Students’ evaluation on a two-stage anatomy curriculum

Abstract

This study evaluated students’ perspectives of the two-stage anatomy course, which is designed to retain the time-honored tradition of cadaver dissection and to include innovative components into anatomy education. A total of 94 sixth-year medical students completed a questionnaire survey at the end of the second stage anatomy course. The results showed that more than half of the students were satisfied with the two-stage anatomy course. Students found that cadaver dissection was most helpful in learning anatomy. The two-stage anatomy course can enhance understanding and memory of anatomical knowledge. However, students disagreed on whether or not the two-stage course can reduce the burden of learning or that the parallel study of anatomy and the ‘Life and Death’ course could change their attitude toward death more effectively. National Licensing Examination revealed no obvious change after the implementation of the new anatomy course. Traditional and innovative components in anatomy curriculum could coexist in harmony. We provided an alternative for those who wanted to retain cadaver dissection in a reformed curriculum. Further study is needed to evaluate the adequacy of anatomy knowledge and student performance in the long run.

Introduction

Curriculum reform affected anatomy education in various ways including the shortening of course hours, integration of pre-clinical and clinical courses, abundance of cadaver dissection, introduction of new educational methods, change in students’ learning objectives and a reduced supply of gross anatomy instructors (Collins et al., 1994; Carlson, 1999). In some medical schools such as McMaster University in Canada, Harvard University in the United States, and Maastricht University in the Netherlands, traditional basic science courses no longer exist. All courses are taught in a problem-based learning (PBL) curriculum and anatomical knowledge is more clinically relevant and discussed in the context of medical problems and the acquisition of clinical skills. An increasing number of schools tend to integrate anatomy with other disciplines. This facilitates the linkage of anatomy with other medical knowledge and the understanding of anatomical reasons behind clinical skills (Dangerfield et al., 2000; Stalburg & Stein, 2002; McLachlan et al., 2004). Another tendency is to spread instruction in anatomy and other basic science disciplines throughout the four years of the medical curriculum (Scott, 1993). These changes in the gross anatomy education raised a lot of debate about the role of teaching anatomy in medical school and how to prepare medical students to become competent physicians (Paalman, 2000; Ellis, 2001; Parker, 2002).

Table

Practice points

•Time-honored tradition of cadaver dissection and innovative education components can be integrated in harmony in an anatomy course.

•Among all basic medical courses, pharmacology, anatomy, physiology and pathology were the first four courses in clinical relevant ranking, respectively.

•Students value cadaver dissection more than other modalities including models and images in learning gross anatomy.

Whether cadaver dissection should be kept in the gross anatomy curriculum has become another controversial topic over the past few years. In some schools, cadaver dissection was replaced by other learning modalities such as PBL, prosections, plastinated specimens, videotapes, diagnostics images and computer simulations. Researchers found that new ways of teaching anatomy were as good as the traditional approach (Nnodim, 1990; Prince et al., 2003). Some schools retained the cadaver dissection in their gross anatomy course, but refocused the learning objectives to cultivate humanistic values and compassionate holistic care (Marks et al., 1997; 2002; Gregory & Cole, 2002).

In Asia, most medical schools preferred a combination of traditional and PBL format rather than a pure PBL curriculum. Lack of faculty manpower, economic constraints and students’ learning styles are reasons for not completely transforming the system into a PBL curriculum. A survey of the opinions of medical students on a new anatomy course in the University of Singapore revealed that most of the students found dissection helpful in learning anatomy and disagreed that prosection can replace dissection in learning. Teaching staffs observed that during demonstrations on prosected specimens, students were rather passive (Leong, 1999). The above issues should be taken into account in the development of an anatomy curriculum, especially for Asia's medical students.

