"Anatomy Lessons, a Vanishing Rite for Young Doctors&qu

[Guest moo]

Here's an interesting article from the NY Times, about how anatomy is being phased out of many med schools. I think it's a good idea, and although using computers can never replace cadavers, I feel that anatomy is an ancient science that is becoming more and more irrelevant to the practice of medicine. Even as a surgeon, I feel that you will learn most of the anatomy during your rotations, not during a dissection in your first year.

 

 

By ABIGAIL ZUGER

 

Published: March 23, 2004

 

 

ver the centuries, dissecting the human body has evolved from a criminal offense to a vehicle of mass entertainment to an initiation rite.

 

In the Middle Ages, human dissections were forbidden. In 17th century Europe, medical school dissections were open to the public and often attracted unruly crowds cracking obscene jokes. By the 20th century, dissection had become the exclusive purview of scientists and a mandatory rite of passage for all doctors.

 

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The scandals reported this month with donated cadavers at the University of California, Los Angeles and Tulane University are simply the most recent in a field long beset by abuses.

 

In 18th and early 19th century America, the public repeatedly rioted against doctors and medical institutions accused of dishonoring the dead. In 1878, the body of Senator John Scott Harrison (the son of President William Henry Harrison) disappeared from its Cincinnati crypt, only to surface in the dissection laboratory of a local medical school.

 

Now, though, the place of dissection in medical education is changing in ways that have not been seen before.

 

The hours devoted to formal anatomy training are sharply down in medical schools. Anatomy instructors are in short supply. Computerized scans and three-dimensional recreations of the human body provide cleaner, more colorful teaching tools than the time-consuming dissections of the past.

 

Some educators say that dissection, as taught to medical students since the Renaissance, is on its way out. Others maintain it is becoming more important than ever, not only for teaching the structure of the human body but also for the more subtle lessons it can impart on the meaning of being a doctor.

 

"It is always difficult to decide how much anatomy should be learned by a doctor," said Dr. Frank Gonzalez-Crussi, a retired pathologist in Chicago who has written extensively on the history and philosophy of human dissection.

 

Much of the traditional anatomy curriculum is irrelevant to medical practice and might easily be eliminated, Dr. Gonzalez-Crussi said, but there is still no substitute for dissection, which forces the student, willy-nilly, to confront human mortality.

 

Through the mid-20th century, medical students typically spent hundreds of hours dissecting. Working in small groups with scalpels and scissors, they would tease out every major structure in the body, including tendons, arteries and nerves, memorizing dozens of tortuous pathways and hundreds of Latin names in the process.

 

But as the focus of medical science has shifted from whole organs to cells and molecules, more and more teaching hours are consumed by molecular biology and genetics.

 

"Something has to give somewhere," said Dr. Arthur F. Dalley II, director of medical gross anatomy at the Vanderbilt School of Medicine.

 

That something has been anatomy. Surveys show that today's medical students may spend more than 80 percent less time in dissections than did students in the 1950's. The personnel to teach anatomy courses have declined in parallel: anatomy faculty members are aging, Dr. Dalley said, and fewer classically trained graduate students are available to replace them. In many universities, anatomy departments have been engulfed by other departments in the biological sciences.

 

A shortage of donated cadavers is not the big problem. Most medical schools receive enough to meet their teaching needs. Anatomical research continues to have practical applications, for example, in the design of new implants or prosthetic devices. Still, startling new discoveries in anatomy are uncommon, and money for research is sparse.

 

"It seems that anatomy has fewer and fewer advocates," Dr. Dalley said.

 

To supplement dissections, medical schools now routinely use computer-based tools, most often C.T. and M.R.I. scans of living patients. Some programs take advantage of the National Library of Medicine's Visible Human Project, which provides radiologic scans and actual digitalized photographs of cross sections of a male and female cadaver.

 

Computer-generated models — like one program that gives the viewer the illusion of flying through the nooks and crannies of a human skull — can clarify tiny, convoluted anatomical structures in a way that actual preserved specimens cannot.

