RELEVANT REVIEW

The Anatomy of Anatomy: A Review for Its Modernization

Kapil Sugand,1* Peter Abrahams,2 Ashish Khurana3 1 School of Medicine, Imperial College London, South Kensington, London, United Kingdom 2 Institute of Clinical Education, Medical Teaching Centre, Warwick Medical School, Coventry, United Kingdom 3 Department of Orthopedics, University Hospital of Wales, Heath Park, Cardiff and Vale NHS Trust, Cardiff, United Kingdom

Anatomy has historically been a cornerstone in medical education regardless of nation or specialty. Until recently, dissection and didactic lectures were its sole pedagogy. Teaching methodology has been revolutionized with more reliance on models, imaging, simulation, and the Internet to further consolidate and enhance the learning experience. Moreover, modern medical curricula are giving less importance to anatomy education and to the acknowledged value of dissection. Universities have even abandoned dissection completely in favor of user-friendly multimedia, alternative teaching approaches, and newly dened priorities in clinical practice. Anatomy curriculum is undergoing international reformation but the current framework lacks uniformity among institutions. Optimal learning content can be categorized into the following modalities: (1) dissection/prosection, (2) interactive multimedia, (3) procedural anatomy, (4) surface and clinical anatomy, and (5) imaging. The importance of multimodal teaching, with examples suggested in this article, has been widely recognized and assessed. Nevertheless, there are still ongoing limitations in anatomy teaching. Substantial problems consist of diminished allotted dissection time and the number of qualied anatomy instructors, which will eventually deteriorate the quality of education. Alternative resources and strategies are discussed in an attempt to tackle these genuine concerns. The challenges are to reinstate more effective teaching and learning tools while maintaining the benecial values of orthodox dissection. The UK has a reputable medical education but its quality could be improved by observing international frameworks. The heavy penalty of not concentrating on sufcient anatomy education will inevitably lead to incompetent anatomists and healthcare professionals, leaving patients to face dire repercussions. Anat Sci Educ 3:8393, 2010. 2010 American Association of Anatomists. Key words: gross anatomy; competence; curriculum; dissection; anatomy education; multimedia; prosection; professionalism; review

INTRODUCTION
Anatomy education has been persistently controversial with concern over its signicance and its teaching standards in medical schools. After a decline for many years, concern that anatomy teaching has fallen below a safe level has been loudly echoed by Warner and Rizzolo (2006) and Turney
*Correspondence to: Mr. Kapil Sugand, School of Medicine, Imperial College London, South Kensington, London SW7 2AZ, United Kingdom. E-mail: ks704@ic.ac.uk Received 13 August 2009; Revised 30 January 2010; Accepted 2 February 2010. Published online 4 March 2010 in Wiley InterScience (www. interscience.wiley.com). DOI 10.1002/ase.139 2010 American Association of Anatomists

(2007). In hope of coping with modern practice, the conventional pedagogy of dissection is in the process of being revolutionized and enhanced if not replaced by more innovative modalities. Gone are the days when hundreds of hours of dissection alone were believed to be essential for proving medical competency. Many institutions have ofcially deemed conventional cadaveric dissection obsolete in lieu of model substitutes and technology (Guttmann et al., 2004; McLachlan, 2004; McLachlan et al., 2004).

PRESENT SITUATION AND CURRENT PRESSURES

At present, the most prevalent pedagogy consists of didactic lectures, which discuss anatomical structure and function while navigating students around the body with clinical phoAnat Sci Educ 3:8393 (2010)

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tographs and computerized animations. Students are expected to study concomitantly from recommended atlases for consolidation and revision and some institutions hire out skeleton models for closer inspection. Having established lectures as the basic framework, universities then choose additional modalities that will best compliment the learning process of this colossal subject. Course organizers have been increasingly compelled to give far less importance to continuing anatomy instead of other priorities that represent a contemporary medical course (Warner and Rizzolo, 2006). Consequently, institutions in North America and Europe have dramatically reduced time in the dissection room or replaced dissection with prosections, plastic models, and multimedia learning packages to aid retention of knowledge (Reidenberg and Laitman, 2002; McLachlan et al., 2004; McLachlan and Patten, 2006). Yet, anatomy teaching is approached differently according to departmental culture and frameworks lack uniformity (Pabst, 2002). However, Raftery (2007) emphasized the necessity to create a national core curriculum for undergraduate medicine based on physical examination, imaging interpretation, and practice of basic procedures at the least. In March 2007, the Raven Department of Education at The Royal College of Surgeons of England (Rainsbury et al., 2007) initiated the National Anatomy and Eagle projects to review and update its anatomy education framework that would ideally develop consistent educational programs for undergraduate and postgraduate trainees.

SIGNIFICANCE OF ANATOMY EDUCATION

It is crucial to teach fundamental principles of anatomy from the beginning of medical school on which to expand over time. These principles are expectedly best taught during dissection and further enforced with supplementary visual aids. Anatomy itself is relevant to the majority, if not all, healthcare specialties and not only to surgery. Healthcare professionals should be formally examined on anatomy as part of their degree and weight should also be put onto learning basic developmental anatomy to thoroughly appreciate the origins of physiology and steps leading to congenital abnormalities. Anatomy, like any other taught module, needs to be constantly revised and examined to demonstrate competency, especially when integrated into the clinical setting as students and even after graduation (Pabst, 2002; Moxham and Plaisant, 2007). Yet, graduates are expected to retain and rely on the knowledge from their preclinical years for the rest of their careers. After all, patients have expectations from medical students too, irrespective of their level of clinical training.

