Advance organizers in a gross anatomy dissection course and their effects on academic achievement
We presented two kinds of advance organizers (AOs), video clips and prosection, for a gross anatomy dissection course and compared their effects on academic achievement and student perception of the learning experience. In total, 141 students at Chonnam National University Medical School were randomly assigned to two groups: Group 1 (n = 70) was provided with video clips AO, whereas Group 2 (n = 71) was provided with prosection AO, the use of cadaveric specimens dissected by the course instructor. Student self-assessment scores regarding the learning objectives of upper limb anatomy improved significantly in both groups. Academic achievement scores in Group 2 were significantly higher than those in Group 1, although the self-assessment scores were not significantly different between the groups. Additionally, students in Group 2 responded significantly more positively to the statements about perception of the learning experience such as helping them understand the course content and concepts, decreasing anxiety about the dissection course, and participating actively in the dissection. It would seem that the application of prosection as an AO improved academic achievement and increased student engagement and satisfaction. This study will contribute to designing effective AOs and developing a teaching and learning strategy for a gross anatomy dissection course. Clin. Anat. 2013. © 2012 Wiley Periodicals, Inc.
Anatomy is a major basic subject in medicine and related biomedical sciences. A central tool most universities use for teaching anatomy is the dissection course, in which medical students learn the basic anatomical principles of the human body by dissecting a cadaver (Korf et al.,2008). Dissection further contributes to the development of competencies specifically related to the medical profession, including emotional control, deep thought about life and death (Arraez-Aybar et al.,2008), responsibility/accountability for actions, teamwork, respect for patients, and social responsibility (Swartz,2006). Despite the value of these experiences, time devoted to cadaver dissection in medical school has been on a steady decline over the last few decades. Active dissection by students has been partly or totally replaced at many universities by learning on prosected material or a combination with computerized teaching aids (Winkelmann et al.,2007).
A considerable number of articles have been written in defense of cadaver dissection for teaching gross anatomy. These have the importance of cadaver dissection for learning gross anatomy (Rizzolo,2002; Biasutto et al.,2006; Korf et al.,2008) and as a teaching method (Winkelmann,2007). Those who believe that cadaver dissection is an integral and necessary part of a medical curriculum are facing a dilemma of how to identify more efficient ways to impart requisite basic information in courses with fewer contact hours (Granger and Calleson,2007). Furthermore, because students within a dissection course seek divergent learning experiences including non–cadaver-related activities (e.g., studying models, reading, and discussing; Winkelmann etal.,2007), effective teaching and learning strategies are needed to encourage student engagement.
Advance organizers (AOs), which are introduced before the learning material, tend to be more abstract, general, and comprehensive than material itself. They are used to highlight key learning objectives and serve to activate students' prior knowledge and cognitive structure related to new learning material (Woolfolk,2004). AOs are related to Ausubel's meaningful learning. Meaningful learning only occurs when new materials can be appropriately integrated into what learners already know. AOs are ways to link old and existing information with something new as a strategy to promote the learning and retention of new information (Ausubel,1968). In addition, AOs provide a structure for student thinking and not just a structure for the lesson. In this aspect, the use of AOs makes students actively engage with their learning (Mohammadi et al.,2010).
In this study, we explored AOs from a teaching and learning perspective in a dissection course. With the aid of AOs, students are able to link what they have already learned in the lecture to new information presented during dissection, because the dissection course is usually conducted after the lecture. We presented two kinds of AOs, video clips and prosection, for a gross anatomy dissection course and compared their effects on academic achievement and student perception of learning experience. It was hypothesized that those students who were given prosection AO would show higher academic achievement and more positive perception of learning experience than those who were given video clips AO.
The study was designed to answer the following research questions:
- 1Is there a significant difference in the self-assessment score regarding the learning objectives of upper limb anatomy between those students who were given prosection AO and those who were given video clips AO?
- 2Is there a significant difference on academic achievement scores between those students who were given prosection AO and those who were given video clips AO?
- 3Is there a significant difference in the students' perception of the learning experience between those students who were given prosection AO and those who were given video clips AO?
