RESEARCH REPORT

Anatomical Knowledge Retention in Third-Year Medical Students Prior to Obstetrics and Gynecology and Surgery Rotations Rosalyn A. Jurjus,1* Juliet Lee,2 Samantha Ahle,1 Kirsten M. Brown,1 Gisela Butera,3 Ellen F. Goldman,4 Jill M. Krapf5 1 Department of Anatomy and Regenerative Biology, School of Medicine and Health Sciences, The George Washington University, Washington, D.C. 2 Department of Surgery, School of Medicine and Health Sciences, The George Washington University, Washington, D.C. 3 Himmelfarb Health Sciences Library, School of Medicine and Health Sciences, The George Washington University, Washington, D.C. 4 Department of Human and Organizational Learning, Graduate School of Education and Human Development, The George Washington University, Washington, D.C. 5 Department of Obstetrics and Gynecology, School of Medicine and Health Sciences, The George Washington University, Washington, D.C.

Surgical anatomy is taught early in medical school training. The literature shows that many physicians, especially surgical specialists, think that anatomical knowledge of medical students is inadequate and nesting of anatomical sciences later in the clinical curriculum may be necessary. Quantitative data concerning this perception of an anatomical knowledge deficit are lacking, as are specifics as to what content should be reinforced. This study identifies baseline areas of strength and weakness in the surgical anatomy knowledge of medical students entering surgical rotations. Third-year medical students completed a 20–25question test at the beginning of the General Surgery and Obstetrics and Gynecology rotations. Knowledge of inguinal anatomy (45.3%), orientation in abdominal cavity (38.8%), colon (27.7%), and esophageal varices (12.8%) was poor. The numbers in parentheses are the percentage of questions answered correctly per topic. In comparing those scores to matched test items from this cohort as first-year students in the anatomy course, the drop in retention overall was very significant (P 5 0.009) from 86.9 to 51.5%. Students also scored lower in questions relating to pelvic organs (46.7%), urogenital development (54.0%), pulmonary development (17.8%), and pregnancy (17.8%). These data showed that indeed, knowledge of surgical anatomy is poor for medical students entering surgical clerkships. These data collected will be utilized to create interactive learning modules, aimed at improving clinically relevant anatomical knowledge retention. These modules, which will be available to students during their inpatient surgical rotations, connect basic anatomy principles to clinical cases, with the ultimate goal of closing the anatomical knowledge gap. C 2014 American Association of Anatomists. Anat Sci Educ 7: 461–468. V

Key words: gross anatomy education; medical education; clinical clerkships; obstetrics and gynecology rotations; pelvic anatomy; knowledge retention

*Correspondence to: Dr. Rosalyn A. Jurjus; Department of Anatomy and Regenerative Biology, The George Washington University School of Medicine and Health Sciences, 461B Ross Hall, 2300 I Street, NW, Washington, DC 20037. E-mail: [email protected] Grant sponsor: GW Office of the Vice Provost for Teaching and Learning (Spring 2013 Grants for High Impact Teaching and Learning Practices; awarded to Dr. R.A. Jurjus)

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Received 19 September 2013; Revised 21 December 2013; Accepted 7 February 2013. Published online 3 March 2014 in Wiley (wileyonlinelibrary.com). DOI 10.1002/ase.1441

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Anat Sci Educ 7:461–468 (2014)

