“Spine to the future”—A narrative review of anatomy engagement

Anatomy has been integral to medical and health education for centuries, it has also had a significant role in wider public life, as an educational resource, a link to their health, and also as a darker deterrent. Historically, public engagement in anatomy is hallmarked by public dissections of convicted criminals across the globe. Artists, specifically non‐medical men, such as Leonardo da Vinci, are reported to have participated in public dissection. Dissection would later rekindle public interest in anatomy as graverobbing led to the reform and regulation of anatomy in many countries. In recent years, there has been growing interest from the public in learning more about their bodies as health and well‐being become of paramount importance, particularly following the COVID‐19 pandemic. Anatomy sits in a prime position to direct and instigate conversations around health, well‐being, and body image. Every human on earth possesses a perfect resource to look at and learn about. Models, art‐based anatomical activities, and crafts provide active learning opportunities for the wider public around anatomy. Most recently, apps, games, and extended reality provide novel and insightful learning opportunities for the public relating to the body. Finally, training and resources must also be made available from institutions and professional bodies to anatomists to enable them to deliver engagement in an already congested and educationally heavy schedule. This resurgence of interest in anatomical public engagement sees anatomy re‐enter the public spotlight, with more appropriate resources and educational settings to offer engagement with the aim of benefiting the public.

bodies for anatomical education are sourced, with some countries still utilizing unclaimed bodies. 3Anatomists of old had to navigate the moral limits between scientific objectivity and morbid theatricality. 4 Throughout the history of anatomy, the lay public were intertwined either as spectators in the case of public dissections or voiced their disapproval of grave robbing and body snatching. 4The following sections will consider the history of public engagement in anatomy.