MATERIALS AND METHODS
Study Participants and Dissection Course
In total, 141 study participants were enrolled in a gross anatomy course and studying upper limb anatomy, which was taught during the first semester of the first year at Chonnam National University Medical School. All participants had completed the lecture and dissection course on upper limb gross anatomy as part of the standard curriculum. Students were randomly assigned to two groups using a computer-generated list of random numbers. Group 1 (n = 70) was provided the video clips AO, whereas Group 2 (n = 71) was provided the prosection AO, the use of cadaveric specimens dissected by the course instructor. The dissection course consisted of three 2-h sessions designed to independently address the shoulder joint, axilla, elbow joint, forearm, wrist joint, and hand. Before performing the cadaver dissection, students received a 30-min introduction covering the topics that would subsequently be pursued in the dissection laboratory using AOs. Students in Group 1 watched videos that were streamed from the University of California, Los Angeles-Guides to Dissection (Teaching Films, 1970). In Group 2, a student representative of each group of students (n = 7 or 8) reviewed the parts being dissected with the instructor using a prosection and then shared the information with other students in their group. After the introduction by the AO, students dissected the upper limb region of the body in groups of seven to eight per table with one human cadaver. They were assisted by two faculty members who aided in the dissection process and explained anatomical details when necessary.
The institutional review board determined that the study was exempt from human subject research regulations. Participation in the survey was voluntary, and students were informed that their answers were confidential. Written consent was obtained from all participants.
This study lasted for 5 weeks from April to May 2008. One week before the session, all participating students were asked to complete a short questionnaire and to rate their knowledge based on the upper-limb learning objectives. In the questionnaire, the students answered questions on demographic characteristics and their approach to learning. Pandey and Zimitat (2007) showed that a positive relationship exists between student approach to learning and the quality of learning in anatomy. Thus, the revised two-factor version of the Learning Process Questionnaire (R-LPQ-2F) was used to distinguish between surface and deep learning approaches used by the students studying anatomy (Biggs et al.,2001). Deep approach to learning is associated with an understanding of the interrelationships between facts and the ability to abstract and generalize, whereas surface approach is more likely to lead to a fragmented knowledge base. The learning objectives for the upper limb are based on the core anatomy syllabus for medical students (McHanwell et al.,2007) and learning objectives for medical students (Korean Association of Medical Colleges,2004).
Additionally, students were asked to complete a questionnaire about their perception of the learning experience and to rate their knowledge after the dissection course. Students' perception of the learning experience was measured by asking the students whether the AOs helped facilitate their understanding of anatomical structures, applied anatomical knowledge to a clinical situation, promoted student engagement in the dissection class, and reduced student anxiety about the dissection. Students were asked to anonymously indicate the degree to which they agreed with each statement on a Likert scale ranging from 1 to 5 (1 = strongly disagree to 5 strongly agree) in self-administered questionnaire survey.
Immediately after completing the study sessions, all students were given a written examination that consisted of multiple-choice questions, short-answer questions, and essay questions focusing on the understanding of anatomical knowledge about the upper limb and application of the anatomical concepts to clinical situations.
We included the self-assessment score regarding the learning objectives, academic achievement score, and the students' perception of the learning experience as outcome variables to evaluate the effects of the AOs.
Repeated measure ANOVA was used to compare the self-assessment scores for 12 items regarding the upper-limb learning objectives between groups at pre- and postdissection courses. We performed an analysis of covariance to compare the postdissection self-assessment score with the predissection self-assessment score as the covariate. The Student's t-test was used to compare the academic achievement score between groups. In addition, we performed the Mann–Whitney U test to compare the students' perception of the learning experience between groups and obtained an adjusted probability value of P = 0.007 (0.05/7 = 0.007) using Bonferroni adjustment technique. All analyses were performed using SPSS software version 17.0 (SPSS, Chicago, IL).
The characteristics of the medical students are summarized in Table 1. No significant differences in gender or approach to learning were found, although the ages of the Group 1 participants were significantly higher than those of Group 2.
