Art macabre: Is anatomy necessary?

ANZ J. Surg.

(2001)

71

, 779–784

LETTERS TO THE EDITOR

Dear Editor,

Art macabre: Is anatomy necessary?

The late Sir Sydney Sunderland, Professor of Anatomy atMelbourne University, would be writhing in his grave and threat-ening resurrection by some mystical force if he knew that ‘post-modernism’ had invaded the teaching of anatomy in his formerprecincts. Sunderland was a charismatic genius who deliveredspellbinding lectures of great eloquence using only his voice, col-oured chalks and a blackboard. He was also a fervent advocate ofa two year stint of cadaver dissection for all medical students andregarded this as essential for surgeons. Sunderland looked many astudent in the eye and said, ‘

The surgeon must know his wayaround

’.Over the ages acquisition of cadavers has always been a con-

tentious practice. Yet even the most macabre efforts to obtainbodies pale into insignificance in comparison to the everydayatrocities of the modern world. In addition, the good enabled bythe use of cadavers far outweighs the distasteful aspects. It wascrucial to the work of the Hunter brothers and thus contributed tothe establishment of modern British surgery.

At a recent hand surgery meeting the audience was treatedto a high-tech demonstration of the anatomy of the wrist joint.The computer-based presentation utilized simulation, models,graphic design and a professional narrator. It was superb andwon a prize. As a vision of carpal anatomy and dynamics is wastrue and a win for postmodernism. But for a practising surgeondissecting a palmar ganglion stalk tentacling its way towardsdorsolateral ligaments it was not a true picture of the realanatomy of the wrist ligaments. These ligaments are notoriouslydifficult to delineate.

This writer would not demean the rightful place of simulationin teaching, especially in situations in which simulation approxi-mates ‘real’ situations. Flight simulators can accurately mimicthe physical sensations caused, for example by unexpecteddescent due to engine failure. The situation is similar for cardio-pulmonary resuscitation. Deep-seated neurosurgical dissection,cardiac surgery and many other cases are amenable to simulationbecause of the mediating significance of display and endoscopicinstrumentation. Other examples, such as microsurgery, seem torequire both traditional anatomical knowledge and laboratorysimulation of neurovascular anastomosis. However, many sur-gical techniques are more vagarious due to the almost infinitevariations in human anatomy. Dissection of a pancreatic or otherdeep tumour is a more difficult proposition and could not be ade-quately simulated.

Would a surgeon of the calibre of Norman C. Tanner, feeling bytactile gnosis around the lesser sac, or, for that matter, D.G. Bradman,have learned the precisions of their skills without decades of practisewith the ‘real thing’.

R

OBERT

V. S. T

HOMPSON

Reconstructive SurgeonMelbourneVictoriaAustralia

Dear Editor,

LETTER TO THE EDITOR


We are writing in response to the editorial and article in the Juneissue of the

Journal

under the joint title ‘Art Macabre’

.

1,2

It isclearly not an ‘obsolete concept that surgeons operating on apatient must literally have the anatomy of the relevant area attheir fingertips’; an intimate knowledge of the anatomy of the rel-evant area will always be vital for safe and successful surgery.However, faced with an inevitable decrease in access to cadavericspecimens, we must find alternative methods of teaching that cansupplement the little dissection that will remain. Fortunately,advances in computer technology promise to deliver teachingmethods that are not only ‘cost-effective, clean, odourless andtime-saving’ but will also put 3-D anatomy ‘at [the surgeons]finger tips.’