HIS TORIC AL ACCOUNT OF ANATOMY AND PUB LI C ENG AG EMENT ACROSS EUROPE
The first recorded public dissection was performed by the Greek physician Herophilus around the third century BC.In Ancient Greece, Herophilos, known as the Father of Anatomy, is recognized as one of the earliest teachers of anatomy.He spent much of his time in Alexandria writing and teaching to pass on his knowledge. 5 was followed by Galen, whose writings were substantial and seen as the authority on anatomical and physiological observations and functions for almost 1500 years.While Galen's work went unchallenged, in subsequent years, it became clear that his efforts were not without errors as most of his published work was based on vivisection rather than humans, but this should not detract from the substantial contributions he made to anatomy and medicine. 6,7errini writes that "public anatomy was an important part of public culture" during the early modern period in Europe. 8The efforts of Mondino de' Luzzi (1270-1326) reinvigorated the public's interest and exposure to autopsy and dissection after the Alexandrian hiatus. 9Dissections of condemned criminals continued in Europe at various universities.This was especially true for universities in Italy during the fourteenth century and the first recorded public dissection outside the Mediterranean occurred in Vienna at the Citizens' Hospital in 1404. 10,11However, the supply of bodies for public dissections in Italy declined due to various reasons.Most notably, this was due to specific funerary rites and traditions of the family, the static nature of anatomy education, and specific university requirements. 10As an example of the latter, public dissections at Florence ranged between six to seven cases per annum during the fifteenth century.Florence University, Studium Generale, specifically stipulated that the body should be a foreigner and hanged during the winter months. 10The cold of winter was preferred as it ensured longer preservation prior to the development of embalming in its modern form. 12Similar stringent regulations existed at Padua University which pardoned criminals who were either a citizen of Venice or born within any territory of Padua. 11e examples mentioned above demonstrate some of the challenges associated with the dissection of human remains.Furthermore, executions of criminals were the exception rather than the rule during the fifteenth century in Italy.Condemned criminals were not the only source and, as interest in anatomy grew, poor foreigners who died at local hospitals became an alternative source. 10e anatomical Renaissance, according to Park, 10 saw a resurgence in the interest in anatomy and occurred around 1490, driven by a revival in art, naturalism, and the rediscovery of the works of Galen.
Anatomical dissection was no longer limited to medical doctors and this revival reached the lay public with an interest in the subject. 13is was especially the case for artists who attended a faculty of medicine and art at any university at the time. 13Artists appeared not to have struggled to obtain bodies to dissect and study in an attempt to further their knowledge.Leonardo Da Vinci (1552-1519), among others, studied the human form 14 and obtained bodies from hospitals in Rome and Florence. 15Public interest in anatomy grew rapidly and the crowds drawn required specialized anatomical theaters, exemplified by the construction and expansion of the theater at the University of Bologna between 1595 and 1637. 13However, the golden age of anatomical theaters waned.Capital punishment was rejected from the mid-eighteenth century onwards and alternative forms of the display of anatomy appeared in museums as models in wood, ivory, clay, wax, and papier-mâché. 13,16atomical wax figures served as an alternative for those with "… the desire to see, without feeling the nausea, and at close range, the various parts of the body…" 13 The primary selling point of anatomy museums was the ability to learn anatomy without the "barbaric" and "macabre" need to dissect.It is estimated that, between 1739 and 1800, 39 anatomy museums existed in England. 13,17However, privately funded legal action under the Obscene Publications Act saw the closure of the last anatomy museum in the 1870s. 17Although these public anatomy museums closed, a few remained for education of medical professionals and were aligned with recognized Royal Colleges, enabling them to maintain their collections.Museums such as these and their collection still exist today and are open to the public.The removal of access to anatomical dissections and specimens from the public was not mirrored in the professional setting, with the need to continue training surgical, and latterly medical professionals, utilizing the generous gift of bodies by donors remained of paramount importance. 18This continued training was available within many medical schools and remains a key resource for the education of health professionals.This source has been supplemented with many new resources which have displayed benefits to educational attainment and lend themselves to wider educational activities beyond traditional settings 19,20 (Figure 1).These events cover a significant portion of the history of anatomy engagement across Europe, many of the issues around dissection and sourcing of bodies, outrage from the public, and changes in legislation were mirrored in the USA. 21th the disappearance of anatomy to the public, removing the shock and punishment element from the public, it also removed any potential educational benefit from them.In recent years, anatomists and educators have tried to bring it back into the forefront of science and public engagement.The development of plastic models, mass produced textbooks and latterly electronic and interactive resources has enabled the public to rediscover anatomy as well as encounter it in new and more palatable formats.While there have been numerous advances in the availability of resources, this has not prevented some entities bringing public F I G U R E 1 A timeline showing significant anatomical events relating to anatomy and anatomical engagement across Europe from 200 B.C. through to modern day.dissection back into the public realm, often challenging the social and ethical values around body donation held by many in the professional field, as well as crossing legislative boundaries that exist in some countries to prevent this type of action. 22Anatomy, to the general public, has a personal connection.The public's preferential interest in sciences is linked to their professional or personal interests.Anatomy is the one science for which every individual on the planet possesses their own personal model of and will at some point in their life reflect on the changes of their model and whether they need help in understanding if those changes are pathological or not.
There is much need for more public engagement and outreach activities considering the science communication challenges throughout the pandemic, and the reduced ability to undertake engagement activities during COVID-19.
Anatomists are at the forefront of science engagement as their educational content relates to the human body, which every person on earth has access to a working model of and with the health and aging journey that every person goes on, at some point, their anatomy is going to be of interest to them.

