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Keywords:

  • education;
  • teaching;
  • dissection;
  • anatomical instruction;
  • Web-based materials

Abstract

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. MATERIALS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. Acknowledgements
  8. LITERATURE CITED

Teaching anatomy by dissection is under considerable pressure to evolve and/or even be eliminated, and curricular hours in the dissection laboratory are decreasing. As a possible means of easing this pressure, an online interactive anatomy program has been created to enhance the dissection experience, observational learning, and three-dimensional comprehension of human anatomy. An assessment was made of the utility of the program in preparing students for dissection laboratories and for examinations. The efficacy of the application was evaluated by first-year students and faculty with pre- and post-use surveys in anatomy courses at three medical schools. It was found that students felt better prepared if they utilized the Web site prior to their dissection laboratory, and faculty reported spending less time explaining basic concepts or techniques. It is concluded that a comprehensive online program significantly enhances the quality and efficiency of instruction in human anatomy in the dissection laboratory and could prove to be a useful tool at other institutions. Anat Rec (Part B: New Anat) 289B:121–127, 2006. © 2006 Wiley-Liss, Inc.


INTRODUCTION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. MATERIALS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. Acknowledgements
  8. LITERATURE CITED

Anatomy is the one curricular component of medical education whose purpose has not changed since it was introduced millennia ago: to learn the structure and the function of the human body. The way in which this is achieved has evolved from a total absence of dissection of the body, based on theological and philosophical considerations, to the passive observation of dissections by barber-surgeons, to the curricular reforms in the United States in the late 19th century, which continued the tradition of dissection as the instructional centerpiece of medical education (Dyer and Thorndike,2000; Gregory and Cole,2002).

After a century of relatively little change in how anatomy was taught in medical curricula, teaching anatomy by dissection at the beginning of the 21st century is under considerable pressure to evolve and/or even be eliminated (Clark,2003; Granger,2004; McLachlan et al.,2004). Curricular hours in traditional medical courses, especially in the dissection laboratory, are decreasing in response to the explosion of information being taught in disciplines such as genetics, pharmacology, and molecular and cell biology. The production of faculty qualified to teach anatomy is down substantially due to the elimination of training programs and the retirement of existing anatomists (McCuskey et al.,2005); additionally, advances in computer technology have led some to assume that it is possible to teach anatomy without a cadaver (McLachlan,2004; McLachlan et al.,2004; Topp,2004). At the same time, it is recognized that anatomy provides a context for the synthesis and integration of data about the human body, the best preparation for an effective physical examination, and an environment for learning the group process, clinical problem-solving, and sensitivity to human mortality (Marks,1999; Granger,2004; Pawlina and Lachman,2004). Anatomy is also viewed as the foundation of three-dimensional learning in medical education (Marks,2000), and the most important basic science course taken by medical students, according to the results of a survey of residency program directors (Cottam,1999).

While those who teach anatomy no doubt feel strongly that dissection is the essential ingredient in learning about the three-dimensional construction of the human body, there is the undeniable possibility that in the future, dissections could be computer-simulated with haptic technology. Yet even this advancement may be unable to replicate fully the necessary touch-mediated cadaver/patient experience and to teach the training in anatomical variability (Aziz et al.,2002) essential to correct diagnoses (Willan and Humpherson,1999; Wise,2000).

Those who believe that anatomical dissection is an integral and necessary part of a medical curriculum must find more efficient ways to impart requisite basic information in courses with fewer allotted contact hours and with fewer qualified instructors, without impacting the learning process and outcomes. At the University of North Carolina School of Medicine at Chapel Hill, we have developed a Web-based program called Interactive Human Anatomy (IHA), which is being used as a supplement to the dissection laboratory. This program may prove essential during a projected period when our laboratories are undergoing renovation and dissection time becomes limited.

Irrespective of the type of online program, it must be shown by accurate and sound evaluation methods that such programs are an effective and efficient way to teach anatomy, before these programs can be widely adopted to replace time spent in the laboratory. With support from the Fund for the Improvement of Post-Secondary Education (FIPSE) of the U.S. Department of Education, we have developed this program and assessed its use in different health profession's educational settings. In this first study, we report the design, construction, content, and implementation of the program and provide the evaluative findings from the first year of program use by students at three different U.S. medical schools, one public and two private, using both quantitative and qualitative data. These focus on student and faculty use and ratings, as well as perceived effectiveness in meeting course objectives. Subsequent studies will analyze the effect of variables on student examination scores and the role of student self-efficacy with respect to the use of this program.