 

A handful of schools now pare down anatomy courses by sparing students all hands-on contact with a cadaver. At the University of California at San Francisco, for instance, students learn anatomy by inspecting important structures in cadavers that have already been dissected by an instructor.

 

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Studies have shown that students who learn anatomy from professionally prepared dissections, called prosections, perform about as well on standardized tests as those who do the dissection themselves. But anatomists bristle at any suggestion that either prosections or computer models will make them obsolete.

 

"It is very definitely not a trend," Dr. Dalley said.

 

Dr. Todd Olson, a professor of anatomy at Albert Einstein College of Medicine in the Bronx, noted, "There are some excellent computer-based resources, but they are not a replacement for the cadaver."

 

Dr. Carol Scott-Conner, a professor of surgery at the University of Iowa who is president of the American Association of Clinical Anatomists, said she was not sure "that every medical student needs an intensive anatomy course."

 

"But everybody needs to learn anatomy," she said, adding that actively participating in a dissection is a better way to learn than looking at an exhibit or a computer screen.

 

Even when the details of anatomy and the Latin names fade from a doctor's memory, memories of the experience remain vivid, Dr. Scott-Conner said.

 

Further, drawings and models ignore the huge variability in human anatomy, in which duplicated, misshapen or aberrant structures are common. Students who spend time searching for an important nerve or a blood vessel that surfaces nowhere near where it is supposed to be learn a hands-on lesson about the huge range of normal in medicine.

 

Anatomists also emphasize that working with a cadaver elicits a sense of reverence that pictures and models do not.

 

Medical attitudes toward human specimens have varied over the years. Apocryphal stories from the 19th and early 20th centuries describe medical students jumping rope with the intestines of cadavers, and playing lewd practical jokes with cadavers' genitalia.

 

As recently as 30 years ago, medical students who expressed any fear or squeamishness about human dissection were often told they were "weak" and in the wrong field, Dr. Olson of Einstein said.

 

Now, however, schools uniformly encourage students to work through their emotions, he said, and also make sure they understand the gravity of the proceedings.

 

"Students are informed at the beginning of the course that gross anatomy is a solemn endeavor and disrespect will not be tolerated," said Dr. Charles Maier, who directs the anatomy course at Case Western Reserve University Medical School.

 

Dr. Maier, like many other course directors, tells students the cadavers are their "first patients," to be treated with all the respect that living patients would command.

 

Funeral services held at the end of anatomy courses emphasize this point.

 

"Many if not most schools have memorial services of one sort or another" Dr. Maier said.

 

The nondenominational service at Case is held at a local cemetery and is similar to a standard graveside ceremony. Family members of the deceased are invited, and afterward, they mingle with the dozens of students who attend. Dr. Maier said he routinely received letters of thanks from families after the events.

 

Medical students at the State University of New York at Stonybrook keep a two-month diary of their time in the dissection laboratory as a part of a course on medicine in society.

 

"Some say they're not affected by it and it hasn't changed them at all," said Dr. Jack Coulehan, a professor of preventive medicine there, but a majority record a cascade of emotions, which the class then discusses.

 

At the Yale School of Medicine, practicing doctors periodically visit the first-year anatomy course to describe some of their dying patients to the students and to talk about the doctor's role in dealing with terminal illness and death.

 

"In medicine now there's a big emphasis on teaching students professionalism," said Dr. Lawrence J. Rizzolo, the director of the Yale course. "In anatomy we begin the discussion — how the student will function as a professional, learning how to react to an uncomfortable situation, facing death and dying. We get them in touch with their feelings."

 

When the anatomy course ends, the Yale students thank their donors, as they call the cadavers, in a ceremony that includes original poems and musical compositions. Every first-year student attends, Dr. Rizzolo said, and the service has come to celebrate not only the rite of passage of the anatomy course but also the students' immersion in medicine.

