- Email: [email protected]
The Value of Clinical Practice in Cadaveric Dissection: Lessons Learned From a Course in Eye and Orbital Anatomy
ORIGINAL REPORTS
The Value of Clinical Practice in Cadaveric Dissection: Lessons Learned From a Course in Eye and Orbital Anatomy Christopher Schulz, BM, BSc*,† Department of Anatomy, Brighton and Sussex Medical School, Brighton, UK; and †Eye Unit, Salisbury District Hospital, Salisbury, UK *
OBJECTIVE: To test the hypothesis that there is greater benefit in a dissection-based anatomy course among those participants with clinical experience in the relevant field, and those without. DESIGN: A retrospective comparative study. SETTING: Brighton and Sussex Medical School Anatomy
Department: an educational facility that provides undergraduate and postgraduate anatomy teaching using cadaveric specimens. PARTICIPANTS: All attendees (n ¼ 40) to a postgraduate
course in eye and orbital anatomy completed course evaluation forms. The course has been attended by delegates from around the country, with experience ranging from that of final year medical students to clinical fellows who have completed their specialist training in ophthalmology. RESULTS: Those participants who were practicing oph-
thalmology tended to be older than those who were not, with a greater amount of time spent on prior learning. Participants scored both the prosection-led and dissectionled sessions highly, with a mean combined evaluation of 8.9 (out of 10) for dissection-led learning and 9.2 for prosection-led learning. Prosection-led learning was regarded equally by those participants currently practicing in ophthalmology, and those who are not. In contrast, dissection-led learning was scored higher by those participants who were practicing ophthalmology (9.4), when compared with those not in ophthalmic practice (8.5; p ¼ 0.018). CONCLUSIONS: The present study supports the hypothesis that the benefits of cadaveric dissection could be
Correspondence: Inquiries to Christopher Schulz, Eye Unit, Salisbury District Hospital, Odstock Road, Salisbury, UK.; e-mail: [email protected]
maximized during postgraduate surgical training. This has important implications given the trend away from cadaveric dissection in the undergraduate curriculum. ( J Surg Ed C 2016 Published by Elsevier ]:]]]-]]]. Crown Copyright J Inc. on behalf of the Association of Program Directors in Surgery. All rights reserved.) KEY WORDS: anatomy and dissection and postgraduate
and education and surgery and ophthalmology COMPETENCIES: Medical Knowledge and Practice-Based Learning and Improvement
INTRODUCTION Anatomical principles underpin the foundations of medical and surgical practice. Because of this, anatomy has historically been taught during the early years of the medical school curriculum. Cadaveric dissection allows a 3dimensional appreciation of the human body and encourages learning through a process of autonomous discovery. Although dissection has played a central role in anatomy education for many centuries, it is often cited as being timeconsuming, resource-intensive, and emotionally disturbing for some students.1 Wherever one sits in this topical debate, there is little doubt that there has been a trend away from dissection-led anatomy in the modern undergraduate curriculum.2,3 It has been suggested that dissection-based learning is better suited to the postgraduate surgical trainee.4 Dissection fosters a spatial understanding, a recognition for surgical tissue planes, and a tangible appreciation for the proximity of structures; these skills are of more value to the practicing surgeon than a preclinical medical student. In addition, it might be expected that postgraduate trainees have a clearer vision of their specific field of interest and would likely have a much better clinical appreciation of
Journal of Surgical Education Crown Copyright & 2016 Published by Elsevier Inc. on behalf of the Association of Program Directors in Surgery. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2016.09.010 1931-7204/$30.00
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applied anatomy; they are more likely to maximize the potential benefits of dissection. The purpose of this study was to test this hypothesis. It was designed to determine whether there was any difference in the educational value of a dissection-led eye and orbital anatomy course between those participants with experience practicing in ophthalmology, and those without.
MATERIAL AND METHODS
fellowship examination (part 1), and prior learning. Participants were also asked to provide a quantitative evaluation of the “educational value of content” and “teaching methods used” for each of the dissection-led and prosection-led sessions. This quantitative evaluation takes the form of a 5-point Likert scale with a score of 1 deemed “very poor” and 5 being “very good.” The combined score (out of 10) formed the primary outcome measure in this study. The individual scores for content and teaching methods were used as secondary outcome measures.
The Course This instructional course was designed specifically for those in postgraduate ophthalmic training, as well as for those with an interest in undertaking a career in ophthalmology. The Royal College of Ophthalmologists recognizes the importance of applied anatomy as a learning objective in its postgraduate curriculum,5 and the course’s content is based on the anatomy-specific syllabus for the first part of the College’s fellowship examination in basic sciences.6 This course has been held annually on 3 occasions since 2014. The course is 8 hours in length during which time delegates undertake tutorials that are both dissection- and prosectionled. During the first 4 hours, the delegates work in groups between 3 and 5 and are supervised in undertaking dissection of the orbit (from a superior approach), the eyelids, and the lacrimal outflow system. The second half of the course comprises tutorials using prosected material that focuses on regional anatomy of the paranasal sinuses, vascular supply to the head, the intracranial visual pathway, and the cranial nerves. The sessions are facilitated by a faculty of experienced specialist consultants and registrars, as well as anatomists from Brighton and Sussex Medical School. Recruitment and Participants Since its inception, this course has been advertised online, through printed media, and by correspondence with the local education and training boards that form Health Education England. The course has been attended by delegates from around the country, with experience ranging from that of final year medical students to clinical fellows who have completed their specialist training in ophthalmology.
