Key words education - anatomy - teaching of anatomy - radiologic anatomy - preclinical curriculum
Introduction
Human anatomy is the basis for almost all clinical action. This fact is highlighted by a survey of 318 medical students, 94 % of whom regard the course of gross anatomy as relevant [1 ]. Specialists before final board examination feel that anatomy is the most important preclinical subject for later work [2 ].
However, the anatomical knowledge of students entering the clinical stage of medical education is often classified as poor for safe clinical practice. Conventional anatomy courses seem to prepare students inadequately for their clinical tasks [3 ]. Even students themselves do not feel properly trained [4 ]
[5 ].
In an article published in 2012, it was yet again demanded to shift the focus of anatomy teaching onto the anatomy of the living which is often different from the anatomy of corpses [6 ]. One possibility for this “anatomia in vivo” is medical imaging. Over the last few years these techniques have been gaining an increasingly important status in anatomy teaching [7 ]
[8 ]
[9 ], but until 2006 they comprised a mere 5 % of actual teaching time [10 ]. However, synergistic effects have been shown to lead to an increased interest in the subject as well as better learning and dissection skills in the long run [11 ]
[12 ]
[13 ]
[14 ]
[15 ]. 80 % of the student body would be happy about the introduction of an imaging course in their anatomical education [16 ]. Positive experiences have been reported about sonography courses as well [17 ]
[18 ]
[19 ]. Combining the traditional dissection course with visual methods seems to be the most effective teaching procedure [19 ].
The present medical faculty has a 30-year record of delivering anatomical knowledge by means of the living ([Table 1 ]). In 2001, “Anatomy and Imaging” was established as a bridging course between the preclinical and the clinical stage. The purpose of this course is to deepen knowledge within a clinical context and to provide first contact with medical imaging.
Table 1
History of the “Anatomy and Imaging” course.
date
activity
1982 – 1999
“Anatomy of the Living” and “X-ray Anatomy” seminars as an accompaniment to the “Gross Anatomy Course”
1995
addition of “Sonographic Anatomy”
1999 – 2001
complementary course “Anatomy in the Preclinical Practice” with the following course parts: clinical examination, X-ray anatomy, sonographic anatomy and clinical evening events
2001
authorization of subsidies through the program “Quality of Education” by the Ministry of Education, Science and Research; establishment of an integrative course concept with the founding of the basic and advanced course “Anatomy and Imaging”
2003
coming into force of the new Licensing Regulations for Physicians (Approbationsordnung of 27/6/2002); recognition of the course as an “Elective with a Graded Certificate”
2012
new concept of the course as a day-long block course on four days of the week
2013
beginning of the curricular offering of the block course “Anatomy and Imaging” in the framework of the “Seminars with Clinical References” according to the Licensing Regulations for Physicians (ÄAppO)
We report our experiences and the course evaluations over the last 10 years.
Materials and Methods
The course is organized into a basic and an advanced course, lasting a semester each. The maximum number of participants per semester was limited to 30 students. The course structure and syllabus are shown in [Table 2 ].
Table 2
Structure and content of the basic and advanced course (as in 2012).
one-year course
lessons, group size, content
part 1: basic course
X-ray and CT-anatomy
12 course entities, 10 participants/group
1 X-ray/CT spine
2 X-ray pelvis/hip
3 X-ray hand/elbow
4 X-ray shoulder/skeletal thorax
5 X-ray thorax (lung/pleura)
6 X-ray thorax (heart/big vessels)
7 CT thorax
8 X-ray abdomen
9 CT abdomen
10 CT skull
11 CT/MRI brain
12 Head injury
ultrasound anatomy
12 course entities, 5 participants/group
6 hours of sonography of the upper abdomen
1 hour of sonography of the lower abdomen
1 hour of sonography of the thyroid gland
4 practice sessions
clinical lectures
8 lessons
1 introduction to radiology
2 sonographic anatomy I
3 sonographic anatomy II
4 hand injuries in sports
5 spine, imaging and clinical examination
6 introduction to nuclear medicine
7 special nuclear medicine heart/brain/PET-CT
8 intracranial bleeding
examination
written (multiple choice)
practical (objective structured clinical examination)
part 2: advanced course
sonography
6 lessons, 10 participants/group
4 topic blocks
11 lessons, 10 participants/group
part a: technique
systematics of chest X-ray
systematics of skeletal radiology
MRI technique
CT technique
digital subtraction angiography technique
part b: applications
brain hemorrhage
stroke
prevalent pathologies in the X-ray of the chest
musculoskeletal MRI
interventions in radiology
part c: synoptic cases
management of trauma
thoracic pain
tumor staging: thorax
tumor staging: skeleton
tumor staging: abdomen
part d: lectures
mammography
pediatric radiology
examination
written (multiple choice)
Basic course
Management of the course came under the responsibility of the Institute of Anatomy. Staff from the Institute of Clinical Radiology as well as medical lecturers from other fields were involved in medical lectures.
