|
Keywords: Anatomy, dissection, teaching, undergraduate, postgraduate surgical training
Surg J R Coll Surg Edinb Irel., 2 April 2004, 79-90
Teaching anatomy to both undergraduate medical students and medical graduates is in the midst of a downward spiral. The traditional anatomy education based on topographical structural anatomy taught by didactic lectures and complete dissection of the body with personal tuition, has been replaced by a multiple range of special study modules, problem-based workshops, computers, plastic models and many other teaching tools. In some centres, dissected cadaver-based anatomy is no longer taught. Changing the undergraduate medical curriculum in the UK has taken place without any research into the key aspects of knowledge necessary or comparing methods of teaching. There is no agreement on a common national core curriculum and as a result, numerous new curricula have been introduced. No external audit or validation is carried out, so medical schools have been free to teach and assess their own work themselves. There is a great divergence in medical schools across the UK and Ireland in teaching medicine in general and anatomy in particular. Published data on the impact of these changes is scant. The reduction in undergraduate teaching and knowledge of anatomy has caused great concern, not only for undergraduates but also to postgraduate students, especially in surgery. This, together with a change in basic surgical training, a marked reduction in demonstrator posts and a change in examination standards, has set up a system that is allowing young men and women with a poor knowledge of anatomy to become surgeons. There should be a full public debate at every level; the Royal Colleges, specialist associations, the Universities, Government, both health and education. This debate should highlight areas of concern, explore in depth and define a minimal core curriculum for anatomy. Teaching must be enhanced with a critical look at both teachers and methods. The dominance of research must be reassessed to establish an equitable cohabitation with teaching. The place of basic science, especially anatomy in basic surgical teaching, must be examined. A thorough knowledge of anatomy should be required in the new MRCS-UK. This should be mandatory as a preliminary to higher surgical training. The teaching of anatomy in surgical specialities must be improved. Does the dissecting room still have a place in educating our under- and postgraduate students? Yes - a sound knowledge of anatomy is essential if the medical practitioner is going to accurately define and successfully treat the problem presented by the patient. The dissected cadaver remains the most powerful means of presenting and learning anatomy as a dynamic basis for solving problems. The cadaver must not be dismissed as obsolete. Dissection has survived the most rigorous test of pedagological fitness - the test of time. The student - cadaver - patient encounter is paramount in medical education
INTRODUCTION
The patient presents the physician with a problem. The art and science of medicine is
defining the problem with as much precision as possible. Defining the anatomical site of the
lesion is crucial if the physician is to resolve the problem effectively and compassionately.
Therefore, a sound knowledge of anatomy is essential from the beginning of a medical
education. This can only be achieved by exposing and examining the tissues and structures within the body, best revealed and
studied by dissection. The traditional anatomy
education was based on topographical structural anatomy taught by didactic lectures
and complete dissection of the body with personal tuition.
Towards the end of the nineteenth century the deceased human was at the core of investigation and knowledge acquisition. Dissection-based anatomical analysis facilitated the classification of bodily components, the development of a vocabulary for describing the body with clarity and precision and mapping the bodily organs and their surface projections, which would be later used in physical diagnosis. Clinical medicine was significantly enhanced by Sir William Osler’s study of anatomy and pathology.1
Figure 1: A demonstrator teaching undergraduates in the dissecting room
The early 1980’s heralded a great reform, spearheaded by McMaster in Canada and supported in this country by the General Medical Council (GMC).2,3 Major criticisms were levelled against contemporary medical education; it was stated to be an overcrowded curriculum packed with clinically unconnected facts, excessive memorisation, didactic lectures which were centred on the teacher, with passive learning and lack of communication with patients. At the same time, the introduction of the computer and associated biomedical informatics reduced the need for excessive memorisation and actual dissection. Previous assumptions that medical students should undertake patient care only after preparation in the basic sciences were rejected.
A core curriculum was introduced that was considered essential fundamental knowledge for general medical practice, with special study modules. Both the general and the particular were presented to the undergraduate in the form of problembased small group learning centred on case studies. These workshops were designed to integrate basic and clinical science assisted by facilitators who would use biomedical informatics with PowerPoint presentations and patients, both actual and simulated in hospital and community centres. This reform has lead to a reduction in both time and content of gross anatomical instruction, more than 50% compared with 25 years ago. In some centres, the pendulum has swung so far that gross cadaver-based anatomy is no longer taught. Teaching anatomy to both under- and postgraduates is in the midst of a downward spiral, so their lack of knowledge has become a steady exponential curve. In 1977, the Surgical Colleges of the English speaking countries, meeting in Melbourne, expressed grave concern at the widespread inadequacy in undergraduate instruction in anatomy together with the steady decline in medically qualified teachers of anatomy.4
In the past 20 years, there has been an impressive list of complaints against the use of actual human cadaver instruction. In the 1970s and 1980s pruning was done with accompanying reorientation to ensure essential components continued to be taught. All aspects of anatomy have been reduced irrespective of vocational relevance.5 It is uncontested that sophisticated clinical imaging is an essential pathway to precise study of structure and how it is maintained. In some centres, the pendulum has begun to swing back towards classical dissection enhanced by using as an adjunct the tools physicians and surgeons will use tomorrow - ultrasound, 3D visualisation, multiaxial computerised image reconstruction, multiplaner magnetic resonance imaging and plasticated prosections.
Medicine is the compassionate solving of problems by the application of scientific knowledge. This is best achieved by the exposure and examination of the tissues and structures inside the body, and is best revealed by dissection. Biomedical informatics and sophisticated clinical imaging have only magnified our knowledge of structural organisation. They have not rendered the source of that information “the cadaver-patient” obsolete.
Educating medical undergraduates in the principles of anatomy has many facets: it introduces students to the reality of death; develops their manual dexterity; emphasises the concept of biological variation and demonstrates common pathologic changes; teaches the basic language of medicine; assists with social bonding and communication; and instructs how to assess information.
Is cadaver-based anatomical instruction in the dissecting room still relevant and essential in educating our students?
THE NODAL POINT
The reformers in the 1980s criticised the two “legislative chambers” of the traditional model of medical education.
