Benefits of extracurricular participation in dissection in a prosection-based medical anatomy program
Abstract
The purpose of this study was to evaluate the extracurricular cadaveric dissection program available to medical students at an institution with a modern (time-compressed, student-centered, and prosection-based) approach to medical anatomy education. Quantitative (Likert-style questions) and qualitative data (thematic analysis of open-ended commentary) were collated from a survey of three medical student cohorts who had completed preclerkship. Perceived benefits of dissection included the hands-on learning style and the development of anatomy expertise, while the main barrier that limited participation was the time-intensive nature of dissection. Despite perceived benefits, students preferred that dissection remain optional. Analysis of assessments for the MD2016 cohort revealed that dissection participation was associated with enhanced performance on anatomy items in each systems-based unit examination, with the largest benefits observed on discriminating items that assessed knowledge application. In conclusion, this study revealed that there are academic and perceived benefits of extracurricular participation in dissection. While millennial medical students recognized these benefits, these students also indicated strong preference for having flexibility and choice in their anatomy education, including the choice to participate in cadaveric dissection. Anat Sci Educ 11: 294–302. © 2017 American Association of Anatomists.
INTRODUCTION
Driven largely by modern accreditation standards (Irby et al., 2010), the preclerkship component of undergraduate medical education (UGME) has evolved. More time is now dedicated to active learning, self-directed learning, and earlier clinical exposure (CACMS, 2015; Harvard University, 2015; LCME, 2016; Stanford University, 2016). These considerations have led to time constraints in preclerkship UGME, the period of medical training that traditionally emphasized gross anatomy (Ghosh, 2015). The resulting constraints have created an environment where UGME anatomy courses have had to consider a number of adaptations (Sugand et al., 2010). Some schools have replaced isolated anatomy courses with integrated, systems-based anatomy teaching (Drake et al., 2009, 2014; Drake, 2014). In addition, professor-centered lectures have given way to student-centered approaches (Nieder et al., 2005; Vasan et al., 2008; Morton and Colbert-Getz, 2017). Finally, markedly less time is now devoted to teaching anatomy in medical schools (Drake et al., 2009, 2014; Bergman et al., 2014; Drake, 2014). Related to this reduction in teaching time is the reduction in time devoted to cadaveric dissection.
This de-emphasis of cadaveric dissection in medical schools has been described in the United States (Drake et al., 2009, 2014), Canada (Ovsenek, 2013), the United Kingdom (Chapman et al., 2013), Europe (Pais et al., 2017), and Australia and New Zealand (Craig et al., 2010; Moscova et al., 2015; Bouwer et al., 2016). Notably, this trend is common to both undergraduate entry medical schools (Ovsenek, 2013) as well as medical schools where graduate-level entry is more common (Craig et al., 2010; Bouwer et al., 2016). In both cases, there appears to be increased reliance on previously dissected cadaveric material (prosections). For example, while cadaveric material is used in anatomy education at nearly every Canadian medical school, only 50% of medical schools offer cadaveric dissection in their formal curricula (Ovsenek, 2013). In fact, at least one institution only utilizes cadaveric material on an elective basis, and another Canadian medical school recently considered discontinuing the cadaveric laboratory resource altogether (Ovsenek, 2013).
It has become increasingly difficult to define what role cadaveric dissection should fulfill in modern medical schools. On the one hand, there is limited quantitative evidence supporting the notion that cadaveric dissection improves anatomy knowledge relative to other methods of anatomy instruction (Nnodim, 1990; Nnodim et al., 1996; Winkelmann, 2007; Cuddy et al., 2013). It must be noted that these studies have typically looked at relatively short-term outcomes such as performance on medical school examinations. Nonetheless, program administrators looking to provide curricular time for new initiatives may argue that de-emphasizing cadaveric dissection will not negatively impact medical student performance. Conversely, cadaveric dissection has long been considered the “gold standard” of anatomy education, in part, for reasons that cannot be easily captured by examinations (Kerby et al., 2011; Chapman et al., 2013; Fillmore et al., 2016). For example, dissection is suggested to improve manual dexterity (Johnson et al., 2012; Ovsenek, 2013) and enhance appreciation for anatomical spatial relationships (Johnson et al., 2012; Chapman et al., 2013; Ovsenek, 2013). Cadaveric dissection may also strengthen professional attitudes (Lachman and Pawlina, 2006; Korf et al., 2008; Patel and Moxham, 2008; Pearson and Hoagland, 2010; Fernandes et al., 2015). Considering that a basic understanding of anatomy is perceived to be critical to delivering patient care across all medical disciplines (Lazarus et al., 2012), reducing cadaveric dissection in medical schools may have negative consequences on trainee clinical preparedness (Bohl and Gest, 2011). The central question to this debate focuses on the value of providing cadaveric dissection opportunities to the modern medical student.
