First patient project: Engaging pathology through the donor dissection experience and its role in professionalism

The peer‐reviewed anatomical education literature thoroughly describes the benefits and drawbacks of donor dissection. Gross anatomy laboratory environments utilizing donor dissection are generally considered to be a premier environment where students foster non‐traditional discipline‐independent skills (NTDIS), including the acquisition of professionalism, empathy, resilience, emotional intelligence, and situational awareness. Therefore, this IRB‐approved study explored the impact of a formal humanism and pathology thread, the first patient project (FPP), on the personal and professional development of pre‐professional undergraduate students in a gross anatomy dissection‐based course. Five reflections from each student were collected across four cohorts (n = 74 students, 370 reflections). A post‐course questionnaire collected data on student perceptions of the project. The framework method was used to analyze reflection and free response data and descriptive statistics were performed on Likert‐style items using Excel. Three themes were identified to encompass the impacts of the FPP on professional development and include: Socialization (through collective dissection experience and pathology), Humanistic Qualities (respect for the donor and their history, and introspection), and Content and Skills (technical and NTDIS, anatomical knowledge). The end of course FPP survey was completed by 29 students across three cohorts (65%) and their perspectives were generally favorable regarding the promotion of respect, empathy, and humanization of their donors. This study underscores the value of incorporating humanism, pathology, and reflection, facilitated through formal curriculum for pre‐professional undergraduate students. It provides evidence of the positive impact on their personal and professional development, supporting the integration of NTDIS in curricula across various disciplines.


