MEDICAL EDUCATION

Gross Anatomy Dissections and Self-DirectedLearning in Medicine

Ma DEL MAR ARROYO-JIMENEZ,1 PILAR MARCOS,1 ALINO MARTINEZ-MARCOS,1

EMILIO ARTACHO-PERULA,1 XAVIER BLAIZOT,1 MONICA MUNOZ,1

Ma TERESA ALFONSO-ROCA,2 AND RICARDO INSAUSTI1*

1Department of Health Sciences, Human Anatomy and Embryology Section, School of Medicine, University of Castilla-La Mancha, Spain2Medical Education Unit, School of Medicine, University of Castilla-La Mancha, Spain

The Medical School of the University of Castilla-La Mancha (UCLM, Albacete Spain)was launched in 1998 and is the most recent one in Spain. Teaching is based on smallgroups of students (20–25 students/group). An objective-oriented self-learning approachprovides maximal autonomy and independence in the achievement of objectives by the stu-dents in close association with academic staff. Gross Anatomy courses take place in thefirst and second years. The one in the first year is a single 10-credit course, where onecredit equals 10 hr of teaching activity. In the second year, Anatomy and Embryology areintegrated with Physiology and Histology, and comprise 70 credits altogether. In addition,all students carry out two mandatory gross anatomical dissections per year, in groups ofthree students, to allow direct handling of human anatomical material. Students are pro-vided with handouts containing general instructions on how to perform the dissection andthe structures (items) that they must expose in a given period of time (4 hr). Afterward, aFaculty member checks the number of items demonstrated and the quality of the dissec-tion. Each group submits a written report that contributes to the final score. We evaluatedthe number of items shown in each of two consecutive dissections for first and second yearmedical students. The data obtained indicate that students engaged in self-directed learningthrough small groups working with Faculty staff are able to self-improve their anatomicalskills. Clin. Anat. 18:385–391, 2005. VVC 2005 Wiley-Liss, Inc.

Key words: medical education; self-learning; modules; objectives; grossanatomy

INTRODUCTION

General Principles of Learning at the School of

Medicine of the University of Castilla-La Mancha

The educational goal of the School of Medicine

of the University of Castilla-La Mancha (UCLM) is

the development of a curriculum to produce medical

graduates who will be fully integrated in terms of

medical knowledge, technical proficiency and social

understanding. Our approach is an advance from the

traditional medical educational system, almost uni-

versally based on lectures, used by most of the med-

ical schools in Spain (Gomez and Pujol, 1998). The

UCLM uses an integrated learning model based on

the development of professional competencies as the

core of the medical curriculum. Although this educa-

tional method is used currently in more than 120

Medical Schools worldwide, it has not been adopted

widely in Europe.

The medical curriculum of the Medical School of

the UCLM is based on three main conceptual foun-

dations: (1) integration of disciplines, (2) active

learning methodology based on objectives, and (3)

*Correspondence to: Dr. Ricardo Insausti, Department of Health

Sciences, School of Medicine, University of Castilla-La Mancha,

Avda. de Almansa s/n, 02006 Albacete, Spain.

E-mail: ricardo.insausti@uclm.es

Received 15 April 2004; Revised 22 July 2004; Accepted 29

December 2004

Published online inWiley InterScience (www.interscience.wiley.com).

DOI10.1002/ca.20129

VVC 2005 Wiley-Liss, Inc.

Clinical Anatomy 18:385–391 (2005)

problem-based learning (PBL), the main method of

education used widely in our clinical courses and

more sparingly on basic sciences (preclinical)

courses.

This educational approach emphasizes the active

participation of the students in developing autonomy

in their own learning process, as well as promoting

motivation and interest in the different topics of the

medical curriculum. The students are responsible for

their own learning, avoiding the passive attitude seen

in many students that follow the lecture system. This

approach is, basically, practice-oriented, and it aims

to integrate the biological, clinical, and psychosocial

sciences. The ultimate goal of this system is, there-

fore, the promotion of: (1) independent learning, (2)

communication skills and team-work among students,

and (3) integration of the basic and clinical sciences,

all three prepare students for the clinical decisions

they will take in medical practice in an atmosphere

of responsibility and guided by tutors.

