Innovative pedagogies series:
Done to death
The use of the living body in anatomy
teaching
Professor John C McLachlan, Professor of Medical
Education
School of Medicine, Pharmacy and Health, Durham
University
Contents
2
Section
Page
Contents
2
Introduction
3
Innovating in anatomy teaching
4
Peer examination
4
Body painting
5
Body projection
6
Clinical skills partners (CSPs)
6
Portable ultrasound
6
Art
7
Challenges
7
Reflections
8
How this practice evolved
8
How this practice is theoretically situated
9
How others might adopt or adapt this practice
9
Conclusions
10
References
11
Acknowledgements
12
Introduction
Paracelsus (Philippus Aureolus Theophrastus Bombastus von Hohenheim, 1493–1541) was, in his career as a
wandering physician, wrong about almost everything. He believed in the medical significance of astrology,
sympathetic magic, and the arcana of philosophies such as those of the Pythagoreans. He was an alchemist
and a seeker after the Philosopher’s Stone. However, he was also unimpressed by adherence to canonical
texts, and promoted the observation of nature, including the study of anatomy. He would, I think, have
appreciated the teachings of Andreas Vesalius (1514–1564) author of one of the most influential books of
human anatomy, the De Humanis Corporis Fabrica, whose publication commenced in 1543.
But the impact of Vesalius and his successors was cultural, as well as practical. Into the chaotic world of
magical thinking inhabited by Parcelsus, came the light and certainty of human anatomy. No matter whether
anatomy was studied in Paris, Milan, or London, it was recognisably similar in all these places. We would
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categorise much of medical thinking in the early 16 Century as magical – indeed, in the light of our current
understanding, nonsensical, and even dangerous. The ‘Humoural Theory’ led to practices such as bleeding,
scarification, and purging, certainly responsible for ushering patients painfully into the next world in
substantial numbers1. Anatomy must have seemed the ultimate validator of medicine – a universal set of
certainties, which could be studied and examined. It rapidly became the core of medical education, especially
after the development of techniques for preservation. Fresh corpses decay rapidly, especially when opened.
Preservation techniques, and the legalisation of human dissection (in the UK, through the Anatomy Act of
1832) enabled them to be stabilised sufficiently for students to work on them repeatedly over extended
period of time, and dissection quickly became the social signifier of being a medical student. Bob Sawyer in
Dickens’ Pickwick Papers, will serve as an exemplar. This is how he is introduced:
“Nothing like dissecting, to give one an appetite,” said Mr. Bob Sawyer, looking round the
table. Mr Pickwick slightly shuddered.
“By the bye, Bob,” said Mr. Allen, “have you finished that leg yet?”
“Nearly,” replied Sawyer, helping himself to half a fowl as he spoke. “It's a very muscular one
for a child’s.”
“Is it?” inquired Mr Allen carelessly.
“Very,” said Bob Sawyer, with his mouth full.
“I've put my name down for an arm at our place,” said Mr. Allen. “We’re clubbing for a subject,
and the list is nearly full, only we can't get hold of any fellow that wants a head. I wish you’d
take it.”
“No,” replied Bob Sawyer; “Can't afford expensive luxuries.”
“Nonsense!” said Allen.
“Can't, indeed,” re-joined Bob Sawyer, “I wouldn't mind a brain, but I couldn’t stand a whole
head.”
“Hush, hush, gentlemen, pray,” said Mr. Pickwick, “I hear the ladies.”
This fictional account nonetheless captures some of the potential moral hazards of dissection. In the modern
era, the preserved cadaver of a (usually) elderly person has become the canonical text we are expected to
read from. But ‘nature’ is the living body, and our current ability to see inside the body while it is still alive has
perhaps not been sufficiently recognised.
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I except those repositories of folk medicine; bone setters, village wise women and herbalists, all alike
despised by the physician community, and many of whom would soon come under legal ban (Henry VIII) if
not of persecution as witches.
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My own experience of the Dissecting Room (DR) came through what I would now call participant observation.
As a newly appointed lecturer in the Anatomy department at a Scottish University, I joined a group of
students, moving anonymously among them as they carried out dissection. It was a rather dismaying
experience, and the degree of engagement of students when the official teaching staff were absent was
slight. This led to the reflections below.
