Is cadaveric dissection essential in medical education? A qualitative survey comparing pre-and post-COVID-19 anatomy courses

Methods

The study was classified as exempt by the Institutional Review Board at the Rowan SOM (protocol #PRO-2021-474). The data compiled for this study was acquired through the distribution of an electronic survey through Qualtrics XM. The survey was developed by the authors and piloted prior to distribution. The target audience was students from the Classes of 2023 and 2024 at Rowan SOM. The Class of 2024 was part of a virtual anatomy lab as compared to the Class of 2023, which had an in-person anatomy lab in their first year of medical school. All of the participants were 18 years or older and completed the informed consent prior to filling out the survey. The Classes of 2023 and 2024 both have approximately 200 students in each cohort. The survey did not collect any name, sex, or age identifiers, and all of the data were confidential. Anatomy is the first course that medical students at Rowan SOM cover over 8 weeks for both the Classes of 2023 and 2024. The difference between the cohorts was that the Class of 2023 had practical, hands-on dissection followed by three in-person practical, hands-on dissections to test the students’ knowledge, whereas the Class of 2024 received online videos and group exercises to substitute for the in-person dissection, which was followed by weekly quizzes and written exams with dissection pictures to test the students’ understanding. For both classes, the quizzes and exams were a part of the grade that they needed to pass the course.

Results

The survey was administered to a total of 400 students from the two classes with different curricula for the anatomy lab before and during COVID-19. The response rate for the survey was 37.3% (n=149); 36.2% (n=54) belonged to the Class of 2023 and 63.8% (n=95) belonged to the Class of 2024. Among the participants, 70.5% (n=149) had no prior cadaver experience before entering medical school. Only 38.9% (n=58) of the students wanted to specialize in surgery and 7.4% (n=11) wanted to specialize in radiology before coming to medical school. Further breakdown of the demographic data based on class groups is shown in Table 1. Table 4 shows a large effect size for the data collected as measured by Cohen’s d.

Regarding Tables 2 and 3, when students were asked about the likelihood of specializing in surgery after taking the anatomy lab, the data showed no difference between the two classes. The achieved p value was 0.329 with a mean of 3.37 (Class of 2023) and 3.28 (Class of 2024). Similarly, the two cohorts did not differ in their preference for specializing in radiology after taking the anatomy lab, with a p value of 0.400. When asked about the understanding of trauma after their respective anatomy labs, the Class of 2023 showed a significantly higher confidence, with a p value of <0.001 and a mean of 2.26 for the Class of 2023 and 3.49 for the Class of 2024. These results represent students’ perspectives of their training, which is assessed through imaging- and trauma-related questions throughout the anatomy curriculum Table 4.

Discussion

With the surge of the novel coronavirus, the modality of teaching anatomy has shifted from in-person cadaveric dissection to virtual lessons for incoming first-year medical students. Considering this, the magnitude of the impact that this change has caused is still under investigation. In a study conducted by Dharamsi et al. [11], no significant difference was found in score outcomes in the groups (n=54) that received only the video-based muscle model vs. groups (n=53) that received standard cadaveric dissection. Furthermore, students expressed a favorable outlook on the video-based muscle model as a complement to their anatomy course. Similarly, in a meta-analysis evaluating the effectiveness of augmented reality in anatomy education, no statistically significant difference was seen in the pre− and posttest scores. However, the students overall expressed decrease motivation due to the complexity of utilizing augmented reality and adjusting to a new digital platform. The study concluded that a lack of statistical difference between test scores can place augmented reality as an alternate teaching method in the traditional cadaveric lab [5]. With this information, we evaluated the obligatory integration of virtual anatomy at Rowan SOM through a qualitative survey received from a total of 149 medical students, with a response rate of 36.24% from the Class of 2023 and 63.76% from the Class of 2024. The overall response number in each group was above the number of responses (n=50) needed to reach statistical significance.

Among the three domains evaluated in the survey, the confidence domain included the questions “How likely are you to specialize in surgery after taking anatomy lab?” and “How likely are you to specialize in radiology after taking anatomy lab?” as well as the statement “My anatomy lab provided me with an understanding of the effects of trauma.” There is no statistically significant difference between the two classes when assessing their interest in pursuing surgery and radiology after taking their corresponding anatomy course, as evident by the nonsignificant p values. This similarity was pronounced because both classes expressed responses that produced a relative equivalent mean for the first two questions. Similarly, when asked about specializing in radiology, both cohorts showed higher inclination toward the negative spectrum of the Likert scale with means of 3.90 (Class 2023) and 3.86 (Class of 2024). We believe that this stems from the low popularity of both surgery and radiology among medical students. Unlike our study, past studies have found that cadaver dissection produced more graduates favoring surgical programs, but to our knowledge, no studies have correlated radiology to cadaver experience [12]. However, when asked about understanding the effects of trauma after taking their respective courses, the Class of 2023 had a beneficial correlation (mean, 2.46), whereas the Class of 2024 had an unfavorable outcome (mean, 3.49). A study done by Dissabandara et al. [13] also found similar results of positive correlation between cadaver experience and understanding of trauma. The significant difference between the means proves that the Class of 2023 is more confident in understanding the effects of trauma in comparison to their counterpart (Class of 2024). Although both cohorts shared a mutual rejection of pursuing anatomy-concentrated fields, the increased confidence demonstrated by the Class of 2023 substantiates the importance of cadaveric dissection. This is probably due to better conceptualization of how the effect of external forces, such as supervised scalpel insertion in an anatomy lab, can be translated to real-life trauma to anatomical structures. Although it can certainly be seen through virtual dissection, it does not provide the level of confidence achieved when done with one’s own hands.

