Anatomy in perspective of modern time

Miloš Grim

Charles University in Prague, First Faculty of Medicine, Institute of Anatomy

MORPHOLOGY 2009 PILSEN SEPTEMBER 7 - 9, 2009

Why outlooks in the future of anatomy

• Gross anatomy: an outdated subject or an essential part of a modern medical curriculum? • Declaration of European consensus conference (EFEM) to the teaching of morphology• Medical curriculum on the First Faculty of Medicine in Prague should be restructured in 2011• How can we be more efficient • Of what status the anatomy we seek? • Different opinions concerning the status of anatomy are published recently in medical journals

Anatomy teaching in the UKRaftery AT, Surgery 25:1 (2006) „Anatomy teaching in the UK is in crisis. At undergraduate level, there is a need for a core curriculum that provides an anatomical basis for patient examination, interpretation of imaging and safe conduct of basic interventional procedures, as well as student-selected components.“

Anatomy in a modern medical curriculum BW Turney (University of Oxford), Ann R Coll Surg Engl 89:104 (2007)

„Anatomy in undergraduate education has been in decline for many years. Some suggest that it has fallen below a safe level.“

Are We Teaching Sufficient Anatomy at Medical School? The Opinions of Newly Qualified Doctors Fitzgerald JEF, White MJ, Tang SW et al., University of Nottingham, UK Clin Anat 21:718–724 (2008)

In recent decades changes have occurred in medical curricula. Time spent studying gross anatomy has declined. The new generation of doctors are leaving medical school with insufficient anatomical knowledge. We investigate the opinions of newly qualified doctors at a UK medical school. Overall nearly half of respondents believe they received insufficient anatomy teaching. They called for greater emphasis on anatomical teaching and for the integration of anatomy teaching throughout the medical school course.

Modern approaches to teaching and learning anatomy Collins JP, Royal Australasian College of Surgeons, Melbourne BMJ 337: 665 (2008)

The view that new doctors have inadequate knowledge of anatomy is not supported by the evidence, argues John Collins, but greater effort is needed to capitalize on the learning potential of new technologies. Efficient use of new technology and teaching methods should allow better teaching and understanding.Departments of anatomy must form closer links or integration with those in surgery or radiology. All clinical teachers must take greater responsibility for sequential teaching of anatomy across the continuum of learning.

Cadaver dissection or prosected cadaver? _

Cadaver dissection (Collins, 2008) - Anatomical dissection is not a primary learning method because pupils must know in advance what to look for in order to achieve the greatest benefit.- Dissection of cadavers is expensive, time consuming, and emotionally disturbing for some students. - The preserved tissues don’t always provide an accurate impression of the living body. + Dissecting cadavers helps gain an understanding of the three dimensional structure of the human body through self discovery and observations. + It also helps to develop the spatial reasoning skills necessary to understand and interpret imaging data.+ Dissection of cadavers is of value principally for those contemplating a career in surgery.

Prosected cadaver (Collins, 2008)

+ provide learners with pre-dissected material. + make more time available for teaching, learning, and + enables understand the inter-relations of anatomical structures

Collins recommended: demonstration of prosected cadavers instead dissection for those students not contemplating a surgical career

My opinion: it is too early for such diversification, it is better to combine dissection with demonstration of prosected cadaver

What Do Students Actually Do during a Dissection Course? First Steps towards Understanding a Complex Learning ExperienceWinkelmann A, Hendrix S, Kiessling C, Charité, Berlin Acad Med. 2007; 82:989–995

On average, students spent33% of their course time with active dissection (*),27% studying prosected material, and 31% with cadaver-unrelated activities

(*) Active dissection ranged from 0% to 82% of daily course time

How Much Anatomy Is Enough?Bergman EM, Prince KJAH, Drukker J et al., Maastricht University, University Amsterdam. Anat Sci Ed 1:184–188 (2008)

Several studies investigating the knowledge of anatomy of students at the eight Dutch medical schools showed that undergraduate students uniformly perceived deficiencies in their anatomical knowledge regardless of their school’s didactic approach. Good test performance by students seems to be related to total teaching time for anatomy, teaching in clinical context, and revisiting anatomy topics in the course of the curriculum. These factors appeared to outweigh the effects of disciplinary integration or whether the curriculum was problem-based or traditional.

European Federation for Experimental Morphology (EFEM)Consensus Conference on Morphological Sciences 2007

The total weight of morphological sciences taught as a discipline (anatomy, histology and embryology) should not fall below an equivalent of 30 ECTS, extending throughout the whole medical curriculum.

Any kind of vertical or horizontal integration, or teaching morphology as an introduction to clinical matters is recommended rather than concentrating basic education in morphology during the first years of the curriculum.

Co-operation between the clinical and morphological associations is needed in order to produce this.

Teaching of Gross Anatomy on Medical Faculties in The Czech Republic (Branch: General Medicine)

Brno 1. 2. 3. sem (14w) 240 h 21 ECHradec Králové 1. 2. sem (14w) 261 h 24 ECOlomouc 1. 2. 3. sem (15w) 315 h 22 ECPlzeň 1. 2. 3. sem (14w) 308 h 25 ECPraha 1. LF 1. 2. 7. sem (15w) 274 h 24 ECPraha 2. LF 1. 2. sem (14w) 220 h 14 ECPraha 3. LF 1. 2. 3. 4. sem (15wt) 261 h 18 EC

-------------------------------------------------------------------------------There is no reason to believe that the gross anatomy has been squeezed from our medical curriculum in recent years as is the case in many other countries

Old-style of teaching anatomy (Turney, 2007)

Old-fashioned overly factual anatomy Dogmatic support for detailed anatomy Students are expected to learn detailLearning of anatomy became a riteLearning without understanding of clinical relevance

Why anatomy is in decline (Turney, 2007)

Failure of anatomy to evolve and adapt to advances of clinical medicine Reduced number of medically qualified anatomy teachersIncreasing number of medical studentsTo prepare future generalists or specialists ?

What changes are under consideration?• To focus on structures that are functionally and clinically significant• To drive for horizontal organization, which would integrate the knowledge of several disciplines. In particular, temporal coordination of educated issues in morphology and physiology would facilitate understanding the relationship of structure and function• Anatomy should be also vertically integrated into medical curriculum• Not succumb to the impression that the E-learning will replace the contact teacher and student. Best tools of education remain face to face contact, the word of teacher and chalk• Basic knowledge of anatomy should be retained in sufficient detail regardless whether it was known already to Vesalius or discovered recently

Bare bones: helplessness….. too much too early. (picture from Collins JP, BMJ 337: 665, 2008)

Doctors without anatomy are like moles. They work in the dark and the work of their hands are mounds.

Tiedemann (1781-1861), Heidelberg