Innovating in anatomy teaching
How do doctors actually use anatomy? The answer is mainly through living anatomy – in most cases
externally – and through medical imaging. Surgeons are an exception, which will be addressed later in this
article. Yet anatomy is still largely taught through the use of the preserved cadaver, and the view can be
expressed that living anatomy and medical imaging are insufficiently addressed in traditional medical school
curricula.
As Director of Phase 1 of a new medical school (Peninsula Medical School, UK), I was sufficiently convinced of
this to espouse a radical new approach, which eschewed the use of the preserved cadaver in medical
teaching. This was not for financial reasons; the new programme was exceptionally well funded; nor for
ethical or religious concerns about the use of cadavers, nor concerns about the supply of cadavers. We
believe we were the first medical school in the world to make such a decision purely for pedagogic reasons
alone.
The process of preservation is very similar to that of tanning. The collagen molecules are cross-linked by
various preservatives. Colour, other than skin pigmentation, is generally lost, and structures such as blood
vessels become hard to distinguish from nerves. Formalin-based preservatives have a characteristic and
unpleasant smell. The preserved cadaver bears much the same relationship to the living body as a prune
does to a plum, and its study can be traumatic for many students. Dissection of the face, in particular, is
difficult and distressing, and almost the only way to deal with this is through objectification. As a
consequence of the distress caused by taking apart a human body, especially in such a bizarre state, black
humour is often used as a defense mechanism, and this in turn can lead to callousness and cynicism.
Without the cadaver it became necessary to re-think the teaching of anatomy in its entirety. It should be
noted that we were not diminishing the role of anatomy itself; on the contrary, we devoted rather more care
and resources to anatomy teaching then many other conventional programmes. It was the methods of
teaching clinically relevant anatomy we were considering.
I therefore developed a range of anatomy teaching approaches through the living body and medical imaging,
in close association with clinical skills teaching itself. These methods included:
peer examination;
body painting;
projection of 3D images on the surface of the body;
use of clinical skill partners – lay volunteers happy to be examined;
use of portable ultrasound;
art (sculpture, drawing and poetry).
These are explored in more detail below.
Peer examination
Young medical students are likely only to have encountered the human body, especially the naked human
body, through sexual contact (if that). As a result, we have observed that their first approaches to the body in
a professional context are fraught with difficulty. They are tense and nervous, and as always when stress
levels rise, become less situationally aware and less capable of constructive thought. This means that they are
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likely to approach the first patients, on whom they must conduct physical examination, in a markedly suboptimal way.
One would think that this would be routinely addressed in medical school. On the contrary, traditional
medical courses contained insufficient physical examination. In particular, it was not uncommon for students
to reach the point of patient contact without having examined a female, or even to have seen a thoracic
examination carried out on a female. This is reflected in interviews we carried out with female patients about
their experiences of thoracic examination.
We therefore instituted a policy by which students would examine each other with regard to non-sensitive
areas (i.e. excluding breast and genitals in females, and genitals in males). This was associated with extensive
research projects to explore how students felt about this practice (see for example Rees et al. 2005), and a
clear consent process, through which students could declare their willingness to be examined by samegender and opposite-gender peers. No student was required to consent to be examined; equally, no student
could decline to examine others of either gender.
We found that, as expected, the barriers to being examined centred on female students being examined by
male peers, and on age, body image, and religious persuasion. However, the surprise lay not in the existence
of these factors, but in their frequency, which was much lower than expected. Fifty-seven per cent of our
female students expressed willingness to have opposite-gender peers carry out breast examination, though
this was not part of the curriculum. Free text comments made clear just how valuable students considered
the opportunity to carry out physical examination on both genders to be for their future clinical careers.
