Effects of four supplemental instruction programs on students' learning of gross anatomy

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<ul><li><p>MEDICAL EDUCATION</p><p>Effects of Four Supplemental Instruction Programs onStudents Learning of Gross Anatomy</p><p>JOSEPH P. FORESTER, PAMELA P. THOMAS, AND DAVID L. MCWHORTER*</p><p>University of Health Sciences College of Osteopathic Medicine, Kansas City, Missouri</p><p>Many researchers have reported that supplemental instruction programs improve medicalstudents performance in various basic sciences. This study was conducted to evaluate thesummative effects of four supplemental instruction programs (i.e., second-year medicalstudent teaching assistant program; directed study program; weekly instructor laboratoryreviews; and a web-based anatomy program) on medical students gross anatomy laboratorypractical performance. First-year medical students from the graduating class of 2006 (n 223) received the four supplemental instruction programs (Experimental Group). The ControlGroup consisted of rst-year medical students from the graduating class of 2005 (n 254)who did not receive the four supplemental learning methods. Mann-Whitney rank sum testswere used to compare the two groups median percentages for the back-upper limb (B-UL)and the lower limb (LL) parts of a gross anatomy laboratory practical. The ExperimentalGroups median percentages for both the B-UL (77.78%) and LL (83.33%) were signicantlygreater than that of the Control Group (B-UL 69.00%; LL 81.00%; P 0.05). Resultsfrom a post-hoc student survey showed that more students both rated and ranked the weeklyinstructor laboratory reviews as extremely useful and most benecial, respectively. A greaternumber of students rated and ranked the web-based anatomy program as not useful and leastbenecial, respectively. The results from this study suggest that the four supplementalinstruction programs improved students learning of gross anatomy as measured by labora-tory practical performance. In addition, students most valued the additional time in the grossanatomy laboratory with the instructors. Clin. Anat. 17:322327, 2004. 2004 Wiley-Liss, Inc.</p><p>Key words: education; medical curriculum; alternative teaching methods</p><p>INTRODUCTION</p><p>The curricular transition of some medical schoolsfrom using a traditional discipline-based curriculum toan integrated basic and clinical science program hascreated a challenge for teaching gross anatomy(Mandin et al., 1995; Drake, 1998; Blue et al., 2000;Woloschuk, 2000; Vidic and Weitlauf, 2002). The in-tegration of basic and clinical science in medicalschool curricula has resulted in less time for grossanatomy lectures and laboratories (Cottam, 1999; Azizet al., 2002). Consequently, many anatomists are usingalternative/supplemental methods for teaching grossanatomy, particularly in the laboratory.</p><p>To enhance students learning of gross anatomy,Op den Akker et al. (2002) implemented the use ofbody paint in the gross and living anatomy courses atUtrecht Medical Center. The entire class of rst-yearmedical students (n 240) painted abdominal and</p><p>thoracic organs on each others skin surface during two3-hr laboratory sessions. Results from students eval-uations (97.5% response rate) indicated increased en-thusiasm towards learning anatomy, and that the sup-plemental method of body painting provided insightinto the spatial relations of internal organs.</p><p>The effects of supplemental instruction in bio-chemistry, gross anatomy, microbiology, and physiol-ogy on mean test scores were studied by Sawyer et al.(1996). In this study, second-year medical studentsdirected an optional, supplemental instruction pro-</p><p>*Correspondence to: David L. McWhorter, PhD, Department ofAnatomy, UHS-COM, 1750 Independence Avenue, Kansas City,MO 64106. E-mail: dmcwhorter@uhs.edu</p><p>Received 11 February 2003; Revised 15 May 2003</p><p>Published online in Wiley InterScience (www.interscience.wiley.com). DOI 10.1002/ca.10219</p><p>Clinical Anatomy 17:322327 (2004)</p><p> 2004 Wiley-Liss, Inc.</p></li><li><p>gram to all 150 rst-year medical students at the Uni-versity of Southern California School of Medicine.The results of this study demonstrated signicantincreases in mean test scores for the students (n 127) who received the supplemental instruction. Ad-ditionally, failure rates for at-risk students (i.e.,composite Medical College Admission Test score of26 and a science grade-point average below 3.0) inthe supplemental instruction group decreased by 46%when compared to previous classes.</p><p>Hallgren et al. (2002) evaluated gross anatomy lab-oratory examination performance after supplementinganatomy instruction with a web-based anatomy pro-gram. Sixty-three of the 124 rst-year medical stu-dents at Michigan State University College of Osteo-pathic Medicine used the web-based anatomyprogram. The results of this study showed that the 63students who used the web-based program performedsignicantly better on both mid-term and nal grossanatomy laboratory exams than the students who didnot use the web-based program.