Medical education in Taiwan is a seven-year program following completion of high school. The curricula are basic college courses in the first two years, basic medical sciences in the third and fourth years, clinical medical sciences in the fifth and the sixth years, and rotating internship in the seventh year. In 1993, curriculum reform was undertaken at the National Taiwan University College of Medicine (NTUCM) in which PBL tutorials, medical humanities and medical informatics were emphasized. The traditional anatomy course was replaced by a two-stage anatomy course in 1997. The lectures and laboratory study are provided in the third year (the first stage) where anatomical prosections, models, images and clinically orientated case discussions are used to enhance the anatomy study. The second stage is a six-week course of cadaver dissection with mini-lectures conducted in the sixth year. Faculty members from the anatomical department lead the cadaver dissection in small groups. A ‘Life and Death’ course is offered in the first six weeks of the semester in parallel with the cadaver dissection (Wang & Lue, 2003). The course hours in the first stage includes 48 hours of lectures, 48 hours of laboratory study and 16 hours of PBL tutorials. The course hours in the second stage include 192 hours of cadaver dissection and radiological images. The total number of course hours for gross anatomy is 304 hours. The rationale of the design of this two-stage anatomy course is to retain the time-honored tradition of cadaver dissection and to include innovative education components into anatomy education. The second stage course is designed to enhance the knowledge of anatomy before students receive the responsibility of taking care of patients in their internship. With clinical exposure in the fifth year clerkship, it was expected that students might have a better idea of what is important for them to learn to become a physician in cadaver dissection.

Further to this curriculum change in gross anatomy, many faculty members worried that the new curriculum may lead to deficiencies in anatomical knowledge. Before we answer this question, we need to know whether students favor the new anatomical course or not, as the quality of the learning process can affect the outcome.

In this study, the following research questions were formulated:

1. Which learning activities do students value in the study of gross anatomy?

2. Do students find the study of gross anatomy and other basic medical sciences relevant to training when becoming a medical doctor?

3. Do students find the two-stage course useful in learning gross anatomy, and to what extent?

4. Will the delay of cadaver dissection to the sixth year affect the learning of basic medical sciences in the pre-clinical period?

5. Do students favor the new anatomy curriculum?

6. Are there any changes in National Licensing Examination passing rates after the implementation of the two-stage anatomy course?

Method

All sixth-year medical students who had completed the two-stage gross anatomy course were invited to participate in this survey. A structured and anonymous questionnaire (in Chinese) was distributed immediately after the final examination as a part of the course evaluation. Students were invited to complete the questionnaire because their feedback would be taken seriously into account to improve the curriculum. The content of the questionnaire was divided into five parts: students’ evaluation on the learning of gross anatomy; relevance of basic medical courses for training to become a doctor; students’ evaluation of the two-stage gross anatomical course; comparisons of the traditional and two-stage anatomy course; and four additional questions concerning the global evaluation of the two-stage gross anatomy course.

The first part was evaluated by five questions concerning the use of anatomical dissection, the use of human models, the use of videos and images and the use of small group discussion in learning gross anatomy, and one question about the relevance of gross anatomy in learning clinical medicine. All questions in this part were rated by a 5-point Likert scale (very helpful, helpful, ordinary, unhelpful, very unhelpful). The relevance of basic medical science courses for training to become a doctor was measured by a questionnaire developed by Pabst & Rothkőtter (1997) with modification of the basic medical course items with items of our own curriculum. Students were asked to evaluate the relevance of the basic science courses with four grades: ‘fundamental’, ‘necessary’, ‘of little relevance’ and ‘superfluous’. Students’ evaluation of the two-stage anatomy course was measured by asking the students whether the new course could facilitate the understanding of gross anatomy, the retention of knowledge, the understanding of clinical medicine, the application of anatomical knowledge in clinical medicine, the connection of anatomical knowledge with clinical medicine and to reduce the burden in learning anatomical knowledge. All questions in this part were answered by a 5-point Likert scale (strongly agree, agree, neutral, disagree, strongly disagree). In the last part, we asked students whether they have had any difficulties in learning basic medical sciences due to the postponement of cadaver dissection course to the sixth year, do they favor the two-stage anatomical curriculum and whether the concomitant learning of ‘Life and Death’ course facilitated a change in their attitude towards death. Students were able to complete the questionnaire within ten minutes.

Data from this study were coded and analyzed by SPSS/PC statistical software (11th edition).