We found that students were actually prepared to volunteer further than we had intended asking them. So,
for instance, we had made very clear that we would not be carrying out breast examination on students as
part of the process (instead that was carried out using our Clinical Skills Partners). However, at one point we
wished to demonstrate the use of 12 lead ECGs for the students. We were aware that this would be slightly
different depending on whether the recipient is male or female. We asked for female volunteers from the
student cohort to have the leads placed on them and were impressed by the fact that a significant number of
females volunteered to take part. In this, as in many other settings, we observed that the embarrassment
about partial nudity was strongest in the staff rather than in the students, and it was staff fears and
prejudices that we had to overcome.
The key to the successful execution of this policy, we found, was information – particularly around induction.
Once the programme was running, we found that students who had experienced and valued the process
were the best advocates in introducing and explaining the policy to new students.
The process of examining and being examined helped students understand the feelings of embarrassment
that patients might feel, and gave rise to some excellent reflective writing on the part of the students about
body image issues.
Body painting
Following the work of Op Den Akker (2002) in the Netherlands, we simultaneously introduced body painting
of realistic projections of internal organs onto the surface of the body (Finn and McLachlan 2009). This had
the unexpected benefit of increasing body confidence on peer examination (by providing a fun distraction
from embarrassment) and we therefore made a painting session the introductory event in the peer
examination classes.
However, it had particular benefits of its own. Painting the anatomically accurate outline of the heart on the
thorax enabled students to use the stethoscope to listen to heart valves with much greater understanding. (In
listening to particular valves, it is essential to grasp that one does not place the stethoscope directly over the
valve in question, but at a slightly more distant position calculated to minimize the sounds of the other
valves.) Painting the lungs on the body surface allowed students to percuss (tap) the thorax to identify the
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difference in sounds during inhalation and exhalation, providing students with a clear mental image of
precisely what was involved. With regard to referred pain, painting the source of the pain, and the referral
site, in the same vivid colour, provided an unforgettable way to remember the relationship. We had rather
assumed that students would learn most from being the artist in body painting; instead, we found that a
significant number learned most from being the canvas. Students also formed self-study groups to carry on
the process in their free time.
Body projection
These methods were supported by developing a genuine 3D understanding of the body through use of 3D
tm
computer reconstruction software (specifically VH Dissector ). Increasingly, cross-sectional views through the
body are presented to doctors as Computerised Axial Tomography (CAT) or Magnetic Resonance Imaging
(MRI) scans. However, conventional anatomy training introduces students to ‘plan’ anatomy rather than
sectional anatomy, and the two are surprisingly different in practice: knowledge of one does not intuitively
lead to knowledge of the other. This was in turn supported by projecting the 3D internal anatomy onto the
surface of the body of living students and staff (staff members of both genders volunteered to undress to
serve as role models in the process). Such projection was particularly powerful in enabling students to
understand lateral views (from the side) and posterior views (from behind), which are less frequently
available through standard dissection approaches.
Clinical skills partners (CSPs)
Since we had not anticipated students examining sensitive areas on each other, but wished students to
become familiar with thoracic examinations on females, we engaged a number of volunteers from the
community, who were happy to be examined in this way. These were initially recruited from life models at
the local College of Art and Design. However, we quickly found that their role was much more powerful and
educational than we had imagined. These were members of the public, not disempowered by illness or
medical hierarchies, so they were very ready to say, “Your hands are too cold” or “You’re pressing too hard” to
the medical students. The clinical skills partners (CSPs) were generous in volunteering their life experiences
and even medical histories with students in a very powerful way. One CSP, who had had a mastectomy,
described the experience for herself as very therapeutic, because it gave her a chance to talk about it and
express her feelings.
After CSPs had taken part in a class a number of times, they themselves had begun to learn the information
that was being presented and we found they performed the role of an intermediate between the tutor and
the student in a way which posed no social evaluative threat to the student. Sometimes this took the form of
whispering an answer to a puzzled student, to which the students would respond with gratitude and a belief
that somehow this was a bonus route to learning.
