Clinical Anatomy 7:156-161 (1994)

The Surgeon as a Teacher of Anatomy HAROLD ELLIS

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

Key words: Anatomy teaching, sueeon-anatomists

Up to the early years of the present century, the ambitious young surgeon would usually commence his career by demonstrating in the dissecting room. There- after, the established teaching hospital surgeon would maintain his close links with the dissecting room. To- day, unfortunately, there is a widening gap between the dissecting room and the operating theater. How many surgeons today are seen either at autopsies or in the dissecting room?

At present, certainly in the United Kingdom, and to varying extents in other countries, teachers of gross anatomy are at a premium. There are a number of reasons for this. In the first place, in many countries, the clinical pay scale is considerably higher than the salary paid to pre-clinical anatomy teachers, a strong disincentive against medically qualified staff from teaching pre-clinical subjects. Many posts in anatomy departments are now held by P h D scientists. Many of them, of course, are dedicated teachers of gross anat- omy in addition to their research interests. However, inevitably the basic scientist has problems when it comes to teaching the nuances of the applied clinical aspects of the subject.

I believe that the time has arrived to overcome this shortage by renewing the association between surgeons and anatomical teaching. Some years ago, at a meeting of the Society of University Surgeons in Toronto, the chairman of the department of surgery at the Univer- sity of California in San Diego gave a paper in which he said that he was fed up with having his medical stu- dents taught anatomy by molecular biologists and stated t h a t he had taken over the organization of the teaching of gross anatomy at his own medical school. H e had 70 surgeons on his staff. He got each of them to

teach for two or three hours a year and this provided a couple of hundred hours of anatomy teaching-prob- lem solved! I got up at the discussion and pointed out that at my own medical school, Westminster, there was a grand total of seven surgeons on the staff! My Ameri- can colleague agreed that I had a problem! As professor of surgery at Westminster, with the best will in the world all that I could find time for myself were three or four lectures a year to the pre-clinical students on ap- plied anatomy and I was able to furnish another three or four hours of teaching a year from other members of my staff.

This underlines the fact that in the UK there is a serious shortage of consultant surgeons which makes it difficult for them, no matter how keen they might be, to find time for anything other than their surgical du- ties. T h e ratio of general surgeons to the population in England is one per 50,000, the lowest ratio by far in the Western World. Even the most dedicated among them can hardly be expected to find sufficient time or energy for more than a token contribution to the teaching of anatomy.

Yet today, more than ever, medical students and postgraduate trainees require instruction in what might be called “clinical anatomy,” the anatomy required in every-day practice. Not only is anatomy as important as

Received for publication October 1, 1993; revised November 8, 1993.

Address reprint requests to Harold Ellis, Division of Anatomy and Cell Biology, UMDS (Guy’s and St. Thomas’s Medical and Dental School), London SE1 9RT, United Kingdom.

Based on a paper given at a symposium on the teaching of Anatomy at the British Association of Clinical Anatomists, Liverpool, July 16th, 1993.

0 1994 Wiley-Liss, Inc.

The Surgeon as a Teacher of Anatomy 157

ever as the basis for the clinical examination of the patient, but the range of surgery is wider than ever before. Moreover, in addition, the interventional radi- ologist and the diagnostician, armed with sophisticated ultrasonography, computerized tomography, and mag- netic resonance, require a superb knowledge of topo- graphical anatomy.

I believe that with today’s shortage of suitably quali- fied teachers of clinical anatomy the time has come for university surgeons once more to take part in the teach- ing of anatomy. However, it should now be not at the beginning, but at the end, of their careers.

By the time a surgeon, and I think this particularly applies to the university surgeon, is approaching the last half-dozen years of his career, his mortgage has usually been paid up and his children have left the fold. A proportion may be persuaded to take early retire- ment, at a lower pension, and to accept the salary of a pre-clinical teacher in the department of anatomy of his medical school. He is the ideal person to teach topo- graphical, surface, and applied anatomy and his radio- logical anatomy is not at all bad! Such surgeons bring a wealth of experience of practical anatomy, the clinical examination of patients, and of teaching. They are also eminently suitable for arranging case demonstrations by erstwhile hospital colleagues, which form such an important part of anatomy teaching, together with visits to the operating theaters and the department of radiology.

I freely admit that radiologists, a smattering of gen- eral medical practitioners, and even physicians can teach anatomy, but it is the surgeon whose knowledge of anatomy has been his bread and butter throughout his career.