Table 1. General Characteristics of Study Participantsa
|Gender|| || ||0.004||0.952|
| Male||46 (65.7)||47 (66.2)|| || |
| Female||24 (34.3)||24 (33.8)|| || |
|Age||25. 7 ± 3.7||24. 5 ± 2.7||2.203||0.029|
|Approach to learning|
| Deep approach||38.16 ± 4.79||37.34 ± 5.14||0.978||0.330|
| Surface approach||33.19 ± 5.15||33.45 ± 5.96||−0.282||0.778|
Table 2 summarizes the results of the pre- and postdissection self-assessment scores regarding the upper-limb learning objectives. In Group 1, the mean score for the 12 learning objectives varied independently between 2.04 and 3.00 predissection to 2.79 and 3.54 postdissection. In Group 2, the mean score for the 12 learning objectives varied independently between 1.87 and 3.11 predissection to 2.77 and 3.56 postdissection. Students' self-assessment scores for 12 items regarding the upper-limb learning objectives were not improved significantly after the dissection between groups. The academic achievement scores in Group 2 were significantly higher than those of Group 1 (t = −2.067, P = 0.041), although the total self-assessment scores were not significantly different between the groups (F = 1.181, P = 0.279; Table 3). Additionally, students' perception of the learning experience revealed that students in Group 2 had significantly higher scores compared to Group 1 for all items (P < 0.001). Students in Group 2 responded more positively to the statements about perception of the learning experience such as helping them understand the course content and concepts, decrease anxiety about the dissection course, and participate actively in the dissection practice (Table 4).
Table 2. Comparison of Self-Assessment Scores Regarding the Upper Limb Learning Objectives Between Groups at Pre- and Postdissection Coursesa
|Describe the facial compartments delimiting the major muscle groups of the upper limbs||2.38 ± 0.91||3.10 ± 0.71||2.29 ± 0.89||3.21 ± 0.74||0.952|
|Describe the origin, course, and distribution of the major arteries and their branches||2.63 ± 0.78||3.11 ± 0.69||2.59 ± 1.01||3.29 ± 0.75||0.561|
|Describe the courses of the main veins of the upper limbs||2.55 ± 0.85||3.38 ± 0.69||2.48 ± 0.82||3.33 ± 0.70||0.575|
|Describe the organisation of brachial plexus, its origin in the neck, and continuation to the axilla and upper limb||2.21 ± 0.85||3.16 ± 0.91||2.16 ± 0.79||3.08 ± 0.92||0.570|
|Describe the origin, course, and function of the axillary, radial, musculocutaneous, median, and ulnar nerves in the arm, fore-arm, wrist, and hand||2.24 ± 0.77||3.17 ± 0.74||2.14 ± 0.78||3.10 ± 0.84||0.431|
|Describe the boundaries of the axilla||2.29 ± 0.98||3.13 ± 0.83||2.34 ± 1.07||3.18 ± 0.93||0.743|
|Describe the movements of the pectoral girdle||2.13 ± 0.88||2.79 ± 0.91||1.87 ± 0.91||2.77 ± 0.97||0.290|
|Describe the factors that contribute to the stability of the shoulder joint||2.82 ± 0.82||3.25 ± 0.79||2.97 ± 0.97||3.22 ± 0.90||0.655|
|Describe the anatomy of the elbow joint||3.00 ± 0.92||3.54 ± 0.74||3.11 ± 1.03||3.56 ± 0.82||0.581|
|Describe the anatomy of the wrist||2.83 ± 0.83||3.33 ± 0.88||2.87 ± 1.04||3.44 ± 0.86||0.520|
|Name and demonstrate the movements of the fingers and thumb||2.61 ± 0.89||3.21 ± 0.83||2.67 ± 0.98||3.25 ± 0.72||0.703|
|Describe the position and function of the retinacula of the wrist and the tendon sheaths of the wrist and hand||2.04 ± 0.73||3.14 ± 0.84||2.10 ± 0.86||3.48 ± 0.82||0.067|
Table 3. Comparison of Self-Assessment and Academic Achievement Scores Between Groupsa
|Total self-assessment score||37.99 (36.79–39.20)||38.94 (37.71–40.17)||1.181||0.279b|
|Academic achievement score||51.59 ± 13.56||56.01 ± 11.73||−2.067||0.041c|
Table 4. Comparison of Student's Perception of the Learning Experience Between Groupsa
|Advanced organizers (AOs; video clips/prosection) help me understand the aims of dissection course.||2.86 ± 1.09||4.44 ± 0.69||<0.001|
|Advanced organizers (AOs; video clips/prosection) make me take an interest in dissection course.||2.64 ± 1.02||4.27 ± 0.71||<0.001|
|Advanced organizers (AOs; video clips/prosection) make me decrease the anxiety on the dissection course.||2.46 ± 1.02||4.15 ± 0.96||<0.001|
|Advanced organizers (AOs; video clips/prosection) help me to find the anatomical structures.||2.74 ± 0.97||4.26 ± 0.77||<0.001|
|Advanced organizers (AOs; video clips/prosection) make me judge the progress of my dissection practice.||2.44 ± 0.97||3.98 ± 0.86||<0.001|