</p><p>Peer teaching is yet another supplemental methodused by some anatomists to instruct their students.Yeager and Young (1992) implemented a system ofpeer teaching due to decreased course hours and fac-ulty time, and to increased class size. Eight studentswere assigned to each cadaver and teams of two stu-dents performed every fourth dissection. Studentevaluations from this study indicated that peer teach-ing was an effective learning tool. Additionally, theauthors reported no change in national board exami-nation performance following the implementation ofthe peer-teaching program.</p><p>In another peer-teaching study, Nnodim (1997)compared students in a traditional dissecting pro-gram with students in an experimental peer-teachingprogram. A total of 160 second-year medical studentswere divided into two equal groups. One group, serv-ing as the Control dissected in every anatomy labora-tory. The other group (Experimental) was further di-vided into two subgroups that participated in a peer-teaching program. In the peer-teaching program, eachhalf of the Experimental Group participated in 50% ofthe dissections and teaching. Results from this studyshowed that the students in the peer teaching pro-gram performed signicantly better than their full-time dissecting counterparts on both a two-choicetheory paper and a 50-station practical exam.</p><p>In the fall of 2002, we implemented four newsupplemental instruction programs in the gross anat-omy course at the University of Health Sciences Col-lege of Osteopathic Medicine (UHS-COM). The foursupplemental instruction programs consisted of thefollowing: 1) second-year medical student teaching</p><p>assistant program, 2) directed study program, 3)weekly instructor laboratory reviews, and 4) web-based anatomy program. These pilot programs were inresponse to an internal S.W.O.T. (i.e., strengths,weaknesses, opportunities, and threats) analysis per-formed by the Continuous Quality Improvement(CQI) teams at UHS-COM. The CQI teams werecomprised of rst- and second-year students, UHS-COM faculty, and Curriculum Department staff.Thus, the purpose of this study was to assess thesummative effect of four supplemental instructionprograms on students gross anatomy laboratory prac-tical performance.</p><p>MATERIALS AND METHODS</p><p>During the 20012002 academic year, rst-year stu-dents in the graduating class of 2005 (n 254) dis-sected in every other 3-hr gross anatomy laboratory(Control Group). After completing the back, upperlimb, and lower limb dissections, students were givena 50-question identication-based (e.g., Identify thetagged structure?) or tag-related (e.g., Which muscle issupplied by the tagged structure?) laboratory practical.The number of back, upper limb, and lower limbquestions related to the number of corresponding lab-oratories. Two anatomy department instructors gradedall laboratory exams using a standardized key.</p><p>The same teaching and testing protocol was fol-lowed during the 20022003 academic year for therst-year students in the graduating class of 2006 (n 223). This group of students (Experimental Group),however, received the following supplemental in-struction programs (SIPs; Table 1): 1) second-yearmedical student teaching assistant program (TA), 2)directed study program (DS), 3) weekly instructorlaboratory reviews (IR), and 4) a web-based anatomyprogram (WP).</p><p>A total of 24 second-year medical students from ofthe graduating class of 2005 were selected to assistUHS-COM anatomy faculty in the laboratory teachingof gross anatomy. Criteria that anatomy faculty usedfor selecting second-year teaching assistants were astrong interest in teaching anatomy, an aptitude ingross anatomy (i.e., 80% average in gross anatomy),and an upper 30% class rank. Teaching assistants metwith anatomy faculty prior to each laboratory sessionto discuss the objectives for each dissection and toreview structures on a prosected specimen. Moreover,teaching assistants were required to attend at least onegross anatomy laboratory per week. Second-year stu-dents earned college credit for their participation inthe anatomy teaching assistant program.</p><p>Supplemental Instruction and Lab Performance 323</p></li><li><p>Because of the alternating dissection program atUHS-COM, students perform 50% of the gross anat-omy dissections. Students in the Control Group reliedmainly on independent study to learn the anatomythat they did not dissect. For the ExperimentalGroup, a directed study program was implemented.The required directed study program consisted of aweekly 1-hr laboratory session in which students inthe Experimental group reviewed the dissection per-</p><p>formed by their peers with the anatomy instructorsand teaching assistants.</p><p>Weekly 2-hr instructor laboratory reviews wereanother supplemental instruction program offeredto the Experimental Group. This optional programgave interested students an instructor-directed re-view of dissected material and an additional oppor-tunity to ask the instructor questions in the labora-tory setting.