MEDICAL EDUCATION

Teaching in the Dissecting RoomHAROLD ELLIS*

Department of Anatomy, King’s College, London (Guy’s Campus), London, United Kingdom

Ever since Mundinus of Bologna, at the beginning ofthe 15th century, stepped down from his professorial“cathedra” and began to teach his medical students bypersonal practical dissection of the human body, dissec-tion has been regarded as one of the main methods ofteaching the basic corpus of knowledge of the humanbody to medical students. So, after five centuries inwhich human dissection has been used as a teachingmethod and has been adopted, as far as I know, in everymedical school throughout the world on its foundation, isit now to be lightly abandoned? Do we, as medicalteachers, have to defend our traditional method of teach-ing in some forlorn rear-guard action?

There is no doubt that today dissecting room teach-ing is unpopular with our masters, the university ad-ministrators, and even more so with that new phenom-enon, the “expert” in medical education, oftensomeone who has not exactly taught a medical stu-dent, has never seen a sick patient, and certainly hasnot visited the dissecting room while I have beenteaching inside it!

With the administrator, we are unpopular as dissec-tion teachers for a number of reasons. We ask for agreat deal of space: the dissection room takes up alarge floor in the medical school at a time when themolecular biologists, with their enormous researchgrants, are clamoring for more research laboratories.We need a large area for preservation and storagespace for the cadavers. Then there is the expense ofthe bodies—transportation, preparation, disposal byburial or cremation, the costs of the administrativestaff for collection of the bodies—and all this adds upto a serious financial drain at a time when our univer-sities and medical schools are being called upon tomake more and more economies.

It is not surprising, therefore, that our masters aretempted by the appeal of teaching anatomy with a fewcheap video cassettes and viewing screens tuckedaway in the library! And how they dislike the “un-pleasant” smell in the dissecting room, in those rareinstances when they can actually be persuaded tocome and see what the students and their teachers areactually doing in the dissecting room!

The medical education “experts” preach to us allsorts of things, often in a jargon that we do not quiteunderstand. They tell us about problem-based learn-ing, that we should be facilitators rather than teachers.They go on at length about the special study moduleand the value of the computer. How certain can theybe that these are the best ways of teaching our firstyear students as they arrive to us, in the great majorityof cases, certainly in the United Kingdom, straightfrom secondary school? Has anyone come across acontrolled prospective randomized trial which provesthat these teaching methods are better or worse, oreven cheaper or more expensive, than classic teachingmethods?

If we get down to basics, what are we actually tryingto teach our students in their first year or two atmedical school?

I believe these should be our aims:

1. To teach the basic language of medicine; thethousands of terms and facts related to the struc-ture (anatomy) and function (physiology) of thehuman body which the medical student simplymust know if he or she is to be able to deal withsick patients.

2. To begin to teach the student some manualdexterity, because every doctor, except perhapsthe psychiatrist, needs this.

3. To introduce the student to the concept of thewonders of biological variation and to begin todemonstrate the common pathologic changes inthe human body.

4. To teach the student how to communicate.5. To teach the student how to access information.

This paper was presented initially under the same title at theSymposium on Modern Imaging of the Human Body, Dissectionand Clinical Anatomy at the XV Congress of the InternationalFederation of Associations of Anatomists, Rome, September 11–16,1999.

*Correspondence to: Harold Ellis, Department of Anatomy, King’sCollege, London, (Guy’s Campus), London S.E. 1–1UL, UnitedKingdom.

Received 11 November 1999; Revised 14 January 2000

Clinical Anatomy 14:149–151 (2001)

© 2001 Wiley-Liss, Inc.

6. To acclimatize the student to the reality ofdeath.

And remember, we are talking about a group, themajority of which, in the United Kingdom at least, ismade up of young students who, in addition, arehaving to cope with the problems of being away fromhome for the first time, having to deal with theirfinances, and are confronting their attitudes towardsex, alcohol, and drugs.

Let us see how modern teaching in the dissectingroom faces up to these six requirements. How doteachers of any other technical subject set about theirtasks? Imagine a garage manager setting out to teach anew entry of car mechanics. Do you imagine for onemoment that he (or she, of course) takes his group outto the back yard, shows them a rather expensive carwith a loud noise coming from under the bonnet, andsays, “Now your first task in this course on problem-based learning is to find out what all this noise underthe bonnet is all about and put it right”? Of coursenot! He starts off by spending a significant amount oftime teaching his pupils the anatomy and physiologyof the normal internal combustion engine, the nameand the purpose of the sparking plug, and so on. Onlywhen his class has mastered this will he set his pupilsloose on automobile pathology!

So I just do not understand how teachers of medi-cine believe that the most efficient way to teach med-ical students is from day one to sit them down in frontof a patient with cyanosis, dyspnea, ascites, andedema, and ask their students to sort it all out.