STANDING THE TEST OF TIME OR REVOLUTION OF A HISTORIC COURSE

Anatomy education has entered another Renaissance to deliver newer and more innovative methods of teaching, but at the cost of centuries-old practice. Vesalius, referred to as the founder of modern human anatomy, struggled to make university dissection mandatory in the 16th century and its signicance is again being questioned today in search for substitutes. Multimodal methods to teach anatomy and basic principles of surgery have gradually become the most popular
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options among all medical institutions, including those in the UK as recognized by the General Medical Council (GMC, 2006). Although, dissection still seems to be the favorite method of teaching as well as providing optimal examples of pathology by both students and teachers alike (Pabst, 2002; Holla et al., 2009; Petersson et al., 2009; Bockers et al., 2010). As educational practices evolve to suit the needs of patients, so do the dissection laboratories adapt to the changing needs of students. Dissection theatre designs from the Renaissance have been revamped to suit current requirements. The commonest layout is to accommodate an entire year into one large room lled with numerous dissection tables for small-group tutorials or workstations in smaller adjacent rooms. Since 2000, UCLA and many others have taken additional measures to support use of unembalmed cadaveric specimen for demonstrating minimally invasive surgical and emergency techniques (Reidenberg and Laitman, 2002; Tabas et al., 2005; Trelease, 2006) that are now being integrated within the UK (Gogalniceanu et al., 2007; Rainsbury, 2007), the latest being the introduction of the Mobile Teaching Unit at Bristol University, UK (Greene, 2009). Gross anatomy is highly regarded by students as being clinically relevant compared to other subjects (Pabst et al., 2001); but with dilemmas like the increasing number of new medical institutions particularly in economically developing nations (Dhingra et al., 2006; Memon, 2009), increased shortage of cadaver donation and their preservation (McLachlan and Patten, 2006), medical faculties are in discussion of eliminating the dissection laboratory altogether in favor of teaching conventionally undermined skills such as professionalism (Slotnick and Hilton, 2006). Many instructors believe that there is insufcient evidence in the literature to indicate dissection as being the most effective method of teaching gross anatomy after the introduction of technological advancements (Pawlina and Lachman, 2004); yet, bias and an absence of standardization among teaching preferences leads to difculty in objectively validating its contemporary signicance (Winkelmann, 2007). The addition of new disciplines (e.g., communication skills, professionalism, and ethics) into the medical curriculum has led to a reduction in total hours of anatomy teaching and factual content (Parker, 2002; Moxham and Plaisant, 2007; Rainsbury, 2007; Drake et al., 2009) despite students preferring longer anatomy courses (Holla et al., 2009). Furthermore, increased weighting in anatomy within overall assessment has been identied as a motivational factor for students to learn the subject more thoroughly (Wormald et al., 2009). As the future of surgery in economically developed countries heads towards super-specialization and minimally access interventions, anatomical details previously regarded as minor have become signicant to the success rate of operations (Pawlina and Lachman, 2004). Yet, the foundations required for budding endoscopic surgeons do not correlate with the importance given to anatomy today.

COURSE CONSIDERATIONS AND RESERVATIONS

Raftery (2007) echoes the wide belief that tough examinations in anatomy are necessary early after undergraduate entry, whereas its teaching is currently becoming synonymous to out of sight, out of mind. Universally, the majority of
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anatomy is usually taught in preclinical years (up to two years) and by graduation, junior doctors naturally tend to fall below expectation due to the lack of dissection practice. Collins (2008) stresses the crucial value of continued learning as the aim of anatomy education, and that universities ought to ensure that graduates satisfy core criteria as outlined by the GMCs Tomorrows Doctors (2009) before proceeding to work. Other proposals to increase student exposure to anatomy include single-year intercalated Bachelors of Science (iBSc) degrees, special study modules (Rainsbury, 2007), and research electives. To keep the tradition of dissection alive, Warwick University, UK, created an extracurricular anatomy exchange program with St Georges University, Grenada (Chambers and Emlyn-Jones, 2009) where selected students have dedicated and protected time to further develop dissection skills and expand their anatomical knowledge. Ideally, the anatomy course should be spread over the entire undergraduate curriculum rather than delivered in a concentrated block in preclinical years, with the added benet of introducing patient contact from the start of medical education. There are ongoing concerns over students being under-prepared and lacking a sufcient knowledge of anatomy within residencies and clerkships (Warner and Rizzolo, 2006). Hence, Evans and Watt (2005) commend Brighton and Sussex Medical School, UK, for continuing anatomy teaching in the later years during specialist rotations so that topics are taught at the most relevant time and in parallel to clinical training, an ideology also championed by Pawlina and Lachman (2004). Other major considerations revolve around handling cadaveric specimen. McLachlan and Patten (2006) from Peninsula School of Medicine, UK, address important issues on dissection that all anatomy departments ought to consider including legal implications and possible hazards to health. Demiryurek et al. (2002) also brings attention to cadaveric pathogens but outlines appropriate safety guidelines to minimize risk.