Analysis Based on their responses, participants were divided dichotomously into those who were already practicing ophthalmology clinically (as a specialist trainee, clinical fellow, associate specialist, or consultant) and those who were not (foundation year doctors and medical students). Owing to the discrete, ordinal nature of Likert-scale data,7 the MannWhitney-Wilcoxon test was used to determine whether there was a difference between these groups in the respondents’ scores for educational value of the content, evaluation of the teaching methods, and the combined score (as the primary outcome). This analysis was conducted on scores provided for both the dissection-led sessions and the prosection-led sessions. To evaluate whether prior educational experience was associated with improved course evaluation scores, participants were again stratified into groups based on whether or not they had any prior experience in orbital dissection, any prior experience with orbital prosections, more or less than 8 hours didactic/ tutorial-based learning in orbital anatomy, and more or less than 8 hours self-directed learning in orbital anatomy. The 8-hour threshold was selected for didactic and self-directed learning as this represents a full working day. For each of these dichotomous subgroups, the Mann-WhitneyWilcoxon test was used to determine whether there was any significant difference in the respondents’ scores for educational value of the content, evaluation of the teaching methods, and the combined score (as the primary outcome). Where data were missing or illegible, this was recorded as such and was excluded from analysis.
RESULTS
At the close of each course, participants were asked to complete a detailed evaluation of the course. Evaluation forms were completed and collected anonymously with the course instructors and study authors masked to the individual participants’ responses. The evaluation forms asked participants to provide information on basic characteristics such as age, level of experience, completion of their College
Forty participants completed the course in eye and orbital anatomy. All participants provided evaluation forms. The baseline characteristics can be found in Table 1. Three participants failed to provide their age, but otherwise the evaluation forms were completed in full. Those participants who were practicing ophthalmology tended to be older than those who were not, with a greater amount of time spent on prior learning and a higher pass rate of the Royal College of Ophthalmologists’ part 1 fellowship examination (Table 1).
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Outcome Measurement
TABLE 1. Baseline Characteristics of Study Participants Not Practicing Ophthalmology (n ¼ 23) Mean (SD) age 25.5 (1.6)* No. (%) of male 11 (47.8%) participants No. (%) of participants at Medical Student 2 (8.7%) Specialty trainee each stage of career (final year) year 1–3 FY1 (Postgraduate 9 (39.1%) Specialty trainee year 1) year 4–7 FY2 (Postgraduate 12 (52.2%) Completed higher year 2) specialty training Mean (SD) no. of hours spent on prior learning in eye and orbital anatomy Dissection-based 1.1(2.2) Prosection-based 2.9 (5.0) Didactic/tutorial 6.3 (12.8) Self-directed 16.1 (23.3) Postgraduate learning Dissection-based 0 (0) Prosection-based 0 (0) No. participants (%) that 1 (4.3%) had passed Part 1 Fellowship examination
Currently Practicing Ophthalmology (n ¼ 17)
Total (n ¼ 40)
30.3 (4.8)† 8 (47.1%)
27.5 (2.0)‡ 19 (47.5%)
13 (76.5%) 2 (11.8%) 2 (11.8%) 2.9 3.2 9.3 67.5
(5.4) (5.3) (13.3) (53.9)
0 (0) 0 (0) 7 (41.1%)
1.9 3.0 7.6 36.3
(2.8) (4.4) (12.9) (32.5)
0 (0) 0 (0) 8 (20.0%)
Complete data available with the exception of: *n ¼ 22. † n ¼ 15. ‡ n ¼ 37.
It is worth noting that more than three-quarters of those practicing in ophthalmology were in their first 3 years of specialty training. For all participants, the vast majority of prior learning in eye and orbital anatomy was self-directed. On average, participants had spent less than 2 hours on dissection, and 3 hours with prosected cadaveric material. In this study cohort, participants reported that all dissectionand prosection-based learning had been undertaken at an undergraduate level. With reference to Table 2, participants scored both the prosection-led and dissection-led sessions highly, with a mean combined evaluation of 8.9 (out of 10) for dissectionled learning and 9.2 for prosection-led learning. Prosectionled learning was regarded equally by those participants currently practicing in ophthalmology, and those who are not. In contrast, dissection-led learning was held in higher regard by those participants who were practicing ophthalmology, when compared with those not in ophthalmic practice (Fig.). This statistical difference was evident for both the combined evaluation score, as well as the participants’ score for teaching methods used (Table 2). That said, both groups rated the content value of these sessions equally. Considering the possible confounding effect of prior learning experiences using the Mann-Whitney-Wilcoxon test, there was no significant difference in the evaluation scores for those students either with prior experience in orbital dissection, or
eye and orbital prosection. Nor was any difference detected for those who had prior exposure to more or less than 8 hours of didactic teaching. Students who had previously committed more than 8 hours of self-directed learning to eye and orbital anatomy were more likely to evaluate the dissection-led teaching higher than those who had not (Table 3). Indeed, for those participants with more than 8 hours of prior selfdirected learning, no difference was detected in the course evaluation scores provided by those who were practicing in ophthalmology, and those who were not. However, for those participants who were not currently practicing in ophthalmology, the effect of self-directed learning remained highly significant on the combined evaluation score for dissectionled teaching (p ¼ 0.01) but not the prosection-led sessions (p ¼ 0.13).
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DISCUSSION In many institutions, there is a trend away from dissectionled learning at undergraduate level.2,3 This is reflected in the present study by the fact that participants who were further into their postgraduate careers had spent more time on cadaveric dissection and prosected material than their more junior colleagues. This was observed despite the fact that no cadaveric-based learning had been undertaken by any of the participants after graduation from medical school.