Results

There were 127 sixth-year medical students (83 male students) who completed the two-stage gross anatomy curriculum enrolled in the questionnaire survey. Of them, 71 male students and 23 female students returned their questionnaires with a response rate of 74%. There were more male students who responded to the questionnaire survey, 75.5% versus 65.4% in the study population. However, this difference did not reach statistical significance (X² = 2.64, d.f. = 1, P < 0.10).

Which learning activities do students value in the study of gross anatomy

Students’ evaluation for learning gross anatomy is shown in Table 1. Most of the students (95.7%) found cadaver dissection helpful or very helpful in learning gross anatomy. A smaller number of students (88.3%) found anatomical models helpful or very helpful. Only 61.7% of the students found small group discussion tutorials helpful or very helpful. Furthermore, 79.8% of the students found videos and images helpful or very helpful. Seventy-three students (77.7%) found gross anatomy helpful or very helpful in the learning of clinical medicine.

Table 1.  Students’ attitude towards the learning of gross anatomy

	Very helpful	Helpful	Neutral	Unhelpful	Very unhelpful
Cadaver dissection	75 (79.8)	15 (16.0)	3 (3.2)	1 (1.1)	--
Anatomical models	40 (42.6)	43 (45.7)	11 (11.7)	--	--
Small group discussion	15 (16.0)	43 (45.7)	31 (33.0)	3 (3.2)	2 (2.1)
Videos & images	23 (24.5)	52 (55.3)	17 (18.1)	1 (1.1)	1 (1.1)
Learning of clinical medicine	29 (30.9)	44 (46.8)	17 (18.1)	3 (3.2)	1 (1.1)

Numbers followed by percentages in bracket.

Relevance of basic medical courses for training to become a doctor

Table 2 presents the results of students’ rating of how relevant the basic medical courses for training to become a doctor were. Gross anatomy was graded ‘fundamental’ by 73.4% and ‘necessary’ by 24.5% of the students. Pharmacology, gross anatomy, physiology and pathology were in the first four places in the clinical relevant ranking, respectively.

Table 2.  Relevance of basic medical courses for training to become a physician

	Fundamental	Necessary	Of little relevance	Superfluous
Biochemistry	17 (18.1)	45 (47.9)	30 (31.9)	2 (2.1)
Physiology	68 (72.3)	24 (25.5)	2 (2.1)	–
Gross anatomy	69 (73.4)	23 (24.5)	2 (2.1)	–
Histology	27 (28.7)	50 (53.2)	17 (18.1)	–
Embryology	18 (19.1)	37 (39.4)	38 (40.4)	1 (1.1)
Pathology	65 (69.1)	25 (26.6)	4 (4.3)
Neurophysiology	33 (35.1)	42 (44.7)	18 (19.1)	1 (1.1)
Microbiology & immunology	45 (47.9)	40 (42.6)	8 (8.5)	1 (1.1)
Parasitology	16 (17.0)	35 (37.2)	40 (42.6)	3 (3.2)
Introduction to medicine	7 (7.4)	35 (37.2)	41 (43.6)	11 (11.7)
Medical psychology	12 (12.8)	46 (48.9)	32 (34.0)	4 (4.3)
Medical informatics	8 (8.5)	23 (24.5)	42 (44.7)	21 (22.3)
Public health	27 (28.7)	46 (48.9)	20 (21.3)	1 (1.1)
Pathophysiology	44 (46.8)	41 (43.6)	9 (9.6)	–
Pharmacology	71 (75.5)	20 (21.3)	2 (2.1)	1 (1.1)

Numbers followed by percentages in bracket.

Students’ evaluation of the two-stage gross anatomical course

Table 3 presents the course evaluation of the two-stage gross anatomy curriculum. Most students (76.6%) strongly agreed or agreed that the two-stage curriculum can enhance the understanding of gross anatomy. Even more students (80.9%) strongly agreed or agreed that the two-stage course can enhance recall of anatomical knowledge. However, more students disagreed that the two-stage course design can reduce the burden of learning for gross anatomy. We assumed that when the second stage anatomic course is learnt with clinical courses, the knowledge of gross anatomy can be connected and be applied to clinical medicine. The answers to these two questions were positive, since most students found that this course could connect the learning of gross anatomy to clinical courses and help them apply the knowledge of anatomy in clinical medicine.