INTRODUCTION Medical students learn the bulk of anatomical sciences either at the beginning of the first year or throughout the first 2 years of their medical education. However, practical applications do not take place usually until clinical exposure, which may be months or years later, making knowledge retention an issue of concern. Opinions of poor retention of anatomical knowledge have been reported in the literature (Prince et al., 2005; Zumwalt et al., 2010). The majority of clinicians feel that the current anatomical education of medical students is inadequate and below the minimum necessary for safe medical practice (Waterston and Stewart, 2005). Surgical specialists have a significantly lower opinion of the anatomical knowledge of medical students compared to medical specialists (Staskiewicz et al., 2007). Students also acknowledge the retention problem. In a 3-year cohort study conducted at the University of Birmingham, only 14% of final-year students felt confident in their knowledge of anatomy (Bhangu et al., 2010). A more recent study conducted at Penn State College of Medicine supports the notion that anatomical knowledge transfer from the classroom to the clinic is perceived as a difficult task by the students (Lazarus et al., 2012). Despite opinions of both faculty and students regarding the lack of anatomical knowledge retention, no studies have been conducted to assess the actual knowledge content gap of third-year medical students prior to entering the surgical clerkships. The literature does, however, suggest means of addressing this problem. There is widespread support among clinicians and students for more vertical integration of anatomy teaching throughout the undergraduate curriculum (Waterston and Stewart, 2005; Bhangu et al., 2010). One promising model is in place at The Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, where anatomy review sessions were introduced during the clinical third year using prosected cadavers in two half-day sessions (Drake, 2007). This approach is referred to as nesting (Goldman and Schroth, 2012). However, a nesting strategy such as this is somewhat general and does not target the specific needs of various specialties at the beginning of each rotation. It also has the limitation of not incorporating a variety of instructional approaches and methods to appeal to different styles of learning. In order for a nesting approach to cater to the needs of medical students, faculty first needs to assess the specific knowledge gaps. Observations of a general anatomical knowledge gap among third-year medical students are similar at the authors’ institution to those reported in the literature: Gaps are perceived but have not yet been quantified or specified. The hypothesis was that anatomical knowledge retention declines in third-year students by the time they start the General Surgery and Obstetrics and Gynecology (OB/GYN) rotations. At present, the curriculum at the institution is being revised to integrate science and clinical knowledge and adopt active learning approaches. An important step in this integration is identifying exactly what is and what is not being retained before blindly repeating or nesting such content. The purpose of this study was to assess anatomical knowledge retention of medical students prior to General Surgery and OB/GYN third-year rotations.

study (IRB # 061208). Participation was voluntary for consenting students.

Design of the Study This is a study conducted to evaluate medical students’ anatomical knowledge retention. Demographics of the participants are displayed in Table 1. Participants were third-year medical students at The George Washington University Medical School that were enrolled in the anatomy course when they were first-year medical students. The anatomy course then consisted of topics in gross anatomy and embryology, extended over 17 weeks, and was divided into three blocks, corresponding to different regions of the body: (1) upper and lower limbs, thorax, and abdomen, (2) head and neck, and (3) pelvis and perineum. In total, the course consists of 52 lecture hours (embryology and gross anatomy), 9-team-based learning hours (a 3-hour session at the end of each 1/3 of the course), and 58 laboratory hours (gross anatomy only involving cadaveric dissection). At the end of each third of the course, the students have both a written and a practical examination. At the end of the course, the students took the National Board of Medical ExaminersV (NBMEV) anatomy and embryology subject examination as well. An assessment of basic anatomy knowledge was administered to medical students in their third year of training. Students were divided into six groups and rotate through the various required rotations every two months at various times during that year. General Surgery and OB/GYN are two required rotations for all students. The number of students (N) in each group that contributed to the study per rotation is detailed in Figures 1 and 2. Students completed a 20question test during the first week of their 8-week OB/GYN clerkship and a separate 25 question test during the first week of their 8-week General Surgery clerkship. One hundred and eighty students completed the test for general surgery and 174 students completed the test for OB/GYN (95 and 92% of the total class, respectively). The interval from formal anatomical instruction until evaluation at the start of either the General Surgery or the OB/GYN clerkships ranged R

R

Table 1. Demographic Data

Students demographics

N (%)

Total number of students

189

Gender Female

100 (53%)

Male

89 (47%)

Age distribution

METHODS

>30

Ethical Approval

25–30

107 (57%)

This project was approved by the Institutional Review Board (IRB) at The George Washington University, as an exempt

21–24

72 (38%)

462

10 (5%)