WHAT IS THE ANATOMIC AL KNOWLEDG E OF PATIENTS AND THE PUB LI C ?
Our research on the knowledge of the public has shown a peak around about the age of 40, but a closer examination of the data shows that there is a biphasic peak which shows increases in anatomical knowledge of individuals in their 20s and then again in the late 40s to early 50s. 23 is well known that there is an increased number of individuals suffering from at least one chronic condition in the United States alone. 24In the United Kingdom, one in three individuals by their late 40s have multimorbidity with asthma and arthritis as the most common conditions. 25These individuals may have increased anatomical knowledge, particularly of the organ or structure affected by their condition.Research from Weinman and colleagues assessed the knowledge of the anatomical location of liver, ovaries, heart, thyroid, lungs, gallbladder, intestines, pancreas, gallbladder, kidneys, and stomach in patients suffering from conditions that affected their respiratory, renal, liver, cardiac, intestinal, and pancreas. 26They compared this to the knowledge of the public, offering a choice of one in four options for the location of the organ/structure.Surprisingly, out of patients from the six clinical systems, only those in the liver and diabetic groups were better at identifying the location of their afflicted organs than the public.In the public group, the location of the lungs, kidneys, and pancreas performed most poorly; surprisingly only 55% of the public could correctly locate the heart, which was better than those participants who were suffering from a cardiac condition. 26The mean age for each group of participants was in the late 40s or early 50s correlating with the 2nd peak of knowledge in our study. 23 Weinman's study showed a small negative correlation with age and knowledge, which matches that of similar studies.In all studies, increasing educational attainment and working in healthcare demonstrate strong positive performance in anatomical knowledge. 23st recently, similar trends of improved performance by healthcare professionals and those with a higher level of education were seen in an engagement event assessing public knowledge of anatomy in Hong Kong. 27This study also replicated some of the results of our earlier work, showing that organs and structures in the abdomen are answered particularly poorly and again reinforced that the knowledge of the heart is less than what we might ordinarily expect. 27is level of performance is surprising in some ways and less so in others.Our work shows that the level of knowledge of the public peaks as individuals come to the end of their formative and educational years, learning about a whole variety of materials linked to their own body as they develop. 23Why this knowledge then drops off in the next two or so decades is unclear, but it can be assumed that some element of this is because the public have little or no use for this knowledge in their everyday life, unless they utilize it as part of their career or personal interests.When the knowledge increases again in the late 40s and early 50s, it remains unclear exactly why, but likely reasons include a greater interest in their own body due to the ailments or conditions that people are suffering from beginning to ignite individuals' interest in their body and trying to understand what normal versus might be abnormal. 24,28me might suggest that the lack of progress in anatomical knowledge could be down to lack of health campaigns or their effectiveness. 29It may be that there is a more fundamental issue in that the general public and patients do not have the basic level of anatomical knowledge to enable them to fully understand the information being conveyed in these public health messages.If this was the case, they are unlikely to be able to make fully informed decisions on information that is being presented and potentially their health more generally.These campaigns are typically targeted to change behavior of an individual, but that individual's outcome(s) are more influenced by social, political, and environmental factors, with the context of outcome and policy direction being important determinants of effectiveness. 30e smaller scale events have shown, at least, short-term increase in knowledge of anatomy by participants, larger scale public exhibitions, such as Body Worlds have shown that they can increase anatomical knowledge of individuals attending these offerings. 31,32hibits such as Body Worlds, which use plastinated specimens, offer a different view of anatomy, with the plastination technique removing some of the visual, tactile, and olfactory information that is associated with human body material, enabling medically untrained people to focus on the awe, fascination, and anatomical learning that these resources offer. 33The preliminary study on the effectiveness of Body Worlds as an educational tool for the public, showed that adults performed better in their post-visit test than pre-visit, demonstrating a value in this resource in increasing the short-term anatomical knowledge of the public. 31th the evidence suggesting that there are some positive educational activities occurring, there is still much work to do in terms of helping the wider public engage and understand anatomy, it is important to reflect on what resources' anatomists have at their disposal and some of the potential successes they have had.

THE RECENT L ANDSC APE OF ANATOMIC AL ENG AG EMENT
In recent years, particularly in the last decade, there has been a resurgence in interest in anatomy engagement from the public, this aligns with the growing need for greater engagement with science from the public more broadly. 34ere is a clear need for anatomical engagement but also health education and engagement more widely, as health and well-being, as well as life expectancy have taken a fall due to the COVID-19 pandemic. 357][38] During the COVID-19 pandemic, much of the critical engagement activity moved online or was postponed.The benefits of anatomical engagement are the faceto-face three-dimensional value of being in and around resources. 39e move to online engagement, necessitated by circumstances, is a learning experience for all involved.However, it is important to note that it is not always inclusive of all the audiences that may want to attend. 40The size and scale of many of the anatomical structures and the location relative to neighboring structures are often noted by participants attending events.Many anatomical education resources already exist online and are available to the wider public, but the value and continued attendance at engagement events remains.
Recent coordinated international engagement events on brain anatomy were undertaken, with dissections of sheep or pig brains, to show common structures and their functions.These events included a pre-and post-test questionnaire relating to the structures included in the presentation.These events showed that there was a positive impact, and in the short-term, showed evidence of audience education and learning. 32These kinds of events have been occurring over an increasing number of years, but they have a history of being sporadic and it is difficult to measure the longer-term effectiveness and knowledge retention of attendees.This means there is still work to do to look at the longer-term learning and retention of knowledge of individuals who engage with anatomical learning opportunities through these kinds of events.
While there is an element of curiosity from the participants' perspectives as to why they choose to become involved, there is also huge potential to inform and help people understand their health, early signs, and symptoms of potential disease.It is well recognized in multiple conditions that earlier intervention reduces the risk of morbidity and mortality. 41e following sections detail the growing number of resources and methods that are available to anatomists to engage the public in discussions around anatomy, their body, and health.