Decreased access to dissection is inevitable. Apart from majorchanges to undergraduate medical curricula allocating less time tothe study of gross anatomy,

3

Mr Magee’s paper poignantly illus-trates the accessibility problem: the appropriation of adequate spec-imens for dissection. Under the provisions of the proposedamendment to the

Human Tissue Act 1983

4

and the

Coroner’s Act1980

,

5

which is currently before the State Parliament of New SouthWales,

6

human tissue for dissection will no longer be availableexcept from patients who give explicit written consent prior to theirdeath. This provision is further complicated by two statements inthe proposed bill. First, the designated officer of the hospital orinstitution must be satisfied that the deceased did not subsequentlyrevoke said consent, either orally or in writing and, second, that nosenior next of kin objects to the use of the body of the deceased forthe purposes of anatomical dissection. Who would be brave enoughto lay claim to a body so donated, given the possibility that suchdonation is open to nebulous dispute, and with hefty penaltiesimposed for lack of prescience?

A viable alternative may involve the use of virtual reality dis-section simulators. A surgical simulation interest group withinthe Royal Australasian College of Surgeons convened for the firsttime during the course of the Annual Scientific Congress, on9 May 2001, and this issue was debated. The inaugural meetingof the Medical Simulation Society of Australasia was held inCanberra on 28 May 2001, bringing together representatives fromAustralasian medical, allied health, health administration, indus-try and education, military, aviation, and information technologygroups. Virtual reality technology has advanced to the pointwhere we believe it can now be usefully deployed in the teachingof anatomy and surgery. In particular, the development of ‘com-puter haptics’ means that the 3-D tactile component of learning –missing from familiar desktop computer systems – can now beincluded in an integrated, multisensory, learning environment.Medic Vision, an Australian telemedicine and medical technol-ogy company, has engaged CSIRO to collaborate with represent-atives from the College and other organizations to produce aroadmap for the development of anatomical and surgical trainingproducts using the latest virtual reality technologies. The Collab-orative Training and Education Centre for medical and surgicalskills in Western Australia has already installed a haptic work-bench, and we aim to have prototype training applicationsdeployed there within a year.

780 LETTERS TO THE EDITOR

We sincerely hope that these new training technologies are notseen as a threat to the traditional methods of teaching and learn-ing anatomy; in certain circumstances, dissection will remain the‘ultimate simulation’. Rather, we expect that virtual reality willallow efficient and effective access to anatomical data to a greaterproportion of students and trainees, while preserving theundoubtedly few specimens that will be available in the future forthose situations where requirements cannot be met by computer-based training. We would do well to recognize that each of thetwo described forms of ‘dissection’ – physical and virtual – hasits place, and to ensure that they both coexist for the differing cir-cumstances to which each is most suited.

REFERENCES

1. Fahrer M. Art macabre: Is anatomy necessary?

ANZ J. Surg.

2001;

71

: 333–4.2. Magee R. Art macabre. Resurrectionists and anatomists.

ANZ J.Surg.

2001;

71

: 377–80.3. Hamdorf JM, Hall JC. The development of undergraduate curric-

ula in surgery: I. General issues.

ANZ J. Surg.

2001;

71

: 46–51.4. Human Tissue Act. New South Wales, 1983.5. Coroner’s Act. New South Wales, 1980.6. Human Tissue Amendment Bill. New South Wales, 2001.

P

ETER

H. C

OSMAN

Department of SurgeryUniversity of SydneySydneyNew South WalesAustralia

M

ATTHEW

H

UTCHINS

CSIROMathematical and Information SciencesCanberraAustralian Capital TerritoryAustralia

P

ATRICK

C

REGAN

Medical Simulation Society of AustralasiaSimulation Interest GroupRoyal Australasian College of Surgeons

Dear Editor,


I read with interest the two articles on teaching anatomy in theJune issue of the

Journal

.

1,2

As a neurosurgeon, I, of course, agree that the members of ourprofession have a need for an intimate knowledge of anatomy intheir relevant area of practice. However, the majority of medicalstudents will not enter surgery and therefore their need foranatomy is much different. Practical anatomy continues to benecessary, for instance of the vessels of the feet to assess pedalpulses or of the pelvis to perform a pelvic exam.