Table 3. Students’ evaluation of the two-stage gross anatomical course

	Strongly agree	Agree	Neutral	Disagree	Strongly disagree
Facilitate learning of anatomy	36 (38.3)	36 (38.3)	11 (11.7)	6 (6.4)	5 (5.3)
Facilitate the retention of anatomical knowledge	37 (39.4)	39 (41.5)	11 (11.7)	3 (3.2)	4 (4.3)
Reduce the burden of learning	16 (17.0)	10 (10.6)	32 (34.0)	23 (24.5)	13 (13.8)
Connect to the learning of clinical medicine	26 (27.7)	41 (43.6)	20 (21.3)	4 (4.3)	3 (3.2)
Facilitate the application of anatomical knowledge in clinical medicine	30 (31.9)	33 (35.1)	23 (24.5)	5 (5.3)	3 (3.2)

Numbers followed by percentages in bracket.

Students’ response to the second stage course

When the students were asked whether the learning of gross anatomy without cadaver dissection in the third year jeopardized their learning of other basic medical courses in particular pathology, six students (6.4%) strongly disagreed, 28 (29.8%) disagreed, 37 (39.4%) gave a neutral response, fourteen (14.9%) agreed, eight (8.5%) strongly agreed and one student gave no response.

When students were asked did they favor the two-stage gross anatomical course, 51 (54.3%) agreed, 25 (26.6%) disagreed, seventeen (18.1%) were undecided, and one student gave no response.

When students were asked whether the parallel of cadaver dissection with ‘Life and Death’ course is more effective in changing their attitude toward death, the results were more diverse. Twelve students (12.7%) strongly agreed, 18 (19.1%) agreed, 36 (38.3%) gave a neutral response, 17 (18.1%) disagreed, nine (9.69%) strongly disagreed and two students gave no response.

National Licensing Examination passing rates after the implementation of the two-stage gross anatomical course

Table 4 revealed the passing rates of the National Licensing Examination of all medical schools in Taiwan from 1995 to 2004. We calculated a passing ratio by dividing the passing rates of NTUCM with the national means to avoid the fluctuation of annual rates on the interpretation of secular change. The first class of students who have attended the two-stage anatomy course graduated in 2001. We did not observe any obvious decline in National Licensing Examination passing ratio after 2001.

Table 4. Change of the National Certification Examination passing rates in NTUCM after the implementation of the two-stage anatomy course

Year	NTUCM passing rates	National passing rates	Passing ratio (NTUCM rate/ national rate)
1995	90.44	66.32	1.36
1996	72.09	52.52	1.37
1997	70.80	51.51	1.37
1998	94.74	58.25	1.63
1999	97.58	67.43	1.45
2000	70.45	32.92	2.14
2001	43.37	32.84	1.32
2002	61.90	31.39	1.97
2003	80.26	68.54	1.17
2004	88.24	66.40	1.33

Discussion

A two-stage gross anatomical course seemed to be accepted by most of our medical students. However, dividing the anatomical course into two separate years did not reduce the burden of learning anatomy.

Cadaver dissection has been an important part of medical education since the late nineteenth century and the learning of gross anatomy was relatively unchanged until recent years. Faced with a reduction of teaching hours in basic science curriculum and the scarce supply of cadavers, some schools totally withdrew human dissection from their anatomical curriculum, yet others gave human dissection a new role in humanistic education. Some believed that a well-designed anatomical curriculum without cadaver dissection might be as good as or even better than cadaver dissection in the learning of gross anatomy (McLachlan et al., 2004). Nevertheless, experience in dissection is an unforgettable memory for most medical students, even though this memory is perhaps negative for a small number of students (Charlton & Smith, 2000; Dinsmore et al., 2001).