They argued that basic science did not connect the student with the ultimate objective, a living patient. The thrust of the
1980s reform has been to direct the student to the living patient without any reference to mortality. The student must come
to grips with human mortality and morbidity. Of course the patient comes first and many argue that the cadaver is the first
patient.6-9 The student-cadaver encounter in medical education
is the “nodal point” - the moment in time between stopping and starting; from absolute convergence to comparative
divergence.10
The first “patient” is a dead one.11 Dissecting a cadaver the student encounters the reality of life, morbidity and mortality, the awesome responsibility of the physician caring for the patient. It is best to begin with the cadaver, the stillness reduces complexity and gives a better understanding of gross anatomy integrated to structure and function which can then be extrapolated to the living. Dissection puts undergraduates at the sharp end of medical education.12 They may experience anxiety and stress not as a detachment or indifference but as a defence mechanism, often coming for the first time, connecting with reality and a detached concern. Common-sense and trust appear to suffice in most cases.13 The “nodal point” in medical education can lead to the compassionate detachment that is essential if a physician is to cope with issues involved in death and bereavement.14
Figure 2: An undergraduate dissecting the hand
A programme which endeavours to connect the student with reality teaches students to observe, conceptualise and test hypotheses.15 The removal or attenuation of cadaver dissection is bound to impair the student’s ability to apply the scientific method during diagnosis.16 Justification of anatomical programmes without dissection is incompatible with the essence of the 1980s reform, which is geared to better application of scientific method in medicine.17,18
Learning anatomy by actual dissection is important for the continuation of the hard-won privilege of receiving bodies by donation. The legally sanctioned donation of human cadavers for medical training evolved over a long and difficult period. Bodies donated by patients themselves for students to learn anatomy by dissection is the ultimate gift, which needs continued appreciation by educators.
THREE DIMENSION AND MANUAL DEXTERITY
The sensation of touch between physician and patient is
essential. This is best learned early in the dissecting room.19
Hands-on teaching on real cadavers is the first experience of the
structural organisation of the body, both at the surface and in
depth, and leads to a real understanding of the three-dimensional
configuration of patients’ anatomy. Three-dimensional
highresolution virtual modalities are an inadequate substitute for
the cadaver itself or its parts. The VHD maybe a valuable
enhancement but Garg et al. (1999) have recently warned
against the simplistic view that virtual modality is superior to
the traditional one of anatomy instruction.20
Today’s undergraduates have not dissected in biological classes at school or even seen their teachers dissect. Experiments in physiology, biochemistry, and pharmacology, using one’s hands, have disappeared from the medical curriculum. The students no longer take blood, the phlebotomist does that. Human dissection is the one remaining educational modality that teaches students how to use their hands. This will help them to develop touch-based skills which can be transformed to palpation, percussion and auscultation.19 Better to learn on a cadaver how to use instruments than to experiment on patients. The manual skills learnt in the dissecting room are essential in almost every branch of the medical profession.
ANATOMICAL VARIABILITY
One of the most important concepts in medicine is biological variation.21,22 No two individuals are necessarily the same
anatomically. As students wander from one cadaver to the next in the dissecting room, they will see anatomical variation
associated with developmental anomalies. It may reveal something new, previously unknown, and especially important
in the rapidly evolving field of molecular developmental anatomy. Students will appreciate the actual complexity
revealed by dissecting the whole body - the concept of individuality. Human anatomical variation is common and
often of clinical importance, especially in invasive surgical procedures such as hysterectomy and
colectomy. The undergraduate will also learn for the first time the various surgical procedures seen in different cadavers, for example
inserted pace makers, artificial joints and bypass vessels.22
Current trends in undergraduate courses involve reduced exposure to dissection and dissected specimens, increased use of plastic bones, models and computer-generated simplified images, which view the body as a fixed identical type or norm.23 A carefully selected computerised “Denver Man” along data super highways spans the nation, even the world.24 Students must be prepared for unpredictable variations. These are best learned in the dissecting room laboratory, not with simplified computers or even prosections, although they can be used to enhance the variations seen in the dissecting laboratory. One of the consequences of poor over simplified undergraduate training is inadequate post-graduate knowledge, which will lead to misdiagnosis and even malpractice.23,25-28
COMMUNICATION AND BONDING
For an accurate and precise diagnosis it is essential to have an anatomical vocabulary which clearly describes the anatomical
science of the lesion or problem. The early 1980s reform was especially critical of the traditional curriculum’s emphasis
on unintelligent commitment to memory of detailed facts unconnected with essential concepts and principles.18 Although
computers can be used to decrease rote learning of facts and assist with problem solving, the more a physician remembers
anatomical facts the better his clinical skills will be. His or her is able to think on their feet. This is especially necessary
in emergency medicine. Attempting to memorise anatomical vocabulary watching a computer screen will leave the student
“never sure of myself.”29,30 Actual cadaver dissection is
essential for the acquisition of anatomical language.31-33 The
principal drawback of the 1980s critique was the failure to extrapolate memorised facts into ideas and theories.
Small group teaching around a cadaver in the dissecting room initiates the undergraduate to bonding with colleagues. He or she must learn to be a variable member of a team caring for sick people. Bonds developed early run deep and are never forgotten. As we viva voce young students on their dissections they learn to martial facts and express themselves; invaluable practice in learning to put up a reasoned response and a good defence. For all too soon they will be quizzed thoroughly and even critically by their patients and relatives.21
Figure 3: The author teaching the demonstrators
TOOLS OF THE TRADE
Powerful new instruments are now available to the diagnostician and surgeon, which the anatomist can use to
observe the internal anatomy with astonishing precision. Computerised tomography (CT), magnetic resonance imaging
(MRI) and ultrasound have all enhanced the importance of cross-sectional anatomy. To some, these imaging modalities
have transcended the cadaver as a learning tool.34 Dissection is
destructive rather than a constructive process. Some authors have suggested that it will be replaced by the cyber cadaver.35
However, there is a growing view that with the new imaging technology and endoscopic procedures, the diagnostician as
well as the surgeon must appreciate accurate cross-section anatomy and topographichal anatomical relationships, which
only dissection can provide.36 Dissection of the cadaver will
help master the vocabulary and topography at the beginning of studies. The VHD is an excellent device to refresh memory
and interpret diagnostic testing. At Mount Sinai School of Medicine, New York the Anatomy Course combines classic
dissection with tools that the physicians and surgeons will use tomorrow. Students are introduced to the newest technologies
available for viewing the body with hands on experience in the laboratory. This requires an interdisciplinary approach with
surgeons, physicians and core anatomy faculty.37
COMPUTER-ASSISTED LEARNING
In the 1980s, there was an explosive growth in research and data of cellular and molecular processes of both the normal
and diseased human body. This led to a great discrepancy between the mass of data and the time set aside for education.
The preoccupation with data at the expense of analysis and synthesis eroded education. The principal goal of the 1980s
reform was instantaneous access, storage, and retrieval of information and hypertext on computers. This relieved the
student and teaching faculty from excessive memorisation. Computer-based learning was said to benefit problem
solving workshops and facilitated the integration of basic and clinical science. The merit of the computer is not disputed or
contested. The debate is to identify its proper use in educating the medical student. Computers do not replace brainpower in
handling information and making decisions.