However, meticulous dissection of the lesser superficial petro-sal nerve or the otic ganglion as suggested by Mr Magee (page379) would seem both an irrelevant and possibly onerous task forthe majority of medical students and many areas are not relevantto general practitioners and physicians. The older model of learn-ing anatomy by rote in preclinical years probably selects out agroup of students who are adept at rote learning, discouragesthose who are not and limits diversity amongst our medical com-munity. Very few students in the future will need to know or willremember the white matter tracts of the brain that they must slav-

ishly learn for student medical examinations. In fact, many train-ees sitting the First Part Examination find that they have torelearn the anatomy that seemed so irrelevant in their preclinicalyears such that they have therefore forgotten it. Hence the popu-larity of spending time working as anatomy tutors for a periodprior to the First Part Surgical Exams in Victoria. So while Iagree with both Mr Fahrer and Mr Magee that anatomy, by dis-section and other teaching methods, is the cornerstone of surgicaltraining and should be taught by surgeons, I applaud the newermedical courses for reducing detailed rote learning of anatomy toa more practical form. I believe that the onus is now on we sur-geons to teach anatomy to those who really need to know it in apostgraduate capacity.

REFERENCES

1. Magee R. Art macabre. Resurrectionists of anatomy.

ANZ J.Surg.

2001;

71

: 377–80.2. Fahrer M. Art macabre: Is anatomy necessary?

ANZ J. Surg.

2001;

71

: 333–4.

K

ATE

D

RUMMOND

Department of SurgeryRoyal Melbourne HospitalParkvilleVictoriaAustralia

Dear Editor,

Art Macabre: Is anatomy necessary?

The title of the recent editorial in this

Journal

1

is rhetorical in theextreme. Of course anatomy is necessary if a medical student is tobecome acceptably competent in eliciting physical signs whichare the indisputable basis of clinical examination. Proficiency inthese relatively simple tasks in someone with an MB BS degreecan reasonably be expected by a society that has funded at leastseven years of attendance at a university, as is the case where aGraduate Medical Program has been introduced.

Physical examination (applied anatomy at its practical best) isat the very heart of the art of the practice of medicine, no matterwhat educationalists and the like might wrong-headedly espouse.The gradual deletion of gross anatomy from medical school cur-ricula, almost to the point of extinction, has dangerously erodedthe foundations of clinical medicine in this and other countries.The question is, ‘What can be done to put the matter right?’

Once, and not so long ago at that, cadaver dissection was a majorcomponent of the preclinical years and it was, at least in this writer’sopinion, a monstrous and disagreeable waste of time. However,Marius Fahrer is quite correct in his assertion that tactile and visualappreciation of gross anatomy is the only way to learn three-dimen-sional morphology so vital for a surgeon,

1

but it is not necessary toanywhere near the same degree for medical students. For them anacceptable grasp of clinically relevant functional anatomy can begained by the use of specifically dissected specimens.

There is no point in beating about the bush. Anatomy will neverregain the place it once held in medical education and so an alterna-tive, practical strategy is urgently needed. For the past three yearsat the Royal North Shore Hospital we have trialled sessions onRegional Functional Anatomy, focusing these on palpable andsurface anatomy as part of teaching in the Skills Laboratory. Theyentail the use of artists’ models, articulated skeletons and dissectedspecimens supplied by the Anatomy Department. A region (hip,

LETTERS TO THE EDITOR 781

knee, foot and ankle etc.) can be well covered in a 90-minute ses-sion, which is complemented by a comprehensive handout distrib-uted beforehand. However, this form of teaching by surgeons islabour-intensive, with small groups of up to eight students. Ouranatomy-starved students have welcomed this experiment, whichis rated very highly in their assessments. It is contended that thissimple approach to a major educational problem may well be thedirection to take in the future. Why not an option term in clinicalanatomy along these lines?