SUGGESTED CONTENT FOR AN OPTIMAL MODERN CURRICULUM

Curricula on gross anatomy, fertilization, and organogenesis were proposed by the American Association of Clinical Anatomists (AACA) at the turn of the millennium (Leonard et al., 1996, 2000). The initiative to maximize learning from a compact course can be categorized in the following sections in addition to the recommended national framework (McHanwell et al., 2007) designed by the Education Committee of the Anatomical Society of Great Britain and Ireland (ASGBI): (1) dissection/prosection, (2) multimedia, (3) practical procedures, (4) surface and clinical anatomy, and (5) radiological imaging. The denitions, applicable to each body system, are explained below.

work (Pawlina and Lachman, 2004; McLachlan and Patten, 2006). However, Collins (2008) suggests that prosections are sufcient to aid anatomy learning of university students so that dissection, increasingly becoming a rare commodity in health education, could be reserved only for postgraduate surgical trainees. Plastination is a relatively new advancement in cadaveric science; an effective technique of tissue preservation of entire organs or cross-sectional body slices (Dhingra et al., 2006) introduced by von Hagens et al. (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 (Reidenberg and Laitman, 2002; Elizondo-Omana et al., 2005) and radiology (Dhingra et al., 2006). University of Warwick is the rst in the UK to teach with plastinated prosections (Warwick Medical School, 2009) followed by other medical schools including St Georges (London, UK) and Nottingham University (UK). Student satisfaction and acceptance has also been recorded using plastinated models as well as a signicant difference between control and experimental groups observed in assessment scores (Latorre et al., 2007). Preservation and dissection of the highest quality allow students to repeatedly study the specimens with minimal wear and tear, similar to the rationale behind using plastic models, while maintaining the natural variance or pathology that plastic models lack. Plastination permits realistic visualization of anatomical concepts that are simply too difcult to describe. Nevertheless, plastinated prosections should ideally be used adjuvant with cadaveric dissection for full appreciation of the interactions between body systems and to understand the body as one entity. Once again it is emphasized that the cadaver must not be dismissed as obsolete (Older, 2004; Elizondo-Omana et al., 2005) since exposure to dissection develops important cognitive skills (Slotnick and Hilton, 2006) and manual dexterity (Moore, 1998; Granger, 2004; McLachlan et al., 2004) required by all medical practitioners. Lempp (2005) sums up dissection as an opportunity to reinforce familiarization and respect for the body and integration of theory into clinical practice. Nonetheless, it would certainly be a shame not to take full advantage of the available technology to supplement revision of the learning objectives from dissection classes (ElMoamly, 2008).

Interactive Multimedia
Teaching anatomy with computerized learning packages [dubbed as anatomical informatics by Trelease (2002)] so that students know exactly what to expect beforehand and how to best spend limited time in the dissection room (Collins, 2008). The future of anatomy teaching must rely more on visual aids outside the dissection room as students who accessed web-based computer-aided instruction resources scored signicantly higher on examinations than those who never accessed the online content (McNulty et al., 2009). The rationale is that students will naturally forget topics covered in dissection class and resources like web-streamed lectures and instructional videos could prove vital for revision. Anatomy teaching and healthcare education as a whole will advance after wide distribution of personal digital assistants (PDA) and other wireless devices (Trelease, 2008) that store essential texts and atlases. This has already been implemented in Project Handful (CILIP, 2004) at Brighton and Sussex
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Dissection/Prosection
This involves teaching gross anatomy with cadaveric dissection and/or prosections preferably guided by demonstrators. Active observation and participation in cadaveric dissection helps the understanding of three-dimensional (3D) structures through curiosity and self-exploration (Lachman and Pawlina, 2006; Collins, 2008) while promoting both psychosocial development and attitudes towards professionalism and teamAnatomical Sciences Education
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School of Medicine, UK, but PDAs are not readily available at other institutions. Atlases of internal imaging and projections of major organs onto body surfaces have been compiled onto an interactive CD-ROM (Putz and Pabst, 2002), in which real-time video sequences of gastroscopy imaging, colonoscopy, bronchoscopy, and ultrasound of heart valves were also featured. There is scope to include learning tools like magnied laparoscopic imaging sequences (Jimenez and Aguilar, 2009) and an accelerated video-recording of the entire alimentary canal using capsule endoscopy (PillCam; Given Imaging, Yoqneam, Israel). Capsule endoscopy used in both normal and pathological cases led to half of medical students achieving a rate of 80% sensitivity in detecting small bowel lesions as novice readers (Chen et al., 2006). Other award-winning resources like Aclands DVD Atlas of Human Anatomy (Acland, 2003), 3D Human Anatomy Software DVD (Primal Picture, 2007), and Anatomy.TV website (2006), which contain rotating 3D anatomical structures from head to toe for virtual dissection should be offered to all students. Another recent innovation is at Warwick Medical School, which has recorded 3D video podcasts, the Coachpod (McEvoy et al., 2008) for anatomy teaching on the move which is available on the Internet. To overcome the dramatic decrease in time dedicated to neuroscience (Drake et al., 2009), an interactive 3D atlas computer software and a mobile-based application have been launched in neuroanatomy education (Nowinski et al., 2009) whereby instructors can rapidly customize test criteria for their students to be done in their own time. Also, randomization of cerebral and vascular anatomy slices within the software can create versatile tests for practice and self-assessments for student users. Vascular anatomy can also be better visualized using virtual contrast injection to convert MRI and CT imaging into 3D virtual reality movie sequences (Petersson et al., 2009). Otherwise, study tools, revision sessions, and examinations can be completed at individual pace, and progression can be measured objectively between time intervals using interactive online e-learning modules (OByrne et al., 2008; Choudhury et al., 2009). In addition, DVD demonstrations may be introduced to overcome the ongoing shortage of qualied anatomy instructors. Although this is a step up from handing a manual to students, it does not take into account that each individual student has a personal pace of learning. There is a possibility of reaching a compromise with Prof-in-a-Box (Moorman, 2006), which consists of an experienced anatomist, potentially from other institutions, to teach and interact with students through video-conferencing. Tele-conferencing using Second Life software (as done in dental education [Phillips and Berge, 2009]) can be universally used as a virtual platform for online didactic lectures and live streaming demonstrations with prospect of global participation. However, by no means is two-dimensional lming adequate substitution for direct visualization and handling of 3D tissue (Chowdhury et al., 2008) to appreciate size, texture, color, and weight (Dhingra et al., 2006). In dissection rooms, students are able to construct their personal interpretations of the abstract body while exercising spatial orientation (Boon et al., 2002a; Parker, 2002). Multimedia has gained substantial user approval in providing opportunities to study microscopic anatomy consisting of histology and pathology (in relation to genetics) through virtual microscopy (Durosaro et al., 2008; Husmann et al., 2009) and a vast library of web-based multimedia animations
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(Downing, 1995; Brisbourne et al., 2002). Yet, the inclusion of microscopic anatomy depends on the institution and may not necessarily exist within the teaching block of anatomy. Regardless of its time of introduction within the course, the topic itself can be better explored using software magnication with associated labeling. Furthermore, multimedia resources are to be used in amalgamation with widely accepted traditional teaching practice rather than students losing out on the art of handling actual microscopes (Pratt, 2009).

