Education for Health

ORIGINAL RESEARCH ARTICLE
Year
: 2019  |  Volume : 32  |  Issue : 2  |  Page : 62--74

Approaches of anatomy teaching for seriously resource-deprived countries: A literature review


Ana Yoe-Cheng Chang Chan1, Olle ten Cate2, Eugène J. F. M. Custers2, Maarten S van Leeuwen3, Ronald L. A. W. Bleys4,  
1 Department of Morphological Sciences, National Autonomous University of Nicaragua, Leon, Nicaragua
2 Center for Research and Development of Education, University Medical Center Utrecht, Utrecht, The Netherlands
3 Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
4 Department of Anatomy, University Medical Center Utrecht, Utrecht, The Netherlands

Correspondence Address:
Ana Yoe-Cheng Chang Chan
Department of Morphological Sciences, Faculty of Medical Sciences, National Autonomous University of Leon
Nicaragua

Abstract

Background: Teaching anatomy is an important but expensive part of the medical curriculum, potentially more than many countries can afford. In the search for efficient methods, cost-effectiveness is of utmost importance for such countries. The aim of this contribution is to provide a review of the literature on anatomy teaching methods, evaluating these for feasibility in resource-deprived countries. Methods: A literature review was carried out to identify distinct approaches to anatomy teaching published in the period 2000–2014, using the databases of PubMed, Wiley Online Library, Elsevier, HINARI, Springer, and ERIC. The approaches found were compared against their conceptual, operational, technical, and economic feasibility and Mayer's principles of effective instruction. Results: Our search yielded 432 papers that met the inclusion criteria. We identified 14 methods of teaching anatomy. Based on their conceptual feasibility, dissection and technology enhanced learning approaches appeared to have more benefits than others. Dissection has, besides benefits, many specific drawbacks. Lectures and peer teaching showed better technical and economic feasibility. Educational platforms, radiological imaging, and lectures showed the highest operational feasibility. Dissection and surgery were found to be less feasible with regard to operational, technical, and economic characteristics. Discussion: Based on our findings, the most important recommendations for anatomy teaching in seriously resource-deprived countries include a combination of complementary strategies in 3 different moments, lecturing at the beginning, using virtual learning environment (for self-study), and at the end, using demonstration through prosected specimens and radiological imaging. This provides reasonable insights in anatomy through both dead and living human bodies and their virtual representations.



How to cite this article:
Chang Chan AY, Cate Ot, Custers EJ, Leeuwen MS, Bleys RL. Approaches of anatomy teaching for seriously resource-deprived countries: A literature review.Educ Health 2019;32:62-74


How to cite this URL:
Chang Chan AY, Cate Ot, Custers EJ, Leeuwen MS, Bleys RL. Approaches of anatomy teaching for seriously resource-deprived countries: A literature review. Educ Health [serial online] 2019 [cited 2019 Dec 6 ];32:62-74
Available from: http://www.educationforhealth.net/text.asp?2019/32/2/62/271196


Full Text



 Background



Anatomical science has long been regarded a cornerstone in medical education.[1],[2],[3],[4] Knowledge of the anatomy of the human body is important to understand how both structure and function are modified by disease,[3],[5] but also to perform a good physical examination.[4] The teaching of anatomy has, for many ages, dominated the medical curriculum.[2],[5],[6],[7],[8],[9],[10],[11],[12] In the second half of the 20th century, the curricula changed and more time became devoted to other disciplines, often at the cost of anatomy.[13],[14] To maintain the required level of anatomy knowledge of medical students, many schools have explored and developed new and more efficient teaching approach. However, a factor that has been considered less frequently is the cost-effectiveness and feasibility under difficult circumstances. Teaching anatomy a dissecting room is one of the most expensive components of the undergraduate medical curriculum.[4] Many countries around the world are seriously deprived of financial means but are at the same time in high need of a well-trained medical workforce.

The medical education literature has abundant examples of new methods of teaching anatomy. Most publications claim that the new strategy has been successful.[15],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25] Failing education is rarely reported. Most reports do not compare approaches to anatomy teaching but describe a stand-alone educational method. Our aim was to identify educational strategies that fit the students' learning needs, specifically in low- and middle-income countries (LMIC), with the purpose to classify methods according to educational approach, resources, and feasibility.

The aim of this paper is to review the state of the art in anatomy teaching available in the scientific literature of the last 15 years, providing an overview or taxonomy of methods with their benefits and limitations with a focus on cost-effectiveness.