Many anatomy departments now employ junior demonstrators, who are for the most part surgical trainees working for Part I of the FRCS for a period of 6 to 12 months. In the UK, their salary is usually found by their being employed part-time, in the accident and emergency department or blood transfusion service or the local private hospitals. These young men and women provide valuable supplements to teaching in the dissecting room, yet we expect them to walk straight into the department at the beginning of the academic year and to start teaching our students. They require, and indeed they deserve, two types of instruc- tion. First, a preliminary course in the month or so before the academic year commences, in which they are given an outline of anatomy to bring them up to the standard of undergraduate teaching. Then they require further intensive tutorials in preparation for the Part I FRCS. Where possible, they also require supervision in suitable anatomical research projects. Again, who better to be engaged in these tasks than senior retired

academic surgeons? Many of them will have already had experience of examining in the Part I FRCS. If not, they should certainly take the opportunity of sitting in on the examination whenever possible.

A word of warning. Even an experienced teacher, such as a professor of surgery, cannot automatically walk into the dissecting room or lecture theater and teach anatomy. In my personal experience it required a good six months of hard work to prepare lectures, slides, and demonstrations and to become familiar with the anatomy of the dissecting room rather than the anatomy of the operating theater. Quite frankly, it is also necessary to revise those parts of anatomy that were not in one’s own field of surgical expertise.

Are these surgeons/anatomists a threat to the careers of the small band of medically qualified anatomy teachers? Not at all! They do not aspire to chairman- ships of departments; indeed, they are only too happy to give up the responsibilities of administering a de- partment. They should be quite content to work under the administrative umbrella of a “professional” anato- mist and merely to carry out those aspects of teaching which the head of the department has identified as present points of weakness in his course.

I was appointed the first clinical anatomist in the department of anatomy at the University of Cambridge at the beginning of 1989 by the late and lamented Professor Hans Kuypers. I believe that this experiment has been a success. I know that the idea of using retired surgeons to teach anatomy, something which, of course, has happened in the past from time to time, is now spreading as one solution to the current problem of teaching anatomy to our medical and dental students and to surgical postgraduates.

THE SURGEON AS A TEACHER OF ANATOMY R E Coupland, Emeritus Professor of Human Morphology, University of Nottingham, UK.

(Comments on the paper by Professor Harold Ellis). Ellis’s paper describes one solution to the prob- lem of the dearth of medical graduates among teachers of anatomy. My own interest in the topic is of long standing. During the last 20 of the 40 years that I spent primarily as a teacher of anatomy, I also held an honor- ary clinical consultancy. Thus I regret more than most the current impasse in recruitment of medical gradu- ates, a problem which also affects other basic medical science disciplines. T h e main reasons are well summa- rized in Ellis’s paper. Difficulties began in UK anatomy departments in the 1950s, largely as a consequence of the establishment of the National Health Service, and have increased since them. When I was invited to the

158 Ellis

Foundation Chair of Human Morphology at the Uni- versity of Nottingham in 1968, the problem was be- coming SO serious that 1 devoted my inaugural lecture to the subject of recruitment of faculty to the basic medical sciences, under the title “Medical Science at the Crossroads.” Regrettably, no solution has emerged in UK and we continue down the slippery slope; curi- ously, the problem seems to be less serious in Western Europe, Scandinavia, and Japan.

THE SURGEON AS A TEACHER OF ANATOMY Dr, Stuart w McDonald, Lecturer in Anatomy, University of Glasgow 9

(Comments on the paper by Professor H Ellis). T h e suggestion that retired surgeons should be increas- ingly used to teach gross anatomy is a complacent one and, if implemented, would be to the detriment of medical education.

Some Zo years ago* a professional human anat’- Anatomists and surgeons both have good knowledge of biological science, but neither group would suggest going into a high school classroom to teach biology. We would recognize that schoolteachers have been trained

mist was whole subject, cell biology and histologY,

to have a working Of the neuroanatomy,

and their clinical relevance. With the rapid advances in all these fields, specialization became inevitable. Further- more, with the ever-increasing emphasis on research output and the ability to raise external research funds, the status of the academic teacher has been degraded. Today, the successful academic anatomist must have a high standing in his research field, and generate large research funding; his contribution to teaching is Often little more than a token, in only one Or two areas of anatomical science. This specialization in teaching, although perhaps inevitable, banishes the ideal of inte- grated teaching by the single individual that was SO

greatly appreciated by medical students and graduate students in the USA in the mid-l950s, when I was in Arnold Lazarow’s department at the University of Minnesota.

