|PRACTICAL ADVICE PAPER
|Year : 2016 | Volume
| Issue : 2 | Page : 152-155
Self-directed learning modules of CT scan images to improve students' perception of gross anatomy
Pananghat Achutha Kumar, Ramakrishnan Jothi, Dharmalingam Mathivanan
Department of Anatomy, PSG Institute of Medical Sciences and Research, Coimbatore, Tamil Nadu, India
|Date of Web Publication||19-Aug-2016|
Pananghat Achutha Kumar
PSG Institute of Medical Sciences and Research, Coimbatore - 641 004, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Background: A contemporary anatomy curriculum that aims to be clinically relevant requires medical students to be introduced to radiological anatomy in the preclinical years. Ideally, the curriculum should also support self-directed learning, a habit best instilled early. Based on these educational requirements, we designed an interesting and clinically-meaningful program of self-learning modules in radiological anatomy to augment students' learning of gross anatomy. The program is guided by current theories of learning, which emphasize an individualized learning pace for students. Methods: This program uses enlarged computerized tomography (CT) scan images and associated resource materials. Scans are posted on the first day of the week in a public area for students to review on their own time. On the second day penciled outlines of important structures are provided to help students identify structures, and students are encouraged to discuss the images with faculty. On the last day of the week the identity of the structures are revealed to students. Results: An open-ended questionnaire used to evaluate the program revealed that 95.5% of students used the program and a great majority recommended the program should be continued for future students. Discussion: The present program enhances learning of gross anatomical relations through having students use visual clues in logically interpreting unlabeled CT scans in an organized and sequential way. The program promotes self-directed learning. In addition to its use with preclinical students, the modules might also help students in the clinical phase of the curriculum bolster their knowledge of spatial anatomy.
Keywords: CT images, self-directed learning, gross anatomy
|How to cite this article:|
Kumar PA, Jothi R, Mathivanan D. Self-directed learning modules of CT scan images to improve students' perception of gross anatomy. Educ Health 2016;29:152-5
| Background|| |
Recent years have witnessed curricular changes in how anatomy is taught to medical students to meet the challenges posed by advances in the field of medicine.  New learning strategies have emerged worldwide for revamping the anatomy curriculum.  Many schools have opted to provide the conventional method with powerful adjuncts as teaching tools, all of which are aimed at making the curriculum clinically oriented, thereby ensuring that the young students are better prepared for medical practice. Considering the relevance of radiological imaging in acquiring competencies in clinical anatomy, utilizing these images to fortify learning of anatomy has been considered more vigorously. ,, These changes, in addition to reflecting the general trends in medical education, address national requirements in the field of medical education as well.
In India, undergraduate medical education spans four and a half years, completed in nine semesters and is followed by a year of compulsory rotating internship. The first year of the curriculum is dedicated to preclinical subjects followed by paraclinical subjects, such as pathology and microbiology, before students proceed to training in clinical subjects. Radiology traditionally is taught during the pre-final (fourth) year for a period of two weeks, followed by clinical rotations during their final year of training. Recommendations have been made for radiological imaging to be introduced during the preclinical stage, since imaging is a common way that these future physicians will encounter anatomy in their careers. ,,
Regulatory authorities like Medical Council of India (MCI) and medical universities have pushed the need to include computerized tomography (CT) scan images in the preclinical curriculum. Through a recent notification, MCI has reiterated this modification in the curriculum of first year MBBS course.  To effectively utilize radiological images to teach spatial anatomy, conventional CT scan films, wherein the images are very small, measuring only 70 mms × 70 mms is, unsuitable. Even though digital images that can be easily enlarged could solve this deficiency, this is not a practical solution in our setting, since not all students have access to the internet. Post-mortem CT (PMCT) images of cadavers dissected by the students are another option to augment learning of spatial relations, but images in this approach have proven to lack clarity and precision. ,
Our school looked for a simple yet effective method to introduce radiological images to preclinical students and to help them learn spatial anatomy in a more interesting, meaningful and clinically-oriented way. We looked for a self-learning format, an important means of learning for physicians  The program we designed was guided by a theory of learning proposed by Honey and Mumford, which emphasizes the importance of an individualized learning pace for every student.  The program we devised ensures that learners can go through the required study material at their own pace.
| Methods|| |
Preparation of resource material
We used CT images from patients who did not show obvious structural pathology of the body regions used to bring out clear spatial relations of important morphological structures of various regions of the body. Images retrieved from the Picture Archiving and Communication System (PACS) of PSG Hospitals, in Coimbatore, India were used for this program. The images on axial, coronal and sagittal planes procured from Siemens SOMATOM Definition Edge machine using routine procedures were edited by the diagnostic software to achieve precise orientation and perfect tissue planes. Images were obtained without labeling the patient's name, age and sex or the technical details of the radiological exposure to not obscure the images and to ensure patient anonymity. For the curriculum we used digital images printed on 9 × 6 inch Kodak Dry film using a Dry View 6850 printer. Digital back-up of this learning material, taken onto a CD was retained as the resource for e-learning.