 Methods



We performed a scoping review with a realist purpose, answering the question: What different approaches are used to teach gross anatomy? Which of them are feasible in LMIC?

A review of original articles was performed in scientific journals on medical education that addressed the subject of anatomy education during a period of 14 years (2000–2014) using the following electronic databases and virtual journal libraries: PubMed, ERIC, Wiley online library, HINARI, SPRINGER, Elsevier sciences direct, LWW, Taylor, and Francis. The starting year of 2000 was chosen as an estimated point in time when electronic media would be substantially introduced in anatomy teaching. All titles and abstracts were reviewed by the first author and were excluded if they did not meet the inclusion criteria.

Inclusion criteria were original articles, articles that addressed one or more approaches, strategies and/or methodologies in the undergraduate anatomy teaching in heath professional careers, and English language.

The articles were categorized as traditional (methods that commonly have been used in medical schools, these methods are mainly teacher-centered and nonintegrative) and innovative (strategies which emphasize an active, self-directed learning and integrative courses; those strategies have been implemented in medical schools for 50 years or less, due to anatomy teaching being very traditional).[26],[27] Next, the approaches found were rated on conceptual feasibility (to supplement academic learning.), organizational feasibility (organizational infrastructure and time needed), technical feasibility (managerial knowledge and skills, human resources, and technological capacity needed) and economic feasibility (cost of the didactic materials and resources needed for both students and teachers) and instructional effectiveness [Figure 1].{Figure 1}

Instructional effectiveness was operationalized by analyzing the teaching strategies and relating to the nine principles that Mayer has proposed:[28]

Coherence principle: eliminate extraneous materialSignaling principle: highlight essential materialContiguity principle: place printed words near corresponding graphicsPretraining principle: provide pretraining in names and characteristics of key conceptsSegmenting principle: break lessons into learner-controlled segmentsModality principle: present words in spoken formMultimedia principle: present words and pictures rather than words alonePersonalization principle: present words in conversational or polite styleVoice principle: use a human voice rather than a machine voice.

All methods found in the literature were viewed from the perspective of instructional theory using these Mayer's principles of instructional design.

 Results



From an initial yield of 607 articles about anatomy education, a total of 432 original articles met the inclusion criteria. We identified 14 methods of teaching anatomy that can be further categorized. Next, we compared the methods with on conceptual, operational, technical, and economic feasibility [Table 1]. All teaching methods are described with their benefits and limitations in [Table 2].{Table 1}{Table 2}

Lectures

Didactic lecturing in anatomy education is as traditional as dissection and follows the learning objectives for students.[12] It is characterized as a teacher presenting theoretical contents to a group. The event requires the presence of the participants in a specific time and location.[29]

Dissection

Dissection, one of the main anatomical learning tools in medical schools, has been used worldwide in teaching anatomy for >400 years.[30] Dissection of human cadavers is the physical exploration of a dead human body through cutting and is essentially a regional-based approach to learning topographical anatomy.[31]

Demonstration

Three anatomical demonstration modes can be distinguished: prosection of cadavers, using plastic models, and plastination.

Prosected cadavers provide learners with predissected material. Some universities have chosen to teach anatomy through prosected cadavers and specimens and have abolished dissection courses.[26] Leung et al. (2006) found course hours in the prosection class to be 74% shorter than dissection class. One study found knowledge retention of anatomy 5 years after training to be similar in prosection group and dissection groups.[32] Plastination is a relatively new advancement in cadaveric science; an effective technique of tissue preservation of entire organs or cross-sectional body slices introduced in 1987. Using polymers such as resin, silicone, and polyester give differing mechanical properties that ultimately result in robust, dry, odorless, and life-like specimens, which can be used well in an educational capacity in gross anatomy and radiology.[12]

Problem-based learning

A problem-based learning (PBL) curriculum enables students to integrate basic and clinical science, evidence-based decision-making, clinical reasoning, and psychomotor skills.[33],[34] PBL's application to anatomy teaching requires a close follow-up of each student with regular feedback on his/her work. Students create and share learning objectives, including ones related to anatomy and obtain the required information through textbooks, the internet, assigned disciplinary resource staff, skill laboratories, anatomy museum, and audio–visual aids. Anatomy is incorporated in the majority of the problems and their accompanying learning activities; the proportions vary according to the problem or the system unit in question.[24],[33]

