Clinical Anatomy 9:263-268 (1996)

Testing Knowledge of Human Gross Anatomy in Medical School: An Applied Contextual-Learning

Theory Method RICH W. CLOUGH ANI) ROBERT P. LEHR

Department ofilnatomy, Southern Illinois University School of Menirine-Carhondale, Carbondale, lllinozs

The traditional gross anatomy laboratory experience, with modifications in evaluations that we outline later, meets the criteria of contextual-learning theory, expands the repertoire of core ob- jectives we identify for our students, and may increase the likelihood of cognitive permanence of anatomical data. Our subjects included approximately 54 first-year medical students from each of three sequential class years (1996, 1997, 1998). As an alternative to more typical writ- ten and practical exams, examinations in a major portion of our gross anatomy program con- sist of two approximately 30 minute oral expositions by each student to his or her peers and a faculty member. Students demonstrate specific detail on cadaver, x-ray, cross sections, or a model. Clinical applications, spatial relationships, nomenclature, and functions are strongly emphasized. The results of this teaching approach to the utilization of anatomical knowledge in clinical situations requires further assessment; however, new attributes have been afforded our students with implementation of the present program: First, students learn anatomical de- tail equally well as the students of the more traditional system (based on board exam results). Second, students who completed the program indicate that this approach provides a useful sim- ulation of what is expected later in their training. Third, students gradually gain confidence in verbal presentation, they demonstrate cognitive synthesis of separate conceptual issues, they retain information, and they are quite visibly more enthusiastic about anatomy and its impor- tance in medicine. Our program demonstrates that the learning of applicable human anatomy is facilitated in a contextual-learning environment. Moreover, by learning anatomy in this way, other equally beneficial attributes are afforded the medical student, including, but not limited to, increases in communication skills, confidence in verbal presentation, synthesis of anatom- ical concepts, appreciation of the clinical importance of anatomy, and the general development of professionalism. 0 1996 Wiley-Liss, Inc.

Key words: tutorial evaluations, curriculum, anatomy

INTROIIUCTION

Knowledge of human gross anatomy continues to serve as 3 primary basis for clinical medicine. As re- viewed by Collins et al. (1994), there is a perceived need for educational strategies designed to promote conceptualization, retention, and usefulness of the basic and clinical anatomical sciences. Moreover, Collins et al. (1994) suggest that the teaching method per se may not be as important, especially to the stu- dent’s future patients, as the method of evaluating those students’ anatomical knowledge. H e states, “from the patient’s point of view, however, the method of teaching is relatively unimportant; what is important is whether the physician (who was formerly a student) knows the anatomy of the relevant part of the normal

body well enough to diagnose illness and prescribe sensible treatment.”

Unfortunately, there exists a paucity of reports on implementation of variant experimental methods in the teaching or evaluation of the anatomical sciences. Certainly, a more general debate continues concerning the most effective ways to address the overall under- graduate medical student’s needs with regard to all the basic medical sciences. Arguments for changes to the traditional discipline-based curricula have been made for an organ-systems curricula (Silber et al., 1978),

Received for publication April 18, 1995; revised July 4, 1995.

Address reprint requests to Rich Clough, Ph.D., Department of Anatomy, Southern Illinois liniversity School of Medicine-Car- bondale, Carbondale, IL 62901 -6503.

0 1996 Wiley-Liss, Inc.

264 Clough and Lehr

problem-based curricula (Barrows and Tamblyn, 1980; however, see Coles, 1991), computer-assisted instruc- tion (Guy and Frisby, 1992), and any of several modi- fied combinations of these methods as the means to providing the most effective undergraduate training (Kaufman et al., 1989). It is interesting to note a histor- ical corollary to the above-mentioned arguments in the Rappleye Report (1932), which suggests that “Medi- cine must be learned by the student, for only a fraction of it can be taught by the faculty. T h e latter make es- sential contributions of guidance, inspiration, and lead- ership in learning. T h c student and the teacher, notthe curriculum [italics ours], are the crucial elements in the program.” [Jnfortunately, this adage is often forgotten and the curriculum content per se becomes the central focus of the teaching/learning interaction.

