The Kaiser Permanente’s Bernard J. Tyson School of Medicine opened this summer, and its students will not learn anatomy by dissecting a cadaver. Instead, they will don virtual reality headsets and dissect virtual bodies. The school does have a collection of pre-dissected, “plastinated” cadavers, but according to the chair of biomedical sciences students will spend the majority of their time studying electronic resources. This reflects a trend in which medical educators are reevaluating the importance of cadaveric dissection. Anatomy labs are expensive and dissection is time-consuming, but medical education will lose something if cadavers are taken out of school.
In America, cadavers didn’t become common in medical schools until after 1910, when a report sponsored by the American Medical Association called for widespread changes in medical education. Dissecting a cadaver has been called a rite of passage for medical students, but today, medical educators are more likely to describe a cadaver as a tool for learning anatomy. Neither term captures the true function of dissection.
Anatomy lab functions a lot like undergraduate science labs; it gives students a chance to directly experience what they learned in class. I still remember the first peripheral nerves I saw in lab, fine threads penetrating a layer of connective tissue by the umbilicus. I will always remember that these were branches of the T10 nerve root. Seeing the real thing was more memorable than the best diagram, or 3-D rendering, could be.
Many medical schools, including Kaiser Permanente, require undergraduate laboratories in biology, general chemistry, organic chemistry, and physics. If direct experience is so important that it’s worth four years of prerequisite coursework, why is it suddenly not needed in medical school? My suspicion is that the temptation to do away with hands-on experience is a direct result of our dependence on standardized testing.
Standardized testing has become the apotheosis of education. It’s objective, and it gives educators a way to demonstrate that they’re doing the data-driven decision making that’s expected of them. These tests embody a science-like view of education, but there are downsides to this metric-driven perspective.
One limitation has to do with multiple-choice tests. A lot of medical knowledge is difficult to ask about in a multiple-choice format. Questions like, “If a patient comes into your ER complaining of chest pain, what diagnoses do you need to rule out?” are too open-ended for multiple-choice. Standardized test questions, therefore, often focus on pathognomonic findings, those specific for a certain disease. Janeway lesions—small, red, non-tender lesions on the palms and soles—are a sign of infective endocarditis that’s easy to write questions about. They’re also a lot less common than chest pain.
Another limitation of metric-driven education is the timing of the measurements. While educators may want to know what makes a good physician 20 years after they graduate, they can only test students while they’re in school. Could insisting on objective data leads us maximize short-term results, possibly to the detriment of more important long-term effects?
Subjectively, I would say that the things that make the biggest difference in physicians 20 years after graduating are engagement with their patients and a sense of curiosity. What could medical schools do to encourage these traits? Dissecting a cadaver is unpleasant, but it’s also one of the few experiences in medical school that creates wonder. There are no Montessori medical schools, but if there were you can bet they’d have an anatomy lab.
The educators at Kaiser Permanente have said that they have an anatomy lab, but that lab uses “multi-user touch-interface anatomy workstations” instead of the real thing. These virtual aides actually have more in common with traditional anatomy atlases than with a cadaver. They not only fail to provide that sense of wonder, but they also cannot have anything that is not in the textbook. They are the textbook! Real cadavers have unexpected anatomic variation. They have evidence of diseases. Allowing students to discover these findings for themselves, instead of on a labeled, idealized model may change how they deal with uncertainty.
Lastly, and importantly, individualism has traditionally been an important part of medicine, not just for patients but for physicians. Patients are always asking me, “What would you do?” They never ask, “What are the national guidelines?” In my experience, patients not only want their care to be customized to their own goals, they also usually want what their physician thinks is the best care.
The seed of physician individualism may get planted during anatomy lab. It’s obvious to every student in lab that they’ve entered into a privileged tribe, one that is allowed to break rules for the good of their future patients. Examining a pre-dissected, plastinated cadaver may not provide the same experience. Physicians go on to break all sorts of taboos, from asking probing questions, to physical exams, to cutting living patients in the hope of making them better. Dissecting a cadaver may be an important part of transitioning into this role.
Regardless of Kaiser Permanente’s medical school, medical education throughout our country will continue to evolve. The cost and time spent in anatomy lab are valid concerns, but for me, this experience was well worth it. I hope that medical educators can look past short-term metrics to see what experiences provide lasting value to future physicians, and that these laboratories remain part of medical schools for years to come.
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