INTRODUC TI ON
"Medicine is the compassionate solving of problems by the application of scientific knowledge" (Older, 2004).At least in part, acquisition of scientific knowledge in medicine starts with learners studying the human form, and in the context of anatomical sciences, often through dissection of donors complemented by formal lecture-based teaching sessions.Anatomical dissections are avenues to introduce social and behavioral principles, or compassionate behaviors such as humanistic and empathetic values, continued independent learning, and communication skills into anatomy education-positioning anatomy education at the nexus of clinical care and basic science (Rizzolo & Stewart, 2006;Louw et al., 2009;Canby & Bush, 2010;Štrkalj, 2016).
The benefits and drawbacks of anatomical dissection have been debated extensively (Korf et al., 2008;Böckers et al., 2010, Bergman, 2015, Ghosh, 2017, McMenamin et al., 2018, Wilson et al., 2018).Knowledge acquisition during an anatomy dissection course goes beyond anatomical content knowledge and introduces students to the reality of death and dying, manual dexterity, biological and anatomical variation, pathology, language of medicine, and communication (Older, 2004).These skills outside of formal content knowledge are collectively referred to as nontraditional discipline-independent skills (NTDIS) (Evans & Pawlina, 2015), and include the demonstration and acquisition of professionalism (e.g., altruism, respect, integrity, accountability), empathy, love, resilience, emotional intelligence, and situational awareness (Evans & Pawlina, 2015;Evans et al., 2018).To underscore their relevance and importance, a lack of NTDIS has been associated with surgical errors, not from a deficiency in technical ability, but from a lack of communication (Yule et al., 2006).Gross anatomy courses, specifically those with donor dissection, are integral to exposing students to NTDIS (Evans & Pawlina, 2015).Therefore, incorporating a humanistic approach into anatomy education is necessary to address crucial skills such as communication, teamwork, empathy, and other NTDIS.These skills should be developed early in students even prior to their entry into healthcare professional programs (Evans & Pawlina, 2015).
Conversely, McLachlan et al. (2004) contend gross dissection may not achieve learning goals beyond immediate anatomical knowledge and may hinder contextual learning, detracting from integration into a clinical context.They further maintain dissection inappropriately introduces students to death and dying.Furthermore, Finkelstein and Mathers (1990) suggest the anatomy dissection laboratory may even contribute to a select few individuals developing post-traumatic stress manifestations.To underscore this point, reflection about death and dying as well as empathy toward the donor has been shown to decrease over time in an anatomy dissection course (Böckers et al., 2010).This decrease in student empathy was countered by Hildebrandt (2010) who offered an alternative interpretation by instead viewing the students decrease in empathy as the development of "clinical detachment" where students were interpreting a gain of "clinical detachment" with a loss of empathy.Historically, the emotional state of clinical detachment was noted and observed by anatomist John Hunter and John Warren in the eighteenth century (Hildebrandt, 2016).
However, self-reflection and grounding oneself through empathy may offset the tendency for extreme clinical detachment or even dehumanization-thereby fostering the integration of clinical detachment and empathy (Hildebrandt, 2016).Nonetheless, anatomical dissection may have an inherent influence on the development of professionalism, and an adoption of a humanistic approach to anatomy may mitigate the reported decrease in empathy (Escobar-Poni & Poni, 2006;Štrkalj, 2016).
While there is little consensus on the best method to teach professionalism, many agree that role modeling and developing a conducive environment to promote and evaluate professionalism are effective (Birden et al., 2013).As Shrank et al. (2004) and Ludmerer (1999) argue, to instill, develop, and foster professionalism, role modeling of those values is important for student development.
Further, Hafferty and Franks (1994) describe in their discussion on the hidden curriculum, "all [emphasis in original] faculty… who have contact with students must be both willing and able to identify ethical issues they encounter… not only by their words but by their behavior, faculty should demonstrate the integration of ethical principles into the everyday work of both science and medicine" (p.868).Thus, it is argued that an anatomy dissection course is an ideal location to develop professional traits, and it can be accomplished through educator role modeling and self-reflection (Escobar-Poni & Poni, 2006;Swartz, 2006;Pearson Jr & Hoagland, 2010;Johnson et al., 2012;Boeckers & Boeckers, 2016;Hildebrandt, 2016).
Assuming a profession is an occupation which addresses complex and ambiguous societal problems, which are often approached through reflective judgment and ethical reasoning, then one may argue that professionalism ("what professionals do") and NTDIS are acquired through reflective exercises focusing on personal beliefs, attitudes, and self-regulation (Slotnick & Hilton, 2006;Sandars, 2009;Uygur et al., 2019).The anatomy dissection laboratory provides a unique opportunity to learn how to handle ill-structured problems, uncertainty, and ambiguity (King & Kitchener, 1994;Robbins et al., 2009;Olejaz, 2017).This is exemplified by Slotnick and Hilton (2006, p. 431) as they ask rhetorically: "how does one reconcile the well-written anatomy text's descriptions with what the cadavers display?"This is furthered by Olejaz (2017) where they describe "epistemological balancing" where the students attempt to balance the universal and idealized anatomy of atlases to the particularity and variance of each unique donor's body.Thus, students may develop uncertainty tolerance in the gross anatomy laboratory through reflective thinking which enables them to individually build multiple logics and frameworks to be applied in future complex situations (King & Kitchener, 1994;Stephens et al., 2021;Lazarus et al., 2023).Furthermore, in adapting to these ill-structured problems, students learn to collaborate with peers thus acquiring the professional domain of teamwork.
To teach and model professional virtues such as respect, compassion, and integrity through a socialization framework (i.e., community of practice), the incorporation of a humanistic view of the anatomy curriculum is justified (Lave & Wenger, 1991;Cruess et al., 2015;Štrkalj, 2016).As Rizzolo (2002) states, the anatomy laboratory provides an opportune environment where students' intentions of becoming an empathetic and compassionate healthcare provider can be modeled and nurtured.This sentiment is echoed by Štrkalj (2016) where they refer to the gross anatomy learning environment as a community of practice.Focusing students' attention of their first dissection, and importantly allowing them space to do so, will enable them to reflect upon death and dying, recollections of family members, or their own mortality where "students can learn to do their work without denying their emotions or becoming detached" (Rizzolo, 2002).As Bertman and Marks (1989, p. 111) state: "dissection can be a paradigm for patient care" manifested as the trust bestowed from the donor to the student as seen in a patient-healthcare provider relationship, with this trust further enabling the student to reconcile feelings of "invasion and violation."Further, "professionalism in the medical field is the expression of responsibility to peers and patients…" such as behaviors manifested as responsibility/accountability for actions and respect for patients (Swartz, 2006, p. 437).Swartz (2006) further argues the dissection laboratory is a unique environment for students to acquire responsibility and accountability through the collective action of group dissection and respect for patient is manifest through the students' initial respect for the anatomic donor.
The skills and values obtained beyond anatomical content knowledge are often left unexplored in undergraduate human anatomy courses.Therefore, to introduce NTDIS into a pre-professional undergraduate gross anatomy course, a donor pathology thread with spaced reflections was developed to create a space for professional development and exploration of humanism.The "First Patient Project (FPP)" was developed with overarching goals of developing communication skills, teamwork, respect for donors, and accountability for actions in all domains attributed to professionalism (Swartz, 2006).To achieve these aims of developing these NTDIS and supply a humanistic approach to anatomy donor dissection, the FPP formally integrates a focus on humanism and empathy through reflection, role modeling, and exploration of pathology and lifestyle and how those may affect quality of life.Specifically, a focus on pathology is implemented based on previous authors' utilization of pathology in the context of anatomy to achieve professionalism and a humanistic approach (Rizzolo, 2002;Swartz, 2006;Eisenstein et al., 2014).Exploration of pathology may further promote student reflection upon the donor's pathology and anatomic variation in a humanistic fashion (Robbins et al., 2009;Olejaz, 2017).As described by Korf et al. (2008) moving from the "object" to telling the story of the human being may be facilitated by correlating the fragility of the bones to the painful process of osteoporosis or the calcified coronary arteries to infarction.In this study, we seek to answer the following research question: "What is the impact of the FPP on the personal and professional development of preprofessional undergraduate students?"

Theoretical framework and researcher positionality
This work is underpinned by a social constructivist paradigm which aligns with the concept of situated learning and legitimate peripheral participation as "an analytical viewpoint on learning, a way of understanding learning" (Lave & Wenger, 1991;Palincsar, 1998).Under a constructivist paradigm, there is the underlying assumption that "learners actively construct their own knowledge through experiences and interactions with others" (Rannikmäe et al., 2020, p. 263).
Furthermore, social constructivism views the basis of learning on interactions through activities which actively engage in the learning process (Rannikmäe et al., 2020).The social constructivist paradigm informed and aligned with the overall collaborative active learning non-didactic pedagogy with the role of the educator as a means of support and guidance in expanding prior knowledge through the FPP (Rannikmäe et al., 2020) This collaborative classroom, including both educators and learners, is typified in situated learning in the form of legitimate peripheral participation (Lave & Wenger, 1991).Henceforth, if viewing the construction of knowledge as a social construct, then it makes sense to view learning as a socially situated phenomenon.As such, Lave and Wenger state: "This view [social practice] also claims that learning, thinking, and knowing are relations among people in activity in, with, and arising from the socially and culturally structured world" (p.51).
Understanding our role as co-creators of knowledge for the FPP and interpreters of this data, we acknowledge our perspectives and backgrounds have influenced the design and analysis of this study.
To be reflexive, we report all authors to be anatomy educators who contend that the gross anatomy laboratory is an environment conducive to the development of humanistic values and NTDIS.

