Medical education is constantly evolving, just like medicine itself. But as we’ve all probably noticed this year, major events in the world can precipitate a huge paradigm shift that sparks rapid changes. This year is one of them: the COVID-19 pandemic has radically changed many aspects of our daily life and structures, and medicine is no exception.
It’s difficult to know which of these changes will persist in our post-pandemic world, whenever that may be; it is always tricky to write a historical analysis when the “history” you’re looking at isn’t very far in the past yet. I think we can learn a great deal, however, from the history of medical education – what it has looked like in the past, and how it is rapidly changing in the present.
I want to focus in particular on anatomy, a universal touchstone of the first-year medical curriculum. Anatomy is certainly what springs to mind for me when I think of medical education – is there anything more quintessentially medical school than spending long hours in the anatomy lab, carefully dissecting a cadaver? In order to understand the body’s functions and pathologies, we first aim to understand its structures. Anatomy also serves as an entry-point for discussions and reflections on human mortality and respect. A cadaver is frequently a student’s first experience with a dead body.
In the time of COVID, however, anatomy looks quite different. Instead of dissecting, we watched prosection videos, painstakingly put together by the anatomy course staff; instead of identifying tagged structures, we studied picture atlases and identified things from the images we were given.
Outcomes were positive by metrics we generally use, like test scores: the anatomy course staff noted that scores on exams were higher than in years past. But one cannot help but wonder what, exactly, these tests measured. The nature of our education and the way in which we navigate the human body have fundamentally changed. We may have learned a great deal according to our score reports, but the approach we took was undoubtedly very theoretical and circumscribed.
Why do we dissect cadavers at all? To understand this practice, we have to dig very far back in the past, to Renaissance Europe and the practices of Andreas Vesalius, perhaps the most famous anatomist of all time. (Though Vesalius is the most well-known anatomist, he certainly did not begin the practice – human dissection was practiced long before, often in religious settings and by women.1) In 1543, he completed and published a volume entitled De Humani Corporis Fabrica Libri Septem (On the fabric of the human body), and an abridgement, De humani corporis fabrica librorum epitome. You’ve probably seen these images at some point – they are beautifully detailed, haunting images of bodies in various states of strippage posed in extremely human, dynamic poses. This was revolutionary. Prior to Vesalius’ work, medical textbooks were for the most part composed of large blocks of text, usually the work of Galen. To learn the workings of the human body was to memorize lists of facts about it. Vesalius’ complete work also contains long, intricate textual descriptions of the body, but it is accompanied by images, and the more widely circulated Epitome is mostly images rather than text. For the first time, learning the human body was a visual task as much as a verbal one.
It is hard to conceive of anatomy not being an extremely visual field (and this change was heavily influenced by the increased ease of printing images as much as Vesalius’ contributions). In normal years in the present, anatomical learning happens both through artistic renderings (in particular, Netter Atlases) as well as in-person dissection experience. Scientific and medical education writ large has developed models, diagrams, and schematics to explain and teach concepts. Learning these is in some way, too, memorizing information, but the visual nature makes it somewhat different – and the visual aspect is only part of Vesalius’ work.
The real revelation of Vesalius’ work was his emphasis on experiential learning. Not only did he perform dissections himself, he encouraged his students to do so; he believed that direct observation was the only reliable source of medical knowledge. What is fundamental in these practices is the idea of experience, of seeing something with your own eyes and doing it with your own hands. You don’t have to “take someone’s word for it” if you can take your own. Early 20th century medical education heavily emphasized the “scientific” aspects of medicine epitomized in anatomy: empiricism. (It is worth noting, however, that Vesalius’ own descriptions of what he saw were far from perfect or even accurate. A classic example is his illustration of the uterus, which looks remarkably like an inverted phallus and really nothing like current images of the uterus.)
This notion has been continuous in medical education since then – not just in anatomical knowledge, but also in the traditional 2+2, classroom-then-clinics structure of medical education (formally institutionalized in 1910 with the Flexner report, which also resulted in shutting down most medical institutions educating predominantly people of color and women2). Simply put, medicine in the late 20th century was largely defined by the motto “see one, do one, teach one.” But what happens when circumstances bar the “doing”?
Some medical schools had moved to virtual dissection and anatomy teaching even pre-pandemic. Digital dissection technology began its development in the late 1980s and early 1990s, as computer use became more widespread. Notably, Case Western Reserve University did away completely with cadaver dissection in 2015 and uses a virtual reality system called HoloLens to teach their students anatomy. Despite initial controversy, CWRU has graduated several classes of physicians under this model who have gone on to successful careers. Indeed, discussion of the role of dissection in medical education is longstanding (at least since the early 2000s), without consensus on best practices – most studies equivocate by finding that it is best to keep cadaver dissection with digital supplementation.
Cadaver dissection plays additional roles in early medical education as well. Not only do students learn to appreciate the spatial relationships between limbs, fascial planes, and how everything connects; dissection is frequently a student’s first time interacting with a dead body. This, too, is an important experience, a “doing,” though less scientific and more humanistic. The dissection space is often a jumping-off point for discussions about mortality, bodily autonomy and respect, gratitude and appreciation for our patients’ generosity in lending their bodies to us to learn. It is also an opportunity for medical schools to talk about the deeply fraught and troubling history of cadaver provenance: this is a window onto the many cruelties medical education has visited upon people of color in the name of “progress.”3
While these discussions are normally a routine part of the Mod 1 curriculum at Penn, they were conspicuously absent this year. We did not have the chance to learn about the lives and histories of the men and women whose bodies became our teaching tools, the way that students often do in first-year anatomy classes; we did not meet their families or partake in a ceremony acknowledging their gift. I’m not sure what I or my classmates would have taken from these experiences, whether they would have been profoundly moving or whether we may have felt nothing, but the fact that these hands-on experiences have persisted while so much else of medical education has become virtual or otherwise digitally altered (even in a pre-COVID world) seems telling of their value.
The impacts of this change on our care for patients are yet to be seen and understood. It seems possible that this moment may be a turning point in medical education: will these advancements in technology allow more and more medical schools to forgo in-person cadaver dissection more permanently? Might this be a good thing? How will we incorporate the touchpoints of discussion elsewhere if it does, ensuring that students have a space to speak about issues of mortality and the body? Regardless of the specific answers to these questions, I hope that we will feel like we are “doing” just as much as we are “seeing” throughout our time at PSOM.
References:
1. See Katherine Park, Secrets of Women.
2. See Steinecke & Terrell, “Progress for whose future? The impact of the Flexner Report on medical education for racial and ethnic minority physicians in the United States.” Acad Med. 2010 Feb;85(2):236-45. doi: 10.1097/ACM.0b013e3181c885be. PMID: 20107348.
3. See Berry, “Beyond the Slave Trade, the Cadaver Trade,” NY Times, 2018. https://www.nytimes.com/2018/02/03/opinion/sunday/cadavers-slavery-medical-schools.html
Further reading:
https://jamanetwork-com.proxy.library.upenn.edu/journals/jama/fullarticle/1845035
https://anatomypubs.onlinelibrary.wiley.com/doi/10.1002/ar.b.20070
https://www-ncbi-nlm-nih-gov.proxy.library.upenn.edu/pmc/articles/PMC4582158/
https://www.cleveland.com/news/erry-2018/10/2cf61b0eb73825/clinic-case-use-virtual-realit.html
Caroline Wechsler is an MS1 at the Perelman School of Medicine.
Image by Andy Revell, a CDY5 at the Perelman School of Medicine.
