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A Surgical View of Anatomy: Perspectives from Students and Instructors

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Title: A Surgical View of Anatomy: Perspectives from Students and Instructors
Language: English
Authors: Dee, Edward Christopher (ORCID 0000-0001-6119-0889), Alty, Isaac G., Agolia, James P., Torres-Quinones, Carlos, van Houten, Trudy, Stearns, Dana A., Lillehei, Craig W., Shamberger, Robert C.
Source: Anatomical Sciences Education. Jan-Feb 2021 14(1):110-116.
Availability: Wiley. Available from: John Wiley & Sons, Inc. 111 River Street, Hoboken, NJ 07030. Tel: 800-835-6770; e-mail: cs-journals@wiley.com; Web site: https://www.wiley.com/en-us
Peer Reviewed: Y
Page Count: 7
Publication Date: 2021
Document Type: Journal Articles
Opinion Papers
Reports - Descriptive
Education Level: Higher Education
Postsecondary Education
Descriptors: Anatomy, Medical Education, Medical Students, College Faculty, Student Attitudes, Teacher Attitudes, Human Body, Donors, Teaching Methods
DOI: 10.1002/ase.1988
ISSN: 1935-9772
Abstract: As curricular emphasis on anatomy in undergraduate medical education continues to evolve, new approaches to anatomical education are urgently needed to prepare medical students for residency. A surgical anatomy class was designed for third- and fourth-year medical students to explore important anatomical relationships by performing realistic surgical procedures on anatomical donors. Under the guidance of both surgeons and anatomists, students in this month-long elective course explored key anatomical relationships through performing surgical approaches, with the secondary benefit of practicing basic surgical techniques. Procedures, such as left nephrectomy, first rib resection for thoracic outlet syndrome, and carotid endarterectomy, were adapted from those used clinically by multiple surgical subspecialties. This viewpoint commentary highlights perspectives from students and instructors that suggest the value of a surgical approach to anatomical education for medical students preparing for procedure-oriented residencies, with the goals of: (1) describing the elective at the authors' institution, (2) promoting similar efforts across different institutions, and (3) encouraging future qualitative and quantitative studies of similar pedagogic efforts.
Abstractor: As Provided
Entry Date: 2021
Accession Number: EJ1280145
Database: ERIC
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  Value: <anid>AN0148078706;[8z8k]01jan.21;2021Jan15.07:19;v2.2.500</anid> <title id="AN0148078706-1">A Surgical View of Anatomy: Perspectives from Students and Instructors </title> <p>As curricular emphasis on anatomy in undergraduate medical education continues to evolve, new approaches to anatomical education are urgently needed to prepare medical students for residency. A surgical anatomy class was designed for third‐ and fourth‐year medical students to explore important anatomical relationships by performing realistic surgical procedures on anatomical donors. Under the guidance of both surgeons and anatomists, students in this month‐long elective course explored key anatomical relationships through performing surgical approaches, with the secondary benefit of practicing basic surgical techniques. Procedures, such as left nephrectomy, first rib resection for thoracic outlet syndrome, and carotid endarterectomy, were adapted from those used clinically by multiple surgical subspecialties. This viewpoint commentary highlights perspectives from students and instructors that suggest the value of a surgical approach to anatomical education for medical students preparing for procedure‐oriented residencies, with the goals of: (<reflink idref="bib1" id="ref1">1</reflink>) describing the elective at the authors' institution, (<reflink idref="bib2" id="ref2">2</reflink>) promoting similar efforts across different institutions, and (<reflink idref="bib3" id="ref3">3</reflink>) encouraging future qualitative and quantitative studies of similar pedagogic efforts.</p> <p>Keywords: gross anatomy education; general surgery education; medical education; undergraduate medical education; curriculum; dissection anatomy; educational methodology; surgery</p> <hd id="AN0148078706-2">INTRODUCTION</hd> <p>Despite many changes in the field of medicine over the centuries, anatomy has always been a fundamental component of medical education (Gregory and Cole, 2002; Moxham and Plaisant, 2014; Standring, 2016). Knowledge of anatomy is key for many medical disciplines, perhaps most critically, surgery (Turney, 2007; Sugand et al., 2010; Bohl and Gest, 2011; Clifton et al., 2020). Students and faculty agree that knowledge of anatomy has an important role in medical education today (Moxham and Plaisant, 2007; Bergman et al., 2013; Orsbon et al., 2014; Sbayeh et al., 2016).