Curriculum design and overview
This study took place in the context of the Cadaveric Human Anatomy (BIOL N461) course at Indiana University-Purdue University Indianapolis (IUPUI), an advanced-level undergraduate course for students interested in health professional programs (e.g., physical therapy, physician assistant, medicine, etc.).More details about the overall course structure can be found in Byram and colleagues (2020).The FPP was first implemented in the spring semester of 2020 as the course instructors sought to formalize what was an informal, or even implicit, focus on humanism in the course.The FPP was conceptualized as a formal curricular component to promote viewing the donor through a holistic lens and included several elements which will be described below and include: a formal presentation about whole body donation, focus on pathology, promotion of teamwork, reflection, and role modeling of professional behaviors.(Ghosh, 2015;Comer, 2022;Organ & Comer, 2022).The presentation provides a timeline of body procurement from executed criminals, to graverobbing and body snatching, to unclaimed bodies, and ends with whole-body donation (Rosner, 2010;Ghosh, 2015Ghosh, , 2022;;Brenna, 2022).The goal of this historical framing is to humanize the donors and promote respect for the donor and the wholebody donation process.
Expectations for respect and care of the donors are established during the course introduction and upheld throughout the course.
Students are required to keep parts of the donor covered when not being dissected and to care for donor tissues through proper covering and moistening.Photography of donors, visitors in the laboratory, and naming of the donors are strictly prohibited.Course instructors use humanizing language, such as referring to the "donor" in lieu of "cadaver," and using gender neutral language (e.g., they/ them, the donor).Students are expected to use the same humanizing language, but they are not penalized for using less-humanizing terms such as "cadaver" and using pronouns that align with the donors' sex assigned at birth.To promote an appreciation of how chronic disease may impact quality of life and how lifestyle may affect chronic disease, pathology was integrated into an existing whole-body donor dissection curriculum.During each dissection, students were asked to collect data on evidence of lifestyle, pathology, anatomic variations, and to conceptualize the impacts of each of those on the quality of life of their first patient through appropriate sources (e.g., pathology textbooks, peer-reviewed articles).Each dissection group had an assigned Google doc where information could be added during dissection and shared with the group.
At the end of each of the 4 units and with their dissection team, students were required to construct a patient report that detailed their findings from that unit.Development of the patient report created a workable context to learn skills such as teamwork by working together for a common goal in exploring characteristics of pathology and anatomical variants to their peers (Swartz, 2006).The patient report is a single document submitted as a group, and students take turns completing each of the four components.At the end of the course, students deliver a group presentation of their patients and their findings to the whole class.
Students were also required to periodically reflect on their experiences in the course.The "First day" reflection asked students to describe how they felt before, during, and after their first dissection, as well as their feelings about whole-body donation.Reflections at the end of each unit encouraged students to reflect on their own and the donors' lived experience.Narratives centered around patients' stories can "aid doctors to recognize patients' lived experiences and might support doctors' awareness of the meanings of their own experience" (Charon & Hermann, 2012, p. 5).As such, each unit reflection asked students to complete a 300-500-word essay addressing the following prompt: "Reflect on your experiences dissecting your donor in Unit #.How has this experience affected you?What have you learned about the donor, others, and/or yourself?"Finally, consciously, and explicitly, course faculty modeled professionalism throughout the course, and a holistic view of the donors was integrated into all interactions with students during laboratory sessions.

Data collection
Data for this study were collected through student reflections and A total of five reflections from each student in the 2022-23 cohorts were included in the analysis and include the "First day" reflection and four-unit reflections.A total of three reflections from students in the spring 2020 cohort were included in the analysis and include the "First day" reflection and first two-unit reflections.The final two-unit reflections were not included in the analysis as this cohort was removed from in-person activities following the second unit examination due to the COVID-19 pandemic.
The post-course survey was administered through Qualtrics XM online platform (Qualtrics, Provo, UT).An anonymous link was sent to the students through the course learning management system.
The survey consisted of 10 Likert-style items asking the degree to which they agreed the FPP achieved the stated goals of the project including the development of respect, empathy, and humanization of the donor.Additionally, there were four free-response items asking students to describe their experience completing the required components of the project.The survey was only administered to the 2022 and 2023 cohorts since they completed the N461 course and the FPP.

