RESEARCH REPORT

Effect of Visual–Spatial Ability on Medical Students’Performance in a Gross Anatomy Course

Rebecca S. Lufler,1* Ann C. Zumwalt,2 Carla A. Romney,3 Todd M. Hoagland4

1Department of Anatomy and Cellular Biology, Tufts University School of Medicine, Boston, Massachusetts2Department of Anatomy and Neurobiology, Boston University School of Medicine, Boston, Massachusetts3Science and Engineering Program, Boston University Metropolitan College, Boston, Massachusetts4Department of Cell Biology, Neurobiology and Anatomy, Medical College of Wisconsin, Milwaukee, Wisconsin

The ability to mentally manipulate objects in three dimensions is essential to the practiceof many clinical medical specialties. The relationship between this type of visual–spatialability and performance in preclinical courses such as medical gross anatomy is poorlyunderstood. This study determined if visual–spatial ability is associated with performanceon practical examinations, and if students’ visual–spatial ability improves during medicalgross anatomy. Three hundred and fifty-two first-year medical students completed the Men-tal Rotations Test (MRT) before the gross anatomy course and 255 at its completion in2008 and 2009. Hypotheses were tested using logistic regression analysis and Student’st-test. Compared with students in the lowest quartile of the MRT, students who scored inthe highest quartile of the MRT were 2.2 [95% confidence interval (CI) 1.2 and 3.8] and2.1 (95% CI 1.2 and 3.5) times more likely to score greater than 90% on practical exami-nations and on both practical and written examinations, respectively. MRT scores formales and females increased significantly (P < 0.0001). Measurement of students’ pre-existing visual–spatial ability is predictive of performance in medical gross anatomy, andearly intervention may be useful for students with low visual–spatial ability on entry tomedical school. Participation in medical gross anatomy increases students’ visual–spatialability, although the mechanism for this phenomenon is unknown. Anat Sci Educ 5: 3–9.

© 2011 American Association of Anatomists.

Key words: gross anatomy education; medical education; anatomy course performance;visual–spatial ability; medical students; mental rotation test

INTRODUCTION

Visual–spatial ability has been defined as the ability to men-tally manipulate objects in three dimensions (Vandenberg andKuse, 1978). The spatial ability literature has been evaluatedand also defined spatial visualization as the ability to men-tally rotate and manipulate two-dimensional (2D) and three-

dimensional (3D) objects (McGee, 1979; Kozhevnikov et al.,2005). Such spatial abilities are essential to medical training,as seen in surgeons and surgical trainees (Wanzel et al., 2002,2003; Boom-Saad et al., 2008), and they are even called onearly in students’ education during the study of gross anat-omy (Garg et al., 2001). To become proficient in anatomy,one must be able to visualize and mentally manipulate 3Dstructures and able to recall this information, when the anat-omy is presented in various planes (Fernandez et al., 2011).Though there are multiple ways to teach anatomy, students’spatial ability plays a critical role when using learning resour-ces that show the structures in multiple positions and fromdifferent directions (Garg et al., 2001). This not only suggeststhat visual–spatial abilities may be related to students’ abilityto learn anatomy but also suggests that pedagogical techni-ques could be developed to enhance these abilities and leadto greater success in medical gross anatomy and future medi-cal training.

*Correspondence to: Dr. Rebecca Lufler, Department of Anatomyand Cellular Biology, 136 Harrison Avenue MV509, Boston, MA02111, USA. E-mail: Rebecca.lufler@gmail.com

Received 6 June 2011; Revised 25 October 2011; Accepted 27October 2011.

Published online 29 November 2011 in Wiley Online Library(wileyonlinelibrary.com). DOI 10.1002/ase.264

© 2011 American Association of Anatomists

Anatomical Sciences Education JANUARY/FEBRUARY 2012 Anat Sci Educ 5:3-9 (2012)

