The rise and fall of anatomy

Anatomy—nearing extinction or set for a come back? Kaji Sritharan went to a conference to find out

Medical students these days “don’t know their elbow from their anus.” Tongue in cheek or fact? On today’s medical school curriculum anatomy is a shadow of its former self, competing for teaching time with subjects such as genetics, public health, and communication skills. As the information revolution in medicine gathers greater momentum, and newer approaches to teaching such as earlier clinical exposure, systems based teaching, problem based learning are trialled, will anatomy be further marginalised perhaps even to extinction?

“Anatomy may be falling—but it is not supine yet!” ­Robin Williamson, dean of the Royal Society of Medicine, reassured us. Speaking at a conference revealingly titled “The Rise and Fall of Anatomy” at the Royal Society of Medicine, he warned of “the dangerous trend to demote anatomy.”

Fuelling the change

Competition
With pressure on the undergraduate timetable to incorporate other subjects “anatomy has become a casualty,” said Williamson.

Changing emphasis
In addition, medical schools increasingly rely on grant funding as a means of generating income to expand research infrastructure. Research is profitable, but sadly teaching and therefore anatomy are not.^{1 2}

A crisis in recruitment
To compound matters, there is a shortage of academics qualified and willing to teach gross anatomy.² Poor recognition and lack of incentives are part of the reason. Moreover, when experienced teaching anatomists retire, their successors are often hired on the strength of their research and not on their ability to teach.²

The General Medical Council has a lot to answer for
Cost, health and safety, and uninformed educationalists are other factors blamed for anatomy’s decline, but Robert Whitaker, assistant clinical anatomist at the University of Cambridge, highlighted “the enormous role the GMC has played. In the early 1990s the GMC described the undergraduate curriculum as ‘overcrowded, having a lot of fact, memorisation, and didactic teaching, and lacking emphasis on communication.’ So what did the GMC do? They suggested having a core curriculum, which was not defined, cut back on course content, and introduced problem based learning. The result—‘A smiling articulate doctor who doesn’t know his stuff (John Alder, 2004).’”

Should the decline of anatomy necessarily be mourned?

“If you accept that anatomy is the language of medicine,” said Whitaker, “then you should accept that all students should have a good understanding of anatomy at an early stage.”

Few would dispute the value at undergraduate level of learning (or cramming) the origin and insertion of every muscle and the intimate, protracted course of every nerve. If we bear in mind that not everyone aspires to be a surgeon, radiologist, or interventionalist, at what level should undergraduate anatomy be pitched? “Look to the PRHO [preregistration house officer],” said Whitaker. “Ask the medical students,” said Professor Harold Ellis, anatomist, speaking from the audience. “Three quarters in a recent survey were appalled that they didn’t know enough anatomy.”

Anatomy and the clinician

Despite the falling standards in undergraduate anatomy teaching, there is no formal teaching in anatomy at postgraduate level. Learning at this stage is self directed and is often facilitated by the optional revision course and posts as anatomy demonstrators. The failure of the royal colleges of surgery to recognise these posts for training sends a confusing message. Surely it’s “better to see and understand mistakes in the dissecting room rather than in the operating room,” lamented Ellis.

Rising litigation—a case for anatomy

The statistics speak for themselves. In the year 2000-1 the National Health Service faced a medical negligence bill of £2.6 billion ($4.9 billion; a, double the amount paid out in 1997. The number of new claims was reported to have increased seven fold between 1995-6 and 1999-2000. In addition, 32% of claims made to the Medical Defence Union in general and vascular surgery were reported to be for “damage to underlying structures.”³ Evidence of “anatomical ignorance leading to tragedies in theatre,” said Whitaker.

Anatomy and the MRCS

The demotion of postgraduate anatomy is further reflected in the current exam for membership of the Royal College of Surgeons (MRCS). “In the old style FRCS [fellowship of the Royal College of Surgeons] anatomy was assessed with a three hour essay paper and viva and had a 25% pass mark. Now there’s a spattering of anatomy within a broad based MCQ [multiple choice question] paper and a ten minute anatomy viva,” said Whitaker. Communication skills interestingly gets a one hour slot.

If only the public knew?

“There is clearly a crisis in anatomy,” proclaimed one member of the audience. “It’s happening in A&E [accident and emergency] departments.” “I expect a bare minimum of anatomy knowledge from my SHOs [senior house officers],” rallied another consultant, “yet, when I put up an x ray of the hand not one SHO can identify all of the carpal bones.” More evidence perhaps of not only a poor knowledge of anatomy failing the patient but also a system failing the doctor.