Excessive exuberance over cybernetic technology has devalued the deceased human in medical education. Machines tell us nothing about life or death. The computer may be a supplement but does not replace the human brain. High technology tends to dehumanise patient care, a growing rejection both of patients and physicians.
We have yet to be convinced of the effectiveness of “Computer Atlases” marketed as innovative anatomy teaching. The dissected cadaver remains the most powerful means of presenting and learning anatomy as a dynamic basis for solving problems. Anatomy involves the integration of form and formation. If students only use models, images, audiovisuals or computers they will not develop the requisite reasoning that comes from investigative dissection of real tissue in acquiring knowledge of the living.38 Medicine is a direct dialogue between the patient and physician. Sophisticated technology can test and establish the diagnosis at the interface but must not abuse the relationship between patient and healer.
FINANCE
The dissecting room is an extremely expensive item in any Department of Anatomy in a Medical school. It has a
very extensive floor space, which now has to compete with molecular biologists with enormous research grants clambering
for more research laboratories. Many Universities have not been able to afford or are not prepared to cover the cost of
upgrading ventilation in the dissecting room to bring it up to European Community Standards.39 Cadavers are expensive,
involving initial transportation and preparation, large space for storage and finally disposal, burial or cremation.21 To obey
every aspect of the Anatomy Act and respect those who have generously donated their bodies is much more expensive than
a few computers. The financial resources of institutions are primarily directed to secure patient income and funding for
research.29 Educating both under- and postgraduate students
is inevitably at the end of the queue in terms of economic stringency. The designers of a new curriculum, hiding behind
“keeping pace with the times,” say “close the dissecting room,” reduce staff and their salaries while the student
numbers increase. But the staffing needs of a department in terms of numbers, preparation and finances are greater both
for prosection-based and small group computer
imagingbased courses than the traditional dissecting-based course. Dissecting room teachers are unpopular with administrators,
who rarely, if ever, come into the dissecting room to see and talk with students and teachers.21
POSTGRADUATE SURGICAL TRAINING
In recent years there has been a major change in postgraduate surgical training, partly correlated with changes in
undergraduate teaching in the Medical schools. The Surgical Fellowship until recently, was a broad-based examination
taken early in training. The initial Primary examination had a high standard in basic sciences, a very testing component
with essay questions and vigorous vivas. A fundamental requirement was an intimate knowledge of anatomy. Once
a Fellow of a Royal College, the young surgeon had a long period of apprenticeship with no further examinations. The
time-expired Senior Registrar was a highly experienced and skilled practical surgeon but often not so well read and up to
date with current literature.
Then came a change. We now have a Membership as an entry examination. No essays, merely MCQs, with tick boxes that the computer will mark. An expedient evaluation which promotes superficial learning.22 The viva is often cursory. At Edinburgh, no prosections or models for surface anatomy, merely a box of bones and a few plastic models of a heart and lung. You can fail anatomy even if you pass other segments of the Membership with a sufficiently high mark. This means that some candidates have a knowledge of anatomy that is hardly up to the old second MB. When challenged, some senior surgeons defend this position by claiming that a high standard of anatomy will be required at the Specialist Fellowship exit examination. The evidence for this is poor. Is it not regrettable that we have in perpetuity set up a system that is allowing young men and women with a poor knowledge of anatomy to become surgeons? When the new Membership and Fellowship examinations were introduced some “wise men” were emphatic that there would be no change, high standards would continue. Many surgeons now disagree and they claim there has been a substantial lowering of standards.
Between 1995 and 2000 there was a sevenfold increase in claims associated with anatomical errors submitted to the Medical Defence Union. It is distressing that it may require several cases of major litigation before some educationalists, administrators and surgeons wake up and acknowledge the lack of anatomy in the new generation of surgeons operating on patients.28 Cahill et al. (2000) have expressed concern that of 80,000 avoidable deaths per year in the United States, at least some can be attributed to anatomical incompetence.29 Oliver Beahrs, an internationally acclaimed surgeon from the Mayo Clinic, and the first President of the American Association of Clinical Anatomists puts this more bluntly - “... today’s residents in surgery are learning their anatomy on sick patients for the first time in the middle of the night; operating without a firm knowledge of anatomy leads to increased mortality and morbidity.”4
A solid grounding in basic science used to provide an invaluable foundation for a successful surgical career. Until relatively recently in the UK and Ireland, most surgeons made every effort to gain a demonstrator post to revise their knowledge of topographical anatomy and at the same time study the other basic science disciplines for the Primary Fellowship, the first hurdle to be jumped in the race to a glorious career in surgery.39 Changes in basic surgical training are related to the restructuring by the Royal Colleges - the initial Membership and exit Fellowship examinations. The Calman report has had a profound effect on the recruitment of surgical trainees to anatomy demonstrator posts.40 This has set up a chain reaction so that anatomy departments can no longer rely on surgical trainees to teach, which has adversely affected the ability of universities to deliver undergraduate teaching of anatomy. In the past the hallmark of gross anatomy courses was small group instruction. This is now at risk.
Figure 4: The dissecting room at the GKT School, Guy’s Campus
Postgraduate surgical training must also be seen in the light of changes implemented in medical schools. Discipline based departments have been reorganised into larger units of biomedical science with divisions. This has resulted in a reduction of time allocated to anatomy, particularly dissection by students. The development of integrated courses with multidisciplinary examinations in which poor performance in anatomy is compensated by good marks in other subjects. There is a decline in faculty staff with expertise in human anatomy and corresponding enthusiasm for teaching it, and fewer demonstrators. These factors leave today’s medical graduates who are embarking on surgical training programmes with a poor knowledge of anatomy.
Basic Surgical Training (BST) has been reduced to a minimum of two years. Surgical trainees are now expected to be taught anatomy at the operating table through the “window” of the operation. As described by Beahrs (1991) this window of anatomical learning is to be deplored.36,41 Their higher surgical training will be based on shifting sand rather than solid rock.4 There have been profound changes in surgical practice recently, with increasing specialisation. This questions traditional surgical training. The surgical trainee must be taught the basic science relevant to his chosen surgery. Surgeons have less knowledge of anatomy of the whole body and retain only knowledge of the specialist region in which they operate and work.41 Specialist surgeons will have to shoulder the burden of teaching specialist anatomy to their trainees.42
WHAT DO TRAINEES AND TRAINERS THINK?