TABLE 2. Course Evaluation Scores, Grouped by Whether the Participant is Currently Practicing Ophthalmology or Not
Dissection-led learning Educational value of content Teaching methods used Combined evaluation score Prosection-led learning Educational value of content Teaching methods used Combined evaluation score
Not Practicing Ophthalmology (n ¼ 23)
Currently Practicing Ophthalmology (n ¼ 17)
All Participants (n ¼ 40)
Mann-WhitneyWilcoxon Test (p Value)
4.37 (4.1-4.6) 4.15 (3.9-4.4) 8.52 (8.0-9.1)
4.70 (4.5-4.9) 4.73 (4.5-4.9) 9.44 (9.1-9.8)
4.51 (4.3-5.0) 4.40 (4.2-5.0) 8.91 (8.6-10.0)
0.13 0.008 0.018
4.61 (4.4-4.8) 4.56 (4.3-4.8) 9.17 (8.7-9.6)
4.82 (4.7-5.0) 4.41 (4.0-4.8) 9.23 (8.7-9.7)
4.70 (4.6-5.0) 4.50 (4.3-5.0) 9.20 (8.9-10.0)
0.22 0.84 0.87
Presented as mean values with lower and upper confidence intervals in parentheses. p-Values are given for Mann-Whitney-Wilcoxon Test between those participants who are practicing ophthalmology, and those who are not. Bold figures indicate statistical significance (p o 0.05).
With doctors now entering higher surgical training with less undergraduate exposure to dissection, there is a growing void in their anatomical education. Apart from simply filling this undergraduate void, it has been suggested that cadaveric dissection might actually be better suited to postgraduate surgical trainees because of their clinical experience and the greater need for a spatial understanding of surgical anatomy.4 A number of postgraduate dissection-based courses in anatomy have been developed and shown to have proven benefit in the fields of general surgery, obstetrics and gynecology, and orthopedics.8-12 Indeed, the Royal College of Surgeons have themselves recognized the need for structured anatomy education as part of their postgraduate curriculum.13-15 Compared with the previously cited literature, the present study offers new insight on 2 parts. Firstly, although it might be expected that any postgraduate educational course would be rated highly by its participants, it would seem that there is significant value in providing an instructional
Prosecon-led sessions
a)
postgraduate course in anatomy that is specifically relevant for ophthalmologists. Secondly, and more importantly, this study specifically compared the benefit of dissection-based learning in those participants who already had practical experience in the relevant clinical field (of ophthalmology in this case), and those who were not. The results support the notion that clinical and surgical experience can enhance the benefits of dissection-led learning. It is proposed that this might be due to 3 primary reasons.
DEEPER APPROACHES TO LEARNING Deep learning involves an integrative approach that leads to personal understanding. Deep learners would use a selfdirected approach to ‘map out’ a topic to see how ideas fit together. This is in comparison to strategic learning that is goal-directed (e.g., for examinations) or surface learning that involves memorizing ideas in isolation. There is evidence
10
Combined Evaluaon Score
10
Combined Evaluaon Score
Dissecon-led sessions
b)
9
8
7
9
8
7
6
6
Not praccing in Praccing in ophthalmology ophthalmology
Not praccing in Praccing in ophthalmology ophthalmology
FIGURE. Comparison between the combined evaluation score for dissection-led versus prosection-led teaching grouped by whether participants are currently practicing ophthalmology or not. n ¼ 23 for participants not practicing ophthalmology; n ¼ 17 for participants practicing in ophthalmology. 4
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TABLE 3. Course evaluation scores, grouped by whether the participant had previously undertaken more than 8 hours of selfdirected learning in eye and orbital anatomy, or not.
Dissection-led learning Educational value of content Teaching methods used Combined evaluation score Prosection-led learning Educational value of content Teaching methods used Combined evaluation score
o8 Hours Self-Directed Learning (n ¼ 13)
48 Hours SelfDirected Learning (n ¼ 27)
All Participants (n ¼ 40)
Mann-WhitneyWilcoxon Test (p Value)
4.14 (3.9-4.4) 3.93 (3.7-4.1) 8.07 (7.7-8.5)
4.70 (4.6-4.8) 4.66 (4.5-4.8) 9.36 (9.1-9.6)
4.51 (4.3-5.0) 4.40 (4.2-5.0) 8.91 (8.6-10.0)
0.015 0.001 0.002
4.50 (4.3-4.7) 4.29 (4.1-4.5) 8.79 (8.4-9.1)
4.82 (4.7-4.9) 4.64 (4.4-4.9) 9.46 (9.2-9.8)
4.70 (4.6-5.0) 4.50 (4.3-5.0) 9.20 (8.9-10.0)
0.10 0.13 0.14
Presented as mean values with lower and upper confidence intervals in parentheses. p-Values are given for Mann-Whitney-Wilcoxon test between those participants who are practicing ophthalmology, and those who are not. Bold figures indicate statistical significance (p o 0.05).
