Student Responses to the Gross Anatomy Laboratory ina Medical Curriculum

CHARLES E. DINSMORE,1* STEVEN DAUGHERTY,2 AND HOWARD J. ZEITZ3

1Department of Anatomy, Rush Medical College, Chicago, Illinois2Department of Psychology, Rush Medical College, Chicago, Illinois

3Director of Asthma & Allergy Service, University of Illinois, Rockford

Working with cadavers, whether through active dissection or by examination of prosectedspecimens, constitutes a potential stressor in medical education although there is no consen-sus on its effect. Some reports have suggested that it creates such a strongly negativeexperience that it warrants special curricular attention. To assess the issue for ourselves, weadministered surveys to the freshman medical students taking the Anatomical Sciences coursein the problem-based Alternative Curriculum (A.C.) at Rush Medical College for fourconsecutive years. We found that although a vast majority of students expressed a positiveattitude toward the experience, both before and after taking the course, there remains a smallpercentage of students for whom human dissection may initially be a traumatic experience.We offer explanations for our findings, comments on disparate results from other studies andsuggestions for appropriate responses by anatomy faculty, who must address these studentneeds. Clin. Anat. 14:231–236, 2001.© 2001 Wiley-Liss, Inc.

Key words: gross human anatomy; medical students; curriculum

INTRODUCTION

The learning of gross human anatomy within amedical curriculum provides education on a numberof different levels, emotional as well as intellectual.While students absorb a substantial amount of contentknowledge about the human body, they must alsoconfront core aspects of their own humanity (Hafferty,1991). For this reason, dissection of the human ca-daver may engender uncomfortable emotional expe-riences and psychological problems for some students.Working with human cadavers thus constitutes anearly potential stressor in medical education.

Discussion of the psychosocial impression of hu-man dissection on medical students is a commontheme in contemporary medical education literature(e.g., Field, 1984; Gustavson, 1988; Bertman andMarks, 1989; Tuohimaa et al., 1993; Dickinson et al.,1997; Marks et al., 1997). Studies of medical studentsat several different colleges of medicine, from Austra-lia (Davies et al., 1968; Horne et al., 1990) to theUnited Kingdom (Field, 1984; Evans and Fitzgibbon,1992), Brazil (Botega et al., 1996) to Canada (Marks etal., 1997), indicate that some novices suffer strongnegative reactions to the dissection or necropsy expe-

rience, or perhaps even to the idea of human dissec-tion. One recent article (Dickinson et al., 1997) statesexplicitly that “gross anatomy is an extremely stressfulexperience for the 1st year medical student.” Theimpact of human cadaver dissection on some studentshas even been likened to a psychiatric pattern called‘Post-Traumatic Stress Disorder’ (Finkelstein andMathers, 1990).

Research concerning whether or not the gross anat-omy lab experience merits the extravagant metaphorof post-traumatic stress, or similar labels, must beconducted carefully. The very nature of the data-gathering process itself may significantly influence thecomplexion of students’ descriptions and what theyreport about their initial experiences with human dis-section. Though perhaps unintentionally encouragedby those administering the questionnaire or perform-ing the interview, the tenor of a student’s responsemay actually mirror subtle cues provided by the inter-viewer or the implied expectations of the survey itself.

*Correspondence to: Charles E. Dinsmore, PhD, Dept. of Anat-omy, Rush Medical College, Chicago, IL.

Received 24 February 2000

Clinical Anatomy 14:231–236 (2001)

© 2001 Wiley-Liss, Inc.

Related Issues

Competent physicians require a solid understandingof the structure and function of the human body. Yet,after centuries of medical education experience, we haveonly recently begun to explore alternative modes bywhich students may acquire that knowledge. To whatextent does the historical presentation of gross anatomyto 1st year medical students—a series of lectures incombination with extensive cadaver dissection—warrantcontinuation in its present, traditional form?

