CHAPTER 2: LITERATURE REVIEW AND THEORETICAL FRAMEWORK
2.4 The Praxis and Research of Anatomy
2.4.3 How much of anatomy do they know?
“For doctors, the human body is the focus of investigation and intervention on a daily basis” (Turney, 2007; p.104). Both anatomists and clinicians jointly agree that a solid and precise knowledge of anatomy and its distinctive variations is important to guarantee safe and efficient clinical practice (Bergman et al., 2011). Anatomy is a subject that is regarded as underpinning the development and maintenance of clinical knowledge and skills (Fasel et al. 2005; Raftery 2006). In the last decade, there have been increasing reports indicating that anatomy teaching is considered insufficient by students, teachers, junior doctors, and experienced clinicians (Tibrewal, 2006; Fitzgerald et al., 2008; Bhangu et al., 2010).
Several authors have reported that the decline in anatomical knowledge of today’s medical students may lead to medical errors (Patel and Moxham, 2006; Rainsbury et al., 2007; Kish et al., 2013). As the body of knowledge of medical sciences gains momentum, growing concerns are articulated about the volume of information in medical curricula and the “increase in factual overload” (General Medical Council, United Kingdom, 2003) due mainly to the integration of molecular biology and genetics into the undergraduate curriculum. Another commonly given justification behind this policy was that learners should be content-driven and not skills-based (Patel and Moxham, 2006). In South Africa, the Health Professions Council of South Africa has not arbitrated on a core anatomy curriculum and each University is responsible for the implementation for their own anatomy curricula. There is agreement that medical students certainly cannot be deprived of anatomical knowledge, although sentiments differ as to its scope (Bergman et al., 2014). The manner in which anatomy is taught to medical students has undergone major changes in recent years (Waterston and Stewart, 2005). The drop in anatomical knowledge has been repeatedly highlighted by authors who lay the blame for its decline on one or more of the following factors:
Anatomy is taught by non-medically qualified teachers
Anatomy plays an important role in the education and training of all health disciplines including providing a foundation for many programms in the biosciences (Fraher and Evans, 2009). Rizzolo and Drake (2008) report that the classical structure of medical schools and other institutes of graduate education have transformed from discipline-centered departments to interdisciplinary programmes and that the expertise of faculty retained in these traditional departments have also changed. There have been several discussions about how much anatomy should be taught and by whom, including when it should be taught in a particular career (Heylings, 2002; McLachlan and Patten, 2006; Azer and Eizenberg, 2007; Collins, 2008; Fraher and Evans, 2009). Despite the increasing growth and relevance of molecular sciences in modern curricula, anatomists are still of the view that the discipline embraces a central role in the teaching of the subsequent generation of clinicians, allied health professionals and scientists (Older, 2004; McCuskey et al., 2005; Winkelmann, 2007). In addition, current public curiosity and general interest in the structure of the human body has resulted in a realization that effective
---35---
anatomical education has to be resurrected and revived (Fraher and Evans, 2009). However, there is a growing lack of suitable educators to convey their knowledge, understanding and skill to junior faculty (McCuskey et al., 2005). In South Africa, medical schools have neglected Anatomy departments. This has led to an older population of Anatomy teachers, who have recently retired or are soon to do so.
These faculty are not replaced by clinician-anatomists or “table doctors,” (these are medically qualified individuals who are part of postgraduate training programmes) who in the past have acted as Anatomy demonstrators. Willan and Humpherson (1999) state that these annual postgraduate training posts are unattractive to trainees.
Moxham and Hanwell (2014) state that it is getting harder to find anatomists (with either clinical and/or scientific qualifications) who have a mastery of their discipline. They further report that faculty without relevant qualifications (and who are appointed in Anatomy departments) are hesitant “to invest the time necessary to master a subject that appears straightforward on the surface, but where it quickly becomes apparent that it requires a significant effort for a fuller understanding” (Moxham and Hanwell, 2014;
216). Van Mameren (2004) reports that faculty with degrees in molecular and cell biology or biochemistry are appointed in Anatomy departments since fundamental biology forms the current body of research in most of these departments. He further elaborates that molecular, cell biologists and biochemists cannot be a considerable source for experienced teachers of anatomy as they are not acquainted with teaching gross anatomy in connection with patient case related instruction.
Memon (2009) states that anatomy teaching faculty with PhDs in anatomical training are an endangered species in his country. This is a similar scenario at the Department of Clinical Anatomy at the University of KwaZulu Natal, where I teach. Of a total of eight faculty members housed in the discipline, only two are clinical anatomists. One has a PhD and the remaining five are currently credentialing towards a PhD (including myself). This reduction in the number of appropriately qualified anatomy teachers within the discipline and the challenges faced by faculty has resulted in an Executive position that embraces the philosophy that “any general scientist can teach anatomy.”