Participants and entry requirements
The basic course was aimed at preclinical students upon their completion of the gross anatomy course. On account of the students’ keen interest, the passing of an entrance exam was a prerequisite for participation. The top thirty students among approximately sixty applicants were admitted to the course.
Course structure
Classes on X-ray anatomy, ultrasound and clinical lectures took place weekly for one hour in each subject, either in small groups or in an assembly (total attendance 4 periods per week throughout the semester).
X-ray and CT anatomy
Initially, an introduction to the systematics of image viewing and analysis was given. Every group study unit (10 students) began with a discussion of a normal X-ray for the purpose of identifying and demonstrating known anatomic structures. Subsequently, two students examined a clinical case. In addition to the X-rays, the anamnesis and cause of referral were made available for this purpose. As a rule, pathologies were chosen in such a way that they could be derived from knowledge of normal anatomy (i. e., distal radial fracture, lobar pneumonia, hemorrhage of the subarachnoid). Following this, one student from each of the teams was required to present the case to the group. Attention was particularly drawn to the observance of systematic image analysis as the core competence to be learned. Every student was required to demonstrate at least one case per lesson.
Ultrasound anatomy
Sonographic anatomy was instructed in small groups of five students in order to achieve a longer active exercise session for learning practical skills. Firstly, technical fundamentals of sonography were conveyed during two introductory lectures. Secondly, the students examined each other in turn. Specific standard planes, in which anatomical structures were to be identified and indicated, had to be reproduced.
Anatomy of the Living
Until 2003, “Anatomy of the Living” was a fixed component of the course and was concerned with the anatomical identification of anatomical ‘landmarks’ on the living. In a second step, fundamental clinical examination methods were conveyed. The students again examined each other in turn. Due to the introduction of a clinical examination course in the preclinical phase in 2003, this part of the course was omitted.
Clinical lectures
Lectures by experienced clinicians complemented the concept of education to demonstrate the relevance of imaging ([Table 2 ]).
Advanced course
The advanced course “Anatomy and Imaging” was for students who had successfully completed the basic course. It took place once a week in small groups of ten participants (2 periods per week throughout the semester). Management of the course was now under the responsibility of the Department of Clinical Radiology. As in the basic course, the syllabus and the personnel were matched with lecturers from the Institute of Anatomy.
Course structure
Initially, the students began with a discussion of essential radiological techniques and the consolidation of the systematics of image analysis. For instance, the Seldinger puncture technique could be tried out on a model. Afterwards, clinical cases (e. g. stroke management) were independently processed by the students under the guidance of one of the student tutors. The emphasis was on the systematic image analysis and on the exact anatomical relationships of the results (e. g. the attribution of the ischemic brain area to the supplying artery and the resulting clinical deficits). In addition, true synoptic cases were treated interactively in the course of which the students could self-reliantly collect an anamnesis and clinical data, as well as arrange for various imaging procedures. Also, the justifying medical indication for the examination was retraced ([Table 2 ]).
In the sonography course, the previously obtained skills could be intensified on real patients. The patients had already expressed their approval for the examination to be carried out by the students. The focus of the course was again based on a systematic line of action concerning the survey of the case history, as well as the physical and sonographic examination.
Tutors and lecturers
The periods of study in the basic and advanced courses were given by student tutors from clinical semesters under the supervision of medical lecturers. Prerequisites for becoming a tutor were a successful participation in the course itself in addition to a top mark in the preliminary medical examination. Further conditions were teaching experience as a tutor in the gross anatomy course and completion of a four-week clinical elective in the Department of Clinical Radiology. Before each course session, a preliminary discussion was held between the medical heads of the course and the student tutors. The majority of the tutors were available for several semesters.
Script
An extensive script covering relevant anatomical and clinical information as well as checklists for systematic reporting were made available in print and/or online for both courses, enabling students to prepare before and after.
Final examination
The basic and the advanced course each finished with a multiple choice exam, covering the content of every lesson.
For the basic course, a practical test in the form of an OSCE (objective structured clinical examination) with stations for X-ray/CT and sonographic anatomy took place. Special attention was given to the observance of systematic reporting and to the correct description of the anatomic structures as well as to an adequate behavior towards the test person. The grading was carried out by the student tutors in accordance with a previously stipulated standardized pattern.