A telephone survey within the Anglican Deanery over a
two-week period in March 1998 showed that half of the
surgical fellowship trainees but only 11% of the surgical
membership trainees had demonstrated anatomy. Eighty one
per cent of the fellowship but only 19% of the membership
trainees thought their current level of anatomical knowledge
was adequate for their current posts. Eighty six per cent of
the surgical fellowship and 68% of the surgical membership
trainees considered anatomy demonstrating should be included
as part of the BST rotation. “All surgical trainees should
demonstrate”, claimed 87% of demonstrators compared with
only 42% of the non demonstrators. Amongst the MRCS
trainees, 85% were taking the STEP course but only a third
of them felt anatomy was well covered by the course. Of
all trainees, 99% would value practical cadaveric teaching,
although this was locally available to only 21%. These results
show that fewer MRCS trainees are now demonstrating. The
majority are not confident their anatomical knowledge is
sufficient for day to day use on wards, theatres and clinics.43
To assess this problem further, in 2002 there was a survey of
past demonstrators and present undergraduates in the anatomy
department at the Guy’s Campus.44 There were 95 responses
(78%) to a questionnaire sent to 122 surgical trainees who had
completed demonstrator posts in the Anatomy Department at
the Guy’s Campus since August 1996. Eighty nine per cent
stated that all surgeons should demonstrate and all thought it
helped in their surgical examinations. Ninety eight per cent
considered the post had improved their communication and
teaching skills and a third obtained a publication from their
post. Demonstrating assisted 96% in their applications for
future jobs; 98% thought it relevant for their future career. In
an assessment of undergraduate medical students, there was a
94% response (340 of 361 students) to a short questionnaire.
The majority of students enjoyed being taught by trainees and
found the clinical relevance invaluable. Ninety eight per cent
of the students would prefer to continue formal dissection
instead of the new computer-assisted learning course. All
students who answered the questionnaire had computer
assisted learning in their anatomy course, so this was an
informed opinion.44 As well as the accumulation of knowledge
on anatomy and the basic sciences, the experience in teaching,
presentation and research are important additional attractions of
a demonstrator post. A break from arduous NHS duties is also
beneficial, allowing time for private study and reflection. The
cost to the universities of demonstrators is minimal. Twenty
seven per cent hold honorary posts and pay their own way. The
rest are either funded by RMO posts or a rotation. However,
the role of demonstrating posts is now being questioned. Many
dissecting rooms are closing and demonstrators may disappear
in many institutions. Applicants for demonstrator posts are
declining.45
In a postal survey of 91 consultant surgeons selected at random from the Medical Register, three quarters felt that demonstrating was relevant to training in their speciality, whilst 82% felt it relevant to a surgical career in general. Seventy one per cent claimed they would look favourably on an applicant for a BST rotation who had demonstrated. No consultant would regard a demonstrator applying for a BST rotation unfavourably. This survey showed that although there have been profound changes in basic and higher surgical training, with a changing emphasis in the new MRCS examination, consultant surgeons still regard a sound knowledge of anatomy, physiology and pathology as important.46
WHAT DO STUDENTS AND THEIR TEACHERS
THINK ABOUT ANATOMY AND HOW IT IS
TAUGHT?
Several surveys were undertaken in the 1990s to gauge the significance of gross anatomy and especially dissection in
medical training. In Germany, Pabst and Roth kotter (1997), in a retrospective evaluation of undergraduate medical education
by doctors at the end of their residency time in hospitals, found 90% of the doctors considered gross anatomy essential and 6%
necessary.47 This review also showed, as have many others, that
not only surgeons and consultants in diagnostic specialities but also physicians in general medicine and paediatricians graded
anatomy high in clinical relevance. Another common feature of many reviews is that three-quarters of undergraduates asked
for specialised dissection courses during their later clinical phase.
A survey by Cottam (1999) in the United States showed that a majority of the residency programmes reported that gross anatomy was either extremely or very important for residents to master and ranked it as the most important basic science.48 In Singapore, 75% of medical students in all five years of their course found gross anatomy clinically relevant and 89% considered dissection helpful or very helpful in their understanding of gross anatomy. When asked whether dissection should be replaced by demonstrations in prosected specimens, 87% gave a resounding “no.”49 Graduates at McMaster, Ontario, Canada considered insufficient attention was paid to basic science in general and anatomy in particular in the McMaster curriculum.50 Many workers have registered concern that the amount of detail in gross regional anatomy has decreased below safety levels.51,52
A recent study, comparing personal dissection versus peer teaching of upper and lower extremities in Virginia USA, has shown that although peer teaching was generally successful, first year medical students preferred to dissect for themselves. The results are consistent with the contention that hands-on dissection enhance learning and confidence in the subject matter.53 Many investigators have compared the performance of students who dissected, with students who studied prosected specimens. Some have found no significant difference.54,55 Other studies indicated that although learning from prosections was not a serious disadvantage, there was a small but significant difference in favour of personal dissection.56-58
Figure 5: Joseph Townes - 1806-1879. Carved wax anatomical models. Based on dissection by Mr John Hilton FRS. Gordon Museum, Guy’s Campus.
Guy’s, King’s and St. Thomas’(GKT) School of Biomedical Science is one of a decreasing number of medical schools where students are encouraged to learn by practical dissection with a modern systems-based medical curriculum. Snelling et al. (2003) have recently reviewed the attitudes towards dissection of 474 first year medical and dental students.59 Data were collected before dissection commenced and at one and twelve weeks after exposure to dissecting. Overall, as a helpful means of teaching, all students scored tutorials highest followed in rank order by textbooks, prosection, dissection, watching student colleagues do it and finally the CD-ROM. The difference between dissection and prosection was not statistically significant. In this study, students benefited from active practical dissection before a prosection-based tutorial on the subject. Active dissection remains popular with the students.59
There is a trend in anatomy teaching to include more integrated problem-based learning (PBL) and computer assisted teaching, while reducing overall content, didactic lectures and mechanical rote memorisation. Problem-based learning is supposed to enhance the integration of student’s knowledge.60 It allows for the horizontal and vertical integration of different disciplines. Using clinical cases, students learn to connect clinical features with underlying basic science concepts. Cognitive psychology has shown that integration of knowledge facilitates storage and later retrieval of relevant information. It should prepare students better for actual clinical practice.61
Studies at the University of Maastricht, Netherlands, reported PBL students felt deficient in basic science knowledge, particularly gross anatomy, when entering clinical clerkships. They expressed a need for more anatomy training, both before and during clerkships.62-64
Generally, the integrated PBL approach is associated with uncertainty and perceived deficiencies in basic science knowledge. Problem-based learning is used to describe many heterogeneous educational activities, so it is hard to prove or disprove the claims made by its advocates.65, 66
In the latest investigation, the Maastricht group studied groups of year four students at eight Medical schools in the Netherlands to see whether PBL and non-PBL students differed in perceived and real knowledge of anatomy at the start of clinical clerkships.67 The results showed no significant difference in the levels of anatomy knowledge between PBL and non-PBL schools. But interestingly, two schools, which scored significantly higher than the other schools, taught anatomy in a clinically meaningful content in terms of patient problems, diagnostic and therapeutic features. This suggests that the more traditional training programmes can teach successfully in a clinically relevant way. There is evidence that repetition of topics has a beneficial effect, confirming a fundamental thesis of learning. Also, there is a discrepancy between what students think they know and what they think they need to know.67 When differences in basic science knowledge are found, these are usually in favour of the non-PBL students.68-71 Generally, the integrated PBL approach seems to be associated with uncertainty and perceived deficiencies in terms of basic science knowledge.67 It is ironic that those who champion radical changes in the new alternative curriculum find regional dissection incompatible with PBL.
