Declining Knowledge with No Vertical Integration

It is widely accepted that with scientific knowledge constantly growing in the face of technological advances, medical knowledge is doubling every 2–5 years (Johnson et al. 2012). Thus, there are immense pressures and challenges to reform the medical curriculum to accommodate this growing body of knowledge so that students will have the necessary information to practice medicine safely as junior doctors, albeit acknowledging the need to embrace lifelong learning behaviours.

The discipline of anatomy has remained constant for decades because it comprises foundational knowledge that is essential for medical students in training. However, as a result of large reductions in teaching hours, the anatomy curriculum has been drastically altered over the past century, and some critics have labelled this

transformation a downward spiral (Brooks et al., 2015; Older, 2004; Pratten et al., 2014; Rainsbury, Barbour, & Mahadevan, 2007). To illustrate the significance of this change, a comparison of historical data indicated that, in the US alone, medical schools allocated an average of 190 hours to gross anatomy teaching in 1990 compared with 549 hours in 1902 and 330 hours in 1955. This further decreased to 167 hours in 2002 with a range of 55–252 hours (Drake et al., 2002), 149 hours in 2009 with a range of 56–231 hours (Drake et al., 2009) and 147 hours in 2014 with a range of 65–249 hours (Drake et al., 2014). Similar data were found in the UK and Ireland, with an average decline in anatomy of around 100 hours (Leung et al., 2006; Older, 2004).

Further, research conducted in 19 Australian and two New Zealand medical schools shows a large difference in teaching hours between these institutions. The time allocated to teaching anatomy ranged from approximately 56–500 hours across a student’s medical training, with an average of 171 hours across all 4–6-year courses. The five-year MBBS courses had the lowest teaching time, with students spending an average of 96.2 hours

on anatomy throughout their course. This was compared with the six-year courses (221.7 hours) and the four-year courses (179.7 hours) (Craig et al., 2010). This large variation creates an area of immediate concern because there is no magic number for the total number of hours of anatomy teaching that a medical student must undertake prior to graduation. Each institution designs its own curriculum; there is no set standard for anatomy or a national curriculum, and such diversity is regarded as a highly valued feature of Australian universities (Booth, Melano, Sainsbury, & Woodley, 2011). However, given the large variation in teaching hours, is there a large gap in anatomy knowledge between graduates from one university and those from other universities? According to the Australian Medical School Assessment Collaboration, which benchmarks the performance of medical students in the pre-clinical years, standards in pre-clinical teaching are similar across universities in Australia (O’Mara et al., 2015). However, the article does not provide details across disciplines; hence, it would be important for future research to examine the differences in anatomy knowledge across universities.

It has been estimated that since the introduction of graduate medical programs and problem-based curricula, anatomy teaching time has been reduced by as much as 80% (Craig et al., 2010), causing fears and concerns about students’ anatomical knowledge or lack thereof upon graduation. For example, the University of Sydney’s four-year graduate medical program came under intense scrutiny for its lack of dissection, its emphasis on PBL and the significant decline of anatomy teaching from 253 hours in 1996 to 50.5 hours in 1997 (Ramsey-Stewart et al., 2010). The negative press surrounding this drastic change in the curriculum was further compounded in 2006, when a review by the Royal Australasian College of Surgeons revealed that the University of Sydney’s graduates had the lowest pass rate in the Basic Sciences

et al., 2010). Following the bad press and a subsequent curriculum review, the

University of Sydney tripled its anatomy teaching time from 50.5 hours to 170.5 hours in 2007, which is the mean in Australia and New Zealand medical anatomy programs.