Academic staff at the Medical School of the

UCLM guide the learning process of the students,

encouraging at all times self-learning, instead of lec-

turing on their own discipline. To achieve its goal,

the medical curriculum at the School of Medicine of

the UCLM tries to potentiate the active participa-

tion of students in every possible aspect of their

education.

The medical curriculum at the Medical School of

the UCLM is 6 years long (mandatory by law in

Spain). The number of students is 80 per year, div-

ided into groups of 20 students for basic courses,

and six for clinical ones.

The curriculum is arranged in modules of objec-

tives. Each module lasts for 2 or 3 weeks and con-

sists of five distinct phases. Phase I starts by careful

reading of the objectives, after which the students

are guided in the understanding of terms and con-

cepts germane to the objectives of the module. The

students pose questions, phrasing them clearly under

the supervision and guidance of academic staff. The

identification of the objective, its conceptual rela-

tionship to other objectives of the module, and the

educational resources required are strongly empha-

sized, aiming at achieving time-efficient work. Phase

2 is devoted to the students’ individual work to

achieve the objectives, with the help of complemen-

tary activities, mostly laboratory practicals. Phase 3 is

the period in which the students, usually a single

student or in groups of up to three students, present

to their peers the main content related to each

objective, supervised by Faculty staff. Participation

and active discussion by the students is encouraged

at all times to develop communication skills. Phase

4 is a self-learning period in which students have

the opportunity to request individual tutorials to

Fig. 1. Contents of the first year curriculum in the Medical School of the UCLM. The distribu-

tion and contents of the anatomy component are specified. Numbers indicate the module distribution

for each course.

386 Arroyo-Jimenez et al.

clarify particular questions. Students can request as

many tutorials and complementary activities as they

deem necessary. In Phase 5, students take a multiple

choice test to evaluate a single module or a number

of modules in a given unit (a unit is a number of

regions anatomically related to a function, i.e., upper

limb and manipulation) (Figs. 1,2). Additional

selected lectures (one per unit) are also given to the

entire class.

The practical approach of both the basic and clini-

cal subjects is emphasized. For instance, beginning

at the second year, students attend family medicine

courses in community health centers concurrent with

basic science courses. In this way, students receive

an early exposure to the social aspects of their future

medical practice.

HUMAN ANATOMY AND EMBRYOLOGYAT THE UCLM

Traditionally, Human Anatomy and Embryology

was taught by lectures and laboratories. Because we

are experiencing an information era, with escalating

development of computer resources, appraisal of the

students’ approach and the methodology of teaching

seems necessary. This represents an enormous chal-

lenge to medical educators, particularly in the field

of the Human Anatomy and Embryology, where

imaging (X-ray, magnetic resonance imaging, compu-

terized tomography, etc.) forms an important part of

the learning materials. The enormous explosion of

molecular and cellular biology in modern medicine

has led to a decrease of time devoted to Anatomy

and Embryology (Yates, 1999; Paalman, 2000). We

need, therefore, to use time allocated to our subject

effectively. One of the institutional goals at the

School of Medicine of the UCLM is an increasingly

better medical education by directing student time

and effort efficiently.

Human Anatomy and Embryology are taught with

other preclinical courses (e.g., cell biology) under

the perspective of different levels of organization of

the human body: macroscopic, microscopic, and sub-

cellular (horizontal integration) and oriented toward

future clinical courses (vertical integration). During

the first year, ‘‘Topographical Anatomy,’’ which

comprises the Locomotor System, is presented as a

10-credit course (one credit equals 10 hr of lectures

or laboratory practicals, 100 hr in total). It is arranged

as 11 modules of objectives (Fig. 1). Topographical

Anatomy starts with an introductory module of gene-

ral principles and nomenclature. This is followed

by four main units or sections. Each unit consists of

2–3 modules of objectives: Unit 1 comprises trunk

and neck (postural systems of the trunk and neck:

two modules); Unit 2 is devoted to the lower limb

(general posture and locomotion: three modules, one

for each segment of the leg); Unit 3 is devoted to

the upper limb (motor system for grasping: three

modules, one for each segment) and, finally, Unit 4

deals with the head (skull, mandible, facial and mas-

ticatory activities: two modules). The number of

modules is related to the division of the total time

Fig. 2. Distribution and contents of the second year curriculum in the Medical School of the UCLM.