Portable ultrasound
As part of the focus on medical imaging (we engaged radiologists and radiographers as part of the teaching
team), we also purchased portable ultrasound machines. These, about the size of a lap top, are state of the
art robust machines with a complete range of capabilities. They are simple enough that with a minimum of
training, students can use them themselves. By their aid, students could visualise anatomy under the skin in
living individuals (particularly powerful in the neck, shoulders and knees) and also develop an appreciation of
how medical imaging will be used in emergency settings in the future. Muscles and tendons can be seen in
action, reinforcing information derived from the study of images and models. An expert can evoke a fourchambered view of the heart and, of course, this corresponds to what students may well see in clinical
practice. In the future, imaging technologies will become more readily available and more readily
interpretable. Portable ultrasound may well be present in paramedic use and in GP surgeries.
In using portable ultrasound it is essential to have a risk-assessment policy in advance with regard to what we
call “untoward circumstances requiring further investigation.” This relates to the possibility that something
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might be observed during physical examination or ultrasound examination that suggests the possibility of an
underlying pathology that has to be addressed. This is, in practice, a relatively rare event and when it does
occur, in the great majority of cases, the “untoward circumstances” turn out to be not significant. However, a
clearly articulated written policy on how to handle such circumstances must be developed. A referral route to
medical practitioners must be available and known to all staff involved and students must be guided in
advance. Many examinations do not carry a risk of discovery of these untoward circumstances but some are
more likely than others. So, for instance, in ultrasound demonstration of a four chamber view of the heart,
we arranged for students who volunteered for this to be screened before the class commenced in a
healthcare setting rather than in an educational one, so that we knew that there was almost no chance of
anything emerging during the session itself.
Art
Finally in this armoury of approaches, we chose to include art, both as practice and experience. Life drawing
classes were organised for students, to help them develop manual dexterity, and skills of observation, but
also to help them enter into sympathetic imagination of the feelings of others. Residential poetry workshops
were organised relating to death and the body, and the poems produced were made available to students as
part of their formal resources. Plastic modelling (of vertebrae, for instance, or the heart) enabled students to
use all their senses to build up a feel for the nature of structure in the body.
One of the most successful art works was the ‘Incisions Gown’, developed jointly with Professor Karen
Fleming, Professor of Textile Art at Ulster University. This is a silk organza gown that carries zips at the sites of
major surgical incisions. It can be used in a straightforward teaching role – for instance, by asking students
wearing the gown what operations might be related to which incisions. However, it also had other roles; for
instance, if the cowl neck is drawn over the face, the wearer can see out, but cannot be seen in any
identifiable way. This gives rise to fruitful discussions and reflections on de-personalisation of patients, and
the embarrassment of wearing a gown reminiscent of a hospital gown in public. Finally, when the gown
appeared in public venues (at the Science Museums in London and Boston, and a fashion catwalk show in
Palo Alto, California), members of the public would approach us anxious to share narratives of their medical
past, which, with permission, we captured anonymously to share with students as narratives.
Challenges
These approaches were successful (see below) but also hugely controversial, since we were subverting
hundreds of years of cultural practice, and apparently challenging the primacy of anatomy in medical
teaching. On a personal level, we were sometimes viewed as striking at the expertise of all anatomists,
acquired through hard work over many years in some cases – striking at the very core of their identity. The
alchemists must have felt very much the same with the rise of chemistry. Perhaps as a result, it was common
in the early years for me to be offered joking comments from anatomists to the effect that I myself would be
a fit subject for dissection – even vivisection. Of course, these remarks were humorous, and could not be
construed as ’true threats’. However, humour is often used as a way of expressing heart-felt but difficult
ideas, and offers a ready retreat if challenge takes place. Surgeons in particular (possibly one of the more
highly encultured categories of specialist) took umbrage, and I was frequently called to meetings and media
events to defend (for undoubtedly there were attacks) the position adopted by the Medical School.
Surgical education, however, may well require the level of detail that study and dissection of the preserved
cadaver brings. My view has been that this is most appropriate as a postgraduate educational activity. The
General Medical Council requires medical schools to produce undifferentiated doctors, capable of entering
any speciality. Each speciality then provides the most appropriate postgraduate training. I have indeed been
involved in providing access to the dissection of preserved cadavers for surgeons and other specialists, who,
as they are at the immediate point of practice, are far more receptive to detailed anatomical knowledge
obtained through the practice of dissection, than are first and second year medical students, who are six or
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seven years from practice – and who may in any case incline to, say, psychiatry rather than surgery as a
career.
