Accepted Manuscript Title: Paying respect to human cadavers: we owe this to the first teacher in anatomy Author: Sanjib Kumar Ghosh PII: DOI: Reference:
S0940-9602(17)30027-4 http://dx.doi.org/doi:10.1016/j.aanat.2017.02.004 AANAT 51139
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Please cite this article as: Ghosh, Sanjib Kumar, Paying respect to human cadavers: we owe this to the first teacher in anatomy.Annals of Anatomy http://dx.doi.org/10.1016/j.aanat.2017.02.004 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Title: Paying respect to human cadavers: we owe this to the first teacher in anatomy
Type of Manuscript: Brief Review Article
Section: Anatomical Teaching
Name of Author: Sanjib Kumar Ghosh1 1
Department of Anatomy ESIC Medical College, Gulbarga Karnataka, India
Institution from which paper emanated: ESIC Medical College, Gulbarga, Karnataka-585106, India
Name & Affiliation of Authors: Dr. Sanjib Kumar Ghosh , MD. Assistant Professor, Department of Anatomy, ESIC Medical College, Gulbarga Sedam Road, Gulbarga-585106, Karnataka, India
Name & Contact Details of the Corresponding Author : *Correspondence to: Dr. Sanjib Kumar Ghosh, P-28, State Bank Garden, Thakurpukur Bazar, Bhakrahat Road, Kolkata-700063, West Bengal, India E-mail: [email protected]
Telephone Number: +91- 8867502575 +91-033- 24675650 Fax Number : +91- 11- 4157-1111
Every human cadaver which undergoes anatomical dissection enriches medical science and deserves to be treated with utmost respect. The aim of the present study is to identify the practices followed by medical schools across the globe to ensure that the human cadaver is treated with respect and dignity while it is utilized within the domain of medical education. The article undertakes a review of the literature and takes note of the practice of students taking an oath prior to dissecting cadavers whereby they reflect on their conduct and habits in the dissection room. It emphasizes the guidelines adopted by medical schools to ensure respectful handling of human cadavers during dissection and highlights traditional ways to honor them followed in some parts of the world. The article attempts to focus on the noble endeavour of funeral ceremonies to pay homage to the departed soul who enlightened the students with the knowledge of human anatomy. Finally it converges on the memorial services incorporated into anatomy programs to instill in students an appreciation of the humanity of those who went under the knife as a service to mankind. Based on the observations made in the present study some recommendations are also proposed regarding good practices in human cadaveric dissection. In order to bind science and humanity it is critical to realize our responsibility to reciprocate the anatomical gift of a human body with respect, compassion, care and dignity.
Key Words: Human cadaver; good practice; respect; oath taking; guidelines; funeral ceremonies; memorial services
Medical students come into contact with the subject of anatomy at the onset of their career and it serves as a platform for learning of all future disciplines. The human cadaver is an indispensable teacher that imparts information and live visualization of the human body. It constitutes a unique educational tool which is exclusive in medical curriculum (Warner and Rizzolo, 2006). Researchers have documented that the cadaver acts as a „silent mentor‟ and plays a pivotal role in the development of professionalism among medical students (ArráezAybar et al., 2014). In fact, the practice of dissection helps to shape attitudes of future medical practitioners and develop the habits of mind of the clinician (Hamilton et al., 2008; Pawlina et al., 2006). At present, there is no other mode of learning that can supersede the hands-on experience derived from dissecting cadavers. A new generation of evolving learning techniques like computer assisted learning (CAL) and problem based learning (PBL) have their own benefits, however, the pedagogical merits of dissection have been time tested. Recent studies have found that practical experience with the human cadaver as a teaching tool remains superior in comparison to all other forms of instruction (Biasutto et al., 2006; McLachlan and Patten, 2006; Ghosh, 2016). By going under the dissection knife, the human cadaver paves the way for the emergence of competent physicians of tomorrow who would serve mankind. As a true teacher, it selflessly guides a student at the threshold of a journey through the marvels of medical science. Without this supreme act of sacrifice, it is nearly impossible for a medical student to comprehend the structural orientation of the human body. Undoubtedly, every human cadaver which undergoes dissection enriches society by an invaluable service, the magnitude of which is beyond description (Arráez-Aybar et al., 2010). In light of the above discussion it is apparent that a human cadaver should be treated with utmost respect while it is being
subjected to academic endeavors (Champney, 2011; Jones, 2014; Weeks et al., 1995). Unfortunately, reports repeatedly surface of documented instances in which the dignity of the cadaver has been compromised at various levels (Gangata et al., 2010; Riederer, 2016). Definitely, this is an area of concern in medical education as it could deter potential donors from pledging their mortal remains after death for the advancement of medicine (Bolt et al., 2010). As body donation programs constitute the sole source of human tissues for anatomical studies in most parts of the world (Biasutto et al., 2014), such misadventures would adversely affect the state of medical education programs. Identification of good practices with regards to human dissection has become essential in the present day. Accordingly, in this article a review of the literature was undertaken to identify the practices followed by medical