Procedural Anatomy
Practicing clinical procedures requires thorough knowledge of anatomy, especially for emergency protocols [e.g., sites of significance for lumbar puncture (Boon et al., 2004a), cricothyrotomy (Boon et al., 2004b), and paracentesis] on either cadavers or plastic models. Helpful demonstrations have also been put on CD-ROM such as the Virtual Procedures Clinic by Boon et al. (2002b) for easy reference. An advanced emergency procedural training program at the University of California uses an online syllabus, videos, and lectures alongside hands-on practice with unembalmed cadavers, models, and ultrasound (Tabas et al., 2005). Having completed self-assessments after the course, all students reported a statistically signicant increase in their comfort level, understanding of the procedural indications and how to perform emergency procedure revolving around deep venous access, tube thoracostomy, and cricothyrotomy. Health science students at the University of New England who are borderline or failing the anatomy course may be remediated with an electronic practical examination (Daly, 2009).

Surface and Clinical Anatomy

This anatomy is applicable to patient care (Boon et al., 2002a) as anatomical landmarks and clinically relevant structural outlines are dened. There is ample opportunity to practice physical examinations (by inspection, percussion, palpation, auscultation, and instructions) early in medical education to prepare for life-long clinical interaction. Simultaneously, there is an opportunity to study the musculoskeletal system (Pabst, 2002; McLachlan and Patten, 2006), which is often understated in curricula. Whereas multimedia may compliment the learning process, nothing could substitute the practical experience gained within peer-groups (Aggarwal et al., 2006) and familiarizing oneself with living anatomy in a safe environment before handling patients. In fact, compared to students on the new systems-based course inuenced by GMCs Tomorrows Doctors (GMC, 2009), McKeown et al. (2003) discovered that students on the old curriculum attained a greater knowledge of surface anatomy.

Medical Imaging
Imaging has become more important diagnostically and in anatomy teaching, which has created a need for new expertise to interpret radiography [helped with clay models (Oh et al., 2009)], ultrasound, metabolic imaging, and multiplanar (virtual 3D) constructions (Dalley, 1999; Miles, 2005) such as high resolution CT cadaveric scans (Durosaro et al., 2008). Recent studies showed that integrated ultrasound imaging courses used in UK (Wright and Bell, 2008), Germany (Pabst, 2002), and USA (Rao et al., 2008) were positively received by both students and staff. Radiology education offers in vivo visualization of anatomy and physiology as well as insight into pathological processes
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(Gundermann and Wilson, 2005). The Royal College of Radiologists (RCR, 2008) advocates the inclusion of clinical radiology within university curriculum, so much so that the FRCR Examination Board is re-introducing an anatomy component in the FRCR primary (Chowdhury et al., 2008). The alliance with radiologists to teach part of the anatomy course, termed the Wessex Model, has been successful at the University of Southampton, UK (Chowdhury et al., 2008). Yet, radiological images or anatomical models cannot substitute the benets of conventional dissection (Gundermann and Wilson, 2005) but hybrid teaching modalities would undoubtedly contribute to better understanding and retention.