387Self-Directed Learning in Gross Anatomy

of the academic year from September to June. Func-

tional aspects of Anatomy are considered together

with sectional, radiological, and clinical examples.

Dissection courses play an important role. General

Human Embryology is presented in five modules

(Fig. 1) integrated with genetics and structure and

function of the cell (Cell Biology in Fig. 1). Those

modules include objectives that go from gametogene-

sis up to the fourth week of embryonic develop-

ment. Special Human Embryology (development of

the organs and systems) is included in the second

year in a course entitled ‘‘Development, morphol-

ogy, structure and function of the body systems in

health.’’ This course integrates in its modules of

objectives Anatomy (including Human Embryology

as stated above), Histology and Physiology in a 70-

credit course (Fig. 2, 250 hr for Anatomy and

Embryology). Students have to learn the develop-

ment and organization of the body systems, integrat-

ing anatomical, histological and physiological con-

tent. The material is organized in ‘‘units,’’ and each

unit relates to a functional system; overall, each unit

is equivalent to one module, except in those systems

where their extent requires more than one module,

(namely nervous and cardiovascular systems, with

four and two modules, respectively). The course

begins with the nervous system and is followed in

sequence by the endocrine, blood, cardiovascular,

respiratory (including phonatory apparatus), diges-

tive, and finally, in one single module, excretory and

reproductive systems.

The assessment of Human Anatomy and Embry-

ology has two parts, theoretical and practical. The

first consists of a variable number of multiple-choice

questions. In the practical examination, students are

required to pass a test based on the material avail-

able at the gross anatomy laboratory. They must rec-

ognize clearly marked structures previously selected

by the instructors using human bones, plastic mod-

els, prosections, images, etc. A maximum of 30 sec

per structure is allocated for identifying and writing

the name of the structure. All this material has been

demonstrated previously during the laboratory peri-

ods (Phases 2 and 4). The final score is the average

of all the tests.

GROSS ANATOMY DISSECTIONS

There are numerous and often divergent opinions

about effective and efficient use of dissection or pro-

sections as a part of a gross anatomy course (Utting

and Winnan, 1995; Jones, 1997; Dinsmore et al.,

1999). In general, even with the increasing availabil-

ity of computer programs and simulations of the

human body, there is a broad consensus that there is

no substitute for dissection (Ashraf-Aziz et al., 2002),

especially to understand the 3D relations of the

structures of the human body (Marks, 2000). We

believe that anatomical dissection offers a direct con-

tact with the human body and, at the same time,

provides the best workbench for students to under-

stand and learn gross anatomy.

The Anatomy Section at the Medical School of

the UCLM has implemented a curriculum in which

40% of the students’ time is devoted to regular prac-

tical anatomical sessions with both prosections and

anatomical models (Phases 2 and 4). Every module,

new prosections are prepared by the instructors to

demonstrate anatomical features related to the forth-

coming module. In addition, the students are

required to perform two gross anatomy dissections

per year of a pre-established anatomical region. The

dissection makes up to 10% of the final score. After

they acquire the theoretical concepts of the region to

be dissected, groups of three students carry out a

gross anatomical dissection with the help of a hand-

out, reference atlases, and also some general intro-

ductory information about gross anatomy dissection

procedures. Students must identify a number of ana-

tomical structures (arteries, nerves, muscles, etc.) pre-

viously determined for each dissection. They have a

maximum of four hours to identify those structures,

after which the students complete a list of the struc-

tures dissected, as well as specific problems and diffi-

culties encountered during the dissection. At the end

of the dissection time, the instructor evaluates the

degree of accomplishment of the dissection and clari-

fies students’ questions on the dissection for the

preparation of the final report. It is worth noting that

the students work on their own, and the role of the

instructor is to answer the students’ questions after

the dissection has been completed.