</p> <p>Recently, however, the vast expansion in biomedical knowledge, coupled with new and emerging health problems and rapid evolution in medical practice, has led to broad changes in the medical school curriculum (Leung et al., 2006). Since the mid‐1900s, time spent teaching anatomy in undergraduate medical education has drastically declined (Berry et al., 1956; Kahn et al., 1966; Blevins and Cahill, 1973; Collins et al., 1994; Drake et al., 2002; Gartner, 2003; Drake et al., 2009; Mc Bride and Drake 2018; Rockarts et al., 2020). One survey of US allopathic medical schools reported a decrease from a mean of 248.7 hours of gross anatomy in the curriculum in 1973 to 143.6 hours in 2001 (Gartner, 2003). A more recent series of studies has shown that this trend has continued, although to a lesser degree, with a decrease from 167 hours of gross anatomy course time in 2002 to 129 hours in 2017 (Drake et al., 2002, 2009, 2014; McBride and Drake, 2018).</p> <p>With reductions in time dedicated to instruction in gross anatomy, there has been concern that medical school graduates lack the necessary anatomical preparation for residency, especially for surgical residencies (Cottam, 1999; Older, 2004; Dickson et al., 2009; Roche et al., 2009, 2011). In a 1999 survey, only 29% of residency program directors thought that incoming residents had adequate anatomical knowledge, while 14% stated that the anatomical preparedness of medical school graduates was "seriously lacking" (Cottam, 1999). In a survey of attending‐level clinicians, a majority of respondents agreed that medical school graduates lacked appropriate knowledge of anatomy (Waterston and Stewart, 2005). Concern over deficient anatomical knowledge also comes from students themselves (Bergman et al., 2013). One study found that 42.1% of medical students thought that their anatomical knowledge was inadequate, despite 78.7% of respondents stating that anatomy was "very important" or "extremely important" to medical training (Triepels et al., 2018). Other survey‐based studies have shown that most students felt that their anatomical education did not adequately prepare them for further medical training (Insull et al., 2006; Mitchell and Batty, 2009). Limited evidence suggests that deficits in anatomical knowledge may be contributing to increased medicolegal claims (Goodwin, 2000; Ellis, 2002). It should be noted that despite the multiple lines of evidence presented here, high‐quality studies showing an objective decline in medical students' anatomical proficiency over time are generally lacking, and further research is needed (Bergman et al., 2011).</p> <p>The combination of shrinking curriculum hours for the teaching of anatomy and the perceived decline in students' anatomical competency have invigorated a debate in the literature over pedagogical techniques in anatomical education, particularly over the necessity and efficacy of the use of cadavers (McMenamin et al., 2018). Many educators and surgical faculty believe that the longstanding approach of cadaver dissection is crucial to anatomical education, as it provides hands‐on, tactile experience of structures in three dimensions, while also enabling students to build professionalism skills (Granger, 2004; Sheikh et al., 2016; Ghosh, 2017; Kumar Ghosh and Kumar, 2019). A recent controlled study suggested that cadaver dissection may be more effective than using prosections alone (Thompson and Marshall, 2020). In contrast, some medical schools have minimized laboratory time of cadaver dissection by medical students (Heylings, 2002; Craig et al., 2010; Patel et al., 2015; McBride and Drake, 2018). Arguments against a solely dissection‐based approach emphasize difficulties in procuring and preserving cadavers and the availability of a wide array of pedagogical materials, including plastic models, videos, three‐dimensional computerized models, and prosections (McLachlan, 2004; McLachlan et al., 2004; Topp, 2004; Patel et al., 2015; McMenamin et al., 2018). Nevertheless, the current general consensus is that cadaver dissection should remain an important part of anatomical education, though it should be combined with more modern tools (Johnson et al., 2012; Ghosh, 2017; Darras et al., 2019), such as digital modeling software and radiological images (Phillips et al., 2013; Lewis et al., 2014; Orsbon et al., 2014; Heptonstall et al., 2016), and should be vertically integrated into the medical school curriculum (Estai and Bunt, 2016; Hu et al., 2018; Memon, 2018). Thus, though most educators maintain that anatomical dissection should retain an important role in anatomical education, many admit that the educational approach to cadaver dissection must be modernized to adapt to a compressed curriculum and other challenges, including a shortage of competent instructors (Sugand et al., 2010).</p> <p>Several solutions to this modernization problem have been proposed in order to focus students' limited time on the most clinically relevant anatomy. One interesting approach is to involve surgeons in undergraduate anatomical education, as they can easily connect the course material to clinical scenarios (Haubert et al., 2011; Burgess and Ramsey‐Stewart, 2015). A study by Seyfer et al. suggests that input from practicing surgeons is beneficial to students' learning (Seyfer et al., 2007). A surgical approach to teaching anatomy, in which anatomical structures are taught in the context of clinical procedures, usually by surgeons themselves, is highly popular with students (Are et al., 2009; Ullah et al., 2012) and may promote a favorable impression of surgery as a future career (Are et al., 2010; Carmichael et al., 2020). A surgical approach may also better motivate students and may facilitate a "deep" learning orientation (Böckers et al., 2014).