 

"Studying medicine is a privilege, and the service paid homage to that," said Zach Goldberger, a Yale student who performed an original piano elegy at the ceremony his class held three years ago.

 

Two years ago, Yale students created a colorful quilt to commemorate the anatomy course, with panels dedicated to each cadaver in their course.

 

Asked to contemplate medical education without cadaver dissection, Yale students were unenthusiastic.

 

"It's not just about the information," said Dagan Coppock, a fourth-year medical student. "It's about the process."

 

Mr. Coppock called the anatomy class "a powerful, sacred experience."

 

Without dissection, students would never get to see "how it all fits together," said his classmate Kavita Mariwalla.

 

"It gives you a real appreciation for the beauty of the human body," she said. "It's amazing. You are so thankful for it. It made me stand in awe."

[Guest cutieyellow]

Personally, i find the cadaver labs very interesting. It's a great occasion to see the real thing, to touch and feel what an artery feels like, how it's different from a vein...and how it's differentiated from a nerve. I feel as though computers can't replace that...TOUCH.

 

At U Laval, the anatomy class is an optional class. This year, they only have 11 cadavers, and that means only 55 students can take the class (we're 190 in my class). Luckily, not all of us want to take it. Once the summer class is done (intensive dissection), the cadavers are kept throughout the year in order to teach the students bits and parts of it (that's how i got to see them) in the different system classes.

[Guest marbledust]

Just out of curiousity, how many people actually enrolled in the optional part of the class.

 

At Calgary a similar option is offered but I don't think many students actually take advantage of it.

[Guest cutieyellow]

Marbledust,

 

There were 88 people that enrolled. Unfortunately, b/c there's only 55 spots, i think it's a lottery game at that point. Results of who gets the class should be coming out soon...

 

It's sad because there is definite interest here. Maybe we'll send the extra ones to Calgary

[Guest McMastergirl]

At Mac, we don't take anatomy at all, except in a self-directed way, of course. We have a wonderful anatomy lab with every specimen you can think of, and superb full-time anatomists (some have a medical background as well) who will arrange sessions with your group. I agree the whole dissection thing is outdated and likely a waste of time (ie, spending too much time cutting and not enough time learning medically relevant things)

[Guest Akane200]

Having done the anatomy dissections as part of our education, I disagree that it is a waste of time. I don't think you can make such a remark without having experienced it yourself to offer such an opinion.

 

We had 10 weeks of continuous anatomy during the first 10 weeks of first year.

 

It does seem like a rite of passage of sorts. But it was one means of learning anatomy. We were motivated to learn it for our many examinations as well. And in the end, we all remember and forget about many parts of anatomy in addition to other things that we learned early on in medical school prior to our clinical years.

 

That being said, I must agree that it was useful. You realize what nerves feel like (and how delicate they really are), that skin is really much tougher than you think to cut through, that the arachnoid mater is very fine (I thought it was pretty), what main muscle groups you are going through for surgery, where the main vessels of the body run with the nerves, arteries are tougher than veins and will harden, what atherosclerotic changes look and feel like on the inside, etc. Some of these things cannot be learned by reading or just looking at nicely dissected specimens. Unfortunately, it may take a lot of time and energy to cut, and may not suit the "efficient use of time", an opinion that a lot of people hold to. However, there are some things that have to be experienced. I think anatomy dissection is one of them.

 

I found it quite an educational experience; and you bond with the members of your group through that time because you're all in this together as a team to learn as much as you can.

 

In addition, it was our privilege to have this opportunity to learn from the kind donations made for the benefit of our learning.

[Guest TimmyMax]

Hey,

 

Well said, akane200- I agree whole-heartedly.

 

Best of luck!

Timmy

[Guest Elaine I]

What other schools still have cadaver labs?

 

While I've been to the U of T anatomy lab (which is very impressive!), I think I would learn better by having to take the time to do the dissections.