Technical competence defines only one part of aphysician’s responsibility in serving the healthcareneeds of fellow human beings. Fear exists amongsome individuals that, although human dissection pro-vides valuable medically-relevant knowledge, it mayalso contribute to a desensitization of physicians-in-training. Contemporary social currents have refocusedmedical education, particularly with an eye towardincreasing the number of those entering the generalistfields, to include contemplation of some of the lesstraditional factors in the training of physicians. Thereis also an expectation by society of an enhanced phy-sician understanding of the social context of that med-ical practice. How, then, can medical school curriculabe changed to produce more ‘humane’ doctors, thosewho have an increased ‘sensitivity’ to patient needs?

Reflections on death and the effects of deathanxiety are not limited to medical students sincethose concerns touch universal, highly emotionalissues. Therefore, determining how people feelabout having their own bodies, or those of a familymember, dissected provides an important gauge ofsocial reaction to the issue. According to a Swedishsurvey in which 1,950 individuals, ranging in agefrom 18 to 75 years, were polled at random (Sanner,1994), there exists an interesting dichotomy in thepublic’s attitudes about dissection of the humanbody. Of the 65% who responded, a large majority(84%) reported acceptance of autopsy and yet 85%noted that whole body dissection for educationalpurposes was personally troubling. The percentageof those inclined to donate their own organs or thoseof a relative at the time of death fell about in themiddle, with those accepting the idea of organ do-nation, also being more inclined to accept the ideaof autopsy. In the absence of empirical data, itwould seem reasonable to assume that those whoenter the healthcare professions likely represent asubset of the general population. The distributionof attitudes toward or emotional responses to dis-section found in previous studies of medical stu-dents may therefore represent self-selection fromamong those accepting dissection, with a small per-

cent of variance from among those who may not beso inclined.

To collect empirical data relevant to these issues,we polled several consecutive classes of students inRush Medical College’s problem-based learning pro-gram, the Alternative Curriculum (AC), to assess theirprior anticipation of, and their subsequent feelingsabout, the laboratory experience of the human grossanatomy course. Not surprisingly, our findings weresimilar to other published general survey data on med-ical student attitudes: the vast majority approaches thetask enthusiastically, but there is a small percentage ofstudents for whom human dissection may initially bea traumatic experience.

MATERIALS AND METHODS

Beginning in the 1993–1994 academic year and forfour consecutive years, we administered a survey (Ta-ble 1) to the freshman medical students prior to (or forone class, at the beginning of) their taking the Ana-tomical Sciences course in the AC at Rush MedicalCollege. The AC, a subset of 24 students from eachclass of 120 medical students, was an elective basicsciences track parallel to the traditional curriculum.Our questionnaire,1 modeled after the one used byShaida et al. (1993), assessed student opinions andobservations on a) effective and efficient delivery of agross anatomy laboratory experience and b) the poten-tial emotional impact of cadaver dissection before

1A copy of the survey instrument is available upon request tocdinsmore@rushu.rush.edu

TABLE 1. Questions from the Two Surveys

A. Initial Survey

1. Which of the following words most closely describe youranticipation of the gross lab? (percentages rounded to nearest.5%)

a. Fear/anxiety: 4%b. Nausea/disgust: 6%c. Neutral/not concerned: 10%d. Mildly interested: 8.5%e. Eager to begin/excited: 72%f. Other

B. Follow-up Survey

1. How do you feel about your gross anatomy lab experienceduring this last quarter?

Negative . . . Positive5 4 3 2 1

2. How has your gross anatomy lab experience changed yourattitude toward anatomy in general?

Negative . . . Unchanged . . . Positive5 4 3 2 1

3. Describe in your own words your current opinion about grossanatomy dissection and/or prosection.

232 Dinsmore et al.

their participation in that experience. Student feed-back relative to the former has been published (Din-smore et al., 1999). Student feedback regarding theirfeelings or emotional responses in anticipation of thegross anatomy lab is presented below, as are data froma follow-up survey administered one month after thestudents had completed the Anatomical Sciencescourse. The second questionnaire asked the studentsto reflect on their gross anatomy lab experience usinga five-point scale (with five at the negative end of thescale and one at the positive end) and to describe theirfeelings/emotions in their own words.

