Mortui vivos docent

... and here are some hints from the literature mirroring an undulating debate:

Davis CR, Bates AS, Ellis H, Roberts AM. Human Anatomy: Let the students tell

us how to teach. Anat Sci Educ. 2013 Nov 18. doi: 10.1002/ase.1424.

Khan HM, Mirza TM. Physical and psychological effects of cadaveric dissection

on undergraduate medical students. J Pak Med Assoc. 2013 Jul;63(7):831-4.

Plaisant O, Courtois R, Toussaint PJ, Mendelsohn GA, John OP, Delmas V, Moxham

BJ. Medical students' attitudes toward the anatomy dissection room in relation to

personality. Anat Sci Educ. 2011 Nov-Dec;4(6):305-10. doi: 10.1002/ase.251.

Quince TA, Barclay SI, Spear M, Parker RA, Wood DF. Student attitudes toward

cadaveric dissection at a UK medical school. Anat Sci Educ. 2011

Jul-Aug;4(4):200-7. doi: 10.1002/ase.237.

Kerby J, Shukur ZN, Shalhoub J. The relationships between learning outcomes

and methods of teaching anatomy as perceived by medical students. Clin Anat. 2011

May;24(4):489-97. doi: 10.1002/ca.21059. Epub 2010 Oct 14.

Moon K, Filis AK, Cohen AR. The birth and evolution of neuroscience through

cadaveric dissection. Neurosurgery. 2010 Sep;67(3):799-809; discussion 809-10.

doi: 10.1227/01.NEU.0000383135.92953.A3.

Patel KM, Moxham BJ. The relationships between learning outcomes and methods

of teaching anatomy as perceived by professional anatomists. Clin Anat. 2008

Mar;21(2):182-9. doi: 10.1002/ca.20584.

Evans DJ, Watt DJ. Provision of anatomical teaching in a new British medical

school: getting the right mix. Anat Rec B New Anat. 2005 May;284(1):22-7.

McLachlan JC, Bligh J, Bradley P, Searle J. Teaching anatomy without cadavers.

Med Educ. 2004 Apr;38(4):418-24.

Mortui vivos docent

... and here are some hints from the literature mirroring an undulating debate:

Davis CR, Bates AS, Ellis H, Roberts AM. Human Anatomy: Let the students tell

us how to teach. Anat Sci Educ. 2013 Nov 18. doi: 10.1002/ase.1424.

Khan HM, Mirza TM. Physical and psychological effects of cadaveric dissection

on undergraduate medical students. J Pak Med Assoc. 2013 Jul;63(7):831-4.

Plaisant O, Courtois R, Toussaint PJ, Mendelsohn GA, John OP, Delmas V, Moxham

BJ. Medical students' attitudes toward the anatomy dissection room in relation to

personality. Anat Sci Educ. 2011 Nov-Dec;4(6):305-10. doi: 10.1002/ase.251.

Quince TA, Barclay SI, Spear M, Parker RA, Wood DF. Student attitudes toward

cadaveric dissection at a UK medical school. Anat Sci Educ. 2011

Jul-Aug;4(4):200-7. doi: 10.1002/ase.237.

Kerby J, Shukur ZN, Shalhoub J. The relationships between learning outcomes

and methods of teaching anatomy as perceived by medical students. Clin Anat. 2011

May;24(4):489-97. doi: 10.1002/ca.21059. Epub 2010 Oct 14.

Moon K, Filis AK, Cohen AR. The birth and evolution of neuroscience through

cadaveric dissection. Neurosurgery. 2010 Sep;67(3):799-809; discussion 809-10.

doi: 10.1227/01.NEU.0000383135.92953.A3.

Patel KM, Moxham BJ. The relationships between learning outcomes and methods

of teaching anatomy as perceived by professional anatomists. Clin Anat. 2008

Mar;21(2):182-9. doi: 10.1002/ca.20584.

Evans DJ, Watt DJ. Provision of anatomical teaching in a new British medical

school: getting the right mix. Anat Rec B New Anat. 2005 May;284(1):22-7.

McLachlan JC, Bligh J, Bradley P, Searle J. Teaching anatomy without cadavers.

Med Educ. 2004 Apr;38(4):418-24.

Pesonal opinion:

Short answer: I think that as cadavers as they are currently used in anatomy, are an insufficeint teaching tool and that time would be better spent learning anatomy by looking at cross-sectional anatomy on MRI and CT scans. Few physicians will in their entire career see an open body, but most will see anatomic corss sections on advanced medical imaging. That being said, I think at least a small amount of cadaver exposure does have its benefits.

The longer version:

Almost every physicians nowadays (including those who don't do US) looks at advanced medical imaging like CT scans and MRI's where a knowledge of cross-sectional anatomy is critical. Cross-sectional anatomy is not well visualizable on cadavers. When you dissect a cadaver, you pull away a three dimensional organ and see what is underneath. If you are trying to figure out what a particular muscle is on a cadaver, you literally track along it until you come to the where it attaches to a bone. Cadaveric dissection trains you to figure out the anatomy by using clues from all three dimensions of space.