that students who are older tend to adopt a deeper approach to learning.16-18 As would be expected, participants in this study who were practicing ophthalmology tended to be older than those that were not. Compared with preclinical medical students learning anatomy, postgraduate trainees are more likely to know where their own specialist interest lies, resulting in greater focus, motivation, and direction. It is suggested that they would have a greater insight into their own educational needs and adopt a deeper approach to learning anatomy, drawing on their greater degree of prior knowledge. This deeper learning approach is complimented by the autonomous, self-directed, and tactile approach to learning that cadaveric dissection offers.19
PRIOR LEARNING EXPERIENCES
SURGICAL APPLICATION Those who are already practicing surgery have a greater appreciation for the need to understand surgical tissue planes and regional anatomy. However well-prepared a surgical trainee feels they are, all surgeons have gaps in their anatomical understanding that would only truly become apparent under the spotlight of the operating theater. It is only with this conscious recognition that one is not adequately competent that measures can be taken to address these deficiencies. Pugh et al.21 observed that knowledge in anatomy was the most frequently reported learning need among surgical residents. Both anecdotal and objective evidence suggest that dissection is a key method for developing the 3-dimensional awareness of human anatomy.23-26
Postgraduate specialty trainees would have greater experience than medical students. The learning process is enhanced by a doctor’s ability to relate new anatomical ideas and concepts to their own prior clinical and nonclinical learning experiences. This continuous cycle of relating prior experience with anatomical constructs helps to develop the foundation upon which new experiences and ideas can be built. Participants in this course that had committed more than 8 hours of self-directed learning toward relevant material were more likely to value a dissection-led approach to learning. This effect remained evident whether or not the participant was practicing in ophthalmology and so emphasizes the importance of anatomy as “a sequential subject in which knowledge acquired is subsequently elaborated upon.”20 Traditionally, most anatomy learning often takes place in the preclinical years of medical school. At this stage in their career, students may struggle to understand the true clinical relevance of anatomy, and often find great benefit in revisiting the basic sciences either in the later years of medical school, or during the early postgraduate years.8,10,21,22
This study was limited by its retrospective design and small sample size. In combination with the heterogeneity of participants recruited, it is not possible to draw on any firm conclusions regarding causal relationships or the interaction of various confounding factors. An attempt was made to evaluate the relationship between prior learning experiences as possibly confounding, and it has become evident that self-directed learning does indeed play an important role in the results of this study. This does not negate the finding that the benefits of dissection appear to be greater in those currently practicing in the relevant field, but rather it helps to offer some explanation as to why this is so. The pros and cons of noncontinuous, ordinal Likertscale data have been discussed extensively elsewhere7 and nonparametric testing was used to limit statistical error. The Likert-scale focused on self-reported evaluations, and this does necessarily equate to the actual benefit of the learning experience. Learning is a complex process, and evaluating the quality of teaching is equally complex. That said, participant-reported evaluations of teaching do appear to
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Study Limitations
be associated with objective learner outcomes, and their use is widespread in educational research.27,28 Although the points discussed this far can be generalized to all surgical specialties, this study was limited to those participants undertaking an anatomy course tailored to ophthalmologists. With that in mind, it does raise some additional points specific to this field of practice. The Royal College of Ophthalmologists recognizes that “all trainees must understand and apply knowledge of the anatomy of the eye, adnexae, visual pathways, and associated aspects of head, neck, and neuroanatomy.”5 When the syllabus for the college’s fellowship examination6 is compared with The Anatomical Society’s core undergraduate syllabus,29 there is clearly a divide between the knowledge expected of a newly graduated doctor, and that of a practicing ophthalmologist. The results of this study suggest that those years of postgraduate training may provide an opportune time for trainees to maximize the benefits of cadaveric dissection. Indeed, previous evidence suggests that ophthalmologists in training do have a desire for further opportunities to undertake cadaveric dissection in order to further their clinical knowledge but are in need of guidance and direction.30,31 Most (76.5%) of the participants on this course who were already practicing ophthalmology were in their first 3 years of specialty training. This makes it difficult to determine at exactly what stage in postgraduate training the benefits of cadaveric dissection might be maximized. It should be stated that as with all learning, anatomical education is a continuous process throughout any surgeon’s career. Learning opportunities should be made available to surgeons of all grades, and these opportunities should be tailored to the experience and learning needs of the individual, dependent on their prior experience. Recommendations The Royal College of Surgeons and The Anatomical Society have previously invested significant time and effort into determining the interplay between undergraduate and postgraduate anatomy education and in setting out a plan to improve standards.14 At the postgraduate level, anatomy training is poorly structured and poorly funded. In order to tackle this, there are 3 distinct areas that require attention.13 Firstly, a clear and definable curriculum is required for postgraduate anatomy training that can act as a framework for developing a new educational model. Secondly, a central and standardized initiative needs to be implemented to provide all surgical trainees with the fundamental anatomical principles that underline their surgical practice. The Royal College of Surgeons recommends that cadaveric dissection is central to this initiative,13-15 and the present study undertaken in trainee ophthalmic surgeons supports this notion. The third area that needs tackling is to develop regional initiatives that allow anatomical development throughout not only a junior surgeon’s training, but that 6
is continued throughout their professional career. Many independently run courses (such as that in the present study) exist and are of great value to surgeons of all grades. The fostering of partnerships between the Royal Colleges and local medical schools could improve postgraduate access to cadaveric material and promote the ongoing anatomical education of practicing surgeons.
CONCLUSION Many stakeholders in postgraduate surgical training (the Colleges, trainers, and trainees themselves) often perceive the changing tide of undergraduate anatomy teaching as posing additional challenges. The decline in undergraduate cadaveric dissection is an often cited moot point. Rather than simply filling the void left by this decline, the present study supports the hypothesis that the benefits of cadaveric dissection could be maximized during postgraduate surgical training. Wherever one sits on this topical debate, there is a push-pull effect that is heading in one direction; it is now more important than ever that postgraduate trainees in surgical specialties are provided with the opportunity to undertake cadaveric dissection.
ACKNOWLEDGMENTS Jon Moore, Alasdair Kennedy, Paul Brittain, Christopher Liu, Simon Rogers, Tracy Young, and Claire Smith for their support in running the course.