RESULTS

Each class in the problem-based learning programbegan with 24 students; in the two final years of thestudy, one student in each group dropped out of theprogram before the second survey was administered.The return rate was 50% for the initial survey and 43%for the follow-up survey. The average age of students inthe program when they completed the initial survey was25.6 years. About 50% of the questionnaires returned inboth the initial and follow-up surveys were from women,a proportion that reflects the general composition ofRush Medical College classes as a whole. Seventy-ninepercent of the responding students had some vertebrateor invertebrate lab dissection experience prior to begin-ning the program and 17% had some exposure to, orpreparation with, human dissection. While significantselection bias may be inherent in the nature of this typeof survey, the process was comparable to those em-ployed in similar surveys at other institutions (e.g.,Finkelstein and Mathers, 1990; Shaida et al., 1993; Tuo-himaa et al., 1993).

Anticipation of Human Dissection (Fig. 1)

Of the 96 students in the four successive classes (24per year), 48 (50%) returned the completed initial

survey form. Seventy-two percent indicated that inanticipation of the gross lab they were ‘Eager to begin/Excited’; an additional 8% chose the ‘Mildly inter-ested’ category. In the negative response groups, 6%listed ‘Fear/Anxiety’ while an additional 4% chose‘Nausea/Disgust’ (see Table 1A). These responsesroughly correspond with those of previous studieswhich have suggested a background rate of approxi-mately 5% of medical students reportedly associatingnegative emotional and psychological reactions to theanatomy lab experience (Finkelstein and Mathers,1988, 1990; Marks et al., 1997).

Post-Course, Follow-Up Responses

Of the 90 students who fulfilled the requirementsof the Anatomical Sciences Quarter, 39 (43%) com-pleted and returned the follow-up survey form. Onthis follow-up survey, students were asked to indicatehow they felt about the gross anatomy lab experienceand how the experience of the anatomy lab hadchanged their attitudes toward anatomy. Both ques-tions (see Table 1B) received an average score of 2.0(on a one–five, Positive-to-Negative scale) reflectingthat, on balance, the gross anatomy experience was apositive one! Typical examples of student-generateddescriptions included: “The gross anatomy lab expe-rience was enjoyable overall;” “I liked it the way ACapproached anatomy. The time spent in lab was fast-paced and filled with clinically relevant material;”“The value of the lab is very great. I dreaded the deadbodies and fumes but I always left feeling glad I hadcome;” “More time in the lab!”

DISCUSSION

Anatomy Lab Stress

In one study of stress potentially induced by thegross anatomy lab, the investigator interviewed 1styear medical students from an anthropological per-spective regarding their experiences. The reportclaimed that the exercise elicited “strong negativearousal” in most of the students (Gustavson, 1988), anobservation that is not supported by our experience.The descriptor ‘negative arousal’ could, among otherthings, indicate that a majority of the students didn’tlike the smell of the gross anatomy lab, thereby plac-ing that exercise in the same category as numerousothers performed in malodorous environments. Theobservation doesn’t discriminate between the task ofinterest and the environment or context within whichit must be performed.

Others have also described extreme negative re-sponses (Finkelstein and Mathers, 1988), which they

Fig. 1. Responses to Initial Survey*

Student Responses to Gross Anatomy Laboratory 233

called “post-traumatic stress among medical studentsin the anatomy dissection laboratory” (Finkelsteinand Mathers, 1990). To support their conclusions, theauthors provided 10 selected student vignettes butwithout a psychological history of, or any other back-ground information about, these students prior to theirenrollment in the gross anatomy course. Anothermethodological problem of that study was that theauthors did not survey all 350 students; they ‘selectedat random’ 175 students and the follow-up “dependedon voluntary cooperation.” It is possible that studentswith a negative experience in the gross anatomy lab-oratory, for whatever reason, might have constituted alarger percentage of the follow-up group in an effort todecrease their discomfort.