</p><p>TABLE 1. Timetable for Supplemental Instruction Programs Implementation*a</p><p>Week Day</p><p>1</p><p>Tu Orientation &amp; Supercial Back Osteopathic Principles &amp; Practices (OPP) Laboratory&amp; Pathology Laboratory</p><p>Th Introduction to Clinical Medicine (ICM) Laboratory&amp; Independent Study</p><p>Directed Study: Orientation &amp; Supercial BackBack &amp; Shoulder Regions</p><p>F Instructor review</p><p>2</p><p>Tu Directed Study: Back &amp; Shoulder RegionsPathology Laboratory &amp; Physiology LaboratoryIntermediate and Deep Back Muscles,</p><p>Suboccipital Triangle, &amp; Spinal CordTh</p><p>Independent studyDirected Study: Intermediate and Deep Back</p><p>Muscles, Suboccipital Triangle, &amp; Spinal CordBreast, Pectoral Region, Axilla, &amp; Brachial</p><p>PlexusF Instructor review</p><p>3</p><p>Tu Directed Study: Breast, Pectoral Region, Axilla, &amp;Brachial Plexus OPP Laboratory &amp; Pathology Laboratory</p><p>Brachial Plexus, Arm, &amp; Cubital FossaTh</p><p>ICM Laboratory &amp; Independent StudyDirected Study: Brachial Plexus, Arm, &amp; Cubital</p><p>FossaAnterior Forearm &amp; Hand</p><p>F Instructor review</p><p>4</p><p>Tu Directed Study: Anterior Forearm &amp; Hand OPP Laboratory, Pathology Laboratory, &amp;Microbiology LaboratoryHand, Posterior Forearm, &amp; Upper Limb Joints</p><p>ThICM Laboratory &amp; Independent Study</p><p>Directed Study: Hand, Posterior Forearm, &amp; UpperLimb Joints</p><p>Supercial Structures, Anterior &amp; Medial ThighMuscles</p><p>F Instructor review</p><p>5</p><p>Tu Directed Study: Supercial Structures, Anterior &amp;Medial Thigh Muscles OPP Laboratory &amp; Pathology Laboratory</p><p>Gluteal Region &amp; Posterior ThighTh</p><p>ICM Laboratory &amp; Independent StudyDirected Study: Gluteal Region &amp; Posterior ThighLeg &amp; Dorsum of the Foot</p><p>F Instructor review</p><p>6</p><p>M Directed Study: Leg &amp; Dorsum of the FootOPP LaboratorySole of the Foot &amp; Lower Limb Joints</p><p>OPP Laboratory Sole of the Foot &amp; Lower Limb JointsTu Instructor reviewTh Gross anatomy laboratory practical</p><p>*Bold titles indicate laboratory dissections for one-half (n 112) of rst-year class (N 223), while the other one-half (n 111) ofrst-year class participated in simultaneously scheduled non-anatomy activities.aLibrary staff provided small group instructions on using the web-based anatomy program to all students in the Experimental groupbefore commencing gross anatomy.</p><p>324 Forester et al.</p></li><li><p>The fourth supplemental program offered to theExperimental Group was a web-based anatomy in-struction program titled Human Anatomy (Rarev etal., 2001). The Human Anatomy Online program of-fered to the Experimental group consisted of threemain instructional parts: 1) Dissector, 2) Quiz,and 3) Clinical Correlations. After entering a loginname and password, students had unlimited access tothe web-based program from both on- and off-campus.</p><p>The purpose of this study was to evaluate thecollective effect of these four supplemental instruc-tion programs on anatomy laboratory practical perfor-mance. Therefore, anatomy laboratory practical per-formance of students who received these programs(Experimental Group) was compared to students whowere not exposed to the four supplemental instructionprograms (Control Group).</p><p>Because of the functional and structural continuityof the back and the upper limb, laboratory practicalperformance for these two regions was combined. Asecond reason for combining back and upper limbperformance was that the same instructor taught bothregions. Hence, we denote back and upper limb labpractical questions/performance in this study as back-upper limb (B-UL) questions/performance. On thelaboratory practical, B-UL and lower limb (LL) ques-tions were randomly positioned for both the Controland Experimental groups. As a result, individual stu-dents performance for the B-UL and the LL had tobe determined rst. After the number of correct B-ULquestions was determined for each student, these datawere entered into a Microsoft Excel le. The use ofMicrosoft Excel program formulas enabled us todetermine quickly, the number of correct LL ques-tions for each student. Because the total number ofB-UL and LL questions were unequal, we used an-other Microsoft Excel formula to convert the correctnumber of B-UL and LL questions for each studentinto percent correct (e.g., 24 correct back-upper limbquestions 27 total back-upper limb questions 88.9%).</p><p>For statistical analysis, percent correct averages forthe B-UL and the LL were calculated for the Controland Experimental groups. Students t-tests were usedto compare the B-UL limb means and LL means ofthe two groups. An alpha level for signicance was setat 0.05. Sigma Stat for Windows (version 2.03, SPSS,Inc.) was used for all statistical analyses.</p><p>RESULTS</p><p>Because the purpose of the study was to examinethe summative effects of four different supplementalinstruction programs on anatomy laboratory examina-</p><p>tion performance, a Students t-test was used to sta-tistically compare the back-upper limb (B-UL) meansof the Experimental and Control groups. The normal-ity assumption of the parametric test failed, however,during execution of a Students t-test. As a result, aMann-Whitney rank sum test was used and revealed asignicant difference in median values for the B-ULof the two groups (P 0.05; Table 2). Descriptivestatistics showed that the B-UL mean SD for theExperimental Group (72.65 17.16)...</p></li></ul>

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