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The Value of Clinical Practice in Cadaveric Dissection: Lessons Learned From a Course in Eye and Orbital Anatomy Christopher Schulz, BM, BSc*,† Department of Anatomy, Brighton and Sussex Medical School, Brighton, UK; and †Eye Unit, Salisbury District Hospital, Salisbury, UK *
OBJECTIVE: To test the hypothesis that there is greater benefit in a dissection-based anatomy course among those participants with clinical experience in the relevant field, and those without. DESIGN: A retrospective comparative study. SETTING: Brighton and Sussex Medical School Anatomy
Department: an educational facility that provides undergraduate and postgraduate anatomy teaching using cadaveric specimens. PARTICIPANTS: All attendees (n ¼ 40) to a postgraduate
course in eye and orbital anatomy completed course evaluation forms. The course has been attended by delegates from around the country, with experience ranging from that of final year medical students to clinical fellows who have completed their specialist training in ophthalmology. RESULTS: Those participants who were practicing oph-
thalmology tended to be older than those who were not, with a greater amount of time spent on prior learning. Participants scored both the prosection-led and dissectionled sessions highly, with a mean combined evaluation of 8.9 (out of 10) for dissection-led learning and 9.2 for prosection-led learning. Prosection-led learning was regarded equally by those participants currently practicing in ophthalmology, and those who are not. In contrast, dissection-led learning was scored higher by those participants who were practicing ophthalmology (9.4), when compared with those not in ophthalmic practice (8.5; p ¼ 0.018). CONCLUSIONS: The present study supports the hypothesis that the benefits of cadaveric dissection could be
Correspondence: Inquiries to Christopher Schulz, Eye Unit, Salisbury District Hospital, Odstock Road, Salisbury, UK.; e-mail: [email protected]
maximized during postgraduate surgical training. This has important implications given the trend away from cadaveric dissection in the undergraduate curriculum. ( J Surg Ed C 2016 Published by Elsevier ]:]]]-]]]. Crown Copyright J Inc. on behalf of the Association of Program Directors in Surgery. All rights reserved.) KEY WORDS: anatomy and dissection and postgraduate
and education and surgery and ophthalmology COMPETENCIES: Medical Knowledge and Practice-Based Learning and Improvement
INTRODUCTION Anatomical principles underpin the foundations of medical and surgical practice. Because of this, anatomy has historically been taught during the early years of the medical school curriculum. Cadaveric dissection allows a 3dimensional appreciation of the human body and encourages learning through a process of autonomous discovery. Although dissection has played a central role in anatomy education for many centuries, it is often cited as being timeconsuming, resource-intensive, and emotionally disturbing for some students.1 Wherever one sits in this topical debate, there is little doubt that there has been a trend away from dissection-led anatomy in the modern undergraduate curriculum.2,3 It has been suggested that dissection-based learning is better suited to the postgraduate surgical trainee.4 Dissection fosters a spatial understanding, a recognition for surgical tissue planes, and a tangible appreciation for the proximity of structures; these skills are of more value to the practicing surgeon than a preclinical medical student. In addition, it might be expected that postgraduate trainees have a clearer vision of their specific field of interest and would likely have a much better clinical appreciation of
Journal of Surgical Education Crown Copyright & 2016 Published by Elsevier Inc. on behalf of the Association of Program Directors in Surgery. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2016.09.010 1931-7204/$30.00
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applied anatomy; they are more likely to maximize the potential benefits of dissection. The purpose of this study was to test this hypothesis. It was designed to determine whether there was any difference in the educational value of a dissection-led eye and orbital anatomy course between those participants with experience practicing in ophthalmology, and those without.
MATERIAL AND METHODS
fellowship examination (part 1), and prior learning. Participants were also asked to provide a quantitative evaluation of the “educational value of content” and “teaching methods used” for each of the dissection-led and prosection-led sessions. This quantitative evaluation takes the form of a 5-point Likert scale with a score of 1 deemed “very poor” and 5 being “very good.” The combined score (out of 10) formed the primary outcome measure in this study. The individual scores for content and teaching methods were used as secondary outcome measures.
The Course This instructional course was designed specifically for those in postgraduate ophthalmic training, as well as for those with an interest in undertaking a career in ophthalmology. The Royal College of Ophthalmologists recognizes the importance of applied anatomy as a learning objective in its postgraduate curriculum,5 and the course’s content is based on the anatomy-specific syllabus for the first part of the College’s fellowship examination in basic sciences.6 This course has been held annually on 3 occasions since 2014. The course is 8 hours in length during which time delegates undertake tutorials that are both dissection- and prosectionled. During the first 4 hours, the delegates work in groups between 3 and 5 and are supervised in undertaking dissection of the orbit (from a superior approach), the eyelids, and the lacrimal outflow system. The second half of the course comprises tutorials using prosected material that focuses on regional anatomy of the paranasal sinuses, vascular supply to the head, the intracranial visual pathway, and the cranial nerves. The sessions are facilitated by a faculty of experienced specialist consultants and registrars, as well as anatomists from Brighton and Sussex Medical School. Recruitment and Participants Since its inception, this course has been advertised online, through printed media, and by correspondence with the local education and training boards that form Health Education England. The course has been attended by delegates from around the country, with experience ranging from that of final year medical students to clinical fellows who have completed their specialist training in ophthalmology.
