834
MEDICAL EDUCATION
Anatomy and the medical school curriculum
"The students’ knowledge of anatomy is lamentable." I cannot ignore this remark because I hear an increasing number of clinicians in Britain say it. Everyone has a view on anatomy teaching. Specialists and surgeons say that students do not know enough specialist and surgical anatomy; some physicians say there is not enough surface and radiological anatomy; and many clinicians feel that students are taught too much irrelevant neuroanatomy. What has happened? I write with some detachment from Ireland, as a medically qualified general anatomist rather than a specialist, and as one who tries to ensure that his course is well taught and appropriate to the needs of the consumer. Anatomy acquired a bad name in the earlier part of this century: courses were inordinately long, and the subject had to be learned in detail irrelevant to clinical practice. Consequently, although a beneficial intellectual discipline was inculcated into some students, most were turned off for life. In the 1960s and 1970s, the duration of anatomy courses was cut drastically, partly as a reaction to the former intransigence and partly as a result of the introduction of other subjects to the undergraduate curriculum. Unfortunately-and this is one of the most pertinent points-this pruning was often done without an accompanying reorientation to ensure that essential components continued to be taught. Thus all aspects of anatomy were pruned, irrespective of vocational relevance. It is not usually the case that there is insufficient time available for anatomy, it is that the time may not always be appropriately spent. The wrong anatomy is being taught. Who will decide what is important? A report1 published earlier this year provides a snapshot survey of anatomy teaching in Great Britain and Ireland in 1990-91. It gives details and comparisons of measurable features of courses such as duration, staff/student ratios, dissection vs prosection, educational technology, &c. Nevertheless, in terms of the approaches that ought to be adopted-what I call the sort of anatomy that we should teach and the identification of essential vocationally relevant anatomy-the report is curiously silent. What are It does
our
aims?
not matter
how many hours
are
spent
on
the
course, or what educational technology is available, or what ratios are, if students are still expected to the
staff/student
learn anatomy that is largely irrelevant to clinical practice. I believe undergraduate anatomy teaching should be aimed at those disciplines for which postgraduate training does not include anatomy teaching-eg, physicians and general practitioners. These doctors will not formally study anatomy again, and for them the basis provided by undergraduate anatomy courses needs to be relevant and secure. (In the UK, The Royal College of Psychiatrists includes a substantial amount of clinical anatomy in its postgraduate examinations.) Most physicians and general practitioners acknowledge the anatomical basis of diagnosis
and can see how important it is that the right sort of anatomy be taught from the beginning. Anatomy teachers must therefore identify the essential core of anatomy that students should know. We cannot continue to allow medical students to pass undergraduate anatomy examinations knowing useless facts about the chorda tympani and its embryology, but being unable to link tenderness in the anatomical snuff box to a scaphoid injury. If students are not competent in surface anatomy and living anatomy, I do not see any grounds for the vocational necessity for medical students to study any anatomy. No amount of enthusiasm for
videotapes
or
computer-assisted learning technology
make up for deficiencies in these
can
areas.
Anatomy and clinical skills teaching The teaching of clinical skills begins in the dissection room and grows naturally out of surface and living anatomy. In the medical school from which I write, basic clinical skills
(stethoscope, abdominal palpation, peripheral pulses, testing of ligaments, muscle groups, nerves, reflexes, &c) are examined as part of the Second MB equivalent by anatomists and clinicians. There is still opportunity for students to gain high marks by displaying all they know about pretrematic branches of branchial arch nerves or the nucleus accumbens. However, our efforts at teaching clinical anatomy are greatly appreciated by physicians especially, and our contributions to clinical teaching and examination are enthusiastically sought. Who should decide what we teach?