MATERIALS AND METHODS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. MATERIALS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. Acknowledgements
  8. LITERATURE CITED

Design of the Online Program

The IHA Web site is organized by body region modules. The dissection videos for each body region module are the centerpiece of the program. The filming of each dissection video is a carefully choreographed process, with simultaneously recorded narration to enable the accurate pacing of the dissection with the filming and the final edited narration.

For each body region, there are a series of dissection modules. For example, there are six for the upper limb: posterior shoulder, anterior shoulder, and pectoral region, flexor and extensor surfaces of the arm, extensor surface of the forearm and dorsum of the hand, flexor surface of the forearm, and the palm. Each module contains a series of 2-min to 4-min streaming videos, one per dissection step, with labels, closed captioning, and narration. Each of the video steps within a module has a glossary of terms used in that step, with links to relevant plates from Netter Presenter (Elsevier), and there is a composite glossary of all the terms used in the online program, compiled alphabetically.

Each dissection step is also linked to a module resource page for that module, which includes QuickTime (Apple Computer) movies of stacked sections from the Visible Human Project (VHP) relevant to that module; a radiological imaging program with labeled radiographs, computerized tomography (CT) scans, magnetic resonance images (MRIs), and angiograms; links to Netter Presenter plates; illustrations; table of information; and self-examinations.

For each QuickTime movie of images from the Visible Human Project (National Library of Medicine), 100–150 sequential transverse images at slice intervals of 2 mm were selected for each body region. Selected structures were labeled on images throughout each stack to allow the students to follow the structure in three dimensions. The sections in the movies are numbered and the movies are chaptered, so that students can “jump” directly to a labeled section by clicking on the section number. Descriptive text accompanies each labeled section.

Figure 1 shows a flow diagram detailing how to use the Web site. Readers may access an introduction to this program online (http://www.med.unc.edu/anatomy). Access to the full program was password-protected for 3 years, under the evaluation guidelines of the grant; the mechanism for access to the program and the means by which to complete it are currently under consideration.

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Figure 1. How to use the Interactive Human Anatomy program.

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Evaluation of Program

The program was used and evaluated by first-year medical students at three partner institutions: 148 at a public medical school (institution 1) and at two private medical schools (39 at institution 2 and 40 at institution 3). In addition, a grant advisory board was established composed of representatives of the three partner schools. The advisory board met once a year with the developers and evaluators of the program to discuss the evaluation results, plan work for the following year, discuss changes to the program, and develop strategies for its dissemination to the partner schools.

Students completed both pre-use (i.e., prior to Web site access) and post-use (i.e., after Web site access) paper surveys. The pre-use survey asked questions related to the students' background (e.g., prior anatomical courses, typical amount of Web use) and standard demographics, while the post-use survey asked students to describe how often they used the Web site for this program and to rate the Web site's design, usefulness, and effectiveness.

During the first year of program use, students were introduced to the program and completed pre-use surveys at the beginning of their anatomy courses, all of which included full dissection, in the fall of 2002. This also coincided with the beginning of their first semester in medical school. Because only the back and upper limb modules were completed and available for year 1, students completed the post-use survey after both the back and upper limb dissection had been taught and the material tested.

Instructors who taught the back and upper limb segments of the courses at the three institutions completed pre-use and post-use surveys. The faculty pre-use survey asked questions about faculty background, demographics, and instructional style. The post-use survey asked faculty to describe their Web site use, to rate the Web site's design, usefulness, and effectiveness, and to describe student behavior with and without the instructional aid.

SPSS versions 11.0.1 and 11.5.0 for Windows (SPSS, Chicago, IL) were used to complete statistical analyses, including descriptive statistics and ANOVA. This evaluation received institutional review board approval at the School of Medicine at the University of North Carolina at Chapel Hill, and through this institution, at the partner schools.

RESULTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. MATERIALS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. Acknowledgements
  8. LITERATURE CITED

The percentages of students who responded to the surveys for each institution are shown in Table 1. The number of students responding to the surveys was high at institutions 1 and 2, where the program was incorporated into the curriculum; at institution 2, the program was also utilized in group sessions prior to the dissection laboratories. The response rate was also high at institution 3, where the program was one of several optional resources. However, at institution 3, only 40 students correctly filled out their pre- and post-use surveys, and thus the responses of the other students had to be dropped.

Table 1. Student response rates to pre- and post-use surveys
 Institution IInstitution 2Institution 3
  • 1

    n represents the number of students who correctly completed both the pre-use and the post-use survey.