Data analysis
Reflections were analyzed using the framework method which involves several iterative steps including familiarization, development of preliminary codebook, application of codebook to the entire dataset, charting, and interpretation (Gale et al., 2013).Familiarization was performed by two researchers (K.A.R., J.N.B.) on a subset of identical reflections by taking marginal notes and independently coding.Analysts developed their own preliminary codebooks and met as a group to reconcile codes and develop the analytical coding framework.One researcher (K.A.R.) applied the framework by coding the transcripts in NVivo 14.As new reflections were added to the dataset, the analysts met to discuss the applicability of the framework to the new dataset.Finally, the analysts met to organize the codes into thematic categories and interpret the results.Descriptive statistics were performed on Likert-style items using Excel (Microsoft 2021).
This study was granted exempt status by the Institutional Review Board at Indiana University (IRB # 10962).
Three themes were identified to encompass the impacts of the FPP on professional development to include: Socialization, Humanistic Qualities, and Content and Skills (See Table 1 for themes, subthemes, and their description).Socialization manifested as how students reflected upon and consolidated their experiences of the initial exposure to the donor, via both an individual and collective coping mechanisms.Further, students utilized experiential learning from their dissection experience, informed by critical examination of self and donor pathology to garner reflection of their own health, social determinants of health, and health equity.Humanistic Qualities through role modeling of the educational team and shared learning of their peer community as well as through their exploration of donor history, enabled students to reconcile anatomizing the donor, and to develop respect and humanity toward the donor.Content and Skills constituted the development of both technical, (i.e., dexterity) and NTDIS (i.e., teamwork, communication, metacognition, and empathy).Moreover, an appreciation of anatomical content and complexity of the human form was demonstrated through the uniqueness of donor pathology and anatomical variation.

Individual and collective dissection experience
Most students, even those with prior dissection experience, described feelings of anxiety and nervousness of the unknown, in TA B L E 1 Themes, subthemes, and descriptions of impact of the first patient project (FPP) on the personal and professional development of pre-professional undergraduate students.

Socialization
Individual and collective dissection experience Consolidation of experiences from the strange and uneasy of students' first donor encounter to a shared community of discovery through experiential learning, and coping via compartmentalization Exploration of lifestyle through pathology Experiences of how students critically examined their self through reflection on own health and the donors lived experience through the discovery of pathology and advancements in medicine.This enabled students to come to value and appreciate health outcomes in the context of social determinants of health and how this may determine health equity

Humanistic qualities Framework of integration
As students progressed from their initial exposure of the dissection experience, they formulated various means to connect and integrate what they were observed with the history of their donor (i.e., pathology and cause of death) to the larger contexts of the donor's possible lived experience, thus informing humanity and respect of donation.Moreover, students recognized how anatomizing through the act of dissection may dehumanize the donor Introspection Through the combination of performing the act of dissection and reflection; students were able to critically investigate self as they encountered imminence of death; appraise how the rigors of the course initiated a self-appraisal of personal well-being; and confirmation or reinvigoration of a passion for medicine to continue the pursuit of a career as a healthcare professional Content and skills Technical skills Students progressed through the practice of dissection, they developed a sense of self-efficacy, specifically in their "surgical" or dissection skills Non-traditional discipline independent skills Discovery, refinement, and expansion of skills other than those attributed to the formal curriculum which may be applied and utilized in context outside of the classroom and transferable to other personal and professional situations Anatomy content knowledge An acquisition of respect for the uniqueness and diversity of everyone's personhood and appreciation of the complexity of the human form addition to the conflicted emotion of excitement.One student described how their first day made them feel strange and uneasy: Before arriving to class, I was nervous and excited.I was excited to participate in the dissections, but I was a little hesitant to perform the dissections on human cadavers.
The idea of dissecting on human cadavers is very intriguing, but I was unsure if I would become squeamish.
I am not typically a squeamish person, but I had never seen a dead body before.I was feeling a mixture of emotions as I headed into the first dissection.P1, SP20 To overcome, or cope, with the vacillation between nervousness and excitement, students described how they were able to compartmentalize the physical act of dissecting from the person they were performing the act upon.This compartmentalization or a separation of emotions from performance of the physical acts of dissection was expressed by one student as: I think one of the most helpful things for me was that we started on the back, and I did not have to look at her face the entire time.In a way, it made it easier to distance myself emotionally and focus on learning.
And, once we had skinned her back, I was only more

Humanism through pathology
A further facet for theme socialization was the subtheme humanism through pathology.As such, observing the pathology, and reflection upon the uniqueness of their donor, enabled the students to come to terms with their own health and start to understand the extent pathology affects individuals with chronic health conditions, situated in the societal context of medicine and equitable discourse, as described: When we are young, it's hard to imagine these conditions from a personal perspective and how they might impact daily life.If Unit 3 has taught me one thing, it's that we often take good health for granted; it's sobering to observe the effects of PVD [peripheral vascular disease] and other chronic health conditions as we continue to dissect our donor's body.P2, FA22 Not only were the students able to reflect upon their own health in the context of pathology but they also develop gratitude for how the gift of donation has allowed for the advancement in medicine.A student stated: If not for the donor's willingness to donate their body, it is probable that many of the procedures we do today would not exist.Others before us have used the Related to health equity, students described their experiences in confronting social determinants of health, specifically how the role of gender identity and/or labeling may affect individuals.A student described discourse around genitalia and how it may impact health: The main effect that this unit had on me was realizing the importance of using gender neutral language when discussing anatomy, especially as it pertains to discussions of genitalia and perineal structures.I never realized how engrained the cisgender view of anatomy was in my mind until I began watching the videos for the pelvis and perineum lab.Even casually referring to all individuals with penises as men and all individuals with vaginas as women can be incredibly detrimental to transgender individuals and others who do not identify as cisgender.P2, SP22 Reflecting upon the pathology of their donor, in the context of their own lived experience, enabled the students to critically examine their own, as well as societal constructs, regarding gender, health equity, and the effects of living with a chronic health condition.The experiences during Unit 3 presented me with a tension that I am learning to navigate even more as this semester progresses, between wanting to be respectful of the donor and moving forward with sometimes intense dissection procedures.One pertinent example of having to navigate this tension was at the beginning of the unit when we cut the lower extremities away from the upper body, and then proceeded to cut the pelvis in half.This procedure felt strangely invasive, yet due to the physical effort required to accomplish it, the task could not necessarily be completed "delicately".With procedures like that one, I sometimes find myself wondering if the donor would have agreed to donate their body to science if they would have actively participated, or perhaps even actively witnessed such a dissection procedure.P4, SP22

Frameworks of integration
The self-discovery of appreciating the incorporation of humanistic qualities through history, humanity, and respect for donation, made students aware of the anatomizing that occurs in the donor dissection space was and is to be treated with respect.