As a viewing box, we used wooden display boards with multiple screens and ground glass front, illuminated by glare-free fluorescent lamps, which were comparable to a multi-screen X-ray viewing lobby [Figure 1]. Images were easily slid behind the glass front and secured in position.
|Figure 1: Viewing system - Enlarged CT scans and the tracings of the CTs are displayed. Tracings of the images are displayed in a separate panel just below the corresponding CT image (Red arrow)|
Click here to view
| Program|| |
From the serialized images pertaining to the region of study, the initial set of images was displayed on the board on the first day of the week. On the second day, line drawings of these images, drawn on tracing sheets were exhibited on the windows just below the first set of displays. Specific structures were marked by numbers on these tracings [Figure 2]. Students had access to these displays during working hours and were encouraged to study the structures and their interrelations at their own pace and chosen time [Figure 3]. They were instructed to identify the structures and record answers to specific questions like 'Where does this structure terminate?' and 'What is this structure a branch of?', The answer key was displayed on the last working day of the week so students could self-evaluate their responses in identifying the numbered structures and the questions. Students were encouraged to discuss the displayed material with the faculty, thus completing the process of self-directed learning. Subsequent sets of images were released on the board on succeeding weeks. The entire display system was placed in the gross anatomy laboratory where the students spend the most contact hours during their Anatomy course. Design of the program ensured that students had the chance to learn the material presented to them in a phased, self-directed manner and at their own pace.
|Figure 2: Tracing of the CT scan image - Close up view of the tracing of the CT image, with numbers on the structures for identification|
Click here to view
When this program was initially conceptualized, CT scan images were not available electronically. Images for display had to be generated by scanning hard copies of the CT images, enlarging them to the desired size and printing them in a photographic studio. The ability print high resolution images from electronically available CT images simplified the process. Similarly, choosing a display viewer system wherein images and their tracings could be projected at the same time was resolved by designing a simple system [Figure 1] which could be fabricated in the hospital workshop. An enlarged print of each CT/MRI image costs Rs. 800 (approximately US$15). We used a total of six display units, each unit costing Rs. 10,000 (approximately US $155 per unit).
| Program Evaluation by Learners|| |
The project approved by the Institutional Human Ethics committee (No: 14/044). The program was validated by students who volunteered to participate in a questionnaire with open-ended questions about the program. Observations of 143 respondent students out of a total of 150 students in the class were recorded and analyzed. The questionnaire asked how often students used the module and how aware they were of self-directed learning. Open-ended comments about the program were sought.
| Results|| |
Analyses revealed that 96% of the students understood the concept of self-directed learning and endorsed the use of self-directed learning modules (SLM). Eight out of ten (82%) of students used SLM during their course in Gross Anatomy to learn spatial anatomy, although their use of SLM varied from 'daily' (43%) to "once in a while" (8%). Only3% of students did not use this module at all. Nearly all students (96%) recommended SLM as a mode of learning for subsequent years. Comments provided by 14% of students included general characterizations of the program as "Excellent," "Challenging" and "Interesting." Many indicated that they would like to use more such images to learn Anatomy. A few felt that such modules could be used for student assessment during the summative examination held by the University.
This program was approved and was earnestly supported by the Dean for the funding and execution as a self-directed learning module for preclinical students.
| Discussion|| |
A contemporary physician does not encounter internal anatomy of the human body in the dissection hall or in the pathology laboratory, or even during surgical procedures. It is when interpreting radiological images that he most often applies his anatomical knowledge.  Because of recent technological advances, the field of radiological imaging now has unparalleled opportunity to contribute to the field of diagnostics. Medical students need to be sufficiently prepared to practice medicine in this 'imaging milieu'. , Building basic knowledge of radiological imaging early in the undergraduate medical training thus becomes a necessary trend in the emerging curriculum. Furthermore, incorporating CT images into undergraduate anatomy courses has shown to increase students' confidence in identifying structures and in highlighting the clinical relevance of anatomical details as they are learned. ,, It has also helped to promote motivation and comprehension of details. 
Interpreting radiological images is not based on rote memory, but utilizes logical thinking and reasoning. Our program, which utilizes unlabeled CT scans, to bring out spatial relations of a region of the brain in an organized and sequential way, has proven to be useful in enhancing the learning of gross anatomical relations.
Gradual development of the learning module utilizing unlabeled CT Scans in a structured manner has helped students' comprehension of 3D anatomy in a logical manner. The exercise of identifying the structures involved attention to details of the image, and it may be that observing CT images and trying to discern structures contributes to enhancing students' power of observation. The importance of the power of observation in learning has been noted  Moreover, it has been reported that repeated retrieval of facts during learning is the key to their long term retention.  It could be surmised that the images and associated study material, which were displayed prominently, prompted students to look at them repeatedly and thereby enhanced learning.
Display of the readily accessible study material, along with directions to learn spatial anatomy through images, tends to foster self-directed learning. ,,, Since the students have accepted this module as an effective learning tool, it is possible that these students would also welcome similar programs in their clinical years of study, thereby promoting self-learning throughout their careers.
Our program can be expanded to include more details by adding structured questions on the anatomical entities that require analytical skills to solve. These could be developed as part of a mini clinical scenario. When the program is expanded, it will involve identification of structures and learning facts about the structure identified and also its clinical significance. These pre-clinical learning modules thus become clinically oriented tools, to help students develop clinical skills in addition to basic anatomy.
The CT images and the material can also be used as a simple tool for student assessment. Students can be asked to identify individual structures seen on a CT image and can be quizzed about this structure as a part of assessment. The program can be easily transferred onto a digital platform, which is easy to use and maintain.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Authors thank Dr. B. Devanand, Professor and Head of the Department of Radiology, Mr A. Rahamathullah and J. Abubakker Sithik. Radiology Technologists, PSG Hospitals for their help in providing processed CT images.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
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