Anatomy in the living body: Physical examination

Anatomy can be studied in the living body through physical examination (through simulated patients and peer examination), where the surface anatomy is vital. This method can be very useful in studying some systems and/or organs such as muscles, bones, joints, peripheral nervous system (through the study of tendon reflexes), abdominal organs, and cardiorespiratory organs.[35],[36]

Anatomy in the living body: Radiological imaging

Radiology education, such as radiographic, ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI), offersin vivo visualization of anatomy and physiology as well as insight into pathological processes.[12],[37],[38],[39],[40],[41] Common methods to integrate radiology with anatomy instruction include concurrent radiology lectures, small group learning with and without formal instructors, and radiologic images of deidentified patients in the dissection laboratory.[42]

Anatomy in the living body: Observation of surgeries

The sixteenth and seventeenth centuries operation theaters were created as the first amphitheaters of anatomy, initially intended for surgical demonstrations, dramatized rather than functional to teach anatomy. These procedures were also known as “theatre operations,” which subsequently, due to the need to train surgeons, the theatres acquired educational functions and therefore became surgical amphitheaters[43],[44] Nowadays, the operating theater is no longer an educational setting but, in contrast, a challenging place in which to learn; and especially suitable for medical residents.[45]

Anatomy in the living body: Body painting or drawing

Painting internal structures on the surface of the body can be effectively used in conjunction with palpation and auscultation.[23],[31],[35] Students find it a highly memorable experience that leaves them with strong visual memories and a heightened appreciation of the links between visual, tactile, and auditory aspects of human anatomy.[46]

Technology-enhanced, self-directed learning in anatomy

Among the basic sciences, gross anatomy represents a unique opportunity for the incorporation of technology and electronic dissemination of information because of the visual nature of the course material.[38] There are teachers who have incorporated the technology into anatomy teaching in different forms or variants.[29],[38],[47],[48],[49] Technology-enhanced learning through didactic resources like the anatomical commercial packages[50],[51] and numerous free and commercial apps[10] can be particularly successful when the teaching content and exemplars are predominantly visual.[29]

Educational virtual platforms

In educational platforms, also called learning management system (LMS) or virtual learning environment (VLE), interactivity is an important element in instructional design, as it serves learner interest, cognitive processing, and curriculum integration.[52],[53] Allen et al. report on the implementation of a website called ARI (Anatomy Reports on the Internet), allowing students to document cadaveric findings online with photographs and text, providing an opportunity for medical students to research, describe, and publish their findings, albeit in a limited format.[53]

Social virtual platforms

Facebook and YouTube invite users to actively participate in content creation and editing through open collaboration between members of communities of practice (collaborative learning).[15],[54],[55] One study showed the use of Facebook to supplement traditional anatomy education as an appropriate instructional tool; they found that 94% of the students rated the page as very good or excellent; in addition, the page was perceived by 89% of students to be effective in contributing to their learning experience.[54] Some authors believe YouTube's popularity should be considered an effective tool to enhance anatomy instruction if the videos are better scrutinized, diversified, and aimed toward course objectives,[15],[56] but there is no consensus in the literature.[55]

Miscellaneous

Some have explored unconventional methods such as Comics trips/Limmerick,[20],[57] Yoga and Pilates,[16] and Plasticine/clay modeling.[21],[39],[58] In such cases, “fun” is one feature they have in common, but they can also be useful for those students with preference for a kinesthetic learning style. However, these methods are limited to the study of a single system (muscle), as in the case of yoga and Pilates and clay modeling.[16],[21]

For each of these 12 anatomical teaching methods, benefits and limitations are described, as well as Mayer's educational principles, and summarized in [Table 3].{Table 3}

 Discussion



For the selection of strategies, we must consider the type of content and skills to be developed, as we have seen, not all strategies are suitable for the teaching and learning of all content (conceptual, procedural, and attitudinal) and skills (cognitive, psychomotor, psychoaffective, and communication). Anatomy for its theoretical–practical nature needs strategies that develop both conceptual and procedural content, as well as cognitive and psychomotor skills.