PL A S TIC MODEL S
Plastic anatomical models are widely available and are easily transportable and can usually weather the challenges that being handled continuously by the public can bring (Figure 2).These models, although reasonably durable, are expensive and so supervision of their use is sensible to prevent unwanted damage and to ensure no parts are lost.There are little data on how effective they are in terms of enabling learning in the public setting, but they provide a useful resource for a hands-on learning experience and have been used in anatomical engagement events. 23They have the scope to enable the start of a conversation around anatomy, health, and well-being.

Anatomical body painting
Anatomical body painting is a unique form of art that involves painting detailed anatomical images on the human body, or clothes.The best and most widely used paints are hypo-allergenic and water based, with beakers and brushes lasting across multiple events.These paints can be applied directly onto the skin, although plain light-colored t-shirts represent an equally useable palette, particularly where questions around skin sensitivity may arise. 42Widely available makeup products such as eyeliners and blushers enable lines to be drawn to demonstrate stark contrast or blusher to smooth edges or transition between colors. 42This type of body painting is not only visually striking and useful for education, but it can also serve as a powerful and multi-faceted tool for public engagement.
External anatomy and the variations seen between individuals are readily seen by the public, with many of the differences being key descriptive characteristics of an individual; hair, eye and skin color, nose shape, and height being easily observable.Beyond these straightforward characteristics, anything beneath the skin is much less readily seen.Anatomical body painting involves painting images of various structures such as organs, bones, muscles, and other anatomical structures onto the skin.This is typically done by anatomists who have a higher level of anatomical understanding to ensure accuracy is maintained, enabling the public to have a purely observational engagement.The level of detail is as good as the artist and the anatomical accuracy can be quite impressive.
One of the primary benefits of anatomical body painting is its ability to convey complex medical and scientific concepts or structures in a visually engaging way.For example, a painted image of the heart can be used to educate the public about the importance of cardiovascular health and disease, while a painted image of the brain can be used to discuss neurological disorders.Body painting has a unique means to make some of these complex topics more accessible and understandable to the public.
A second benefit of anatomical body painting is its ability to promote body positivity and acceptance.By painting images of the human body onto actual human bodies, artists can help to normalize the diversity of the human form.This can be particularly powerful in a society that often places unrealistic and damaging expectations on individuals' appearances. 43,44It is important to note that traditional body painting can sometimes be less effective on models with darker skin tones but UV painting can overcome this barrier to make the activity more inclusive for diverse public audiences. 45atomical body painting has the potential to serve as a powerful tool for wider social and political engagement, especially in the current climate where issues around sexual health, reproductive rights, and gender equality are being discussed and debated.This modality offers an opportunity to draw attention to misconceptions and open conversations around these issues. 46,47This material helps the public visualize muscles and location of bones, with the added effect of seeing them change position as the body moves.While it possesses many visually stimulating attractions to the public, again it is difficult to know what it does to assist with learning and knowledge retention in the public, although it has a strong contribution to learning in the field of medicine, with students retaining knowledge for 4 weeks post-session. 48dy painting, particularly of superficial structures has had a positive impact on anatomy-based education in health fields, with anatomists' toolkits expanding from the typical dissecting room implements of old to include various art-based resources such as clay, paints, and pipe cleaners which while often used in the university classrooms, lend themselves to public engagement. 46,47