The Mental Rotations Test (MRT) is a validated tool thatmeasures a subject’s ability to mentally visualize the rotationand orientation of a 3D object that is presented in a 2D plane(Vandenberg and Kuse, 1978). The MRT tests what cognitivepsychology has determined a primary visual–spatial ability,‘‘visual imagery involving 2D and 3D whole object rotationsand translations’’ (Anastakis et al., 2000). Studies using theMRT have demonstrated variability in visual–spatial abilitythat corresponds with both gender and practice. The Vanden-berg and Kuse version of the MRT has received considerableattention for revealing significant gender effects in whichmales perform better on the test than females (Vandenbergand Kuse, 1978; Linn and Petersen, 1985; Voyer et al., 1995;Peters, 2005; Peters and Battista, 2008). Additional factorssuch as age, sexual orientation, handedness, and geneticshave all been linked to visual–spatial abilities, however, gen-der differences remain the strongest influence on MRT per-formance (DeFries et al., 1976; Bouchard and McGee, 1977;McGee, 1979; Peters et al., 2006, 2007). In the effort to iden-tify environmental factors that affect visual–spatial ability,repeated testing has been shown to lead to increased scores(Baenninger and Newcombe, 1989); however, Peters et al.(1995) found minimal improvements in performance on theMRT during a one month period when administered weekly.Finally, in a study of physical education undergraduate stu-dents, practice of rotation tasks led to significantly increasedmental rotations test scores, however, this study did not findany correlation between visual–spatial ability and anatomyscores (Hoyek et al., 2009). Although there have been multi-ple studies regarding the effects of variables such as genderon visual–spatial ability, few studies have examined theeffects of taking an intensely visual course on students’ vis-ual–spatial ability and more attention needs to be turned tothe implications of visual–spatial ability on performance inpreprofessional education programs.

Learning spatially complex relationships is an essential as-pect of medical education that occurs during the study ofgross anatomy. Students’ inherent spatial ability has beenshown to play a critical role in their ability to learn anatomi-cal spatial relationships (Rochford, 1985; Garg et al., 2001;Guillot et al., 2009). For example, students’ abilities to learncarpal bone anatomy are affected by their visual–spatial abil-ities and from studying the carpal bones from rotated viewsrather than in one static view (Garg et al., 2001). Guillotet al. (2007) also found significant correlations between vis-ual–spatial abilities and results on a test composed of rotatedanatomical structures. Both of these studies show relation-ships between visual–spatial ability and a student’s ability toidentify anatomical structures when shown rotated in 3Dspace. Rochford and coworkers demonstrated that studentswith poor scores on a battery of geometrical exercises alsoshowed deficits on anatomy spatial multiple-choice questionsand practical examinations as compared to students withhigh geometrical exercise scores (Rochford, 1985). However,no differences in performance on nonspatial multiple-choicequestions were found when comparing the two groups of stu-dents (Rochford, 1985). Further, spatial abilities have beencorrelated with success in mathematics (Hegarty and Kozhev-nikov, 1999), dental education (Hegarty et al., 2009), andveterinary education (Provo et al., 2002), however, none havelooked specifically at first-year medical student performancein a gross anatomy course in the United States. These studiessuggest that educators could use knowledge of students’ vis-ual–spatial abilities to select pedagogical approaches that may

help students to adjust their approach to learning. Early rec-ognition of students who possess weak visual–spatial abilitiescoupled with appropriately targeted academic interventionsmay lead to greater success in medical gross anatomy and inother aspects of their medical training.

In this study, we investigate the relationship between vis-ual–spatial ability and performance in a medical gross anat-omy course. To learn gross anatomy, it is imperative tounderstand the spatial relationships among anatomical struc-tures. Therefore, we propose that visual–spatial ability will beassociated with academic performance in medical gross anat-omy. Specifically, we focus on students’ performance on labo-ratory practical examinations during which students mustmentally rotate and manipulate structures from various viewsto identify anatomical structures. We tested the following twohypotheses: (1) visual–spatial ability will be positively associ-ated with practical examination scores and (2) students’ vis-ual–spatial abilities will increase during the medical grossanatomy course.

METHODS

Subjects in this study included Boston University School ofMedicine first-year medical students enrolled in the MedicalGross Anatomy course in Fall 2008 (Lufler et al., 2010) andFall 2009 (N 5 352). There were no exclusion criteria forthis study. This study was given exempt status by the Institu-tional Review Board, which grants ethics approval for humansubject research studies at Boston University School of Medi-cine. Participation in the study was voluntary and studentscould opt out at any time during the course.