How to design a gross anatomy course is a question with no standard answer, and is affected by the resources available in different medical schools. In curriculum reform, there should be a great deal of discussion regarding this issue among faculties and course directors. Since the customers of medical education are the students, one way to solve this issue is to better understand students’ feelings and let the students make their own decision. In this study, more than 95% of the students favored cadaver dissection in learning gross anatomy. This result is similar to the student survey conducted at the University of Singapore, where 87.7% of the students found dissection helpful in their understanding of gross anatomy. The majority felt that dissection should not be replaced by prosection (Leong, 1999). Cadaver dissection is a very unique experience for medical students. To explore a cadaver opens a door leading to the mystery of human life and the power to handle life problems. As a result, although cadaver dissection may be a stressful, and in some cases, a challenging experience for some medical students, most found this experience exciting and they are unwilling to give up this opportunity (Dinsmore et al., 2001). For other learning materials, our students felt that tangible objects such as models are better than visual images. One possible explanation is that models can give students a three-dimensional image and a perception of the actual size of the human organs. Without training in cross-section anatomy, radiographic images, especially computer topography, are more difficult to master for our students. Moreover, as more and more medical schools excluded cadaver dissection from their anatomy curriculum, faculty members should pay more attention to how they best make use of teaching modalities in gross anatomy education.

The results of this study contradict some previous studies of anatomy curriculum, which revealed high student satisfaction for curriculums using prosections, images and small group PBL modules, but not cadaver dissection (Nnodim et al., 1996; Dinsmore et al., 1999; McLachlan et al., 2004). Due to the heterogeneity of gross anatomical courses and comparison of students from different cultures, it is very difficult to evaluate which course design is better in learning gross anatomy. It is possible that with a student-centered and well-design curriculum, all students can learn what they should learn, regardless of having the experience of cadaver dissection or not.

Without a doubt, the teaching of the anatomical structure of the human body constitutes an essential feature of any medical education program, traditional or problem-based. Our results—like another similar survey on residents—showed gross anatomy was the most fundamental course in medical education (Pabst & Rothkőtter, 1997). Although students’ point-of-view may not supersede the professional obligation of faculty to determine the appropriate course structure and contents, they can provide useful feedback and perspective. An unexpected finding was that the parallel of cadaver dissection with the ‘Life and Death’ course did not facilitate the development of a positive attitude towards death and dying. Our explanation is with one year of clinical experience in the clerkship, cadaver dissection is not the students’ first encounter with death. The effect of cadaver dissection on learning about dealing with death may be more pronounced in pre-clinical years.

The total course time in the two-stage anatomy course is 304 hours, which is even longer than the course time of the traditional course (232 hours of lectures and cadaver dissection). This resulted in a more compact time schedule for the third and sixth year course and was reflected in the students’ evaluation that splitting the anatomy course into two stages did not reduce their burden.

One major limitation of our study is the lack of a control group for comparison. Since all fifth-year students only took the two-stage curriculum, comparison between the two-stage course and the traditional course was not possible. Moreover, students’ satisfaction cannot translate into the acquisition of anatomical knowledge. Although there was no obvious change in the National Licensing Examination passing rates after the implementation of the two-stage anatomy course, further evaluation on the performance of students after graduation is needed to judge the effectiveness of the two-stage gross anatomy curriculum.

Acknowledgements

The authors wish to thank all staff in the medical education office for their work on this study.

Additional information

Notes on contributors

Kai-Kuen Leung

KAI-KUEN LEUNG, MD, MPH, is an Associate Professor of Family Medicine and director of Medical Education Research Group at the National Taiwan University College of Medicine. He has research interests in medical education especially in problem-based learning and program evaluation.

Bee-Horng Lue

BEE-HORNG LUE, MD, is an Associate Professor of Family Medicine and Social Medicine at the National Taiwan University College of Medicine. She has research interests in medical education and psychosomatic medicine.

Kuo-Shyan Lu

KUO-SHYAN Lu, PhD, is a Professor in Department of Anatomy and Cell Biology at the National Taiwan University College of Medicine. He is the former director of the Office of Academic Affairs at the National Taiwan University College of Medicine.

Tien-Shang Huang

TIEN-SHANG HUANG, MD, is a Professor in Internal Medicine and director of Office of Medical Education at the National Taiwan University College of Medicine. He has an important role in medical education reform and general medicine education in his country.