Perfection in Surgical Anatomy many times solve the problems during surgical procedures.Usually anatomy is taught in First Prof. and Surgery in last prof. in undergraduate medical courses. between the two profs. student never bother about the anatomy.

In medical science there are no mathematical rules are applied. You open an abdomen for appendectomy and you may find any other problem too. So a surgeon must be able to tackle any problem, which he/she can face anytime during surgery.This ability comes from the perfection in basic knowledge of anatomy and physiology along with surgery.

So to refresh and to achieve perfection Surgical anatomy must be taught during residency.

I agree with above comments.. and the reason for asking this question was that traditionally extensive coverage of anatomy was performed as part of medical or premedical curriculum... whereas the emphasis on anatomy has been less and less more recently.. in the current circumstances, it is rather unfair for trainees to just 'pick-up' anatomy as they go along... may be there is a need for a separate module in surgical anatomy as part of surgery training..

regards, raza

Surgical anatomy should be an important part of surgical training. As surgical science progresses toward minimally invasive procedures, the need for a firm grasp in surgical anatomy becomes even more critical.

The ability for surgeons to use tactile feedback to assist them to identify anatomic structures and to determine relationships between viscera is removed with laparoscopic procedures. We find ourselves relying heavily on a firm appreciation of surgical anatomy in order to identify anatomic structures at laparoscopy.

Without being able to definitively identify important anatomic structures, the incidence of inadvertent visceral injuries and/or the incidence of conversions should increase. Therefore, the dwindling attention to the discipline of anatomy seems counter-productive to goals of surgical training. We agree that more attention should be paid to this aspect of training.

The viability of continuing anatomy teachings based on cadaveric specimens has also been questioned. This has been on the decline in Caribbean training programmes as we witness a move toward electronic and/or paper-based anatomy teaching resources. These teaching methods do not allow a comparable appreciation of anatomic relationships.

As trainers, should we not be advocates for continued anatomic teaching based on cadaveric specimens?

Absolultely. The Anatomy taught in Medical School has a different focus than what is required for surgeons. I think a Surgical Anatomy course with a focus on exposures would be a great addition. I know I spent much of my residency trying to apply the Anatomy I knew with what I was seeing in a live patient.

Surgery as an art and science is based on the intricacies of navigating human anatomy. Surgical anatomy, ideally, should distil one's skills to near perfection - upgrading the structured topographical approach learned through cadaver dissection in medical school to standards that appreciate aesthetics, efficiency and safety for the patient. Thus, surgical anatomy should be the bedrock of surgical residency training and only after demonstrating competency beyond reproach should a surgical resident be considered truly a master.

The art science of surgery is a bargain between the "benefits" attained and the "harm" done by the surgical procedure. While it is important to realise anatomical relations usually (that which is learnt in basic Anatomy classes start from undergraduate level), a surgeon will need to know the variations and the ability to identify these variations.

This will mean the difference between protecting or destroying an essential structure. There were times when surgery was supposed to complete expediently and fast and that 'complications' and 'loss of function' was an accepted danger. But, today, even a 1sq. cm of paresthesia can be deemed as 'functional morbidity' by patients!

As a resident in Maxillofacial Surgery, I have often found it difficult applying the standard textbook material/knowledge of head and neck anatomy in the Operation Theater on a live surgical patient ... Sometimes bizarre though it might seem, certain surgical anatomical concepts bear no relevance to the anatomy of the region!

Relevant surgical anatomy will vary procedure wise and region wise ...

For example, while the close relation of facial nerve with the Styloid process is important from anatomical point of view ... someone who wish to identify facial nerve to protect it based on this landmark might have most probably already injured the nerve in his approach!

Lucky to have had a good guide and mentor who did not make us feel embarrassed when we struggled with identification and location of certain surgical landmarks on table! Interestingly, we do not have lots of excellent texts that expound on this ignored aspect of surgical science. Mc Gregor's Surgical Anatomy and Hollinshead's surgical anatomy are some excellent texts in this regard ...

Another important applied aspect of surgical anatomy is the ability to use the high definition CT scans and MRI to be able to make surgical judgements as well as modifications to approaches, or gauge the extent of a lesion accurately so as to have a sound back up plan in doubtful cases.