It is essential for self-evident reasons that departments ofanatomy continue to flourish in our universities. The presentGilbertian situation is that graduates enter basic surgical trainingwith virtually no knowledge of anatomy. Hence, the respons-ibility of bringing them up to scratch now rests squarely with theprofessional associations. Anatomy departments with minimaland ever-reducing staff cannot be expected to continue to producedissected specimens, and preparation is a time-consuming exer-cise. It is reasonable to integrate this task to a considerable degreewith teaching programs in basic and advanced surgical training.This too has been successfully trialled in a limited way withorthopaedic trainees at Royal North Shore Hospital.

No doubt many older readers of this

Journal

still feel thewearisome yoke of the vast amounts of seemingly meaningless,irritating detail of infinitely dull descriptive anatomy they had tolearn more or less by rote as undergraduates in order to pass evenmore irritating examinations. No doubt also that this prerequisitecoloured, and continues to colour, the views of earlier graduatesin all branches of medicine. Be this as it may, the pendulum hasswung far too far in the opposite (wrong) direction. Now anatomyfor medical students and aspirant surgeons will have to be taughtby surgeons. This is a nettle that must be grasped and promptlyso. Time is on no one’s side in the present sorry state of affairs.

REFERENCES


ANZ J. Surg.

2001;

71

: 334.

T

HOMAS

K. F. T

AYLOR

Department of Orthopaedics andTraumatic Surgery

University of SydneySydneyNew South WalesAustralia

Dear Editor,


We write to support Marius Fahrer’s editorial on the teaching ofanatomy

1

and agree with him and Reginald Magee that anatomyis central to the study of surgery and the training of surgeons.

1,2

The almost complete disappearance of clinically trained person-nel from academic departments of anatomy in this country is anindex of the widening gap between medical practice and anat-omy. Recent global trends have directed medical curricula awayfrom basic sciences, in particular gross anatomy, promotinginstead public health, communication and compassion. Not sur-prisingly, some medical students have been left to cater for them-selves and complain of anatomical disorientation. Others feel thatthey are poorly equipped to understand the pathophysiology,diagnosis and treatment of common illnesses all of which requirea modicum of knowledge of 3-D anatomy.

The traditional undergraduate dissecting programme of yester-year is no longer appropriate nor is it sustainable because of cost,time restraints, and shortage of skilled staff. This is evident bydifficulties experienced by many departments to maintain evenprosection programmes and indeed, the College is finding itincreasingly difficult to maintain an adequate supply of specimenssuitable for the part II fellowship examinations. The solution to thisdilemma is not to rely simply on innovative computer programmesto make up the deficit. Medical students should not be left to bridgethis gap alone. How then can the problem be resolved?

Basic knowledge of clinically relevant anatomy should not beoptional, it should be assumed and expected. There needs to be anational consensus that basic anatomical knowledge is essentialto medical learning and what constitutes basic knowledge needsto be defined. Innovative programmes then can be developedcontaining a mix of self-directed learning, problem solving andsupervised practical classes, where students are taught with theuse of prosected specimens. However, the opportunity to dissectanatomical regions relevant to common clinical problems (e.g.the anterior abdominal wall, the cubital fossa etc.) must beincluded.

3,4

Indeed students claim that dissecting with and guidedby a demonstrator who is able to emphasize clinically relevantanatomy is far more valuable than being taught only on prosectedspecimens.

5

Option terms should be available to those wishing topursue a specific project. Could not such programmes be staffedin part by surgical trainees to consolidate their own preparationfor fellowship, allowing them to participate in small group teach-ing of undergraduates and provide a much needed clinical inputto anatomy teaching?

Medical training without a good foundation in basicanatomy is perilous in that it will produce doctors who lackspatial understanding and recognition of the body. This willdisadvantage them should they wish to pursue a clinical careerin any branch of medicine including surgery.

6,7

It is inconceiva-ble that such a risk can be taken with Australian graduates.Marius Fahrer describes himself as one of the ‘now extinctspecies of anatomist surgeons’.

1

We should heed his warningthat anatomical knowledge and orientation is as essential toclinical medicine as are public health, good communicationand compassion.