Low fidelity resources
Clay modeling presents a useful tool for anatomy engagement, offering a hands-on activity for individuals to learn about the human body in a fun, engaging, and creative way.As with many public engagement tools, its effectiveness in anatomical learning for the public has yet to be determined.As a modality, it offers a huge opportunity to gain insight into how the public view, the structure(s) and relationship of them, to each other, within the human body.In university settings, observation of clay modeling being undertaken gave higher performance than actively participating. 49Clay modeling has shown significant differences in the attainment of preschool children (4-5 yrs) with learning science-based vocabulary. 50Similarly, clay modeling improved scientific vocabulary acquisition in high school students. 51While these examples are too directly anatomical, it shows that there is a benefit and opportunity in utilizing clay-based activities to help deliver anatomical education to the public.As with many other resources used to teach the public, their effectiveness is often trialed in the university educational setting, where clay-based anatomy is demonstrated to improve student knowledge in the short term and their experience, this is supported by a systematic review of the use of clay-based modeling which demonstrated a consistent pattern of engagement and knowledge gain from this activity. 52pe cleaners are also a useful tool, in terms of learning anatomy in the formal educational setting, they have been demonstrated to be a low-cost and dynamic tool that helps students visualize and build their own models of vasculature.They are also beneficial for enabling students to increase their understanding of the brachial plexus and providing them with a revision resource to take away. 53,54is low-cost, interactive, tactile dynamic tool would also lend itself to utilization in public engagement, particularly for something for participants to take away to help maintain the public's interest beyond the engagement activity.

Games and interactive resources
The changes in the educational resources available to learners have seen significant development in recent years, with websites and apps becoming commonplace on most smart devices of individuals learning anatomy.These bring many of the resources that were typically only available in libraries and dissecting rooms into the hands of anyone with a smartphone or tablet.While many of these apps are aimed at those with an educational interest in anatomy, 55 there are a growing number of resources that are targeting the public.One example shows a strong increase in the understanding of the anatomy of the skull having collected bones as part of an educational activity on the skull merged with messaging around helmet wearing and bike safety. 56e availability of anatomical apps on smartphones and tablets has grown and given most people on the planet access to some interactive resource relating to the body.This kind of resource is beneficial to an extent, but only for those who have a basic understanding of anatomy, which research has shown, is not always the case among the public. 23ard games also represent a novel tool to aid in student learning but also present the public with an opportunity to learn anatomy in a way that is competitive and at a level that is appropriate for them.Anatomy Adventure is one such game that has shown to have a positive effect on the anatomical knowledge of medical and dental students, removing barriers to learning, and enabling fun while learning and improving knowledge retention. 57This game sits in the shadows of the one of the most well-known anatomical games, which is "Organ Attack" and advocates playability with no medical knowledge, ranked at #1038 in board games on Amazon. 58These resources are designed to make learning anatomy fun and engaging, they are likely to be popular with individuals who find other resources hard to understand. 56Other immersive games are available to help engage the public, escape rooms are a growing commonality in many towns and cities, as well as appearing as digital assets during COVID-19.These resources are becoming an experiential and engaging pedagogical tool. 59They present a resource for the public, as well as school children, to explore different means of learning anatomy and the history of anatomy. 60Although they have not been studied as a means to increase the knowledge of the public in relation to anatomy, they have been shown to be a valuable tool to increase the learning experience and the anatomical knowledge of nursing students. 61ey also present a means by which they are far more accessible than physical resources and have the potential to include individuals who may not have the ability to interact with physical resources such models.Games and apps are becoming a tool to increase civic learning and engagement, particularly in younger groups. 62