Residents would do good to read technical notes, modifications introduced and classical literature on particular surgical approaches as they have lots of tips and pointers in relation to surgical anatomy. Dissection for anatomical demonstration is entirely different from surgical 'dissection' on a cadaver! Moreover, exposure / work on fresh cadavers/specimens is of utmost importance especially in today's age of microsurgical procedures!

In absence of a structured surgical anatomy modules / exams, I believe it is the resident's duty to work in this regard and use the experience and knowledge of the mentors/guides as well as use the textbooks/cadaver specimens and literature to improve his skills and surgical 'orientation'! A surgeon should be well oriented to the 'location', 'relation' and 'variations' of his area of training /expertise ... and must be able to anticipate structures rather than them coming as a surprise to him! That will mean less morbidity, speedy procedures and less blood loss!(yes.... in intricate areas like facial regions .. we residents have at times wasted time achieving hemostasis when a bit of anticipation and care would have avoided a flooded field!)

It's my favorite area of interest .... have always been around hunting for concepts / ideas and tips on maxillofacial surgical anatomy .... and ... I guess, I got caried away ... this turned out to be much longer reply than I had anticipated ...

Regards,

Akilesh. R

I am surprized a little to read this discussion. I thought that a Chair of Topographic Anatomy and Operative Surgery has been existing everywhere from times beyond memory.

At any rate, our senior medical students have been having the course from the last quater of the 19th century. That discipline was introduced by prof.Nicolay Pirogov. I thought also that the same practice had been in German universities for longer, app.150 years at least.

That is very good!

But with due respect ... that is not the situation in most other parts of the world. And even if it exists in the curriculum, little attention is given to it. It is "asssumed" the residents should and would get that expertise / knowledge that is required by their own perseverence ...

And nevertheless, that part of Europe has had some of the great surgical minds .... no doubt! It is just that in the name of a 'structured' curriculum, the essence of training has been lost is what I feel. The importance that anatomy enjoyed in the earlier times of surgery has been lost today ... is my humble opinion too!

I am from India and a place which has a very ancient history with surgical procedures since the times of Sushrutha in B.C, but even here the curriculum and exam systems has made surgical trainees view anatomy as just a 'non scoring' subject. For most surgical procedures are reduced to a list of 'moves' - a memorized sequence of steps .... for most .... though not for all perhaps. ... !

Where does surgical anatomy come to play a part in their understanding ? I think people should adapt from such curriculum training methods that incorporate surgical anatomy as an essential part of the training and exams ...

This is a chronic and still unanswered question!

As an anatomy professor and orthopaedic surgeon I hav been managing for 21 years a teaching program (1 year) for the residents in Paris area. This program focuses on surgical approaches in orthopaedic surgery.

The base of this course was : approaches are of major importance in orthoaedic surgery (maybe more than 50% of the success of a procedure).

This experience leads to the following conclusions

1) a place should be given for a specific cadaver programm for young surgeons

2) this kind of program shouln't proposed before the second or third-year residents

3) the simulation programs will not replace cadaver work before long time sice the available simulation programs involve only very specific tasks (like a knot in a box) and not at all the knowledges and the practice of approaches.

THe "ideal teaching" should include theoretical anantomy during the two first years and then practical cadaver courses focused on approaches. The specific technical courses should take place later.

F Bonanno put a very important point concerning the differencies between the usefulness of pictures compared to drawings. PIctures (assuming they are top technical level) provides a huge amount of information. Drawing contains much less information but focused only on the very subject. Therefore it is easier to understand since you have not to sort the information in order to get the proper one.

This is the main basis of anatomy teaching : always introduce with blackboard instead of slides or computer, this allows to put the main landmarks. After this step, students will find self auto improvement withe computer very helpful!

It is critical. Systematic anatomy has a lesser value than regional anatomy in the practice of surgery; and moreover the precise spatial surgical anatomy visualised during approaches should be second nature. Medical schools in both North America and the UK are going away from didactic anatomy teaching and this has an immediate effect on residents who are trying to learn surgical anatomy. 3 dimensional disciplines such as surgery and radiology need an earlier introduction to anatomy if the trainee can capitulate on the opportunies presented in surgery for cementing and reinforcing regional anatomy.

I agree with many of the points above. From my experience in Britain and Australia, anatomy has been side-lined and marginalized in favour of 'softer' disciplines. The fact remains that knowledge of anatomy is the bedrock for surgeons. Application and experience build on this.