Testing Visual–Spatial Ability

We assessed visual–spatial ability using the MRT, adapted byVandenberg and Kuse in 1978. The test was administered attwo time points: during orientation before the anatomy classbegan (August 2008 and 2009) and just before the studentstook the final examination (December 2008 and 2009). TheMRT was administered according to the instructions thataccompany the test. Each item consists of a target figure andfour comparison figures; each figure is composed of 10 blocksarranged in 3D space (Fig. 1). The students’ task was todetermine which two comparison figures could be rotatedinto congruence with the target figure. The correct figures areidentical to the target figure and only differ by rotation. Theremaining two distracter figures are either rotated mirrorimages of the target figure or rotated images of a target figurebelonging to a different item. This commonly used assessmentof visual–spatial ability was chosen, because it has a set timeto complete the task (five min to complete the first set of 10items and five min to complete the second set of 10 items),thereby emulating the time pressure experienced by studentswhen they take gross anatomy practical examinations.

We scored the MRT by assigning each item two pointsthat corresponded to the correct identification of both com-parison figures. No points were given for one correct and oneincorrect answer. When only one answer was given and itwas correct, one point was awarded. This scoring approachdiscourages guessing and eliminates the need to apply a cor-rection for guessing. The maximum possible score on this testwas 40 points.

4 Lufler et al.

Assessment of Student Population

During orientation, we collected baseline data when the stu-dents completed the MRT for the first time and filled out aquestionnaire. The questionnaire established students’ gender,undergraduate major and minor, previous gross anatomy andradiology experience, path before entering medical school,and course load at the time they were taking gross anatomy.Additionally, we obtained Medical College Admission Test(MCAT

1

) scores to have a measure of baseline knowledge onmatriculation to medical school. Additionally, MCAT

1

scoresare considered to be a predictor of United States MedicalLicensing Examination (USMLE

1

) Step 1 performance, andtherefore, they should be included in statistical analysis(Donnon et al., 2007; Zhao, 2010).

To assess individual learning styles, the VARK question-naire (Fleming, 2011) was administered to students via apassword-protected course website (Lufler et al., 2010). Theacronym VARK stands for the Visual, Aural, Read/write, andKinesthetic sensory modalities that people use to learn infor-mation. Results of this survey can indicate a mild, strong, orvery strong tendency to learn in each of the individual modal-ities. Similarly, when individuals show a tendency to learnusing two to four of these modalities, they were identified ashaving a multimodal learning style. This measure of learningstyle was used over other instruments, such as the LearningStyles Questionnaire (LSQ; Honey and Mumford, 2006),because it directly assesses whether learners benefit from vis-ual stimuli as used in anatomy teaching (pictures, models,charts, or diagrams; Fleming and Mills, 1992). Further, theHoney and Mumford’s LSQ has been found to have poor reli-ability and validity (Klein et al., 2007).

Assessment of Anatomical Knowledge

The Boston University School of Medicine medical grossanatomy course is comprised of three major sections: Backand Limbs; Thorax, Abdomen, and Pelvis; and Head andNeck. In the laboratory component of the course, eight stu-dents form a team and are assigned to a specific cadaver. Theteams of eight are further divided into two groups of fourstudents, and each group dissects during separate laboratorysessions. Each group is required to explain their dissection tothe other group on their team. All students dissected theirassigned cadaver with assistance from faculty, graduate

student teaching assistants, and fourth year medical studentprosectors.

Practical and written examinations are given at the end ofeach section of the course, yielding six examinations total.The written examination is made up of � 80% multiple-choice questions and 20% fill in the blank and short answerquestions. The written examination includes a blend of clini-cal, functional, and identification questions. Students’ abilitiesto learn anatomical spatial relationships were assessed bytheir success in answering practical examination questions.The practical examination questions require students to men-tally rotate structures from various views to identify anatomi-cal structures. For example, a question may ask for identifica-tion of bony landmarks on articulated or disarticulated skele-tons, structures within cadavers, structures on organsremoved from the cadaver, and structures on specimens ran-domly positioned on a table. Each examination was gradedout of 100%, and the overall percentage of questionsanswered correctly was used in this study.