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Figure 1. Mean Test Scores on the Surgery Pretest by Rotation: Student performance and anatomical knowledge is on average very similar from one group to another, independent of timing of the rotation in the academic year. The data above represent the means and standard deviation of surgery pretest scores based on the time during the third year in which the students rotated in Surgery. The error bars are the respective standard deviations. Mean rotation scores for the General Surgery rotation were very similar for each rotation, ranging from 62.1 6 2.4 to 70.6 6 2.2 (Mean 6 SD), with an overall rotation score of 66.98%. A one-way ANOVA with post hoc tests shows a statistically significant (P < 0.001) drop in the scores from the first to the second rotation with no differences seen between the rotations thereafter, except for a drop in scores again during rotation 4. No statistically significant difference in the mean scores between the first and sixth rotation (P > 0.05). N 5 number of students that participated in each rotation.

Figure 2. Mean Test Score on the OB/GYN Pretest by Rotation Number: Student performance and anatomical knowledge is on average very similar from one group to another, independent of timing of the rotation in the academic year. The data above represents the means and standard deviation of OB/GYN pretest scores based on the time during the third year in which the students rotated in OB/GYN. The error bars are the respective standard deviations. Mean rotation scores for the OB/GYN rotation were very similar for each rotation, ranging from 62 6 2.1 to 69.7 6 2.8 (Mean 6 SD), with an overall rotation score of 64.4%. A one-way ANOVA with posttest shows a statistically significant improvement in the scores for the fourth rotation (P < 0.001), but with no other significant differences seen between the other rotations from the beginning to the end of the academic year (P > 0.05). N 5 number of students that participated in each rotation.

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Table 2. Percentage of Questions Answered Correctly on the Surgery PreTest and Compared to Matched Questions from the Anatomy Course by Anatomic Category: Specific Areas of Anatomical Knowledge Gaps and Decrease Retention were Identified Students prior to surgery rotation

Students in anatomy course Number of test items

Correct (%)

Number of test items

Correct (%)

Inguinal canal

1 MCQ

95.7

2 MCQs

45.3

50.4

Esophageal varices

1 MCQ

71.9

1 MCQ

12.8

59.1

Vasculature

5 MCQs

93.2

4 MCQs

53.4

39.8

Orientation in abdominal cavity

3 MCQs

92.9

2 MCQs

38.8

54.1

Appendix

2 MCQs

82.4

3 MCQs

86.1

23.7

Colon

1 MCQ

83.2

1 MCQ

27.7

55.5

Lymphatic drainage

1 MCQ

98.8

1 MCQ

97.2

1.6

Vertebral landmark

1 MCQ

77.8

1 MCQ

50.3

27.5

N/A

N/A

2 images 5 lables/image

89.1

Compilation by broad category

Cross Section on CT

Mean of matched items

86.9

51.5

6SD

69.4

628.1

Number of students

185

180

Drop in retention (%)

35.4%

MCQ, Multiple choice questions.

18–30 months. Students were not informed in advance of the test to prevent preparation and a possible bias of results and were asked to keep the information about the tests confidential from classmates coming in later in the rotations. Data were analyzed by rotation group, so no students could be individually identified. The deidentified data were collected over an entire academic year. Anatomy faculty collaborated with surgical specialty faculty to choose the questions from a 100-question pool utilized in assessment of anatomy knowledge from the gross anatomy basic science curriculum. The examinations consisted of approximately 15–20 board-style multiple choice questions and 5–10 image labeling questions, designed to target anatomy recall (Custers, 2010). The topics covered in the examinations are shown in Tables 1 and 2. Each administration of the test was followed by discussion with the students regarding the correct responses. Test items reliability (point biserial) and overall test reliability (Kuder–Richardson Formula) were calculated at each time by the grading software Remark Classic OMRV, version 4.0 (Gravic Inc., Malvern, PA). Tests were scored, and percentages of correctly answered questions were tabulated by anatomical category. Questions from this cohort of students’ exam as first-year medical students was retrospectively grouped into matching categories and retention difference between the two time points was calculated. Questions were either identical or testing the same material that are known to be equally difficult. The drop in R

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retention is the difference over time in the percentage correct answers.

