Education in the Health Professions

ORIGINAL RESEARCH
Year
: 2020  |  Volume : 3  |  Issue : 2  |  Page : 47--53

The impact of a radiological anatomy-based intervention in a gross anatomy course for undergraduate medical students


Roxanne J Larsen1, Deborah L Engle2,  
1 Department of Veterinary and Biomedical Sciences, College of Veterinary Medicine, University of Minnesota, Saint Paul, MN, USA
2 Office of Curricular Affairs, Duke University School of Medicine, Durham, NC, USA

Correspondence Address:
Dr. Roxanne J Larsen
Department of Veterinary and Biomedical Sciences, College of Veterinary Medicine, University of Minnesota, 295 Animal Science Veterinary Medicine Building, 1988 Fitch Avenue, Saint Paul 55108, MN
USA

Abstract

Background: The integration of radiology into undergraduate medical education is becoming a popular method of providing early and meaningful clinical experiences. Aims and Objectives: The primary aim of our educational intervention was to provide increased radiologic anatomy resources and support to medical students in their first-year preclinical medical school curriculum. An additional objective was to evaluate how the intervention impacted learners through a pretest/posttest protocol and traditional student feedback questionnaires. Method: Two cohorts of first-year medical students voluntarily participated in an assessment of the intervention that required the identification of anatomical structures in radiological images. Changes in learning gain and aggregate scores were calculated, and students' perceptions of the intervention were assessed through open feedback and Likert-style questions at the end of the course. Results: The results revealed a significant increase (P < 0.0001) in absolute learning gain (25.6%–33.1% higher scores) for both cohorts when comparing pretest and posttest responses. Statistical differences (P < 0.05) were found between cohorts in the pretest responses associated with questions on the thorax and those that were based on X-rays and in posttest responses associated with questions at the cognitive level of understanding. Conclusion: This study adds to the growing area of research supporting the integration of early meaningful clinical experiences into undergraduate medical school curricula, especially those that include radiology as a mechanism to connect preclinical courses with clinical training and experience.



How to cite this article:
Larsen RJ, Engle DL. The impact of a radiological anatomy-based intervention in a gross anatomy course for undergraduate medical students.Educ Health Prof 2020;3:47-53


How to cite this URL:
Larsen RJ, Engle DL. The impact of a radiological anatomy-based intervention in a gross anatomy course for undergraduate medical students. Educ Health Prof [serial online] 2020 [cited 2020 Oct 20 ];3:47-53
Available from: https://www.ehpjournal.com/text.asp?2020/3/2/47/290919


Full Text



 Introduction



Human gross anatomy is an integral aspect of medical education and serves as an important transition into the medical profession. Medical schools and their faculty are often tasked with implementing new or continuing initiatives within basic science courses, as these courses are students' first experiences in their health professions program and serve as a foundation for clinical experiences. Several large-scale initiatives have attempted to bridge the perceived preclinical and clinical divide in health professions curricula, some of which include integrating clinical experiences at the beginning of medical school;[1],[2] coordinating student-run clinics;[3] or implementing competency,[4],[5],[6] disease mechanism,[7] or symptom/complaint-based curricula.[8] One-way institutions have increased early exposure to clinical experiences and practice has been by including radiologists in anatomy courses and the use of radiological images in course materials.[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26] Wilson et al.[26] also suggest “that the best time to begin to learn to read radiographic images is when students are actively dissecting cadavers.” In addition, “many directors of residency programs consider radiology an essential skill for graduating physicians” and “there is general agreement by preclinical and clinical faculty in the US and abroad for the increase in training radiology including ultrasound during medical school.”[26] The large surge in the integration of radiology into medical curricula includes national guidelines from the American College of Radiology and their Alliance of Medical School Educators in Radiology [27] and specific guidelines for an ultrasound.[28] In addition, across the diverse set of curricular initiatives aimed at incorporating radiology into anatomy, many have focused on computed tomography (CT),[14],[18],[26],[29],[30],[31],[32],[33],[34] ultrasound,[13],[15],[35],[36] or both.[10],[11],[21],[25],[37],[38],[39]

Although there may be increased interest in developing and integrating radiology into anatomy courses (or the larger curriculum), many medical education programs lack resources including institutional and faculty support or buy-in (e.g., number of contact hours available for educational personnel, sustainability of the initiative, and guidelines on content [19],[23],[26],[40],[41]), financial support (e.g., instructional personnel and imaging costs [19],[20],[26]), and/or time in the curriculum.[19],[20],[25],[26],[41] These factors can result in poor reception by students or faculty [18],[25] or minimal changes in student performance in anatomy courses [14],[21] when these types of educational initiatives are implemented. Some educators have designed initiatives with a smaller footprint and include the integration of radiology into active learning settings; short lectures, demonstrations, or workshop sessions; or self-directed activities and modules.[25],[26],[30],[35],[37] At the same time, other institutions are able to support initiatives that integrate CT imaging into the anatomy course as a supplement to traditional lectures and cadaveric dissection laboratories [10],[11],[26],[32],[39] or with CT imaging of cadavers in the dissection laboratories.[14],[18],[21],[29],[30],[33],[34],[38] Finally, a handful of these studies did find improvement in course examinations or final course grades,[14],[34],[37],[38] improvement in pre/posttest protocols or study-specific assessments that were based on anatomy and the use of radiological images,[11],[29] or improvement in general knowledge of radiological modalities or radiology skills.[21],[42]