This example demonstrates that a significant decline in anatomy knowledge leads to dissatisfaction among the medical community, in particular the surgical community where knowledge of anatomy is paramount in terms of safe surgical interventions. “The falling standard of anatomy has been inferred as a major factor in the rising failure rate in surgery” (Singh & Tubbs, 2015, p.56) and studies have shown that surgeons believe that anatomy in the modern curriculum is taught to very poor standards (Lawson & Bearman, 2007) and consequently surgeons often faced difficulties when attempting to teach clinical medicine and surgery to a group of students lacking essential anatomy knowledge (Staskiewicz et al., 2007). Ellis (2002), who was an examiner in Part II of the Membership of the Royal College of Surgeon’s examination, which allows students to apply for specialist registrar training posts, expresses amazement regarding students’ lack of anatomy knowledge:

I have sat in on this examination on a number of occasions and have been amazed at candidates who do not know how to find the ureter, or who have such little idea of surface anatomy that they would put a chest drain into the liver if they carried out in practice their description of this procedure. (p. ii)

Ellis (2002) further elaborates that when students are faced with a ten-minute examination in practical surgical anatomy, it becomes evident that some of the

candidates are encountering a real anatomical specimen for the first time. Oliver Beahrs, an internationally acclaimed surgeon and the first President of the American

Association of Clinical Anatomists, states that “today’s residents in surgery are learning their anatomy on sick patients for the first time in the middle of the night: operating

without a firm knowledge of anatomy leads to increased morbidity and mortality” (Green, 1998, p. 69). As Singh and Tubbs (2015) state, “A skilled and successful surgeon has to be a perfect anatomist first, by not only mastering anatomy at the start of medical education but also by commanding/refreshing it during surgical practice” (p.56).

Critics of the modern curriculum have expressed concern that the new methods of teaching, which involve problem-based sessions, e-learning, computer-based

technology, and plastinated and plastic models, and that have replaced the centuries-old practice of dissection and lecture-based teaching, have been adopted without an ‘external audit or validation’ (Judson, 2012). Some critics have argued that the cessation of dissection in most medical schools has resulted in graduates leaving medical school with far less anatomical knowledge than ever before (Ellis, 2002; Older, 2004;

Standring, 2009). Others feel that without a good understanding of the workings of the human body obtained through a sound knowledge of anatomy and dissection, doctors are more likely to order unnecessary tests and imaging studies, which not only increase costs for patients, but also create undue stress on the healthcare system (Kanzaria et al, 2015; Leung et al., 2006). Further, the lack of dissection opportunities provided to students affects their ability to develop key critical thinking skills required during emergency circumstances (Sugand et al., 2010). Having access to a cadaver or a simulated surgical resource enables students to practice procedures in the presence of a trained clinician to improve their technique, skills and confidence on the ward.

Examples of such procedures include cricothyroidotomy (incision in the neck between the thyroid and cricoid cartilage to establish an airway in a patient in a life-threatening situation), lumbar puncture (insertion of a needle in the back to assess for meningitis or a haemorrhage in the brain) and intercostal chest drains (insertion of a tube in the chest

in the event of air or blood or a combination of the two accumulating within the chest wall and compressing the lungs).

For years, cognitive psychologists have emphasised the importance of integrating knowledge in the learning process because it facilitates the storage and retrieval of information. Therefore, modern curriculum design has been based on this theory of learning, with the aim that integration of the different sciences will enable students to be better prepared for clinical practice. However, this integration has mostly taken place on a horizontal basis, and it has only been covered in the pre-clinical years, with all disciplines incorporated into a number of clinical cases and assessed as part of an integrated examination. There also appears to be a lack of vertical integration of anatomy throughout students’ clinical years. As Craig et al. (2010) state:

A key tenet of problem-based courses has been to strongly integrate clinical subject matter into the earlier stages of courses, often at the expense of basic sciences. However, it appears that as yet, basic science has not been integrated into the later stages of courses to compensate. (p. 215)

This is an indictment of the so-called spiral curriculum because, there is often not enough time or willingness to revisit material taught earlier. In the absence of a vertically integrated and core curriculum, institutions have been free to develop their own curriculum and teaching style. Further, there is a lack of sufficient evidence on the effect of reduced anatomy teaching in various institutions (Judson, 2012).