Data Analysis

We began by summarizing student characteristics with meanvalues for continuous variables and percent or frequencies fordichotomous or categorical variables. We then divided theMRT scores into quartiles (Quartile 4 included those studentswith the highest MRT scores) and dichotomized all examina-tions at 90%, which was considered a level of proficiency ortrue understanding of the material. To assess the relationshipbetween MRT scores and examination performance, we usedlogistic regression with generalized estimating equations (toaccount for the correlation between examination scoreswithin the same subject) while adjusting for students’ individ-ual background characteristics that were confounding(MCAT

1

, VARK learning preference, gender, prior radiologyexperience, and path to medical school matriculation). Theperformance of students with MRT scores in Quartiles 2, 3,and 4 was compared to the performance of students withMRT scores in Quartile 1 (reference group). We additionallyperformed analyses keeping examination scores as continuousvariables (not dichotomizing at 90%) and used analysis of co-variance (ANCOVA) to determine the adjusted mean exami-nation score in each MRT quartile. To determine if MRTscores changed over the course of the anatomy course, apaired t-test with an alpha level 0.05 was used to analyze the

Figure 1.

Sample item from the MRT. The first and third figures can be rotated into congruence with the target figure on the left. Adapted with permission from Vandenbergand Kuse (1978).

Anatomical Sciences Education JANUARY/FEBRUARY 2012 5

mean difference between initial and final MRT scores and toassess gender-specific differences. To assess gender differencesat each of the time points, for each initial MRT and finalMRT, a Student’s t-test with an alpha level 0.05 was used.Analyses were performed using SAS statistical software, ver-sion 9.1 (SAS Institute, Cary, NC).

RESULTS

Three hundred and fifty-two students were included in thisstudy, and no students opted out of the study. Student back-ground variables that were confounding and included in sta-tistical analyses can be seen in Table 1 (gender, previous radi-ology experience, path to medical school matriculation,VARK, and MCAT

1

scores). All regression analyses were per-formed using complete data sets of students’ initial MRTscores and background variables and therefore included datafrom 285 students. The mean initial MRT score was 26.1,with the lowest quartile ranging from 2 to 19 and the highestranging from 34 to 40. Overall 39.0% (415/1065) of practi-cal examination scores were 90% or greater. Students whoscored in the highest quartile of the MRT were 2.2 (95% CI1.2, 3.8) times as likely as students who scored in the lowestquartile to score greater than 90% on all practical examina-tions, when adjusted for confounding variables (Table 2). We

performed additional analyses including the three writtenexaminations into the model to determine, if there was anassociation between visual–spatial ability and all gross anat-omy examinations, and we found similar results. Looking atthe written examinations alone, the odds ratio was 2.0 (95%CI 1.0 and 4.1) for the highest quartile, indicating that thevisual–spatial ability has a slightly increased effect on writtenexamination performance. Finally, the odds ratio for scoringgreater than 90% as a final score in gross anatomy for stu-dents who scored in the highest quartile on the MRT was 2.5(95% CI 1.3, 4.9) compared to those in the lowest quartile.ANCOVA results showed that those students who scored inthe highest quartile on the MRT had a significantly highermean practical examination score (85.5%) than students whoscored in the lowest quartile on the MRT (81.1%, P 5 0.03).

Results of the MRT are summarized in Table 3. No stu-dents opted out, however, 97 students were lost for follow-up. Therefore, statistical analyses comparing initial and finalMRT scores were performed on data from the remaining 255students, because we had complete data sets for these stu-dents. The paired t-test showed significant increases betweeninitial and final mean MRT scores (t 5 217.42, P < 0.0001).There were also significant gender-specific increases for bothmales and females (t 5 29.33, P < 0.0001; t 5 215.44, P <0.0001, respectively). Males scored significantly higher thanfemales on the initial (N 5 352, t 5 29.82, P < 0.0001) andfinal MRT (N 5 255, t 5 26.31, P < 0.0001).

Due to the apparent gender differences in MRT scores, weanalyzed the gender variable within the examination regres-sion models to determine the effect of gender on examinationperformance. ANCOVA results showed that female studentswere 1.5 (95% CI 1.0, 2.2) times as likely as male studentsto score greater than 90% on all practical examinations.There were no significant gender effects, however, on writtenexamination performance [odd ratio (OR) 1.1, 95% CI 0.7,1.8].