Evaluation
Within the framework of the final examinations, the students were required to evaluate each course. The evaluation form had been kept constant over the entire period of the last 10 years ([Table 3 ]). We used a 5-point Likert scale (1: fully agree, 5: do not agree). After every semester, a discussion about the course evaluation took place between lecturers and tutors for future improvement.
Table 3
Questions on the evaluation form in the basic course.
part 1: X-ray and CT-anatomy
fully agree do not agree
The course was well organized.
1
2
3
4
5
comments:
The material was structured clearly.
1
2
3
4
5
comments:
The selection of topics was good.
1
2
3
4
5
comments:
The instructors and tutors communicated the material appropriately.
1
2
3
4
5
comments:
part 2: Ultrasound anatomy
fully agree do not agree
The course was well organized.
1
2
3
4
5
comments
The material was structured clearly.
1
2
3
4
5
comments:
The selection of topics was good.
1
2
3
4
5
comments:
Training time was sufficient.
1
2
3
4
5
comments:
The instructors and tutors communicated the material appropriately.
1
2
3
4
5
comments
part 3: Clinical lectures
fully agree do not agree
The course was well organized.
1
2
3
4
5
comments
The selection of topics was good.
1
2
3
4
5
comments
The instructors and tutors communicated the material appropriately.
1
2
3
4
5
comments
part 4: “Anatomy and Imaging” in total
fully agree do not agree
The choice of media was adequate.
1
2
3
4
5
comments
The script provided a good working basis.
1
2
3
4
5
comments
The course contributed to my learning process.
1
2
3
4
5
comments
Relevance for medical education was evident.
1
2
3
4
5
comments
The course enhanced my interest in medicine.
1
2
3
4
5
comments
I am satisfied with the course.
1
2
3
4
5
comments
Expenditure of time spent was
too high:
appropriate:
too little:
comments
The course level was
too high:
appropriate:
too low:
comments
further remarks, criticism, suggestions
Results
Participants
During the period from 2001 to 2012, 618 students (311 males and 307 females) enrolled in the basic course “Anatomy and Imaging”, and 614 (99.4 %) attended the complete course and took the final examination. The majority of the students were in the third preclinical semester when they started the basic course. 316 students (149 males, 167 females) attended the subsequent advanced course.
Evaluation results
Of the 618 participants of the basic course, 557 completed assessment forms were available (90 % of the total). Of the 316 participants of the advanced course, 292 of the assessment forms could be evaluated (92 % of the total). The results are displayed in [Fig. 1 ], [2 ], [3 ].
Fig. 1 Evaluation results for basic course for A X-ray and CT-Ultrasound anatomy, B sonographic anatomy, C clinical lectures, D total assessment 5-point Likert scale (1: fully agree, 5: do not agree).
Fig. 2 Evaluation results for advanced course 5-point Likert scale (1: fully agree, 5: do not agree).
Fig. 3 Evaluation results for time invested and basic and advanced course level.
On a 5-point Likert scale (1 = fully agree; 5 = do not agree), the statement “the relevance for medical education was evident” received the highest rating of 1.17 (basic course) and 1.24 (advanced course). The statement “the script provided a good working base” received the lowest rating (1.53 for the basic course; 2.58 for the advanced course). The quality of the tutors was rated with 1.42 and 1.51, respectively. The summarizing statement “I am satisfied with the course” received the rating 1.33 and 1.56 respectively on a ten-year average.
Discussion
The increase in medical knowledge confronts teaching in medical faculties with new challenges [20 ]. With the introduction of the new Licensing Regulations for Physicians (Approbationsordnung of 27/6/2002) in 2003, basic medical training in Germany was faced with new demands. These included a stronger link between preclinical theory and clinical knowledge, a stronger interdisciplinary, subject-focused learning method as well as new forms of examination and continuous evaluation of the teaching system [21 ].
Thereby anatomy teaching is also a hot topic of discussion. Various concepts have been developed in order to improve the quality [16 ].
A recent article once again called for the modernization of anatomy teaching at German faculties, demanding a closer liaison with clinical subjects. Dissecting exercises were questioned. One should focus on the anatomy of the living [9 ].
The use of imaging processes to improve visualization of anatomical relationships is a recommended possibility to obtain anatomical knowledge and to connect preclinical with clinical subject matter [22 ]. A simultaneous application of dissection, radiological film material, clinical cases and the achieving of clinical skills lead to a significant improvement of the understanding of anatomy [23 ]
[24 ]. According to a survey, 80 % of students would welcome the introduction of imaging courses within the framework of teaching anatomy [16 ]. Also, the introduction of sonography courses has led to positive experiences with high rates of acceptance among students and a positive influence on the interest of anatomical knowledge [17 ]
[18 ]
[19 ].