ALTERNATIVE PEDAGOGICAL RESOURCES

Plastic Models
Many institutions have overcome problems surrounding dissection with plastic models (McLachlan et al., 2004; McLachlan and Patten, 2006). Plastic specimens are modeled to perfection and possess a longer shelf-life than cadavers but they will eventually pose problems. No human body is ever modeled to perfection where all organs are color coordinated and impeccably shaped. Plastic models and textbooks (Granger, 2004) do not account for biological variation and lack pathological authenticity which can lead to misdiagnosis and malpractice in the clinical setting. Students who were deprived from the dissecting experience and exposure to human material were likely to acquire misleading information and a supercial orientation of the human body without appreciating any biological variation (Pawlina and Lachman, 2004; Gillingwater, 2008). Eventually, the government will be obliged to invest more funds, time, and resources to train prospective surgeons and other specialists, who will inevitably learn from dissection later on in their training to demonstrate competency.

tors like colorful visuals and tactility authentic to life (McMenamin, 2008; Finn and McLachlan, 2009). In addition, this exercise creates a more comfortable and non-judgmental environment for students to volunteer as models in surface anatomy classes which has been a long-standing issue due to factors such as embarrassment, especially among female participants from ethnic minorities (Aggarwal et al., 2006). Consequently, males are usually expected to or are many times compelled to volunteer because no one else will. However, Aggarwal et al. (2006) commented that single sex anatomy classes did not result in a substantial increase in volunteering rates. Gender segregation, particularly in anatomy, should be discouraged since clinical practice requires a balance between comfort and professionalism to interact with both genders as vulnerable patients. It is essential that issues surrounding body image are addressed (Finn and McLachlan, 2009) as early as possible to instill condence in medical students to examine any patient competently.

Virtual Simulation
Since learning is correlated to level of involvement (Bergman et al., 2008), interactive and problem-orientated learning adds interest and aids in long-term retention of knowledge to identify clinically relevant anatomical structures (Boon et al., 2002a; Miles, 2005; Turney, 2007). Surgical trainees have the recent luxury to practice procedures using virtual reality simulation (Van Sickle et al., 2008; Windsor et al., 2008). Similar simulations can also be effective for university students to visualize and interact with internal organs while offering a more accurate insight into surgical careers. Moreover, haptic feedback technology permits simulation of surface textures of parenchyma in different states. Haptic feedback, pertaining to sense of touch, consists of kinesthesia and tactility. Kinesthetic feedback, often referred to forcefeedback in literature, provides internal sensory information about position or movement of muscle, tendons, and bones through proprioception. The principal objective of most force-feedback studies is to augment haptic realism of virtual models for palpatory training. Palpation remains vital in open surgery to differentiate between tissue natures and compliances of organs and tumors. Howell et al. (2008) developed the Virtual Haptic Back to simulate mechanical properties of the human back for students to practice their manual skills. First-year students at the Royal Veterinary College, University of London, were taught to appreciate bovine abdominal anatomy using a rectal palpation simulator, The Haptic Cow, which provided 3D visualization and life-like feel of internal anatomy. One hundred eighty-four students provided positive feedback via a questionnaire and approved of the Haptic Cow simulators engaging learning technique without the need to use cadavers (Kinnison et al., 2009).

Autopsy
As a means of keeping updated with anatomy over time, students on clinical rotations are encouraged to attend autopsies (Parker, 2002; Burton and Underwood, 2007). Unlike preserved and discolored cadavers, newly deceased patients are much more realistic, accompanied with medical histories and possess signs that govern diagnostic and prognostic implications. Students will also be able to relate cause of death due to visible and often interacting pathomorphology supported by microscopy of histopathology.

Body Painting
Some universities offer students time to pursue passions outside the core curriculum like arts, humanities, and life-drawing classes that can compel the mind to better establish anatomical relationships and reinforce humane issues (Phillips, 2000; McLachlan, 2004). However, body painting has been an additional visual aid in surface anatomy classes for reviewing underlying systems in which questionnaire studies indicate that this technique has been accepted to enhance learning by staff and students (Op Den Akker et al., 2002; McMenamin, 2008; Finn and McLachlan, 2009). A survey of 133 preclinical students concluded that besides being enjoyable and interactive, body painting promoted retention and recall of knowledge, which was helped by sensory facAnatomical Sciences Education
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ALTERNATIVE PEDAGOGICAL STRATEGIES