DISCUSSION

The overall objective of this study was to determine the rela-tionship between visual–spatial ability, as measured by theMRT, and performance in medical gross anatomy, with anemphasis on determining whether students’ visual–spatialabilities changed during the medical gross anatomy course.Specifically, we investigated the relationship between students’visual–spatial abilities and performance on questions thatrequired students to identify anatomical structures on practi-cal examinations. We also examined the effect of participat-ing in the gross anatomy course on students’ visual–spatialabilities.

Visual–Spatial Ability and Performance in GrossAnatomy

Our results indicate that students who scored in the highestquartile of the MRT perform better on spatially complexquestions than do students in the lowest quartile of the MRT.This finding was expected, because practical examinationsinclude identification of bony landmarks on articulated anddisarticulated skeletons, as well as structures tagged oncadavers, cross-sections, and radiographic images. Cadaversare placed in multiple positions, and organ systems areremoved from the cadavers and intentionally not placed in

Table 1.

Confounding Characteristics of Medical Students Enrolled in theMedical Gross Anatomy Course at Boston University School ofMedicine, 2008 and 2009

Students’ characteristics N Percentages

Total number of students 352 100.0a

Male 166 47.2

Female 186 52.8

Previous radiology experience 47 13.4

Matriculated directly from

undergraduate institution

212 60.2

MCAT1

score, mean (6SD) 352 31.9 (63.82)b

Total students tested for learningstyle (VARK method)

285 100.0c

Visual 21 7.4

Auditory 19 6.7

Read/write 26 9.1

Kinesthetic 41 14.4

Other 178 62.4

aValues are expressed as percentage of total number of students.bMCAT

1

performance is expressed in scores and standard devia-tion.cValues are expressed as percentage for total number of studentstested for different learning styles with (VARK method).

6 Lufler et al.

anatomical position. Therefore, students had to be able tomentally manipulate and rotate these structures, to correctlyidentify the 3D conformation of each structure. This findingalso validates the results of Rochford on the predictive valid-ity of a battery of spatial exercises on practical examinationscores (Rochford, 1985). The agreement of our study withthe only other study to examine this relationship suggeststhat testing student visual–spatial abilities can identify weak-nesses on practical examinations and potentially failing stu-dents. The MRT used in this study, however, would be amore efficient choice of performance predictor because of itsease of use and short time allotment (� 15 min). An under-standing of one’s MRT score may also benefit students intheir future careers in medicine, because visual–spatial abilitymay influence their performance in specialties such as surgeryand radiology that rely on the ability to understand 2D and3D spatial relationships. For example, as surgery has movedtoward minimally invasive techniques such as laparoscopy,visual–spatial skills have become even more important toboth the surgeon and the patient.

An unexpected result in this study is that students whoscored in the highest quartile on the MRT performed betteron all examinations, including practical and written examina-tions. This was unexpected, because we initially hypothesizedthat visual–spatial abilities would be related only to successon questions that require mental manipulation of 3D objects.This is contrary to a previous study, which showed that stu-dents performed equally well on nonspatial multiple-choicequestions, regardless of their performance on a battery of ge-ometrical spatial exercises (Rochford, 1985). Written exami-nation questions include a mix of clinically oriented questionsand structure location questions, both of which may involvespatial orientation knowledge or memorization. Our datasuggest that students may visualize anatomical structures

related to the written examination questions and may men-tally manipulate the structures to identify relationships andstructural features while answering multiple-choice questions.However, further neuropsychological evaluation would benecessary to truly evaluate this phenomenon.

In this study, visual–spatial ability may be used as a pre-dictor of success in medical gross anatomy. Anatomy educa-tors can use the MRT as a pretest to evaluate students’ vis-ual–spatial ability and thereby identify those who may strug-gle in the course, so that early interventions with extraresources and tutoring can be implemented from the begin-

Table 2.