schools across the globe to ensure that the human cadaver is treated with respect and dignity while it is being utilized within the domain of medical education. An extensive search of the literature was undertaken using standard search engines, such as Pubmed, Scopus, Google search, Google Scholar and Wikipedia for identification of relevant published material. The following terms were used during the literature search: “respect for human cadaver”, “respectful handling of human cadaver”, “ethical guidelines for cadaveric dissection”, “ethics in cadaveric dissection”, “good practices in human dissection”, “human dissection in anatomy teaching”, “dissection room guidelines”, “respect for body donors”, “honoring body donors” and “dissection and medical education”. For this study, observations made in research articles, review articles, brief communications as well as letters and editorials published after the year 2000 were taken into account when found to be relevant. However, a few earlier published articles were also consulted when the findings were perceived as significant with respect to the outcome of the present study.
PRACTICE OF OATH TAKING BEFORE ANATOMICAL STUDIES Undertaking an oath prior to cadaveric dissection is a novel way to introduce the basic elements of bioethics to first-year medical students (Morar et al., 2008). In other words, the practice of oath taking at the onset of the dissection schedule, whereby students pledge to show respect and gratitude towards the cadaver, could possibly ensure that, as future clinicians, they would treat each and every patient with due respect and dignity. An oath is a statement made in public, whereby the person concerned agrees to follow certain guidelines. Cadaveric oath is an avenue to emphasize to students that the cadaver presently lying before them and waiting to be dissected was once alive and belonged to the same society to which the students belong (Sawant et al., 2016). Moreover the cadaveric oath enables students to comprehend the eventual fate of life, which, in turn, leads them to appreciate the actual value of life (Lala, 2016). The practice of cadaveric oath has been included in the anatomical curriculum by medical schools in different parts of the globe. The students in the Anatomy Department, National University of Singapore, Yong Loo Lin School of Medicine have to recite a solemn oath at the onset of academic session with gloved hands placed on cadavers lying on gurneys in front of them. Accordingly, students pledge to treat the once living human body with dignity as they dissect the same to further their professional goals. Further, they also declare that they would conduct themselves in a manner in line with the highest standards of professionalism (Prakash et al., 2007). In Liverpool, United Kingdom, to ensure that the expectations of a health care professional are made explicit from the outset, medical students are required to assent to the Declaration of Geneva (the contemporary World Medical Association equivalent of the Hippocratic Oath) on their first day of medical school. During the ceremony, all students recite the memorized oath in unison, thus creating a feeling of dedication towards mankind, which guides their behavior in the dissection room and beyond (Ali et al., 2015). At
the School of Medicine, Oregon Health & Science University, Portland, Oregon, United States, the White Coat Ceremony is undertaken for students entering the profession of medicine, whereby the students stand together to recite the oath of Geneva. In doing so, the students pledge to dedicate themselves to their teachers, future patients and to support each other at all times. Such a ceremony creates an important focus area for the students to respect their first teacher (human cadaver) as they begin their medical career with anatomical studies (Snelling et al., 2003). Recently, the Department of Basic Medical Sciences at the Durban University of Technology, followed the above trend as their first-year anatomy students undertook a modified Hippocratic Oath, whereby they swore to treat the mortal remains of human bodies with respect while conducting their studies in the dissection room. Subsequent to this, the faculty members sensitized the students to the fact that they were fortunate enough to dissect a human body and to have hands on experience in the study of the structure of the human body. They also guided the students to carry themselves in an exemplary manner which reflects the conduct of an ideal health professional from the beginning of the anatomy course (Satyapal, 2012). In India, K.J. Somaiya Medical College, Sion , Mumbai, has pioneered this trend. Here students are required to recite the cadaveric oath on the first day of their anatomy course. The oath is administered by the Head of the Department of anatomy along with other faculties of the department and the Dean of the Institute. The ceremony is an emotionally charged moment, where students stand around a cadaver with their right hand lifted up and pointing in the direction of the cadaver. They recite the oath from a printed copy held with their left hand (Lala, 2016; Sawant et al., 2015). The practice of cadaveric oath presents an opportunity for the students to reflect upon their conduct in the dissection room and in particular their handling of the human cadaver. It guides them to the realization that the cadaver should be considered as their „first teacher‟ as
well as „silent mentor‟ and not merely learning material. The trend is becoming popular around the world as is evident from the discussion above and it is a relatively new element that has been inducted into the exercise of human dissection. Notably available literature from Asian countries refers to a specific term “cadaveric oath” in this regard, whereas elsewhere it is a modified version of the Hippocratic Oath.
