POURING THE FOUNDATION

Learning to run before you can walk

The Greek philosopher Heraclitus (535BC – 475BC) is credited with the concept, “Change is the only constant in life”. But is it change for the better? A recent article about medical schools changing anatomy teaching methods made me wonder if the proposed changes will improve students’ knowledge.¹

The core foundational piece of medicine is anatomy. Everything else is built on that foundation. Knowledge acquired from dissections began during ancient Egyptian and Greek civilizations. Since then, cadaveric dissections have become central to medical education, providing the first insights into human form and function.²

As a medical student, I loved anatomy. The generously gifted body was the first patient for our dissecting room table of 8. Each layer we peeled back revealed secrets of the underlying specialized tissue. Most of us had never encountered death so our first patient taught us how to approach the structure of life without fear.

Compared to atlases or textbooks, cadaveric blood vessels were not bright blue or red. Nerves were not yellow and lymphatics were not green. Everything was a tinge of grey. In addition, we encountered pathology for the first time encountering tumours, surgical scars, and developmentally abnormal or even absent organs. The range of anatomic variants was there for us to appreciate and understand.

The downside of a room full of preserved cadavers was the overwhelming smell of formalin and the occasional vasovagal attack. On the first morning of class there was a loud thud when one of my classmates fainted at the sight and smell. To reassure her that fainting was not uncommon, the instructor remarked she hadn’t been the only one - it also happened to Dr. Christiaan Barnard, who went on to become the world-famous cardiac surgeon that performed the first human heart transplant.

Few of us would continue studying anatomy for our eventual medical careers; only radiology, surgery, and anatomical pathology require a comprehensive knowledge of anatomy. Regardless, understanding the structure of the human body through anatomy served as the basis for subsequent courses on function (physiology), and then disease (pathology, bacteriology). Once these basic sciences were absorbed, bedside clinical teaching could be layered on top.

That is the basis of traditional medical school training. So, reading a debate about altering its foundation - whether to continue cadaveric dissection or replace it with new technology¹ was disappointing. The arguments for the latter focussed on the cost of procuring and storing cadavers, ethical issues about “body parts” being sold for educational purposes, and students’ distress when encountering their first dead body.

The primary argument against use of cadavers appears to be economic, especially for a new program that has not established or maintained a body donor bequest program.¹ Once initiated, however, continued funding is needed for long term planning including staff salaries to oversee the program.

Ethical issues regarding economics have been raised in the U.S. following reported scandals of a for profit body parts trade often acquired from the poor.³ Here, in Canada, it is illegal to sell organs or tissues; given the difference in our not-for-profit body parts program, e.g. blood donation, this likely does not occur.

The non cadaveric teaching methods are numerous. They include prosections (dissected specimen in a clear case), plastination, 3D printing,⁴ digitization of images, and virtual reality.¹ Will these new methods replace anatomical dissection, a structural standard some regard as fundamental?⁵ Simplistically, can learning based on two senses (seeing and hearing) be equivalent or superior to learning based on three senses (seeing, hearing, and touching)?

Attempts have been made to compare students’ retention of anatomy based on conventional dissection with the new methods. One study reviewed 14 different papers comparing active dissection with different teaching methods such as prosections and computerized teaching aids.⁶ The quality of the studies were poor but overall, considering the bias for the new methods, the author concluded there was a slight advantage for traditional dissection.

A more recent paper reported a double-blind randomized trial comparing 3D printing versus cadaveric teaching for external cardiac anatomy.⁷ Fifty-two participants completed the trial: 18 using cadaveric materials, 16 using 3D models, and 18 using a combination of both. The students who used the 3D models scored higher than those who received cadaveric materials or a combination of both. Apart from the unusual conclusion (why would 3D printing be superior to 3D printing plus cadaveric dissection?), the study could hardly be considered as blinded since each student would easily find out which group the others were allocated to.

The answer as to which method is superior may be unclear but keep in mind what the comparison is measuring. Regardless of teaching method, student learning, unfortunately, is geared towards an assessment exam rather than incorporating new knowledge to be able to formulate new opinions or question dogma.

How will altering the foundation of medicine integrate into the overall teaching of medicine? Looking at the curriculum of the new Simon Fraser University medical school⁸ shows a mish mash of classroom based clinical case studies mixed with community teaching in doctors’ practices and lab learning. What kind of cases will be selected for discussion? In community clinics students will see whatever comes through the door. And how will they match that to lab learning using anatomical models which may have no relevance to what they see in the clinics?

There is nothing magical about teaching to beginners if you have a goal in mind. If your goal is to produce a professional level hockey player, you need to start with the basics – skating. That can only be taught on the ice. No advanced simulation can teach you how to skate. After one can go forward, backwards, turn, and stop, then you can add stick handling, passing, shooting, game strategy etc.

But, if your goal is for kids to have fun, just throw out the puck and let them at it. What will be apparent is a disorganized clump of kids relentlessly chasing the puck.

Is society’s goal to produce physicians with serious outstanding organized knowledge or happy individuals who call themselves doctors but lack the fundamentals ?

REFERENCES

1. Lin K, Hildebrandt S, McMenamin P. Teaching anatomy – to dissect or not to dissect? N Engl J Med 2026; 394:1862-64. DOI: 10.1056/NEJMclde2518072

2. Al-Rubaie A. From Cadavers to Codes: The Evolution of Anatomy Education Through Digital Technologies. Med Sci Educ. 2024 Dec 27;35(2):1101-1109. doi:10.1007/s40670-024-02268-6.

3. Reuters. The body trade. Part 7: The chop shop; a business where human bodies were butchered, packaged and sold. 2017 (https://www.reuters.com/investigates/special-report/usa-bodies -business/)

4. McMenamin PG, Qualye MR, McHenry CR, Adams JW. The production of anatomical teaching resources using three-dimensional (3D) printing technology. Anat Sci Educ 2014; 7: 479-86. https://doi.org/10.1002/ase.1475

5. Older J. Anatomy: a must for teaching the next generation. Surgeon. 2004 Apr;2(2):79-90. doi: 10.1016/s1479-666x(04)80050-7.

6. Winkelmann A. Anatomical dissection as a teaching method in medical school: a review of the evidence. Medical Education 2007; 41: 15-22. https://doi.org/10.1111/j.1365-2929.2006.02625.x

7. Lim, K.H.A., Loo, Z.Y., Goldie, S.J., Adams, J.W. and McMenamin, P.G. (2016), Use of 3D printed models in medical education: A randomized control trial comparing 3D prints versus cadaveric materials for learning external cardiac anatomy. American Association of Anatomists, 9: 213-221. https://doi.org/10.1002/ase.1573

8. https://www.sfu.ca/medicine/programs/md-program/curriculum.html