T h e traditional medically qualified professional anatomist had not only clinical experience, but also a good working knowledge of pathology. Both are essen- tial in selection of topics and emphasis; in their ab- sence, the teacher is limited in his ability achieve vocational orientation. In consequence, contributions to anatomy by dedicated and willing clini- cians-including not only surgeons, but also physi- cians, radiologists, and pathologists-become desir- able, provided it is accepted by the clinician that this is

tion and good presentation.

to teach and have valuable experience which could not readily be matched.

The Same is true in anatomy; lecturers have less formal training than schoolteachers but experience is of great value. Lecturers of some years’ standing recog- nize that new demonstrators have difficulty distin- guishing basic concepts from trivial detail. How often do we find students bogged down in the details of muscle attachments, the components of the perineum, or the arrangement ofthe synovium at the knee joint? I t probably takes three years or more to acquire this per- spective and the ability to generalize, by which time a retired surgeon coming into anatomy would be drawing to the end of his contract.

Anatomy teachers are most effective when they can provide an approach which connects gross anatomy, histology., embryology, and neuroanatomy. Most sur- geons are relatively poor at the last three subject areas, outside their speciality- Even in gross anatomy, a gen- eral Surgeon’s experience is largely of the abdomen, neck, and superficial tissues, an orthopaedic surgeon’s Of the back and limbs, a neurosurgeon’s Of the system, and so on. In addition, the idea that surgeons might teach undergraduate anatomy presupposes a specific link between surgery and the dissecting room; study of cadaver material is just as relevant in preparing students for cardiology, gynecology, and obstetrics, pa-

forth. A number of anatomists have been at pains to

a Prio~CY commitment, demanding adequate Prepara- thology, gastroenterology, respiratory medicine, and so

An approach is that at Not- ensure that teaching is at a level appropriate for a gen- eral training and does not include details which are tingham during the past Zo years, for

qualified anatomists to have an officially recognized, limited clinical Contract. Regrettably, these posts Seem almost certain to be casualties of the current emphasis on the need for academics to attract external research funds.

In short, the present situation is unsatisfactory, but given the instability that now afflicts so many organiza- tions and services, and the apparent desire of politi- cians to change all variables simultaneously, a rational solution seems remote.

irrelevant to practical needs or belong to postgraduate work. T h e anatomy which is taught to undergraduates is not surgical anatomy but an overview of the structure of the body, with special emphasis on concepts of im- portance to many clinical specialities.

In his article, Harold Ellis claims that surgeon-anato- mists do not aspire to chairmanships of departments and are not, therefore, a threat to the careers of medi- cally qualified anatomists. H e has missed the point. In British medical schools, departments of anatomy have

The Surgeon ae a Teacher of Anatomy 159

merged with other departments. In London, whole schools have fused. Dental schools have closed. In some universities, chairs have not been replaced. There are few anatomy chairmanships left to which to aspire.

Pay is often quoted as explaining why few medical graduates become career anatomists. This is false; lack of opportunities is the real reason. T h e junior doctor embarking on a career in anatomy will usually study for a Ph.D. He/she may be able to do this while working as a demonstrator, but what happens next? The drive to increase research ratings means that departments are looking for staff with expertise in techniques from var- ious laboratory disciplines, often people of similar age to a medical graduate but who, having trained in sci- ence, have postdoctoral experience as well as a Ph.D. A frequent strength of the medically qualified career anatomist is interest and ability in teaching. With the merging of disciplines and departments the realistic medically qualified anatomist, along with many com- petent teachers with other backgrounds, is probably not aspiring to a chair but to run courses in anatomy and to carry out good research in clinically orientated topics. T h e last thing he/she needs is to find the posi- tions filled by retired surgeons.

There tends to be an assumption that no-one in anatomy is willing or able to run dissecting rooms, such that surgeons are invited to the posts. This is untrue. If more of these jobs were advertised, recent medical gradu- ates, with the drive and enthusiasm of younger people developing their careers, would see that such positions are available and be attracted to the discipline.

Common experience tells us that someone in the latter part of a successful career should feel satisfaction that goals have been achieved and that younger genera- tions have been encouraged to continue the work and set their own targets. Distinguished surgeons should savor their success and retire completely when appro- priate and not block the job opportunities which would entice medical graduates into anatomy.