The GMCs “Tomorrow’s Doctors” attempted to address the overcrowding of the undergraduate medical curriculum by recommending a reduction of factual content across the curriculum.72 It did not define a national core curriculum. By allowing each institution to define its own core systems and optional study modules, it encouraged the establishment of variety in the curricula. In the absence of comparative research and an agreed national curriculum, newer curricula have been coming on stream at the various medical schools in the UK over the past six or seven years.
An important article has recently appeared concerning anatomical teaching in the UK and Ireland.73 Heylings (2002) has reviewed the impact of the GMCs “Tomorrow’s Doctors 1993” to establish whether a consensus has emerged on the format and duration of teaching and impact on staffing. He has analysed a postal survey of 20 medical schools with data relevant to the academic year 1999-2000. The overall response was 75%. This represents 21 courses, 19 in the UK and two in Ireland. Five units had a “traditional” base to their curriculum, not yet specifically adapted to post “Tomorrow’s Doctors”. Four departments used a PBL curriculum, whilst the remaining twelve units (57%) had a systems-based curriculum. Overall, dissection by students had been retained as the main teaching tool in sixteen (76%) courses with twelve of them using a combination of dissecting and demonstrations and four using dissection only. (Demonstrations involved the use of prosected human material.) The five traditional curricula all used dissection supplemented with demonstrations. Nine (75%) of the systems-based curricula used dissection with six of those also using demonstrations. The remaining three systems-based curricula relied on specimen demonstrations only. Perhaps surprisingly, dissection did play some part in the four PBL curricula. There was a great variability in the allocation of teaching time for all four anatomical disciplines of gross anatomy, histology, embryology and neuroanatomy. They have been substantially reduced to comply with the GMC recommendations. The overriding aim appears to be a decrease in the content. In some courses embryology and histology have disappeared. Some, however, consider an understanding of anatomy requires knowledge of embryology and comparative anatomy.74 In all institutions, the teaching allocation was considerably less than previously published.75 In this survey, only departments with a traditional curriculum approached the recommended teaching times of Fitzgerald. Staff numbers across teaching units showed great variation. There were a high proportion of part-time clinically qualified teachers. Units with a high proportion of clinical teachers were using traditional or problem-based curricula, while systems-based curricula had almost equal numbers of clinical and non clinical staff available. A larger proportion of clinically qualified staff was part-time. Staff / student ratios varied with the type of curriculum; dissecting room teaching and PBL curricula were associated with higher numbers of either full or part-time clinically qualified teachers. In a dissection class there was an overall average staff / student ration of 20:1.
Heylings (2002) appreciates that, as with all surveys, this study can only provide a snapshot.73 Nevertheless, it is a very thorough documentation of the main differences in curricula and staffing levels in medical schools in the UK and Ireland for the academic year 1999-2000. The great variation in the duration of the anatomy curricula is the principal issue revealed by this survey. There is a lack of consensus concerning the content and level of knowledge in anatomy required for a junior doctor in the UK It may also provide a sound basis for including anatomy in postgraduate study.
THE TEACHERS
An important feature of the Heylings review was the wide variation to which anatomy staff were in control of how their
subject could be delivered.73 Some have total control over
content, approach, allocation of times, breakdown of lectures versus practical class time; at the other extreme all these
variables were apparently determined outside the control of the anatomy teaching staff.73
Medical undergraduates are now a tiny and temporary cog in an enormous university machine, the survival of which depends on research and research income. Research holds primacy and for many academics teaching has a low priority. Dedicated teachers amazingly are still to be found, but often derided in common rooms - “well they are not much good on the research front you know, but at least they take a teaching load off those of us who really cut the mustard”. Even writing a student textbook is frowned upon as a waste of research time.76
However, there are researchers who do want to teach but the exigencies of the Research Assessment Exercise in Universities render this less important. In the current UK tertiary education climate there is a strong emphasis on achieving research targets. This has resulted in substantial reductions in funding to some medical schools. There is a perception that teaching, both basic science and clinical, is less valued as an academic activity than research and is adversely affected by the research assessment exercise.77 Also; there is now a distinctly unattractive salary structure for anyone with clinical qualifications. Institutions are unlikely to employ gross anatomists for core teaching. So who should teach? Throughout the world it is now extremely rare for medically qualified personnel to teach topographical anatomy. “Rich in mitochondria but starved of meat” as expressed by Monkhouse (1992).78 Most non-medical anatomists simply cannot bring a clinical perspective to their anatomical teaching. So we must maintain or reintroduce medically qualified anatomists. This will require a process of peaceful cohabitation. Some departments now find retired or semi-retired clinicians/surgeons valuable members of their teaching team.79 Almost all Anatomy Departments in Universities have disappeared. Will clinical anatomy teaching be shared with radiology, medicine, surgery and pathology?78
CONCLUSIONS
A review of anatomy teaching in the UK and Ireland has revealed some interesting and outstanding issues.73 Key
factors in teaching anatomy were not properly researched
prior to changing the curriculum. There was no agreement
on a common national core curriculum. Despite criticisms,
until 2002, there has been no published data on the impact
of the GMC “Tomorrows doctors” on anatomical teaching in
the UK and Ireland. In the absence of comparative research
and an agreed national core curriculum, newer curricula have
been coming on stream over the past six or seven years.
Currently, there is a great divergence between the different
medical schools in teaching anatomy. There is no national
medical licensing examination, so medical schools are free to
teach anatomy and to assess the content and quality as they
see fit and independent of external validation. As a result,
anatomy teaching, as most of us know it, is dead!