Our literature review revealed fourteen distinct approaches to the teaching and learning of anatomy. Of those 14 different approaches, we specifically evaluated their feasibility for LMIC and classified this feasibility (conceptual, economic, operational, and technical). Different approaches to teaching and learning experiences in anatomy are driven by many factors and perceptions, for example, the curriculum, assessment, previous educational experience, and the influence of staff and fellow students. Not all faculty teaching anatomy appear to have had appropriate training in dissection techniques, radiological images reading, teaching methodology, or computer skills.[25],[59],[60] Anatomy teachers are usually medical doctors and senior medical students or recently graduated doctors, usually serve as teaching assistants. Some aim primarily at gaining work experience or securing a temporary income and do not feel much passion for teaching anatomy. This may affect education, as the quality may not to be optimal when teachers do not fully understand or do not enjoy what they teach. Motivation of faculty affects motivation of students.[61]

Dissection and prosection remain useful for understanding the three-dimensionality of the human body and the haptic perception, distinguishing the texture of the different tissues of the body.[4],[5],[25],[30],[46],[62] However, its expenses are clear limitations, given the high costs of transportation, maintenance, and the disposing of cadavers.[4],[25],[36],[59],[63],[64],[65] These and other limitations, such as safety risks due to the exposure to formaldehyde[36],[38],[59],[66] and the time-consuming nature,[67] make prosection and dissection operationally, technically, and economically unfeasible methods in LMIC.

While PBL is known to stimulate retention and acquisition of basic science knowledge,[27] inadequate resources are often a limitation; it requires faculty training on PBL facilitation and adequate infrastructure to assist small groups,[68] making it operationally and technically a less feasible method in LMIC. PBL was not originally designed for the acquisition of basic science knowledge and is generally believed to be more suitable for clinical knowledge.[69]

The use of radiological imaging helps to give a more practical and applicable sense to the knowledge of gross anatomy, as radiology is rapidly expanding as a domain in medicine to visually represent the body in numerous ways.[42],[70] However, it only meets 5 of 9 Mayer's principles, also its economic and technical feasible are not optimal. Many anatomy departments may not be large enough to purchase facilities for ultrasound, CT, or MRI[71] and have trained staff to use these.[72]

Online tools can be very attractive for current generations of students, and it helps to increase the interest of a difficult topic such as the gross anatomy.[73],[74] Online learning is reported to be as effective as traditional methods in the training of health professionals, yielding retention of skills and knowledge up to 25% more than traditional methods.[75] However, computer skills vary among learners, and there may be technical difficulties using the programs or platforms.[52],[76] Despite these the risks, specifically for LMIC if adequate technical support staff lacks, its operational feasibility is one of the most appropriate, providing learners with content and interaction anytime and anywhere.[77]

Mayer's principles that are most found are the signaling and segmenting. These principles go hand in hand and complement each other, since anatomy can be studied segmented, addressing only one anatomical system or region (segmenting). It keeps students focused on the task by highlighting the truly essential information (signaling) [Table 2].

The literature highlights successes of several approaches in the teaching of anatomy used so far. Therefore, an eclectic model, it means, a combination of complementary strategies could be the better way of teaching and the key to meet the curricular changes and the current needs of teaching and learning, for better understanding, retention, and application of anatomical knowledge.[72],[78],[79] For example, at the beginning of anatomy course, traditional strategies such as lectures can be used to give a general orientation of the topic to study. Next, innovative strategies such as VLE for self-study session with the aid of a study guide, homework and academic chat to clarify doubts using. At the end, it can be practical classes on 2 phases, the first one, traditional with models and prosected specimens and the second one, innovative with use of radiological imaging and CAL (Computer Aided Learning), that way the anatomy is studied both in the dead (specimens/cadavers prosected) andin vivo(use of imaging) with an emphasis on self-directed learning. However, none of these methods are useful without a proper instructional design and without well-trained anatomy teachers.[4]

Our review was set out to yield recommendations for anatomy teaching in resource-deprived countries. If viewed from the perspective of educational principles, combined with feasibility of execution, technology-enhanced learning and educational platform methods seem most promising. However, it is important to remember that, despite the many benefits of technology in the teaching of anatomy, “the most important thing in e-learning is not the technology, it's the teaching.”[80] An aspect to consider is the pretraining principle in both students and teachers; these methods need training in how to use them (platform or software), how to design an online course and also professional staff who manage the educational platforms. In addition, it is important to have constant electrical power, a good and fast internet service, which fail in resources-deprived countries.[81] Not all these methods are economically and technically optimal, but it is expected that the economic and technical cost will decrease as the initial investments may serve many generation of students. In addition, compared to the cost of the maintenance that entails dissection, technology-enhanced learning and LMS are cheaper in the long term.

Acknowledgments

The authors wish to thank Dr. Ligia Cruz, MD, PhD and Dr. Sonia Acevedo, MD, Family doctor specialist, for their collaboration reviewing and editing the paper.

Financial support and sponsorship

The authors received no financial support neither sponsorship.

Conflicts of interest

There are no conflicts of interest.[110]

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