REFERENCES


ANZ J. Surg.

2001;

71

: 333–4.2. Magee R. Art macabre: Resurrectionists and anatomists.

ANZ J.Surg.

2001;

71

: 377–80.3. Pabst R. Gross anatomy: An outdated subject or an essential part

of a modern medical curriculum? Results of a questionnairecirculated to final year medical students.

Anat. Rec.

1993;

237

:431–3.

4. Leong SK. Back to basics.

Clin. Anat.

1999;

12

: 422–6.5. Pearse EO, Parkin I. Undergraduate medical students view on

the value of dissecting.

Med. Educ.

2000;

34

: 493.6. Raftery AT. Basic surgical training 1: Postgraduate surgical

examinations in the UK and Ireland.

Clin. Anat.

1996;

9

: 163–6.7. Willan P. Basic surgical training 2: Interactions with the under-

graduate medical curriculum.

Clin. Anat.

1996;

9

: 167–70.

L

ES

B

OKEY

AND

P

IERRE

C

HAPUIS

Department of Colon and Rectal Surgery,

Concord Hospital,Sydney


Dear Editor,

LETTER TO THE EDITOR


In an era beset with demands for evidence it is difficult to argueabout the teaching of anatomy. For the issues at hand, there is noevidence. No one conducts research on the teaching of anatomyas surgeons understand it. No one seems likely to fund suchresearch. The interested parties are consumed by other responsi-bilities and imperatives. We are left therefore with the lowestlevel of evidence: emotional concerns and anecdotes.

The emotional concerns relate to diminishing standards ofundergraduate anatomy education. Some surgeons and othersbelieve that a thorough grounding in anatomy is essential for sur-geons but that medical students are no longer exposed to the fullbreadth and depth of anatomy; nor is there an opportunity forgraduates to obtain this exposure before or while undertakingsurgical training.

For a variety of reasons, modern medical curricula havereduced the time allocated for anatomy and the emphasis given toit. Intent on exposing undergraduates to their own ever-increasingknowledge base, other disciplines compete for curriculum time.Classical subjects give way to greater emphasis on professionalskills and psychosocial medicine. Beliefs prevail that much ofwhat used to be taught in anatomy was superfluous to the needsof medical graduates.

These influences are perhaps most starkly evident in graduatemedical programmes, in which the mastery of individual, basicscience subjects has been replaced by pragmatic, clinical problemsolving. Students learn just enough anatomy to solve the currentclinical problem. Depth of study is prevented by constraints oftime, and is replaced by urgent harvesting of only what is imme-diately useful.

While that may be a satisfying solution for generic medicaleducation, and while it may be endorsed by contemporary expertsin medical education, it does not serve surgical education. Thereare things that surgeons need to know, and know well, that are notof concern to general practitioners and physicians.

A typical response to this dissonance is that if surgeons need toknow more anatomy, they can learn it as postgraduates. But therecomes the educational vacuum. Surgeons in training are not pro-vided with courses of instruction, by talented and experiencedindividuals, in the details of surgical anatomy and how to masterit. Instead surgical trainees see to their own education by relatingto a book. Be it from a prescribed textbook or from modulesposted to them by the College, trainees are relegated to learningwritten words. This they can do well, just as they could memorizea stamp album or a telephone directory. But while this may con-stitute learning, it does not provide for insight and understanding.It is on this matter that the anecdotes arise.

Anecdotes maintain that surgical trainees have a shallow com-prehension of anatomy, despite having passed the Part I examina-tions. Surgeons relate how their new registrar has absolutely noability to recognize anything encountered in the conduct of a cer-vical sympathetectomy. Other examples are more stark, namely:‘The registrar rang to report that he had successfully treated thepatient with compartment syndrome by debriding the necroticmuscle. When asked by the Consultant – which muscle, the regis-trar replied: the one at the front of the thigh.’