Statistics Tests were corrected and analyzed using the grading software Remark Classic OMRV. For each item Remark Quick Stats calculates: mean, variance, standard deviation, standard error, min, max, range, median, skewness, kurtosis, t-value, percentiles, confidence intervals, P-values, and point biserial correlation. For each answer choice Remark Quick Stats calculates: frequencies, percentages, and point biserial. For each student Remark Quick Stats calculates: total score, raw score, grade, deviation, IQ, number correct, incorrect, and unanswered questions. For the test Remark Office OMR calculates: number of graded tests and items, max, min, median, range, percentile scores, mean, variance, standard deviation, confidence intervals (1, 5, 95, 99%), KR 20, KR21, coefficient (Cronbach) alpha. Pooled data were subject to statistical analyses using InStat software (Graphpad Software, Inc., San Diego, CA). Unless otherwise indicated, the differences between rotation groups were determined by two-tailed unpaired t-tests or an ANOVA (Univariate Analysis of Variance). Statistical significance was set at P  0.05 for the t-tests and P  0.001 for the ANOVAs. Bar graphs were generated using means and standard error of the mean. R

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Table 3. Percentage of Questions Answered Correctly on the OB/GYN Pre-Test and Compared to Matched Questions from the Anatomy Course by Anatomic Category: Specific Areas of Anatomical Knowledge Gaps and Decrease Retention were Identified Students in anatomy course

Students prior to OB/GYN rotation

Number of test items

Correct (%)

Number of test items

Correct (%)

Drop in retention (%)

Pelvic organs

6 MCQs

72.6

6 MCQs

46.7

25.9

Pelvic ligaments and landmarks

3 MCQs

86.0

3 MCQs

78.1

7.9

Location of fertilization

1 MCQ

96.8

1 MCQ

71.8

25.0

Urogenital development

2 MCQs

93.5

1 MCQ

54.0

39.5

Cardiac development

2 MCQs

99.5

1 MCQ

72.6

26.9

Pulmonary development

1 MCQ

100.0

1 MCQ

17.8

82.2

Pregnancy

1 MCQ

93.0

1 MCQ

17.8

75.2

Pelvic bone X-ray

N/A

N/A

1 image 5 labels/image

84.0

Structure identification of perineal image

N/A

N/A

1 image 5 labels/image

73.2

Compilation by broad category

Mean of matched items

91.6

51.2

6SD

69.6

625.3

Number of students

185

174

40.4

MCQ, Multiple choice questions.

RESULTS Anatomical Knowledge Retention for General Surgery Scores for specific anatomy categories related to General Surgery are presented in Table 2. Ninety-seven percent of the students correctly answered questions of lymphatic drainage. Similarly, 89.1% of students were able to identify cross sections of anatomical structures on Computed tomography scans. Eighty-six percent of students correctly answered questions on the appendix. Slightly lower scores were seen with questions on the vasculature (53.4%) and lumbar vertebral landmarks (50.3%). An even lower percentage of questions were correctly answered for inguinal (45.3%), orientation in abdominal cavity (38.8%), colon (27.7%), and esophageal varices (12.8%). In comparing those scores to matched test items from this cohort as first-year students in the anatomy course, the drop in retention overall was from 86.9 to 51.5%, very significant (P 5 0.009 by unpaired t-test with Welch Correction). Item analysis per topic revealed above 50% retention drop in knowledge of the inguinal canal, esophageal varices, colon, and orientation in the abdominal cavity. Lower scores on specific topics reflected a lower retention rate for those topics. As shown in Figure 1, mean scores for the General Surgery Anatomical Sciences Education