Analysis Based on their responses, participants were divided dichotomously into those who were already practicing ophthalmology clinically (as a specialist trainee, clinical fellow, associate specialist, or consultant) and those who were not (foundation year doctors and medical students). Owing to the discrete, ordinal nature of Likert-scale data,7 the MannWhitney-Wilcoxon test was used to determine whether there was a difference between these groups in the respondents’ scores for educational value of the content, evaluation of the teaching methods, and the combined score (as the primary outcome). This analysis was conducted on scores provided for both the dissection-led sessions and the prosection-led sessions. To evaluate whether prior educational experience was associated with improved course evaluation scores, participants were again stratified into groups based on whether or not they had any prior experience in orbital dissection, any prior experience with orbital prosections, more or less than 8 hours didactic/ tutorial-based learning in orbital anatomy, and more or less than 8 hours self-directed learning in orbital anatomy. The 8-hour threshold was selected for didactic and self-directed learning as this represents a full working day. For each of these dichotomous subgroups, the Mann-WhitneyWilcoxon test was used to determine whether there was any significant difference in the respondents’ scores for educational value of the content, evaluation of the teaching methods, and the combined score (as the primary outcome). Where data were missing or illegible, this was recorded as such and was excluded from analysis.
RESULTS
At the close of each course, participants were asked to complete a detailed evaluation of the course. Evaluation forms were completed and collected anonymously with the course instructors and study authors masked to the individual participants’ responses. The evaluation forms asked participants to provide information on basic characteristics such as age, level of experience, completion of their College
Forty participants completed the course in eye and orbital anatomy. All participants provided evaluation forms. The baseline characteristics can be found in Table 1. Three participants failed to provide their age, but otherwise the evaluation forms were completed in full. Those participants who were practicing ophthalmology tended to be older than those who were not, with a greater amount of time spent on prior learning and a higher pass rate of the Royal College of Ophthalmologists’ part 1 fellowship examination (Table 1).
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Outcome Measurement
TABLE 1. Baseline Characteristics of Study Participants Not Practicing Ophthalmology (n ¼ 23) Mean (SD) age 25.5 (1.6)* No. (%) of male 11 (47.8%) participants No. (%) of participants at Medical Student 2 (8.7%) Specialty trainee each stage of career (final year) year 1–3 FY1 (Postgraduate 9 (39.1%) Specialty trainee year 1) year 4–7 FY2 (Postgraduate 12 (52.2%) Completed higher year 2) specialty training Mean (SD) no. of hours spent on prior learning in eye and orbital anatomy Dissection-based 1.1(2.2) Prosection-based 2.9 (5.0) Didactic/tutorial 6.3 (12.8) Self-directed 16.1 (23.3) Postgraduate learning Dissection-based 0 (0) Prosection-based 0 (0) No. participants (%) that 1 (4.3%) had passed Part 1 Fellowship examination
Currently Practicing Ophthalmology (n ¼ 17)
Total (n ¼ 40)
30.3 (4.8)† 8 (47.1%)
27.5 (2.0)‡ 19 (47.5%)
13 (76.5%) 2 (11.8%) 2 (11.8%) 2.9 3.2 9.3 67.5
(5.4) (5.3) (13.3) (53.9)
0 (0) 0 (0) 7 (41.1%)
1.9 3.0 7.6 36.3
(2.8) (4.4) (12.9) (32.5)
0 (0) 0 (0) 8 (20.0%)
Complete data available with the exception of: *n ¼ 22. † n ¼ 15. ‡ n ¼ 37.
It is worth noting that more than three-quarters of those practicing in ophthalmology were in their first 3 years of specialty training. For all participants, the vast majority of prior learning in eye and orbital anatomy was self-directed. On average, participants had spent less than 2 hours on dissection, and 3 hours with prosected cadaveric material. In this study cohort, participants reported that all dissectionand prosection-based learning had been undertaken at an undergraduate level. With reference to Table 2, participants scored both the prosection-led and dissection-led sessions highly, with a mean combined evaluation of 8.9 (out of 10) for dissectionled learning and 9.2 for prosection-led learning. Prosectionled learning was regarded equally by those participants currently practicing in ophthalmology, and those who are not. In contrast, dissection-led learning was held in higher regard by those participants who were practicing ophthalmology, when compared with those not in ophthalmic practice (Fig.). This statistical difference was evident for both the combined evaluation score, as well as the participants’ score for teaching methods used (Table 2). That said, both groups rated the content value of these sessions equally. Considering the possible confounding effect of prior learning experiences using the Mann-Whitney-Wilcoxon test, there was no significant difference in the evaluation scores for those students either with prior experience in orbital dissection, or
eye and orbital prosection. Nor was any difference detected for those who had prior exposure to more or less than 8 hours of didactic teaching. Students who had previously committed more than 8 hours of self-directed learning to eye and orbital anatomy were more likely to evaluate the dissection-led teaching higher than those who had not (Table 3). Indeed, for those participants with more than 8 hours of prior selfdirected learning, no difference was detected in the course evaluation scores provided by those who were practicing in ophthalmology, and those who were not. However, for those participants who were not currently practicing in ophthalmology, the effect of self-directed learning remained highly significant on the combined evaluation score for dissectionled teaching (p ¼ 0.01) but not the prosection-led sessions (p ¼ 0.13).
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DISCUSSION In many institutions, there is a trend away from dissectionled learning at undergraduate level.2,3 This is reflected in the present study by the fact that participants who were further into their postgraduate careers had spent more time on cadaveric dissection and prosected material than their more junior colleagues. This was observed despite the fact that no cadaveric-based learning had been undertaken by any of the participants after graduation from medical school.
