Human skills for human[istic] anatomy: An emphasis on nontraditional discipline‐independent skills

While attending the 18th Ottawa Conference on the Assessment of Competence in Medicine and the Healthcare Professions in Abu Dhabi last month, we were struck by the prominence given to the integration of human skills across all medical disciplines (Barach, 2018). These skills, which traditional science-based curricula generally regard as secondary to cognitive skill are often referred in basic science literature as nontraditional discipline-independent skills (NTDIS) (Evans and Pawlina, 2015), or in clinical literature as non-technical skills (Pearson and McLafferty, 2011; Roche, 2016), or simply human factors (Jones et al., 2018). These relate to the demonstration of professionalism, empathy, love, resilience, emotional intelligence, situation awareness, and other such intangible skills and attributes (Pearson and McLafferty, 2011; Barach, 2018). Traditionally, in preparing our students for the next stage in their learning journey as potential healthcare professionals, focus within basic science curricula has been directed on providing building blocks for their subsequent training, theories and knowledge as well as a range of disciplinary skills. However, curricula that once provided students with these basic educational units no longer and should no longer focus solely on knowledge-based competencies but instead should promote the development of human skills. Curricula have already begun to be more integrated, holistic, and focused on the patient, a new trend that is gaining momentum even outside of medical education. Undergraduate colleges for example are incorporating coursework relevant to the development of human skills across all disciplines, including the humanities, business, STEM (science, technology, engineering, and math) and health sciences (Idrus, 2014; Cunningham et al., 2016; Husin et al., 2016; Michalec et al., 2018). Interestingly, early childhood education also includes a strong focus on development of human skills with much stronger emphasis on holistic child development than what exists in subsequent elementary education (Siraj, 2017). In health professions education, the concept of “health care provision” and the mindset of the health care “provider” urges students to now learn how to relate theory with practice and patient care at an earlier stage in their educational journey. In addition, the organization and delivery of health care in many countries is being affected by profound cultural, social, demographic, economic, and political changes with significant implications for the future of the healthcare professions. The role that healthcare professionals will be playing is also being disrupted by diagnostic, pharmaceutical, and innovations in healthcare information technologies with distinct goals to strengthen health systems and to improve efficiency, quality, safety and access to medical care (Sligo et al., 2017). At the same time, the spotlight on physician competency and effectiveness is no longer exclusive to the hands of professional evaluators. With the provocation of social media and related web platforms, the impact of direct, unfiltered patient feedback further adds to the challenge of physician rating and reputation. As our students enter the healthcare profession, development of a portfolio of skills and attributes to facilitate the process of professional socialization and the advancement of professional identity become crucial to their success (Hafferty, 1988; Byszewski et al., 2015; Gibbon and Crane, 2018). Such nontraditional discipline-independent skills will enable them to navigate challenges within the health care setting by exhibiting collaborative leadership, promoting team success, displaying cultural competency, and communicating effectively as they provide holistic care and start recognizing the person when treating the patient. These skills are recognized as important factors in the safe delivery of care by enhancing clinical performance through an understanding of the effects of teamwork, leadership, communication, and organizational culture on human behavior in the healthcare environment (Flin and Patey, 2009; Youngson, 2011; Gordon et al., 2012; Moneypenny, 2017). Deficiency in NTDIS contributes to significant increase in medical errors (Panesar et al., 2012; Roche, 2016; Uramatsu et al., 2017). In the past, teaching of the NTDIS skills and assessment of competencies in this arena has been neglected in medical school curricula (DeTata, 2015), however studies indicate that even a brief seminar highlighting NTDIS does improve students’ behavior, attitudes, and performance during simulated patient treatment (Hagemann et al., 2017). The simulation environment is highly effective in teaching NTDIS to health care professions students (Arora et al., 2011; Pearson and McLafferty, 2011; Jorm et al., 2016). Within this paradigm, medical educators are compelled to promote an authentic learning environment that focuses on real-life situations and challenges in the clinical arena (Flin and Patey, 2009; Pawlina and Drake, 2016; Swartz, 2016) with emphasis on the importance for developing, teaching and assessing these less tangible skills in our students (Evans and Pawlina, 2015; Lachman and Pawlina, 2015). As with any change, making a paradigm shift involves internalization of a philosophy that aligns with the academic objectives and deliverables. Evolution should entail a threefold approach whereby (1) the educator understands and develops a commitment toward facilitating the non-cognitive segment of the curriculum, (2) the educator focuses on development of students’ non-cognitive skills embedded within core activities within a conventional curriculum, and (3) the patient becomes the center of strategic and authentic learning. In basic sciences and anatomy in particular, this means as basic science educators we have an opportunity to provide a bridge or link into the realm of this health practice development. By introducing NTDIS into the early curricula we will prepare our students for engaging more effectively and efficiently within a complex and changing healthcare environment. To align with these changes a new and much broader definition of 'basic science’ is emerging that encompasses clinically relevant teaching with incorporated social and behavioral sciences (Kuper et al., 2017; Bandiera et al., 2018). The anatomy curriculum by default is a preeminent platform for initiating NTDIS in early medical education. In dissection-based courses the body of the donor serves as the first patient for the student. Even when practical anatomy is taught through provision of prosected material, digital imaging or 3D printing, the use of human tissue and the human forms is representative of the future patient. Literature to date have focused discussion on the body donor, student reaction to dissection, ethical and legal issues of working with human tissue, arguments regarding availability of donor health history to students, and on reinforcing the recognition of the body donor as a patient (Hafferty, 1988; Cahill and Ettarh, 2008; Evans and Fossey, 2011; Jones et al., 2014; Williams et al., 2014). Students are held accountable for quality of dissection (Nwachukwu et al., 2015) and confidentiality as they will be entrusted to, and be responsible for the quality of care for their future