Alternatively, contextual learning is an active pro- cess of information acquisition and mental consolida- tion that couples cognitive demand with experiential discovery in a contextual environment. Importantly, this approach also fosters the development of analyti- cal and personal skills so that knowledge can be ap- plied to future challenges in similar contextual envi- ronments. Cognitive demand includes the necessary memorization of the vast and detailed nomenclature of anatomy, while experiential discovery involves the co- ordination of cognitive knowledge to direct observa- tions of the physical aspects of anatomy. T h e consoli- dation of cognitive and experiential information into useful mental constructs depends largely on the con- text of the environment in which these processes are occurring. A contextual environment is one that facili- tates the consolidation process and that attempts to induce more meaningful perception and to promote retention of more readily available data for use in the context in which it will eventually be used. T h e process is guided by an instructor whose charge is to facilitate the formation of a “contextual” atmosphere of inquisitiveness, discovery, excitement, and necessity. T h e outcome of this type of learning is similar to that described as elaborated learning, as detailed by Coles (1990). It is based on the structure of initial knowledge acquisition and the intricacies of the coordinated inter- connections of this knowledge necessary for later prob- lem solving in clinical situations. A similar paradigm to contextual learning is experiential learning (Kolb, 1984). Experiential learning describes the ability to move from concrete experiences, to observations and reflections on the concrete experiences, to the formu- lation of abstract concepts, and to the application of these concepts in new situations. Both of these theo- ries focus on the learning of information in a rich envi- ronment representative of the context in which the in- formation will be used at a later time. These theories

may find their appropriate application in organ-system, problem-based learning, or the traditional discipline curriculum.

Contextual-learning and experiential-learning theo- ries bring to mind Piaget’s concept of developmental operativity in which a concrete object is grasped, ma- nipulated, and operated upon, and through this method is mentally conceptualized or “learned” (Furth, 1969). Indeed, our interactions with the very concrete experi- ences of the physical world form the foundation upon which we begin to develop our cognitive ability. In try- ing to promote meaningful establishment of the neces- sary basic science foundations in medical students, Coles (1990) has suggested that the more concrete the experience, the more rapid and more permanent is the memory of the experience.

Human gross anatomy dissection is clearly an oper- ative process, and the cadaver is a concrete learning tool. Year after year, the authors hear from students that it is the gross anatomy laboratory experience from which the students learn their anatomical concepts and the relationships that are later applied to clinical situa- tions and physical examination requirements. Indeed, the human gross anatomy laboratory experience con- tinues to play a major role in early medical curriculum design because of its overall importance to all of the clinical disciplines (Lehr, 1981; Collins et al., 1994). T h e authors suggest that by using the method of test- ing described presently the gross laboratory experience can be used to achieve not only the objective of learn- ing anatomical detail, but also additional objective?, such as the ability to communicate effectively with professional colleagues, and the ability to yynthesize anatomical concepts and verbally relate these to clini- cal scenarios, and to induce in the student a sense of the necessity of learning. T h e authors present an alter- native method of evaluation of gross anatomy that in- corporates the features of contextual-learning theory and effectively expands the basic objectives and out- comes of the gross anatomy laboratory experience for our medical students.

CONTEXTUAL LEARNING

Contextual learning involves three components: (1) the context of the learning situation, (2) the informa- tion to be Icarned, and ( 3 ) the opportunity to use the information. We briefly examine these three compo- nents in light of the human gross anatomy laboratory experience.