The University of Ottawa Medical Program features an anatomy component that can be considered representative of several current trends in medical anatomy instruction (Whelan et al., 2016). Anatomy content is delivered in an integrated, systems-based curriculum over two preclerkship years, featuring a relatively recent (2008) and marked reduction in anatomy teaching time, from 81 hours to 46.5 hours. Classroom anatomy lectures have been almost completely eliminated, as anatomy content is now delivered through prosection-based laboratories. Cadaveric dissection opportunities are, however, available to medical students through extracurricular elective dissection. These electives are offered concurrently to match the subject matter being covered in the prosection laboratories. In 2014, a global evaluation of curricular and extracurricular anatomy education was performed. A previous publication focused on student perceptions of the small group learning environment in the prosection-based curriculum (Whelan et al., 2016). Medical students noted appreciation for the efficiency and student-centeredness of the prosection-based laboratories. However, students also noted that the learning experience could be improved by optimizing the teaching approach used and support provided by small group facilitators (Whelan et al., 2016). The goal of the present article was to delineate student perceptions of elective dissection and to evaluate the value of optional dissection in the context of a modern medical anatomy curriculum. An additional aim was to determine whether optional participation in dissection was related to performance on student assessments.
MATERIALS AND METHODS
Organization of the Prosection-Based Anatomy Curriculum
The prosection laboratories in the curriculum are organized in a systems-based approach over two preclinical years in the University of Ottawa Medical Program (Table 1). Anatomy education is delivered through 31 laboratories, with each session lasting 1.5 hours (46.5 hours of laboratory instruction). The small group learning approaches utilized in the curricular laboratory sessions involve select elements from team-based learning (TBL) and flipped classroom pedagogy, such as individual readiness assurance tests (IRATs), an emphasis on pre-session preparation using online resources, and the devotion of session time to student-driven learning. The teaching approaches used in the curricular laboratories have been discussed in a recent publication by these authors (Whelan et al., 2016). It must be noted that there are major differences between conventional TBL and the approaches utilized at this institution (Whelan et al., 2016). For example, the IRATs used locally are abbreviated (two-item, 5 minutes) versions of those used in conventional TBL. Furthermore, formal peer evaluation, considered a core element of TBL, is not included in these laboratories (Nieder et al., 2005; Vasan et al., 2008).
| Extracurricular dissection | |||||
|---|---|---|---|---|---|
| Participating students | |||||
| Unit | Prosection-based laboratories in medical program: number of sessions (hours) | Dissection electives: number of sessions (hours) | Dissected regions | Dissectors | Peer teachers |
| First year | |||||
| MSK | 9 (13.5) |
3 (10) 3 (10) 3 (10) |
Back Lower Limb Upper Limb |
M1 | M2 |
| CARDIO-RESP-RENAL | 8 (12) | 3 (10) | Thorax | M1 | M2 |
| Second year | |||||
| GI-REPRO | 9 (13.5) | 3 (10) | Abdomen | M2 | M2 |
| NEURO | 5 (7.5) | 3 (10) | Head/neck | M2 | M2 |
- MSK: musculoskeletal unit; CARDIO-RESP-RENAL: cardiovascular-respiratory-renal unit; GI-REPRO: gastrointestinal-reproductive unit; NEURO: neurology unit; M1: first year medical students; M2: second-year medical students.
