TITLE: A systematic review of evidence on the effectiveness of human anatomy teaching models used in tertiary education SHORT TITLE: Human anatomy teaching models

AUTHOR NAME: M.M. de Jonge PLACE OF WORK: School of Health Science, University of South Australia, Australia, [email protected]

NAME AND ADDRESS OF CORRESPONDING AUTHORS: Mackintosh S.F.H., School of Health Science, University of South Australia, Australia, and Fryer C.E., School of Health Science, University of South Australia, Australia

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A systematic review of evidence on the effectiveness of human anatomy teaching models used in tertiary education

Abstract There has been much debate about the best delivery mode for human anatomy teaching to tertiary students. Traditional methods of lectures and human cadaver dissection have expanded to include computer-assisted learning, multimedia use, prosected specimens and problem-based learning. This systematic review aimed to explore the evidence supporting different delivery modes of human anatomy teaching with tertiary students. Health and education databases were searched using relevant key words. The 40 included studies were reviewed using a critical appraisal tool. Where two or more comparable studies were identified, data were pooled for meta-analysis using Review Manager software. In studies where statistical pooling of results was inappropriate, findings were reported in a narrative summary. This review did not find conclusive evidence that any teaching delivery mode is superior in terms of student test results. There was little difference in scores between students who dissected cadavers to those who viewed prosections, but the latter was a more efficient use of time and resources for both students and staff.

Introduction The study of human anatomy is the cornerstone of medical programs and an integral part of most allied health programs. The traditional teaching mode of lectures and dissection is a strongly supported model. However, much debate has emerged over the last 40 years concerning best practice in anatomy education. Stimuli for this debate include: the cost and difficulties associated with access to sufficient numbers of human cadavers; an increasing 47

number of students; a reduction in the number of allocated hours within programs; fewer available qualified anatomists; and an explosion of education research proposing alternative teaching modes, including multimedia and computer-assisted learning (CAL), problem-based learning (PBL), where basic science knowledge and application of clinical skills are taught simultaneously, and peer teaching. Use of prosections (the superficial or deep dissection of human cadavers to produce pre-prepared specimens for student learning) has many supporters. More recently, plastination of human material has been offered as a durable alternative. We have come a long way from the grave robbers and ‗night doctors‘ waiting for the next criminal execution (Halperin 2007). Sinclair (1965) observed that while dissection is historically the best way to learn, it has perhaps been more a case of the only acceptable way to learn; until 1958, the British Medical Council had stipulated that medical students must perform a complete dissection, and so prior to this no studies could feasibly be conducted into alternative teaching methods. Arguing the need for evaluating effectiveness of teaching methods rather than supporting any particular practice, he noted that dissection is a ‗lengthy and tedious process‘ (1965: 401) of group activity in which not all students are active participants. Current debate about anatomy course delivery also extends to whether stand-alone anatomy courses are required. Terrell (2006) aptly notes that ‗anatomy educators are currently facing many of the most daunting pedagogical challenges‘ of tertiary medical science courses (2006: 252). Due also to the inherent lack of standardised tests, teachers, student cohorts, information delivery and curricula, it is very difficult to test which mode is best for learning anatomy. Bias towards tradition or trialled programs, PBL or didactic mode, dissection versus prosection or texts versus CAL is also difficult to exclude. Two descriptive reviews of anatomy delivery modes have been undertaken. Lewis (2003) reviewed ten studies investigating the use of CAL in anatomy and physiology courses 48

and concluded that well-designed and appropriately used CAL increased satisfaction with the learning process for both students and educators. Winkelmann (2007) systematically sought published trials of human anatomy teaching, but due to the wide range of study variables was unable to pool data. These reviews do not provide direction for ‗best practice‘ teaching in anatomy to maximise student outcomes. Therefore, the objective of our review was to systematically search the health and education literature to determine what the best available evidence is to support different delivery modes for human anatomy teaching in tertiary students.

Criteria for considering studies for this review All randomised controlled trials (RCTs) with tertiary-level human anatomy teaching models as a study factor were considered. In the absence of RCTs, other research designs identified as level III evidence by NHMRC (1999) guidelines were considered for inclusion. The intervention was the delivery mode of educational material. Modes were defined as a single, or combination of, teaching method/s used by educators to increase student knowledge of human anatomy. These included practical modes of delivery (for example prosection or dissection) and theory delivery modes (for example lectures, CAL or multi-media packages). Outcomes of interest were those considered to indicate an effective method of improving anatomy knowledge, including results from oral, practical or written tests expressed as a percentage. Studies reporting only student satisfaction and/or teacher satisfaction with teaching methods were excluded. The following databases were searched: MEDLINE, Cinahl, PsychInfo; Amed; AUSThealth; A+education; EdResearch online; ERIC; and Google Scholar. Initial key words were: human anatomy; teaching; learning; education; dissection; simulation; online; computer-assisted. These initial keywords were expanded using the MeSH website and 49

keywords given in retrieved studies. Databases were searched from inception to June 2007. Studies identified were assessed for relevance from a review of title, abstract and study descriptors. Reference lists of all relevant studies were also reviewed for relevance. Only studies published in English were included.

Methods of review Each study retrieved was reviewed using a critical appraisal tool (NHMRC 1999) by two reviewers independently. Discrepancies between reviewers were resolved through discussion. Where two or more comparable studies were identified, data were pooled in meta-analyses using Review Manager software. All outcome data were expressed as test score percentages. Heterogeneity between comparable studies was tested using the standard chi-square test (p40%. The test results did not contribute to academic grades, so perhaps students made little effort to use the educational materials. No studies reported negative results of CAL compared to traditional teaching. In summary, descriptive analysis suggests CAL may be useful but does not suggest that any particular version of CAL is superior. Other studies investigated different aspects of CAL. Two randomised comparative trials investigated the use of key views compared to multiple views with on-line learning for complex anatomical areas (brain and carpal bones; Levinson et al. 2007; Garg et al. 1999). Both studies concluded that multiple views may actually impede learning, particularly in students with relatively poor spatial abilities. Fleming et al. (2003) attempted to evaluate the relationship between individual learning style, test performance, and attitudes towards the use of web-based self-instruction and slide/audiotape self-instruction. No statistically significant difference in test scores was observed based on instructional method. Learning style did not predict preference of instructional method, but 70% of participants preferred the web-based format to slide/audiotape. A final study investigated whether the amount of web use of course materials was associated with grades obtained (Rizzolo, Aden & Stewart 2002). The 20

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students with lowest scores accessed the web resources significantly less than the middle and top 20 students.

Miscellaneous studies A few studies did not fit the above categories. Forester, Thomas and McWhorter (2004) evaluated the summative effects of additional structured learning activities (student teachingassistant program, directed study, laboratory reviews, and a web-based program) and concluded that the supplemental program significantly improved students‘ practical exam scores (p