If it is our aim to train active, caring, compassionate medical doctors and dentists who are committed to patient care by heightened communication, then abandoning well designed cadaver dissection-based instruction is contrary to achieving these goals.18,52 The cadaver must not be dismissed as obsolete, for the patient is paramount. Jones et al. (1978) have challenged anatomists to gather hard evidence to support assertions of the importance of dissection; not withstanding it has survived the most rigorous test of pedagological fitness - the test of time.17 Various individuals and groups advise judicious use of dissection, lectures, small group discussion, case studies and living anatomy to link up with faculty teachers, students, the computer, diagnostic imaging involving human to human and human to machine interactions.47,80-82 Bring the computer close to the dissected cadaver, allow students to engage in amplified learning experiences.80 Computers should be used to enhance anatomical education and to assist the dissecting room, not replace it. In the present climate of curricula reform, the problem-based and system orientated studies, together with gross anatomy, must show flexibility and innovation.
Some predict there will be a rapid spread of PBL through our medical schools. Smithers (2002), however, has been very critical of this approach.83 As an experienced educationalist, he emphasised that PBL is a discredited progressive educational philosophy from which our children’s schools are only just being rescued by literacy and numeracy strategies. Acquiring essential knowledge and skills depends on sympathetic teaching together with perseverance and practice by the student. This is now accepted throughout the education world. Smithers (2002) is puzzled that medicine “ which has at its heart a thorough and detailed understanding of the human body”, should have taken up what has failed so spectacularly elsewhere.83 A bedrock of knowledge is essential to make sense of new information. There is no substitute for the sheer slog of achieving mastery of a subject. Communication skills are as important as anatomy, claim the GMC Education Committee. But what good is a smiling articulate doctor who does not know his stuff? According to Smithers (2002), medicine appears blissfully unaware of the disaster it is perpetrating.83
There is now a great divergence in the teaching of medicine, and especially gross anatomy, in the UK and Ireland. Some medical students never dissect. The new four year fast track schools have no anatomy. The Peninsula medical school, which opened its doors in September 2002, has computers and models - not a cadaver or prosection is seen in their five-year course. Instead they will meet and help treat real patients from their first week.84 The expectation of this new medical school is that the integration of the Life Science Research Centre with the Clinical Skills programme will be of value to their students. In particular, “traditional anatomy teaching has negative predictive validity.”85
Newcastle medical school recently announced - “surely it is time to break undergraduate anatomy from the traditional shadow of the surgeon and concentrate on providing a curriculum that has relevance and applicability.”86
Non-dissection courses are “fads of fancy” in medical education.22 What is the evidence to support the new methods? We must not use our students nor patients as experimental subjects.29 It is sad that the undoubted enthusiasm for anatomy in some teachers should have produced such abreaction in others. There are very different ideas and no agreement as to what constitutes core anatomy in the undergraduate curriculum. Reduce the amount at the start of the course, emphasise surface and radiological anatomy and teach sufficient general anatomy for systems based courses. Teach more anatomy later and through the course.74 But it is rare to have sufficient time later. The perception of the depth of knowledge required by both student and examiner varies widely. Anatomical knowledge is less important for tomorrow’s doctors according to the GMC.72 But this reduction in undergraduate knowledge is causing great concern both at undergraduate level and for postgraduate students, especially in surgery. Alarm bells are ringing, and there is growing unease amongst both anatomists and clinicians. However, there has been little public debate. A full debate is urgently needed to highlight areas of concern which should be explored in depth to define the minimum core curriculum for anatomy. Closer links must be established between basic scientists and clinicians to enhance teaching and research. Anatomy is a living subject, not a collection of facts learnt early and then forgotten. Retaining anatomical details requires constant practical application, to be taught by scientists and clinicians with a clinical perspective.74
In this journal, Kaufman (1997) the anatomist and Green (1998) the surgeon registered their concerns.4,39 They advised the surgical community to address the problem seriously and not just pay lip service. Despite lobbying the Colleges and government, through articles principally in anatomical and not surgical journals, there has been little headway.41 This issue must be addressed before the cost of litigation brings sense and action.4,39
It is fundamental for a surgeon to acquire a detailed knowledge of anatomy. This can only be obtained by diligent study, preferably as a demonstrator. It usually involves six months performing prosections and teaching undergraduates, together with master class type of anatomical tutorials. The new MRCS UK should contain a rigorous examination in anatomy using dissections, imaging and surface anatomy. This should be a mandatory preliminary to entry into higher surgical training. Anatomy should not be left to the exit Fellowship. This will give us better trained young surgeons.21
So what can we learn from both the failure and success of teaching the next generation the principles of anatomy so they can correctly diagnose and successfully treat the problems of their patients? Does the dissecting room still have a place in educating our under- and postgraduate students? The study of anatomy should take place early in the course and be clinically orientated. Dissecting is the most important procedure at the threshold of medical undergraduate education and training. To have access to his or her own cadaver is a unique opportunity and privilege. It is an early encounter with mortality; often it is the first time that the students confront death. In the process their manual dexterity and bonding by team work will develop and improve; a direct encounter with active and not passive learning. The students will have verification of facts from the primary source, will enjoy the art of discovery and check the interpretation of others. They will gain a three-dimensional understanding of the body, its variation and pathology. They will also begin to acquire communication skills. This will give them confidence and enrich their clinical competence.
A PERSONAL NOTE
At the combined undergraduate school of anatomy at Guy’s and St. Thomas’ Hospitals pupils were dissecting as part of
their course in 1770.87 The College of Surgeons in Dublin
had a dissecting room for its pupils in 1796.88 In Edinburgh,
dissection by students became compulsory in 1826.89
Nearly 50 years ago the author entered Guy’s to be educated in anatomy, initially as a dental student and later as an undergraduate in medicine. He spent 18 months as a demonstrator, in those days a fully employed and paid junior lecturer, teaching anatomy at Guy’s. For the past 10 years he has been an examiner at the Royal College of Surgeons of Edinburgh for the FRCSEd. Currently, after 28 years in clinical practice and now, a semi-retired consultant orthopaedic surgeon, he has returned to the Guy’s campus as a clinical anatomist involved in educating both under- and postgraduates in anatomy and principles of surgery. This surgeon-anatomist would consider it a needless tragedy if, despite the arguments marshalled above, the flame of learning anatomy by dissection which has burnt bright over the past two and a half millennia since Herophilus of Chalcedon, and has lit the pathways of John Hunter, Astley Cooper, Arbuthnot Lane and many others, was to be extinguished by the new educators in their quest to be modern. It would send anatomy into a dark abyss and result in a lower standard of care for our patients and their problems.
REFERENCES
1. Bliss M. Osler W. A life in Medicine Oxford University Press 1999. New
York.
2. Spaulding WB. The Undergraduate medical curriculum McMaster University Can Med Assoc J 1969;
100: 659-664.
3. General Medical Council Recommendations on basic medical education 1987; 1988: London.
4. Green NA. Anatomy training for surgeons: Letter J R Coll Surg Edinb 1998;
43(1): 69-70.