Organization of Elective Dissection
Preclerkship first- and second-year medical students (M1 and M2) have the opportunity to complement their prosection-based anatomy education with elective dissection (Table 1). The electives are offered to correspond in time with the prosection-based curriculum (i.e., dissection of the limbs is available to the students when the curriculum is focused on musculoskeletal anatomy). Each elective is 10 hours in duration, divided into three sessions. Credit is attendance-based (no assessment is involved). During each session, students were assigned to groups of four to six students and work through the specific objectives guided by M2 peer teachers and instructions provided in Grant's Dissector (Tank, 2012). Students and peer teachers were provided with the dissection objectives and assigned to read relevant sections of the dissection manual prior to electives to encourage self-directed preparation. Preparation was not assessed. Every student who registered for the elective was accommodated. Peer teachers were encouraged to relate dissection-based objectives to relevant curricular and clinical anatomy and to challenge participants with questions. Typically two or three faculty members circulated between dissection groups to offer guidance.
Program Evaluation Survey Development, Data Collection and Analysis
The methods relating to the present characterization of elective dissection are similar to the procedures used for the anatomy curriculum program evaluation at this medical school (Whelan et al., 2016). Using feedback from faculty and medical trainees, a pilot medical student survey was created using the SurveyMonkey® platform (SurveyMonkey, Palo Alto, CA). Feedback from the pilot was collected, the survey was optimized, and the final survey (Supporting Information File S1) was sent electronically to all 478 medical students who had completed their preclerkship anatomy education in May 2014 (classes MD2014, MD2015, and MD2016). These students would have participated in elective dissection between the 2011–2012 and 2013–2014 academic years, during which the electives were consistent in several regards. Specifically, the level of peer teacher involvement, number of electives offered, and pre-session materials available for preparation were consistent during this time period. Survey items included close-ended (with options for elaboration via open-ended commentary) and open-ended questions. Three qualitative researchers used grounded theory (Charmaz, 2006; Watling and Lingard, 2012) to identify key themes that emerged from open-ended commentary (Finn and McLachlan, 2010). Working independently, these researchers used an open coding approach to identify themes in the first ∼33% of the qualitative data set. Themes were defined via group consensus (Saldaña, 2013). Inter-coder reliability was approximately 80% and the final structure was administered to the entire data set using the NVivo software, version 10 (QSR International Pty Ltd., Melbourne, Australia). The reliability of specific survey items related to the construct of cadaveric dissection value was formally assessed. Cronbach's alpha was calculated to be 0.68 and considered to be satisfactory. It must be noted that Cronbach's alpha for the entire survey was low do to the assessment of several, unrelated constructs, including many items devoted to the prosection-based curriculum that were published previously (Whelan et al., 2016).
Analysis of Performance Outcomes
Practical examination data (which included items related to anatomy, histology, pathology, and radiology) were collected for all of preclerkship for the MD2016 cohort. Analyzing one cohort enabled the study of a group of students who were assessed at the same time with identical examination items, and were subjected to the same delivery of curricular content. The impact of elective dissection participation on performance on the non-anatomy component (pathology, histology, and radiology items), the anatomy component, and the discriminating subset of anatomy items was determined. Discriminating anatomy items were considered to be those with discrimination indices of at least 0.20. The discrimination index is the difference between the proportions of individuals responding correctly in extreme groups (conventionally the top 27% of a group versus the bottom 27% of a group) and can vary between −1.0 and 1.0 (Sax, 1989). A discrimination index of 0.20 in this study indicated that the top 27% of the class performed 20% better on a given item relative to the bottom 27% of the class. This item can be interpreted as successfully distinguishing between top and bottom performing students. All assessment items featured multiple choice questions (MCQs, with five choices and one correct answer) and anatomy MCQs were related to tagged cadaveric structures. In each practical examination, approximately 50% of all anatomy items assessed basic knowledge (e.g., structure identification), while 50% of all anatomy items assessed application of knowledge (clinical presentation or loss of function associated with a tagged structure). Sample identification and knowledge application items that were discriminating are included in Supporting Information File S2. These assessment data were analyzed and statistical significance (P < 0.05, one-way ANOVA) was determined utilizing SPSS software, version 24 (IBM Corp., Armonk, NY).