Professionalism and Attitude to Ethics Surrounding Anatomy Education
Medical students may not fully appreciate the value of dissection and how difcult it is to prepare a good cadaveric specimen for optimal learning. If body donations are taken for granted, it becomes more difcult to fully welcome the
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opportunities provided in the dissection room that cannot be learned from simply reading. Simple techniques for students to evoke a sense of humanity for their cadavers through a patient-centered approach and practicing humanistic values have been thoroughly explored (Weeks et al., 1995; Marks et al., 1997; Rizzolo, 2002; Schwartz et al., 2008; Lin et al., 2009). Most medical schools within UK and USA hold Memorial Days from as early as 1970 (Warner and Rizzolo, 2006) that are lled with poetry, songs, and spiritual readings (Lachman and Pawlina, 2006; Lin et al., 2009) in honor of those who altruistically donated their bodies for medical teaching. Holding services offer an opportunity to show respect (Pawlina and Lachman, 2004) and appreciation to donors families (Parker, 2002) but these events require more advertising and commitment. Much like jury duty, attendance at these Memorial Days could become compulsory for student representatives to offer their respects on behalf of their colleagues and institution. Teaching professionalism within anatomy education has become a recent topic of interest and one component of the six areas of competency within the Accreditation Council for Graduate Medical Education (Escobar-Poni and Poni, 2006) in 90% of American medical schools (Pawlina and Lachman, 2004). Learning professionalism or rather yet proto-professionalism (Slotnick and Hilton, 2006), the period between the initial days of medical school and independent practice, enables students to reect on the logic and ethical implications behind cadaver donation (Pawlina and Lachman, 2004; Gunderman, 2008). Hence, self-reection and emotional pressure develops the maturity (Netterstrm and Kayser, 2008; Kawashiro et al., 2009) and empathy (Warner and Rizzolo, 2006) that is required from early on to face other difcult questions, such as the bio-psycho-social impact on the donors families, especially in context with differing cultures and the absence of religious processions. There has been a demonstration by Pawlina et al. (2006) for the need of teaching both professionalism and leadership skills from as early as rst-year medicine in anatomy courses where integrity and responsibility signicantly and positively correlated with gaining higher scores in both practical and written examinations. Furthermore, developing leadership adaptability contributes to optimal healthcare delivery due to more effective interpersonal and communication skills with the healthcare team, patients, and their families (Pawlina et al., 2006; Swartz, 2006). Essential non-technical transferable skills with respect to qualities such as altruism, integrity, compassion among other desirable characteristics can be introduced and evaluated at medical school through peerevaluation to provide leader awareness (Chen et al., 2009; Pearson and Hoagland, 2009). Hence, offering constructive criticism (Pabst et al., 2001) to the demonstrators via evaluation forms (Yamashina, 1999) after every session is vital so that their instructional skills can gradually reach a level of prociency for the benet of teaching future generations of healthcare professionals. Conversely, since unprofessional conduct is the most common cause for disciplinary action against medics, from higher education to professional practice (Escobar-Poni and Poni, 2006), students who are deemed to lack appropriate professionalism or demonstrate inappropriate behavior within teaching groups and clinical clerkships may be monitored and counseled by senior mentors. San Francisco School of Medicine, University of California, introduced the newly modied
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Physicianship Evaluation Form (Papadakis et al., 2001) in which any concerns regarding preclinical students can be identied and discussed with a senior educator. Multiple evaluation forms throughout time at medical school indicate persistence of unacceptable behavior which is then referred to in the deans letter of recommendation for residency after graduation. Despite satisfying pass marks, receiving two or more such forms may lead to probation or dismissal. In a study of 235 disciplined doctors by Papadakis et al. (2005), disciplinary action was found to be three times more probable with unprofessional behavior stemming from time at medical school (odds ratio 5 3.0 and 95% condence interval 5 1.94.8), which reinforced the necessity to introduce professional competency within the curriculum. As professional attitudes may be introduced, monitored, and evaluated from the start of the medical course (Pawlina, 2006; Swartz, 2006), the aim of the Physicianship Evaluation scheme (Papadakis et al., 2001) is to potentially predict any unprofessional behaviors from an early stage in training that can be duly addressed before exposing patients to avoidable risk. Likewise, extent and lack thereof, of reliability, responsibility, initiative, and motivation have been correlated with disciplinary actions for physicians in violation which may be potentially extrapolated from the attitudes demonstrated as students (Teherani et al., 2005).

Committing to Patient Responsibility

In addition to the signicance of student professionalism in anatomy education, since much of the medical course is spent on the wards there is nowadays a greater incentive for new students to swear an oath at White Coat ceremonies (Wear, 1998; Gillon, 2000; Veatch, 2002) to be reminded of future expectations and responsibilities towards patients. As a result, students ethos and attitudes towards self-directed revision and retention of medical knowledge including anatomy will be taken more seriously. Overall, there is very little difference in rst-year clinical students and nal-year students since both are equally exposed to patient contact.

Medico-Legal Cases
Doctors may be more relaxed with the fact that dissection is not included in their nals but graduates still have a responsibility to be able to locate and treat underlying pathology and not only manage symptoms. Medical studies persist throughout the professional career and are not solely pertinent at medical school. Repercussions for the lack of anatomy knowledge should be presented using case studies in more contemporary modules like Medical Ethics within undergraduate curricula if fewer hours are to be dedicated to anatomy education. Moreover, patients are empowered to exercise their legal rights more now than ever before, especially towards medical practitioners. So-called anatomical ignorance has resulted in a steady upraise of surgical malpractice and litigation (Waterston and Stewart, 2005), most likely due to damage to underlying structures (32% frequency) as found by the Medical Defense Union in vascular and general surgery from 1990 to 2000 (Goodwin, 2000). As a consequence, popularized media cases of medical litigation will diminish the faith of the general population as well as necessitating large scal compensations; both which cannot be sustained by a free-forall healthcare system in the United Kingdom.
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Perceptions on Death and Its Education

Another aspect of handling cadaveric material not considered relevant until just a few years ago was the traumatic and emotional disturbances (Parker, 2002; Arraez-Aybar et al., 2004; Warner and Rizzolo, 2006) experienced by students. On this note, Marks et al. (1997) attends to featuring death education within the anatomy course to avoid students from resorting to depersonalization or denial when confronted with suffering. Instead, students are encouraged to develop coping mechanisms and support systems before starting their emotionally demanding careers (Pabst, 2002; Warner and Rizzolo, 2006; Arraez-Aybar et al., 2008; Netterstrm and Kayser, 2008) while fostering sensitivity to dying (Pawlina and Lachman, 2004). The instructor also plays an important role to aid students in overcoming qualms and anxiety over working with cadavers (Tschernig et al., 2002). Although some desensitization is inevitable over time and correlated with extent of exposure, a career in medicine heavily depends on retaining a strong sense of humanity. Learning humane values cannot be achieved by solely focusing on anatomical principles, a revolutionary idea promoted since 1960s followed by the pledge of behavioral rehumanization by 1970s so as to preserve the art in medicine (Warner and Rizzolo, 2006). It is crucial to educate students about death (Granger, 2004) as part of the life cycle, so that they are appropriately equipped to support themselves and more importantly patients emotionally, particularly those who require end-of-life care (Rizzolo, 2002) and their families to the best of their abilities.

munication but also resulted in mutual respect for both roles in healthcare provision.