At the same time, other studies have emphasizedthat a vast majority of first year medical studentsreport “positive emotions” associated with their firstdissecting room experience (Shaida et al., 1993), or“showed a favorable attitude to the dissection course”(Tuohimaa et al., 1993).

It should also be noted that a number of factorsother than the gross anatomy course contribute to thestresses of medical education. For instance, Evans andFitzgibbon (1992) have shown that human dissectionis just one of many stressful events to which medicalstudents are exposed, and in fact relatively minorcompared with other tension-generating circum-stances. In their study of 14 identified stressors forthese first year medical students, the dissecting roomranked 12th; even the histology lab, ranked eighth,was perceived as more stressful!

Medical School Stress

Several studies have pointed out that a certainpercentage of medical students regularly exhibit ordevelop psychiatric illness (e.g., Pearson, 1982; Sal-mons, 1983), depressed mood being among the betterdocumented issues (e.g., Clark and Zeldow, 1988).Exposure to the human cadaver, and particularly thedissecting experience, may precipitate expression ofthose problems among susceptible students. Surveysof psychiatric morbidity among medical students re-flect measurable incidences ranging from 2.4% (Sal-mons, 1983) up to 12% (Davies et al., 1968; Clark andZeldow, 1988). Other studies have focused on theimpaired physician and concluded that the root prob-lem generally stemmed from earlier psychological is-sues (e.g., Borenstein and Cook, 1982; Thomas, 1976;Waring, 1974). Pearson (1982) cites papers from thepreceding 40 years that reported anywhere from 20%to as high as 47% of medical students having “emo-tional problems,” “mental illness with some psycho-sis,” or “neurotic handicaps of a major character.”

Firth (1986) surveyed 4th year medical students atthree British medical schools and subsequently esti-mated the prevalence of emotional disturbance at31.2%. She also remarked that it was “not surprisingthat students, faced with constant evaluation and ashortage of money and time, should suffer the symp-toms of strain more than young employed people.”

One might reasonably ask if medical students re-porting serious emotional disturbances associated withthe dissection room represent a population of studentsat risk for becoming impaired physicians. If that isindeed the case, an alternative or at least supplemen-tal approach might consist of addressing the specificproblems of those few individuals whose ‘psychosocialneeds’ may require special attention. Associating thatdistress with the dissection experience and creating acourse supplement required for all students seemsunwarranted and may simply mask the real problems.

Compensatory Strategies

A Finnish program instituted to address “possibleemotional problems caused by the medical curricu-lum” (Tuohimaa et al., 1993) consists of three 1-hrlectures prior to the dissection course. A psychiatristprovides an introductory lecture on a physician’s per-spective on death and possible reactions to the dissec-tion situation. An anatomist provides background of amore routine nature including how cadavers are ob-tained and prepared, and also comments on properlaboratory behavior. The hospital pastor contributes athird presentation of a more discursive nature, includ-ing light humor “to ease tension of the situation.”

A second dissecting experience for most medicalstudents comes with anatomical pathology, describedby Marks et al. (1997) as one of the two “unavoidabledeath encounters” for medical students. While theirstudy appears to present that aspect of the pathologycurriculum in negative terms, data from an earlierstudy at Rush Medical College (Tazelaar et al., 1987)reflected a positive student attitude toward the au-topsy dissection experience. The authors of the lattersurvey even suggested that the use of the autopsy inmedical education may be underutilized and under-valued. A more recent study from the Medical Collegeof Ohio (Conran et al., 1996) reinforced that sugges-tion, concluding that “the autopsy elective had a pos-itive influence on the students’ attitudes.” Further-more, 85% of the students responding to thequestionnaire felt that “the autopsy should be man-datory for all students.” Perhaps programs to preparestudents for the dissection experience should moreactively engage students who have previously com-pleted the course, taken away a very positive attitude

234 Dinsmore et al.

about it, and can therefore provide encouraging, sup-portive peer perspectives.

