Adequacy of Medical School Gross Anatomy Educationas Perceived by Certain Postgraduate Residency

Programs and Anatomy Course DirectorsWAYNE W. COTTAM*

Department of Neurobiology and Anatomy, University of Utah Medical School, Salt Lake City, Utah

In light of the many changes that have been made in medical gross anatomy instruction, anattempt was made to determine the adequacy of medical student preparation in gross anatomyupon arrival at a postgraduate residency program and whether the adequacy of preparation hadchanged in the last 10 years. To address these questions, a survey was mailed to all of theprograms in four postgraduate residencies in the United States. This survey requestedinformation about the importance of gross anatomy to the discipline, the adequacy of residentpreparation, how today’s residents compare to those of 10 years ago, and in what areas they aredeficient. Another survey was mailed to all medical school anatomy departments to followchanges in curriculum, teaching methods, curriculum hours, and staffing in gross anatomy.Overall, of the surveys mailed, 79% were returned, 78% from the residency programs, and81% from the anatomy departments. A majority of the residency programs report that grossanatomy is either extremely important or very important to mastery of their discipline and rankit as the most important basic science. Overall, 57% of the residency program directors felt thatresidents need a refresher in gross anatomy upon arrival, 29% felt that they were adequatelyprepared, whereas 14% felt they were seriously lacking. Fifty-six percent of the residencyprograms indicated that the residents are as prepared as those of 10 years ago, 41% indicatedthat they are less prepared, and only 4% said that they were better prepared. There weresignificant differences in the responses between the different residency programs. Theresidency programs indicated that residents need to arrive more proficient in clinicalapplications, general knowledge, and cross-sectional applications. Anatomy departmentscontinue to modify their curriculum and teaching methods, decrease the curriculum hours andfaculty devoted to gross anatomy, and foresee problems obtaining qualified gross anatomyteachers in the future. Clin. Anat. 12:55–65, 1999.r 1999 Wiley-Liss, Inc.

Key words: curriculum; anatomy departments; residency programs; adequatepreparation; deficiencies

INTRODUCTION

During the last 30 years there have been significantchanges in the teaching of gross anatomy in under-graduate medical schools. Several studies have docu-mented these changes that include changes in curricu-lum, educational methods, a decrease in curriculumhours, and a reduced supply and demand for grossanatomy instructors (Eldred and Eldred, 1961; Blevinsand Cahill, 1973; Collins et. al., 1994). These and otherauthors have identified a decline in emphasis given togross anatomy teaching and the training of qualifiedgross anatomy instructors (Mortimer, 1967; Pilgrim,1972; Moosman, 1980; Collins et. al., 1994). Further-more, many have suggested that this de-emphasis

could have serious consequences for the preparation ofcompetent medical school graduates and their abilityto deliver medical care (Sinclair, 1975; Skandalakis,1980; Skandalakis and Gray, 1983).

To date, no studies have assessed the effect of thesechanges on student preparation in gross anatomy upongraduation from medical school. This report describestwo surveys, conducted simultaneously, that follow thechanges being made in medical school anatomy depart-ments as well as assess the adequacy of preparation in

*Correspondence to: Wayne W. Cottam, D.M.D., 554 5th Avenue,Salt Lake City, UT 84103. E-mail: ldelhoyo@xmission.com

Received 17 June 1998; Revised 2 July 1998

Clinical Anatomy 12:55–65 (1999)

r 1999 Wiley-Liss, Inc.

gross anatomy once a resident arrives at a postgraduateresidency program.

The first survey was sent to all U. S. medical schoolsto follow the ongoing changes in anatomy depart-ments. This survey requested information on changesin curriculum emphasis, teaching format, curriculumhours, and faculty. It also inquired about hiring andtraining of faculty as well as predictions for the futurestaffing and teaching of gross anatomy courses.

The second survey was sent to the directors of fourresidency programs in the United States: FamilyPractice, Emergency Medicine, Diagnostic Radiology,and General Surgery. This survey assessed the follow-ing: importance of gross anatomy in relation to otherbasic sciences, adequacy of preparation in grossanatomy of new residents, whether the level of prepa-ration has changed in the last 10 years, in what specificareas they felt students were lacking, and whetherthey provided additional gross anatomy education tothe residents upon arriving at the residency program.These programs were selected because of the largenumber of programs and the large number of residentsin them, thereby increasing the chance of exposure toa variety of schools and educational approaches. Fur-thermore, it was assumed that some residency pro-grams would be more acutely aware of the degree ofpreparation than others depending on the importanceof gross anatomical knowledge to the mastery of theirdiscipline. Therefore, Emergency Medicine and Fam-ily Practice were used for comparison to GeneralSurgery and Diagnostic Radiology, whose programs, itwas assumed, would be more aware of any deficienciesdue to a heavier reliance on gross anatomical informa-tion.