Although there is much to be said for asking the users of "products" for their views, most clinical professors are not known for their interest in undergraduate anatomy courses and so anatomy teachers are left to bring their own perspectives to the task. Such perspectives will vary according to training and background—eg, the views of a medically qualified teacher will differ from those of a non-medically qualified teacher. Both approaches are valid and both are educationally desirable, but in terms of course supervision and the identification of vocational requirements of anatomy courses, medically qualified staff have an advantage. So why are there more and more medical schools without permanent anatomy staff who are medically qualified? This is already the case in the UK, and in the USA it is extremely rare for medically qualified personnel to teach topographical anatomy. Courses thus become unbalanced. They are rich in mitochondria but starved of meat: the structure of the body is often dealt with in one semester. How can students undertaking such courses ever gain an understanding of enough topographical anatomy to underpin their clinical studies? our
ADDRESS Department of Anatomy, Royal College of Surgeons in Ireland, St Stephen’s Green, Dublin 2, Ireland (Prof W S Monkhouse, MB, PhD)
835
Recruitment
of
It is not so much that non-medical staff have been recruited into anatomy departments over the past twenty years but that, in many institutions, medical graduates have been positively discriminated against by indiscriminate paper counting and other doubtful criteria. Most nonmedical anatomists simply cannot bring a clinical perspective to their anatomy teaching. I do not believe this is an argument for dispensing with non-medically qualified staff, but it is an argument for peaceful cohabitation-ie, for action to maintain the presence of some medically qualified anatomists and, if necessary, for action to reintroduce them.
influence in this respect on university senates and selection boards. Or is it, perhaps, that clinical professors do not care either? The appointment in at least two UK medical schools (Cambridge and University College, London) of highranking directors of anatomy teaching in addition to the head of department tells us much about the changed role of the head of department. None of these issues is new. The anatomical societies in the British Isles (British Association of Clinical Anatomists, Anatomical Society of Great Britain and Ireland) remain silent, apparently uninterested. Yet ever more clinicians express their dismay and displeasure with the students that come their way. Perhaps more anatomy departments will disappear and clinical anatomy teaching will be shared by
When should we teach
anatomy? In view of the vocational importance of essential anatomy, it seems logical that the subject should be taught, at least partly, alongside clinical training. Thus, students of cardiology will be instructed in clinical anatomy of the heart and vasculature, and students of neurology will be taught clinical neuroanatomy, and so on. Very few anatomy departments are invited to participate in this way. There are obvious difficulties with such schemes-geographically separated science and hospital campuses, lack of suitable or willing personnel, and lack of resources. Moreover, bearing in mind the financial restrictions and work loads, it is simply not practicable for this to be the only way in which anatomy is taught. I favour a well-directed and clinically oriented ’anatomy course early in the medical training, with relevant clinical sessions subsequently for refreshment and reinforcement. In my experience, if the early course is sufficiently directed and applied, later teaching of clinical anatomy can be extremely effective. In my department we teach clinical students for four hours in obstetrics and
gynaecology (implantation, fetal membranes, pelvic and anatomy, congenital anomalies), three in otorhinolaryngology (including brainstem), one for the chest, one for the abdomen, one for the limbs, and two for
appointment?
Clinical
professors
could wield their
radiology, pathology, medicine, and surgery. There is too to be lost by this approach. Anatomy encompasses many aspects of the morphological basis of medicine and provides a structural framework for the development of clinical logic. In a period when the medical curriculum is becoming more and more fragmented by an increasing number of specialties fighting for curriculum and examination time, we need general disciplines on which medical education can be founded: anatomy provides just much
such a rock. We need the wholehearted support of the medical profession. REFERENCES 1. FitzGerald
MJT. Undergraduate medical anatomy teaching. J Anat 1992; 180: 203-09. 2. Moy RH. Critical values in medical education. N Engl J Med 1979; 301: 694-97. 3. Fraser RC.
Undergraduate medical education: present state and future needs. BMJ 1991; 303: 41-43. 4. McManus IC. How will medical education change? Lancet 1991; 337: 1519-21.
The
Hong Kong Academy of Medicine
the brain and nervous system.
