To our knowledge, this is the first study to describe the current state and future of medical school gross anatomy education with over 80% course director participation. It is also the first study to objectively and subjectively analyze the impact of COVID-19 and how this impact fits within recent trends in US medical school anatomy education. While we found a continuation of general educational trends described by previous authors(7, 9), we also report on recent changes in didactic approaches and novel future directions for anatomy education, potentially catalyzed by social distancing mandates imposed by COVID-19.
In accordance with prior work, we found that a growing number of institutions have integrated anatomy education into organ-system blocks. Cadaveric dissection remained the most popular mode of interactive learning among course directors, and our study found the proportion of schools using dissection (90%) prior to COVID-19 (2018-2019) to be similar to that reported by a similar study assessing the 2016-2017 year.(9) We also found that a majority of medical schools provided some form of supplemental external online resource, including phone or table applications, for their students to use as a supplement to traditional lectures and coursework. Interestingly, our survey results indicate that some schools do not utilize practical learning as a form of formalized assessment. We found that 78.4% make use of in-person practical exams, while 13.6% use virtual practical exams. By extension, this implies that a minimum of 8% of schools do not use any form of practical evaluation of knowledge, despite previous literature assessing its efficacy as a summative assessment tool.(10) A small proportion of institutions also incorporate standardized patients into their student performance assessments, which may be of particular use in developing students’ competencies beyond the application of anatomy knowledge.
Our study also sought to examine recent major changes to US anatomy curricula prior to COVID-19. In addition to a compression of course hours and integration of anatomy into other courses – which have been previously reported on7,9 – we found that many institutions have recently adopted, or plan to adopt, a ‘flipped classroom’ approach to learning, wherein students independently gain an understanding of material, allowing greater class time to be devoted to application and discussion.(11) A recent meta-analysis examining the flipped classroom approach in healthcare professional education courses, including anatomy, concluded that flipped-classroom approaches to learning were preferred by students and resulted in increased learning performance(12). The authors attributed these findings to increased temporal flexibility in synthesizing material and—importantly—to an increase in the amount of active learning afforded by the lecture time saved. Flipped classroom teaching modalities may be especially pertinent for anatomy education, given our study’s findings indicate that the most common weakness of anatomy curriculum as reported by anatomy directors is insufficient dissection time, which may be considered a form of active learning. Furthermore, a lack of time devoted to practical and in-person learning were the most cited reasons for the pandemic’s negative impact on anatomy education. These findings are logical, as anatomy requires an understanding of three-dimensional relationships that may be appreciated through cadaveric dissection but may be difficult to capture through two-dimensional media, such as lecture slides or textbooks. Utilization of a flipped classroom approach may be a prudent future direction for anatomy education as it will allow educators to maximize formalized curriculum time spent on interactive or in-person learning.
In assessing the effects of COVID-19 on anatomy education, we were unsurprised to find that a majority of anatomy course directors found the COVID-19 pandemic to have a slight or significant negative impact on the quality of learning due to a reduction in practical and in-person learning. Specifically, social distancing mandates tended to lead to an increase in the fraction of course time devoted to lecture, with a corresponding decrease in the amount of active learning time. Interestingly, however, most course directors indicated that student performance on assessments did not change. This can likely be explained in part due to changes in how student assessments were conducted during COVID-19. Prior to COVID-19, 78% of schools reported the use of in-person practical exams as part of their assessment. In contrast, during COVID-19, 25% of course directors reported a completely virtual curricula this year. The lack of an in-person cadaveric practical exam may in part explain these findings, as students may not have needed to demonstrate a proficiency in three-dimensional relationships of the body, but rather memorize images that appeared on virtual assessments. There was also a significant decrease in the number of schools that taught clinical anatomy correlates during this period, which have previously been linked to significant enrichment in student knowledge.(13, 14) These findings highlight the importance of interactive and practical application-based education in learning complex relational subjects such as anatomy. While the majority of surveyed institutions intended to return to their pre-COVID-19 course curriculum following the pandemic, 16% indicated otherwise, potentially reflecting permanent adoption of new educational tools developed or acquired as a result of the pandemic.
Looking ahead at anticipated future changes to US anatomy education, it appears there will be a growing movement away from time dedicated to dissection as well as an embracement of virtual-reality software. In this light, the COVID-19 pandemic has further highlighted the need to leverage modern technologies to improve efficiency in anatomy education8,(15, 16). While decreases in dedicated cadaver dissection time has been a well-recognized trend in recent years(8, 17), we found that 23% of institutions planned on incorporating virtual software/mixed-reality learning into their pedagogical armamentarium in the near future. In certain ways, this may reflect one of the few benefits to medical education spurred upon by the COVID-19 pandemic, as a recent article examining the use of mixed-reality technologies during the pandemic found it to be an effective method of learning anatomy with advantages over traditional approaches(18). Similar findings have also been shown in a previous meta-analysis(19). Furthermore, the cost of obtaining, storing, and appropriately caring for cadavers can also be costly, especially during the COVID-19 era during which numerous institutions have taken the precautionary step of ceasing acceptance of cadaver donations. Virtual educational tools may help account for such shortages and decrease costs associated with conducting anatomy education. While virtual dissection as a supplement to traditional cadaveric dissection appears to be a promising direction for anatomy education, our findings that most course directors intend to revert back to their pre-COVID curriculum indicate that virtual software, in its current form, is an insufficient substitute for cadaveric dissection. Thus, an increased emphasis on virtual learning should be incorporated with caution to ensure there are no negative tradeoffs in education with this approach.