Sadly, an increasing number of systems and institutions are more interested in publishing papers, undertaking research, and so on, at the expense of core knowledge and theatre- (O.R.-) experience. This is an unfavourable situation, and whilst I am not denigrating the value of aforementioned areas, I see them as far less valuable than core knowledge AND experience to a surgeon (vs. a clinical researcher or clinical scientist).

My juniors and I have composed two papers on the benefits of anatomy demonstrating, particularly in the context of today's medical educational environment, and the first one is due to be published in 'Bulletin of The Royal College of Surgeons of England', very shortly.

I beg to pardon me if I understood your intentions incorrectly, are going to publish a couple of articles critisizing the existing system of the high medical education? D'you really believe it makes any sence?

Hi Andrew. Allow me to clarify...

1) Critique is an important mechanism for improving matters;

2) Medical curricula are, and rightly, should, be dynamic;

3) If an undergraduate curriculum/ system has been changed and found to have unfavourable consequences, then it is our duty, as today's educators or tomorrow's doctors, to discuss our concerns.

Do you have experience with the medical curricula in Australia and/ or Britain? If so, then you shall realize that anatomy has been devastatingly cut down at many medical schools to allow for other disciplines.

Our articles are highlighting that there is much benefit from being an anatomy demonstrator (i.e. as a postgraduate, junior doctor) given this situation. In other words, we are providing emphasis to the advantages of the role/ position of anatomy demonstrator, especially in today's context.

Hope that clarifies things for you!

Thank you for this profound explanation, moreover that I know almost nothing of the medical curricula in the Commonwealth!

However, there are some questions to discuss. Save the points about critique as an important mechanism, dynamics of the curricula, and these of the anatomical knowledge importance which are quite self-evident.

On the other hand, these very curricula have been developed for some reasons. Times have changed since I was a medical student or surgical resident. There are definite shortage of... so to say... of the corps for anatomy lessons and for dissections everywhere including Russia. Junior students have had lesson of the Normal Anatomy (as it called in my country) on mannequins and by presentations in the PowerPoint. It is terribly bad, but it is forced by environment. Senior students who choose Surgery as their future speciality do perform dissections themselves, but in rather a limited way.

I think so the situation in the UK is alike. If so, would you suggest anything to solve this really actual challenge?

Good evening,

Reading all the contributions lead me to the following statement : in many contries (including France) all of us emphasize the high importance of anatomy in surgical training and regret that the official programs include so few anatomical training. Am I right ?

If yes, the amazing point (at least existing in France) is the absence of official concerns coming from surgeons and the lack of co-operation between surgeons and anatomists to build teaching programs devoted to our residents!

Is it the same in your countries ?

Simulation in surgery is limited to very specific tasks, there are still no possibilities of simulation in the field of surgical approaches (especially for orthopaedic and ENT surgery).

Specimens are, fore more long time, our main "simulator"

The importance of Surgical Anatomy is unquestionable. When I did my part 1 FRCS from London in 1985 Anatomy was a large part of the exam. Also I distinctly enjoyed preparing for this component after having trained in General Surgery for 4 years and my perspective to anatomy teaching and learning was very different than what I had on entering medical school. I am no longer in touch with the current practice in England now, but in India and the US there is only lip service to surgical anatomy.

I value the commnets and opinions of experts above.. The importance of anatomy has been established in this discussion, and so is the trend towards decreasing attention to this field in the undergraduate curriculum across the world..

what remains is suggestions to overcome this 'gap in learning' in surgical training curricula. This could be assessment based on anatomy quiz or teaching anatomy as a separate module, or perhaps holding frequent 'surgical anatomy retreats'.. does anyone have experience with such interventions..

regards, raza

Yes of course. I have published on the relevance of anatomy and demonstrating for surgical trainees. Having undertaken a traditional intensive anatomy programme at university I still felt that a period of 12 months demonstrating was essential for the primary examination and for future practice. The FRCS primary examination acted as a control gate to assess trainees knowledge and commitment to the specialty, Unfortunately it is now possible to gain entry to specialist training with relatively little core anatomy knowledge and therefore it is essential that it is taught and assessed during higher surgical training and for exit examinations.