Introspection
The presence of the donor, with various ailments, brought to the forefront the students' own mortality and how the imminence of death may change the lens of how they view their own life, as stated by one student: It is hard to work on someone who has passed and then to go home and focus on insignificant things.
Working twice a week with something that makes you acknowledge your own mortality changes how you see the world.P5, SP20 As pre-professional students, anatomy is often one of, if not the most cognitively demanding courses they have encountered.Therefore, introspection on the challenge the course presented and resulting personal well-being was discussed:

Technical skills
An efficacy in "surgical" or dissection skills enabled students to demonstrate respect toward their donor, as it was felt they could then obtain the optimal learning experience through the donor's gift, as this student stated: This unit taught me more, however, than terms and structures.It taught me how to be a dissector.I have learned how my donor's body is able to be manipulated and moved to gracefully remove skin and clear away fat and fascia.I am more comfortable with techniques used to expose nerves, arteries, and muscles so they can be appreciated to their full extent giving integrity and respect to my donor's ultimate sacrifice of body donation.P1, SP20 This relieved some of the unease of the first day, as students did not want to "mess up" the dissection from a lack of skill.Therefore, as their self-efficacy improved it allowed them to respect their donor through their matured skill set.
Non-traditional discipline independent skills (NTDIS) For this study, NTDIS includes teamwork, communication, metacognition, and empathy.Engaging in the dissection process and the FPP provided the context for collaboration with their dissection team.
Students described how all were working toward common goals, but that everyone brought a unique contribution in the form of teamwork: am looking at when it is time to dissect.I believe having a hands-on approach after learning the material has helped me to learn more effectively than doing the reverse process.P2, SP22 An additional student reflected upon how their peers were a great resource for review that was a way to reduce their anxiety around their own perceived knowledge mastery: This unit helped me refine my study approach and study skills.I continued reviewing the material weekly with my team members.This allowed me to remember better and reduced my anxiety and stress levels.
I also learned that different people have different approaches to learning.I find the best approach for me is to learn the material alone, but then study the identification part as a group.I like this method because I find it difficult to study identification alone, I'm not sure if what I label a structure as is correct.P6, SP23 The culmination of the NTDIS manifested as empathy toward their teammates and donor.One student stated: I now understand how this process affects my lab partners and myself in different ways because we use the pathologies to make our own connections with him.I have more patience and empathy for my lab partners and others when they feel squeamish about dissecting or talking about the pathologies we come across.P2, SP22 The combination of the course content and the FPP provided a context for students to acquire and develop skills to be utilized beyond the classroom.

Anatomy content knowledge acquisition
The attainment of anatomic knowledge was the overarching objective of the course.As such, students gained a respect for the uniqueness and diversity of everyone's life.Students were often mesmerized at the complexity of the human form, and appreciation of the tactile experience where words and images do not suffice: The human body is a complex, but a beautiful sight and having the opportunity to learn hands-on is a blessing.It gives me the ability to touch and understand how tough arteries are and that is something a description in a book could never give me.P3, SP20 Beyond anatomical knowledge, students appreciated the unique individual qualities of each donor's anatomical variation and individual presentation of pathology.One student described how it made each donor unique: As I looked at other cadavers in the lab, I noticed that many of them had differences from ours.These anatomical variances have illustrated that each individual and life is unique.When I go on to have a career in the medical field, I don't want to treat a person as just another patient.P5, SP22 Exploring anatomy via donor dissection and with the students' willingness to embrace ambiguity of donors' anatomy and pathology not as a hindrance or barrier to learning but as a benefit that enabled them to highlight human individuality.

Student perception survey
The end of course FPP survey was administered to three cohorts Students' perception of the FPP was overall favorable regarding the promotion of respect, empathy, and humanization of their donors.
Furthermore, all student respondents agreed that the investigation of pathology fostered a respect for the lived experience of the donor (Table 2).
Reflecting on their experiences of developing the FPP Case reports, responses of students' perceptions were overwhelmingly positive with the following students elaborating on their experience: Developing the first patient case really brought everything together for me.Going through the donors on an anatomical level was one of the best educational experiences I could ever have.Overall, students appreciated First Patient Project's approach of humanizing the donor dissection experience through investigation of the donor's lived experience as expressed through pathology and student's exploration during dissection.As a student stated: "I think that this is a great approach to being able to humanize your donor and become a little more sympathetic toward them."