To validate the effectiveness of self-learning

shown in these dissections, we analyzed the results

obtained for each group of three students in the first

and second medical years. All data shown here corre-

spond to the year 2000 at the Medical School of the

UCLM. The scoring of the gross anatomical dissec-

tion was calculated as the percentage of anatomical

structures listed in the handout provided shown in

the dissection. Figure 3a shows the percentage of

items correctly identified by the students. Figure 3b

shows the same data for the second year. The mean

percentage of successfully dissected items was

always >60% with limits of 0% (one group) and

100% (11 groups). Furthermore, we have analyzed

the variation between the first and the second dis-

sections of the same group of students.

388 Arroyo-Jimenez et al.

Comparison of the results of the first and second

dissections for first year students showed a small, but

not significant, improvement of their dissecting skills

by increasing their successful percentage of items

from 60.2–61.7% (paired t-test ¼ 0.28; P ¼ 0.78).

Some groups had worse scores in the second dissec-

tion compared to the first one. This may be due to

difficulties in specific dissections such as the gluteal

region and palm of the hand.

Similar comparison for second year students also

showed a significant improvement in the mean per-

formance between the first and second dissections,

from 73.7–85.8% (paired t-test ¼ 1.88; P ¼ 0.07). In

addition, we found that students of the second year

used the experience of the previous year and

achieved a higher level of success than in both dis-

sections in first year (t ¼ 4.5; P < 0.001).

Figure 4 shows the mean number of structures to

be dissected and the mean rate of success in dissec-

tions. The average number of items for the first and

second years was similar (13 items; Fig. 4) with

higher variability in the first year. The average num-

ber of items successfully found ranged between 7.6–

10.2 for the first and second years, respectively.

Given that the total number of anatomical items

in the four dissections was similar, the increase of

the number of items successfully found between the

first and second dissections in the first year (albeit

not significant; it reached statistical significance if

one group that did not show any improvement is

Fig. 3. Plot of the percentage of successfully dissected items for the two dissections carried out during

first (A) and second (B) courses. Note that some groups had worse scores in the second dissection than the first

one. Mean6 SD as well as SEM (in parenthesis) are indicated.

Fig. 4. A: Histogram for the mean number of items per dissection and mean number of success-

fully dissected items for the first and second courses. B: Mean values and SD of the number of items

found and successfully demonstrated.

389Self-Directed Learning in Gross Anatomy

removed), and in the second year, indicates that pre-

vious experience, although short, improved the score

in subsequent dissections. Likewise, comparisons of

first and second year scores showed an improvement

in the second round of dissections. The increasing

level of dissection time and experience thus allowed

a better performance, even though several months

elapsed between the first and second years.

Failure in the demonstration of assigned items may

be due to lack of interest or cooperative skills (noted

only in one single group of 3 of 160 students) or diffi-

culty in defining the depth of a structure through inad-

equate dissection by the preceding group (i.e., superfi-

cial and deep dissections of the anterior forearm). This

occurred occasionally, although usually very few items

were affected.

At the end of the dissections, students completed

a questionnaire where three questions were asked:

1. What is the value of gross dissections for the

understanding of the Anatomy course?

2. What expectations did you have of dissection?

3. What did you think about dissection?

Analysis of the questionnaires showed that most

students (47%) felt that personal experience of dissec-

tion was very useful, and that it was an efficient and

effective way of understanding and learning gross

anatomy. 32.8% stated that direct contact with a

human body helped to know the ‘‘real’’ structure.

Only 7.4% mentioned dissection as a means to

improve the final score, 6% saw dissection as a train-

ing for surgical practice, 5.8% expressed a genuine

interest in knowing dissection techniques, and 4.3%

mentioned the value of team work. In general, the

students expressed a great interest in having more ses-

sions because dissections increased comprehension of

material learned during the modules. They regarded

the dissection as putting into practice the ‘‘theory’’

presented in textbooks and atlases, and as a work-

bench for appraisal of the human body organization.