MATERIALS AND METHODS

After completing the survey design and con-ducting an initial survey to refine the questions, 1,148surveys were mailed to all 126 U. S. medical schoolanatomy departments and 1,022 residency programs inFamily Practice (440), Diagnostic Radiology (204),Emergency Medicine (112) and General Surgery (266).The list of anatomy departments was obtained fromthe Directory of American Medical Education, 1996-97, and the list of residency programs from theGraduate Medical Education Directory, 1996-97. Threemailings were made to elicit responses. The firstmailing was in February 1997, followed by two subse-quent mailings in April and June of that year. Re-sponses were returned by regular postage, fax, andInternet.

RESULTSReturns. Of all surveys mailed, 79% (903/1,148)

were returned. Anatomy departments returned 81% ofthe surveys (102/126) and residency programs re-turned 78% (801/1,022). The residency program re-turns by program type were as follows: DiagnosticRadiology 84% (172/204), General Surgery 84% (224/266), Emergency Medicine 83% (93/112), and FamilyPractice 71% (312/440).

Results from the anatomy department survey arepresented first to update the reader on trends in thedepartments, followed by the results from the resi-dency program survey.

Anatomy Department Survey

Most questions were asked from the reference of1991 because that was the last comprehensive surveyof anatomy departments and gross anatomy education(Collins et al., 1994). The respondents were mostlycourse directors (53%) and department chairpersons(45%). One associate professor and one former actingdepartment chairperson also responded.

Changes in curriculum emphasis and teachingformat. The survey suggested 11 types of curriculumareas and educational methods and asked if thedepartment had either increased or decreased theiremphasis of that area or format since 1991. Most of thedepartments (88%) reported making some changes incurriculum emphasis or educational methods since1991(see Table 1). Other comments regarding changesin teaching format were offered. Five departmentswere merging their gross anatomy course with otherbasic science courses, usually embryology or histology.Two departments were implementing more formalreview sessions and quizzes, whereas two other depart-ments were spreading out the course over the 4 years.Two departments were implementing more smallgroup sessions, whereas one department had begunusing more imaging techniques such as laproscopy andendoscopy. One department produced written textsand exercises presumably for independent study, andanother increased the demonstration time in thelaboratory to make up for a decrease in dissection time.One department reported that it decreased the num-ber of lectures and that the students were ‘‘shoutingfor more lecture time.’’ The respondent indicated thatthey probably would be increasing the lectures again.

Curriculum hours. Departments were asked toreport how many curriculum hours were assigned togross anatomy in 1991 and in 1997. The averagenumber of hours reported in 1991 was 190 and theaverage in 1997 was 165 which represents a 13%decrease. The most hours reported were 280, and thefewest were 50. One-half of the departments had

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made no change in curriculum hours since 1991, 42%had decreased their hours, and only 8% had increasedthem. The average decrease was 32 hours with thelargest decrease being 150 hours. The average increasewas 21 hours with the largest increase being 73 hours.Table 2 compares the curriculum hours reported bythis survey (1997) with those reported by previousstudies and demonstrates the reduction in grossanatomy curriculum hours since 1939 (Eldred andEldred,1961; Blevins and Cahill, 1973; Collins et al.,1994).

Faculty. Departments were asked to report thenumber of faculty FTE positions that were in thedepartment in 1991 and 1997, as well as how manywere/are involved in teaching gross anatomy. Sincefractions of FTEs may be a useful number, theexpression of FTE numbers is extended to the firstdecimal place. The average departmental faculty FTEsin 1991 was 13.8; the average today (1997) is 14.4. Thisrepresents a 4% increase. The average faculty FTEsinvolved in teaching gross anatomy in 1991 was 5.5;the average now (1997) is 5.1. This represents a 7%decrease. This change resulted in the percentage oftotal faculty involved in teaching gross anatomy drop-ping slightly from 40% to 35%.

Slightly less than one-half (45%) of the departmentshad made no change in the number of faculty involvedin teaching gross anatomy since 1991, whereas 32%had decreased that number, and 18% had increasedfaculty involved in gross. The average decrease inthose teaching gross was 2.0, with the largest decreasebeing 13.0. The average increase in faculty teachinggross was 1.7, with the largest increase being 5.0. Thehighest number of FTEs involved in teaching grossanatomy was 12.0, whereas 1.3 was the fewest.