DISCUSS ION
This current study demonstrates a formal curricular focus on humanism through pathology, reflection, and modeling is a viable means to foster students' ability to form nascent professionalism ideals along with other non-traditional discipline independent skills (NTDIS) in a humanistic fashion (Slotnick & Hilton, 2006).Specifically, guided reflection and explicit focus on the donor as the first patient, enabled students to challenge the notion that it is best to detach from their emotions and dissection experience, but provided them with the space to examine, notice, observe, and appreciate their emotions and experiences (Rizzolo & Stewart, 2006).Furthermore, this demonstrates students' capacity to retain and further foster an empathetic orientation toward donor dissection, confirming Rizzolo's supposition that: "In the dissection lab, students can learn to do their work without denying their emotions or becoming detached" (2002, p. 243).While others have reported a loss of an empathetic lens (McLachlan et al., 2004;Böckers et al., 2010) and negative emotions and reactions throughout donor dissection (Finkelstein & Mathers, 1990;Lempp, 2005) the current study demonstrates that a focus on humanism may encourage continued empathy and disquiet initial fears and reservations about performing the act of human dissection.
Pathology has been successfully implemented into gross anatomy courses, specifically within medical student education (Eisenstein et al., 2014).Eisenstein and colleagues stated objectives for their addition of pathology into the anatomy curriculum, was in part to "bring a patient-oriented approach to the study… recognize the relevance of basic science concepts in clinical and therapeutic algo-rithms… and promote small group learning and collaboration" (2014, p. 51).This current study demonstrated pathology to be beneficial in engaging students in small group work and collaboration as demonstrated via NTDISs such as teamwork and communication.
Furthermore, pathology enabled the student's ability to explore humanistic aspects of the donor and health through pathology, specifically reflection of one's own health, social determinants of health, and health equity.Moreover, the integration of pathology into a pre-professional undergraduate gross anatomy course is a novel approach.
Some have expressed reluctance in incorporating and assessing NTDIS in an existing dissection-based curriculum that is ever constricting with curricular reform.Reasons cited include lack of time, instructors to implement and assess NTDIS content, and resources (McLachlan et al., 2004;McCuskey et al., 2005) These results support the notion that NTDIS can and should be delivered early in educational programming (Evans et al., 2018;Lee et al., 2020) and that reflective writing is an effective method to promote humanism (Abrams et al., 2020).
Theories and perspectives on the potential viability of utilizing the gross anatomy laboratory as a means of incorporating professionalism into curricular design is well documented (Rizzolo, 2002;Escobar-Poni & Poni, 2006;Slotnick & Hilton, 2006;Swartz, 2006).
Escobar-Poni and Poni proposed modifications of the Lists of Behaviors pertaining to professionalism for the gross anatomy laboratory (2006).Specifically, respect for a patient in a clinical context was modified to "displays compassion and respect for all cadavers even under the most difficult circumstances" which was exemplified in this current study through respect of donation and empathy (Escobar-Poni & Poni, 2006, p. 465).Further, Swartz hypothesized ways to incorporate professionalism domains into a gross anatomy course, one of which being "working with others" ( 2006).The results of this study support the use of these professionalism domains in gross anatomy.To promote teamwork, the FPP implemented a collaborative team approach to the development of the donor pathology report.This approach was reflected in the students' experience of teamwork, communication, and shared community all of which centered around their collaborative effort to investigate and communicate their understanding of the donors lived experience through pathology.
Although theoretical perspectives on implementation of professionalism competencies in gross anatomy are abundant, there are limited empirical studies.One study measured the change in professionalism attitudes via a quantitative questionnaire and found no significant decrease in the professionalism domains measured, but they did find a significant change in the prioritization of professionalism domains (Pearson Jr & Hoagland, 2010).In this current study, there is no quantitative measure of professionalism domains, however, students demonstrated professionalism domains of respect, altruism, and accountability which manifested in the themes of humanistic qualities (e.g., respect of donation) and content and skills (e.g., teamwork and empathy).Further, these professionalism domains were present throughout the study period (e.g., semester) and across multiple cohorts of students.
While teaching of professionalism has been a consistent objective across professional education, medical educators have suggested using professionalism to support professional identity formation (PIF; Cruess et al., 2015).Cruess and colleagues place socialization as a key process in identity formation and advance reflection on experiences as a key approach to facilitate an understanding of who students are and who they want to be (2015).While professional socialization has been studied in the context of medical students within gross anatomy (Hafferty, 1988;Bertman & Marks Jr, 1989), this study demonstrates how reflection and focus on pathology promoted socialization of pre-professional undergraduate students as they explored values of medicine (e.g., health equity, social determinants of health) and reconciled emotions and ethics associated with death, disease, and dissection.The FPP also highlighted the importance of shared community of practice in clinical problem solving as students engaged in activities peripheral to those in medical programs (Lave & Wenger, 1991;Slotnick & Hilton, 2006).Furthermore, collaborative learning through teamwork and shared community of learners underpins the social constructionist paradigm within this community of practice (Lave & Wenger, 1991;Wenger, 1999).