What is needed? anatomy course-I hope that such an imposition be necessary on respectable academic would and yet the evidence, no less valid for being departments, in is that some places it is necessary. anecdotal, Involvement of anatomists in clinical teaching-clinicians may well say that they are capable of teaching the clinical anatomy relevant to their own specialty. Indeed they are, but they seldom have time. More medically qualified staff teaching anatomy-this impinges on selection criteria, assessment and promotion criteria, and clinical/preclinical salaries. Many departments employ radiologists and retired surgeons for regular anatomy teaching, and my department has a tradition of appointing retired surgeons to posts that involve dissection A
core
not
teaching. Recognition of teaching=some medical school employees are less than fully committed to teaching.2.3 Teachers should be trained;4 good teachers should be rewarded, as are productive researchers; and poor teachers should be counselled. It is not difficult to assess teaching: I fmd that the anonymous views of the students are intelligent and devastatingly perceptive, giving constructive advice with unerring accuracy: Not all professors of anatomy are interested in these matters. Why should they be when they were not conditions room
In Hong Kong the importance of postgraduate medical education (PME) has been recognised for many years and graduates began travelling to overseas countries in the 1950s to undertake research and to obtain higher professional qualifications, usually from one of the UK Royal Colleges. As local expertise increased, PME units were set up in the universities and Government hospitals but training was ad hoc, lacked coordination, and was poorly resourced. The main reason for the lack of funds is that the University and Polytechnic Grants Committee calculates its grants to universities according to undergraduate and higher degree (PhD, MPhil) student numbers, while Government bases its resource allocation to health care on service requirements. Thus, postgraduate training in hospitals has been conducted by dedicated staff with no designated time or extra resources. A better organised and adequately funded training programme was needed. Furthermore, with Hong Kong’s change in sovereignty in 1997, our dependence on professional qualifications from the Royal Colleges may have to change. Fortunately, there is now a core group of fully trained specialists in the major branches of medicine ADDRESS. Department of Medicine, Queen Mary Hospital,
Hong Kong (Prof
D Todd,
FRCP)
MEDICAL EDUCATION
Anatomy and the medical school curriculum
"The students’ knowledge of anatomy is lamentable." I cannot ignore this remark because I hear an increasing number of clinicians in Britain say it. Everyone has a view on anatomy teaching. Specialists and surgeons say that students do not know enough specialist and surgical anatomy; some physicians say there is not enough surface and radiological anatomy; and many clinicians feel that students are taught too much irrelevant neuroanatomy. What has happened? I write with some detachment from Ireland, as a medically qualified general anatomist rather than a specialist, and as one who tries to ensure that his course is well taught and appropriate to the needs of the consumer. Anatomy acquired a bad name in the earlier part of this century: courses were inordinately long, and the subject had to be learned in detail irrelevant to clinical practice. Consequently, although a beneficial intellectual discipline was inculcated into some students, most were turned off for life. In the 1960s and 1970s, the duration of anatomy courses was cut drastically, partly as a reaction to the former intransigence and partly as a result of the introduction of other subjects to the undergraduate curriculum. Unfortunately-and this is one of the most pertinent points-this pruning was often done without an accompanying reorientation to ensure that essential components continued to be taught. Thus all aspects of anatomy were pruned, irrespective of vocational relevance. It is not usually the case that there is insufficient time available for anatomy, it is that the time may not always be appropriately spent. The wrong anatomy is being taught. Who will decide what is important? A report1 published earlier this year provides a snapshot survey of anatomy teaching in Great Britain and Ireland in 1990-91. It gives details and comparisons of measurable features of courses such as duration, staff/student ratios, dissection vs prosection, educational technology, &c. Nevertheless, in terms of the approaches that ought to be adopted-what I call the sort of anatomy that we should teach and the identification of essential vocationally relevant anatomy-the report is curiously silent. What are It does
our
aims?