3D printing, museum specimens, and photogrammetry
Anatomical museums are much lesser in number than previous years and fall under legislation, in some countries, that limits what can be done with the specimens.However, the utilization of social media and the increasing visibility it brings to specimens and the entity means that it is becoming an increasingly effective tool in educational engagement. 63This has been hugely aided by the development of tools and techniques to digitize anatomical and pathological specimens that present them in such a manner that makes them high quality enough to be widely available and appear closely enough to represent the appearance of the real specimen. 64More recently, extended reality has been shown to be a valuable tool in making museum specimens into resources for wider learning. 65,66ny of the museums and their exhibits hold important specimens that offer the opportunity to learn anatomy but do so using many techniques and preparations that at the time were considered state of the art, such as wax models, skeletal specimens, and pathology collections. 67,68The utilization of augmented reality in digitizing museum specimens represents a novel means to make these specimens available to the public but also increasing the amount of information that can be added to them to help guide viewers through their history, as well as adding significant information in a way that is not possible with physical specimens due to challenges such as correct orientation by novices, or labels and pins obscuring the specimen itself. 69,70e rapid advances in 3D printing also offer the opportunity for anatomically accurate specimens to be produced to allow for engagement with the public.These offer a great benefit for small structures that are difficult to see, examples of structures include the malleus, incus, and stapes.As the 3D printing revolution continues to gather pace, one area where it useful engagement and patient education is around bones.Over 2.4million hip and knee replacement surgeries took place in the United States in 2021. 71The capacity for bone to naturally heal is surpassed in complex injuries or in disease state. 72The failure of such joint complexes requires replacement, which has previously been of a "best-fit" prosthesis.3D printing now offers a custom-fit, made to measure implant which has the capacity to increase longevity and reduce surgery times. 73This type of clinical grade printing could be dovetailed with a more basic "replica" print for the patient to take away, helping as an educational tool for their own surgery.
Complementing the growing prospects of 3D printing is the digitization of anatomical specimens (Figures 3 and 4).Digitization of anatomical and pathological specimens, both current and historical in nature, requires laser surface scanning and photogrammetry. 74The work of Rea et al. explored the challenges of scanning specimens and more recently, Dixit et al. presented the workflow associated with the generation of photorealistic 3D scanned specimens. 64,74The digitization of anatomical artifacts holds many benefits.Potted specimens can be transformed into 3D models and rare and historical specimens can be transformed to make them more accessible to the general public through the establishment of virtual museums. 64,75pert digital manipulation of the rendered images to remove possible inaccuracies could extend further to the restoration of specimens that are rare and of historical importance. 74The educational value of digitized specimens has been highlighted but could extend further in the form of an online database that is accessible to higher education institutions. 64The wider value of these digitized resources would be an ideal tool for public engagement, enabling multiple individuals to view from anywhere, as well as being accessible to people far beyond the location of the engagement event.

DISS EC TION ROOM TOUR S/L AB TOUR S/ HIG H SCHOOL COUR S E S
Due to the varying laws in different countries, some institutions can offer dissection room tours to individuals not affiliated with a class or registered course, this disparity means that access to resources may have a different influence on the learning of non-specialists about the body.There is a small but growing body of evidence that access to these resources and facilities for high school students also helps them learn anatomy and may provide inspiration for a career in Medicine. 76Similarly, anatomy lab tours have the capacity to increase the interest in healthcare careers, rather than just Medicine, with attendees at established dissection lab tours seeing it as an opportunity to test their compatibility with a career in healthcare. 77e of the values of these experiences is the significant positive impact it has on the attendees, improving their anatomical knowledge and reinforcing or increasing their interest in healthcare careers. 77ese experiences are based around lectures and then laboratory session using prosected specimens and isolated organs, combining normal anatomical structure and pathology, followed by a postsession assessment or feedback questionnaire. 76,77There are also ethical questions regarding the access to human body donor tissues by high school children attending these programs and how their access is managed.This issue is outside the scope of this review, it is an F I G U R E 3 An image of plastic and 3D printed anatomical models for an engagement event at the University of Namibia.important area that needs to be carefully examined and considered in light of the differing legislation governing access to human body donor tissues across the globe.While this practice may be legal in some countries, this does not equate to ethical practice.
Other approaches also see high school students and their teachers undergoing outreach education.This not only aids in educating students but also gives their day-to-day educators skills, knowledge, and take away resources to help reinforce the learning at later dates in the classroom.The variety and opportunity offered by these courses positively impact student engagement, knowledge, and their desire to learn more.8][79] Some of these programs also instill more than anatomical knowledge into students, they help them develop ethical and humanistic skills.These skills are demonstrated when guiding donor families, academics, and members of the public around the Museum of Anatomy; a display of prosections produced during their course.This involvement of the public and donor families are events that incorporate viewing of body donor dissections by the public to improve the visibility and profile of dissection programs and the significant role they play in healthcare education. 80 summary of all these resources, many have shown benefits in their academic setting and lend themselves to being of value, for a variety of reasons, in public engagement in anatomy.One of the major challenges of any of these sessions and resources is that they are likely to draw individuals who self-select for the subject, so those individuals who would benefit from increasing their basic anatomical knowledge may miss out. 23