Context of the Learning Situation T h e gross anatomy laboratory clearly provides a con-

crete learning situation. T h e student is presented with

Testing Gross Anatomy in Medical School 265

directed. Importantly, these techniques usually sub- ject the student to exposition to their peers and, thus, to the judgment and criticism of others. T h e utilization of oral evaluation before peers and faculty serves the purpose of preparing the student beyond the bounds of content knowledge. It is one thing to understand a con- cept and find the answer in a multiple-choice question in anonymity; however, it is quite another to explain it to an informed audience. We report that the establish- ment of formal oral expositions before peers and fac- ulty as the sole method of evaluation in a portion of our anatomy training provides great incentive to learn and effectively simulates what occurs later in the clinical years and throughout the physician’s professional life.

a deceased human being, which represents a mystery of structural and functional components inviting dis- covery. T h e student is encouraged to realize that the knowledge to be gained in this situation will provide a foundation for much of his or her future practice. T h e assumed incentive to learn is thus implicit but should not be taken for granted. This incentive requires con- tinual reinforcement by concrete or theoretical exam- ple, by demonstration where appropriate, and, most importantly, by concomitant student participation in dissection. Potential diminution of “maintenance of in- centive,” which may present itself and greatly interfere with learning, can be effectively avoided with the application of the evaluation method to be discussed later. Additionally, the traditional small-group nature of the dissection tank and the close association of the faculty with the students creates the necessary en- riched learning environment.

Information to Be Learned Learning the structural and functional components

of the cadaver must be approached by both the students and faculty with the goal of understanding what acqui- sition of the knowledge will mean to clinical practice. T h e simple memorization of listed origins and inser- tions, arterial branches, terminal nerves, etc., although necessary at times, is not sufficient for a conceptual un- derstanding of basic anatomy as relevant to clinical medicine (a long-term objective of contextual learn- ing). Additionally, rote memorization is not conducive to learning to synthesize and inter-relate conceptual is- sues, nor does it foster communication skills, which are vital in the physician’s actual practice. In the anatomy program of the authors, content and behavioral objec- tives are clearly outlined in an “objectives module.” In the laboratory setting, the nature of the questions posed to students are entirely conducive to contextual learning and usually address anatomical features from a clinical standpoint. T h e probing for answers by dis- section, discussion, and reflection at the cadaver tank should simulate a future clinical situation. Although obviously more didactic in this setting than in a clinical situation, this approach gives meaning and theoretical permanence to students’ understanding of the impor- tance of learning anatomy, as well as of what they need to learn.

Opportunity to Use the Information The student must be an active learner (Rogers,

1960)! Th i s is a major focus and an essential compo- nent of problem-based, self-directed, and contextual- learning methods. These curricular approaches put the responsibility of learning directly on the student, al- though contextual learning is not expressly self-

METHODS: IMPLEMENTATION OF THE PROGRAM

Students in the first year at the Southern Illinois IJniversity (SI‘LJ) School of Medicine typically number about 70-75. Approximately 20+ of these students are engaged a separate but parallel problem-based learning curriculum (PBL), while the remaining 50-t are en- gaged in an integrated organ-based curriculum. Throughout the last 3 years, all SO+ students in the organ-based curriculum have participated in the pre- sently described anatomy program. Our program cen- ters around evaluations by oral exposition of anatomi- cal understanding by an individual student in the presence of his or her peers and a faculty member. Concomitant with the tutorial, the student demon- strates the subject matter in question on his or her ca- daver, x-ray, cross-section, other students, or an appro- priate model. T h e determination of when a particular student makes his or her presentation is made by the student, although guidelines and suggested deadlines are offered by the faculty. By termination of the block (i.e., the semester or general unit), each student must have completed two such oral expositions.

T h e oral evaluation is not a loose unstructured event, but a carefully described, goal-directed encounter for the student. An explicit “module” that details the ob- jectives of the exercise (Fig. 1) is part of the material given to the individual at the beginning of the year. This module provides the clear direction of what is ex- pected in terms of content and behavior. It specifies the criteria for evaluation as objectively as possible. This module is supplemented in class by example demonstrations performed by the participating faculty.

During the oral presentation, following the specific module guidelines, the student is expected to utilize the cadaver he or she has dissected. Students are re- quired to be very specific as to the nomenclature, posi- tion, function, and relationships of all structures, as

266 Clough and Lehr

DOMAIN: Gross Anatomy Evaluation FACULTY: Clough

ESTIMATED WORK TIME: 2hom Lehr

ONE-AN 1 1994

EVALUATION CRITERIA: Successful completion of gross anatomy for the Neuromuscular Block will depend on two Criteria: 1. Accumulation of two check marks (4) for successful

oral presentations of and answers concerning the cadaver dissection, cross section, radiographs, and bones of designated anatomical regions. One check mark is to be obtained for the axial skeleton and the head (items A-C below) and one for the appendicular skeleton (items D-G below). Additionally, one check mark is to be obtained from each of the two primary faculty (Clough and Lehr).