Number of Students (n)11403940
Response Rate83.8%86.7%45.5%

Student Use of Web Site Components

The way in which the program was used within the curriculum at each institution affected the use of Web site components for laboratory and examination preparation (Table 2). On the post-use survey, students were asked how often they used each of the Web site's components (i.e., dissection video clips, cross-sectional videos, the imaging program, Netter pop-up images, the glossary, and self-evaluations) for laboratory preparation and examination preparation, when available. Students were asked to respond on a Likert scale (1, never; 2, rarely; 3, often; and 4, consistently).

Table 2. Student use of website components: Laboratory and examination preparation
WEBSITE COMPONENTSLABORATORY PREPARATIONEXAMINATION PREPARATION
Inst. 1*Inst. 2*Inst. 3*Total*Inst. 1**Inst. 2**Inst. 3**Total**
  • *

    Mean ± standard deviation (SD) of student reported use of each website component for laboratory preparation at each institution and for students overall.

  • **

    Mean ± standard deviation (SD) of student reported use of each website component for examination preparation at each institution and for students overall.

  • Note: For the Likert scale (1-4) used: Never = 1; Rarely = 2; Often = 3; and Consistently = 4

Dissection Videos3.74 (n=140) SD=0.582.67 (n=39) SD=0.582.03 (n=39) SD=0.713.24 (n=218) SD=0.922.32 (n=139) SD=1.131.92 (n=38) SD=0.881.50 (n=40) SD=0.782.10 (n=217) SD=1.08
VHP Cross Sections2.06 (n=140) SD=0.891.66 (n=38) SD=0.781.38 (n=39) SD=0.671.87 (n=217) SD=0.872.20 (n=139) SD=1.051.50 (n=38) SD=0.801.35 (n=40) SD=0.701.92 (n=217) SD=1.02
Imaging Program2.89 (n=140) SD=0.941.66 (n=38) SD=0.711.50 (n=40) SD=0.602.42 (n=218) SD=1.053.46 (n=138) SD=0.801.50 (n=38) SD=0.761.40 (n=40) SD=0.712.73 (n=216) SD=1.24
Netter plates2.32 (n=139) SD=0.961.50 (n=38) SD=0.601.38 (n=40) SD=0.712.00 (n=217) SD=0.962.09 (n=138) SD=1.021.32 (n=38) SD=0.571.38 (n=40) SD=0.711.82 (n=216) SD=0.97
Self-Evaluations2.54 (n=140) SD=1.031.64 (n=39) SD=0.741.50 (n=40) SD=0.642.19 (n=219) SD=1.033.25 (n=140) SD=1.031.51 (n=39) SD=0.791.47 (n=40) SD=0.752.62 (n=219) SD=1.26
Glossary2.04 (n=139) SD=0.981.47 (n=38) SD=0.691.30 (n=40) SD=0.461.81 (n=217) SD=0.921.81 (n=135) SD=1.001.34 (n=38) SD=0.671.18 (n=39) SD=0.391.61 (n=212) SD=0.90

Program Use for Dissection Laboratory Preparation

Students at all three institutions collectively reported that they used the dissection videos most often to prepare for the dissection laboratory (mean = 3.24) and used the glossary least (mean = 1.81). Although the dissection videos were used most often at three institutions, their use at the different institutions varied significantly [F(2,215) = 145.005; P ≤ 0.001)], with students at institution 1 using the dissection videos most often (institution 1: mean = 3.74; institution 2: mean = 2.67; and institution 3: mean = 2.03). On average, students at both institutions 2 and 3 reported seldom using any component of the Web site, other than the dissection videos, for laboratory preparation. Thus, each of the overall means is heavily weighted by student use at institution 1.

Program Use for Examination Preparation

In preparing for examinations, students at all three institutions reported that they used the imaging program (mean = 2.73) and self-evaluations (mean = 2.62) most often. Overall, the glossary was again used the least (mean = 1.61). However, when student use at the individual institutions is examined, it is apparent that students at both institutions 2 and 3 reported minimal use of any Web site components for examination preparation, with the overall means again being weighted by student use at institution 1.

Student Rating of Web Site Components

As part of the post-use survey, students who used the materials on the Web site for laboratory preparation and examination preparation were asked to rate each component on a Likert scale (1, poor; 2, fair; 3, good; and 4, excellent).

Students had the option not to respond to this question by indicating that they did not use the component for laboratory and/or examination preparation. The ratings of students who used Web site components for laboratory preparation and for examination preparation are shown in Table 3. For laboratory preparation, students at all three institutions combined rated the dissection videos highest (mean = 3.63) and the self-evaluations lowest (mean = 2.43). However, when the students are separated by institution, students at institution 2 rated the QuickTime movies of the VHP cross-sections as high as the dissection videos for use in laboratory preparation (means = 3.45 vs. 3.46, respectively).