not matter
how many hours
are
spent
on
the
course, or what educational technology is available, or what ratios are, if students are still expected to the
staff/student
learn anatomy that is largely irrelevant to clinical practice. I believe undergraduate anatomy teaching should be aimed at those disciplines for which postgraduate training does not include anatomy teaching-eg, physicians and general practitioners. These doctors will not formally study anatomy again, and for them the basis provided by undergraduate anatomy courses needs to be relevant and secure. (In the UK, The Royal College of Psychiatrists includes a substantial amount of clinical anatomy in its postgraduate examinations.) Most physicians and general practitioners acknowledge the anatomical basis of diagnosis
and can see how important it is that the right sort of anatomy be taught from the beginning. Anatomy teachers must therefore identify the essential core of anatomy that students should know. We cannot continue to allow medical students to pass undergraduate anatomy examinations knowing useless facts about the chorda tympani and its embryology, but being unable to link tenderness in the anatomical snuff box to a scaphoid injury. If students are not competent in surface anatomy and living anatomy, I do not see any grounds for the vocational necessity for medical students to study any anatomy. No amount of enthusiasm for
videotapes
or
computer-assisted learning technology
make up for deficiencies in these
can
areas.
Anatomy and clinical skills teaching The teaching of clinical skills begins in the dissection room and grows naturally out of surface and living anatomy. In the medical school from which I write, basic clinical skills
(stethoscope, abdominal palpation, peripheral pulses, testing of ligaments, muscle groups, nerves, reflexes, &c) are examined as part of the Second MB equivalent by anatomists and clinicians. There is still opportunity for students to gain high marks by displaying all they know about pretrematic branches of branchial arch nerves or the nucleus accumbens. However, our efforts at teaching clinical anatomy are greatly appreciated by physicians especially, and our contributions to clinical teaching and examination are enthusiastically sought. Who should decide what we teach?
Although there is much to be said for asking the users of "products" for their views, most clinical professors are not known for their interest in undergraduate anatomy courses and so anatomy teachers are left to bring their own perspectives to the task. Such perspectives will vary according to training and background—eg, the views of a medically qualified teacher will differ from those of a non-medically qualified teacher. Both approaches are valid and both are educationally desirable, but in terms of course supervision and the identification of vocational requirements of anatomy courses, medically qualified staff have an advantage. So why are there more and more medical schools without permanent anatomy staff who are medically qualified? This is already the case in the UK, and in the USA it is extremely rare for medically qualified personnel to teach topographical anatomy. Courses thus become unbalanced. They are rich in mitochondria but starved of meat: the structure of the body is often dealt with in one semester. How can students undertaking such courses ever gain an understanding of enough topographical anatomy to underpin their clinical studies? our
ADDRESS Department of Anatomy, Royal College of Surgeons in Ireland, St Stephen’s Green, Dublin 2, Ireland (Prof W S Monkhouse, MB, PhD)
835
Recruitment
of
It is not so much that non-medical staff have been recruited into anatomy departments over the past twenty years but that, in many institutions, medical graduates have been positively discriminated against by indiscriminate paper counting and other doubtful criteria. Most nonmedical anatomists simply cannot bring a clinical perspective to their anatomy teaching. I do not believe this is an argument for dispensing with non-medically qualified staff, but it is an argument for peaceful cohabitation-ie, for action to maintain the presence of some medically qualified anatomists and, if necessary, for action to reintroduce them.