The transmission of information into long-term memory and the rapid recall in a clinical situation depend crucially on the conditions under which the information was learned. Chiefly, active involvement, a connection with present knowledge, the obtaining of knowledge in similar situations like the recalling of knowledge, clear clinical relevance and a high rate of repetition are favorable to learning [4 ].
“Anatomy and Imaging” as a bridging course between preclinical and clinical semesters achieved the outlined goals by providing students with the means of repetition after their successful completion of the gross anatomy course, with facts and clinical radiological cases in a problem-oriented setting. It is well known that the interactive form of a course as well as practical applications support the learning process [25 ].
The success of this concept is reflected in the results of the evaluation. The students of the basic and advanced courses rated almost all the statements with 1 to 2. With a participation of over 90 %, this can be considered representative. The clinical relevance of the obtained correlation was noticeable, as the very good correlation results with 1.17 and 1.24, respectively, demonstrate.
Only the presented learning material of the advanced course was graded with 2.58. The reasons for this most likely were the lack of illustration of the individual cases of the patients in the sonography lessons, and the omission of the synoptic cases in the third part of the course. These synoptic cases had been left out on purpose, so that the correct diagnosis could not be anticipated.
The course level was considered appropriate by almost all the students (more than 95 %). The amount of time used in the basic course was considered too much by 15 % of the students. This could be explained by the fact that in the early years only half of the time spent in the course was recognized for the performance certificate. From 2006 onwards, the course was finally recognized as an elective course with graded certificates of 4 periods per week during the semester.
In addition, the question of efficacy of a preclinical imaging course for further education must be discussed.
A total of two-thirds of all graduates at seven German medical faculties feel badly prepared for their clinical work. Interpreting X-rays already ranks fifth among all deficiencies [26 ]. Taking a chest X-ray course as an example, the primary benefit lay less in the memorization of facts but rather in the alleviation of later repetition and intensification of the material from previous experiences [27 ]. Furthermore, a systematic analysis of a chest X-ray in an early study phase has the potential to create a reliable basis for the later daily working routine [28 ].
Because of its vital clinical significance, special emphasis was placed on the chest X-ray in our course as well. Conveying a systematic and reliable method for image interpretation was especially important.
“Anatomy and Imaging” is set up as a small group study in order to encourage active and practical work for students. A much discussed problem of this teaching method is the large amount of workload and use of personnel which leads to excessive costs and as a rule can hardly be carried out by qualified medical people.
A solution to the problem – in spite of uttered reservations [29 ] – could be the use of specially trained student tutors under the supervision of qualified medical personnel.
Comparing professional and student tutors by questioning participants of a pharmacology course, it became evident that neither specialized competence nor teaching experience had any significant influence on the students’ results in the written final examinations [30 ]. Positive experiences were also reported regarding the student tutor system in the area of ultrasound courses [17 ]
[18 ].
In the above course, the quality of the tutors was assessed by the participants with 1.42 and 1.51, respectively. This shows the high acceptance of tutors in small group study. It must be noted that the tutors also expressed satisfaction with the demanding requirements which resulted in the fact that the majority stayed for many further semesters.
It was also advantageous for the medical tutors. Maximum flexibility with respect to time planning was reached because of prearranged meetings with the well-trained student tutors. A meeting between instructors and tutors together at the end of the semester has proven to be very helpful. Evaluation results were assessed together and the following course was planned.
A difficulty of problem-oriented learning is that students can develop a special interest in the clinical background and then neglect their achieved basic knowledge [4 ]. An important task for the tutors of “Anatomy and Imaging” therefore was to maintain a systematic priority with image analysis and image interpretation.
The total positive resonance and the high number of applicants for the limited number of places indicated that an enlargement of the course concept would be desirable. For that reason, the basic course of ‘Anatomy and Imaging’ was enlarged as a block course for the winter semester 2012/2013 for a complete semester cohort, with 98 voluntary applications.
Following a decision by the local medical faculty, the course “Anatomy and Imaging” is now, since 2013, part of the curriculum for the third preclinical semester as a “seminar with clinical reference”.
For radiology, the chance exists that students could be brought closer to this subject already in the preclinical stage and to develop an early interest in imaging.
The implementation of modern clinical imaging techniques into the preclinical phase of medical studies represents a successful concept.
„Anatomy and Imaging“ in undergraduate medical education creates a win-win situation: For the students to achieve relevant anatomical knowledge in a clinical context; for the radiologists to prime future clinicians for their field.