Totally agree with the above experts. Nothing can replace the anatomy training done by a surgical anatomist, if available, or by very experienced surgeons. And for my specialty, embriology courses and demonstrations, as part of the anatomy program for surgical residents, would be a must. I myself, acted as a voluntary assistant professor at the Medical Shool, during my early years of surgical training. For my younger surgical residents, before taking them to assist in opreations, I strongly recommend them to review the anatomy of the region, rather than the technical procedure.

The best way to learn anatomy is surgery.

The best way to learn surgery is surgery.

...see also:

"Surgical anatomy and anatomic surgery - Clinical and scientific mutualism."

by John Calvin Coffey [Surgeon. 2013 Aug;11(4):177-82.]

I agree with Dr. Spartalis,

Even the theoretical anatomical background is an absolute prerequisite, the only effective way to learn SURGICAL anatomy is surgery. The problem (from my point of view) is that knowledge of anatomy itself is not enough for the surgeon. We act. And there is a need to learn to handle real bleeding (instead of digital models and cadavers), feeling of tissue, gentle handling, perception of pathology etc. – all those things are integral part of understanding and using the knowledge of surgical anatomy. And the latter is always changed by pathology for which we do surgery. My personal approach is to teach residents to learn and follow embryonal avascular planes whenever possible. I believe that knowledge of embryology is one of the keys for understanding surgical anatomy. I also believe (even not evidence-based) that the best and most effective way to learn and teach surgical anatomy is procedure-based.

"...Knowledge of embryology is one of the keys for understanding surgical anatomy.." - agreed completely. However, this approach is not supported still, to the best of my knowledge at any rate.

On the other hand, which resident would be best in surgical anatomy knowledge improvement, one who did/does not study a classic anatomy in proper way , or that one who did, does and keep on it outside the operational room?

Anatomy is 3 dimensional. I think that embryology and anatomy should be incorporated and taught as simulation and 3D demonstration along with the common abnormalities associated with it so the students mind grasps it properly. A contrast shown is always grasped quickly.

I couldn't agree more - all are speaking total sense. Anatomy and the understanding of anatomical planes are essential if one is training in surgery. It really is the sound knowledge of anatomy that gets you out of trouble, esp if tissue is deranged by pathology.

Now in Bristol we have tried to do cadaveric teaching sessions for junior surgical trainees and they seem to enjoy it and benefit greatly. As a demonstrator I am amazed (and concerned!) at the extreme range in abilities, due to perhaps different Medical schools placing different emphasis on anatomy.

This programme has been reintroduced by Prof Alice Roberts. Certainly in the 90's and early after there was a sound Anatomy programme at Bristol. I'm pleased to see it reintroduced for the Core Trainees (residents). It is nice for us as more senior trainees to be in the lab also.

It may not just be useful for trainees but anyone needing a refresher. I think this is particular relevant to surgical oncologists to appreciate mesenteric planes, TME and adequate lymphadenectomy.

JB.

And the confusing lesser sac! It is much easier for trainees to understand this by seeing it rather than just reading about it.

JB.

Yes

But the emphasis should be on the surgical anatomy and not pure anatomy and evaluation should have a practical viewpoint to it rather than pure academic

If implemented correctly the system would enhance the skill, confidence of the surgeon and definitely the decrease the time of surgery, complications and unexpected tragedies

I totally agree with Habeeb Mohamed: clinical relevance is paramount, as opposed to pointless lists of pro-academia material.

John Bunni has correctly noted what a few of us tried to address previously with regard to greatly variable medical curricula across Britain, without a uniform/ standardized examination. Different medical schools, of course, attract candidates with different abilities and achievements, but it is shocking to note the variability in knowledge between graduates of different medical schools. I know many senior doctors who, quite correctly, view graduates of Oxford, U.C.L., Cambridge, Imperial, and a handful of other 'established' medical schools quite differently from those of some medical schools.

This is always a sensitive point - particularly for those who run some of the medical schools that are unofficially scorned upon - but as surgeons, we have to call a spade a spade; for failure to do so is deceptive to all involved.

yes it should be taught separately in the anatomy dissection hall and assessed during the operations and in final exit exam

I teach anatomy to MBBS students in year one and also to Post graduate students in surgery in year 3 ( in a 3 year residency programme during MS Surgery). We also assess students during final MS exam on knowledge of soft parts and bones in the anatomy dissection hall.

