Anatomy Teaching and Its Challenges
The subject of anatomy has long been central to medical and veterinary education and once formed the foundation of preclinical teaching (Bardeen, 1905); however, in recent years, the way in which anatomy is taught has undergone a multitude of changes. Gradual advances in scientific knowledge and experimental techniques have led to a need to teach other preclinical subjects in more depth (Warner and Rizzolo, 2006; Drake et al., 2009), with the result that increasingly fewer hours are dedicated to anatomy teaching. As early as 1923, a report by the American Association of Medical Colleges recommended that the time devoted to teaching anatomy should be restricted (AAMC, 1923; Keiller, 1923; Reid, 1931; Eldred and Eldred, 1961), and more recently, following the publication of Tomorrow's Doctors (GMC, 1993, 2003, 2009), many medical curricula in the United Kingdom have evolved to incorporate the teaching of general competencies such as communication skills and professionalism, leading to a reduction in traditional scientific content (Harden et al., 1997; McHarg and Kay, 2008; Jaarsma et al., 2009). Specific to the field of veterinary education, the release of the Pew National Veterinary Education Program Report (Pritchard, 1988) initiated a similar change in emphasis, with an increased focus on learning the necessary professional behaviors and attitudes of a veterinarian. Most recently, the publication of a list of Day One Competences by the Royal College of Veterinary Surgeons marked a major shift in the United Kingdom toward an outcome-based approach to veterinary education (RCVS, 2001).
These changes have led many academics to register concerns about the effect of reduced teaching hours on anatomical knowledge and clinical practice. Studies comparing anatomy test scores between traditional and new (post-1995, systems-based) medical curricula demonstrate that students taught under the traditional system scored better (McKeown et al., 2003). When differences in anatomical knowledge between students from different medical schools were explored, unsurprisingly, students who spent longer in anatomy classes, or who had increased frequency of exposure to anatomy, were found to hold better anatomical knowledge (Blunt and Blizard, 1975; Prince et al., 2003; Bergman et al. 2008). Other studies also support the fact time on task does result in increased knowledge of a subject (Verhoeven et al., 2002). It is therefore not unreasonable to suggest that the reduction in anatomy teaching hours experienced in recent years by the medical/veterinary professions may have impacted on the anatomical knowledge of students and graduates. This has been acknowledged by experienced clinicians and newly qualified doctors alike (Monkhouse, 1992; Prince et al., 2005; Ahmed et al., 2010, 2011), with studies indicating that recently qualified doctors feel poorly prepared for everyday practice because of their perceived lack of anatomical knowledge (Bagley et al., 2011), and that poor anatomical knowledge may negatively influence career direction and progression (Smith and Mathias, 2011). Given these potential implications, anatomy educators are faced with the challenge of finding alternative methods by which to enhance anatomical learning in the face of reduced contact hours (Sugand et al., 2010).
Of course, while changes to medical and veterinary curricula have provided challenges, they have also presented opportunities. The increased focus on the development of nonknowledge-based competencies does offer benefits to students, providing them with the essential social and professional skills they will need to become well-rounded practitioners in the future. Experience has shown that noncognitive skills are well adopted and engaged with when taught alongside traditional subjects such as anatomy (Sprunger and Smith, 2005; Burns et al., 2006; Lachman and Pawlina, 2006; Pawlina et al., 2006), and thus, teaching methods that combine a balance of the two should be encouraged.
Adult Learning Challenges
Malcolm Knowles (1913–1997), an American adult educator, coined the term “andragogy” and developed the concept that adults learn, or should be taught, differently from children (Knowles, 1968). According to Knowles (1984), adult learners should be taught in such a way that explains why certain knowledge/skills are taught (readiness); is task oriented, rather than requiring memorization (problem-oriented); acknowledges the diversity of learners (builds on past knowledge); and allows adults to learn on their own and from their mistakes (self-directed). As such, teaching that encourages “active-learning” (Mayer, 2004), requiring students to reflect on ideas, assess their own degree of understanding or skill, and participate actively, is closely aligned with Knowles' principles and has been suggested as a method to help students achieve a more meaningful learning experience (Michael, 2001; Novak, 2002; Michael, 2004). Active learning principles have been widely incorporated in basic science, and specifically anatomy, teaching in recent years (Chan and Wiseman, 2011), in particular using peer-assisted learning (PAL) (Nnodim, 1997; Johnson, 2002; Krych et al., 2005) and team-based learning (TBL) approaches (Nieder et al., 2005; Vasan et al., 2008, 2009, 2011).
Peer-assisted learning, defined as “People from similar social groupings who are not professional teachers helping each other to learn and learning themselves by teaching” (Topping, 1996), has been widely used for centuries, and can take many forms, from the more literal PAL, which involves students of a similar level teaching each other, to near-peer teaching, where more experienced students teach those who are less experienced. PAL is based on the principle of increasing the “active” component of learning, encouraging collaboration between classmates, and fostering development of professional skills such as communication, teamwork, and mutual respect for peers (Krych et al., 2005). PAL teaching methods reportedly fulfill the objectives of a constructivist learning environment by extending students' responsibility and ownership; promoting study, investigation, and problem solving in authentic, meaningful, and satisfying contexts; and utilizing dynamic learning activities that promote higher-level operations (knowledge construction) (Lebow, 1993; Wilson, 1996).
Peer-assisted learning studies have been used and evaluated widely in anatomy teaching, many with positive results in terms of improvement of student knowledge and skill acquisition (Nnodim, 1997; Krych et al., 2005; Nieder et al., 2005; Ballie et al., 2009; Schauseil-Zifp et al., 2010). Reported benefits of PAL depend on role, that is, tutor versus tutee (Annis, 1983), with tutors receiving benefits in terms of improved subject comprehension (“learning through teaching”) and improved instruction and communication skills, and tutees benefiting through the informal and nonthreatening environment that PAL fosters. Many examples of PAL initiatives to date involve (often more senior) students demonstrating aspects of anatomy to one another on their cadaver/dissection, and/or using PAL to plug a gap in teacher resources (Hendelman and Boss, 1986; Yeager, 1996; Nnodim, 1997; Johnson, 2002).
Team-based learning is a specific form of PAL, which sets out to link structured individual out-of-class preparation by students, with in-class team-based discussions (Vasan et al., 2008). It has been shown to be an effective method of conducting interactive small group peer teaching (Parmelee, 2007) with enhanced learning benefits (Vasan et al., 2009). TBL provides students with a structured, preparatory framework on which to build their learning (Vasan and DeFouw, 2005), and it is this which distinguishes TBL from traditional PAL. This “scaffolding” of preparatory activities is likely to be one of the keys to the success of TBL. A structured, scaffold approach has been implicated as a useful tool for easing the transition of the student from a pedagogical to an andragogical (adult) learning style, providing students with direction to learn more effectively (Rosenshine and Meister, 1992), but encouraging rather than enforcing independence. Such a scaffold can be gradually removed or adjusted, allowing students to participate at “an ever increasing level of competence” (Palinscar and Brown, 1984). This is particularly pertinent for teachers in higher education, as many undergraduate students are young individuals, moving into adulthood, and the use of scaffolds may ease the transition between two very different styles of learning.