Table 3. Student ratings of website components: Laboratory and examination preparation
WEBSITE COMPONENTSLABORATORY PREPARATIONEXAMINATION PREPARATION
Inst. 1*Inst. 2*Inst. 3*Total*Inst. 1**Inst. 2**Inst. 3**Total*
  • *

    Mean ± standard deviation (SD) of student reported usefulness of each website component for laboratory preparation at each institution and for students overall.

  • **

    Mean ± standard deviation (SD) of student reported usefulness of each website component for examination preparation at each institution and for students overall.

  • Note: For the Likert scale (1-4) used: Poor = 1; Fair = 2; Good = 3; and Excellent = 4

Dissection Videos3.72 (n=138) SD=0.533.46 (n=35) SD=0.613.35 (n=23) SD=0.653.63 (n=196) SD=0.573.36 (n=76) SD=0.733.16 (n=19) SD=0.773.30 (n=10) SD=0.683.31 (n=105) SD=0.73
VHP Cross Sections2.72 (n=61) SD=0.713.45 (n=11) SD=0.692.86 (n=7) SD=0.902.84 (n=79) SD=0.762.97 (n=75) SD=0.723.00 (n=8) SD=0.763.00 (n=7) SD=0.822.98 (n=90) SD=0.72
Imaging Program3.42 (n=98) SD=0.673.31 (n=13) SD=0.482.38 (n=8) SD=0.743.34 (n=119) SD=0.703.64 (n=131) SD=0.483.18 (n=11) SD=0.752.90 (n=10) SD=0.883.56 (n=152) SD=0.57
Netter plates3.33 (n=89) SD=0.723.00 (n=6) SD=0.632.71 (n=7) SD=0.493.26 (n=102) SD=0.723.33 (n=75) SD=0.663.00 (n=3) SD=1.002.75 (n=8) SD=0.713.27 (n=86) SD=0.69
Self-Evaluations2.28 (n=71) SD=1.003.22 (n=9) SD=0.672.88 (n=8) SD=0.642.43 (n=88) SD=0.992.45 (n=122) SD=1.013.11 (n=9) SD=0.782.90 (n=10) SD=0.882.52 (n=141) SD=1.00
Glossary3.24 (n=67) SD=0.583.00 (n=6) SD=0.632.44 (n=9) SD=0.533.13 (n=82) SD=0.623.09 (n=53) SD=0.603.00 (n=4) SD=0.822.75 (n=4) SD=0.963.07 (n=61) SD=0.63

For examination preparation, the students at all three institutions combined rated the imaging program the most useful (mean = 3.56) and the self-evaluations the least valuable (mean = 2.52).

Faculty and Student Perceptions of Web Site Effectiveness in Meeting Course Objectives

As part of the post-use surveys, both faculty and students who used the Web site were asked to rate the impact of the Web site use in terms of several pedagological objectives. Faculty (overall n = 18) reported that the Web site program prepared students to perform dissections, enabled students to learn more from the laboratories, enabled students to learn anatomical structures/landmarks, helped students learn anatomical terms, was applicable to overall course content and objectives, and was useful as a learning tool for the students.

Students who used the Web site and completed the surveys also agreed that the program met these objectives. Faculty and students at institutions 1 and 3 most strongly agreed that the Web site was applicable to overall course content and objectives and that it was a useful tool for the students.

DISCUSSION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. MATERIALS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. Acknowledgements
  8. LITERATURE CITED

Effectiveness of Program in Accomplishing Course Objectives

Faculty and students were extremely consistent in their level of agreement that the Web site had a positive impact on laboratory activities, acquisition of knowledge and anatomical language, and meeting course objectives. Furthermore, a majority of the faculty completing both pre- and post-use surveys reported that use of the Web site enabled teaching in the laboratory to focus more on the anatomy and less on the performance of the dissection, thus improving the quality of both the teaching and learning experience.

Use of Web Site Components and Variability Among Institutions

Student use of the Web site components for laboratory preparation varied, with institution 1 showing the highest usage in all categories. Although radiographic anatomy and VHP cross-sectional anatomy were incorporated into the courses at institutions 2 and 3, these components of the IHA program were underutilized because they were not emphasized and/or because the students in these courses had other imaging and review resources available, with which they were more familiar. With regard to use of the program for examination preparation, this same pattern was observed, with high usage of the imaging program and self-evaluations at institution 1, where the examinations test the ability to read radiographs, CTs, and MRIs of normal anatomy.