</p> <p>One innovative surgical approach to anatomical education is "cadaveric surgery," in which trainees roleplay as surgeons and practice surgical procedures on cadavers (Nutt et al., 2012). Cadaveric surgery provides a safe space for trainees to make errors during the learning process without causing harm to patients (Holland et al., 2011; Nutt et al., 2012; Hu et al., 2018). Studies of the utility of cadaveric surgery among surgical trainees have reported significant improvements in written and oral examination scores, operative confidence, and video assessments of operative technique (Kim et al., 2016; Sharma et al., 2016, 2018). Participants commonly found this method of dissection to be enjoyable and conducive towards active thought (Nutt et al., 2012). Several courses using the cadaveric surgery approach have been described in the literature, though most are intended for surgical residents, not undergraduate medical students (Kim et al., 2016; Schoeb et al., 2016; Sharma et al., 2016). Cadaveric surgery has also been implemented on a smaller scale by embedding procedure‐based dissections within a more traditional head‐to‐toe dissection manual (Jeyakumar et al., 2020).</p> <p>At Harvard Medical School, approximately 65 hours are dedicated to teaching anatomy within an integrated one‐year preclinical curriculum. This is in stark contrast to the already reduced average of over 100 hours in other institutions and countries (Craig et al., 2010; McBride and Drake, 2018; Rockarts et al., 2020). To accrue greater hours necessary for improved anatomical learning, a month‐long advanced clinical anatomy course is available. Led primarily by pediatric surgeons from the affiliated children's hospital, the elective was designed to provide focused anatomy education in the context of surgical procedures. The elective consists of two 3.5‐hour sessions per day for 19 days, totaling an additional 133 hours of instruction. This elective course was taken by third‐ and fourth‐year students as a supplement to the introductory anatomy course taken during the first year of medical school. While pre‐clinical anatomy at Harvard Medical School is taught concurrently with other foundational science fields such as histology and biochemistry, the elective allows students one month to focus entirely on learning anatomy as their sole academic activity.</p> <p>Here, the authors describe the structure and pedagogy of the course. The results from two focus groups are presented. One focus group consisted of four students, and the other consisted of the four head faculty/instructors of the elective. Both groups met independently. The focus groups' semi‐structured interviews were guided by leading questions developed by the authors. The main interview questions were: (<reflink idref="bib1" id="ref4">1</reflink>) What were the strengths and limitations of the elective course? and (<reflink idref="bib2" id="ref5">2</reflink>) How did the surgical approach to anatomy affect students' learning? The data were recorded and analyzed for themes and subthemes by researchers (C.W.L. and R.C.S.) and dominant themes after consolidation are described here.</p> <p>The Harvard Medical School Institutional Review Board deemed this study exempt from formal review. It is the authors' hope that an outline of this course may prove useful to those seeking to design an advanced anatomy curriculum with a surgical approach.</p> <hd id="AN0148078706-3">ADVANCED CLINICAL ANATOMY ELECTIVE COURSE</hd> <p>This course was the newest iteration of an advanced clinical anatomy elective that has existed at our institution for over two decades. It was designed to supplement the approximately 65 hours of pre‐clinical anatomy instruction the students received during their first year with 133 hours of further instruction after the core clerkship year. The course originated as a partnership between anatomists and surgeons, with the goal of performing dissections based on surgical approaches. The course was never a traditional or 'abstract' anatomy course in which anatomy was studied outside the context of surgical procedures; instead, it was founded on the combined expertise of anatomists and clinicians.</p> <p>In the current version of the course, the senior authors' institution hosted a month‐long advanced anatomy elective designed to allow students to learn anatomy through case‐based surgeries performed on cadaveric donors. The cost estimate for each cadaveric donor was: US $5,630 for traditionally embalmed donors, and US$7,000 for donors embalmed with non‐formaldehyde Surgical Reality Fluid (Trinity Fluids, LLC, Harsens Island, MI). The outline of the course consisted of 32 different surgical procedures chosen to cover important anatomical regions and to expose students to various surgical subspecialties, including neurological, cardiothoracic, vascular, gastrointestinal, urological, gynecological, endocrine, and orthopedic surgery (see curricular map in Table 1). Examples of procedures included carotid endarterectomy, in which students studied major blood vessels and nerves of the neck; left nephrectomy, in which students familiarized themselves with the structures neighboring the kidney in the retroperitoneal space; and first rib resection for thoracic outlet syndrome, in which students encountered the subclavian vessels and brachial plexus in relation to the surrounding musculoskeletal structures.