So what do we traditional teachers do? In our med-ical school, for example, we start with dissection andphysiology of the thorax, as well as classes in cellstructure. During the first year the students are sub-sequently taken through the abdomen, pelvis, andlimbs, along with the appropriate physiology. Thehead and neck and neuroanatomy and neuroscienceoccupy the second year. I assure the students that, asfar as is possible, we shall only teach the anatomy thatis going to be clinically relevant to them in theirsubsequent practice. Considerable emphasis is placedon radiological anatomy, which is displayed on specialscreens in the dissecting room (DR) and on osteology,aided by skeletons in the DR and by lending eachstudent a set of disarticulated bones.

While it may take the garage manager a month ortwo to teach his mechanics all about the normal inter-nal combustion engine, we all know that four or fiveuniversity terms just about suffice, at least for ourmedical students in the United Kingdom, who, ofcourse, are also being taught a wide range of othersubjects: biochemistry, pharmacology, ethics, and so

on. All the time we are emphasizing clinical relevance,and this is reinforced by clinical demonstrations ofpatients several times a term. Thus, when the stu-dents are dissecting the heart they will be shown apatient who has had a coronary bypass, will hear thepatient’s story from him, be shown his angiograms,and have demonstrated to them the surgical anatomyof shunt procedures.

While teaching anatomy on the cadaver, we alsouse the dissecting room teaching area for what I regardas one of our most important tasks, the teaching ofsurface anatomy, or, as we prefer to call it, livinganatomy. We emphasize that a doctor, in examining apatient, must have a clear mental picture of what islying below his examining fingers. We do the teachingof this topic first by showing a home-produced videoof myself and a couple of demonstrators going throughthe surface anatomy of the area under consideration,e.g., the thorax, marking out the relevant anatomy onone of the demonstrators. We then get the students todo this on each other in small groups, assisted by theirteachers and aided by a booklet, again produced in-house. The importance of the subject is stressed inthe dissecting room, when the displayed tissues arerelated to the body surface, and, even more, by stress-ing to the students that surface anatomy, or livinganatomy, will play a significant part in their end-of-term tests!

Today’s students have little opportunity to developthe manual skills that are essential to almost everybranch of the profession. They no longer dissect thedog fish (shark), the frog, and the rabbit in their schoolor college biology class, as did students of my gener-ation. They will have been fortunate indeed if theyhave even witnessed a dissection performed by theirteacher. No longer does the student carry out practicalclasses in physiology, like the “frog-jumps” experi-ments we used to do in neurophysiology, or the Stan-nius ligature procedures in cardiac physiology. Inpharmacology, they no longer cannulate the jugularvein of the guinea pig. Now, I am not arguing whetheror not these experiments are justified today, I ratherthink not, but my argument is that these exercises inusing one’s hands have disappeared from the curricu-lum. That leaves human dissection as the one remain-ing educational modality in the preclinical course thatteaches our students how to use their hands: how tohold a scalpel (and to put on and take off the bladewithout amputating a finger), how to use a scissors andforceps, how to appreciate tissues. Better to learn thison the cadaver, surely, than on a long-suffering pa-tient!

One of the most important concepts in medicine isthat of biological variation and the definition of nor-

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mal, and therefore recognition of abnormal, states.The dissecting room is the ideal place to demonstratethese as the students examine their own cadaver andcompare their findings with their neighbors’. More-over, most dissecting rooms have a collection of bones.These again teach the lesson of variation, unlike theplastic substitutes that most students have to usetoday, which, although perfectly adequate, have theawful sameness that simply does not occur in nature.

Each cadaver is inevitably a repository of pathol-ogy. This provides us, as teachers, with a rich oppor-tunity to introduce junior students to the basics of thisimportant subject. We use the video cameras in thedissecting room to demonstrate common conditionssuch as gallstones, cancer, secondary deposits in thelung, liver, and lymph nodes, arteriosclerosis, and cor-onary disease. Moreover, we make sure that the stu-dents at each table become quite familiar with thecause of death of their cadaver.

It is never too early to teach trainee doctors tocommunicate. Our students visit patients from thebeginning of the course and have classes in this art.However, in the dissecting room itself we have a richopportunity to teach these young students to expressthemselves as they describe their findings and to learn

to put up a good defense as we viva voce them on theirdissections—valuable practice for when, all too soon,they are to be quizzed unmercifully by their patients.

When a problem crops up in the dissection, e.g., ananomaly or pathology is revealed, or there is a ques-tion about function or clinical significance, the oppor-tunity is taken to guide the student to the library,textbooks, journals, video cassettes, and other richsources of information. What a reward for the studentwhen he finds some gem of knowledge that no oneelse in the class is familiar with or has even heardabout before!

Finally, most of our students have never encoun-tered the reality of death, yet this is going to be anever present phenomenon throughout the rest of theirprofessional lives. In the dissecting room we can talkabout mortality while we are surrounded by examples,a far more realistic scenario than in the lecture theater.Better for our students to be well familiar with deathearly in their careers than to come face to face with itfor the first time on the wards of the hospital as clinicalstudents.

My case rests. I defy my detractors. Let them closethe dissecting room at the peril of destroying one ofthe most valuable of our modalities of teaching.

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