Reflections
These approaches, we found, created cohorts of students who were confident in physical examination
(Chinnah et al. 2007), and who, despite their lack of exposure to the anatomy of the preserved cadaver, were
highly rated for their clinical skills when they entered clinical practice. The students had also developed cooperative working (an essential for peer examination and body painting) and significant skills of manual
dexterity. These are measurable; however, we also believe that they develop a more appropriate attitude to
the living, not having undergone the painful objectification of the corpse that most students do. Through
these events, and through exposure to death in a hospice care setting, we believe that they proceed in their
medical careers with a more balanced attitude to death itself.
How this practice evolved
This practice evolved in a number of directions, from our first explorations. The first of course, was through
experience. Many of the things that we thought would be true in our (McLachlan et al.) 2004 paper, turned
out to be significantly different in the light of practice and experience with students. The first of these was
perhaps the willingness of students to examine and be examined. In a developing culture of caution and
safety with regard to issues that may impact on sexuality, asking students to undress and examine each
other had seemed fraught with challenges. In fact, we discovered that the challenges (at least for UK
students) were largely confined to the staff – not so much our own internal Medical School staff, but visiting
staff from the National Health Service and other stakeholders. These tended to assume that undressing in
itself was wrong or problematic and even if they were brought to accord with the general principle would
often explicitly exclude females from taking part. A sense of annoyance or grievance on the part of female
students on this emerged clearly from our qualitative research with students (McLachlan et al. 2010).
The second surprise was around the role of CSPs (Collett et al. 2009). Initially in fact, we had called these ‘Life
Models’ and I think our expectation was that these would be passive figures in the way that life models are in
art classes. Indeed, we had recruited a number of life models from Plymouth College of Art and Design and
this may have influenced our expectations. However, we rapidly found that the role they played went far
beyond that of a passive lay figure.
The project was significantly supported by my original National Teaching Fellow (NTF) grant. In 2003 NTFs
received £50,000 to carry out a research project associated with their scholarship. We chose to use this
money exploring Arts and Humanities in anatomy teaching and this proved a small but invaluable boost to
our learning.
A third ‘evolving practice’ aspect has been the involvement of anatomy teachers in education research as a
result of this approach. Anatomy teachers, in medical schools in particular, struggled to carry out research in
anatomy itself or in any of its associated disciplines. This is partly because of the nature of anatomy, but also
because they tend to be relatively isolated without a peer group who are research active in the same area.
Research as an isolated individual is very difficult to carry out. However, by developing anatomy teachers
(and other teachers such as whole body physiologists in the same situation) as education researchers, they
then gained the intellectual satisfaction of carrying out original research and also the benefits in terms of
possible promotion and pay, which unfortunately are largely reserved for researchers rather than teachers. A
glance at the reference list of this report will indicate the names of some of the outstanding people I have
had the pleasure to work with on this basis. In turn, this generated further information to refine and hone
our approach to anatomy teaching through the living body.
The fourth evolving aspect came through international collaborations, for instance, with Professor Paul
McMenamin (now at Monash University in Australia). Sparking off ideas against similar-minded colleagues at
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international cross-cultural settings proved extraordinarily stimulating and our practices changed without
losing their original core concept.
The use of portable ultrasound also proved particularly suitable for community sharing. A total of eight
MicroMaxx portable ultrasound machines were purchased with the help of CETL4Health, and a community of
users across the North East was developed. Students were able to be scanned by trained staff, and even to
use the machines, under guidance, on each other.
While these practices were developed with regard to medical students, it is also as appropriate for the
education of allied health professionals, such as nurses and physical therapists. For example, the process of
body painting has been used in the teaching of radiographers at the University of Ulster, based on our work,
and has proved highly successful in that context also.
How this practice is theoretically situated
It is really helpful to describe this work as ‘theoretically situated’ rather than ‘theoretically derived’ because (as
I suspect many practical teachers do) I developed this innovative approach first according to my personal
experience and beliefs, and then subsequently looked for connections to educational theory! However, such
connections were not hard to find, although they represent an unusual blend of education and neuroscience
approaches. These are different in paradigm, as I explain below.
