Third Year Medical Student Review of Basic Anatomy During the Surgery 110 Rotation

Andre Campbell, MD
Fall 2003

Background and Significance:

For many years surgeons and anatomist have debated what the impact is of the reduction in the length of time medical students spend doing anatomical dissection and reviewing anatomy. Well before more recent changes at many US medical schools, twenty-five years ago the members of the Royal College of Surgeons of England approved the following resolution in response to the medical student curriculum changes: "that undergraduate instruction in anatomy has, in the opinion of English speaking colleges, contracted to such a point at which is no longer as a basis for the practice of clinical medicine"(1). Several other authors have debated in the surgical literature what the changes in the anatomy curriculum has done to the knowledge of medical students and surgical residents(2,3,4). No one currently knows exactly how much a student needs to spend doing anatomy in order to be facile with the material. It is also controversial what the best method of teaching anatomy, i.e prosection versus dissection. More recently the Web-based tools are showing promise in helping first year students improve their scores on anatomical landmark exams(5). Historically, anatomy has been at the beginning of medical school dating back to the recommendation made in the Flexner report(6). It is hoped that this program will help supplement the knowledge gap these students have in their knowledge of basic anatomy.

The concept of a clinically relevant anatomy review the first day of the clerkship has only been reported in one paper in the literature. Ilgenfritz et al. reported that the one-day review of surgical concepts helped improve the basic knowledge of anatomy (7). Their curriculum was quite different than what we propose. They had third year students spent 7 hours going through 12 stations in the anatomy lab. An anatomist and surgical faculty member taught this laboratory session jointly. The surgical faculty was present to help answer clinically relevant questions. They found that there was a statistical significant improvement when they tested them during the rotation and afterwards in the students who had the review. The students who had the review did statistically better on the anatomy quiz during the rotation and when it was given two months later. Thus indicating a higher level of retention in the students that had the review done. Our curriculum has elements of an anatomy practical but we also rely on case presentations, basic lecture and video presentations to help the student's review abdominal anatomy. If we are successful we hope to add to the review other elements. Our preliminary data suggests that the students show significant improvement in many areas of anatomy. We would have to look at additional subgroups to see if our demonstration of improved scores is durable over time.

Curriculum reform has helped foster an early and exciting integrated clinical experience for the medical students at UCSF. In the previous curriculum students had over 180 hours of basic anatomy that featured intensive small group dissection. Many hours were spent in the anatomy lab discovering anatomical structures that the students mastered over time. It is apparent from the results of our pilot study (Appendix 1) and testing results of the fourth year student Clinical Practice Exam (CPX)(Appendix 2), that students did not remember pertinent abdominal anatomy. In the new curriculum the initial front-loading of the anatomy course has been reduced and the course is pro-section based with limited time to digest the material and explore their cadaver. With the number of hours reduced in the essential core, it is imperative that we review the relevant anatomy during the surgery clerkship.

The purpose of the proposed course is to revisit anatomy in a detailed and clinically relevant fashion at the beginning of the Surgery 110 clerkship. It is essential for third year medial students to have a strong working knowledge of anatomy during the surgery rotation. The goal is to provide a review of anatomy to help bridge the gap between the knowledge expected of the students and that which they would have retained from their Essential Core courses.

Over the past few months, the Departments of Surgery and Anatomy have been working together on possible ways to accomplish the task of presenting a clinically relevant review conducted in a short period of time.

We have begun a pilot course to see how to best review the subject matter that is necessary for the students to have a better handle on the material. It is essential that all students have a firm grasp of the anatomy that is required for each operation in which they participate in the operating room. It is suspected that since some of these students may in some cases, not have any exposure to certain parts of anatomy that they may be learning the material for the first time.

Proposal:

The anatomy review project will start with an overview of the contents of the abdominal cavity from a basic science point of view. The viscera, arterial and venous supply, nervous innervation will be reviewed in a lecture format. This will begin to reintroduce the students to anatomically relationships. With the advent of UCSF's new curriculum, courses in the Essential Core have been run with exhaustive syllabi. The students have come to expect such detailed syllabi from each course. We plan to develop a similarly detailed syllabus for the surgical anatomy review and the Surgery 110 clerkship. This effort will demand regular and weekly collaboration between the surgeon and anatomist involved with this project.

The second part of the review will be a surgical anatomy review with the use of select clinical vignettes to help the students understand the relationships of structures in the abdominal cavity. The ramifications of surgical problems involving these structures will be discussed in detail. Clinical scenarios will be presented to get students to better understand anatomy.

The third element of the review is to develop a series of videotapes of the most common surgical procedures the students will see during the rotation including herniorraphy, exploratory laparotomy, Whipple procedures, liver resections, liver transplantation, gallbladder procedures, Nissen fundoplication and other procedures. Successfully digitized and edited videos of these procedures will help facilitate the review. Other procedures may be added as needed to further supplement the series. Minimally invasive surgery is a growing part of what is done on the surgery rotation. We will integrate these laparoscopic procedures into our introduction to help bring the anatomy alive for the students who are laboring to make the connection between the surgical procedure and the basic science review.

The fourth part of the review will be a prosection driven review of the anatomy of the abdominal wall, inguinal region, peritoneal cavity, retroperitoneum, perineum, and rectum. The goal is provide a tour of the abdominal cavity to insure that the students understand the relationships of the structures that were discussed in the previous three sessions. In the pilot project, prosections were used from the Anatomy department's collection from this part of the review. These prosections were originally developed to teach basic anatomy in the Prologue, and their usefulness in a surgical anatomy review has been found to be limited. Specific prosections need to be developed for dedicated use in this project, and this demands that cadaveric material be dissected to illustrate a surgeon's approach to abdominal anatomy. When maintained appropriately, the life of prosected material can be as long as fifteen years. However, we do expect some deterioration in the specimen with usage over time, and we may need replacement specimens occasionally with fresh dissections. The Department of Surgery may be able to assist in such an endeavor.

Finally, this project will be added to iROCKET so that students may access the review at anytime during their time on the rotation or once they have completed their core surgery rotation. The slide sets can be scanned and the syllabus will be placed on the web.

A proposed calendar for activities on the day of the review is found in Appendix 3. Each of the above items is listed in the schedule in the appendix.

Evaluation:

We are in the process of developing an instrument that will help us the impact this review has on the anatomical knowledge of the students. Part of the pilot course has been assessing the baseline knowledge of anatomy in third year medical students. We have administered a multiple-choice test to access the student's knowledge prior to the surgical anatomy review. Then, a second test, with questions matched for content to the first test, is administered at the end of the review. A statistical comparison of the results of the two tests will allow us to confirm the positive impact that the review will have on the student's fund of knowledge.

We will also develop and instrument to test the impact of the program on the knowledge of anatomy by the surgical faculty. I will work with Dr. Hodgson to develop a questionnaire to examine the qualitative aspects of the program.

Future Directions:

The goal of this project is to develop a permanent anatomy review to be used by UCSF medical students. After the end of the funding period we plan to make the course available to all third year students. They will also be able to gain access through iROCKET once we have completed the curriculum. The students in preparing for USMLE Part II could use these review materials. Once we perfect this model we maybe able to use it in other clerkships to help facilitate mastery of anatomically concepts.

We plan to initially concentrate our efforts on reviewing the anatomy of the abdomen. Once we have successfully incorporated an abdominal anatomy review into the clerkship, we hope to add reviews of the thorax and the neck, to ensure that students understand anatomical issues related to those areas.

For further information, please contact:
Andre Campbell, MD