Ethical Approval
The protocol was reviewed by the Ottawa Hospital Research Ethics Board and was considered a study for the purposes of program evaluation, and thus received exempt status. All data (survey items and assessment data) were anonymized, and surveys were completed on a voluntary basis.
RESULTS
Characteristics of Survey Respondents: Previous Anatomy Education and Career Interests
The overall response rate of all students was 47.1% (225 out of 478 possible students), representing 98 out of 162 preclerkship (M2) students, and 127 out of 316 clerkship students (M3 + M4). Response percentages were not statistically different (P < 0.05, one-way ANOVA) between preclerkship and clerkship groups so these data were pooled for subsequent analyses.
More than half of all respondents (121/225, or 53.8%) noted participation in at least one dissection elective (Dissectors) while 46.2% did not participate in any electives (Non-dissectors). Approximately two-thirds of individuals (61/93, or 65.6%) who reported no pre-medical human anatomy education participated in electives. While there only few students reporting prior education using cadaveric prosection or dissection (31/225), only 41.9% (13/31) of these students participated in dissection. Medical students were asked to self-report their level of interest (no interest, moderate interest, or strong interest) in the surgical specialties at the onset of medical school. Of the 61 students who reported strong interest, 49 (80.3%) participated in at least one elective. A much lower percentage (43.9%, or 72/164) of students who expressed no or moderate interest in surgery participated in dissection.
Perceived Benefits of Participation in Elective Dissection
Dissectors were also asked to describe the benefits gained from participation in dissection. Several themes emerged from the collected commentary (Table 2). The most frequently cited theme related to learning style. Within this theme, students showed regard for the hands-on approach provided by dissection: “I learned more being involved in exposing nerves, arteries than when they were dissected for us. It gave me a better understanding of the relevant material.” Students also valued the ability to improve three-dimensional and spatial knowledge of anatomy during the course of dissection, in addition to the opportunity to physically apply curricular knowledge.
| Theme | Representative general perceptions |
|---|---|
| Benefits | |
| Learning style | Strengths and valued aspects of dissection include hands on approach (ability to work manually, become proficient with dissection tools); opportunity to appreciate aspects not apparent in prosection (i.e., 3D relationships, fascial planes); application of knowledge provided sense of accomplishment |
| Knowledge | Students expressed great value for both reinforcing curricular anatomy material and learning clinically relevant anatomy supplemental to formal curriculum |
| Group dynamics | Students appreciated team-based approach to dissection; certain benefits of team-based learning were better realized in Electives than in curricular laboratories; value for near-peer teachers |
| Faculty | Students valued opportunity to engage faculty, have questions or confusion (related to either curriculum or elective) resolved by faculty |
| Areas requiring improvement | |
| Time considerations | Reservations regarding time included the time-intensive nature of the Electives, the inflexible nature of the schedule, the reluctance committing to several afternoons in advance, and the perception of “dead time” (time not actively dissecting) during Elective |
| Group sizes | Some electives featured too many students per cadaver and reduced opportunities for active dissection per individual |
| Peer teacher variability in quality | The peer teachers (second year medical students, for both first and second year dissections) were highly variable in preparedness, familiarity with dissection procedures, ability to address confusion, and ability to engage group with relevant questions or clinical implications |
| Educational value of electives | Adding educational activities (clinical cases, quizzes) to address “downtime” when students not actively dissecting; improving student accountability (for both peer teachers and dissecting students) |
- Themes are listed in order of prevalence (percentage of student comments representing that theme).
The second most cited benefit was related to knowledge. Some students stated that the process of dissection helped “clarify items that I found confusing in the regular class,” and that “dissection electives allowed me to consolidate knowledge gained in the limited class time.” Other students expressed value for learning clinically relevant material (including surgical anatomy) beyond the scope of the formal curriculum. Other benefits that emerged from the thematic analysis of commentary included the opportunity to participate in group-based learning, the opportunity to teach near-peers, and the level of interaction with faculty.