A number of authors have put forth recommenda-tions that courses be developed to address the “psy-chosocial needs” encountered by 1st year studentsperforming human dissection. Some institutions havein fact implemented ancillary programs in “death anddying” to meet this apparently unsatisfied need (e.g.,Marks and Bertman, 1980; Field, 1984; Penney, 1985,1987; Bertman and Marks, 1989). The instituting ofdeath education in anatomy programs may simply be“pushed by consumer demand” and “the popularityof alternative resources” (Marks et al., 1997). Thatdistinct possibility calls for a critical exploration as totheir academic legitimacy. Data used to justify inser-tion of such programs into the curriculum are ambig-uous at best and may simply appeal to current trendsand misconceptions common in contemporary society.As a cautionary note, the practice of offering a sepa-rately-identified program on death and dying linked tothe gross anatomy lab experience may actually inducesome students to believe that it should be a problem.As noted above, those few students who actually needdirect attention would be less likely to receive it.Would it not be more prudent to rely on or improvedelivery of such topics as they typically occur in “Be-havioral Sciences” curricula?

Future Research

In colleges of medicine, gross human anatomy is arequisite core course, not an option; within it thecadaver dissection lab figures prominently. In con-trast, courses for college and university students inwhich human cadaver dissection occurs draw studentswith explicit interests in anatomy. These programstrain students of physical anthropology, mortuary sci-ence, and primatology, among other similar fields ofstudy. It would be useful to compare the reactions ofcollege students who voluntarily undertake participa-tion in academic human dissection programs with thereactions of medical students.

As indicated above, medical schools in several dif-ferent countries have generated programs aimed ataddressing perceived problems of student encounterswith death and dying associated with human cadaverdissection. For instance, at the University of Massa-chusetts Medical School, Marks and colleagues (1997)have provided a program for developing a sensitivityin their medical students to issues of death and dyingfor approximately 20 years. It might be instructive toassess whether or not students who went throughthose courses and are now-practicing physiciansprovide a measurably greater degree of sensitivityin treating their patients than physicians who were

not provided a discrete 1st year course on death anddying.

CONCLUSION

We conclude, as have others (Clark and Zeldow,1988; Evans and Fitzgibbon, 1992), that high stresselements converge in the general medical school en-vironment and that the dissection lab appears topresent some students with additional anxiety. Whatthen might the faculties in anatomy departments rea-sonably do in preparation for students who find thedissection experience, and even the anticipation ofthat experience, emotionally overwhelming? Bourguetet al. (1997) conducted a survey of anatomy depart-ments at each US and Canadian allopathic and osteo-pathic medical college and found the faculty in strongagreement that they have a “responsibility for accul-turating preclinical students to medicine.” This opin-ion included a recognition of emotional needs of thosestudents for whom the dissection lab may be their firstpersonal experience with human death. Facilitatingthat aspect of the encounter places an additional andimportant responsibility on anatomy faculty, wellabove and beyond that of colleagues in the other basicsciences. No single faculty response seems appropri-ate since each student brings unique personal experi-ences and cultural biases to the formidable task ofcadaver dissection. Common sense and trust appear tosuffice in most cases. Where student reactions havewarranted greater professional engagement, calling onprofessionally qualified colleagues in the behavioralsciences supplements the anatomy faculty’s capacityto assist students in acclimating to the process. Withthat in mind, each generation of anatomy facultyshould become informed about compensatory strate-gies used by their more experienced anatomy facultycolleagues. They should also learn of the various waysthat medical students cope effectively with humandissection, and be prepared to help those students inneed of additional support.

ACKNOWLEDGMENTS

We thank Drs. Sandy Marks, Jr. and Donald Cahillfor their constructive comments and suggestions dur-ing the early development of this manuscript.

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