THE SURGEON AS A TEACHER OF ANATOMY Dr Ian McGregor, formerly Head of Plastic and Reconstructive Surgery, Canniesburn Hospital, Glasgow, and Past-President, The Royal College of Physicians and Surgeons of Glasgow, UK.

graduates has certain attractions, particularly in the light of the current disenchantment of clinicians with the changes in the Health Service, and the numbers opting for early retirement, but the problems of con- verting the idea into a practical scheme, though not necessarily insoluble, are not inconsiderable.

With many of the current medical curricula, anatom- ical facts are learned with only a vague awareness on the part of the student of their clinical relevance. This may be regarded by some clinicians to be the wrong way to teach anatomy, but it remains the situation. In their learning of anatomy the students are not merely learn- ing facts. They are also learning a new vocabulary, almost a new language, in terms not just of the anatomi- cal structures themselves, but of the way they are de- scribed, both individually and in relation one to an- other. The surgeon may have been fluent in this language in the distant past, but it is a language with which he has become decreasingly familiar over the years. Anatomical nomenclature also changes with what appears to the clinician to be depressing regu- larity, and surgeons have a habit of continuing to use the nomenclature they learned in their student days, with a sprinkling of the eponymous names which recall the alleged giants of the past, adding to the language problems of the student.

It is also assumed at the outset that by the very nature of their craft surgeons must have a wide knowl- edge of anatomy. This is a dubious assumption. As surgeons become older they tend to focus their activ- ities on a narrower spectrum. Admittedly in the process they become increasingly knowledgeable on the anat- omy relevant to its practice, but this knowledge is likely to concern aspects which are either irrelevant to, or beyond the scope of, the knowledge required of the undergraduate-for example, anatomical abnormal- ities created by the disease processes. Beyond the con- fines of that circumscribed area their anatomical knowl- edge, although adequate for clinical purposes, is unlikely to be wide enough, and accurate enough, to fit them to teach anatomy to undergraduates unless they have retained a specific interest in the subject.

Comments made by anatomists on their surgical co- examiners in Fellowship examinations are apt to be critical of the circumscribed extent of their knowledge, and their lack of anatomical precision. I have a personal awareness of this problem. My knowledge of intra- abdominal anatomy, though enough to satisfy most oral examiners if I were a candidate, is still quite inadequate

(Comments on the paper by Professor H Ellis). T h e concept of encouraging surgeons to retire early and take on responsibility for teaching anatomy to under-

for teaching purposes, and as an examiner I have learned to avoid it in case the candidate knows more than I.

160 Ellis

Surgeons, invited to give lectures in the anatomy department, are notorious for straying from the con- fines of the purely anatomical into the realm of clinical anecdotage, where they have the confidence of greater familiarity. T h e students may enjoy this thoroughly, since it adds a pleasing leaven to the anatomical lump, and gives them a glimpse of the uplands of clinical surgery, away from the more mundane flatlands of structural anatomy. T h e extent to which it provides anatomical fact of the sort which will see them through their examination in anatomy is more doubtful, and it is this sort of approach by surgeons to anatomical teaching which gives concern to the academic anatomist.

to accept the intellectual discipline involved in relearn- ing much of his anatomy, in the 1anPage and style and

THE SURGEON AS A TEACHER OF ANATOMY Stanley Monkhouse, Professor and Chairman of hatomy, ~~~d College of Sueeons in Ireland, Dublin, Ireland.

(Comments on the paper by Professor Harold Ellis). If you were to ask the man in the street what he thought an anatomist was, he would probably say some- thing like ,,a doctor who teaches anatomy to medical students and who dissects dead bodies.,, If you then asked him what he thought was the main job of a university teacher, he would probably say teach students, of course.” It’s a curious and sad thing, that

voca- tionally qualified anatomists, it is likely that clinicians

In short, Potential surgeon-teacher have the man in the Street would be wrong, wrong, wrong. Unless something is done to reintroduce

with the degree Of precision necessary to be an effec- tive teacher of anatomy, admittedly anatomy of which he retains a remembrance, but one which the Years

will be increasingly frustrated with our products (i.e., human beings, not publications), and thus more and more inclined to take matters into their own hands

have often made marginally inaccurate. T o listen to an and teach anatomy themselves. ~ ~ ~ ~ l d ~ l l i ~ ’ ~ anatomist asking questions at an oral examination is to thoughts on this problem suggest one solution and be aware of the gulf of anatomical Precision which hint at others. All his ideas are valuable, and reiterate separates the anatomist and the surgeon, even one with similar points made over the years by others; they are good anatomical credentials. infinitely preferable to the solution contemplated in