Current trends in educational methods. Depart-ments were asked which of four current trends ineducational methods they felt needed additional fac-ulty or curriculum hours for proper implementation.The choices given were: problem-based learning,clinical correlation, computer learning, and indepen-dent learning. Of these choices, 81% of the respon-dents said problem-based learning needed additionalfaculty or curriculum hours, 54% of the respondentssaid implementing more clinical correlation requiredmore resources. Computer and independent learningwere marked by 25% and 21% of the departments,respectively, as needing more resources.

The data were then examined to determine whetherany departments that had increased their use of anyone of these educational methods had actually experi-enced an increase in the resources they felt wereneeded. There were 62 departments that had in-creased educational methods for which they felt re-quired additional teaching staff or curriculum. Only 12(19%) of those departments reported an increase ineither staff or curriculum. Thirty-three departmentshad increased problem-based learning and indicatedmore staff or curriculum hours were required, but onlyfour (12%) reported an increase in either. Three ofthose four departments reported an increase in faculty,and one reported an increase in hours. Thirty-eightdepartments had increased the clinical correlation in

TABLE 1. Curriculum Areas and Educational Methods in Which AnatomyDepartments Are Increasing or Decreasing Their Emphasis

Curriculum areas being increased Curriculum areas being decreased

Radiography, MRI, CAT 58% Topographical 10%Clinical correlation 58% Clinical correlation 6%Cross sectional 53% Cross sectional 5%Topographical 20% Radiography, MRI, CAT 4%

Educational methods being increased Educational methods being decreased

Computer learning 57% Lectures 52%Case studies 41% Dissections 33%Problem-based learning 35% Video tapes 7%Independent learning 25% Independent learning 3%Dissections 10% Case studies 2%Video tapes 7% Computer learning 1%Lectures 5% Problem-based learning 1%

TABLE 2. Trends in Curriculum HoursDevoted to Gross Anatomy

Year Number of hours

1939a 3381955a 3301966b 2901973b 1971991c 1821997 165

aEldred and Eldred, 1961.bBlevins and Cahill, 1973.cCollins et al., 1991.

Adequacy of Medical School Gross Anatomy Education 57

their courses and indicated more staff or hours wererequired, but only seven (18%) reported an increase ineither. Two of the seven increased faculty, threeincreased hours, and two increased both.

Hiring and training of faculty. One trend that hasbeen identified recently is that very few anatomists arebeing trained for teaching gross anatomy. Further-more, departments are hiring faculty not trained in thesubject and then training them to teach the entirecourse or certain sections (Collins et al., 1994). Thissurvey asked the departments to what degree they arefollowing this trend. Of the departments that re-sponded, 31% said that they were hiring facultyuntrained in gross anatomy and then training them toteach in the course. In those departments an averageof two faculty had been hired under these conditionssince 1991, and on average, 28% of their faculty fellinto this category (ranging from 1% to 80%).

Future problems in training and teaching. Depart-ments were asked if, in the future, they could foresee aproblem in obtaining qualified teaching staff for theirgross anatomy course. Sixty-eight percent of the respon-dents said they did foresee this as a problem. Thosedepartments cited many reasons for their concerns.Twenty-three departments indicated the main prob-lem was the fact that most graduate programs nolonger require a gross anatomy course. Sixteen depart-ments cited the conflict between research and teach-ing as the problem. Sixteen departments said that notenough teachers were being trained. Six departmentssaid that their current research faculty was unwilling toteach gross anatomy. Three departments cited the lackof administrative support for gross anatomy.

Several comments were offered by the 33 depart-ments that said they did not see a problem obtainingteachers in the future. Eight reported that they werehaving no problem training the scientists that theyalready had. Seven departments indicated that therewould always be people who need jobs and thereforebe willing to be trained to teach gross anatomy. Fourdepartments said that it was not a problem for themyet, and three departments felt they could hire retiredMDs when needed. Two departments indicated thattheir tendency was to hire researchers whose interestis close to gross anatomy, and one department said thatthey did not have a gross anatomy course.

This question of future staffing in gross anatomycourses is similar to a question asked in two previoussurveys, Blevins and Cahill (1973) and Collins et al.(1994). Both of which inquired as to whether respon-dents felt that enough anatomists were being trainedto meet the teaching requirements in the future. Eventhough the question was stated differently in thecurrent survey than the two previous surveys, the

trend can be summarized as follows: In 1973, 70% ofdepartments were concerned with future staffing forgross anatomy teaching; in 1994 that number rose to78%; and in the current survey dropped to 68%.

Residency Program SurveyRespondents. Most of the respondents (71%) were

program directors, 20% were department chairpersonsor vice chairpersons, 4% were division chiefs, and 3%were assistant or associate program directors. Otherrespondents included faculty or chief residents. Theaverage length of time the respondents had been onstaff at their current or similar residency programs was12 years.