CONCLUSION

Gross anatomy is one of the fundamental topics in a

medical curriculum. In gross anatomy, we face the

well-known dilemma that at the time students have to

master a large body of anatomical information, they are

not aware of its application to clinical medicine. When

they are ready to use anatomical knowledge, a substan-

tial part of the information is forgotten. The importance

of anatomical reasoning and the application of anatomi-

cal principles in the explanation of clinical signs and

symptoms, however, is clear. The theoretical develop-

ment of the methodology we use is borne out by the

satisfaction of the students expressed in the answers to

the questionnaire. In addition, staff profited from a very

direct experience of the students’ difficulties in the

learning process in the anatomy courses, and learn how

to direct tutorials more efficiently.

Nevertheless, there is still a long way to go. Diffi-

culties found by both teachers and students relate

mainly to the identification of individual student

participation on the assigned dissections (groups

were of three students because of the number of

cadavers available) and to the evaluation system

(i.e., some items were not identified due to inappro-

priate exposure by a previous dissection). We are

now hoping to introduce individual student dissec-

tion that would allow personal assessment and

greater benefit for the students.

The Spanish medical educational system is based

on individual disciplines, most often by lectures to

large groups of students, not only in the medical cur-

riculum, but in primary and secondary schools as

well. When students enter our novel system they

usually are surprised and challenged by their active

participation and the integration of the different sub-

jects. Our system challenges students’ learning hab-

its, and requires additional effort to adapt to self-

learning, especially at the beginning of the first year.

Once they become familiar with the system, most of

them appreciate the benefits of active learning and

increase their motivation to learn. This model also

brings about a more direct interaction with Faculty

members. Additional benefits of the method are the

honing of the students’ communication skills in peer

teaching, the learning of the importance of collabora-

tive effort and the appreciation of the need to organ-

ize their thoughts for an oral presentation (Phase 3,

see Introduction), taking into account that every stu-

dent, on average, must give at least six oral presenta-

tions (peer-teaching) per academic year. Group-work

provides additional incentive to study, as well as a

preparation for future medical practice. Staff must

cope with the additional effort required in working

with students and in providing quality cooperative

teaching. This system, however, promotes integration

of the different courses in basic and clinical sciences.

In the academic year 2003/2004, the first students

have completed their medical studies under this

teaching system. After that, they take the Spanish

national examination that allows them to initiate

their specialty training. After that examination, we

will know how our students have scored. We will

then be in a better position to assess the results of

our curriculum and decide whether we ought to

implement further educational strategies in Human

390 Arroyo-Jimenez et al.

Anatomy and Embryology and their integration with

other basic and clinical sciences.

ACKNOWLEDGMENTS

This work is dedicated to Prof. J. Fermoso and to

Prof. L. Arroyo, two visionaries of the implementa-

tion of new educational approaches to medical cur-

ricula in Spain. We thank Prof. L. Branda for reading

the first draft of the manuscript.

REFERENCES

Ashraf-Aziz M, Mckenzie JC, Wilson JS, Cowie RJ, Ayeni

SA, Dunn BK. 2002. The human cadaver in the age of

biomedical informatics. Anat Rec (New Anat) 269:20–32.

Dinsmore CE, Daugherty S, Zeitz HJ. 1999. Teaching and

learning Gross Anatomy: dissection, prosection, or ‘‘both

of the above?’’ Clin Anat 12:110–114.

Gomez JM, Pujol R. 1998. Changes in medical education in

Spain. Acad Med 73:1076–1080.

Jones DG. 1997. Reassessing the importance of dissection: a

critique and elaboration. Clin Anat 10:123–127.

Paalman MH. 2000. Why teach anatomy? Anatomists

respond. Anat Rec (New Anat) 261:1–2.

Marks SC. 2000. The role of three-dimensional information

in health care and medical education: the implications for

anatomy and dissection. Clin Anat 13:448–452.

Utting M, Winnan P. 1995. What future for dissection in

courses of human topographical anatomy in universities in

the UK? Clin Anat 8:414–417.

Yates RD. 1999. The present and future of anatomy. Anat

Rec (New Anat) 257:43–44.

391Self-Directed Learning in Gross Anatomy