Consequently, upon graduation, many undergraduate students from universities around the world have felt inadequately prepared for clinical practice because of their self- appraised poor anatomy knowledge (Farey et al., 2014; Fitzgerald et al., 2008; Linacre; 2005). Some graduates—particularly those who are interested in a surgical career—who want to develop and expand on their anatomical knowledge enrol in postgraduate

surgical training programs to further their professional development and increase their confidence in the workplace (Insull, Kejriwal, & Blyth, 2006; Raftery, 2007).

According to clinicians from a variety of specialities, anatomy is viewed as one of the most important basic sciences in the medical curriculum (Arraéz-Aybar et al., 2010; Cottam, 1999; Orsbon et al., 2014) because it enables anatomical reasoning to occur through integration of the three-dimensional aspects of the body with an

understanding of the various structural, functional and pathological processes (Hall & Durward, 2009). Therefore, “inadequate retention of anatomical detail may adversely affect efficiency and effectiveness of clinical practice” (Hall & Durward, 2009. p. e27). Given this view, it is not surprising that the overall effect of undervaluing anatomy in the medical curriculum has led to an outcry in the medical community, with clinicians (especially surgeons) complaining about the low levels of anatomical knowledge among medical students and new medical graduates (Cottam, 1999; Craig et al., 2010;

Gogalniceanu et al., 2010; Herle & Saxena, 2011; Lawson & Bearman, 2007; Waterston & Stewart, 2005). It has been suggested (by many clinicians) that the current standards of anatomy education in medical schools are inadequate for preparing students to practice medicine safely (Staskiewicz et al., 2007; Lawson & Bearman, 2007; Craig et al., 2010; Warner & Rizzolo, 2006; Waterston & Stewart, 2005) and the main factors associated with this perceived decline in students’ knowledge are reduced curriculum and teaching time, loss of experienced anatomy teachers and integrated curricula (Standring, 2009).

The attitudes of clinicians towards medical students’ knowledge of anatomy are not unwarranted. A study that examines the retention of anatomy by third-year medical students commencing their clinical rotations in general surgery and obstetrics and gynaecology shows that students’ anatomical knowledge declined by 30% from the first

year, as measured by 20- and 25-question anatomy tests assessing students’ knowledge of the abdomen and pelvis respectively (Jurjus et al., 2014). Given that students receive formal anatomy teaching and basic science teaching during their pre-clinical years before entering clinical rotations, these results suggest that knowledge retention and transfer into long-term memory cannot take place without reinforcement and relearning. Hence, a spiral curriculum needs to be implemented in medical education.

Further, results from Cottam’s (1999) survey provide strong evidence to support clinicians regarding the importance of anatomy in clinical practice. A retrospective study by Pabst and Rothkotter (1997) reveals that physicians who were seven years out of medical school considered anatomy the most relevant discipline to clinical practice. Similar findings are evident in a larger study of 1,000 specialist doctors, who rated anatomy as the most relevant discipline by surgeons, and anatomy and physiology together were rated as very relevant by non-operating doctors, although anatomical knowledge was applied differently depending on their speciality (Pabst, 2009).

As medicine heads towards technological advances and innovations relating to super specialised and minimally invasive interventions, the importance of anatomy and its finer details are critical to a doctor’s ability to investigate, diagnose and treat future patients (Sugand et al., 2010). Thus, for the modern curriculum to be most effective in optimising learning and retention of learning, there must be vertical integration of anatomy across the pre-clinical and clinical years in addition to horizontal integration. In this way, students can be trained to further develop their knowledge of anatomy in clinical practice, and therefore become better equipped as future physicians. As far as the Monash graduate-entry curriculum is concerned, no formal teaching of anatomy is implemented in the clinical years; thus, the concept of vertical integration will be explored in this study as a measure of how it affects the learning of anatomy.

4.1.3 Lack of Core Curriculum and Competency-based Education in Anatomy