|Advanced organizers (AOs; video clips/prosection) facilitate me to actively participate in dissection course.||2.61 ± 1.00||4.10 ± 0.82||<0.001|
|Advanced organizers (AOs; video clips/prosection) efficiently help the management of dissection practice time.||2.53 ± 1.05||4.32 ± 0.92||<0.001|
In our study, AOs were introduced to improve the active learning experience by the students in a gross anatomy dissection course. AOs aid in learning, because they activate relevant preexisting knowledge within a student's cognitive structure (Ausubel,1978). In the 1990s and 2000s, many researchers conducted studies on AOs using a variety of formats, such as visual and multimedia AOs (Hirumi and Bowers,1991; Herron et al.,1995; Yeh and Lehman,2001). Most researchers continue to suggest a positive effect of AOs on learning and retention (Chen et al.,2007).
This study addressed the research question whether there was a significant difference on academic achievement and student perception of learning experience between those students who were given prosection AO and those who were given video AO. Students who were given video clips AO could not achieve academic scores as much as students who were given the prosection AO. This result was consistent with the findings of Mahmud et al. (2011), who showed that dissection videos did not improve final examination scores when used as an adjunct to cadaver dissection. In addition, those students who were given prosection responded more positively to perception of the learning experience than those who were given video clips AO. We postulate that high-academic achievement of the group that had the prosection AO was related to the level of satisfaction with the AO. Winkelmann et al. (2007) showed that students tended to devote more time to active dissection, who having high motivation and positive attitude toward dissection as a teaching method.
Our preliminary evidence suggests that the application of prosection as an AO would improve academic achievement and increase student engagement and satisfaction. One possible explanation was prosection AO provided the reality that allowed students to recognize toughness, elasticity, friability, etc., as well as the actual size and site of human structures by activating all senses, while video clips AO provided just the visual component which might make students passive learners. However, a great deal of consideration should be given regarding this application among medical schools, because the design of a gross anatomy dissection course is affected by the available resources. In our curriculum, the anatomy faculty members require an additional cadaver and must spend much time and labor to prepare the prosection in advance of the class.
The findings in this study should be interpreted considering the following limitations. First, the use of a single institution limits the representativeness of the study for the entire population of medical students. Second, because “teacher-prosectors” are the same for Group 1 who were given prosection AO and Group 2 who were given video clips AO, teacher effect needs to be considered. Third, one of the inherent limitations of educational research using a questionnaire is the role of subjectivity. Fourth, although this study is experimental study, it is necessary to consider equality of the educational opportunity of the study participants. Fifth, factual recall by examination was focused on to compare the effect of the AOs. This study did not assess dissecting skills, knowledge comprehension, and transfer. Further research should be conducted including various evaluation tools to examine the effects of AO in a gross anatomy dissection course based on the rigorous study design.
Lempp (2005) stated that cadaver dissection can impart anatomical knowledge and offer other relevant, positive learning opportunities to enhance skills and attitudes of future doctors. However, no consensus exists on the best method for a dissection course. Tools for better learning, based on evolving technologies, are being actively sought and evaluated. This study will contribute to developing an effective teaching and learning strategy for a gross anatomy dissection course.
This work was supported by a grant of The Brain Korea 21 Project, Center for Biomedical Human Resources at Chonnam National University.