Importance of gross anatomy to their discipline.The respondents were asked to what extent a soundknowledge of gross anatomy was important to themastery of their discipline - extremely important, veryimportant, somewhat important, very little, or not atall. Results when all of the programs were looked attogether were as follows: 46% said that gross anatomywas extremely important, 40% said it was very impor-tant, 12% said it was somewhat important, and about1% said gross anatomy was of very little or no impor-tance. Figure 1 shows how each program ranked grossanatomy in terms of importance to mastery of theirdiscipline. Gross anatomy was assigned more impor-tance by Diagnostic Radiology and General Surgerythan by Emergency Medicine and Family Practice,and the difference was statistically significant (Mann-Whitney test P , .0005).

Relative importance of gross anatomy as com-pared with other basic sciences. Respondents wereasked to rank gross anatomy in order of importance totheir discipline with respect to physiology, pharmacol-ogy, pathology, microbiology, biochemistry, and genet-ics. Table 3 shows all of the basic sciences, how oftenthey were ranked first in order of importance, and thepercentage of the total first place rankings eachreceived. Table 4 shows the number of times eachbasic science was given each ranking as well as whatranking was most often given to each basic science.

The program that most often listed gross anatomyas first in order of importance was Diagnostic Radiol-ogy, 161 times, or 89% of its first place rankings.General Surgery listed gross anatomy first in order ofimportance 121 times, or 46% of its first place rank-ings. Both Diagnostic Radiology and General Surgeryranked gross anatomy first in order of importance moreoften than any other basic science. However, Emer-gency Medicine listed gross anatomy first in order ofimportance 17 times for only 16% of its first placerankings, whereas Family Practice listed gross anatomyfirst in order of importance 32 times for only 10% of its

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first place rankings. Emergency Medicine rankedphysiology and pharmacology first in order of impor-tance more often than gross anatomy, in that order.Family Practice listed physiology, pharmacology, andpathology first in order of importance more often thangross anatomy, in that order. A majority (70%) of theprograms that ranked gross anatomy as extremelyimportant, also ranked it first in order of importance.

Adequacy of resident preparation. Respondentswere asked to rank the gross anatomical knowledge offirst-year residents arriving from medical school as:seriously lacking, needing a refresher, or adequatelyprepared. Over all, 57% of the residency programsindicated that incoming residents need a refresher,whereas 29% reported that they were adequatelyprepared and 14% reported that they were seriouslylacking. The ranking of resident preparation given byeach individual program is shown in Figure 2.

Diagnostic Radiology and General Surgery respon-dents were less satisfied with the gross anatomicalknowledge of residents today than Emergency Medi-cine and Family Practice, and the difference wasstatistically significant (Mann-Whitney test, P 5 .020).Respondents were then asked whether residents arriv-ing today are: better prepared, less prepared, or as wellprepared as residents 10 years ago. Overall, 56% of theresidency programs reported that the level of prepara-tion was the same as 10 years ago, 41% reported thatresidents were arriving less prepared, and only 4%indicated that residents were arriving better prepared.

Fig. 1. Importance of gross anatomy by residency program type.Two other choices, Very Little or Not at All, are not shown in thisfigure. One Emergency Medicine program (1%) and five Family

Practice programs (2%) indicated that gross anatomy was of very littleimportance. One Family Practice program (0.3%) indicated that grossanatomy was of no importance at all.

TABLE 3. Residency Program Ranking of BasicScience Courses

Basic scienceNumber of firstplace rankingsa

Percentage of firstplace rankings

Gross anatomy 331 38%Physiology 280 32%Pharmacology 116 13%Pathology 100 12%Microbiology 20 2%Biochemistry 12 1%Genetics 6 1%

aTotal first place rankings is greater than total respondentsbecause several programs assigned more than one basicscience a first-place ranking.

Adequacy of Medical School Gross Anatomy Education 59

How each individual program compared today’s resi-dents with those 10 years ago is shown in Figure 3.

Diagnostic Radiology and General Surgery com-pared the preparation of today’s residents with those of10 years ago less favorably than did Emergency Medi-cine and Family Practice, and the difference wassignificant (Mann-Whitney test, P 5 .001).