 

Thanks for the info,

Elaine

[Guest strider2004]

I agree with Akane. I don't think you can make a judgement on anatomy labs and cadavers without being through it. The system at Queen's is a hybrid of the two choices. We have a cadaver lab and are formed into small groups but instead of us doing the dissections, this is done by 2nd year medical students and anatomy grad students who dissect, then teach the anatomy to a couple of people in our small group the night before. Those 2 people then teach the rest of the group what they learned the next day (using the same cadaver). We don't get to do the dissections in first year but if your interest is in surgery(where planning the approach is VERY important) then you get that chance by being a preceptor in 2nd year. I think there's always room for preceptors.

 

Typically the preceptors try to do their best to make their cadavers presentable for the groups. This means they are very methodical in their cuts to ensure that all of the nerves and vessels are carefully excised and not a big mess. What I didn't like about the cadaver lab was that a preserved specimen does not have the same colour of feel as a real person. For example, the preserved lung is more like a hard sponge and grey, as opposed to the delicate pink that it is in real life(I want to be a respirologist, go figure). So in terms of getting a feel for things, it's a bit more difficult that real life. But when do med students actually get to explore every part of a real unpreserved body? Only in autopsy observerships.

 

Queen's does pride itself in having a very nice lab including predissected displays and plasticized specimens. It also doesn't smell(which is a big plus) because of the new air circulation system and mild preservation techniques(some cadavers are from Boston and they actually smell much more of formaldehyde. We students play a russian roulette in picking the stinky ones).

[Guest ManitobaMed]

Ah, how I miss the Queen's anatomy museum...

 

Currently, dissection labs are mandatory here at the U of M -- complete with an attendance sheet -- and occur in all systems blocks. The problem for us is that this is pretty much the ONLY anatomy lab time we get; frequently, we spend so much of our lab time dissecting that we don't feel we've actually *learned* anything from the time we've put in. Having taken undergrad anatomy at Queen's on prosects/plastinated/parts in a jar, my feeling is that the dissection portion makes such a comparatively minor contribution to learning that we'd be better off eliminating it in favour of learning from pre-existing specimens. That being said, even as someone who does the majority of her anatomy learning from a photographic atlas rather than from actual specimens, I really don't feel contact with cadavers should be foregone in favour of computers; I just don't think *we*, the med students, should necessarily be the ones doing the dissection.

[Guest McMastergirl]

I haven't done dissection and personally I'm glad! I've talked to lots of people who have (mostly in undergrad anatomy courses, many of my friends took them), and the feeling was pretty much what ManitobaMed just said.

 

I think it's great at Queens that you have a choice whether or not to do the dissections... obviously there are some people who like the hands-on and some who can do without it.

 

I don't think at McMaster we're missing anything by not doing the dissection ourselves, that's all.

[Guest Elaine I]

Does Western have a cadaver lab? If so, do the med students do the dissections?

 

Thanks for the info,

Elaine

[Guest TimmyMax]

Hey,

 

Oh it does (newly renovated anatomy lab and everything!) and we do get to do the dissections ourselves!

The way anatomy works in 1st year at UWO is that students are divided into groups of 8 and within that, are further subdivided into pairs. Each week or so, a different pair is responsible for doing the dissection and then presenting it to the group. There are tutors there during the anatomy lab time (the rest of the 8 students that are not dissecting that particular week get the anatomy lab time off to go and do whatever) to help out with the dissection. Some of the dissections are very complicated and delicate and require prosections (no dissection is required if this is the case), while others are just complicated and test one's dissection skills thoroughly. At the end of the anatomy 'week', there is a demonstration time with tutors present during which the pair that dissected presents their dissection to the rest of the group. Then the next pair starts on their dissection the following day and so on.

I'm not sure how things work with the 2nd year student tutors this year (aneliz), but that is how things worked when I was in 1st year.

Sadly, there is no anatomy lab in 2nd year...

 

Best of luck!

Timmy

[Guest Elaine I]

Thanks Timmy (as always)!