2. Successful completion of the assigned dissection of +e cadaver in coopemion with your tank partners. Dissection must be complete for adequate demonstration during check mark session.

Suggested schedule for completion of checks: You may move at your own pace, but faculty time could be limited near end of the block. F i i t Check-by end of week eight (8) (October 11)

Second Check-by end of week fdteen ( 15) (December 2) Not having the two checks completed and the completion of dissection will result in a recycle consisting of two more checks of oral examination to be scheduled as a regular recycle. Conscientious participation in the dissection shows professional cooperation with your colleagues and will be required. Application of Above:

1. Faculty will query students in the laboratory, asking them to explain, describe. taIk about a previously undesignated anatomical region (the area to be selected by the faculty). Students may reply that they are not ready or don’t know. There will be no penalty for this. There is no penalty for beginning and then stopping.

2. The designated anatomid regions to be evaluated am A. Ne-BadC B. Head C. CranialNerves D. Arm-Thigh E. Forearm--Leg F. Hand-Foot G. Shoulder-Hip

3. Faculty will usually limit their involvement in the presentation. however, prompts or requests for clarification will be usual.

4. More than one faculty may hear the presentation: however the prompts and comments will come from only one.

5 . The student’s approach to the presentations should follow something like: A. B.

C.

D.

E.

identify the region in a general way. Discuss broadly how it relates to other regions. Discuss the embryological derivation of the region or structures. Discuss musculature of the region-innervation, blood supply, origins, insertions, and actions. Discuss bones of the region-parts, ligaments. foramina, etc. Discuss special features or common clinical correlates and how they are related to the anatomy.

6. The criteria for receiving a check mark will incluk A. Use of proper anatomical terminology with

regard to the anatomical position and the relationship of the struchues.

B. Confidence in verbal presentation C. Synthesis of functional anatomical

organization D. Specific anatomical knowledge-knowing

the correct names of structures and relating them to clinical situations.

7. Faculty may converse togethex before assignment of a check mark following a session, and in some instances return to the student for limited further information.

8. Check marks will be assigned or postponed promptly.

To assist you, the faculty will demonstrate how the questioning will go. This will give the student an idea of what is expected in a presentation.

Fig. 1. A “module” that details the testing procedures in anatomy. A module is described as a detailed list that catalogs the key objectives and operations of a given event or describes in detail the learning issues and set of requirements for any particular unit of information. For example, there are separate modules for back anatomy, neck anatomy, soft tissues of the face, cranial nerves, shoulderdhips, and all other regions.

Testing Gross Anatomy in Medical School 267

well as their functional and clinical significance. In ad- dition to the cadaver, the student is directed to use a cross-sectional cadaver, radiographs, and articulated and disarticulated skeletons. Clinical aspects during the presentation are strongly emphasized, and the stu- dents present their expositions to their classmates (who are requested to stay silent).

T h e authors have implemented this evaluation pro- gram for the teaching of axial (head, neck, and back) and appendicular anatomy. Thoracic, abdominal, and pelvic anatomy are evaluated using the more tradi- tional written and practical exam types (taught by other faculty). T h e time required for each oral evaluation is approximately 30 minutes or more (but many students try to lengthen this time), to be officially done twice, once individually with each participating faculty (RC and RL). This amounts to approximately 1 hour of evaluation per student over the course of the semester. T h e second hour indicated in the module “estimated work time” (Fig. 1) is comprised of estimated practice time. Requiring two faculty to evaluate each student ensures that the individual student has a fair opportu- nity to demonstrate competence given the possible subjective differences in interpretations of the event by the two faculty. T h e faculty look for an approximate 80% level of performance, considering the criteria listed in the module (Fig. 1).