Prof Anurag Srivastava MS, FRCS, PhD, MPH

Head, Department of Surgery

ALL India Institute of Medical Sciences NEW DELHI

Yes, surgical anatomy should be tought separately. In our Medical school there is a special academic program of surgical anatomy. It consists of basic anatomy and lectures in all surgical specialties, it takes a year to finish it with final exam and a paper related to importance of surgical anatomy in various surgical procedures. Some of my collegues and myself have finished this program and I can say that that the knowledge we obtained was very helpfull in our surgical training.

Dear all, I agree definitely that knowledge of surgical anatomy and even more to respect principles derived from surgical anatomy will enhance therapeutic benefit and reduce morbiditiy to a great extent. To know embryological develpment of anatomical structures not only facilitates to do preparation in the right layers it furthermore enables to proof concepts of pure surgical control of locoregional tumor spread, as it has been shown for rectal and cervical cancer (TME and TMMR, respectively). Thus, it implies not only more efficacy in techniques but also in strategies.

There is no doubt, that in this century there is no place any longer to learn surgical anatomy by doing, only. With the rapid development of excellent visualization of surgical procedures, accelerated dramatically by "robot-assisted" laparoscopy, there is a huge body of excellent educational videos to learn the strategie and also of "surgical simulators" to train the technique virtually, before performing the procedure in real situation, assisted by a professional surgeon.

Thus, it is convincing evidence that the theoretical knowledge has to be obtained during medical studies and trainee education followed by virtual training and assistance before allowed to perform surgery autonomously.

Examples for gynecological oncology have been given in 3 papers with respect to compartmental surgery in uterine cancer published in WJSO and ISRNobstetric and gynecology in 2013 by R. Kimmig. This way of presenting surgical procedures combined with full length educational videos of the procedure could serve as one way to optimize education of surgicall skills.

Rainer Kimmig, Head of Dpt. Gynecology and Obstetrics, West German Tumor Center, Essen, Germany

Dear Raza

In orthopedic residency program of which I am the coordinator, in the first year of medical residency is obligatory the module of surgical anatomy comprising lectures and dissections in cadaver lab. Its essential for a surgeon

I agree with the surgical anatomy being a separately assessed component of training!

Dear Friends,

I would like to share my family tale to you. I am a third generation surgeon. 70 years ago my father founded the Department of operative surgery and topographic anatomy at the Medical Academy in Sofia, Bulgaria . It has been made under the influence of the Soviet medical school. This department practiced many and different surgical procedures by patients, but simultaneously to these operations performed also anatomical studies on preserved corpuses. After 14 years of existence, this Department has been closed down. One of the former to this time medical director used to deride: “I do not want to be a cadaver surgeon…"

I’m convinced that the study of topographic anatomy is crucial in the current medical education and very essential for the training of a future surgeon. Well, in the modern times, this depends mainly from the local educational programs.

Independently of them, if you perform open or/and mini-invasive surgical procedures, you should be well acquainted with the human anatomy and pathology.

That is an interesting issue ,surgical anatomy may be a missnomer!

Anatomy is one's navigator for short and safe managemnt journey!

Without full knowledge of anatomy ,you can not perform a safe and timely operation.

Surgical anatomy ,medical anatomy ,urological,vascular ,etc ...I don't agree with these classifications ,it is simply anatomy ,the map of human body.

This map has to be known by heart and it has great infleunce on the outcome of any intervention including major procedures.Paying little attention to anatomy is what cause trouble!!!!

Anatomy has to be an essential course of any medical education and the fine details of specific anatomic area of interest can be explored during and after postgraduate specialization .

Anatomy is the cornerstone of surgery. Deeper understanding of anatomical variations will only improve a surgeon's breadth of experience and knowledge. Not only that but also improve his/her ability to deal with the unexpected. I am a strong advocate of teaching the anatomical basis in surgical training.

