Relevance of anatomy to medical education and clinical practice: perspectives of medical students, clinicians, and educators

Table 1 describes agreement ratings for statements addressing the role of anatomy within the undergraduate medical curriculum in UCC DEM, UCC GEM, and UL GEM students.

As indicated in Table 1, UCC DEM provided higher agreement ratings relative to UCC GEM and/or UL GEM for the following areas of relevance: anatomy and patient/cadaver contact (UL GEM, t (436) = 9.84, p < 0.0001); anatomy and structure of human body (UCC GEM, t (482) = 3.30, p = 0.001; UL GEM, t (436) = 10.64, p < 0.0001); anatomy and professionalism (UCC GEM, t (481) = 3.30, p = 0.001; UL GEM, t (435) = 5.61, p < 0.0001); anatomy and ethics of medicine (UCC GEM, t (480) = 3.15, p = 0.001; UL GEM, t (437) = 6.97, p < 0.0001); anatomy and teamwork and communication skills (UCC GEM, t (481) = 4.64, p < 0.0001; UL GEM, t (437) = 4.29, p < 0.0001). UL GEM demonstrated higher agreement ratings relative to UCC DEM for the following area: anatomy and self-directed learning (t (437) = 4.00, p = 0.001).

UCC GEM demonstrated greater agreement ratings relative to UL GEM for the following statements: anatomy and patient/cadaver contact (t (216) = 6.40, p < 0.0001); anatomy and structure of human body (t (216) = 6.03, p < 0.0001); anatomy and ethics of medicine (t (215) = 3.79, p < 0.0001).

Table 2 summarizes mean agreement ratings (±SEM) for statements addressing the role of anatomy in the undergraduate medical curriculum and its relationship with clinical practice in clinicians and anatomy educators, respectively. Clinicians de-emphasized the link between anatomy education and professionalism, principles of scientific method and evidence-based medicine, and awareness of ethics of medicine (agreement rating range = 3.2–3.5), while also minimizing its contribution to lifelong, self-directed learning, teamwork and communication skills, and critical thinking. Anatomy educators provided generally high agreement ratings for each of the statements; the statement which received least support indicated that educators were equivocal about whether the course should be responsive to feedback from the wider society.

When asked whether the time dedicated to anatomy education within the curriculum was ‘too little’, ‘too much’, or ‘sufficient’, UCC DEM were most likely to indicate that it was ‘sufficient’ (89 %), followed by UCC GEM (79 %) and UL GEM students (48 %) (χ₂ = 11.20, p < 0.004). Among clinicians, 80 % indicated that the time dedicated to anatomy was ‘sufficient’, while 9 % indicated that it was ‘too little’. Of the anatomy educators, 50 % felt that there was ‘too little’ time dedicated to anatomy, with remaining educators satisfied that it was sufficient.

Table 3 provides a summary of mean rankings (±standard error of the mean, SEM), based on perceived importance, for anatomical teaching methods in UCC DEM, UCC GEM, UL GEM, clinicians, and anatomy educators and a description of results of ANOVA analyses and subsequent post-hoc group comparisons in relation to ranking of teaching methods.

All groups showed a high level of agreement with the proposition that anatomy education was an important element of the medical curriculum. However, the agreement rating data indicated that clinicians were equivocal about whether anatomy education contributed to their ability to function effectively in a clinical role. This may also underlie their perception that anatomy education has not contributed majorly to professionalism-related competencies. Clinicians showed comparatively low agreement ratings (ranging from 3.1 to 3.4 on the 5‑point scale) with statements indicating that anatomy promoted professionalism, teamwork and communication skills, as well as critical thinking and scientific methods. It has been suggested that the anatomy course initiatives including the introduction of inter-professional activities at the preclinical level (including anatomy) may help to foster a sense of professional identity, and increase competencies in areas such as teamwork, communication, and awareness of ethics [5]. However, a recent intervention-based study, which aimed to integrate professionalism into anatomy teaching using a case-study-discussion intervention, reported that the intervention was largely without effect on various outcome measures of professionalism [14]. The present study highlights the perceived lack of relevance of anatomy education to such competencies among selected groups (i. e. clinicians, as well as GEM students where the same pattern was observed), and is suggestive of a complex relationship between anatomy course content and teaching of medical professionalism. Specifically, it is proposed that the present data might reflect the tendency for medical students and recently graduated clinicians to view professionalism as a topic which can only be addressed in a clinical setting, and ideally based on observation of doctors rather than formal teaching [15]. However, recent research indicates that relatively junior clinicians in the present study may not fully appreciate the relevance of anatomy content to diagnostic reasoning and clinical decision-making. It has been shown that junior medical doctors in particular use anatomical knowledge in all phases of the consultation, especially during physical examination [16].

It is generally recognized that the viewpoint of clinicians should be taken into account if the aim is to develop an anatomy curriculum relevant to daily clinical practice [10]. Previous work has shown that while there may be areas of clinical care which rely to a greater (e. g. imaging and diagnostics) or lesser (e. g. doctor-patient communication) extent on anatomical knowledge, all groups in the current study (echoing previously published results) rated clinical relevance as a crucially important element of the anatomy curriculum.