In the skills domain, students’ clinical engagement in common imaging modalities were assessed through the following three questions: (1) “Did the anatomy lab enhance your skill in point-of-contact ultrasound?”; (2) “If you were given an X-ray or a CT, would you be able to identify all the pertinent anatomical structures and their respective locations?”; and; (3) “How confident are you in identifying pathology in radiographic images?” Presumably, an acquaintance with anatomical structures through physical touch in a cadaver dissection assists in understanding their spatial relationship in radiological images. Indeed, the survey results confirm this notion because all three questions provide a statistically significant p value, accentuating the difference in experience between the two classes. The average mean of responses for all three questions was of a lower value on the Likert scale for the Class of 2023 than that of the Class of 2024. In general terms, it can be deduced that the Class of 2023 is more likely to identify pertinent anatomical structures in an X-ray or a CT, is able to recognize pathology in radiographic images, and has an enhanced skill in point-of-care ultrasound when compared to the Class of 2024. This finding is congruent with similar studies that demonstrate the importance of cadaver dissection even during surgical residency. In a study conducted by the UCLA Department of Surgery, surgical interns, when exposed to cadaveric dissection focusing on teaching procedure-related anatomy and surgical techniques, had an increase in their practical scores from 50.5 to 83.5% [14]. Even so, 96% of the participants reported that the implementation of cadaveric dissection enhanced their knowledge in anatomy and improved their technical skills [14, 15]. While these favorable results reassure the aptitude of medical students who had an opportunity for in-person dissection, the skills gained via the virtual platform by incoming medical students during the pandemic are certainly under scrutiny. To ensure the appropriate attainment of technical skills, an in-person cadaveric dissection may be offered with caution prior to the end of their medical education.

With the following statements, “My anatomy lab enhanced my respect towards the human body” and “My anatomy lab was not engaging in the way it was carried out” and the question “Do you think cadaver experience is important in understanding anatomy?” the attitude of each class toward its respective anatomy course was explored. Both classes strongly believed in the importance of cadaver dissection in gaining anatomical knowledge, as supported by the lack of statistically significant difference between the cohort’s responses (p>0.05). More so, the mean response values for both classes indicated a positive meaningful attitude toward the importance of cadaver dissection. However, when asked if their respective anatomy courses enhanced their attitude toward the human body, a significant difference demonstrated that the Class of 2023 had a more positive outcome in comparison to its counterpart. Why the Class of 2023 expressed a stronger attitude toward respecting the human body can surely be attributed toward its in-person cadaver experience, as corroborated by past research [16, 17]. However, when asked to comment on the engagement of the anatomy lab, no statistically significant difference was achieved between the two classes due to the 95% confidence interval carrying the value one. While the response mean value for the Class of 2023 was slightly toward the disagreement spectrum (mean=3.70) and the response mean value for the Class of 2024 was toward the agreement spectrum (mean=2.31), the lack of significant difference calls for exploration of why the classes are not finding anatomy engaging enough. Evidently, the Class of 2024 had an anatomy course with virtual lessons and no hands-on experience, justifying the disengagement they expressed with the course. Chapman et al. [18] reported that innovative approaches such as computer programs, models, and radiological anatomy alone scored comparatively lower than traditional methods of dissection. However, a plausible explanation as to why the Class of 2023 did not express a strong attitude toward its anatomy lab could be the class size. A Class of 160 SGL medical students divided into groups of five to a single cadaver and supervised by a total of five instructors in a limited time frame per week can certainly think that cadaveric dissection is disengaging. In fact, further study can be performed between PBL and SGL students to understand how smaller cadaveric dissection groups impact the engagement level in the anatomy course. Overall, based on current results, it can be established that medical students who had in-person cadaveric dissection had a favorable attitude toward their anatomy course compared to students who had virtual anatomy during the COVID-19 pandemic.

Based on the domains of confidence, skills, and attitude, it is evident that the presence of an in-person cadaver dissection is integral in shaping the finest physicians of the future. The results are consistent with this hypothesis while bringing attention to the effects of virtual learning during the pandemic. However, there are a few limitations of the study that must be considered. Primarily, the number of students who responded to the survey was comparatively lower in the Class of 2023 compared to the Class of 2024. Furthermore, the survey only included students from a single medical institution, thus limiting the generalizability of its results. Nevertheless, the technical skills of the instructor involved in the creation of the virtual anatomy course may also contribute to the student’s experience. Perhaps, if the anatomy course was carried differently than watching optional dissection videos and completing CALAs, the student responses may have shown no difference relative to the previous classes. To overcome these drawbacks, the study can be expanded to other medical schools, which can compare the different modalities of virtual anatomy and the impact that the study had on the student population. More so, with results from multiple schools and a greater sample size, cadaveric dissection in anatomy can be shaped accordingly for the best student learning experience.

Conclusions

The findings of the current study demonstrate the importance of cadaveric dissection in the delivery of an anatomy curriculum in a medical program. Our study showed by quantitative methods the value that students place on an in-person dissection course as compared to a virtual anatomy course. The students with cadaver dissection overall were more self-assured in their skill, perception, and confidence in the anatomy after being trained with hands-on cadaver experience. Further research needs to be conducted to identify what specific anatomy teaching resources are most effective beyond cadaveric prosection for students without access to a gross anatomy laboratory.