Areas Where Elective Dissection Could Be Improved
Several items generated open-ended student feedback regarding how the electives could be improved (Table 2). Non-dissectors were asked to identify factors that deterred participation in these electives. Commentary revealed that the time-intensive nature of the elective (three afternoons/10 hours) was the most frequently perceived barrier. In addition, some students cited that the electives were redundant based on their previous cadaveric dissection experience. Several students identified that there was excessive “dead time” and passive learning in the electives. Commentary suggested that the reduction of group sizes could increase active dissection time per participant. Other issues related to the educational value of the electives. Dissection participants felt that the variability in peer-teaching direction had a profound impact on student experience: “Some tutors took great time in going over the objectives and teaching anatomy whereas others sort of left the students do whatever they liked. I found the latter to be a less meaningful learning experience (sic).” Several suggestions for improvement were related to enhancing the educational structure of the electives. Students believed that clinical correlations should be incorporated into the electives. One student suggested offering dissection during clerkship. A less prevalent theme encountered in the commentary was that the dissection elective objectives could be better achieved if Dissector and peer-teacher accountability was reinforced.
Should Dissection Remain Available to Undergraduate Medical Students?
Respondents were asked to express their level of agreement (on a six-point Likert scale, where 1 = indicated strong disagreement and 6 = strong agreement) with the statement: “The opportunity to participate in cadaveric dissection should remain available to undergraduate medical students.” Both Dissectors (5.83 ± 0.27) and Non-dissectors (5.75 ± 0.33) expressed similarly strong agreement (mean ± SEM; no significant difference between groups) with this statement. Open-ended commentary reflected this appreciation: “Though I personally did not participate in a dissection elective, I believe this should remain as an option for students, as I know quite a few students who participated in these electives with a keen interest in strengthening their anatomy knowledge and/or a surgical specialty.” Comments accompanying this survey item praised dissection, citing most of the benefits outlined in Table 2. Few comments suggested that dissection should be incorporated into the formal curriculum. To the contrary, most students believed that the curriculum should remain prosection-based.
Examination Performance Related to Dissection Participation
Preclerkship practical examinations (Table 3) from the MD2016 class were analyzed to characterize the relationship between dissection elective participation and student performance in each systems-based unit (Table 4). Dissectors outperformed their Non-dissector peers on non-cadaveric anatomy items by a relatively small (4–5%) margin in the musculoskeletal unit (MSK), cardiovascular-respiratory-renal unit (CARDIO-RESP-RENAL), and gastrointestinal-reproductive unit (GI-REPRO), with no difference in performance in the neurology unit (NEURO). Dissectors also outperformed their Non-dissector peers by a similar 5–6% margin on cadaveric anatomy items, with the exception of GI-REPRO, where Dissectors scored 10% better on these items. Finally, on discriminating cadaveric anatomy items that typically assessed knowledge application, Dissectors were far more successful, particularly in GI-REPRO (10% better) and NEURO (13% better) units. The class of MD2016 students who participated in two or more dissection electives (n = 39) tended to outperform students who participated in just one elective (n = 57) across all three categories (non-anatomy, anatomy, and discriminating anatomy items), though these differences did not reach significance (P < 0.05, data not shown).
| Number of questions | ||||
|---|---|---|---|---|
| Unit | Non-cadaveric anatomy | Cadaveric anatomy | Total | Discriminating cadaveric anatomy (with application of knowledge) |
| MSK | 65 | 38 | 103 | 20 (15) |
| CARDIO-RESP-RENAL | 68 | 28 | 96 | 9 (7) |
| GI-REPRO | 74 | 24 | 98 | 19 (14) |
| NEURO | 23 | 16 | 39 | 8 (6) |
- MSK: musculoskeletal unit; CARDIO-RESP-RENAL: cardiovascular-respiratory-renal unit; GI-REPRO: gastrointestinal-reproductive unit; NEURO: neurology unit. Discriminating items were defined as assessment items with a discrimination index >0.20.