HANDLING HUMAN CADAVERS WITH RESPECT The human cadaver is a complex, socially constructed entity, laden with all possible attributes, from frivolous to tragic to sinister to religious. However, in the context of an anatomy dissection room, it is a teacher whose function is not to symbolize mortality but to help us learn about the elements that supported life (Jones, 2014; Sañudo et al., 2007). Developing an ideal balanced viewpoint for the human cadaver is a challenge for first-year medical students who are, in general, young members of the society (Weeks et al., 1995). Hence predesigned guidelines governing the behavior and habits of medical students in the dissection is significant in this regard. In the Department of Anatomy and Cell Biology, Indiana University School of Medicine, Bloomington, Indiana, United States, the faculty emphasizes the importance of proper care and respect for the human bodies throughout the duration of human anatomy course, and they ensure that the students realize their responsibility towards maintaining proper professional conduct in this regard. Detailed accounting of the status and location of all anatomical material in the department is meticulously maintained and special care is taken such that tissues from each cadaver remain with the same cadaver during the dissection classes (Ousager and Johannessen, 2010). At Mt San Antonio College, Connecticut, United States, a set of regulations regarding cadaveric handling is handed to the participants of the human anatomy dissection course at the very beginning. Accordingly, taking any photographs or videos at any time within the cadaver lab is strictly prohibited. Students are strictly advised against removing any body parts or tissues from the dissection room. Moreover, the dissection room is treated as a highly restricted area with the doors being closed and locked at all times with entry being limited only to the students enrolled in the cadaver course. All kinds of food and drinks are absolutely prohibited within the dissection room. During the dissection hours, students are required to place any tissue removed from the cadaver within a
designated container which is kept along with the respective cadaver. Students are advised not to put any disposable items like gloves, paper towels etc. within the same container and not to leave behind any tools/ instruments on the dissection table. Furthermore, students have to ensure that those areas of the cadaver not being dissected should be covered and, at the end of dissection period, the body should be wrapped carefully and body bag closed. Each student is tasked with the responsibility to keep the work area clean. Any disregard of these above regulations or disrespect for the cadaver in any form carries the risk of immediate dismissal from class (Gregory et al., 2009). Similar regulations and guidelines are also followed in the human anatomy laboratory of Daemen College, New York and at the School of Medicine, Wayne State University, Detroit, Michigan, United States (Canby and Bush, 2010; Jones et al., 2014). The undergraduate medical education program at the Cumming School of Medicine, University of Calgary, Canada has made it mandatory for their students not to leave the human body or specimens unattended and to use gloves and proper attire when handling cadavers and/or anatomical specimens. Moreover the institute guidelines clearly mention that study of cadavers and anatomical specimens are to be undertaken solely for educational purpose (Rosenfield and Jones, 2004). The Royal Australasian College of Surgeons emphasize the fact that use of human tissues is a privilege. Here dissection sessions are closely monitored by the staff and any person found to be treating cadaveric materials in an unprofessional manner is ejected immediately (Parker, 2002). In Bangladesh, the first year students of Government Medical colleges have to sign a document prior to onset of dissection sessions, whereby they pledge to follow a set of rules and regulations towards maintaining the highest standard in the dissection room. Students are required to observe professional conduct while in the dissection room as well as outside the same, whereby they are required to refer to the cadaver as “human anatomical gift”, restrict themselves from making casual/
derogatory remarks in a public place. Further they have to provide a pledge that they will not take any photographs of the cadaver or any part of it in the dissection room without prior permission (Nurunnabi et al., 2011). However, respect for the cadaver cannot always be incorporated by rules and regulations and at times it is shown by the students as part of traditional values. In Thailand, respect for the cadaver in the dissection room is paramount. At the beginning of laboratory dissection students, faculty, family of body donors and Buddhist monks attend a ceremony in the dissection room whereby donors are honored by having their names read aloud. During the dissection course, Thai students refer to human cadavers as „ajarn yai‟ or great teacher and never as „sop‟ (cadaver). Remarkably, in