Dear all, I coudn’nt agree more with all of you for your different interesting point of views. As a matter of fact as a tranplant surgeon I tried to teach to my residents in surgery both anatomy and surgical anatomy during the multiorgan harvesting procedures. I tried always to convey my personal enthusiasm in recognizing in details all anatomical landmarks, with the respect of all anatomical structures and their preservation during the warm phase of multiorgan harvesting in order to have the shortest time possible during the cold phase of bench surgery. During my last 20 years and in more than 400 personal multiorgan procurements I tried also to convey to my residents the knowledge and passion of surgical anatomy increasing their surgical confidence during many basic surgical manoeuvres such as quick sternotomy, quick control of vena cava, thoracic and abdominal aorta, the Cattel and Braash manoeuvre, in recognizing all anatomical variations, or in splitting one liver into two hemi-livers with lovely recognition of all details of complex liver anatomy. This practice of teaching surgical (and non surgical) anatomy I believe and I hope could offer to my residents (compared to others who had not the opportunity of a transplant experience training) a kind of extra gear in term of enthusiasm and ability to learn the basic methodology of navigation in the ocean of human anatomy not only for surgical practice.

I propose and support whenever possible the structured teaching of anatomy and surgical anatomy during multiorgan harvesting for organ transplantation as one of the best oppotunity.

As against the 'old school' where anatomy was a subject to begin with in a medical student's long and wide spread college years, the 'new school' includes anatomy as an integral part of final year medical student teaching where the relevance of anatomy is very well recognized and appreciated. Actually embryology becomes interesting to add to the armamentarium. As regards to the new structured teaching with modules, this integration becomes possible.

At the postgraduate level (General Surgery to subspecialties) the anatomy is so tightly required to be incorporated so that the resident appreciates the basis of the surgical procedures.

Anatomy is no more a 'boring' and difficult subject but a vital tool to build further on, in any medical course, be it MBBS, paramedical like nursing, physiotherapy, etc.

threre was a famous sentence I had heard during my residency programme in geheral surgery which states " SURGERY IS THE SHIP WHICH SAILS ON THE OCEAN OF ANATOMY. this applies to any branch of sugery the results of surgery can definitely gptmised if one masters in basic surgical techniques added with sound anatomical knowledge.. modern gadgets are also helpful in better appreciation of loco regional anatomy ang doing more and more of minimally invasive surgeries which alco helps in early mobilisation of patients and fast track surgery.

Knowledge of anatomy makes the difference between surgeons in complex and complicated cases. A surgeon must have a strong base of knowlede in anatomy and the knowledge will turn into skill with experience.

Surgical anatomy must be taught, again, to the resident of surgery from the angle of view of a surgeon; which is different form what is taught to the basic science student.

Assessment of knowledge of anatomy should be part of every exam during residency.

Anatomy,Physiology and Pathology were tought in our Fellowship training in UK.We used to love the surgical Anatomy lectures.The knowledge of surgical Anatomy

is a MUST in surgical practice and especially as we are in to minimally invasive and Robotic surgeries.Road map for any surgery is sound knowledge of Anatomy.It is worth considering surgical Anatomy as part of surgical training.

yes we should teach Surgical anatomy during residency programmae for all surgical disciplines viz, general surgery, cardiac, urology , pediatric, plastic, ENT, Orhtopaedic Neurosurgery etc.

I teach surgical anatomy to surgical residents in year three and also to MBBS students during year one . It is a fun teaching anatomy because you can co-relate or explain so many clinical phenomena so explicitly .

With every wish for your prosperity, I have the pleasure to remain,

Your's most Humbly, sincerely and gratefully,

Prof Anurag Srivastava , MBBS, MS ( Surgery) -University of Allahabad, FRCS- Royal College of Surgeons Edinburgh, PhD- University of Wales Cardiff, MPH- University of North Carolina-Chapel Hill

Head, Department of Surgery ,

All India Institute of Medical Sciences

Ansari Nagar

New Delhi

INDIA

110029

Phone : Office - 011- 2 6 5 9 4 5 6 0 ; Home : 011- 2 6 5 8 8 2 2 9 ;

mobile : 9 8 6 8 3 9 7 7 2 9

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I think surgical anatomy is best learned during surgery or a lesson included before each chapter for surgical techniques of different parts of the body because this way the student will practically understand the importance of the points he/she had learned in surgical anatomy.

Surgery without being fully aware of anatomy is incomplete.The subject has modified a lot in previous years and a new subject of minimal access or laparoscopic anatomy has also been added.Best way to teach anatomy is to deliver lectures using ppt slides and surgical videos as well, both of open as well as laparoscopic surgical procedures.Overall one should have it as a part of training during residency.

Absolutely, especially now that embryology and anatomy are less comprehensively taught at medical school.