patients. Because of its foundational importance in healthcare training, anatomy is usually taught early in the curriculum and therefore is an ideal forum for introducing a range of NTDIS and attributes important for subsequent practice. Anatomy should expose students to an array of skills including interpersonal skills, staff-staff, staff-peer communication, peer-near-peer active teamwork, and leadership (Evans and Pawlina, 2015). The interaction of students with teachers and tutors provides opportunities for identifying and practicing the professional behavior expected within the healthcare setting. The team-based environment of the dissection laboratory should allow students to learn how to work within interpersonal and interprofessional settings (Kirch and Ast, 2015; Thistlethwaite, 2015). It provides an opportunity to practice teamwork and collaborative leadership when assigned projects or other course activities to team members (O'Connell and Pascoe, 2004; Lerner et al., 2009). Such an environment also teaches students how to communicate effectively whether to an audience while delivering a presentation, or to their teammates when problem solving, or to faculty and near-peers when engaging in learning, or to patients through innovative exercises such as embryology pamphlets (Evans, 2008). Current anatomy curricula should continue to move away from a memorization (Miller et al., 2002) and eradicate the single-minded approach of learning anatomy to pass the final examination. These approaches limit students’ learning ability by keeping a final examination as an end point of their knowledge without seeing its application in forthcoming clinical rotations. With more self-directed, problem-based, clinically oriented line of questioning, students have opportunity to learn how to think for themselves thereby strengthening critical thinking and clinical reasoning skills (Elizondo-Omaña et al., 2010). In the rapidly changing health care setting the goalpost for competency is dynamic and hardly remains in the same position for a long period of time. The current health care system now demands that all health care providers be equipped with interpersonal non-cognitive skills, which are currently the subject of many continuing professional development interventions. We hope that newer graduates would already be armed with these skills. The process of acquiring these skills in medical curriculum should be truly integrated across the entire spectrum of medical training (Bandiera et al., 2018). Peer and self-evaluations of leadership opportunities, small team-oriented activities, as well as faculty evaluations should become part of an integrated anatomy curriculum where both cognitive and non-cognitive competencies are valued. Since NTDIS are not discipline dependent, all courses should contribute in some way to their teaching and assessment. If this does not occur students are simply provided with null curriculum message that these competencies are not important for their future practice, because these skills are not being taught and definitely not being assessed (Flinders et al., 1986; Hafferty and Castellani, 2009; Jones, 2013). Perhaps it may be timely and quite necessary therefore to gain insight from our clinical colleagues through their shared experiences of current health care practice needs. Several questions should guide our teaching in anatomy such as: What are the challenges facing health care providers’ well-being in the clinical environment? What are these challenges for students in the learning environment? What is the impact of evolving technologies or ever-changing approaches in clinical practice? Uncertainty within the clinical landscape could also be explored in light of uncertainty in dissection findings, and making patients the focal point of teaching and learning provides insight into what patients of today expect from their providers. If anatomists are genuinely committed to creating opportunity to develop and evaluate NTDIS sets, our focus should be on promoting situation awareness, mental readiness, risk assessment, anticipation of problems, decision making, adaptive strategies, uncertainty, and flexibility while teaching anatomy. Improvement of these skills is strongly dependent on evaluation and feedback. Placing value on NTDIS within the curriculum (Evans and Pawlina, 2015) will require formal assessment that reinforces their importance in achieving future milestones. In addition, promoting student wellness through resource management, seeking advice and feedback and coping strategies for pressure, stress and constant change ought to become the responsibility of the entire teaching and learning team (Pawlina et al., 2018). Faculty, near-peers, teammates and institutional support teams including the student themselves should prioritize wellness. In each case, this diversity of skills will become increasingly important and enabling. Developing such skills must happen early so that the student embeds them within their learning and practice psyche and sees them as inherent characteristics, strengths and attributes. What better place to start that journey in their education than through their experience with learning anatomy? It is clear that anatomy already provides opportunities for development of some of the necessary NTDIS, but these are often hidden or implicit rather than explicit and visible to both students and educators. Therefore, critical to the success of including NTDIS within the basic science curriculum is appropriate embedding into the student learning outcomes, the associated learning activities of the course or unit and the assessment regime, ensuring they are an integral part of the curriculum design. Such integration provides the necessary relevance to students for learning such skills and how applicable they are to their future practice. It also allows them to recognize and track their own portfolio of skills and be able to articulate these to others. The learning activities and assessment must therefore be authentic to provide the relevance and context, which in turn should stimulate learning engagement. The assessment of NTDIS must be integrated within the overall course assessments so they are not isolated from the discipline outcomes. Nontraditional discipline-independent skills also need to be constantly re-visited in the curriculum including other basic science (Jones, 2013) and clinical courses. In order to succeed in the 21st century health care environment, professionals will need to be able to reinvent themselves if they are to take advantage of the opportunities afforded to them. They will need to be adaptable and resilient and have the ability to constantly recognize and evolve the diversity of NTDIS sets needed for practitioner success and provision of excellent patient care. Indeed, some anatomists may not be convinced of the impact or relevance that these small changes in design of the anatomy learning experience can have on students' ability to overcome future learning curves. However as medical educators, we should look to our sense of holistic judgment to reconcile the responsibility we have for maximizing the learning potential innate to the anatomy curriculum. In paraphrasing President Franklin D. Roosevelt, perhaps we may not be able to build the future for our students, but we can certainly take the responsibility for preparing our students for the future (Roosevelt, 1940).