When I was in medical school, I could figure out any large muscle's identity by using this techniue, but identifying the muscles on 2D MRI or CT scans was very difficult for me.

In advanced medical imaging (eg. CT and MRI) , you only get 2D cross sections, which means that you have to be able to figure out what you are looking at without the information that can be gained by a view of the 3rd dimension. This means that you really have to know anatomy well, because you have less clues to figure things out. I do not think that cadaveric dissection teaches this approach to anatomy well. In my medical school, we looked at slices of cadavers to learn cross-sectional anatomy, but often slices of cadavers do not stay together, small pices of connective tissue (wich are visible on MRI or CT) fall out, and the original anatomic arrangement is not well preserved.

In short, for surgeons and pathologists, cadaveric anatomy is critical. For every other physician, a knowledge of cross-sectional anatomy is much more important, so if we are going to focus our efforts somewhere, make it on cross-sectional anatomy.

I therefore, have the opinion that anatomy teaching in medical school should focus more on medical imaging and cross sections and less on cadavers. I do think that some cadaveric anatomy exposure is still worthwhile to give some sense to a physician of what organs look like, but that the basis of anatomy education should be cross sectional anatomy, which is probably best done not on cadavers.

Very interesting perspective Paul!

My personal opinion slightly differs. I will try to keep this very short (and vague to some extent).

Yes, technology is great, and has come a long way (I have a huge fan/geek of all the gadgets out there). The tools we have at our disposal truly push the boundaries and allow us to save individuals that we would’ve never thought we can save 10 years ago.

The same is true for medical imaging, MRIs, etc. However – in a case scenario, where you do not have access for an MRI – i.e paramedics, ER Drs. Rushing to save someone who is bleeding profusely – what would you do?

I believe this is where a core knowledge of anatomy, attained from prior exposure to true anatomical structures (i.e cadaveric dissections) would truly help. Seeing anatomical structures on computer screens, anatomical cross sectional slides, or even prosections do not give you the best practice for such a scenario.

A patient could be bleeding from their IMA – a huge artery that one may have studied numerous times on slides and prosections, yet when you go to operate on the patient, you’ll be presented with new obstacles that you never had exposure to – i.e fat and fascia, how much deeper shall I go to find the IMA?

Other health professionals need this exposure as well – such as physiotherapists, massage therapists, chiropractors, etc. Rarely do they have access to these cool gadgets, yet some of them (the good ones) who had exposure to cadaveric dissections truly understand what is underneath your skin. They can pinpoint the path of a nerve and get in where they need to.

Putting my personal opinion aside – Anatomical Ignorance is a recent term circulating in the literature. There are a few articles that examine the negative effects associated with reduced anatomical education, specifically cadaveric exposure.

Here is an article that examines some of these papers (Crtl + F: Ignorance)

http://www.ncbi.nlm.nih.gov/pubmed/15971223

As a patient, I would strongly desire my new surgeon to have practised on a few dead bodies before operating on me.

Hi,

I would say cadaveric dissection is important to a certain extent as anatomy is all about dissection ( Almost forgotten latin meaning of anatomy : to cut a body and study), otherwise how can medical and paramedical students (especially those who are aspiring to become surgeons) tell a difference between an artery, nerve and a vein?, so I feel dissection demonstration is important, to visualize and to identify structures within the human body (in-situ learning).

However, imaging technique such as CT/MRI should also be introduced in the medical curriculum early on, as in a routine clinical setting even before any surgery is done on a patient the most important protocol is investigation by imaging techniques etc., thus according to me medical/ para medical students should have experience with both forms of anatomical teaching (cadaveric dissection and learning through imaging).

Polly

Thank you all for your stimulating and well voiced responses.

I offer these probing questions:

What is the lowest allotment of hours that should be offered to medical students for the study of human anatomy?

The authors of the attached study speculate that if the allotment of anatomy hours were to fall below ~150hrs, the students would suffer greatly in their experience. Could this lead to an increase in cases of 'anatomical ignorance'?

In the case of digital imaging, it is undoubtedly an important aspect of medical education and arguably more important than cadaveric dissection for some branches of medicine. However, in order to orient one's self and understand these images (MRI, CT, etc.), is a thorough understanding of the three dimensional organization of anatomical structures not of upmost importance?

Finally, can students attain the level of understanding required to interpret these images through means other than cadaveric study (atlases, models, etc.)?

Drake et al. (2009):

http://onlinelibrary.wiley.com/doi/10.1002/ase.117/full

Dear Sean

Adequate knowledge of human anatomy is crucial to the development of a surgical technique .. The poor state of preservation of anatomical specimens and its scarcity to a large contingent of students are some of the factors that contribute to this deficit .

Although there is no consensus , the use of cadavers for teaching anatomy and surgical skills in undergraduate and graduate has enhanced its importance when they are used in the training of graduate students as well as residents of the areas and also surgical anatomy pathology and forensic medicine.

Another option is the virtual reality into an " operating table " touchscreen technology may represent the future, both for teaching future doctors about anatomy and in preparation for operations

The Imperial College and Saint Mary's Hospital , London , bought the table in partnership , at a cost of about $ 90,000 ..