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rotation were very similar, ranging from 62.1 6 2.4 to 70.6 6 2.2 (mean 6 SD), with an overall score of 66.98% for students. A one-way ANOVA with posttest shows a statistically significant drop (P < 0.001) in the scores from the first to the second rotation with no differences seen between the rotations thereafter, except for a drop in scores again during rotation 4. No statistically significant difference in the mean scores between the first and sixth or last rotation (P > 0.05) is noted (Fig. 1). Completing a prior surgical rotation, such as OB/GYN, did not improve anatomy knowledge in the General Surgery rotation compared to no reported surgical experience in the first three rotations. At the beginning of the surgery rotation, the group of students who rotated through OB/GYN previously scored 68.1 6 12 (mean scores 6 SD). The group of students that did not rotate through OB/GYN previously scored 64.25 6 11.3 (mean scores 6 SD). Based on data from rotation groups 1–3 only, no major statistical difference was found (P 5 0.25).

Anatomical Knowledge Retention for OB/GYN Scores for specific anatomy categories related to OB/GYN are presented in Table 3. Students obtained 84% correct for 465

identification of radiologic anatomy. Knowledge of pelvic ligaments and landmarks (78.1%) and cardiac development (72.6%) were areas of strength. Students correctly answered at 71.8% the question on location of fertilization in the Fallopian tubes. Correct answers were lower for questions related to pelvic organs (46.7%), urogenital development (54.0%), pulmonary development (17.8%), and pregnancy (17.8%). In comparing those scores to matched test items from this cohort as first-year students in the anatomy course, the drop in retention overall was from 91.6 to 51.2%, very significant (P 5 0.0056 by unpaired t-test with Welch Correction). Item analysis per topic revealed above 25% retention drop in knowledge in most areas except pelvic ligaments and landmarks. Lower scores on specific topics reflected a lower retention rate for those topics. As shown in Figure 2, mean rotation scores or mean scores for the OB/GYN rotation were very similar for each rotation, ranging from 62 6 2.1 to 69.7 6 2.8 (Mean 6 SD), with an overall average score of 64.4%. A one-way ANOVA with posttest shows a statistically significant improvement in the scores for the fourth rotation (P < 0.001) but with no other significant differences seen between the other rotations from the beginning to the end of the academic year. No statistically significant difference is seen in the mean scores between the first and sixth or last rotation (P > 0.05) (Fig. 2). Experience on a surgical rotation, such as General Surgery, did not improve OB/GYN-related anatomy knowledge in the first three rotations. At the beginning of the OB/GYN rotation, the group of students who rotated through Surgery previously scored 65.4 6 15 (mean scores 6 SD). The group of students that did not rotate through Surgery previously scored 67.8 6 14 (mean scores 6 SD). Based on data from rotation groups 1–3 only, no major statistical difference was found (P 5 0.63).

DISCUSSION A strong basic science, and specifically anatomical science, knowledge base is critical for students as they approach clinical decision making and surgical procedures. Unfortunately, retention of this critical knowledge may be compromised as students enter the clinical years in various disciplines as shown by several NBME staff retention studies (Ling et al., 2008). Our study uniquely focuses on the anatomical sciences knowledge and points to the areas, where the knowledge retention gap exists and, therefore, need to be addressed. Overall anatomical knowledge retention scores were similar prior to both General Surgery and OB/GYN rotations at approximately 50% for a retention interval ranging from 18 to 30 months. This is lower than the percentage retention for anatomical disciplines reported in the literature, which ranged from 75 to 83% for similar retention intervals (Blunt and Blizard, 1975; Kennedy et al., 1981; Custers, 2010). Unlike these previous studies that relied solely on USMLE scores, this study examined retention in specific anatomical categories at various time points during the third year and demonstrates that anatomical knowledge retention declines in third-year students by the time they start the General Surgery and OB/GYN rotations. Data also show that this is not a knowledge acquisition issue but rather a retention problem. On those similar topics relevant to general surgery and OB/GYN, students had scored 86.9 and 91.6% during the first-year anatomy course. 466