5. Monkhouse WS, Farrell TB. Tomorrow’s Doctors: Today’s mistakes? Clin
Anat 1999; 12: 131-134.
6. Peabody FW. The case of the patient. JAMA 1927; 88; 877-882.
7. Engel GL. Case and funding of the medical student: The foundation of professional competence.JAMA 1971;
215: 1135-1141.
8. Kasper A. The doctor and death. The meaning of death. Ed. Feifel H.: New York McGraw-Hill 1969; 259-270.
9. Coulehan JL, Williams PC, Landis D, Naser C.The first patient: Reflections and stories about the anatomy cadaver.
Teach Learn Med 1995; 7: 61-66.
10. Pelligrino ED. Educating the humanist physician: An ancient ideal reconsidered
JAMA 1974; 277: 1288-1294.
11. Bertman SL, Marks SC Jnr. Humanities in medical education Rationale and resources for the dissection laboratory.
Med Educ 1985; 19: 374-381.
12. Maguire P.Barriers to psychological care of the dying. Br Med J 1985;
291: 1711-1713.
13. Dinsmore CE, Daugherty S, Zeity J. Student responses to the gross anatomy laboratory in medical curriculum.
Clin Anat 2001; 14: 231-236.
14. Evans EJ, Fitzgibbon GH. The dissecting room: Reaction of first year medical students.
Clin Anat 1992; 5: 311-320.
15. Pabst R, Westerman J, Lipper H. Integration of clinical problems in teaching gross anatomy.
Anat Rec 1986; 215: 92-94.
16. Aziz MA, McKenzie JC. The dead can still teach the living: The status of cadaver-based anatomy in the age of electronic media.
Perspect Biol Med 1999; 42: 402-421.
17. Jones NA, Olafson RP, Sutin J. Evaluation of gross anatomy programme without dissection.
J Med Educ 1978; 53: 198-205.
18. Muller S. Physicians for the 21st century: Report of the project panel general professional education of physicians and college preparation for
medicine. J Med Educ 1984; 59: 1-200.
19. Moore NA. To dissect or not to dissect? Anat Rec (New Anat) 1998; 253:
8-9.
20. Garg A, Norman GR, Spero L, Maheshwari P. Do virtual computer models hinder anatomy learning?
Acad Med 1999; 74: 587-589.
21. Ellis H. Teaching in the dissecting room. Clin Anat 2001; 14: 149-151.
22. Cahill DR, Leonard RJ, Weiglein AH, von L¸dinghausen. Viewpoint: unrecognised values of dissection considered.
Surg Radiol Anat 2002; 24: 137-139.
23. Willan PLT, Humpherson JR.Concepts of variation and normality in morphology. Important issues at risk in modern undergraduate medical
courses. Clin Anat 1999;12: 186-190.
24. Stepney R. Anatomy without scalpels. The Independent 1993; 19th September: 57
25. Wise GE.The new anatomy: A forecast of hope. Clin Anat 2000; 13: 148-149.
26. von L¸dinghausen M.The goal of dissection in clinically orientated teaching
Clin Anat 1992; 5: 488-489.
27. Zucconi WB, Guelfguat M, Solounias N. Approach to the educational opportunities provided by variant anatomy, illustrated by discussion of a
duplicated inferior vena cava. Clin Anat 2002; 15(2): 165-168.
28. Ellis H. Medico-legal litigation and its links with surgical anatomy. Surgery
2002:
29. Cahill DR, Leonard RJ, Marks SC Jnr. Standards in heathcare and medical education.
Clin Anat 2000; 13: 150.
30. Mutyala S, Cahill DR. Catching up. Clin Anat 1996; 9: 53-56.
31. Keller H. The story of my life 1990; New York: Bantram Books.
32. Vermeij G. Privileged Lands. A scientific life 1997; New York: W. H. Freeman and Co.
33. Graney DO. Letter to Editor. Clin Anat 1996; 9:61.
34. Spitzer VM, Whitlock DG. The visible human dataset: The anatomical platform for human simulation.
Anat Rec (New Anat) 1998a; 253: 49-57.
35. Rosse C. Terminologia anatomica considered from the perspective of next generation knowledge sources.
Clin Anat 2001; 14: 120-133.
36. Beahers OH. Gross anatomy in medicine. Clin Anat 1991; 4: 310-312.
37. Reidenberg JS, Laitman JT. The new face of gross anatomy Anatomical Record
2002; 269(2): 81-8.
38. Miller SA, Perrotti W, Silverthorn DU, Dalley A F, Rarey KE. From college to clinic: reasoning over memorization is key for understanding
anatomy. Anatomical Record 2002; 269(2): 69-80.
39. Kaufman MH. Anatomy training for surgeons - a personal viewpoint. J R
Coll Surg Edinb 1997; 42(A): 215-216.
40. Calman K. Hospital Doctors. The Report of the Working Group on Specialist Medical Training.
HMSO 1993
41. Raftery AT. Basic surgical training. Postgraduate surgical examinations in the UK and Ireland.
Clin Anat 1996; 9: 163-166.
42. MacIntyre ICM. Anatomy training for surgeons. J R Coll Surg Edinb 1998;
43: 71.
43. Power MP, Forshaw KJ, Dinkare EB. Anatomy, Demonstrating and Basic Surgical Training.
Ann R Coll Surg Eng (Suppl) 1999; 81: 133-134.
44. Gossage JA, Horner B, Halsey T, Ellis H. How will the loss of the Anatomy
Demonstrating Posts affect the medical student and surgical trainee. Clin
Anat; in press
45. Willan PLT, Humpherson JR. Profiles of applicants for junior faculty posts to teach anatomy.
Clin Anat 1999; 12(4): 272-276.
46. Jones OM, Parkin IG. Consultants opinions of anatomy demonstrating. Ann R Coll Surg Eng; (Suppl)1999;
81: 10-12.
47. Pabst R, Rothkotter HJ. Retrospective evaluation of undergraduate medical education by doctors at the end of their residency time in hospitals:
Consequences for the anatomical curriculum. Anatomical Record 1997; 249(4): 431-434.
48. Cottam WW. Adequacy of medical school gross anatomy education as perceived by certain postgraduate residency programs and anatomy course
directors. Clin Anat 1999; 12(1): 55-65.
49. Leong SK. Back to basics. Clin Anat 1999; 12(6): 422-426.
50. Woodward CA, Ferrier BM. The content of the medical curriculum at McMaster University: graduates’ evaluation of their preparation for
postgraduate training. Med Educ 1983; 17: 54-60.