</p> <p>1 TableCurricular Map of the Advanced Clinical Anatomy Elective Course at Harvard Medical School.</p> <p> <ephtml> <table><tbody><tr><td align="left">Week 1 (7 January – 11 January 2019)</td></tr><tr><td align="left" /><td align="left">Day 1</td><td align="left">Day 2</td><td align="left">Day 3</td><td align="left">Day 4</td><td align="left">Day 5</td></tr><tr><td align="left">AM</td><td align="left">Neuro‐radiology imaging lecture</td><td align="left">Laminectomy for intraspinal cord or trauma; consequences of injuries or tumor at various levels</td><td align="left">Introduction to incisions and flaps</td><td align="left">Right first rib resection for thoracic outlet syndrome</td><td align="left">Right lobe sleeve resection for carcinoid tumor of the bronchus intermedius converted to a right upper lobectomy for positive distal margins</td></tr><tr><td align="left">PM</td><td align="left">Brain tumor approaches</td><td align="left">Surgical treatment of hydrocephalus</td><td align="left">Embryologic defects and resultant congenital anomalies</td><td align="left">Patent ductus arteriosus ligation followed by a left upper lobectomy for squamous cell carcinoma</td><td align="left">Cardiac transplantation including ventricular assist devices and cardiopulmonary bypass</td></tr><tr><td align="left">Week 2 (14 January – 18 January 2019)</td></tr><tr><td align="left" /><td align="left">Day 6</td><td align="left">Day 7</td><td align="left">Day 8</td><td align="left">Day 9</td><td align="left">Day 10</td></tr><tr><td align="left">AM</td><td align="left">Cardiac embryology and resultant malformations; cow heart dissection</td><td align="left">Inguinal/femoral hernia repair and Ladd's procedure for malrotation</td><td align="left">Right hepatic lobectomy converted to an extended right lobectomy (trisegmentectomy)</td><td align="left">Left nephrectomy for Wilms tumor</td><td align="left">Total abdominal colectomy for ulcerative colitis</td></tr><tr><td align="left">PM</td><td align="left">Repair of aortic valve</td><td align="left">Porto‐caval shunt for portal hypertension</td><td align="left">Total gastrectomy for adenocarcinoma with proximal jejunal J‐pouch</td><td align="left">Right adrenalectomy</td><td align="left">Whipple procedure (pancreaticoduodenectomy)</td></tr><tr><td align="left">Week 3 (21 January – 25 January 2019)</td></tr><tr><td align="left" /><td align="left">Day 11</td><td align="left">Day 12</td><td align="left">Day 13</td><td align="left">Day 14</td><td align="left">Day 15</td></tr><tr><td align="left">AM</td><td align="left">National holiday (Martin Luther King Day)</td><td align="left">Exposure for central abdominal neuroblastoma resection, left adrenalectomy</td><td align="left">Cystectomy for diffuse transitional cell carcinoma</td><td align="left">Endovascular repair for lower extremity atherosclerotic occlusion and open femoral popliteal graft</td><td align="left">Carotid dissection for occlusive plaque; endovascular and open approaches</td></tr><tr><td align="left">PM</td><td align="left" /><td align="left">Musculoskeletal imaging lecture</td><td align="left">Hysterectomy for cervical cancer</td><td align="left">Radical neck dissection for melanoma</td><td align="left">Thyroid lobectomy for malignant nodule (papillary carcinoma of the thyroid gland); cricothyroidotomy</td></tr><tr><td align="left">Week 4 (28 January – 1 February 2019)</td></tr><tr><td align="left" /><td align="left">Day 16</td><td align="left">Day 17</td><td align="left">Day 18</td><td align="left">Day 19</td><td align="left">Day 20</td></tr><tr><td align="left">AM</td><td align="left">Brachial plexus exposure for injury</td><td align="left">Knee exploration and repair of torn anterior cruciate ligament; arthroscopy demonstration</td><td align="left">Supracondolar humeral fracture with neurovascular compromise</td><td align="left">Thoracoabdominal imaging case presentations</td><td align="left">Conclusion and feedback</td></tr><tr><td align="left">PM</td><td align="left">Applied anatomy of common adult and pediatric hand surgery procedures</td><td align="left">Shoulder instability and repair for rotator cuff injury tear</td><td align="left">Examination of the hand and correlative anatomy</td><td align="left">Anterior and posterior exposure of the hip</td><td align="left" /></tr></tbody></table> </ephtml> </p> <p>1 The Advanced Clinical Anatomy Elective Course consists of two 3.5‐hour sessions per day for 19 days, totaling an additional 133 hours of instruction. This four‐week elective course was taken by 19 third‐ and fourth‐year students from 7 January to 1 February 2019 as a supplement to the introductory anatomy course taken during the first year of medical school.