ORs Representing the Relationship Between Students’ Mental Rotation Test (MRT) Scores and Scoring Greater than 90% on the Out-come Measures, Adjusted for Confounding Variables, Boston University School of Medicine, 2008 and 2009

Quartile 1 Quartile 2 Quartile 3 Quartile 4 P valuefor trend

MRT

MRT range 2–19 20–26 27–33 34–40

Number of students 88 87 87 90

All practical examinations

Students scoring >90 (%) 34.9 44.4 37.9 39.6

Adjusted OR 1.00 1.90 1.54 2.16 0.004a

(95% CI) (reference) (1.13, 3.18) (0.94, 2.52) (1.23, 3.81)

Adjusted mean 81.08b 84.78 83.47 85.48b 0.0005a

(95% CI) (78.52, 83.63) (82.25, 7.20) (81.20, 85.73) (83.18, 87.79)

Adjusted means examination scores for students in each MRT quartile. The column containing P value for trend indicates whetherthere is a significant linear trend between students’ MRT scores as a continuous variable and the outcome measure.aA significant linear trend at P < 0.05.bSignificantly different at P 5 0.03.

Table 3.

Initial and Final Mean Medical Students’ Mental Rotation Test(MRT) Scores and Gender-Specific Scores at Boston UniversitySchool of Medicine in 2008 and 2009

MRT Mean score (SD)

Initial MRT 26.1a (68.67)

Male (N 5 166) 30.3a (66.90)

Female (N 5 186) 22.3a (68.35)

Final MRT 31.6a (67.48)

Male (N 5 112) 34.7a (65.86)

Female (N 5 143) 29.3a (67.63)

Maximum score for MRT is 40 points.aP < 0.0001.

Anatomical Sciences Education JANUARY/FEBRUARY 2012 7

ning of the course. The relationship between visual–spatialability and academic success is interesting and requires fur-ther research on visual–spatial abilities and performance inother disciplines within medical education.

Changes in Students’ Visual–Spatial Ability

Our study demonstrates that both males and females experi-ence significant visual–spatial benefits during participation inthe medical gross anatomy course. Previous research hasshown that spatial abilities can improve with experience.Both test-specific practice (retaking the same test over setintervals of time) and training in spatial activities not specificto the test improve performance on spatial ability tests (Baen-ninger and Newcombe, 1989; Hoyek et al., 2009). Hoyeket al. (2009) found significant improvements in undergraduateMRT scores after students practiced mental rotation exer-cises. Our observation that students’ visual–spatial abilityincreased during the anatomy course leads to speculationabout what may have caused this improvement. Terleckiet al. (2008) have shown that videogame training canincrease MRT scores. Most interestingly, videogame trainingwas found to have larger transfer effects to other tests of vis-ual–spatial ability than repeated testing alone, indicating thatthe ability to improve one’s innate visual–spatial ability maybe possible. Studies performed specifically to address differen-ces in visual–spatial ability have retrospectively linked activ-ities such as sports, classes, building models, and designing tosubjects’ ability (Newcombe et al., 1983). Terlecki et al.(2008) even ventured to conclude that girls should becomemore involved in activities such as videogames to attempt toclose the gender gap in visual–spatial ability. The increases invisual–spatial ability that occurred with our students duringgross anatomy could be a result of active participation in dis-section of a 3D cadaver in concert with studying 2D repre-sentations of anatomy such as textbooks and radiographs.Regardless of what contributed to the increases in MRTscores, we have confirmed that students exhibit a wide rangeof visual–spatial abilities, and these abilities should be consid-ered as a factor contributing to performance in a gross anat-omy course (Langlois et al., 2009). Although practice effectscaused by repeatedly taking the MRT have been shown (Ster-icker and LeVesconte, 1982; Terlecki et al., 2008), we werenot concerned with this phenomenon during this study. Peterset al. (1995) demonstrated that when the MRT was givenonce weekly for four weeks, extensive practice resulted inminimal performance improvements. Therefore, taking thesecond MRT approximately four months after the initial testis unlikely to have demonstrated a significant improvement inscore due to a practice effect.

Gender Effects

The significant relationship of gender and MRT scores wasnot unexpected, as it is well known throughout the literaturethat males have higher innate visual–spatial abilities thanfemales (DeFries et al., 1976; Bouchard and McGee, 1977;McGee, 1979; Peters et al., 2006, 2007). However, it is inter-esting that female students are more proficient than male stu-dents on practical examinations considering females scoredsignificantly lower than males on the MRT. Further, a previ-ous study found that females score significantly higher thanmales on written examinations in anatomy, however, we didnot find any significant differences between male and female

students on written examination performance (Peplow, 1998).It is difficult to directly compare these studies, because thereare obvious curriculum differences, therefore investigation ofthe effects of gender on performance in anatomy should beconsidered in future studies. This also further demonstratesthe necessity for controlling for variables such as gender orvisual–spatial abilities in anatomy education studies, depend-ing on the predictor and outcome variables.