The drop in retention is about 50% in both areas by the time they reach third year. A large proportion of students were unable to recall concepts introduced in the basic science curriculum, which are crucial to clinical practice and procedure in General Surgery. With the move toward minimally invasive and laparoscopic surgeries within limited areas, a solid knowledge of anatomical details and relationships is growing in importance (Pawlina and Lachman, 2004). As inguinal hernia is the most common general surgical procedure in United States, third-year students should expect to be exposed to inguinal anatomy during the surgery clerkship. Similarly, students should anticipate that review of pelvic organ anatomy is essential to the preparation for the OB/GYN clerkship. However, students were able to answer less than 50% of questions concerning these anatomically critical areas correctly (inguinal canal, 45.3% and pelvic organs, 46.7%). In contrast, students’ retention of cross sectional, radiological anatomy, and labeling images was high. This may reflect transfer of learning from the gross anatomy course during the first year of training, which emphasized cross-sectional radiology as well as the preference for visualization by the learners in understanding the anatomical relationships (Wilhelmsson et al., 2011). A topic like the appendix, however, improved over time which probably correlates with the recurrence of this common topic in the medical curricula. These last two points suggest that although retention seems to be lost over time, some visualizations and contextualizing approaches seem to be retained (Wilhelmsson et al., 2010). However, these are not sufficient and more in depth knowledge is needed for surgical anatomical details (Ilgenfritz et al., 1990; Pawlina and Lachman, 2004). It is important to recognize that completing a surgical rotation, such as OB/GYN, did not improve performance on later rotations, such as General Surgery, or vice versa. Although specific surgical procedures and related anatomical anatomy may be different, the emphasis on identifying and comprehending relevant anatomy is required for all surgical fields. Having more clinical experience also did not improve anatomical knowledge retention, as students who had surgical rotations later in the clinical academic year did not perform better on the pretest than students, who had a surgical rotations earlier. Anatomical knowledge is ultimately regained but not well retained by students over the clerkship as they study independently and spend time with surgeons in the operating room (Ilgenfritz et al., 1990). A way to insure proper retention is by reinforcement and repetition, moving away from surface approaches to learning like memorization to deeper approaches like actively searching for meaning and correlation (Eizenberg, 1988; Ilgenfritz et al., 1990; Pandey and Zimitat, 2007). Knowledge of the basic sciences, and more specifically, the anatomical sciences, and its retention, does not depend on the type of curricula a school has for the first 2 years of medical education (Prince et al., 2003; Nouns et al., 2012; Cuddy et al., 2013). Repetition and reinforcement are suggested to improve recall and retention of important material (Feigin et al., 2007). Advanced courses should start with a review of the knowledge covered in preceding courses (Custers, 2010). The knowledge should be linked to a context, or a structured clinical case, to become a part of the experience of the learner (Bowen, 2006). This might also play an important role in improving clinical and diagnostic reasoning of the medical students at an early stage in their training. By correlating medical reasoning involving basic science experience Jurjus et al.

and structured clinical cases from the start, it may be possible to ease the transition to the clerkships where they will encounter unstructured clinical cases in nonclassroom settings (van Gessel et al., 2003).

Strengths This study did not suffer from any selection bias as 92–95% of the students in the class choose to participate. This study has assisted medical educators and medical students at our institution in understanding the anatomical knowledge gap. Longitudinal integration of anatomical modules across the curriculum should improve the anatomical knowledge of medical students entering surgical rotations. The first step in nesting the anatomical sciences into the clinical years started by administering this test to students at the beginning of the surgical rotations. By completing the MCQ test and then discussing the answers in teams, the students retrieve “the active, cue driven process of reconstructing knowledge” that has been shown to produce greater gains in meaningful learning than more elaborate ways of study (Karpicke and Blunt, 2011).

In conclusion, the first step in nesting the anatomical sciences into the third-year curriculum revealed that knowledge of surgical anatomy is varied for medical students entering surgical clerkships. This study helped medical educators and medical students to understand the potential gap in anatomical knowledge that has been reported at this institution. In addition, it provided an effective means to address anatomical knowledge gaps in the clinical years. This research will also have wide-spread implications for medical school curriculum change, with data potentially informing decisions about basic science nesting in the clinical rotations.