P OTENTIAL IMPAC T OF IN CRE A S ING ANATOMIC AL KNOWLEDG E IN THE PUB LIC
The level of anatomical knowledge of the public may be challenging to truly answer, particularly given that the level of knowledge is not clear in the medical field, from students to specialists. 81However, what is clear is that the public (and the point when they become patients) have an important role to play in the decision-making processes around their own health. 82This is particularly relevant in many countries where there is a shift toward the shared decisionmaking model of healthcare.This relies on patients having as much of an input into their healthcare decisions and aligns with their preferred routine of care.This ideal co-operative model requires a solid understanding of basic anatomical and medical terminology, which at the moment appears to require more work. 83e example of anatomical knowledge of patients relates to knowledge around women's genitalia and pelvic organ prolapse (POP), where a recent UK study of 191 patients attending a hospital in the United Kingdom demonstrated that only 46% of participants could correctly identify that the correct number of holes in a women's perineum as three.The same cohort was also asked to label a view of the women's genitalia with seven structures, with 46% leaving the diagram completely blank and only 9% able to correctly label all the structures.Although women scored better than men, there is clearly an unmet educational need around women's genital anatomy. 84Given that worldwide, 40% of women will experience POP and it leads to over 200,000 surgeries in the United States alone, more education around anatomical structures and preventative measures may help reduce the severity of symptoms or need for surgery. 85Public health campaigns target multiple organs and their F I G U R E 4 An image showing a 3D printed upper thorax and related brachial plexus and key arterial structures at an engagement event at the University of Namibia.
diseases to screen and capture diseases earlier, to improve the patient outcomes, but there are still questions over whether patients and the public know where the organs are that they are being invited to be checked for. 26

FUTURE DIREC TIONS AND CHALLENG E S -A D IFFERENT L ANDSC APE FOR ENG AG EMENT ?
Anatomy continues to sit in a healthy place, not least because it revolves around the one piece of scientific apparatus that every human on earth possesses-their own body.The return to "normal" beyond the pandemic enables broader scientific engagement and outreach to recommence.This is coupled with an increased interest in health awareness and increased scope for reaping the benefits of activity considering COVID-19 infection outcomes. 86ile there is scope and need for engagement around health and the human body, there is a more significant challenge than ever facing anatomists and other scientists trying to share educational and helpful scientific information with the wider public.It could be considered a novel post-COVID-19 phenomenon where anti-science and social media have come together.
The COVID-19 pandemic has led to unprecedented scientific research and development efforts around the world, including the rapid development of vaccines and treatments. 87,880][91] This combined with the power of social media means that good science does not always become visible, and more concerning is the fact that false, misleading, or even potentially dangerous science can be disseminated widely and rapidly. 91,92This is likely going to increase the amount of time allocated and needed to dispel these challenges. 93,94liticians and other public figures have also played a significant role in shaping public perceptions and responses to the pandemic and science more broadly; promoting unproven treatments or remedies for COVID-19, such as hydroxychloroquine or ivermectin, despite a lack of scientific evidence supporting their use. 95,96[99] Others have downplayed the importance of public health measures like social distancing and wearing masks, 100,101 despite overwhelming evidence that these measures can help slow the spread of COVID-19 and other respiratory viruses. 102fortunately, there has been a loss of trust in science from some politicians during the COVID-19 pandemic. 103Much of the "official" communication came from politicians with limited understanding of science, and in some instances, the communications came with clear hostility toward scientists. 104It is not clear how damaging the comments were on the public's opinion of scientists, but they have damaged the public's opinion of science and its societal benefit. 105,106This has led to confusion and mistrust among the public, which may have serious consequences for public health and longer-term life expectancy. 107While anatomists undertake niche engagement, they are still part of the academic scientific community that puts them at risk of some of the broader hostility and challenges that face scientists in the public eye, and during engagement activities there is often very little between scientists and the public. 108is unique set of circumstances bringing mis-and disinformation is likely going to increase in the amount of time allocated and needed to dispel these challenges. 93,94