TABLE 2. Course Evaluation Scores, Grouped by Whether the Participant is Currently Practicing Ophthalmology or Not
Dissection-led learning Educational value of content Teaching methods used Combined evaluation score Prosection-led learning Educational value of content Teaching methods used Combined evaluation score
Not Practicing Ophthalmology (n ¼ 23)
Currently Practicing Ophthalmology (n ¼ 17)
All Participants (n ¼ 40)
Mann-WhitneyWilcoxon Test (p Value)
4.37 (4.1-4.6) 4.15 (3.9-4.4) 8.52 (8.0-9.1)
4.70 (4.5-4.9) 4.73 (4.5-4.9) 9.44 (9.1-9.8)
4.51 (4.3-5.0) 4.40 (4.2-5.0) 8.91 (8.6-10.0)
0.13 0.008 0.018
4.61 (4.4-4.8) 4.56 (4.3-4.8) 9.17 (8.7-9.6)
4.82 (4.7-5.0) 4.41 (4.0-4.8) 9.23 (8.7-9.7)
4.70 (4.6-5.0) 4.50 (4.3-5.0) 9.20 (8.9-10.0)
0.22 0.84 0.87
Presented as mean values with lower and upper confidence intervals in parentheses. p-Values are given for Mann-Whitney-Wilcoxon Test between those participants who are practicing ophthalmology, and those who are not. Bold figures indicate statistical significance (p o 0.05).
With doctors now entering higher surgical training with less undergraduate exposure to dissection, there is a growing void in their anatomical education. Apart from simply filling this undergraduate void, it has been suggested that cadaveric dissection might actually be better suited to postgraduate surgical trainees because of their clinical experience and the greater need for a spatial understanding of surgical anatomy.4 A number of postgraduate dissection-based courses in anatomy have been developed and shown to have proven benefit in the fields of general surgery, obstetrics and gynecology, and orthopedics.8-12 Indeed, the Royal College of Surgeons have themselves recognized the need for structured anatomy education as part of their postgraduate curriculum.13-15 Compared with the previously cited literature, the present study offers new insight on 2 parts. Firstly, although it might be expected that any postgraduate educational course would be rated highly by its participants, it would seem that there is significant value in providing an instructional
Prosecon-led sessions
a)
postgraduate course in anatomy that is specifically relevant for ophthalmologists. Secondly, and more importantly, this study specifically compared the benefit of dissection-based learning in those participants who already had practical experience in the relevant clinical field (of ophthalmology in this case), and those who were not. The results support the notion that clinical and surgical experience can enhance the benefits of dissection-led learning. It is proposed that this might be due to 3 primary reasons.
DEEPER APPROACHES TO LEARNING Deep learning involves an integrative approach that leads to personal understanding. Deep learners would use a selfdirected approach to ‘map out’ a topic to see how ideas fit together. This is in comparison to strategic learning that is goal-directed (e.g., for examinations) or surface learning that involves memorizing ideas in isolation. There is evidence
10
Combined Evaluaon Score
10
Combined Evaluaon Score
Dissecon-led sessions
b)
9
8
7
9
8
7
6
6
Not praccing in Praccing in ophthalmology ophthalmology
Not praccing in Praccing in ophthalmology ophthalmology
FIGURE. Comparison between the combined evaluation score for dissection-led versus prosection-led teaching grouped by whether participants are currently practicing ophthalmology or not. n ¼ 23 for participants not practicing ophthalmology; n ¼ 17 for participants practicing in ophthalmology. 4
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TABLE 3. Course evaluation scores, grouped by whether the participant had previously undertaken more than 8 hours of selfdirected learning in eye and orbital anatomy, or not.
Dissection-led learning Educational value of content Teaching methods used Combined evaluation score Prosection-led learning Educational value of content Teaching methods used Combined evaluation score
o8 Hours Self-Directed Learning (n ¼ 13)
48 Hours SelfDirected Learning (n ¼ 27)
All Participants (n ¼ 40)
Mann-WhitneyWilcoxon Test (p Value)
4.14 (3.9-4.4) 3.93 (3.7-4.1) 8.07 (7.7-8.5)
4.70 (4.6-4.8) 4.66 (4.5-4.8) 9.36 (9.1-9.6)
4.51 (4.3-5.0) 4.40 (4.2-5.0) 8.91 (8.6-10.0)
0.015 0.001 0.002
4.50 (4.3-4.7) 4.29 (4.1-4.5) 8.79 (8.4-9.1)
4.82 (4.7-4.9) 4.64 (4.4-4.9) 9.46 (9.2-9.8)
4.70 (4.6-5.0) 4.50 (4.3-5.0) 9.20 (8.9-10.0)
0.10 0.13 0.14
Presented as mean values with lower and upper confidence intervals in parentheses. p-Values are given for Mann-Whitney-Wilcoxon test between those participants who are practicing ophthalmology, and those who are not. Bold figures indicate statistical significance (p o 0.05).