</p> <p>For each 3.5‐hour session, the course directors invited an attending surgeon with clinical expertise in performing the surgical procedure in focus; this surgeon was the lead instructor for that laboratory session. Visiting surgical faculty were all contacted by one of the course co‐directors and all agreed to volunteer their one‐half day to participate in the course. Of note, all who participated have wanted to be involved in the subsequent two renditions of this course. The authors do not anticipate any problems with securing the same faculty in future years. The current faculty including the co‐directors volunteered their time and received no reimbursement for their teaching activities.</p> <p>Each session begins in the classroom with a one‐hour lecture by the lead instructor. During the lecture, the lead instructor describes the anatomy of the region in question and the basic steps involved in the surgical procedure, with modifications to account for the difference between living and donor tissue. The class moves to the anatomy laboratory, where the lead instructor reviews the relevant anatomy in a prosected specimen. Students, in groups of three or four, then perform the procedure on cadaveric donors using operating room‐quality surgical instruments and suture material (obtained by the senior authors). The lead surgeon and course co‐directors circulate among the student groups, providing guidance on dissection strategy and feedback on instrument handling and surgical technique. They also highlight anatomic relationships and discuss critical "missteps" in each surgical procedure. Each procedure was performed by every student, and these were done in groups of three or four. Students took turns leading the procedures within their small groups, such that for each procedure each student would have some time leading a portion of that procedure.</p> <p>The student‐to‐teacher ratio was kept low to encourage personal, informal instruction and to enable students to have their questions answered during the dissection. In January 2019, course enrollment was capped at 19 students across third and fourth years (7 females, 36.8% and 12 males, 63.2%), equivalent to roughly 7% of those eligible each year. At least six instructors were available during each session, including the lead surgeon, three to four assisting surgeons, and two anatomists. Five cadaveric donors were procured for the course under standard policies and procedures at Harvard Medical School. Thus, at least one instructor was always available to each of the five groups of three to four students, making it easy for students to ask questions.</p> <hd id="AN0148078706-4">DISCUSSION</hd> <p></p> <hd id="AN0148078706-5">Students' Perspective</hd> <p>The course provided an opportunity to learn anatomy through the lens of surgical exploration. Students did not simply memorize all of the structures; instead, they learned which of the structures were important, why they were important, and how they related to each other through frequent presentations to faculty and their classmates as they continued the procedure. In short, they learned how surgeons view anatomy.</p> <p>During each session, they practiced surgical procedures and techniques using operating room‐quality instruments, under the guidance of experienced surgeons and anatomists. They "operated" as if they were the attending surgeons for each case, carrying out carotid endarterectomies, performing pulmonary resections, and repairing trauma to the hand. At each step of the dissection, they thought about anatomy from a surgeon's perspective, asking themselves which important structures could be nearby and how they could avoid damaging these structures (e.g., by finding the proper tissue planes and avascular spaces). Their relative independence in the dissection laboratory helped them define anatomical relationships, and this self‐direction facilitated learning and retention of anatomical knowledge. However, experienced surgeons were always available to guide them in the right direction when they went astray. Furthermore, they received verbal feedback on their surgical technique in ways that improved their confidence for subsequent clinical rotations. For instance, students progressively performed better at suturing and knot‐tying as noted by faculty. Indeed, the students' experiences are in line with literature suggesting possible benefits of involving surgeon instructors, who make connections between anatomy and clinical scenarios (Seyfer et al., 2007; Ramsey‐Stewart et al., 2010; Böckers et al., 2014; Burgess and Ramsey‐Stewart, 2015).</p> <p>Unlimited access to the anatomy laboratory facilitated self‐directed learning. As students were given 24‐hour access to the laboratory, they were free to delve further into their specific interests. For example, with the permission of the instructors, a small group of students carried out an orthotopic liver transplant between two cadaveric donors one evening after class. Notably, the cadaveric procedure focused on ligating and re‐anastomosing the portal vein, hepatic artery, and hepatic veins to the inferior vena cava. Although the incision had to be widened to gain adequate exposure with the embalmed donors, the students were able to accomplish this procedure successfully.