Elaine

[Guest justanotherpremed]

I find it kind of funny that the two mcmaster people both posted against anatomy labs. it really perpetuates the stereotype of mcmaster students.

 

I'm not a med student yet (and will I ever be?). But I don't see how you could be a doctor and not have had extensive training in anatomy. Since I'm an anatomy major, I know that I am biased.

 

But I mean how could you really understand what is going on with your patients without knowing what their anatomy looks like? How could you go into surgery having never seen the inside of an abdominal cavity? What kind of basis do graduates have for pathology if they've never even seen dead bodies (i know i'm exaggerating)?. Anyhoo, I think it's a damn shame that students aren't given rigorous knowledge of human anatomy in med school. :hat :smokin

[Guest Ian Wong]

I don't think the question is one of whether a student should know anatomy, but rather, is the actual physical process of dissection valuable? The med schools that don't necessarily have mandatory dissection time still use pre-dissected prosection specimens to demonstrate the relevant anatomy. In so doing, it separates the display of the anatomy from all the digging around done during a gross lab where you might spend a large amount of time tunneling through a large amount of fascia or fatty tissue to find the nerves or arteries you seek.

 

Personally, Gross Anatomy was my favourite class in medical school, and I went on to do some TA'ing of Anatomy sessions as my schedule allowed, so obviously I'm not on the fence on this subject. Still, one could make the convincing argument that there are many/most specialists out there who do not utilize the full range of anatomy they learned during medical school.

 

Don't ask an ophthalmologist about the sensory innervation of the thumb, or a psychiatrist where the capitulum is located (it's on the humerus), or an obstetrician what the branches of the left coronary artery are, or a cardiologist what the blood supply of the parotid gland is. They won't be able to tell you. Is this necessarily a good thing? Probably not, but the reality is that if you don't use something, you lose it, and in very few specialties, if any at all, will you employ all the anatomy that you've been taught.

 

Even the surgeons are generally only really good with the anatomy in the area that they operate on. Radiologists need to know a bucketload of anatomy as well, but they also often subspecialize into regions of the body.

 

Ian

[Guest McMastergirl]

First of all, "justanotherpremed," only one McMaster student has voiced an opinion - me. Please don't assume that my opinion speaks for all Mac students!

 

Mac has provided ample opportunity for me to become very well versed in anatomy if I wish. Knowing that I am going into a specialty where anatomy is less important than other skills (scientific inquiry, critical appraisal, counselling, etc), I chose not to spend too much time over and above what I felt I needed to understand the clinical aspects of medicine. That's the great thing about Mac. If you want to learn it, you can, if not, just learn what you need and focus your time on what you do want to learn. If I were going to be a surgeon you'd better believe I'd be in that anatomy lab every day.

 

Ian's right - this isn't about whether we should learn anatomy (of course we should!) - it's about dissection. Anatomy's not my thing. I'm sure if I went to a school in which I was forced to dissect I would still be against it!!! This has nothing to do with McMaster - if anyone is perpetuating stereotypes, it's people who don't know anything about it.

[Guest justanotherpremed]

you're right in the sense that I know nothing about mcmaster... I can only make decisions based on what I see. But I don't know what you expect me to conclude when I hear that at mcmaster you aren't forced to know the human anatomy. I mean how does such a person start their clerkship rotation in surgery? Do they open up their first patient and exclaim "so that's what it looks like!" ?

 

Of course I'm using some hyperbole here, but it kinda blows me away that human anatomy doesn't play a big role in med school. Of course I'm naive since I'm not in medicine. :hat :smokin

[Guest marbledust]

I think you are missing the point of the above posts and still have some misconceptions. Cutting and probing is fascinating and has great value (I got the chance to do it in an undergrad course), but it takes time that could be better used elsewhere. Medicine is changing and the changing atttiude towards anatomy labs is a reflection of that.

 

I don't know, but if I wasn't a med student, specifically a Mac med student, I probably wouldn't jump to conclusions about how proficient they are at anatomy. But that's just me :hat