In addition to the two oral evaluations per student, each group of four students per cadaver is required to complete the total dissection of the cadaver to the sat- isfaction of the participating faculty (evaluated subjec- tively by experience). Ongoing monitoring of each dis- section group and requiring demonstration during the evaluations ensures participation by all members of the group in dissection.

RESULTS ANL) DISCUSSION

We have adopted oral evaluations for major portions of the gross anatomy taught to our first-year medical students, of which there have been approximately 54 participating students for each of three years (the remain-

der of our students are in a separate PBL curriculum). With reference to faculty-time comparisons between the present method (oral evaluations) and traditional evaluations ( is . , written and practical evaluations cov- ering the same amount of material), we find that the oral evaluation approach is actually time favorable. For example, in the years when the participating faculty (RC and RI,) examined the students using traditional methods (written tests and lab practicals), the time re- quired by each faculty for preparation of a written evaluation was roughly 3 hours per exam per faculty member. T h e estimated preparation time of each lab practical evaluation was approximately 4 hours per exam per faculty member. T h e time required for actual testing was approximately 4 hours/evaluation/faculty. Grading for the 54 students took approximately 3 hours each for the written and the practical evaluation, for a total time of 6 hours per exam per faculty member. Pro- viding that only two such evaluations occur over the aforementioned material (i.e., see Fig. l), the total es- timated faculty time for the traditional evaluations was 34 hr/exam X 2 exams = 68 hours (or 34 hdfaculty member). These time estimates are summarized in Table 1. I t is also noted that this time allotment was only for the initial evaluation. If, as was customary in our program, there is an opportunity for students who fail any exam to retake the exam, this time is roughly doubled to approximately 136 hours.

In the present system (oral presentations), our stu- dents in the organ-based curriculum (as opposed to those in our PBL program) require an approximate total time of 54 hours for the oral evaluations or 27 hours per faculty member. If a student fails this exam, it simply means another encounter (i.e., approximately 30 minutes) for that student with the faculty member. ‘Typically however, since the individual student deter- mines when he or she takes an oral evaluation, they are usually quite ready and knowledgeable (although ini- tially nervous) about the current topic. Therefore, it appears that the contact time using an oral evaluation approach, at least with a smaller class such as ours, is very favorable. In addition to time commitment, we

TABLE 1. Approximate Faculty Time in Hours Required for “Traditional” Testing in a Typical Medical School Human Anatomy Course

Function (Faculty#l) + (Faculty#Z) X (Exams) = Iota1 ,. Prcpare written exam 3 3 2 12 Prepare practical exam 4 4 2 16 Administer exams 4 4 2 16 Grade exams 6 6 2 24 ‘Total hours2 17 17 2 68

&Based on the historical performance of two faculty members (RC and RI,) during the tenure of a “traditional” evaluation program that included a pair of written tests and a pair of lab practicals.

268 Clough and Lehr

have found that the quality of the assessment is much greater and the scope of our objectives is much broader. Subjective evaluation of the program, following stu- dent feedback during discussion, by the observations of student performance over time and by the general impressions of the faculty at large has been very en- couraging. We are able to obtain more information on each student as a person, not just as a student.

Although results of the absolute effectiveness of this teaching approach to the utilization of gross anatomy in clinical settings still needs to be assessed in objective ways, that is, clerkship evaluations, residency sum- maries, etc., we have found that the following attributes are afforded to our students that were not present prior to implementation of the present program of evaluation: First, we found that students learn anatomical detail equally as well as students in the past more traditional system (performance on anatomical sections of the board exams have not been different from the students of earlier years, (data not shown). Second, we found through round-table discussions with students who have gone through the program that this approach does provide them with a useful simulation of what is ex- pected later in, for example, clerkships. Thirdly, over the course of the gross anatomy laboratory sessions (which are characterized by students practicing amongst themselves prior to their formal presentations), we found that students gradually but significantly gain con- fidence in verbal presentation, they demonstrate cogni- tive synthesis of separate conceptual issues, they appear to retain information, and they are quite visibly enthu- siastic about anatomy and its importance in medicine.