</p> <p>As they gained experience with surgical instruments and techniques, students were able to practice suturing blood vessels, developing pedicle flaps, anastomosing bowel, and repairing tendons. These techniques were practiced on the human cadavers but also on bovine hearts and porcine livers, under the supervision of surgeons. This environment of controlled failure allowed students to gain proper respect for tissues and provided unparalleled insight into the way an attending surgeon interacts with three‐dimensional anatomy during an operation. Perhaps most critically, they were able to make mistakes safely, without posing any risk to living patients.</p> <hd id="AN0148078706-6">Instructors' Perspective</hd> <p>An advanced clinical anatomy elective has been available for many years at Harvard Medical School. Surgeons were involved in this course, providing lectures on surgical procedures and the relevant anatomy. Dissections were performed with the anatomic faculty, but not always in the manner of a surgical procedure. In this recent iteration of the course offering, the involvement of the surgeons was expanded, taking them from the lecture hall into the anatomy laboratory to perform surgical procedures on the donor cadavers. The students were considered essentially residents or fellows who were expected to have studied the relevant anatomy prior to the laboratory experience, just as is expected of a surgical trainee in the operating room environment (Holland et al., 2011; Nutt et al., 2012; Hu et al., 2018). The hypothesis behind this course was that the anatomy would be studied for its vital importance in the safe completion of a surgical procedure. It was thought that when approached in this manner, the significance of the anatomic relationships would be appreciated by the students, and hence their retention of this knowledge would be enhanced (Böckers et al., 2014).</p> <p>While the anatomic learning was our primary goal, the secondary goal was instructing students in proper surgical technique for tissue dissection during their future careers in surgery. Principles were relevant whether their surgical careers were to be in general surgery, orthopedic surgery, neurosurgery, urology, gynecology, or otorhinolaryngology. While all of the current students have surgical careers planned, the instructors believed that an appreciation of proper surgical techniques could be of considerable value even for those not pursuing traditional surgical careers.</p> <p>Added benefits were the satisfaction and confidence for the students to actually perform the operative procedures themselves. At the end of sessions, the instructors often asked each surgical group to demonstrate their findings to other students, functioning as educators themselves, and making use of the known beneficial aspects of peer‐teaching (Nnodim, 1997; Dickman et al., 2017).</p> <p>This approach of basing learning around surgical procedures and disease appeared to be particularly appealing to the students. They were remarkably engaged in the course, and whether or not the procedure was in their selected specialty appeared to have no effect on their attention to the anatomy and the procedure. The instructors observed that the greater the dissection was centered around a particular surgical procedure, the more engaged were the students. The faculty found that students often remained after the scheduled hours of the course to pursue additional dissections or procedures on the donors. It was particularly gratifying to see the students work together as a surgical team, discovering anatomic relations, offering suggestions and encouragement to each other. The instructors learned to balance their offering of guidance while permitting a degree of autonomy typically not available until much later in students' surgical training. Indeed, these observations are in line with recent studies that suggest that a surgical approach to anatomic education may facilitate a favorable impression of surgery as a future career (Are et al., 2010; Carmichael et al., 2020).</p> <p>The limitations of the course were the availability of costly surgical instruments such as drills, saws, and microscopes, but instructors were able to have advanced arthroscopic equipment available for the dissections of the shoulder and the knee. Laparoscopic procedures offered challenges not only with respect to the substantial equipment costs involved, but also tissue character. Alternate embalming techniques such as fixation using non‐formaldehyde Surgical Reality Fluid™ (Trinity Fluids, LLC., Harsens Island, MI) of some of our donors offer the promise of more realistic tissue texture for the dissections. The instructors' goal was to continue to focus the sessions on the surgical procedures which they believe will offer the students the greatest anatomic education. Particular emphasis was placed on the anatomic variants which occur and will have considerable impact on the surgical procedures, such as a replaced right hepatic artery or a retroaortic left renal vein. Placed in the context of a surgical procedure, the critical importance of these anomalies was apparent to the student, and again retention of this knowledge was expected to be increased.