that students who are older tend to adopt a deeper approach to learning.16-18 As would be expected, participants in this study who were practicing ophthalmology tended to be older than those that were not. Compared with preclinical medical students learning anatomy, postgraduate trainees are more likely to know where their own specialist interest lies, resulting in greater focus, motivation, and direction. It is suggested that they would have a greater insight into their own educational needs and adopt a deeper approach to learning anatomy, drawing on their greater degree of prior knowledge. This deeper learning approach is complimented by the autonomous, self-directed, and tactile approach to learning that cadaveric dissection offers.19
PRIOR LEARNING EXPERIENCES
SURGICAL APPLICATION Those who are already practicing surgery have a greater appreciation for the need to understand surgical tissue planes and regional anatomy. However well-prepared a surgical trainee feels they are, all surgeons have gaps in their anatomical understanding that would only truly become apparent under the spotlight of the operating theater. It is only with this conscious recognition that one is not adequately competent that measures can be taken to address these deficiencies. Pugh et al.21 observed that knowledge in anatomy was the most frequently reported learning need among surgical residents. Both anecdotal and objective evidence suggest that dissection is a key method for developing the 3-dimensional awareness of human anatomy.23-26
Postgraduate specialty trainees would have greater experience than medical students. The learning process is enhanced by a doctor’s ability to relate new anatomical ideas and concepts to their own prior clinical and nonclinical learning experiences. This continuous cycle of relating prior experience with anatomical constructs helps to develop the foundation upon which new experiences and ideas can be built. Participants in this course that had committed more than 8 hours of self-directed learning toward relevant material were more likely to value a dissection-led approach to learning. This effect remained evident whether or not the participant was practicing in ophthalmology and so emphasizes the importance of anatomy as “a sequential subject in which knowledge acquired is subsequently elaborated upon.”20 Traditionally, most anatomy learning often takes place in the preclinical years of medical school. At this stage in their career, students may struggle to understand the true clinical relevance of anatomy, and often find great benefit in revisiting the basic sciences either in the later years of medical school, or during the early postgraduate years.8,10,21,22
This study was limited by its retrospective design and small sample size. In combination with the heterogeneity of participants recruited, it is not possible to draw on any firm conclusions regarding causal relationships or the interaction of various confounding factors. An attempt was made to evaluate the relationship between prior learning experiences as possibly confounding, and it has become evident that self-directed learning does indeed play an important role in the results of this study. This does not negate the finding that the benefits of dissection appear to be greater in those currently practicing in the relevant field, but rather it helps to offer some explanation as to why this is so. The pros and cons of noncontinuous, ordinal Likertscale data have been discussed extensively elsewhere7 and nonparametric testing was used to limit statistical error. The Likert-scale focused on self-reported evaluations, and this does necessarily equate to the actual benefit of the learning experience. Learning is a complex process, and evaluating the quality of teaching is equally complex. That said, participant-reported evaluations of teaching do appear to
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Study Limitations
be associated with objective learner outcomes, and their use is widespread in educational research.27,28 Although the points discussed this far can be generalized to all surgical specialties, this study was limited to those participants undertaking an anatomy course tailored to ophthalmologists. With that in mind, it does raise some additional points specific to this field of practice. The Royal College of Ophthalmologists recognizes that “all trainees must understand and apply knowledge of the anatomy of the eye, adnexae, visual pathways, and associated aspects of head, neck, and neuroanatomy.”5 When the syllabus for the college’s fellowship examination6 is compared with The Anatomical Society’s core undergraduate syllabus,29 there is clearly a divide between the knowledge expected of a newly graduated doctor, and that of a practicing ophthalmologist. The results of this study suggest that those years of postgraduate training may provide an opportune time for trainees to maximize the benefits of cadaveric dissection. Indeed, previous evidence suggests that ophthalmologists in training do have a desire for further opportunities to undertake cadaveric dissection in order to further their clinical knowledge but are in need of guidance and direction.30,31 Most (76.5%) of the participants on this course who were already practicing ophthalmology were in their first 3 years of specialty training. This makes it difficult to determine at exactly what stage in postgraduate training the benefits of cadaveric dissection might be maximized. It should be stated that as with all learning, anatomical education is a continuous process throughout any surgeon’s career. Learning opportunities should be made available to surgeons of all grades, and these opportunities should be tailored to the experience and learning needs of the individual, dependent on their prior experience. Recommendations The Royal College of Surgeons and The Anatomical Society have previously invested significant time and effort into determining the interplay between undergraduate and postgraduate anatomy education and in setting out a plan to improve standards.14 At the postgraduate level, anatomy training is poorly structured and poorly funded. In order to tackle this, there are 3 distinct areas that require attention.13 Firstly, a clear and definable curriculum is required for postgraduate anatomy training that can act as a framework for developing a new educational model. Secondly, a central and standardized initiative needs to be implemented to provide all surgical trainees with the fundamental anatomical principles that underline their surgical practice. The Royal College of Surgeons recommends that cadaveric dissection is central to this initiative,13-15 and the present study undertaken in trainee ophthalmic surgeons supports this notion. The third area that needs tackling is to develop regional initiatives that allow anatomical development throughout not only a junior surgeon’s training, but that 6
is continued throughout their professional career. Many independently run courses (such as that in the present study) exist and are of great value to surgeons of all grades. The fostering of partnerships between the Royal Colleges and local medical schools could improve postgraduate access to cadaveric material and promote the ongoing anatomical education of practicing surgeons.
CONCLUSION Many stakeholders in postgraduate surgical training (the Colleges, trainers, and trainees themselves) often perceive the changing tide of undergraduate anatomy teaching as posing additional challenges. The decline in undergraduate cadaveric dissection is an often cited moot point. Rather than simply filling the void left by this decline, the present study supports the hypothesis that the benefits of cadaveric dissection could be maximized during postgraduate surgical training. Wherever one sits on this topical debate, there is a push-pull effect that is heading in one direction; it is now more important than ever that postgraduate trainees in surgical specialties are provided with the opportunity to undertake cadaveric dissection.
ACKNOWLEDGMENTS Jon Moore, Alasdair Kennedy, Paul Brittain, Christopher Liu, Simon Rogers, Tracy Young, and Claire Smith for their support in running the course.
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