Perceived areas of deficiency. Respondents wereasked to indicate in which of eight areas it is importantfor residents to arrive more proficient. Table 5 showsthe responses. In anticipation of comparing the re-sponses of the residency programs with the areas thatanatomy departments were emphasizing, the choices

of problem-based applications, computer applications,and dissections were included. In reality, this madecomparison more difficult. The value of dissectionskills or computer applications of gross anatomy to theclinical practitioner is probably very minimal from theperspective of patient care. It is not likely that respon-dents would place a high degree of importance onthese areas, and in fact they did not. A higherpercentage of respondents expressed a desire thatstudents be more proficient in problem-based applica-tions. It is hard to say whether this is an endorsementfor problem-based learning as an educational tool, orsimply a desire that students be able to apply their

TABLE 4. Each Basic Science and Number of Times It Was Given Each Respective Rankinga

Basic science Number of times given each ranking

Gross anatomy #1–330 #2–147 #3–93 #4–91 #5–77 #6–31 #7–9Physiology #1–280 #2–204 #3–208 #4–43 #5–26 #6–12 #7–3Pathology #1–100 #2–240 #3–210 #4–114 #5–68 #6–31 #7–16Pharmacology #1–116 #2–127 #3–120 #4–131 #5–113 #6–84 #7–58Microbiology #1–20 #2–36 #3–80 #4–216 #5–252 #6–103 #7–43Biochemistry #1–12 #2–18 #3–40 #4–875 #5–95 #6–247 #7–246Genetics #1–6 #2–6 #3–18 #4–66 #5–101 #6–212 #7–340

aNumbers in boldface represent rank most commonly given.

Fig. 2. Preparation in gross anatomy of incoming residents.

60 Cottam

gross anatomical knowledge to real problems in theclinical setting, regardless of the educational methodthat teaches them to do so. Because of the difficulty ofinterpreting the responses to these three choices, theywere separated from the rest of the responses in Table5 and are omitted from the discussion of this question.The responses were then examined to see whichcurriculum areas each individual program indicated asneeding improvement. The curriculum areas that atleast 50% of the respondents indicated are shown inTable 6.

Additional anatomy training given during resi-dency. The respondents were asked if they felt thatadditional anatomy training was needed for incoming

residents. When asked if they felt the necessity to give‘‘remedial’’ training to incoming residents, 71% saidno. However, 58% said they did teach discipline-specific details that they did not expect to be taught inundergraduate medical training. When asked if theyused formally trained gross anatomists to give theadditional anatomy training, 94% said that they didnot. The question was then asked, if not gross anato-mists, who provided the additional anatomy educa-tion, and why. The majority (79%) said that they usedtheir own faculty. The most common reason for this

Fig. 3. Comparison of resident preparation in gross anatomy today versus ten years ago.

TABLE 5. Areas in Which Residents Needto Arrive More Proficient

Area Percentage

Clinical application 76%General knowledge 63%Radiography, MRI, CAT 50%Cross sectional 36%Topographical 25%

Problem-based applications 49%Computer applications 10%Dissection 6%

TABLE 6. Curriculum Areas in Which At Least 50%of Respondents Indicated That First-year ResidentsNeed to Arrive More Proficient

Program Curriculum area Percentage

Diagnostic Cross sectional 78%Radiology Clinical application 71%

General knowledge 69%

General Clinical application 67%Surgery General knowledge 60%

Emergency Clinical application 65%Medicine Radiography, MRI, CAT 61%

Family Clinical application 75%Practice Radiography, MRI, CAT 58%

General knowledge 57%

Adequacy of Medical School Gross Anatomy Education 61

was that they could present the needed material in amore clinically relevant manner than what was beingtaught in gross anatomy courses. A few programs citedthe lack of availability of anatomists. Beyond their ownfaculty, programs said that they routinely called inother specialists to emphasize anatomy. Family Prac-tice and Emergency Medicine programs called insurgeons, orthopedists, and radiologists most com-monly. A few General Surgery programs indicated theyused radiologists for help, but no Diagnostic Radiologyprograms reported using anyone except their ownfaculty for anatomy education.

The few programs using anatomists to help traintheir residents reported that they were near enough toa medical school that they could borrow anatomistsfrom that institution. These programs were asked ifthey could foresee a problem obtaining anatomists inthe future and 75% said they did not foresee aproblem. Only a very few respondents (8%) reportedusing any kind of formal format for reviewing anatomy;i.e., lectures or conferences. Most programs expectedindependent, or ‘‘on the job’’ review and education.

DISCUSSION

Anatomy Department Survey

It is evident from the anatomy department returnsthat medical schools are continuing to modify theircurriculum and educational methods with respect togross anatomy. The majority of anatomy departmentsare increasing emphasis on imaging techniques, clini-cal correlation, and cross-sectional anatomy. Relativelyfew departments are increasing emphasis on topo-graphical anatomy. They are delivering this informa-tion more and more via computer learning, casestudies (presumably in small groups), and problem-based learning, rather than by lectures and dissections.