</p> <hd id="AN0148078706-7">Limitations of the Study</hd> <p>This viewpoint commentary must be viewed in light of its limitations. First, the context in which the course is taught is unique to our institution. It is the authors' hope that other institutions with similar pedagogic practices and others in which a course similar to ours seems applicable may benefit from the present description. Second, the above analyses are based on the focus groups' interviews projecting subjective experiences of instructors and four selected students. The focus on students' perspectives may shed light on ways in which anatomical instruction can be further improved. Lastly, the study does not make use of formal and objective evaluation of the described elective's experiences. The viewpoint commentary may prove useful to readers in promoting similar surgical anatomy courses for undergraduate medical students at different institutions, and in encouraging future qualitative and quantitative studies of similar pedagogic efforts.</p> <hd id="AN0148078706-8">CONCLUSIONS</hd> <p>There continues to be room for growth in the way anatomy is taught to undergraduate medical students, especially for those interested in surgical careers. The course presented here demonstrates one avenue through which an advanced elective in anatomy can be taught: through the lens of surgical procedures conducted on cadaveric donors, as experienced by students and as taught by attending surgeons. Viewpoints of both students and surgical instructors suggest that this method—bringing surgical anatomic training to undergraduate medical students—galvanized student interest, encouraged teamwork, and facilitated retention of the material, thereby preparing strong foundational training for successful surgical careers. Further studies are required to quantitatively characterize the educational value of this approach. The authors hope that a surgical approach to anatomy will provide a means to further engage and prepare students for the care of patients.</p> <hd id="AN0148078706-9">ACKNOWLEDGMENTS</hd> <p>The authors thank those who made possible the many iterations of the advanced clinical anatomy course that have led to its current state as described in this letter. They recognize that decades of effort and evolution have shaped the course as it stands today. Many of the anatomists, surgeons, residents, and fellows who assisted in the original course remain integral parts of the Harvard Medical School community, as teachers, mentors, and drivers of education. Their wisdom and insight were crucial then as now in cultivating the way anatomy is taught to medical students of all levels. The authors are grateful to those who came before them, and are humbled by those on whose shoulders they stand.</p> <hd id="AN0148078706-10">NOTES ON CONTRIBUTORS</hd> <p>EDWARD CHRISTOPHER DEE, B.S., is a fourth‐year medical student at Harvard Medical School, Harvard University in Boston, Massachusetts. His research interest is in disparities in access and outcomes of oncologic care.</p> <p>ISAAC G. ALTY, M.D., is an intern in general surgery at the Brigham and Women's Hospital in Boston, Massachusetts. His interest is in global surgery and sociodemographic disparities in surgical care access.</p> <p>JAMES P. AGOLIA, A.B., is a fourth‐year medical student at Harvard Medical School, Harvard University in Boston, Massachusetts. His interest is in central nervous system tumor biology.</p> <p>CARLOS TORRES‐QUINONES, M.D., is an intern in internal medicine at the Legacy Emanuel/Good Samaritan Medical Center and an incoming resident in ophthalmology at the Health and Science University, both in Portland, Oregon. His interest is in ophthalmologic clinical research.</p> <p>TRUDY VAN HOUTEN, Ph.D., is an anatomist and lecturer of radiology at Harvard Medical School, Harvard University and Brigham and Women's Hospital in Boston, Massachusetts. She has extensive experience in anatomy education and she directed the foundational version of the elective Advanced Clinical Anatomy course. She is currently an instructor in this anatomy elective course.</p> <p>DANA A. STEARNS, M.D., is an assistant professor of emergency medicine at Harvard Medical School and Massachusetts General Hospital in Boston, Massachusetts. He is the director of anatomy education for the Pathways curriculum at Harvard Medical School. He co‐directs the elective Advanced Clinical Anatomy course.</p> <p>CRAIG W. LILLEHEI, M.D., is an associate professor of surgery at Boston Children's Hospital and Harvard Medical School in Boston, Massachusetts. He has a strong interest in undergraduate and graduate medical education and is the program director for the pediatric surgery fellowship at Boston Children's Hospital. He co‐directs the elective Advanced Clinical Anatomy course and his research interest is in pediatric transplant surgery and immunology.</p> <p>ROBERT C. SHAMBERGER, M.D., is the chief emeritus of the Department of Surgery at Boston Children's Hospital and the Robert E. Gross Professor of Surgery at Harvard Medical School in Boston, Massachusetts. He co‐directs the elective Advanced Clinical Anatomy course and his research interest is in pediatric solid tumors.