Revealing insights emerged during the Diploma of Anatomyexaminations when these were conducted in the past by the Ana-tomical Society of Australia and New Zealand. When asked todemonstrate the structures in the left paravertebral region (ureter,

inferior mesenteric vein, gonadal vessels), no candidate could so.Yet all had just passed the Part I.

But all this is the limit of evidence: emotions and anecdotes.Rather than reflecting a parlous state of affairs, it could be thatemotions are expressed by only a small minority of surgeons whoare vociferous and nostalgic for the old ways. It could be that theanecdotes describe exceptional instances. We have no recourse toimmediately available data by which to test these possibilities.

One option would be to canvass Fellows with a double question:(i) upon entering advanced surgical training do your registrars havean adequate understanding of anatomy; and (ii) should advancedsurgical trainees come with a better education in anatomy?

The validity of such questions might be challenged. Perhaps thewording could be refined. Nevertheless, a comprehensive responsefrom the Fellowship could put to rest the concerns and anecdotes,if they are wrong. If the answers to the questions are ‘yes’ and ‘no’,that should be sufficient evidence that undergraduate education andbook-learning for the Part I are sufficient for surgical training; andthe emotional, vociferous minority should fall silent. If the answersare ‘no’ and ‘yes’, the College will need to do more than it is doingat present. Even if there was no response to the survey, one couldinfer that the Fellowship did not view this matter as serious enoughand that fundamentally there was no problem, notwithstanding theemotion, notwithstanding the anecdote.

The hidden message, however, to the Fellowship is that no oneelse is looking after anatomy; no one else cares. The AnatomicalSociety of Australia and New Zealand is defunct, and has notfunctioned for some 10 years. Surgeons are the only corporateorganization left with a vested interest in anatomy. It is up tothem to say what goes.

N

IKOLAI

B

OGDUK

Professor of Anatomy and Musculoskeletal Medicine,

University of Newcastle,Newcastle Bone and Joint Institute,Royal Newcastle Hospital, NSW 2300,Australia

Dear Editor,


The editorial that appeared in the June issue of the Journal hasstimulated this retired surgeon to remember his own experiencesin learning anatomy and then to wonder on the relevance ofanatomy instruction for undergraduates in medicine in thispresent day.

In Med II (1929) the whole body was dissected apart fromthe cranial cavity contents. Dissection was carried out by threegroups of four students on each cadaver, one group each to head/neck, thorax/abdomen and the extremities in each term. Rotationof the areas by the groups assured a full dissection over the year.Lectures and demonstrations also took place.

Med III (1930) saw a repetition of Med II dissections plus dis-section of the cranial cavity and lectures in neuro-anatomy.

Our three clinical years brought lectures and demonstrationson basic surgery including a course in so-called surgical anatomy.The first postgraduate year was generally spent in hospital(not compulsory), where one first realized the great differencebetween corpse anatomy and dissection of the living body on theoperating table and in the casualty department. We had the priv-elege of working as first assistant to various leading surgeons ofthe time; a part now occupied by registrars in training.

LETTERS TO THE EDITOR 783

Without that type of teaching in anatomy and surgery I couldnever have practised in the isolated one-man country area300 miles from specialist support with bad roads, no aerial serv-ices, the nearest railway 100 miles away and one ambulancestationed 30 miles away from my local hospital. Thank you to mymany teachers now long departed!

What about the teaching of anatomy today? The abundance ofavailable corpses has disappeared, few doctors are prepared tobecome anatomy teachers, live anatomy in the operating theatreis available only to the more senior graduates and undergraduateteaching in anatomy is ceasing. Ah! But GPs are no longer iso-lated and without surgical and emergency support thanks to thebase hospital, better roads and aerial services.

However there is still a gap: minor surgery demands a knowl-edge of anatomy, especially surface anatomy, and there will be anincreasing dearth of applicants for rural postings unless some pro-vision is made for anatomy teaching.

Surgeons in training could be used as basic anatomy teachersto classes made up of first- and second-year graduates or perhapseven final-year undergraduates.