Oratory and Presentation Skills

American institutions like John Hopkins University School of Medicine and Southern Illinois University School of Medicine are encouraging students to communicate using their anatomical knowledge when under pressure to develop condence, anatomical conceptualizations, professionalism, and better examination performances due to longer retention spans (Clough and Lehr, 1996; Chollet et al., 2009). Similarly, anatomy case studies (Cliff and Wright, 1996) in British medical schools are becoming increasingly popular practice where students are expected to present on individual cadavers. The benet of asking students to make oral presentations is the gain of valuable transferable skills in public speaking and formulating well-rounded arguments from scientic deductions.

PeerPeer Partnerships
Whereas independent learning is encouraged in all medical institutions, some schools put more responsibility onto students to be academically proactive. Manchester School of Medicine, UK (2006) advertises their medical course as mostly problem-based learning (PBL) and claims to be particularly designed for active self-directed learners, which doctors must be throughout their professional lives. For the past two decades, Harvard Medical School has been promoting PBL tutorials including in anatomy curriculum to bridge between lectures and laboratory experience while still counting on dissection (Yiou and Goodenough, 2006). Anatomy PBL and small-group teaching (Chan and Ganguly, 2008) have resurged in more institutions internationally, thus making their syllabi more dependent on student initiative and less reliant on rudimentary lecture notes. Instead of students simply attending lectures with differing amounts of knowledge, PBL requires its participants to actively prepare for a team-based discussion. Each individual team member researches mutually agreed learning objectives, which are then further explored and discussed with the entire group to contribute to a holistic picture. Prior preparations may consist of reading recommended texts to create learning objectives and discussion points. Finally, self-assessment tests can be administered before and after PBL sessions to evaluate its usefulness and whether the learning objectives have been mastered. Vasan et al. (2008) report that students who actively participated in teaching and learning from each other in problem-based and team-based scenarios achieved higher marks in examinations than those who passively learned from conventional didactic anatomy lectures. Anatomy PBL and setting projects (Philip et al., 2008) will familiarize students with basic pathology and research opportunities to encourage synergy so that students work together to complete learning aims (El-Moamly, 2008). PBL is effective at allowing students to ask questions about the purpose of their actions in anatomy and evokes curiosity beyond the set learning objectives (Slotnick and Hilton, 2006). These sessions also provide a protected environment where individuals may share their reections or epiphanies relative to differing backgrounds as well as learning resources to tackle such a vast subject (Warner and Rizzolo, 2006). The Nexus Portal at Mayo Medical School (USA), allows multimedia use to share reections, knowledge, and deductions from dissection ses89

Multidisciplinary Input
Modern healthcare practitioners, from nurses to doctors, are required to work effectively in a team and rely on each others expertise to provide holistic and optimal patient-centered management from admission to discharge and beyond. Besides the demand for radiologist instructors (McLachlan, 2004), a paradigm shift in anatomy education means that the workload of anatomists can be shared with physiotherapists, surgeons, and speech therapists (Purkayastha et al., 2007; Raftery, 2007; Collins, 2008). External facilitators may compensate for the lack of anatomy instructors as more medical institutions open within the UK (McLachlan and Patten, 2006). Not only will the quality of inter-professional education improve but the importance of multi-disciplinary collaboration will be reinforced at an early stage (Pawlina and Lachman, 2004; Hamilton et al., 2008). With respect to teaching anatomy to inter-professional groups, a Common Foundation Practice (CFP; Mitchell et al., 2004) course was introduced at St. Georges London (a hospital-medical school based in UK), which assessed the attitudes towards learning anatomy on cadavers for a multi-professional group (consisting of biomedical, nursing, physiotherapy, radiography, and medical students). The CFP course is an effective method to teach anatomy within a multi-disciplinary group regardless of the differences in test performance. Similarly, a survey of students from Doctor of Medicine and Doctor of Physical Therapy degrees on a gross anatomy course in Mayo Medical School elicited that 92% of participants (n 5 70) were convinced of the signicance of inter-professional learning (Hamilton et al., 2008). Their cooperation not only led to the expected benets of promoting teamwork and comAnatomical Sciences Education
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sions which students are comfortable utilizing (Durosaro et al., 2008). Similarly, team-based learning (TBL; Vasan et al., 2009) received overall positive feedback from 317 students when evaluating their preference for these sessions and teamwork irrespective of the grades attained with strongly positive internal consistencies (Cronbachs alpha 5 0.908 and 0.884, respectively) and with reproducible success in other countries like India (Shankar and Roopa, 2009). PBL sessions may include staff supervision but reciprocal peer teaching (RPT) enables participants to alternate as student and as chairperson. The chairperson is responsible to lead the discussion and cover all learning objectives as well as encouraging dialog between fellow team members while developing necessary transferable skills for professionalism and leadership. In a survey by Krych et al. (2005), 100% of participants in RPT dissection schemes agreed that their teaching experiences helped with understanding topics that they taught and 97% believed that there was increased retention of anatomy facts through teaching others. Students in gross anatomy RPT acquired more knowledge in this way than from staff teaching (Hendelman and Boss, 1986). Besides also becoming more independent learners, which is crucial to self-directed learning in the medical profession, the students attained improved attitudes to anatomy and an overwhelming majority agreed that RPT further developed essential communication skills (Hendelman and Boss, 1986; Krych et al., 2005). Other advantages of RPT include requiring less number of cadavers, a more economical teaching budget and a smaller studentteacher ratio. Conversely, whereas Bentley and Hills (2009) echo the perception of benets from RPT, no signicant differences in gross anatomy laboratory grades were found between RPT and non-RPT classes and a major concern is the unreliable quality of teaching from fellow colleagues. Therefore, to maximize reliability of knowledge while attempting to overcome the shortage of anatomy demonstrators, near-peer tutoring has been suggested as a possible solution by Evans and Cuffe (2009), which was positively received by fourth-year tutors and their rst- and second-year students. More senior students teach their junior peers in hope of reinforcing and expanding their own knowledge as well as developing teaching and communication skills that they will be expected to utilize in a supervisory role throughout their careers. Among the four leadership styles identied by Hersey and Blanchard (1993), Pawlina et al. (2006) assessed that the telling and selling leadership styles in rst-year students in a gross anatomy course led to lowest average group examination scores, most likely due to having no more experience with the material than their fellow peers. In fact, the optimal leading style is one that empowers communication and encourages taking responsibility within the team while monitoring the entire group.