An additional problem for the surgeon is his knowl- one school, that of using non-academic staff to super- edge of those aspects of a particular anatomical site vise gross anatomy labs. which are of surgical relevance, with the temptation it Harold Ellis will be pleased to know that this depart- creates to intersperse his teaching with less aca- ment, where all nine gross anatomy lab teachers are demically demanding clinical vignettes. T h e problem medically qualified, has been using surgeons for many for the student is that any relevance which the surgeon years. They are called surgeon-prosecters, and they are may discuss has no real validity unless the anatomical paid a token salary, to keep them Out of mischief- Their facts are already known. wisdom, knowledge, and experience are greatly appre-

~ 1 1 of this may legitimately be criticized as being ciated by our students and by other teachers, and one of essentially negative, and that while it may apply to the majority of surgeons the number required for teaching

them in Particular gives stunningly Popular lectures on Subjects Of his Own choosing, fitted into the depart- mental schedule. They know what are the major pro- fessionally relevant topics, and are very good at surface anatomy and the basic clinical skills, which are a major component of our anatomy course. I value them very much, and am grateful that I inherited this tradition. Unlike Ellis at Cambridge, of our surgeons is in chaqe of gross anatomy teaching-I am. Perhaps we

their hands dirty instead of just talking about itPthey may come to enjoy it and learn from their students. I have always thought that a professor of anatomy should profess anatomy.

One problem with surgeons teaching anatomy is that they tend to teach swgical anatomy. This is fine for graduate students, but medical students do not need to know surgical anatomy-they need clinical anatomy, which is not quite the same thing: for example, a work- ing knowledge of the functional anatomy of the nervous system (particularly the cranial nerves) is more impor-

students is small, and those interested would presuma- bly be anatomical enthusiasts in any case. Such a com- ment is valid, but it leads on to the problem of recruit- ment of suitable individuals. Self-selection is unlikely to be satisfactory, since insight into one’s failings is not something which increases with the aging process. Fur-

have to abandon his preconceived notions of what was involved in teaching anatomy to students, and be Pre- pared to learn what would be virtually a new discipline, becoming an anatomist, and not remaining a surgical anatomist-a distinction which should be apparent to anyone who compares a textbook of anatomy with one of surgical anatomy. These are major hazards to sur- mount, and while I agree that the recruitment of sur- geon-anatomists is an excellent idea, having thought about the practical difficulties, I suspect that suitable candidates are likely to be few and far between.

ther, SUCCeSS would require that the individual would need professors who actually do the work and get

The Surgeon as a Teacher of Anatomy 161

tant for the general physician than for the surgeon. Since surgeons return to the detailed study of anatomy as part of their graduate training, they should not be bombarded with too much surgical information as med- ical students. This means that we must decide what is properly undergraduate material, and what is not. So surgeons who teach anatomy to medical students must be controlled by a head of department who ensures that they behave themselves. They must have the right disposition: our surgeons seem to me to get younger in spirit each year as they are more and more in contact with the enthusiasm and intellectual resilience of the students. T h e dissecting room is certainly no place for Sir Lancelot Spratt.

These issues apply of course to any clinician invited to teach anatomy. I like the idea of radiologists and primary physicians teaching also, but only if they are committed and attend regularly. I t is no use having them lecture once a month, or only occasionally attend- ing lab classes.

When I was a student at Cambridge, Max Bull taught me that anatomy was the study of the “growing and changing living organism, not necessarily human”

(his words) and so should include human embryology, neuroanatomy, and histology. Few surgeons are likely to be of much use for these topics, and I suspect that Harold Ellis’s “Anatomy” is more circumscribed than Max Bull’s-and mine.

Increasingly, I wonder about the value of surgeons- in-training on short-term appointments as demonstra- tors (called instructors in the US). They do not contrib- ute to the department’s administration, they are not sufficiently experienced to take part in major examina- tions, they are only a page or two ahead of the students, and they tend to go “egotripping” in the gross lab. Although in theory they are working for the professor of anatomy, in practice they are often not seen except in the lab, perhaps because they are cultivating a senior clinician, with an eye to the future.

To sum up: by all means use surgeons to teach anatomy, but in addition to professional anatomists. Think about using other physicians too, but make sure that they are informed, committed, amenable, and able to deal with the intellectual mischief that one likes to see in students.