Thai medical schools, identification of cadavers is mandatory (which is a significant deviation from the trend followed by medical schools in the rest of the world as they maintain the anonymity of the cadavers) and the name, age, cause of death of the cadaver is indicated on each dissecting table such that the students can readily reproduce the name when asked. Moreover Thai students greet the cadavers with the traditional Thai bow (wai), offer flowers and even pray for them, which reflects the gratitude towards their „ajarn yai‟ (Prakash et al., 2007; Winkelmann and Guldner, 2004). A similar trend is followed in Japanese medical schools, where everybody in the dissection course silently prays for the souls of body donors (Sakai, 2008). Anatomical dissection is a time-honored element of medical education and is a critical procedure undertaken at the threshold of medical undergraduate education program (ArráezAybar et al., 2004; Korf et al., 2008). Experiences related to respectful handling of the human body and anatomical specimens allow the students the opportunity for self realization, which is critical to their eventual personality development (Arráez-Aybar et al., 2008; Plaisant et al., 2011; Rosenfield and Jones, 2004; Sukol, 1995). Anatomy education programs around the world have adopted a no-nonsense approach regarding adherence to the dissection room
guidelines with a focus on the ethical perspectives in relation to the practice of human dissection. As the students learn to respect the cadaver and handle the human tissues with care as well as compassion, they embark on a journey to build a strong foundation personally and socially as future physicians.
FUNERAL SERVICES FOR CADAVERS AFTER DISSECTION Proper cremation/burial of the remains of human bodies after anatomical dissection is an act of bidding farewell to a teacher who has enlightened the students with the knowledge of human anatomy and has selflessly contributed towards the welfare of the society. Respectful cremation of human bodies post dissection is a responsibility of the medical schools, concerned students as well as faculty members and should be conducted with similar dignity which was shown during the course of dissection (Rizzolo, 2002). In fact, researchers have opined that it should be considered as an extension of the human dissection program (Morris et al., 2003; Riederer et al., 2012). Studies have reported that majority of the potential body donors request a respectful and ceremonial cremation of their remains after anatomical studies (Jones, 2016; Richardson and Hurwitz, 1995). In a way, it presents the society with an opportunity to fulfill their wish and express thankfulness for their noble services even after death. At the Juntendo University School of Medicine, Tokyo, Japan, after a human body is donated it takes 2 to 3 years to complete dissection. This is followed by rightful cremation, the expenses being fully borne by the institution and the ashes are returned to the family of the donor (Sakai, 2008). Korean medical schools hold various types of funeral ceremonies to honor the donors whose bodies have been dissected. These ceremonies are viewed as a suitable way to pay proper respect to the dead and to promote knowledge about body donation programs in Korea (Park et al., 2011). At Tzuchi University Medical School in Hualien, Taiwan, at the end of the dissection course, students sew up the body of the cadaver, wrap it up with cloth, write a letter addressed to their „silent mentor‟, and participate with family members in funeral rites (Kanter, 2010; Tseng and Lin, 2016). In Thailand, at the end
of the dissection course, a ritual is undertaken whereby students, being led by Buddhist monks carry their „ajarn yai‟ to the site of final cremation (Prakash et al., 2007). Very recently, Trinity School of Medicine, Caribbean Islands, retired one of its cadavers and took the opportunity to reaffirm respect for the practice of donation. The cadaver, which was referred to as „Walter‟ by the faculty and students to protect its anonymity, was cremated and the ashes were buried at the Kingstown Cemetery with a full funerary procession. The funeral service was preceded by a brief ceremony which included recitations and songs by students. Moreover there was a surprise musical performance by one of the faculty members of Medicine. At the conclusion of the ceremony the Trinity president received a plaque specially prepared to commemorate „Walter‟s‟ place among cadavers used at Trinity (Jones and King, 2016). The Basic Biomedical Sciences Division at the University of South Dakota, United States also ensures funeral services for all dissected cadavers. Upon completion of anatomical studies, all cadavers are properly cremated and according to the wishes of the family, the ashes are either buried at the cemetery or returned to the family at the expense of the institute (Jones et al., 2014). The authorities of the School of Medicine, University of Alabama, Birmingham, United States, have made it mandatory for all dissected bodies to be cremated, which is usually undertaken by the administrators. The ashes are either returned to the family members or buried in the nearby cemetery. There is one single granite stone acknowledging the donors located in the cemetery area. The family members of the donor are allowed to visit the cemetery as per their wish after prior communication with the administrator (Pawlina et al., 2011). The school of Anatomy, Physiology and Human Biology, The University of Western Australia, also ensures respectful funeral services of the dissected cadavers, which is followed up by handing over the remains to the next of kin of the donor. In the event that ashes are not required to be returned, they are buried in the cemetery within the university