As curriculum continues to be modified, curriculumhours and the number of faculty involved in teachinggross anatomy continue to decrease. These resourcesare diminishing, even while departments increaseteaching methods such as problem-based learning andclinical correlation, for which the same departmentsreport they need more resources. It is difficult to seehow those departments are effectively employingthese methods unless curriculum time is being shiftedfrom more traditional methods of teaching. This couldbe the case given the percentage of schools decreasingusage of both lectures and discussions. The decreasein curriculum time devoted to gross anatomy is a trendthat has been noted with some concern for many years.In 1961, when the average number of hours for grossanatomy was still hovering at 338; it was suggested that‘‘. . . in view of the reduction in time that has already

taken place, that the teaching load in anatomy willshow little further change’’ (Eldred and Eldred, 1961).However, in 1975, the curriculum hours had decreasedto 197, and it was feared that because of the drasticreduction in time devoted to gross anatomy, that‘‘. . . the amount of detail in many courses in grossregional anatomy has now decreased below the safetylevel’’ (Sinclair, 1975). As long ago as 1980, some werecalling for a restoration to ‘‘. . . no less than 200 hours,’’a suggestion that obviously has been difficult to followin the current educational environment (Moosman,1980).

A decrease in curriculum time is not a phenomenonunique to gross anatomy. Almost every other basicscience has experienced a decrease in curriculumhours since 1991, according to the curriculum directorypublished by the Association of American MedicalColleges. Data published in the 1991 directory werecompared to data in the 1997 directory and showedthat microbiology received a 13% decrease in curricu-lum time during that period. Physiology showed a 12%decrease, genetics an 11% decrease, biochemistry a 9%decrease, and gross anatomy an 8% decrease duringthe same time period. Pathology, pharmacology, andmicroanatomy all experienced a 3-4% increase incurriculum time during that period.

Another trend identified over the years relates tothe training of faculty teaching anatomy. Collins et al.(1994) reported that 41% of the medical schools hiredresearch faculty not trained in teaching gross anatomyand then trained them to do so. The percentage ofschools actively following this trend was down to 31%in this survey. However, of the departments thatanswered yes to this question, an average of 28% oftheir faculty were teaching under this situation. Thiswould indicate that this practice is firmly in place inmany departments, regardless of whether they arecurrently hiring. Several respondents indicated that ifand when they begin hiring for gross anatomy, theyfully expect to hire under this arrangement.

The fact that departments are developing a ten-dency to train other basic scientists to teach anatomyhas not eliminated the concern that, in the future,there may be a dearth of qualified teachers. However,the percentage of those concerned had decreased by atleast 10% from former surveys. This drop in percent-age could be due to some departments becomingrelatively comfortable with the practice of trainingresearchers to teach. One department chairpersoncommented, ‘‘There always seem to be people whoneed jobs. I have hired anatomists whose researchinterests are in paleobiology.’’ Another commentedthat, ‘‘Any molecular biologist who needs a job canlearn to teach gross.’’ Some departments indicated that

62 Cottam

they had developed research programs closely tied togross anatomy and therefore had a tendency to recruitfaculty interested in the subject. The commonalityamong these departments that do not foresee a prob-lem obtaining staff in the future is that they havefound some peace between the teaching and researchrequirements.

Still, a majority (68%) indicated they could foresee aproblem in obtaining qualified teachers in the future.Reasons for their concern were centered on the sameconflict between research and teaching. Judging fromthe comments of the respondents, this conflict beginsupon entrance to graduate school and continues intofaculty hiring and promotion practices. One depart-ment explained that the staffing of their gross anatomycourse could become a problem for them within thenext 10 years and made this comment, ‘‘For someschools it is a problem now. Many, if not most, graduateprograms do not train gross teachers or even requirethe course. The emphasis is to get students into theresearch lab and completely ignore the future teachingcapabilities/opportunities of the student.’’ Anothercommented, ‘‘National trends not to educate graduatestudents in the teaching of gross is resulting in anational shortage of gross teachers. Young research-active faculty, not trained in gross teaching, don’t wantto teach it, or tend not to be good at it.’’ Logically,research, not teaching, remains the emphasis oncethey secure faculty positions. One respondent said,‘‘Research pressures and dollars select for facultyunwilling to commit time to labor intensive course likegross.’’ Another commented, ‘‘As current (trained)anatomists retire . . . there will be none who know andare committed to anatomy. The new faculty are, atbest, reluctant part-time anatomists.’’ Indeed, onerespondent reported that new faculty candidates areactually negotiating for packages that keep them fromteaching gross anatomy. ‘‘Who wants a job that theuniversity administration, including the dean, sees asunprofitable and a drain on faculty time and re-sources.’’