51. Sinclair D. The two anatomies. Lancet 1975; 1: 875-878.
52. Aziz MA, McKenzie JC, Wilson JS, Cowie RJ, Ayeni SA, Dunn BK. The human cadaver in the age of biomedical informatics.
The Anatomical Record 2002; 269: 20- 32.
53. Johnson JH. Importance of dissection in learning anatomy: personal versus peer teaching.
Clin Anat 2002; 15: 38-44.
54. Alexander J. Dissection vs prosection in the teaching of anatomy. J Med
Educ 1970; 45: 600-606.
55. Nnodim JO, Ohanaka EC, Osuji CU. A follow-up comparative study of two modes of learning human anatomy by dissection and from
prosections. Clin Anat 1996; 9: 258-262.
56. Yeager VL. Learning gross anatomy: dissection and prosection. Clin Anat
1996; 9: 57-59.
57. Wilson JT, Tarby TJ, Seale RU, Whitlock DG. The two-course system in gross anatomy.
J Med Educ 1975; 50: 788-796.
58. Dinsmore CE, Daugherty S, Zeitz HJ.Teaching and learning gross anatomy: dissection, prosection or “both of the above?”
Clin Anat 1999;12(2): 110-114.
59. Snelling J, Sahai A, Ellis H. Attitudes of medical and dental students to dissection
Clin Anat 2003; 16: 165-172.
60. Barrows HS. A taxonomy of problem-based learning methods. Med Educ 1986;
20(6): 481-486.
61. Regehr G, Norman GR. Issues in cognitive psychology: implications for professional education.
Acad Med 1996; 71(9): 988-1001.
62. Prince KJAH, van der Wiel MWJ, Scherpbier AJJA, van der Vleuten CDM, Boshuizen
HPA. A qualitative analysis of the transition from theory to practice in undergraduate training in a PBL Medical school.
Adv Health Sci Educ 2000; 5: 105-116.
63. Drukker J, van Mamereh H, Croonen HGHM, Wanders AJB, Verwijnen GM, van der Vleuten
CPM. Physicians’ restrospective evaluation of anatomy teaching. Bull Med Onderwijs 1999;
18: 9-16.
64. van Mameren H, Leiner T, Wanders A, van der Vleuten CPM. Students evaluation of anatomy / embyology teaching at Maastricht University.
Bull Med Onderwijs 1997; 16(2): 91-100.
65. Maudsley G. Do we all mean the same thing by “problem-based learning?” A review of the concepts and a formulation of the ground rules.
Med Teacher 1998; 20: 323-330.
66. Bickley H. Comparison of problem-based and traditional curricula still not possible.
Acad Med 1993; 68(7): 545.
67. Prince KJAH, van Mameren H, Hylekema N, Drukker J, Scherpbier AJJA van der Vlenten
CPM. Does problem-based learning lead to deficiencies in basic science knowledge? An empirical case on anatomy.
Med Educ 2003; 37: 15-21.
68. Schmidt HG, Dauphinee WD, Patel VL. Comparing the effects of
problembases and conventional curricula in an international sample. J Med Educ
1987; 62: 305-315.
69. Albanese MA, Mitchell S. Problem based learning: a review of literature on its outcomes and implementation issues.
Acad Med 1993; 68(1): 52-81.
70. Vernon DT, Blane RL. Does problem-based learning work? A
metaanalysis of evaluative research. Acad Med 1993; 68(7): 550-563.
71. Verhoeven BH, Verwitjnen GM, Scherpbier AJJA et al. An analysis of progress test results of PBL and non PBL students.
Med Teacher 1998; 20(4): 310-316.
72. General Medical Council Education Committee Recommendations on Undergraduate Medical Education.
London General Medical Council; 1993.
73. Heylings DJA. Anatomy 1999-2000: the curriculum who teaches it and how. Med Ed 2002;
36: 702-710.
74. Standring S. Anatomy - do I need to know that? 2000 Diploma in teacher
education for medicine and dentistry.
75. Fitzgerald MJT. Undergraduate medical anatomy teaching. J Anat 1992; 180: 203 209.
76. Stott P. Academics prefer a glass of cheap wine to students. The Times
2003; 27th January :18.
77. Tomlinson S. The Research assessment exercise and medical research. BMJ 2000; 320: 637-639.
78. Monkhouse WS. Anatomy and the Medical school Curriculum. Lancet 1992;
340: 834-835.
79. Ellis H. The surgeon as a teacher of anatomy. Clin Anat 1994; 7: 156-161.
80. Marks SC Jnr. The role of three dimensional information in health care and medical education. The implications for anatomy and dissection.
Clin Anat 2000; 13: 448-452.
81. Levine MG, Stempak J, Conyers G, Walters JA. Implementing and integrating computer bases gross anatomy curriculum.
Clin Anat 1999; 12: 191-198.
82. Nieder GL, Scott JN, Anderson MD. Using quicktime virtual reality objects in computer assisted instruction of anatomy.
Clin Anat 2000; 13: 287-293.
83. Smithers A. Medical training heading for disaster. The Independent Education Supplement 2002; 19
th September:2.
84. de Bruxelles S. Medical school consigns cadavers to history. The Times
2002; 30 September: 3.
85. McLaughlan J.Anatomy in a new medical school. Exeter and Plymouth Anatomical Education: Present advances and future developments. One
day symposium 25 th September 2002; 17-18.
86. Bradley P. The role of assessment in a case-led outcome-based anatomy
curriculum. Newcastle Anatomical Education: Present advances and future developments.One day symposium 25th
September 2002; 13-14.
87. Cameron HC. Guy’s Hospital 1954; London: Langmans, Green & Co; 94
88. MacGowan WAL. The Royal College of Surgeons in Ireland. Ann R Coll Surg Eng
1973; 52: 102-112.
89. O’Rahilly R. Anatomy 1969; 3rd Ed. Philadelphia. W B Saunders & Co; 7.
Copyright: 5 December 2003
HIPFEST SIX - Hip Fracture Care: The changing picture
Friday, 11 June 2004
at
Royal College of Physicians of Edinburgh
Sessions will include:
• Presentations based on SHFA Database (Casemix trends; Surgical techniques; Resource use; Outcomes: mortality and other)
• Changing practice (Good practice presentations)
• The Changing Context (Audit, guidelines and standards: clinical governance and hip fracture care in Scotland; Findings from the 2004 NHS Quality Improvement Scotland survey of hip fracture care in Scotland; Discussion of revised national standards for hip fracture care; Casemix-adjusted outcome assessment following hip fracture).
Registration fee: £60.00
Further details:
Margaret Farquhar
Tel: +44 (0) 131 247 3636
Email: m.farquhar@rcpe.ac.uk