In education, Knowles (1973) describes a theory as “a consistent system of ideas” (p. 10). To this I would add
the comment “that makes sense to practitioners in the field”. In Sciences, a theory is a hypothesis that has
survived critical experimental testing. In particular, this means that other theories have been dismissed after
failing a critical test. In education theory, however, there is often considerable overlap between theories. For
instance, ‘Adult Learning Theory’ and ‘Social Constructivism’ share many features in common. The idea of a
critical experimental test is therefore less meaningful. Instead, I tend to use the construct of ‘immediate
usefulness’, and am happy to ‘pick and mix’ approaches ad lib from the library of theories. So, in regularly
inviting students to imagine themselves solving a problem in future practice (and to envisage themselves as a
patient), there is an element of preparation for situated learning. Since the activities are carried out in groups
(which may well spill over into after-hours activities) that are only gently supported by teaching staff at the
students’ request, there is a strong social constructivist element. And since healthcare students self-direct for
much of the time, there are connections with Malcolm Knowles adult learning theory.
The neuroscience aspect comes from the engagement of multiple sensation modalities in the process (Addis
et al. 2015). It is known that memory and recall are significantly enhanced by a number of factors. These
include multiple exposures to the same piece of information through a variety of sensory inputs, as
experienced in body painting and peer examination. Heightened alertness in a positive way also enhances
retention, as promoted by the fun aspect of these approaches. ‘Elaboration’ of information is also essential to
effective recall, and this is required by the integration of 3D information with the surface appearance of the
body. Information thus stored in multiple locations in the brain via multiple input modalities, and reflected
upon, and repeated (e.g. beginning each session by identifying the major landmarks) leads to the
construction of complex ‘schemas’, as they are known, which allow new information to be readily integrated.
We also help the students develop both verbal and physical ‘scripts’ that promote fluent physical
examination, including ways of dealing with embarrassment, both on the part of the examiner and the
examined.
How others might adopt or adapt this practice
In introducing these methods elsewhere, and in observing others introducing them, we have noted that it is
particularly important to be aware of local cultural factors (Sato et al. 2009).
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Often key to this is overcoming student fears, and, as our research has shown, these fears relate to age,
gender, ethnicity and religion, and body image.
These can be addressed by student-led induction, explanation with clear description of the boundaries,
emphasis on the clinical relevance and consent processes which are clearly laid out and adhered to. Also
‘untoward circumstances requiring further investigation’ policies must be established and observed.
But often more important is overcoming staff fears of working with students in this way – staff themselves
may have issues of a lack of body confidence and prudishness, and fear of accusations of harassment. But
staff should ask themselves: Why is it OK for Art students to study the living nude body, but not medical
students? Why is it acceptable for medical students to have never examined the female thorax during their
preparation for practice? The way to overcome these concerns is for frank dialogue to take place among staff,
and with students, and for staff to allow themselves to be guided by the students as to what they are
comfortable with, rather than staff intervening to impose what they personally are comfortable with.
Overcoming the long-standing culture of anatomy is another barrier – and requires thinking again about the
true goal – which is not ‘learning to be an anatomist’ but ‘learning to be a doctor’. The two are not
synonymous.
It is also essential to think about appropriate outcome measures. The assessment processes should be
aligned to the teaching. Students should be required to demonstrate their practical skills of physical
examination, not just write about them. Even multiple choice questions benefit from clinically and culturally
enriched stems – not just “name the structure pierced by pin 17”, but “Mrs Ahura has suffered a deep venous
thrombosis… identify the likely consequences” (Ikah et al. 2014).
We have attempted to make these approaches readily available to others. Papers such as McLachlan (2004)
and McLachlan and Regan de Bere (2004) gave accounts in the professional literature, not infrequently in the
form of debates, as to the best way to proceed. Other members of the team also published their experiences
and reflections – for instance, the publication ‘12 tips for running a successful body painting session’, by one
of my former PhD students (Finn 2010), and a parallel account relating to the use of ultrasound (Gritsaikis et
al. 2014).