and approval for effectively allowing students to self-assess their anatomy knowledge (Stein et al., 2006; Wait et al., 2009). Along with real-time feedback, using ARS demonstrated a statistically signicant positive correlation with student performances in summative examinations (Alexander et al., 2009).

Short Perspectives
As medical education has progressed exponentially over the past decades, there are unanimous concerns regarding the decline in students knowledge of anatomy as discussed (Waterston and Stewart, 2005; Warner and Rizzolo, 2006; Turney, 2007). It is vital to tackle this problem head on; otherwise, the deconstruction of anatomy education and undermining the crucial knowledge and skills gained from the course will inevitably lead to under-qualied educators for future generations (Fraher and Evans, 2009) as well as unsafe and incompetent doctors. Whereas the public have expressed major concerns over the lack of professionalism of physicians in sensationalized news stories (Swartz, 2006), a national television poll recently revealed that the public was also apprehensive about the extent of anatomy knowledge of their doctors and would prefer their doctors to have experience with real human anatomy, especially with dissection (Chowdhury et al., 2008). Collaboration between the Anatomical Society of Great Britain and Ireland (ASGBI) and American Association of Anatomists (AAA) resulted in the development of a distance-learning training program for budding anatomy educators (Fraher and Evans, 2009) after successful federally funded training grants were introduced for graduates and postdoctoral fellows in USA (McCuskey et al., 2005) and recommendations of graduate training by the American Association of Anatomists (Rizzolo and Drake, 2008). Universities cannot afford to produce negligent graduates in careers lasting 40 years on average. The protection of patients and provision of safe and optimal healthcare must be held as the highest priority. Fortunately, there are a wealth of new innovative resources and more pioneering methodology to enhance the life-long learning experience of something as fundamental as anatomy and to objectively measure progression within the course (Tabas et al., 2005; OByrne et al., 2008; Vasan et al., 2008; Alexander et al., 2009; Chollet et al., 2009; Choudhury et al., 2009; Daly, 2009; McNulty et al., 2009; Nowinski et al., 2009) while maintaining the individual learning climate of universities. It now depends on universities all over to unite for promoting the signicance of anatomy education and an optimal curriculum for all medical, surgical, nursing, and biomedical specialties, before its decline will lead to inevitable dire consequences for global patient healthcare.

Lectures
Didactic lecturing in anatomy education is as traditional as dissection itself and provides a summary of the learning objectives for students but may seem outdated to many (Pawlina and Lachman, 2004). However, technology has also been able to contribute to the enhancement of the learning experience within lecture theatres through interactive participation. Lectures no longer have to be passive after the introduction of the audience response system (ARS). ARS not only engages listeners but also has equally gained wide acknowledgment
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NOTES ON CONTRIBUTORS
KAPIL SUGAND, B.Sc. (Hons.), is a senior medical student at Imperial College, London, United Kingdom. He is an active member of the Royal Society of Medicine National Student Committee. PETER ABRAHAMS, M.B.B.S., F.R.C.S., F.R.C.R., D.O., is a professor of clinical anatomy at Warwick Medical School, University of Warwick, Coventry, United Kingdom. He is currently leading an active career within postgraduate teaching and research.
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ASHISH KHURANA, M.R.C.S., M.Sc., M.S., pedic registrar in University Hospital of Wales, Vale NHS Trust, Cardiff, United Kingdom. He specializing in foot and ankle surgery as well undergraduate students.

is an orthoCardiff and is currently as teaching

ACKNOWLEDGMENT
The authors thank Mr. Paraskevas Paraskeva (Ph.D., F.R.C.S., Consultant Surgeon in the Department of Biosurgery and Surgical Oncology at St. Marys Hospital, London W2 1NY, United Kingdom) for his support and guidance as well as the Reviewers for their time and efforts.
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