A number of students at institutions 2 and 3 commented that the reason they did not use the Web site was due to time limitations and/or the large number of other resources available, reinforcing the conclusion that the instructors should have introduced this particular resource, its components, and how to use them, to the students at the beginning of the course. It was also determined that the partner schools especially needed a formal introduction to the program for their students given by someone other than their course director.

Ratings of Web Site Components for Laboratory and Examination Preparation

Students using the program found the dissection videos most useful at all three institutions for both laboratory and examination preparation as compared to the other Web site components. The imaging program, associated Netter plates, and the glossary were also rated highly at institutions 1 and 2, where they were integrated into the curriculum. Students reported that the self-evaluations were the least useful Web site components for laboratory and examination preparation, with the majority of responses from students at institution 1. Many students commented that the items on the evaluation were not representative of the questions on the examinations at their school and that the evaluation did not provide sufficient explanations as to why an answer was correct.

Written comments on the surveys about the program were generally laudatory and encouraged the further development of the program. One student commented: “this Web site is a great resource and a useful tool, especially for those who are visual learners.” The authors recognize that not all medical students are visual learners (Mathewson,1999; Marks,2000; Garg et al.,2001; Mayer and Massa,2003) and that every year there are a few students who struggle with anatomy for that reason. Whether this program is useful for students who are not particularly good visual learners is not known, but is well worth exploring in the future.

Limitations

There were a number of problems encountered in program usage, as reported by student and faculty comments on the surveys and from discussion with the advisory board. Students gave time limitation and the large number of other resources available as reasons for not using the program. Both students and faculty noted that unless they had high-speed access to the Internet at home, they were unable to use the program except in their classroom buildings due to the size of the files to be downloaded. Because the program is password-protected, all students and faculty other than those at institution 1, where the program is located, had to be issued passwords. The password had to be used each time the program was accessed, creating another step in the use of the program. Faculty at institution 2 commented that students frequently lost or forgot their passwords and thus could not use the program until they were reissued passwords. By the final year of the grant, use of the program at other institutions was converted to access by IP range, which obviated this problem.

Since both the project development team and the advisory board noted that if the different components were not introduced or made integral to the courses, the students did not use them, a 7-min videotaped introduction to the program was created. It began with an explanation of the rationale behind the IHA program and a visual description of how the program was organized and the ways in which each part of the program could be used. The program analyst then explained how the evaluations were to be conducted, why certain permissions were required from the students, and the uses to which the survey data would be put. Students were assured that their personal information and responses would be used anonymously. This video was downloaded to DVDs and was played for the first-year students at the different schools at the beginning of their courses the following year.

Summary and Future Direction

It is clear from our analysis that in instances where the program is integrated into the anatomy curriculum and can be introduced appropriately with regard to why and how to use it, it is a useful learning tool (Bransford, 1999). Those students using the program rated the dissection videos the highest and also valued the Netter plates, the glossary, and the imaging program. The self-evaluations were not perceived to be as useful, a situation that could be improved with adapting the self-evaluation to the institution's testing style and by offering explanations for the correct answers. The planned introduction of practical self-evaluations, using images from the dissection, should prove more useful to the students, as should more comprehensive questions using clinical scenarios. Most importantly, the faculty felt that the program improved both the students' and the instructors' use of time in the dissection laboratory and the quality of the learning experience there. We conclude that a comprehensive online program can significantly enhance the quality and efficiency of instruction in human anatomy in the dissection laboratory and could prove to be a useful tool at other institutions and in other disciplines where human resources for teaching are a limiting factor (McCuskey et al.,2005).

The manner in which the IHA program will be disseminated (restricted or open access, downloadable or provided on a DVD), maintenance of the Web site, the costs of maintenance and dissemination, and how this cost will be borne are important future considerations of the advisory board and the onsite development team.

Acknowledgements

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. MATERIALS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. Acknowledgements
  8. LITERATURE CITED

The authors acknowledge the members of the Medical Educational Technology Group (Jamie Hahn, Edward Holm, and Charles Hitlin) for their tireless efforts in filming, editing, designing, and assembling the online program; James Scatliffe and Jesse Cannon for their creation of the imaging program; Young-Sook Jung for her contributions to the design of the surveys, data entry, and analyses; Maureen Noh for her beautiful illustrations; and the other advisory board members for their input and advice. The authors also thank the members of the classes of 2006 at each of the medical schools involved in this study for their participation.

LITERATURE CITED

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. MATERIALS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. Acknowledgements
  8. LITERATURE CITED