</p> <ref id="AN0148078706-11"> <title> LITERATURE CITED </title> <blist> <bibl id="bib1" idref="ref1" type="bt">1</bibl> <bibtext> Are C, Stoddard HA, Northam LC, Thompson JS, Todd GL. 2009. An experience in surgical anatomy to provide first‐year medical students with an early exposure to general surgery: A pilot study. J Surg Educ 66 : 186 – 189.</bibtext> </blist> <blist> <bibl id="bib2" idref="ref2" type="bt">2</bibl> <bibtext> Are C, Stoddard HA, Thompson JS, Todd GL. 2010. The influence of surgical demonstrations during an anatomy course on the perceptions of first‐year medical students toward surgeons and a surgical career. J Surg Educ 67 : 320 – 324.</bibtext> </blist> <blist> <bibl id="bib3" idref="ref3" type="bt">3</bibl> <bibtext> Bergman EM, Van Der Vleuten CP, Scherpbier AJ. 2011. Why don't they know enough about anatomy? A narrative review. 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Learning surgically oriented anatomy in a student‐run extracurricular club: An education through recreation initiative. Anat Sci Educ 5 : 165 – 170.</bibtext> </blist> <blist> <bibtext> Waterston SW, Stewart IJ. 2005. Survey of clinicians' attitudes to the anatomical teaching and knowledge of medical students. Clin Anat 18 : 380 – 384.</bibtext> </blist> </ref> <aug> <p>By Edward Christopher Dee; Isaac G. Alty; James P. Agolia; Carlos Torres‐Quinones; Trudy Houten; Dana A. Stearns; Craig W. Lillehei and Robert C. Shamberger</p> <p>Reported by Author; Author; Author; Author; Author; Author; Author; Author</p> </aug>
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  Data: A Surgical View of Anatomy: Perspectives from Students and Instructors
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  Data: <searchLink fieldCode="AR" term="%22Dee%2C+Edward+Christopher%22">Dee, Edward Christopher</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0001-6119-0889">0000-0001-6119-0889</externalLink>)<br /><searchLink fieldCode="AR" term="%22Alty%2C+Isaac+G%2E%22">Alty, Isaac G.</searchLink><br /><searchLink fieldCode="AR" term="%22Agolia%2C+James+P%2E%22">Agolia, James P.</searchLink><br /><searchLink fieldCode="AR" term="%22Torres-Quinones%2C+Carlos%22">Torres-Quinones, Carlos</searchLink><br /><searchLink fieldCode="AR" term="%22van+Houten%2C+Trudy%22">van Houten, Trudy</searchLink><br /><searchLink fieldCode="AR" term="%22Stearns%2C+Dana+A%2E%22">Stearns, Dana A.</searchLink><br /><searchLink fieldCode="AR" term="%22Lillehei%2C+Craig+W%2E%22">Lillehei, Craig W.</searchLink><br /><searchLink fieldCode="AR" term="%22Shamberger%2C+Robert+C%2E%22">Shamberger, Robert C.</searchLink>
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  Data: <searchLink fieldCode="SO" term="%22Anatomical+Sciences+Education%22"><i>Anatomical Sciences Education</i></searchLink>. Jan-Feb 2021 14(1):110-116.
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  Data: Wiley. Available from: John Wiley & Sons, Inc. 111 River Street, Hoboken, NJ 07030. Tel: 800-835-6770; e-mail: cs-journals@wiley.com; Web site: https://www.wiley.com/en-us
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  Data: <searchLink fieldCode="DE" term="%22Anatomy%22">Anatomy</searchLink><br /><searchLink fieldCode="DE" term="%22Medical+Education%22">Medical Education</searchLink><br /><searchLink fieldCode="DE" term="%22Medical+Students%22">Medical Students</searchLink><br /><searchLink fieldCode="DE" term="%22College+Faculty%22">College Faculty</searchLink><br /><searchLink fieldCode="DE" term="%22Student+Attitudes%22">Student Attitudes</searchLink><br /><searchLink fieldCode="DE" term="%22Teacher+Attitudes%22">Teacher Attitudes</searchLink><br /><searchLink fieldCode="DE" term="%22Human+Body%22">Human Body</searchLink><br /><searchLink fieldCode="DE" term="%22Donors%22">Donors</searchLink><br /><searchLink fieldCode="DE" term="%22Teaching+Methods%22">Teaching Methods</searchLink>
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  Data: 10.1002/ase.1988
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  Data: 1935-9772
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  Data: As curricular emphasis on anatomy in undergraduate medical education continues to evolve, new approaches to anatomical education are urgently needed to prepare medical students for residency. A surgical anatomy class was designed for third- and fourth-year medical students to explore important anatomical relationships by performing realistic surgical procedures on anatomical donors. Under the guidance of both surgeons and anatomists, students in this month-long elective course explored key anatomical relationships through performing surgical approaches, with the secondary benefit of practicing basic surgical techniques. Procedures, such as left nephrectomy, first rib resection for thoracic outlet syndrome, and carotid endarterectomy, were adapted from those used clinically by multiple surgical subspecialties. This viewpoint commentary highlights perspectives from students and instructors that suggest the value of a surgical approach to anatomical education for medical students preparing for procedure-oriented residencies, with the goals of: (1) describing the elective at the authors' institution, (2) promoting similar efforts across different institutions, and (3) encouraging future qualitative and quantitative studies of similar pedagogic efforts.
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