Limitations

The strengths of this study are that it was prospectivelydesigned and that we controlled for the effects of confound-ing variables, specifically MCAT

1

scores. There are alwaysvariables that are either logistically impossible or not avail-able to include in statistical analysis. For example, furtheranalysis of performance on specific types of questions on thewritten examination by individual students’ would have beeninteresting, however, this was not possible, as it was not partof the original protocol admitted by the IRB and would haveinvolved identifiable data. Age has been related to visual–spa-tial ability in the past (Peters et al., 2007), however, this pop-ulation of students was relatively homogeneous with respectto age, as determined by the ‘‘path to medical school matricu-lation’’ covariate. Previous videogame experience would alsobe an intriguing variable to include in all analyses, as thisvariable has been linked to visual–spatial ability. Additionaleducational variables, such as students’ use of resources out-side of the course requirements, may also affect the outcomevariables. Time studying in the laboratory and practice practi-cal examinations were also considered as variables that mayaffect the results of this study, however, logistically, this infor-mation could not be gathered.

It should be acknowledged that as in most educationalstudies, our data were subject to ceiling effect that must betaken into consideration. The distributions of the scores inour data were skewed toward higher grades, however, this isto be expected considering the population. A limitation ofthis study is the loss of students for follow-up testing. MRTtesting was performed during course lecture time, and the 97students who did not complete the final MRT were not pres-ent in lecture on the day that it was administered.

Finally, the lack of a control group is a limitation to thedesign of this study. It is not possible within the curriculumat Boston University School of Medicine to form a controlgroup consisting of first year medical students who do nottake the Medical Gross Anatomy course. However, this issuewas addressed in part by gathering possible confounding vari-ables and adjusting for them in statistical analysis.

FUTURE DIRECTIONS ANDCONCLUSIONS

A study further investigating relationships among the varia-bles gathered in this study is currently underway using a dif-ferent student population. Analysis of the roles of covariatesin this study has been kept to a minimum for this reason.Future studies should be executed on different populations tobetter understand the role of visual–spatial abilities in learn-ing. In doing so, we could identify, develop, and implementpedagogical techniques to help students with visual–spatialdeficits. Pedagogical techniques could include mental rotationexercises, such as those used by Hoyek et al. (2009), to

8 Lufler et al.

fundamentally increase one’s visual–spatial abilities. Thesetypes of exercises could be taken one step further to includeanatomical models and structures rotated in space. As tech-nology continues to infiltrate medical education, educatorsmay want to consider the variability of spatial abilitiesamong students. Providing extra resources, such as tutoring,to students with visual–spatial deficits may augment class-room and laboratory learning.

NOTES ON CONTRIBUTORS

REBECCA S. LUFLER, Ph.D., is a lecturer in the Departmentof Anatomy and Cellular Biology at Tufts University Schoolof Medicine, Boston, Massachusetts. She received her doc-toral degree from Boston University School of Medicine,where research presented in this report was part of her doc-toral dissertation.

ANN C. ZUMWALT, Ph.D., is an assistant professor inthe Department of Anatomy and Neurobiology at BostonUniversity School of Medicine, Boston, Massachusetts. Sheteaches medical gross anatomy and clinical anatomy coursesto medical students, and she is the faculty advisor for theAnatomical Sciences Interest Group.

CARLA A. ROMNEY, D.Sc., is an associate professor andChair of Science and Engineering Program at Boston Univer-sity Metropolitan College and assistant dean of GraduateMedical Sciences at Boston University School of Medicine,Boston, Massachusetts. She is responsible for the design andevaluation of K-12, undergraduate, and medical educationinitiatives.

TODD M. HOAGLAND, Ph.D., is an associate professorin the Department of Cell Biology, Neurobiology, and Anat-omy, Medical College of Wisconsin, Milwaukee, Wisconsin.He is teaching gross anatomy to medical students and servesas director for Clinical Human Anatomy and Advanced Clini-cal Anatomy courses.

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