In a study conducted by Kramer et al. (2008) of the eight medical schools in South Africa, three of these institutions admitted difficulties in obtaining suitably qualified faculty to teach anatomy. In their study, the percentage of faculty teaching anatomy ranged from 10-100 per cent and at one institution (which was not identified), all the teaching faculty were medically qualified and had Ph.D. degrees, highlighting the dichotomy of recruitment criteria at the different Institutions within the country.
The absence of a core anatomy curriculum and decreased time for anatomical education
Anatomy education faces a disadvantage as it is not afforded the time and resources necessary to ensure a teaching curriculum that is effective in providing evidence-based knowledge to students. Clinical
---36---
practice, like other medically based subjects, is an imperative skill that needs to be imparted in medical education. A clinician is required to examine patients on a regular basis and should have a thorough understanding of anatomy as this knowledge forms a basis for physical examination (Lockwood and Roberts, 2007). The interpretation of medical images (Allen and Roberts, 2002), as well as the ability to perform clinical procedures in a safe and effective manner (Fitzgerald, 2008), are both examples of the many tasks in a clinician’s daily tasks that require a solid anatomical background. It should, therefore, be a fundamental subject within general medical training. According to Raftery (2007), there are increasing reports of cases of litigation in the United Kingdom originating from a lack of essential anatomical knowledge and training and its clinical application in surgery.
In light of the decreased contact hours with students, some medical educators advocate the implementation of a core-curriculum of the most clinically-relevant areas (Fincher et al., 2009; Craig et al., 2010). According to Orsbon et al., (2013), pre-clinical anatomy curricular recommendations have been established by surveying clinicians in a single specialty or through consensus opinions of groups of expert anatomists. A review of the literature reveals that although many clinicians value anatomy as the most important basic science, they appreciate and relate anatomical knowledge differently, depending on the specialty in question (Pabst, 2009; Arraez-Aybar et al., 2010). If a core anatomy curriculum were in place, teachers (both basic science and clinical) would be aware of what clinically applied anatomy that students were expected to know and it would assist learners in achieving that knowledge. A report published by Louw et al. (2009) describes an ideal anatomy course as having aspects of principles and problem based orientations included in the curriculum. Furthermore, it focuses on the definition of and distinction between ‘general’ and ‘specific’ anatomies, and how these can be taught by using diverse teaching approaches, learning resources and assessment programmes.
At the University of KwaZulu-Natal, the incorporation of anatomy into the medical curriculum has had a turbulent history. Over the last decade, there have been periods where the programme incorporated a prosection-based anatomy course only. Currently, the course entails dissection of anatomical systems within themes. Additionally, the current programme does not have a theme dedicated to Head and Neck Anatomy. The design of the curriculum is handled by a team of medical and non-medically trained scientists which forms the core expert group which generates guidelines on the content of the curriculum. Anecdotal reports from senior faculty at my University illustrate the lack of adequate anatomical knowledge of senior medical students, interns and registrars which prompted the initiation of this study.
Decreased use of dissection as a teaching tool
Anatomy teaching through the time-honoured approach of cadaveric dissection is decreasing, mostly due to time and/or money constraints (Bergman et al., 2011). The teaching methods used in anatomy
---37---
education can be categorised as the follwoing viz.: i) cadaver-related; ii) clinically-related; iii) computer/internet-related; iv) other related material (e.g. models or books); and v) other (e.g. lectures, practical classes, seminars, tutorials). Winkelmann (2007) conducted a broad review study to determine the effect of students’ anatomical knowledge using both cadaveric dissection and the use of prosections (cadavers previously dissected by others). His study revealed that classical dissection seemed to propose a minor added advantage when compared to prosections. However, Biasutto et al. (2006) reported that best student performances were established in a group of students who learnt by both dissection and the use of computer resources.
According to a recent South African study by Dachs et al. (2010), interns demonstrated a particularly poor knowledge of anatomy in an assessment questionnaire. The authors suggest that the anatomy component should receive increased emphasis in the undergraduate curriculum as a good knowledge of anatomy is essential, not only to understanding any injury or disease process, but to also practise safely in any clinical medical field. Dachs et al. (2010) have suggested further studies to define why medical students perform poorly. He recommends a review of the curriculum including aspects like time allocation and content and cites teaching methods and teacher skills as being essential in ensuring that medical students obtain the knowledge and skills in their undergraduate training which will enable them to go out into the community and practise good medicine.
Further, a study conducted by Griffiths and Roberts (2005) illustrated that junior doctors were ignorant when it came to identifying correct anatomical landmarks for the safe insertion of intercostal chest drains; these would have been placed outside of the safe triangle as recommended by the British Thoracic Society.
A review of the above literature inspired me to write the manuscripts on autoethnography, viz.
“Bits, bytes and bones: An Autoethnographic Account of Challenges in Anatomy Education:
Perceptions Emanating from a Selected South African University” and
“Communities of practice: a new methodology in anatomical research and teaching”
Using the gross anatomy laboratory as an ideal setting, the next section explores the methodological stance of “reflection” by students about their learning of human anatomy.