| Unit | Participation in dissection electives | Students (n) | Non-cadaveric anatomy items % (±SD) | Cadaveric anatomy items % (±SD) | Discriminating cadaveric anatomy items % (±SD) |
|---|---|---|---|---|---|
| Year one | |||||
| MSK | +DIS | 83 | 76.0 (±8.1)a | 87.7 (±7.8)a | 81.9 (±12.6)a |
| −DIS | 81 | 72.3 (±8.8) | 81.6 (±12.3) | 75.2 (±15.0) | |
| CARDIO-RESP-RENAL | +DIS | 31 | 65.7 (±9.2)a | 85.8 (±6.2)a | 82.1 (±14.3)a |
| −DIS | 133 | 61.2 (±9.7) | 80.6 (±9.42) | 74.2 (±18.8) | |
| Year Two | |||||
| GI-REPRO | +DIS | 28 | 77.8 (±7.2)b | 88.8 (±8.7)a | 87.6 (±9.7)a |
| −DIS | 134 | 73.2 (±9.0) | 78.2 (±12.9) | 74.2 (±15.0) | |
| NEURO | +DIS | 14 | 82.0 (±10.1) | 87.1 (±10.5) | 76.8 (±20.7)a |
| −DIS | 147 | 81.6 (±10.0) | 82.1 (±10.3) | 66.5 (±18.2) | |
- Performance data on the practical examinations are shown as mean percentage ± standard deviation. Significant differences between group that participated in Dissection Electives (+DIS) versus corresponding group that did not (−DIS) demarcated by a(P < 0.01) or b(P < 0.05, one-way ANOVA). Discriminating anatomy items were cadaveric-based anatomy examination questions that featured a discrimination index >0.20; MSK: musculoskeletal unit; CARDIO-RESP-RENAL: cardiovascular-respiratory-renal unit; GI-REPRO: gastrointestinal-reproductive unit; NEURO: neurology unit.
DISCUSSION
The prosection-based anatomy curriculum at the University of Ottawa is, in many ways, a model representing several current trends in medical anatomy education discussed elsewhere (Bergman et al., 2014; Drake, 2014). The opportunity to participate in extracurricular dissection is available to students through dissection electives. A program evaluation study of these electives offered the opportunity to address uncertainty regarding what role cadaveric dissection should occupy in modern UGME. This study determined that, in the context of a modern approach to medical anatomy education, students perceive that cadaveric dissection is valuable in terms of knowledge and skill development. Furthermore, elective participation was associated with increased performance on examination items, particularly discriminating items that assessed anatomy knowledge. However, while medical students expressed strong value for having the option to participate in dissection, students also remarked that dissection should remain voluntary and not be incorporated into the formal anatomy curriculum.
Dissection electives appeared to be more desirable to those without any previous exposure to cadaveric-based education. These findings are consistent with previous observations by Larkin and McAndrew (2013) regarding the selection of extracurricular dissection classes and previous anatomy training. Medical students will likely continue to vary in pre-existing anatomy knowledge, particularly in Canada, where anatomy courses are not a prerequisite for admission to any medical school (AFMC, 2016). As such, optional dissection during medical school or educational interventions prior to medical school, such as anatomy “boot camps” (Herling et al., 2017) or pre-courses (McNulty et al., 2016), may reduce differences in anatomy preparedness that exist in students early in medical training.
The pool of students who identified strong interest in surgery was dominated by individuals participating in dissection. However, many individuals that self-identified limited inclination for the surgical specialties also participated in these electives. This suggests that dissection is valued by medical students regardless of career interests. This notion is consistent with studies establishing that cadaveric dissection and anatomical knowledge are perceived by clinicians and residents across various fields to be essential (albeit to differing extents) to their clinical preparedness (Pabst, 2009; Bohl and Gest, 2011; Lazarus et al., 2012; Orsbon et al., 2014; Fillmore et al., 2016).