Limitations
This study has several limitations and the first of which is transferability.Data were collected from a single course at one institution, albeit across four cohorts.Also, the course is an elective, marketed toward students interested in a graduate-level health professional program.As such, students may be inherently inclined to discuss humanistic values due to their interest in a health profession.However, the course description does not explicitly state the details of the FPP, and therefore students are not informed of the humanism curriculum until reading the course syllabus and/or attending course introduction.Finally, the course being an elective may explain the overall positive perceptions of the FPP as there is ample time to dedicate to anatomy content and less pressure for students to perform well on high-stakes examinations.Regardless, students are broadly supportive of NTDIS and professionalism being delivered in the context of an anatomy course (Krych & Vande Voort, 2006;Heidenreich et al., 2016).
A second limitation relates to data collection through graded reflections.First, the unit reflection prompt was inherently broad to solicit a broad range of perspectives but may have reduced nuance in perceptions on particular aspects of personal (i.e., introspection) and professional development (i.e., socialization).Second, the reflections are a graded component of the course which may have resulted in a courtesy bias where students may have written what they thought the faculty wanted them to write.
Third, even though reflections on pathology were a key component of the FPP, this engagement was purely speculative as we currently do not confirm donor pathology through collection and interpretation of histopathology.Regardless, faculty with background in pathology were available to consult on potential pathology to assist students with differential diagnoses to guide their interpretations of how a particular pathology could impact the donors' quality of life.In addition, it is recognized the lifestyle, illness, and pathology are personal topics, specifically discussing weight-normative and weight-inclusive perspectives to health (Tylka et al., 2014).However, having the students reflect on the possible was not meant to replace or speak for the donor but to restore the personhood of the donor.
Finally, it is acknowledged, recognized, and appreciated viewing the donor as a "first patient" is not universally accepted and that other viewpoints such as "silent teacher" are valid and noteworthy (Chen et al., 2011;Štrkalj, 2016).
A future direction of this project is to formally incorporate the collection of specimens for histopathological analysis.This will allow for an exploration of the impact of diagnosis on the professional