influence in this respect on university senates and selection boards. Or is it, perhaps, that clinical professors do not care either? The appointment in at least two UK medical schools (Cambridge and University College, London) of highranking directors of anatomy teaching in addition to the head of department tells us much about the changed role of the head of department. None of these issues is new. The anatomical societies in the British Isles (British Association of Clinical Anatomists, Anatomical Society of Great Britain and Ireland) remain silent, apparently uninterested. Yet ever more clinicians express their dismay and displeasure with the students that come their way. Perhaps more anatomy departments will disappear and clinical anatomy teaching will be shared by
When should we teach
anatomy? In view of the vocational importance of essential anatomy, it seems logical that the subject should be taught, at least partly, alongside clinical training. Thus, students of cardiology will be instructed in clinical anatomy of the heart and vasculature, and students of neurology will be taught clinical neuroanatomy, and so on. Very few anatomy departments are invited to participate in this way. There are obvious difficulties with such schemes-geographically separated science and hospital campuses, lack of suitable or willing personnel, and lack of resources. Moreover, bearing in mind the financial restrictions and work loads, it is simply not practicable for this to be the only way in which anatomy is taught. I favour a well-directed and clinically oriented ’anatomy course early in the medical training, with relevant clinical sessions subsequently for refreshment and reinforcement. In my experience, if the early course is sufficiently directed and applied, later teaching of clinical anatomy can be extremely effective. In my department we teach clinical students for four hours in obstetrics and
gynaecology (implantation, fetal membranes, pelvic and anatomy, congenital anomalies), three in otorhinolaryngology (including brainstem), one for the chest, one for the abdomen, one for the limbs, and two for
appointment?
Clinical
professors
could wield their
radiology, pathology, medicine, and surgery. There is too to be lost by this approach. Anatomy encompasses many aspects of the morphological basis of medicine and provides a structural framework for the development of clinical logic. In a period when the medical curriculum is becoming more and more fragmented by an increasing number of specialties fighting for curriculum and examination time, we need general disciplines on which medical education can be founded: anatomy provides just much
such a rock. We need the wholehearted support of the medical profession. REFERENCES 1. FitzGerald
MJT. Undergraduate medical anatomy teaching. J Anat 1992; 180: 203-09. 2. Moy RH. Critical values in medical education. N Engl J Med 1979; 301: 694-97. 3. Fraser RC.
Undergraduate medical education: present state and future needs. BMJ 1991; 303: 41-43. 4. McManus IC. How will medical education change? Lancet 1991; 337: 1519-21.
The
Hong Kong Academy of Medicine
the brain and nervous system.
What is needed? anatomy course-I hope that such an imposition be necessary on respectable academic would and yet the evidence, no less valid for being departments, in is that some places it is necessary. anecdotal, Involvement of anatomists in clinical teaching-clinicians may well say that they are capable of teaching the clinical anatomy relevant to their own specialty. Indeed they are, but they seldom have time. More medically qualified staff teaching anatomy-this impinges on selection criteria, assessment and promotion criteria, and clinical/preclinical salaries. Many departments employ radiologists and retired surgeons for regular anatomy teaching, and my department has a tradition of appointing retired surgeons to posts that involve dissection A
core
not
teaching. Recognition of teaching=some medical school employees are less than fully committed to teaching.2.3 Teachers should be trained;4 good teachers should be rewarded, as are productive researchers; and poor teachers should be counselled. It is not difficult to assess teaching: I fmd that the anonymous views of the students are intelligent and devastatingly perceptive, giving constructive advice with unerring accuracy: Not all professors of anatomy are interested in these matters. Why should they be when they were not conditions room
In Hong Kong the importance of postgraduate medical education (PME) has been recognised for many years and graduates began travelling to overseas countries in the 1950s to undertake research and to obtain higher professional qualifications, usually from one of the UK Royal Colleges. As local expertise increased, PME units were set up in the universities and Government hospitals but training was ad hoc, lacked coordination, and was poorly resourced. The main reason for the lack of funds is that the University and Polytechnic Grants Committee calculates its grants to universities according to undergraduate and higher degree (PhD, MPhil) student numbers, while Government bases its resource allocation to health care on service requirements. Thus, postgraduate training in hospitals has been conducted by dedicated staff with no designated time or extra resources. A better organised and adequately funded training programme was needed. Furthermore, with Hong Kong’s change in sovereignty in 1997, our dependence on professional qualifications from the Royal Colleges may have to change. Fortunately, there is now a core group of fully trained specialists in the major branches of medicine ADDRESS. Department of Medicine, Queen Mary Hospital,
Hong Kong (Prof
D Todd,
FRCP)