Advantages of this approach for the faculty are sev- eral. T h e oral tutorial provides information concerning not only the accuracy of content, but also an opportu- nity to see the process of thinking that the student uses when confronted. It provides insights into how stu- dents conduct themselves in a professional setting, how they handle stress, how confident they are concerning what they know, how well they can communicate, how they handle difficult questions, and how they relate to their peers from a professional standpoint. While it may seem to require more time on the part of the faculty, in practice it does not. Even if this method did require more time than conventional evaluation methods (i.e., as necessary with larger classes or longer evaluations), this approach may be more valuable in terms of evalu- ation of other cognitive attributes of thc students. Clearly, there is a well-defined need for faculty to as- sess more than just the cognitive base of medical stu- dents, as called for in the GPEP report (Muller, 1984).

We suggest that the described modification of human gross anatomy testing procedures in medical school, with incorporation of oral evaluations inclusive of clinical applications, contains the three theoretical

components of contextual-learning theory. T h e impor- tance of learning the knowledge database in the con- text (or simulation) of its later utilization cannot be overemphasized. Moreover, the attributes of additional non-knowledge-based training of performance in front of peers and faculty is extremely valuable to a medical student’s training. For the faculty, the oral evaluation provides a rich opportunity to make assessments con- cerning the critical thinking processes of the students, their demeanor during presentations, and something about them as individuals not revealed by simple writ- ten evaluations. Also, we suggest that this modification to the gross anatomy laboratory of oral evaluations is possible within any curriculum without massive changes. Finally, we suggest that this approach fosters learning in subsequent curriculum segments and throughout the students’ professional careers because it often initiates and, in fact, necessitates the becoming of an “active learner.”

REFERENCES Barrows, €IS. and R.M. ’I‘amblyn 1980 Problem-Rased Learn-

ing: An Approach to Medical Education. New York: Springer. Coles, C.R. 1990 Elaborated learning in undergraduate medical

education. Med. Ed. 2414-22. Coles, C.K. 1991 Is problem-based learning the only way? In

The Challenge of Problem-Rased Learning. D. Boud and G. Feletti (eds.). New York: St. Martins Press.

Collins, ‘I’.J., R.L. Given, C.E. Hulsebosch and B.T. Miller 1994 Status of gross anatomy in the ITS. and Canada: Dilemma for the 21st century. Clin. Anat. 7275-296.

Furth, H.G. 1969 Piaget and Knowledge: ’l’heoretical Founda- tions. Englewood Cliffs, NJ: Prentice-Hall.

Guy, J.F. and A.J. Frisby 1992 LJsing interactive videodiscs to teach gross anatomy to undergraduates at Ohio State “ni- versity. Acad. Med. 67132-133.

Kaufman, A,, S. Mennin, R. Waterman, S. Duban, C. Hansbarger, H. Silverblatt, S.S. Obenshain, M. Kantrowitz, ‘T. Recker, J. Samet and W. Wiese 1989 T h e New Mexico experiment: Educational innovation and institutional change. Acad. hled. 64285-294.

Kolb, D.A. 1984 Experiential Learning: Experience as the Source of Learning and Development. Englewood Cliffs, NJ: Prentice-Hall.

Lehr, R.P. 1981 A clarion for dissection. N. Engl. J . Med. .?04 1370.

Muller, S. (Chairman) 1984 Physicians for the ‘Twenty-First Century. Report of the project panel on the general profes- sional education of the physician and college preparation for medicine ( T h e GPEP report). J. hled. Ed. 5 Y (1 1).

Kappleye, W.C. (director) 1932 Medical Education: Final lie- port of the Commission on Medical Education. New York: Association of American Medical Colleges Commission on Medical Education.

Rogers, C.R. 1960 O n Becoming a Real Person. London, Con- stable.

Silber, D.L., R.G. Williams, R E . Amitrano Paiva, D.D. ‘I‘avlor, and R. Robinson 1978 T h e SIU medical curriculum: System- wide objectives-based instruction. J. hled. Ed