CON CLUS IONS
This study examined the impact of the FPP on the personal and professional development of preprofessional undergraduate students.
The findings highlight several important insights.First, formal integration of humanism into the curriculum was an effective approach at fostering professionalism and other NTDIS as it gave students the space to examine and appreciate their emotions and experiences.
This formal curriculum also demonstrates a balance may be achieved between clinical detachment and empathy (Hildebrandt, 2010(Hildebrandt, , 2019) ) via dissection and counters previous reports of a loss of empathy and negative emotional reactions during dissection (Böckers et al., 2010).Second, the incorporation of pathology into the gross anatomy course allowed for small group work, collaboration, and exploration of the interaction between lifestyle and health and is a novel but effective approach in an undergraduate, pre-professional gross anatomy curriculum.Finally, despite concerns about time constraints and lack of resources, this study demonstrates the feasibility of implementing a dedicated humanism curriculum that promotes professionalism, NTDIS, and reflection without a significant outlay of time and resources.These results support the early delivery of NTDIS in educational programs and highlight the effectiveness of reflective writing in promoting humanism.
Overall, this study underscores the value of incorporating humanism, pathology, and reflection into the education of preprofessional undergraduate students.It provides evidence of the positive impact on their personal and professional development, supporting the integration of these elements in curricula across various disciplines.
During the course introduction, students are given a 45-minute presentation that covers three topic areas: (1) The anatomical education program (AEP), (2) a brief history of anatomy, dissection, and whole-body donation, and (3) expectations for respect of the donors.The AEP is a program administered by Indiana University school of Medicine to acquire and distribute donated human remains for medical education.The program director delivers the presentation about the AEP and answers any questions the students have prior to beginning dissection.The historical presentation follows and serves to situate the students to understand the necessity of a willed body program considering ethical transgressions committed by medical and anatomical educators in search of bodies for dissection responses to an anonymous post-course survey about the FPP.Reflections were collected from four cohorts of N461 students: spring 2020, spring 2022, fall 2022, and spring 2023.The course was not offered during 2021 due to the COVID-19 pandemic and was offered for the first time in the fall semester beginning in 2022.
focused and interested in what I was looking at and how it functions than on any of the reservations I had about the class.P2, SP20 An alternative lens of compartmentalization was for students to see the act of dissection with a purpose of fulfilling a wish of the donor and not the mere act of performing the act of dissection, without forethought.A student describes this shift in their cognitive approach to dissection: I felt emotional discomfort as we were "disassembling" the bodies like an inanimate object, a sense of guilt overcame me that slightly distracted me day one.Therefore, I viewed it from a different perspective, that the honor was fulfilling the donor's expectations toward learning and so that is what I decided to do… After our first dissection, I gained a compelling sense of purpose and responsibility-to embrace the process and I will never forget the generosity of the gift we received.P4, SP23Segregating emotional experiences from learning in the moment allowed students to perform donor dissection, but a shared community of students and educators also enabled the students to create a safe and empathetic learning environment to alleviate fears and anxieties.This shared community held a common interest of anatomy and enthusiasm for discovery was formed not only by their peers but through the connection to the educational team.A student expressed the value of a shared community as they stated:My experience with Unit 1 has also allowed me to realize how much I value having a team of other students who are going through the same process.It helps to have people to share this experience with as you feel a sense of support and belonging.P1, FA20 A further student expressed their experience of enjoyment and meaning drawn from being able to discuss a topic of common interest, human anatomy, with those who make up their social learning space and community as they stated:The more I work with my group, the more I learn how much they love human anatomy.It's amazing to be able to share these experiences with them, as we all have the same appreciation for what our bodies can do.P5, SP23A shared community allowed for the co-creation of knowledge and a safe space for discovery.Students described how they gained knowledge through the dissection process and how it provided essential context to their knowledge from previous coursework.One student described how prior knowledge scaffolded this experience: A lightbulb turned on for me during the dissection of the digestive tract.It was one of my favorite parts of N261 [non-dissection, prerequisite human anatomy course], but actually seeing it and going through the dissection was something else entirely.All of the concepts and definitions I knew so well gave way to a deeper understanding of how the human body works and how each piece fits together with the rest.Everything made sense.P1, SP22 Coping through both compartmentalization and a shared community enabled the students to reconcile the strange and uneasy experiences of their first day in the dissection laboratory and further allowed them to scaffold on previous knowledge through their acts of discovery.
knowledge gained from dissections to develop technologies to help the human body in situations where it is not working properly.Thoughts such as this came to my mind when I saw the pacemaker from one of the donors in the lab.P2, SP22 Furthermore, students discussed how they have come to understand how health equity may be affected by healthcare access or availability.One student discussed how their specific donor's pathology led to their conceptualization of how access to healthcare may affect patient outcomes: I believe the accessibility to health care is often overlooked when dealing with donors.Many students just see the illnesses or problems our donors lived with, but they might not consider how many resources our donors had in order to take care of their illnesses and how that could have impacted the state and progression of the illness.This experience has opened my eyes to have a better understanding of what having health care and accessibility truly means.P3, SP20 Humanistic qualities are defined as grounding the students into the present, respecting the individuality of the donor, and the students' own personhood.Observing the donor's history through pathology was described by students to add depth and context to what it means to be afflicted with such ailments.One student stated: Seeing the toll that an illness has on a person up close is not what you would expect.It's totally different hearing the diagnosis vs. seeing its actual effect in the body.It's kind of odd to see things like pneumonia or heart failure from a different light.For example, instead of symptoms, we get to see the actual hardened lung.Even though there is a lot of space to come to our own conclusions about who our donor was and their quality of life because we don't know anything about them, we still get to know them on a really personal level.P4, SP20 The act of reflecting upon donor pathology in the context of quality of life afforded the students an opportunity to view their donors through a humanistic lens.Building on this acknowledgement of the personhood the donor's possessed, allowed a respect for the humanity of the donor, as this student stated: After lab, my curiosity about the body grew.I wanted to learn more about the structures in my cadaver's body and try to learn his story through what his body told me… These thoughts helped me humanize the act of whole-body donations and appreciate the sacrifice he and his family made for my education.I think further dissections will reveal more about him to me and I am excited to learn more about his life while learning anatomy.P1, SP20 By bringing the humanity to the fore, and modeling of humanistic qualities by the educational team, a respect of donation was consistently discussed throughout the course, such as stated: I started the class so excited to dissect and learn anatomy hands on, but over the course of unit one I have found myself being more mindful of the donor.I no longer want to succeed just to get a good grade, but I also want to make sure that I am doing right by the donor.I have spent a lot of time in the lab in my free time, so the initial fear of cutting into the donor is gone and replaced with the desire to dissect them to the best of my abilities.P3, SP22 However, for some, respecting the donation was sometimes at odds with the act of dissection.Students reflected upon these conflicting and contradicting constructs of what anatomizing the donor meant and how to perform the dissection in a respectful manner: have learned that, during this unit, I was struggling with my mental health and motivation to study, and that I was overall feeling exhausted.Nonetheless, I am going to continue to push forward for the next unit and give it my all.P3, FA22 Notwithstanding the cognitive challenges of the course, visualizing the complexity of the human form sparked or rekindled the passion for medicine which was often why students entered their preprofessional undergraduate studies.A student described how this course allowed them to refocus on their goal: Last semester, due to external circumstances and my internal perception of these circumstances, I felt as if I was losing sight of my ultimate goal of becoming the best osteopathic physician I am capable of.This first BIOL-N461 lab rekindled my excitement and reminded me partly why I have chosen the path I'm on.P6, SP20 Frameworks of Integration and Introspection enabled students to develop humanistic qualities through reflective practice that provided the means to articulate and synthesize their experiences of dissection in relation to pathology, and further the self-awareness of who they are and who they want to become.
think this course is also strengthening my teamwork skills.In studying for the first test, everyone in my group had a strength and we used it to further our knowledge.[Student A] knew bones and had resources from her lab.[Student B] knew muscles and fun mnemonics.[Student C] had real life stories that applied to the cubital fossa.P7, SP20 Another NTDIS that enabled teamwork was communication; not only formal communication as part of the FPP, but the day-to-day discussions among team members as they accomplished the dissection and group study: Our team has worked well together and communicates what areas they are concerned with dissecting in the future and when they feel they're tired from dissecting.We've reflected on how we did after the first exam and have communicated what we think needs to change moving forward to make sure we all continue to strive to get an A. P7, SP20 Furthermore, as study techniques adapted to meet the demands of the course, and through communication and teamwork, students were able to reflect upon their thought processes, thus thinking about thinking or metacognition: Additionally, throughout this unit, I have learned how to effectively study for classes such as this.I have been proactive in learning the material prior to coming to lab, and it has helped me to understand what I (n = 46) and completed by 29 students with an overall response rate of 63% (29/46; 12 [SP22, 55%], six [FA22, 67%], 11 [SP23, 73%).
development of undergraduate pre-professional students.Additional future directions include evaluating the long-term impact of the FPP on former students, particularly those who have matriculated into or graduated from a health professional program.Finally, we hope to implement narrative feedback on reflections based on the objectives of the FPP.Narrative feedback aims to provide the student information about their performance on the reflection and may promote increased reflection of personal and professional development.
Results of end of course survey of first patient project.