While all participants were in agreement that patient/cadaver contact is important, it was clear that GEM students (in particular UL GEM students) found this to be less of a priority, reflecting the non-cadaveric nature of the UL GEM programme which focuses on diagnostic imaging and case-based problem solving. All agreed that anatomy teaching is important for integrating basic and clinical science content. It has been found that the introduction of a greater clinical focus in basic science teaching may help to bridge the gap between basic science and clinical practice [17]. All participants in this study agreed with the statement that anatomy education is closely related to reading of diagnostic imaging scans. The clinical images may help students to put into perspective the significance of learning the anatomical information and allow them to apply their newly learned anatomical knowledge to real-life situations. Anatomy teaching programmes incorporating radiological images tools such as MRI, X‑ray, CT, have generally proven successful [18].

GEM students were also significantly less likely than their DEM colleagues to agree that anatomy education contributed to the development of professionalism or their awareness of ethics in medicine, or that it improved their teamwork and communication skills. It has been suggested that international GEM curricula often seek to harness their broader life and work experience, allowing them to develop the more equal partnerships, encouraging reflective practice, and more outward looking perspectives that underlie medical professionalism [19]. One explanation for the perceived lack of focus on professionalism within the anatomy curriculum among GEM students is that it reflects the increased academic load which is a consequence of the compression of the traditional five-year courses into the four-year GEM timeframe. Several initiatives designed to foster professionalism development within the anatomy curriculum, including meeting the families of anatomical donors (e. g. Halliday et al) [20], can be logistically challenging to incorporate into crowded and time-poor GEM curricula. Another explanation is that it might reflect differences between GEM and DEM students with respect to attitudes to professional behaviours and medical professionalism [21]. When medical undergraduates (particularly GEM) were asked how they felt professionalism is best taught, role models and learning through experience were identified as being the most useful instructional techniques [21]. These results would suggest that GEM students in the present sample find it more difficult than their DEM counterparts to appreciate the relationship between anatomy curricular content and professionalism, well as transferable skills including teamwork and critical thinking.

Educators expressed dissatisfaction with the number of hours dedicated to anatomy teaching within the curriculum; this sentiment is congruent with reports of increasingly fewer hours dedicated to anatomy education within medical curricula [1, 3]. Additionally, educators also displayed little enthusiasm for the proposal that they should undertake course modification in response to feedback from the wider community and society.

Lecturing and anatomical laboratory practicals are the main preferred methods for learning and teaching anatomy across all groups. These findings also support the use of cadavers as a tool for teaching by either dissection or prosection. Some studies have shown that dissection is essential for understanding and learning anatomy, and that retention is highest when learning is combined with experience of dissection [17]. It has been suggested that active observation and participation in cadaveric dissection guided by demonstrators helps the understanding of three-dimensional structures and enhances development and attitudes towards teamwork [17].

Demonstrator-led small group teaching was also rated by all stakeholders as one of the three most important teaching methods. A recent comparison of structured vs. unstructured anatomy learning environments revealed that levels of anatomical knowledge for the strictly guided, station-based learning group were higher than for the loosely guided, self-directed learning group. These data suggest that unstructured learning environments may be less appropriate for junior learners, who may lack an appropriate mental framework and are therefore hindered in taking up new information [22]. In this context, it is noteworthy that the preference for demonstrator-led teaching was highest among the youngest students cohort, the DEM cohort, in the present study.

One important question arising from these data is whether medical education curriculum developers should in fact take into account research evidence for preferred pedagogical methodologies and/or individual learning strategies and requirements of specific student cohorts when designing anatomy courses. Kirschner and Van Merrienboer [23] suggested that one of the most popular ‘urban legends’ in education is the pervasive notion that learners know best how to adapt learning to their own preferred learning styles. The assumption arising from this notion is that teachers or instructional material developers should take into account their preferences so as to facilitate their learning and help them achieve the best possible learning outcomes. However, it is known that preference for a particular mode of instruction is not correlated with improved productivity among those who experience their preferred instructional technique [23]. Others have suggested that self-regulated learning theory should be invoked to explain the relationship between students’ learning engagement and academic performance in anatomy courses [24]. Self-regulated learning theory focuses on the active participation of students in personal, behavioural, motivational, and cognitive efforts to achieve valued academic goals. In this context, level of self-regulation modulates students’ employment of learning strategies, engagement with anatomy course material, and the extent to which activities and taught sessions are linked with expected learning outcomes [24]. Therefore, a failure of self-regulation might underlie the reported disconnect between preferred teaching methods and academic achievement. With respect to implications for course development, rather than focus on tailoring the curriculum to match the stated preferences of specific learner cohorts, it has been proposed that it may be more valuable to focus on the fundamental things that learners have in common rather than on the multitude of styles on which they may be different from each other [23].

One of the limitations of the present study was the limited sample size achieved for anatomy educators, and the likely diversity within the entire sample with respect to experience and familiarity with various anatomy teaching methods. Additionally, among the clinicians, several of the teaching methods referred to in the survey, including computer-assisted learning, would not be as easily available as they are for current medical students. In a similar vein, while differences in how anatomy is taught between UCC and UL graduate-entry programmes produced a number of interesting differences in perceptions and attitudes between both groups, their different experiences of anatomy education provides a degree of context to the observed differences in attitudes/perceptions. Another limitation of the present study is that selected types of validity (e. g. predictive, construct) and reliability were not established for the survey tool employed in this study. Measurement of validity was limited to contact validity, bearing in mind that many of the survey items were based on content adapted from the World Federation for Medical Education guidelines for integrating basic sciences into medical curricula [25]. Lastly, the response rate for the clinician sample (14.1 %) is considerably lower than that reported for the other groups in the current study. This is likely due to a combination of factors including a busy clinical schedule, inaccurate mailing list information, and the difficulty associated with increase in web-based survey requests in recent years.