I am sorry I won’t even know what has happened!

K

EITH

J

ONES

Bayview GardensBayview, NSW

Dear Editor,


Reginald Magee’s fine history of Anatomy

1

and MariusFahrer’s accompanying Editorial

2

touch on the issue of how thestructure of the body should be taught to medical professionals.I am more optimistic than either that classical anatomy has along future in our medical and science faculties. Dissection waseliminated during a recent overhaul of the medical course in myUniversity (Sydney), but the demand for dissection has resurgedand we are busier than ever. We are teaching more and more inthe new medical course (though not yet by dissection), and tostudents of medical science, of our Summer School and fromother universities (which lack the infrastructure). US students inour medical course express concern that they are missing thedissection courses, which are still part of the medical curricu-lum ‘at home’ and that they will not be equipped to pass thenational board exams they must take if they are to practice inthe USA. (They are being given extra time and help). Medicalstudents see dissection as an essential rite of passage, as well asa source of vital knowledge, and in the US, though thankfullynot yet here, some have sued their alma mater for not givingthem adequate grounding.

As to the community’s view, I still recall a non-medical chap, afriend of our Faculty, pressing me on whether the new Sydney cur-riculum would include anatomy: ‘Will the students still dissect thebody?’ I said it seemed unlikely (we were still in the planning phase).‘Well, will they study it systematically.’ I replied that they wouldstudy areas of anatomy as it came up in their weekly problems, oneweek the forearm, the next week the brain, and so on. ‘Will they do adissection of what a surgeon has to deal with here?’ (he patted histummy) – I admitted that they would not in this course, feeling a bitmiserable. ‘

Strewth!

’ he said, and I felt immediately better.The community expects doctors to know bodily structure, and in

the long term the community’s view will prevail, if only becausethe community pays for medical education. Changes back to tradi-tional teaching are already quietly under way at Sydney.

I agree with Dr Magee that anatomy is more interesting whenrelated to other things – to function, dysfunction, surgery, embryol-ogy. We have always traced those connections and our courses havebeen correspondingly popular. If it happens that the subject goes‘back the surgeons’ (as he suggests), I could not object. Knowledgeshould be taught by people who have a passion for it, who know it,who will work to teach it. Whether the teachers of anatomy are sur-geons or academic anatomists is, in this broad view, less importantthan their knowledge, passion and commitment.

Last year, the New South Wales College of Surgeons approachedmy department, and our sister departments at the University ofNew South Wales and at Newcastle, to run dissection courses forsurgeons-in-training. It was a great experience. Surgeons and anato-mists taught side-by-side to highly motivated young professionals.Near each cadaver was a computer, full of anatomical images andinteractive learning modules, just a click or two away. The comput-ers stayed off all week, as the trainees took to the cadavers. Classicalanatomy is alive and well, because the students, the community andthe professionals all value it. Its teachers, both anatomists or sur-geons, must maintain our cooperation, so that we can continue torespond creatively to new fashions in teaching and technology.

REFERENCES

1. Magee R. Art macabre. Resurrectionists of anatomy.

ANZ J.Surg.

2001;

71

: 377–80.2. Fahrer M. Art macabre: Is anatomy necessary?

ANZ J. Surg.

2001;

71

: 333–4.

J

ONATHAN

S

TONE

Challis Professor of AnatomyUniversity of SydneySydneyNew South Wales

Dear Editor,

Art macabre: Is anatomy necessary: Reply

My less-than-300-words contribution has triggered a substantialcorrespondence from my fellow anatomists and surgeons. Forbrevity’s sake I will replace separate answers to each letter bycomments on some of the questions raised.

Is anatomy necessary?

As expected, anatomists and surgeons all agree upon the neces-sity of anatomy for the practice of medicine and surgery. ‘Thegradual deletion of gross anatomy from medical school curricula,almost to the point of extinction, has dangerously eroded thefoundations of clinical medicine in this and other countries.’ As aresult ‘some medical students … complain of anatomical disori-entation. Others feel that they are poorly equipped to understandthe pathophysiology, diagnosis and treatment of common ill-nesses all of which require a modicum of knowledge of 3-Danatomy.’