AVAIL AB ILIT Y OF FACULT Y AND FACULT Y TIME
There are increasing numbers of healthcare programs, particularly those focused on education of medics and nurses, with growth in the number of estimated graduating medics doubling and nurses and midwives tripling across the world between 2008 and 2018. 109ny of these programs have significant fundamental anatomy content, which is delivered by anatomists.There is a growing challenge in relation to the availability of anatomists, 110,111 this does not appear to be anywhere near a resolution with trained faculty retirements likely to further exacerbate the problem, certainly in the short to medium term. 112Specialized anatomy graduates, those with a PhD in anatomy are also becoming a rarity, with a decline in the programs offering this option, on top of fewer graduates emerging from the programs. 113Their shortage is further complicated by ever increasing demands on their time, many carry significant teaching and administrative loads, as well as a research portfolio. 114,115If they are also undertaking engagement activities to meet their promotion requirements and contribute to their institutions' civic agenda, the burden on their time increases.These factors represent a "perfect storm" of circumstances where increase in demand for anatomists, increased demands on their time and a pipeline that is trickling to produce the next generation of anatomists presents a significant problem. 111

TR AINING FOR ENG AG EMENT
With the growing availability of resources and opportunities for engagement, the importance of training anatomists and academics is incredibly important, particularly given the sensitive nature of some areas of anatomy.One of the greatest challenges with anatomical engagement is the wide variety of subject areas that questions or content form the audience can cover.Training can increase the ability of anatomists as public educators but also realize the boundaries and challenges around the limit of their knowledge in the ever-changing landscape they operate in Ref. [116].The American Association for Anatomy has supported its members to undergo science communication training, equipping attendees with the ability to communicate their science in an effective way when engaging with the public, policy makers, and funders.The importance of leadership recognizing the value of the skills for its members, as well as the value to the scientific field, is a key message in enacting change in both a top-down and bottom-up coordinated response to a long-term legacy issue. 117,118The inception of World Anatomy Day (WAD), coinciding with Andreas Vesalius' birthday, represents a global initiative to bring anatomy and its educators into the public light.WAD highlights their contributions to science through coordination and publicity around engagement activities and their contributions to so many things relating to the body. 119e resurgence of engagement and rebuilding of science communication will take time, but anatomists and their toolkits, expertise, and resources have a key role to play in this.Gone are the days when resources were solely bodies and specimens of criminals dissected in public, multiple resources are available to the public in a variety of environments, such as smart phone apps in their home allowing access to a wealth of anatomical information that impacts their knowledge and health.Anatomical Associations, Federations, and Societies have an opportunity to play a pivotal role in equipping their members with resources and tools that enable them to make a strong and positive impact on the knowledge and health of the public and those beyond the borders of the academic environment.
Anatomy, anatomists, and the work they do is at a delicate point, the value of anatomy in medical education is clear, if the demand and usefulness of it as a subject in an engagement forum grow then adequate resources, time, and recognition of its importance has to be made to enable those who deliver it to do it in a way that offers benefit to them and those who are engaging with them.

E TH I C S S TATEM ENT
The authors confirm that there is no ethical requirement for this narrative review article.The authors confirm that the article has been written by themselves with no utilization of AI or other external software or parties.

R E FE R E N C E S
Interestingly, the study by Weinman compared performance to an earlier study by Boyle and colleagues showing how knowledge had changed very little from 30 years previous, with the Boyle study now being 50 years old and showing similar levels of knowledge in Weinman's study in 2009 and ours in 2018.

F I G U R E 2
An image showing plastic models and 3D anatomical projector for the Campus in the City engagement at Lancaster University.