Conclusions
The impact of these approaches can be seen in a variety of ways. Our original prospectus for the project,
published in Medical Education (McLachlan et al. 2004), has been cited over 270 times, and the four medical
schools which have started in the UK since that publication, have all eschewed the use of cadavers. And, I no
longer receive the jocular death threats from anatomists described above.
More significantly, although patient level outcomes are not available, we have access to supervisor ratings of
students in their first placements, which can take place anywhere in the UK. In these, the first wave of
students graduating from a full programme of this kind, are highly rated in practice – even the years that
have passed between teaching (or more cogently, learning) have not had a negative impact on their rated
performance (Van Hamel and Jenner 2015; Brennan et al. 2010). Then too, the students themselves speak
positively about their learning experience of anatomy (Chinnah et al. 2011).
It may be postulated that the success of these approaches as a teaching methodology lies in several aspects.
The first, not to be under-rated, is fun. It is impossible to take a photograph (with due consent, of course), of a
living anatomy body painting session without capturing the students smiling. Student evaluations of the
process are both positive and reflective.
How are these successes achieved? We believe that learning is supported through a variety of means. At the
neurological level, we believe that the act of body painting, for instance, is encoded by the brain through
multiple modalities. These include, for instance, reading and reflecting on the anatomy instructional text, and
10
then implementing it through haptic movements; the use of active colour as a signifier; the use of either
authentic or representational colour as in areas of referred pain; and through sensation as in ‘experienced
touch’. Information multiply-encoded is also multiply-retrievable.
Then there is a level of preparedness to learn. Since the classes are almost universally experienced as fun,
students are well situated to learn without the known adverse effects of stress on learning. The mild
embarrassment students may initially feel in early classes may gently enhance this learning, as well as serving
as an introduction to the feelings of future patients on being examined.
There is an element of support for the social role of being a doctor, in that students are explicitly requested
to consider themselves in the role of a qualified doctor in contact with a future patient. Knowles (as many
authors do) refers to the importance of support for future social roles. When students perceive that their
learning is directed towards the goal of successfully performing the role of the doctor, their enthusiasm for
learning is considerably enhanced. For instance, we have shown that dressing them in hospital scrubs rather
than white coats actually enhances learning of anatomy.
Overall, it has been a long and interesting journey, and we are only part of the way down the road. If the
ultimate goal was to improve the patient experience and patient outcomes, these are consequences which
are hard to confirm, especially since students disperse over the UK, indeed, over the world, after achieving
full registration. However, it is possible to be confident that student enjoyment of anatomy learning has
increased, and clinical skills have not suffered, as a result of this challenge to the canonical approach to
anatomy teaching. And identifying the living, breathing, sensing human body, with all its complex emotional
attributes, rather than the preserved cadaver, as ‘the real thing’ must surely have brought other benefits in
how students are taught to see patients.
References
Addis, D.R., Barense, M. and Duarte, A. (eds.) (2015) The Wiley handbook on the cognitive neuroscience of
memory. New York: John Wiley and Sons Ltd.
Brennan, N., Corrigan, O., Allard, J., Archer, J., Barnes, R., Bleakley, A. and Regan, S. (2010) The transition from
medical student to junior doctor: today’s experiences of tomorrow’s doctors. Medical Education, 44 (5)
449–58.
Chinnah, T.I., De Bere, S.R. and Collett, T. (2011) Students’ views on the impact of peer physical examination
and palpation as a pedagogic tool for teaching and learning living human anatomy. Medical Teacher, 33
(1) e27–e36.
Collett, T., and McLachlan, J. C. (2005) Does 'doing art' inform students' learning of anatomy? Medical
Education, 39 (5) 521.
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Acknowledgements
Grateful thanks are due to the colleagues who helped me in coming to these views, and then to developing
these practices. However, not only are these too many to name, but some of them would profoundly
disagree with what I have said!
I have no hesitations, though, in recording my grateful thanks to Mrs Dee Corbett, whose help was invaluable
in preparing this manuscript.
I am also grateful to Dr Jennie Osborn for very helpful comments and suggestions on a draft of the
manuscript, and to my NTF colleagues at the Residential Event for their valuable input in the very early
stages.
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