New path for teaching anatomy: Living anatomy and medical imaging vs. dissection

How should we best teach anatomy? For centuries, the answer has been through dissection. A few have argued that prosections can replace the experience of individual dissection. Until recently, no one has argued that the cadaver can be dispensed with altogether. Peninsula Medical School, one of four new medical schools to open recently in the United Kingdom, has taken this radical step (McLachlan et al., 2004). So, what was behind our thinking? We asked ourselves how doctors encounter anatomy in clinical practice. The answer is through living and surface anatomy on the one hand, and medical imaging on the other. It therefore seemed to make sense to teach students anatomy in these contexts right from the beginning. This matches our desire for authentic experiences throughout the course. Students meet patients in community settings in their first days. They learn clinical skills from the first week, throughout the entire course. In teaching anatomy, we decided that we would rely on living anatomy delivered to the students through the extensive use of peer examination and life models and on medical imaging delivered by qualified radiologists. Doctors encounter anatomy in clinical practice … through living and surface anatomy on the one hand, and medical imaging on the other. It therefore seemed to make sense to teach students anatomy in these contexts right from the beginning. This decision received comment in the media and has stimulated criticism and discussion. It was not, incidentally, based on costs. Our program is expensive in clinician time, especially for radiologists, and trained anatomists are still required as teachers. Anatomy teaching takes place in tutor-led small groups (eight students per group; 80 sessions per student over years 1 and 2). Medical imaging (20 sessions) is led by clinical radiologists and features X-rays, ultrasound, MRIs, CT, and 3D imaging. Living anatomy (40 sessions) is studied through consented peer examination, supported by life models. Palpation and auscultation are covered, along with projection of still and moving images onto the body surface. Life-size full-color transverse cryosections and other imaging material are used with the living body, and high-verisimilitude body painting of underlying structures has proved useful. Portable ultrasound equipment is available to visualize structures in the living body. There are 24 integrated structure and function lectures in the first 2 years, although this is a problem-based learning course, which does not rely on didactic methods. Arts and humanities are integrated with anatomy learning as a core curriculum activity to help expand awareness of humane issues. Our course has sometimes been misrepresented as the use of either plastic models or 3D computer models in place of cadavers. These are valuable adjuncts to anatomy learning, but not a substitute for working with the living human body. A variety of benefits have traditionally been ascribed to the use of dissected or prosected material in anatomy teaching, some of which can be achieved by other means. For instance, self-directed learning and teamwork can be developed in a variety of settings, such as problem based learning groups. Manual dexterity can usefully be practiced in clinical skills settings. Application of the scientific method is a slightly implausible benefit of dissection, but can be developed in more relevant ways by studying the application of scientific method to current topics. It is a widely held view that dissection gives students a 3D view of human anatomy and reinforces knowledge acquired in lectures and tutorials. We believe that our students can achieve this 3D understanding by working extensively with living bodies in conjunction with projection of color images on the surface of the body, which can be dissected away layer by layer; by use of color transverse sections in association with the living body; and by extensive use of imaging. Indeed, modern 3D reconstruction and imaging methods give views of the internal structures of individual living patients during medical procedures that can be superior to those observed during dissection, and this may modify surgical practice in the near future. Dissection is frequently seen as serving purposes of personal development in promoting humanistic values, specifically as an introduction to death in a controlled manner. However, evidence on the benefit of such an introduction is mixed. Students may find the process stressful and it may encourage inappropriate attitudes toward human remains as students attempt to deal with this stress. Our students will encounter death in a much more natural setting, within communities, where the meaning of the death is clearly recognized. We do not wish our students to experience desensitization, which is sometimes proposed as a benefit. We wish them to remain sensitive while functioning effectively in their roles. Study of human material may also be seen as an opportunity to appreciate the range of variability present in real human materials, as opposed to that described in the textbooks and in plastic specimens. This is a significant issue, which we are addressing through our extensive peer examination process and through the creation of an electronic surface anatomy atlas, which, instead of focusing on a few individuals (usually a young lean white male), enables us to represent the range of body morphologies observed in a variety of different subjects. Cadavers may present a number of disadvantages. Their color, texture, and smell are not like real life, and cadavers cannot be palpated, auscultated, or usefully asked to change position. Their use may present health hazards and ethical/legal difficulties. While cost alone should not be the issue, the expense of maintaining a cadaveric facility means the cost-benefit ratio must be carefully considered. Real evidence of the efficacy of different methods of anatomy study on clinical practice has always been lacking. Naturally, we are evaluating our program. However, our desired goal is to produce better clinicians, rather than better anatomists, and our first students will not qualify until 2007. It may therefore be some time before the best evidence arrives. The U.K. General Medical Council has been supportive of our approach so far. This article is one of four invited papers that address the following question in a moderated debate format: “To what extent is dissection necessary in the learning of medical gross anatomy?” These articles were published in the November 2004 issue of The Anatomical Record Part B: The New Anatomist (Vol. 281B#1, pp 2–14). These articles can also be accessed online through our virtual issue on dissection and medical education (www.wiley.com/anatomy/dissection).