The main benefits to participation in dissection electives were related to learning style, group-work, and knowledge development. The positive notions regarding learning style and teamwork represent benefits attributed to cadaveric dissection described elsewhere (Patel and Moxham, 2008; Kerby et al., 2011; Davis et al., 2014; Bouwer et al., 2016). Notably, these benefits are not easily captured by conventional examinations. Students also articulated a strong appreciation for dissection in terms of strengthening curricular and extracurricular anatomical knowledge. This extracurricular material was frequently recognized as being useful for the preparation for clinical duties. Similarly, students also commonly perceived benefits regarding surgical anatomy knowledge, an area severely underrepresented in modern medical schools (Fillmore et al., 2016; Sheikh et al., 2016).
These knowledge-based benefits perceived by Dissectors were accompanied by better examination performance on anatomy items relative to Non-dissectors. Moreover, when isolating the subset of discriminating items that typically tested application of anatomy knowledge, the difference in performance between Dissectors and Non-dissectors was even greater. This advantage was largest in the second year of the curriculum during assessment of ability to apply gastrointestinal-reproductive anatomy and neuroanatomy knowledge. This academic advantage of dissection is consistent with recent studies objectively demonstrating improvements in knowledge as a result of optional anatomy dissections (Ramsey-Stewart et al., 2010; Pizzimenti et al., 2016; Rae et al., 2016; Pais et al., 2017). In addition, another study indicated that the quality of dissection has a positive association with assessment performance (Hofer et al., 2011; Nwachukwu et al., 2015). However, other research has demonstrated either advantages for prosection-based education relative to dissection-based education (Nnodim, 1990; Nnodim et al., 1996), a small advantage for students who learned from prosection and dissection relative to dissection alone (Cuddy et al., 2013), or negligible differences between students who learned from prosection versus dissection (Winkelmann, 2007). These discrepancies may be attributable to the nature of the anatomy items used on the various assessment tools. It has been recently shown that examination items assessing higher order levels of learning can discriminate between students who perform similarly on items that assess lower order levels of learning, such as structure identification (Whelan et al., 2016; Morton and Colbert-Getz, 2017). However, extracurricular time (whether part of the electives or not) spent in the laboratory was not tracked in this study. As a result, it is unclear whether the stronger performance by Dissectors was related to increased time working with the cadaveric specimens, as opposed to being strictly related to the dissection experience per se.
Nonetheless, the response from the medical students surveyed was resoundingly clear: cadaveric dissection should remain available in UGME. Many students cited that the benefits previously described would be lost if dissection electives were discontinued. This appreciation and regard for cadaveric dissection is consistent with recent studies (Kerby et al., 2011; Chapman et al., 2013; Ovsenek, 2013; Davis et al., 2014). Despite the perceived value for dissection locally, only a minority of students expressed a desire for integrating dissection in the formal curriculum. It appears that medical students at this institution preferred the flexibility of choice and the time-efficiency provided by a prosection-only curriculum. This finding is consistent with the notion that modern millennial students place great value in determining how they learn in medical school (Pettit et al., 2017; Ramnanan and Pound, 2017).
Advocates of cadaveric dissection, such as Bohl and Gest (2011), have argued that dissection is essential to anatomy education and to preparing graduates for careers in surgery. Dissection may also facilitate the development of competencies related to professionalism (Pearson and Hoagland, 2010), interprofessionalism (Fernandes et al., 2015), and the humanities (Lachman and Pawlina, 2006). However, these competencies may also be developed via prosection-based anatomy education (Topp, 2004). Furthermore, others (Topp, 2004; Bergman et al., 2008) have argued that modern anatomy education may not need full-body dissection so long as established pedagogical approaches are incorporated in anatomy instruction. Considering the limited time afforded to anatomy education locally, the limited use of full body dissection in Canadian UGME programs (Ovsenek, 2013), and the results of this program evaluation study, a prosection-based curriculum with optional dissection may best serve University of Ottawa medical students. Invested, interested students can then be exposed to the benefits of dissection described herein. These students tend to be those with no previous cadaveric-based education or students with strong interests in surgery.