Many of the trends that were identified in previoussurveys are confirmed by this study. Anatomy depart-ments are using computer-based learning, case stud-ies, problem-based and independent-based learning toteach gross anatomy in favor of lectures and dissection.Departments report that increasing the use of theseeducational methods requires more curriculum hoursand faculty. Nonetheless, the curriculum hours andfaculty devoted to gross anatomy teaching continue todecrease. A majority of the departments fear a shortageof qualified teachers for their gross anatomy courses inthe future, but most training and hiring within thedepartments continues to favor the funded researcher.

Residency Program Survey

The central question of the residency programsurvey was to obtain some assessment, outside of themedical school environment, of how well studentswere being prepared in gross anatomy. Before gettingto this specific question, the survey attempted toassess the degree of importance of gross anatomy tothe discipline. It was hoped that this would give someindication of the attention paid to how well preparedthe students arrived. When the responses from all ofthe programs were examined, gross anatomy emergedas the most vital basic science. The majority of theprograms marked gross anatomy as extremely impor-tant or very important, and gross anatomy was rankedfirst in order of importance by more programs moreoften than any other basic science.

There were significant differences in the degree ofimportance and ranking of importance given to grossanatomy when the responses from Diagnostic Radiol-ogy and General Surgery were compared to the re-sponses from Emergency Medicine and Family Prac-tice. As expected, the importance of gross anatomy toGeneral Surgery and Diagnostic Radiology was morethan to Emergency Medicine and Family Practice.Furthermore, Diagnostic Radiology and General Sur-gery ranked gross anatomy as the most important basicscience more often than the other two. Even with thedifferences in where gross anatomy was placed, therewas a strong consensus about what the most importantbasic sciences were for clinical practice in thesedisciplines. Gross anatomy, physiology, pathology andpharmacology were, with only one exception, namedas the top four most important basic sciences to thesedisciplines. That one exception found General Sur-gery programs placing pharmacology sixth in order ofimportance and biochemistry as fourth.

Admittedly, it is very difficult to assign a degree ofimportance to these basic sciences, and indeed severalrespondents refused to give any rankings based on thebelief that all are equally important. However, whenstruggling with decisions about allocating resourcesand time, it may be helpful for medical schools torealize what practitioners feel is most important in theclinical environment and avoid the tendency to,‘‘. . . equate areas of great scientific progress and largegrants, with areas of teaching necessary for medicalstudents’’ (Skandalakis and Gray, 1969). A recentsurvey completed in Germany obtained the residentsperspective about what subjects were most important.They asked residents, upon completion of their resi-dency, to grade the relevance of medical school sub-jects. The top six subjects were internal medicine,gross anatomy, physical examination, physiology, phar-

Adequacy of Medical School Gross Anatomy Education 63

macology, and pathology, in that order (Pabst andRothkotter, 1997). This ranking is strikingly similar tothat suggested by the residency programs in thissurvey.

The question of how well prepared the residentswere arriving in gross anatomy was then asked of theprograms. When data from all of the programs areexamined together, a majority of respondents indi-cated that arriving residents need a refresher in grossanatomy to be up to speed for work in the residency.Less than a third indicated that residents were arrivingadequately prepared, and over a tenth of the respon-dents found that the preparation of incoming residentswas seriously lacking. When the data from eachprogram was examined, a similar pattern emerges tothe pattern in the question of gross anatomy impor-tance. Diagnostic Radiology and General Surgerygraded resident preparation less favorably than didEmergency Medicine and Family Practice. As wasexpected, the programs for which gross anatomy wasmost important, were those most concerned withpreparation of residents.

The survey did not make an overt attempt tointerpret how a respondent felt about the fact thatstudents needed a refresher in anatomy. Certainly thisdoes not give as clear a signal as a response of seriouslylacking or adequately prepared, but it could indicatetacit approval of the preparation, considering the timelapse between actual participation in the course andgraduation. Perhaps some indication of how the respon-dents feel about this situation is indicated by the factthat a majority of the programs (71%) do not give‘‘remedial’’ training in anatomy once a resident arrives.It remains hard to say whether this is because they donot feel the need or simply do not have the time.However, there were a few comments similar to theFamily Practice program that indicated, ‘‘. . . it is tootimely and inefficient to try to make up for poormedical training.’’ The survey did reveal that someanatomy is being taught in the residency programs,mainly by the clinicians of the program in an informalor ‘‘on the job’’ manner. The comments indicated thatthis method is preferred, because the program facultybring more clinical relevance to the setting, andanatomists are either hard to find, or the programs do

not have the money nor the time to incorporate theminto the schedule.