The device has the same length and size of a table of normal operation. The " corpse " on the screen , dubbed Melanie , is a virtual body created from a combination of graphics and actual scans of the body .

Surgeons and students can interact with the body , either through touch or with a traditional mouse. The skin can be removed to expose the internal organs , the areas can be expanded to a more detailed study , and the software can work with data from actual patients , but it is impractical in developing countries like Brazil

Great points everyone.

Nelson, I believe you may be referring to a similar apparatus to the one demonstrated in the following video:

https://www.ted.com/talks/jack_choi_on_the_virtual_dissection_table

This is a very cool and innovative tool that definitely introduces a new direction for anatomy education. The table has many interesting and useful features that undoubtedly have the potential to enhance anatomical education. However, I have to argue that this tool will have its most profound impact only when used in conjunction with standard cadaveric dissection.

The images used to create the interactive environment in the dissection table were likely based upon a select group of cadaveric specimens. As such, far fewer anatomical variations will be available to the student, similar to the outcome if students were to solely use textbooks for their anatomy education. Furthermore, the complex 3D organization of structures will lose some of its impact when presented on a 2D screen. Finally, many students suggest that the tactile experience of exploring a genuine human body is irreplaceable in their medical education.

Attached is a report from the University of Saskatchewan regarding the state of their human anatomy program and its future. I found the literature review and student comments (near the end) to be the most telling clues in the "to dissect, or not to dissect" debate.

Let me know what you think!

Might this be of interest?

http://www.bjuinternational.com/bjui-blog/the-value-of-fresh-cadaveric-dissection/

Thanks for putting up this great discussion, which is indeed going on probably for ages.

TL;DR: Further aspects which make dissection worthwhile are three-dimensionality, variations (individuality), practical skills and especially medical professionalism.

As anatomist I have to agree that dissection is an important, probably the most important educational method to teach threedimensionality and spacial relations of the human body. Modern technology often happens on screens, which are also two-dimensional. Models, even if very detailed, are a generalization as every atlas picture is. Still every human is different, that is what students can experience when they dissect by themselves and take a look at the work of their peers. This lesson is important for future surgeons (not only abdominal, but orthopedic, thoracic, heart, gynaecologic, trauma, neuro ophthalmic, dermatologic ....) who might face a different situation and anatomical variations in every patient. The practical skills learned are also useful, also radiologists or internal medicine specialists sometimes insert catheters.

Another area I would like to mention here are the psychosocial aspects of the dissection course. The Globe and Mail article describes it as 'rite of passage' which is in my opinion a bit harsh as I do not view dissection as a "ritual". There is something happening with the students' minds during the course, but might better be described as professionalization. The dissection course is often the first time they realize they study medicine, which has something to do with people and not with the molecules, cells and particles of (bio-)chemistry, biology and physics. They may perceive the specimen as their first patient which is entrusted to them. The course might be the first situation they are confronted with death and a cadaver, which is a powerful experience. Therefore, the dissection course may stimulate self-reflection and help to develop a professional attitude. The work in small groups over a longer time amy also foster team work.

Some publications I consider useful:

Swick HM. Medical Professionalism and the Clinical Anatomist. 2006 Clinical Anatomy 19:393–402.

Esteban-Poni B, Poni ES. The Role of Gross Anatomy in Promoting Professionalism: A Neglected Opportunity! 2006. Clin Anat 19:461–467.

Netterstrøm, I, Kayser, L. 2008. Learning to be a doctor while learning anatomy! 2008. Anat Sci Educ 1: 154-158.

Weyers S, Noack T, Rehkämper G. Psychosocial aspects of donation and the dissection course: An extra-curricular program with the objective of assisting students confront issues surrounding gross anatomy lab. GMS Z Med Ausbild. 2014;31(2):Doc16.DOI:10.3205/zma000908,URN:urn:nbn:de:0183-zma0009081

Dear Sean,

Anatomy is the very basic and essential subject in medicine. The cadaveric dissection is mandatory because it provides the three dimensional perspective of the human structures, The students can feel the soft, hard, brittle, friablenature of varios organs.

Hence, Dissection is essential.

I would disagree with anatomic dissection being essential. Cadaveric anatomy is not living viable anatomy. Have cut on cadavers as well as living tissue I can assure you that there is little similarity between a cadaver and a living person. Cadaveric anatomy to me was an exercise that I found particularly disturbing. By the end of the two semesters we had reduced a body to a pile of nearly unrecognizable bits and structures into nothing resembling surgical anatomy.

i can teach a lot of anatomy in Vivo using images, actual physical exam, ultrasound and intraoperative experience without the exorbitant cost of an anatomy lab. Plus I can demonstrate what living tissue actually does and how it responds to incision.

That said, in my. Mind the real value of the anatomy lab comes after medical school in the surgical specialties when surgeons need to develop their dissection skills for surgical procedures that are novel or for familiarization with their area of expertise. For me as a medicine man and not a surgeon, my exposure to anatomy was not overly valuable and in many cases again, I found it disturbing. I would also point out that I do minor surgical procedures and have no issue using surgical I instrumentation in living people. 

Its an interesting question that I am sure will divide a lot of people.