As with any program evaluation study, these findings indicated that the student experience in the dissection electives could be improved. To address these items, initiatives that have been characterized at other institutions were adapted and piloted in the electives in 2015–2016. Modern students value clinical context (Bergman et al., 2008; Bohl and Gest, 2011; Orsbon et al., 2014; Ramnanan et al., 2014). As such, PowerPoint-based clinical cases with relevant clinical imaging were loaded on laboratory computers during the electives. Because modern students value structured learning (Hofer et al., 2011; Kooloos et al., 2012; Davis et al., 2014) and formative feedback (Burgess and Ramsey-Stewart, 2014), itemized checklists and formative quizzes have also been incorporated into dissection activities.
These tools are also now provided to peer-teachers, to guide their preparation for teaching. These resources are also made available in the laboratory outside of dissection electives, for all students (regardless of elective participation) to use during self-study. Finally, enrollment in electives and group sizes (approximately four students per cadaver) has now been limited to increase dissection opportunity for each participant. Future program evaluation will determine if these adaptations effectively addressed concerns related to “dead time,” variability in peer teacher preparation, and improving clinical context. Future vertical integration of dissection electives may allow clerkship students to benefit from dissection at the same time they are applying anatomical knowledge in clinic (Bergman et al., 2008; Lazarus et al., 2014; Orsbon et al., 2014; Fillmore et al., 2016).
Study Limitations
Demographic data were limited to certain relevant items (previous anatomy education, surgical interests) but did not include conventional age, gender, or pre-medical academic information. This study focused on student perceptions and was therefore limited by the caveats associated with survey data. For example, students with a strong appreciation of anatomy may have been more likely to participate in the survey, and their views may have been over-emphasized in this study. Moreover, the assessment data only measured one cohort (class of MD2016), while the survey data conveyed perceptions from a proportion of three cohorts, making it difficult to relate one set of findings to the other. Assessment of future cohorts will be necessary to confirm whether these findings can be replicated. As with any study of elective education, Dissectors were a self-selecting group which itself presents limitations relative to other study designs. This study was also performed at a single site in a particular context (prosection-based, student-centered anatomy instruction). As such, the generalizability of these findings is limited relative to multi-institutional studies, especially when one considers that the delivery of medical anatomy instruction is highly variable. Finally, future studies need to determine the impact of differential dissection elective participation on longer-term outcomes (residency choices, performance on anatomy items on clerkship examinations, etc.).
CONCLUSION
In light of these program evaluation data, it appears that optional cadaveric dissection holds value and provides benefits across all invested UGME students (not just those surgically-inclined) in the context of a medical school with compressed curricular anatomy education. Students (regardless of interest in surgery) can benefit from perceived gains in curricular and extracurricular knowledge, the opportunity for manual application of knowledge, and observing three-dimensional anatomical relationships not readily appreciable on prosections. Dissection elective participation was associated with enhanced examination performance on anatomy items, particularly on items that assessed application of knowledge. Modern medical students expressed great value for having the ability to choose whether or not to supplement their anatomy education with dissection experience.
NOTES ON CONTRIBUTORS
ALEXANDER WHELAN, M.D. is a resident in the Division of Physical Medicine and Rehabilitation, Department of Medicine at Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada. He is a graduate of the undergraduate medical program at the Faculty of Medicine, University of Ottawa, Ottawa, Canada.
JOHN J. LEDDY, Ph.D. is a an associate professor in the Department of Cellular and Molecular Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Canada. He is the Director of Evaluations and the Director of the Francophone Preclerkship Curriculum for the undergraduate medical program and his research interests include student assessment and factors related to admission to medical programs.
CHRISTOPHER J. RAMNANAN, Ph.D. is an associate professor in the Division of Clinical and Functional Anatomy, Department of Innovation in Medical Education, Faculty of Medicine, University of Ottawa, Ottawa, Canada. He teaches all dissection- and prosection-based anatomy sessions to the medical students and his research interests include anatomical education and characterizing scholarly activities in medical students.