There is no time or scope for each medical student to performpersonally the dissection of the whole body, ‘a monstrous anddisagreeable waste of time’, nor is there any need for all medicalstudents to do a minute ‘dissection of the lesser superficial petro-sal nerve or the otic ganglion’.

A simple solution for problem-solving teaching of anatomycould be by starting the new curriculum with the physical exami-nation of a normal person. Surface anatomy integrated with pros-


ected specimens and radiological imaging will provide the basisfor clinical cases presentation. A second step will be the anatomyof routine clinical procedures.

The experience of the Department of Orthopaedic Surgery ofSydney’s North Shore Hospital in teaching the anatomy of thelocomotor apparatus by clinical examination and prosected speci-mens is positive.

Is dissection necessary?

It is, for prospective surgeons. After graduation as MBBS ‘thereare things that surgeons need to know, and know well, that are notof concern to general practitioners and physicians’. One of thesethings is ‘to know his way around’ the whole human body bydissection, as emphasized by the late Sir Sydney Sunderland. Theexperience of a nonagenarian surgeon stresses the need for realgeneral surgeons in isolated rural areas.

Recent advances in electronics have led to the construction ofincredibly advanced simulators in all fields of endeavour, fromaviation to endoscopic surgery. The development of ‘computerhaptics’ means that ‘the 3-D tactile component of learning cannow be included into an integrated, multisensory learning envi-ronment’. This brings us a step closer to Aldous Huxley’s

BraveNew World

‘feelie movie pictures’. I am sure that in a not toodistant future, simulation will become a precious supplement todissection.

In the University of Sydney’s Department of Anatomy andHistology ‘the demand for dissection has resurged’ and theteachers ‘are busier then ever’. Medical schools in Sydney andMelbourne, in collaboration with the College of Surgeons, haverun successful courses of dissection for postgraduate surgicaltrainees.

Teaching and examinations

‘The older model of learning anatomy by rote in preclinicalyears probably selects out a group of students who are adept atrote learning, discourages those who are not, and limits diver-sity among our medical community’. Teaching of undergradu-

ates by Part I College examination candidates is beneficial toboth medical students and prospective surgeons. However, it isfraught with the danger of the young tutors saturating the brainsof their young charges with the details required by Collegeexaminations, and that because their own examinations inanatomy are based on ‘learning written words. This they can dowell, just as they could memorize a stamp album or a telephonedirectory’. and the result? ‘Anecdotes maintain that surgicaltrainees have a shallow comprehension of anatomy, despitehaving passed the Part I examinations’.

The Royal Australasian College of Surgeons and the teaching of anatomy

The basement of the College building, once upon a time, wasdedicated to the teaching of anatomy and also contained a pathol-ogy museum. It has now been invaded by offices and archivematerial. Because formal study of regional anatomy has been allbut deleted from most medical schools’ curricula, the Collegeshould resume its teaching of this subject. Recently the Collegehas introduced, in collaboration with departments of anatomy inSydney and Melbourne, courses in surgical anatomy based onhuman body dissection. These postgraduate courses give a goodgeneral knowledge of surgical anatomy and should enable Part Icandidates to find their ‘way around the human body’ as well aspass their examinations. For Part II, detailed courses for special-ists can also be organized by the College and the medical schoolsin each State. Competent teachers can be recruited from both theCollege and the various departments of anatomy.

The role of the College, in teaching as well as in examininganatomy, should be formalized because ‘surgeons are the onlycorporate organization left with a vested interest in anatomy. It isup to them to say what goes’.

M

ARIUS

F

AHRER

Department of Anatomy and Cell Biology,

University of Melbourne, Melbourne,Victoria

Documents

Art macabre: Is anatomy necessary?