerstone of our anatomical teaching, we also integrate aspects of living anatomy, including three-dimensional imaging and surface anatomy. By offering our students a selection of learning environments, we believe we are equipping them with the appropriate level of functional and clinically important anatomical knowledge to prepare students for a wide range of medical career destinations. Until our first cohorts of students graduate and enter the postgraduate years of their training and development, we will not be able to evaluate fully the success or failure of our approach to anatomical teaching. However, our earliest indications from student questionnaires and the encouragement we have had from the General Medical Council suggest we are indeed achieving the right mix.
The authors thank Professor Ken Miles, chair of medical imaging, for useful discussions during the preparation of this manuscript.