campus. The family members are allowed to organize a funeral ceremony at the time of cremation, which is closed to outsiders, however (Ramsey-Stewart et al., 2010). Without the cremation ceremony, the entire exercise of cadaveric dissection would become too mechanical and appear as an act driven by the rigors of medical science. Funeral services are an opportunity to reflect on the humanistic side of the person, whose body has gone under the knife for the benefit of science (Pawlina and Drake, 2016; Riederer and Bueno-López, 2014). Such ceremonies not only allow students as well as faculty members to pay homage to the departed soul, but also provide a window for the bereaved family members to perform the last rites of the donor. Funeral services following dissection of human cadavers have been embraced by medical schools as an integral component of anatomy curriculum as observed in this review and it has been perceived to enhance the societal impact of the practice of human dissection.
REMEMBERING THE PERSON WHO TAUGHT US ANATOMYxxx A person who has dedicated his mortal remains for the advancement of medical science can inspire and illuminate the minds of many long after he/she has bid adieu to the mortal world. Hence, it makes sense to practice memorial services organized by medical schools in remembrance of those who had donated their bodies for anatomical dissection (Tschernig and Pabst, 2001). These memorial services are intended to instill an appreciation of the humanity of the donors in students and give them an opportunity to express gratitude to the families of the donors while at the same time learning more about their lives (Pawlina et al., 2011). The majority of the medical schools in United States, where human cadaveric dissection is included within the anatomy curriculum, conduct memorial ceremonies to express gratitude towards body donors. These ceremonies are organized by the students and faculties of respective institutions with participation by other health care students. The core of these ceremonies includes learners‟ reflections on mortality, respect, altruism, and personal growth depicted through various humanities modalities (Jones et al., 2014). The Department of Anatomy, College of Medicine, Mayo Clinic, Rochester, Minnesota has a long standing tradition of organizing a “Convocation of Thanks” as an annual ceremony commemorating the gift of body donation. In this ceremony, participants reflect their feelings through poetry, music dance, ballet and artistic multimedia presentations (Pawlina et al., 2011). At Yale University School of Medicine, a “Service of Gratitude” is undertaken to celebrate the life of donors and an annual compilation of reflections expressed during the ceremony is published (Eze et al., 2009). At the College of Medicine, University of Florida, at the close of the memorial ceremony, students come down the stairs of the Medical Education building to
release red balloons, scrawled with messages, in honor of the body donors (Jones et al., 2014). At the Auckland Institute of Technology, New Zealand, a prayer service is organized for the donated bodies at the beginning of an academic session and a memorial service at the end of it. The memorial ceremony includes poetry readings, the reading of letters written by relatives of anonymous donors and musical performances. Researchers have noted that such ceremonies contribute to students overcoming the stress and anxiety associated with human dissection (Hancock et al., 1998). Such ceremonies have also been reported by the Department of Structural Biology of The University of Otago, Dunedin, New Zealand (McClea, 2008). In Japan, memorial services to pay respects to the cadavers have a long history and can be traced back to 17th century during the Edo period (Kozai, 2007). Annual gatherings in honor of body donors is a century old ritual followed in Taiwan. These ceremonies are still popular in present times and are used to enhance the practice of body donation and express gratitude for donors and their families (Kao and Ha, 1999; Lin et al., 2009). In most medical schools in Germany, a memorial service is organized to honor those who had donated their bodies for dissection. It was observed that at the end of the anatomy course many students felt the urge to express their gratitude to the body donors and these ceremonies actually fulfilled this desire of the students (Korf et al., 2008; Pabst et al., 2016; Tschernig and Pabst, 2001; Winkelmann, 2007). In 2009, the Department of Anatomy, at the Radboud University Nijmegen Medical Centre (RUNMC), The Netherlands, unveiled a monument as a memorial for body donors. The monument comprises of a marble dissection table in the shape of an altar, which is an expression of gratitude for the anatomical gift of body donors and also has a bronze sculpture of a phoenix which symbolizes imperishability of the noble soul. The objective behind the memorial was to reciprocate the selfless gesture of the donors