The rise of anatomy

“From the Act of Union of Barbers and Surgeons in 1540, anatomists embarked on a period of discovery, ‘claiming the body for knowledge, ownership and revelation,’” said Professor Buckland Wright, renter warden, Worshipful Company of Barbers.

“By the 1700s much of the gross anatomy of the body was well understood and further advancements in anatomy relied on advancements in technology,” said Dr Stuart McDonald, UK editor of Clinical Anatomy. “Knowledge of anatomy generally preceded its usefulness until the development of anaesthesia and antiseptics, and during the great war never was the need to apply anatomy greater, and with it came the development of pioneering surgery by the likes of Gillies and Cushing.”

Failing to evolve

“The problem with anatomy now is that it’s not changing,” said Whitaker. “Any subject where there is active research sustains interest and therefore advances.” This is not true of anatomy and this places it on a potentially “slippery slope to anonymity.”

Skeletons are finding themselves in need of a morale booster

A path through the storm—fighting talk

“It’s not all doom and gloom though,” he added. “On the bright side: passive, didactic, learn every detail courses are out and a functionally and clinically relevant core course in. Perhaps the title ought to be changed to the Rise and Fall and Rise Again of Anatomy.”

Too many opinions, not enough fact

Despite a proliferation in the methods being adopted to teach anatomy, very little evidence exists to support them. “We need to define the needs of a medical student and doctor and we need facts not opinions,” demanded Whitaker. “If cadavers have been used for 500 years then we need a good reason to abandon them.” Yet that is exactly what Peninsula Medical School, at the UK universities of Exeter and Plymouth, has done with their trans­theoretical approach to teaching. “And good luck to them,” he said.

Anatomy in the future

Although anatomy is not ready to be consigned to the scrap heap quite yet, its status on the medical curriculum is far from secure. The level to which anatomy should be taught is unlikely to be an argument that will be easily settled and is likely to change with prevailing public and political opinion and changes to postgraduate training. However, to its credit anatomy has withstood perhaps the strongest test of all—that of time.

Kaji Sritharan, vascular research fellow, London
Email: kajisritharan@yahoo.co.uk


studentBMJ 2005;13:309-352 September ISSN 0966-6494

1. Fasel JHD, Morel P, Gailloud P. A survival strategy for anatomy. Lancet 2005;365: 754.
2. McCuskey RS, Carmichael SW, Kirch DG. The importance of anatomy in healthcare professions’ education and the shortage of qualified educators. Acad Med 2005;80:349-51.
3. Ellis H. Medico-legal litigation and its links with surgical anatomy. Surgery 2002;20:8.

       

           

	Responses published this month

Articles	Responses
CAREERS The rise and fall of anatomy       Kaji Sritharan(Sep 2005)	Seye Abimbola (September 8th, 2005) Read this response
CAREERS The rise and fall of anatomy       Kaji Sritharan(Sep 2005)	Awad Al Beshray (September 6th, 2005) Read this response

	CAREERS The rise and fall of anatomy       Kaji Sritharan(Sep 2005)
	Seye Abimbola (September 8th, 2005)       fifth year medical student, affiliation: Obafemi Awolowo University, Ile-Ife, Nigeria. vosofa@yahoo.com
	Anatomy has thrived all through these years and I don't see anything changing its status. In the US as well as in Nigeria, it is still the course that takes most preclinical lecture hours. The dwindling status of Anatomy is simply a fault of the planners UK medical education to recognise how important Anatomy has remained. Of course, we should not expect any more from Anatomy than physical scientists will expect from Mathematics. Anatomy is essentially a language, the basic language of medicine, frame for communicating. It is the failure in the UK to understand this significant concept of what Anatomy actually is, and not Anatomy itself that is failing.

	CAREERS The rise and fall of anatomy       Kaji Sritharan(Sep 2005)
	Awad Al Beshray (September 6th, 2005)       3th year medical student affiliation: Qassim University awa733@hotmail.com
	Only 20 years ago, students used to memorize Greys textbook from cover to cover now "thankfully" students are only supposed to study from much easier books like Moore's or Snell's. I think the adopted trend now in teaching anatomy is more useful than the former one. Now we only study the clinically important things that we will face in clinical year even though anatomy teachers keep asking about minutiae that are totally clinically irrelavent.