ACKNOWLEDGMENTS The authors acknowledge the generous support of the George Washington University Himmelfarb Library staff and the students who completed the tests. The authors thank as well Dr. Yolanda Haywood, Assistant Dean for Curricular and Student Affairs and Associate Professor, Emergency Medicine at GW SMHS for her continuous support of this project.

NOTES ON CONTRIBUTORS

Limitations The test questions were limited in number and may not have covered all topics. However, a larger number of questions might have significantly decreased the high rate of student participation. The test results might not be comparable across years and different populations of students. Additionally, the findings may have limited generalizability to other institutions for areas of potential anatomical strengths and weaknesses because of differences in student populations. Nevertheless, the concept of decrease in anatomical retention should be applicable everywhere and the results of this study provide a proof of concept.

Future Directions As these results may not be comparable to other institutions, the next step is to conduct a similar study at other locations to further validate these findings on a wider scale. Additionally, the investigators aim to utilize this needs analysis to create clinically relevant interactive anatomical modules highlighting topics essential to surgical clerkships. Using principles of adult learning and instructional design (Knowles, 1984; Kaufman, 2003; Jurjus et al., 2013), we built two educational models of nested modules: (1) E-modules highlighting clinically relevant anatomical topics where we identified gaps, including an assessment of baseline knowledge, an interactive learning session, and postactivity evaluations. (2) Hands-on gross lab sessions reflecting the content of the emodules, with model building and practice of clinical techniques to reemphasize surgical anatomical concept and to further solidify basic anatomy retention (Ilgenfritz et al., 1990; Rao and Rao, 2009). We are currently evaluating their effectiveness at our institution These modules will be nested in the General Surgery and OB/GYN curriculum in an effort to close the anatomic knowledge gap through linkage of previous basic science exposure and new clinical applications. They will require active integration and collaboration between surgeons and anatomists (Johnson et al., 2012).

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ROSALYN A. JURJUS, M.D., Ph.D., is an assistant professor in the Department of Anatomy and Regenerative Biology at the George Washington University School of Medicine and Health Sciences, Washington, DC. She teaches the anatomical disciplines, gross anatomy, embryology and microscopic anatomy to first-year medical students and other graduate and undergraduate students. SMANATHA AHLE, B.S., is a fourth-year medical student at the George Washington University School of Medicine and Health Sciences, Washington, DC. She plans to pursue her residency in general surgery. JULIET LEE, M.D., is an assistant professor in the Department of Surgery at the George Washington University School of Medicine and Health Sciences, Washington, DC. She is the Division Director for Surgical Education and the Associate Program Director for the Surgery Residency in the Department of Surgery. She is also a practicing surgeon, working regularly with medical students on clinical rotations. KIRSTEN M. BROWN, Ph.D., is an assistant professor in the Department of Anatomy and Regenerative Biology at the George Washington University School of Medicine and Health Sciences, Washington, DC. She teaches the anatomical disciplines, gross anatomy, and neuroanatomy to first-year medical students and other graduate and undergraduate students. GISELA BUTERA, M.L.I.S., is a reference instructional librarian at Himmelfarb Health Sciences Library, the George Washington University School of Medicine and Health Sciences, Washington, DC. She teaches practice of medicine, problem based-cased learning, and medical informatics to firstyear medical students. ELLEN F. GOLDMAN, Ed.D., is an associate professor in the Department of Human and Organizational Learning, Graduate School of Education and Human Development at George Washington University, Washington, DC. She is also the Director of the Master Teacher Leadership Development Program for the George Washington University School of Medicine and Health Sciences.

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Jurjus et al.

Anatomical knowledge retention in third-year medical students prior to obstetrics and gynecology and surgery rotations.

Surgical anatomy is taught early in medical school training. The literature shows that many physicians, especially surgical specialists, think that an...
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