and raise awareness among students to value and treat donor bodies with proper respect (Koolos et al., 2010). Memorial ceremonies honoring the body donors have also been reported from the Republic of South Africa, where many anatomy programs have started organizing formal services of gratitude to which families and friends of donors are invited (Lachman and Pawlina, 2006; Manicom, 2015). Memorial services have added a new dimension to anatomy education. It is a window for going down memory lane and highlight the life of the departed soul, who had served the society even after death (Hildebrandt, 2016; Hull and Shea, 1998). Nevertheless, these ceremonies also help to bind science and humanity and, in a way, humanize the dissection room experience (Kahn and Gardin, 2016). They are an eye opener to the realization that celebrating the life of the donors guides us to the threshold of happiness associated with the act of giving. Anatomy educators have recognized the value of memorial services in health education as a noble gesture through which generosity and humanistic attributes are perpetuated in the minds of future generation of physicians.
CONCLUSION AND PROPOSED RECOMMENDATIONS In the anatomy dissection room, we come across a person who has gifted his/her body for exploration of the anatomical details. Our journey through the structural orientation of the human body is made possible by the kind gesture of a person which reflects the art of giving in a vivid manner. As fellow human beings it is our responsibility to reciprocate the anatomical gift with respect, compassion, care and dignity. The key to developing a proper respectful attitude towards the human cadaver while undertaking anatomical studies is imbibing the thought that much has been given and much is expected. Based on the observations made in the present study, the following recommendations may be considered as good practices regarding human cadaveric dissection: i) Students should undertake a solemn oath at the onset of dissection course whereby they pledge to show respect and gratitude towards the human cadaver ii) Dissection of human cadaver and study of human tissues to be undertaken solely for academic purposes iii) Dissection sessions should be strictly monitored by the faculty members/ staff of respective medical schools to ensure maintenance of highest possible professional standards iv) Students should address the cadaver as „teacher‟/ „mentor‟ and avoid making any casual comments regarding the same
v) Photography/ videography of cadaver or cadaveric specimens should be prohibited unless necessitated for educational/ research purpose vi) Dissection room should be treated as a highly restricted area with entry limited to enrolled students and deputed staff from the department vii) Cadaver should remain covered all the time with only the area being dissected to be exposed. Every day at the end of dissection body should be wrapped and placed inside a body bag viii)
Use of gloves and proper attire should be mandatory while undertaking dissection
ix) Care should be taken to avoid mixing of human tissues and disposable items. The work area including the dissection table should be kept clean x) Food items and drinks should be strictly prohibited within dissection room premises xi) Respectful cremation of human bodies following dissection should be carried out by medical schools with active participation from students as well as members of the faculty in presence of family members xii) Memorial services/ Ceremonies of gratitude should be organized annually to honor those who had donated their bodies for dissection Although most of these recommendations are already implemented by majority of the medical schools, nevertheless, documented basic guidelines could possibly contribute to standardization of the exercise of human dissection globally. This would be a significant step as students would be acclimatized to comply with the highest ethical standards as they prepare to serve precious human lives.
ACKNOWLEDGEMENT The author expresses heartfelt gratitude to all the clinical tutors and faculty members of the Department of Anatomy, ESIC Medical College, Gulbarga, Karnataka, India for their unconditional support throughout the study. I am grateful to the authorities of ESIC Medical College, Gulbarga, Karnataka, India, for their kind cooperation during the course of this study.
ETHICAL CLEARANCE Not Required
CONFLICT OF INTEREST None to Declare
FUNDING None to Declare
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