When asking the programs to compare the prepara-tion in gross anatomy of residents today to those in thepast, they were asked to look back ten years. Thisturned out to be a very appropriate time frame as theaverage length of time the respondents were on staff atthe programs was 12 years. Once again, the programsthat consider gross anatomy more essential to theirdiscipline, Diagnostic Radiology and General Surgery,were more likely to judge the preparation of residentstoday as less adequate than that of ten years ago. Theanswers to this question show that a majority of theseresidency programs report that the preparation ofresidents in gross anatomy is as good as ten years ago.However, almost half of the respondents feel thatresidents are arriving less prepared in gross anatomy.Diagnostic Radiology, Emergency Medicine and Fam-ily Practice all had very similar percentages of theirrespondents reporting that the residents were lessprepared than those of ten years ago, while GeneralSurgery was the only program in which a majority ofrespondents felt that way. Also worth noting is thesimilarly low percentage of respondents from eachprogram that feel the preparation is better. Almost noone, in any program, feels that the preparation in grossanatomy of incoming residents is getting any better.

The responses to the question about perceivedareas of deficiency were looked at to see if any patternsemerged. Several programs commented that, from apurely anatomical perspective, there is little differencebetween the categories of cross-sectional anatomy andradiography, MRI, CAT. For purposes of this discus-sion, these two categories will be combined into onecategory of imaging/cross-sectional anatomy. Giventhis adjustment, the most commonly chosen areas forimprovement in order were: clinical application, gen-eral knowledge and imaging/cross-sectional anatomy.A majority of respondents from every individual pro-gram indicated clinical application as an area forimprovement. A majority of respondents from everyprogram but one, Emergency Medicine, said thatimprovements in general knowledge were needed,and only General Surgery did not have a majority

TABLE 7. Curriculum Areas in Gross Anatomy in Which a Majority of Medical Schools Have Increased Their Emphasis andAreas in Which a Majority of Residency Programs Feel First-year Residents Need to Arrive More Proficient

Curriculum areas in which majority of medicalschools have increased their emphasis

Curriculum areas in which a majority of residency programsfeel first year residents need more proficiency

Clinical correlationImaging/cross-sectional anatomy

Clinical applicationGeneral knowledge

Imaging/cross-sectional anatomy

64 Cottam

indicating that students needed improvement in imag-ing/cross-sectional anatomy.

Table 7 compares the curriculum areas in which amajority of medical schools have increased their empha-sis with the curriculum areas in which a majority ofresidency programs indicate residents need improve-ment. There appears to be general agreement thatclinical correlation and imaging/cross-sectional anatomyare the most important areas to emphasize. Thequestion of general knowledge remains. Most resi-dency programs indicate that the overall general knowl-edge in gross anatomy of residents needs to beimproved.

Arguably, the only way to improve this situation isby employing more effective educational methods ordevoting more time to the subject. As was seen fromthe anatomy department responses, the educationalmethods being utilized more often are computerlearning, case studies, problem-based learning andindependent learning. The educational methods be-ing used less often are lectures and dissections. Further-more, curriculum time devoted to gross anatomycontinues to be reduced. During the last ten yearscharacterized by these changes, only a slight majorityof residency program directors indicate that the ad-equacy of preparation in gross anatomy has not changedsignificantly. Almost one-half of the respondents feelthat the preparation is worse. Almost no one feels thatthe preparation is getting any better. The degree towhich the residency programs are concerned with thissituation today depends largely on the degree ofimportance that the program gives to gross anatomy.Furthermore, at this time, most programs seem ableand willing, if not forced, to compensate for anyperceived deficiencies.

The results from this survey are not completeenough to hand down an indictment of any educa-tional method or curriculum design, and it is not theintention of this study to do so. Indeed, many resi-dency programs indicated that the quality of prepara-tion depends much more on the individual than theschool or educational methods. What the results dosuggest is that careful discussion is warranted beforeany further modifications in educational methods ordecrease in curriculum time occurs, especially if thecurrent environment is not able to offer any moreencouragement and outward support for those whose

emphasis is in the classroom instead of the laboratory.The curriculum reform that has taken place at mostschools has been met with varying degrees of accep-tance and enthusiasm, and these results suggest vary-ing degrees of success. Hopefully the current trend isfor faculty, administration and students to work to-gether in evaluating the changes and developing aresult that best suits their institution and situation. It ishoped that the results of this study may prove to behelpful in these future discussions.

ACKNOWLEDGMENTS

I would like to thank my supervisory committee fortheir time, patience and encouragement during thisproject. Those family and friends whose computerassistance and long hours stuffing envelopes made themailings possible. Most importantly, my wife andfamily whose love, encouragement and patience defylogic and truly made this endeavor possible.

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