In 2015, we began the initial stages of our educational intervention by intentionally bringing together medical educators from the basic sciences and clinicians from the radiology department, all with common interests in the education of medical students. It was very important at the outset to gain support from the radiology department chair, curriculum deans, and gross anatomy course leadership to move this project forward. This study aimed to investigate the potential impacts of the integration of radiological resources into a medical gross anatomy course within an accelerated curriculum format (i.e., a 1-year preclinical science curriculum). We introduced a series of radiological anatomy presentations by radiologists and then augmented our lectures, laboratory dissector, laboratory practicals, and lecture examinations with radiological images.[43] Our efforts were different from other studies as we combined components of other studies into this larger initiative, including who was involved in teaching (e.g., radiology faculty and residents [16],[19],[41] and anthropologists and other basic scientists [9],[18],[26]), how radiological images and materials were integrated into the course at multiple levels (e.g., lecture, laboratory, examinations – most studies referenced describe these efforts, listed are reviews of the literature [16],[19],[24],[26],[34]), and the format of our curriculum (e.g., accelerated preclinical [38]). We investigated the impact and effectiveness of this intervention by administering a pretest/posttest protocol, calculating learning gain, and through the review and summary of student evaluations.

 Methods



This study was classified as exempt and approved by the University's Institutional Review Board (IRB-Pro00075841). The study recruited first-year medical students enrolled in a Doctor of Medicine Program from the 2016–2017 and 2017–2018 academic years. Only students who completed both the pretest and posttest were included in analyses. All students were provided equitable access to the materials developed for the intervention, and students who voluntarily participated were distributed throughout the lecture and laboratory settings.

Gross anatomy curriculum

To provide a brief overview, the first-year curriculum during the cohort years of 2016–2017 and 2017–2018 included these preclinical courses: molecules, cells, and tissues (including genetics, biochemistry, and histology – microscopic anatomy of the basic tissues); normal body (including physiology, anatomy, embryology, and microanatomy – microscopic anatomy of the major organ systems); brain and behavior (including neuroanatomy, psychology); body and disease (including pathology, immunology, microbiology, and pharmacology); and clinical skills. Courses were presented in a combination of traditional lecture, team-based learning, clinical sessions/correlations, flipped classroom, and laboratory-oriented classes (gross anatomy, histology, and microanatomy). The gross anatomy course was described in part in an earlier study.[44] During the time of this educational intervention, the human gross anatomy course occurred in the fall semester across 13 weeks. There were approximately 25 h of lecture or large classroom sessions and approximately 75 h of laboratory sessions. During laboratory dissections, students were in teams of 5-6 and dissected one cadaver by following an online dissection manual. The online manual allowed students access not only to dissection images but also to radiological images and images from the course lectures.

Background and development of the radiology-based educational intervention

There was not an explicit radiology component in the gross anatomy course for several years prior to this intervention. Our intervention explicitly highlighted and integrated radiological imaging and radiologists in the course [Table 1]. The topics presented by radiologists included Introduction to radiology (history and modalities), thorax, abdomen (liver, biliary), musculoskeletal (shoulder and knee), and neuroradiology (cerebrospinal fluid). The radiologists who participated in lecture and laboratory sessions included residents, fellows, and departmental faculty. The intervention was developed over 3 years and is still being implemented in the curriculum. The project originated from a needs assessment and curriculum review and was initially supported by the school and program administration.{Table 1}

Assessment instrument

To assess medical student learning of gross anatomy content, we developed an assessment instrument consisting of 12 questions (including multiple choice, fill in the blank/free response, and ordering questions) derived from a set of “Radiology Exams” developed by Phillips et al.[45],[46] where the authors had mapped the questions to different levels of cognitive processing (e.g., remember, understand, and analyze). After looking over all of the region-based questions, one author chose questions that most closely represented the content (thorax, abdomen, pelvis, limbs, and head) and the radiological modalities (X-ray, magnetic resonance [MR], and CT) covered in our course.

Members of our anatomy instructional team reviewed the assessment instrument to determine the appropriateness of questions in terms of their level of difficulty and in relation to course learning objectives. The assessment instrument was first administered to volunteer students prior to the start of the course in mid-September (pretest). Students were provided 15 min to complete the assessment. At the end of the gross anatomy course (after the final examination in mid-December), the same assessment was re-administered, and volunteer students were provided another 15 min to complete the assessment (posttest). The pretests/posttests were administered via an online exam system (Examsoft – SofTest/Examplify, 2016–2017, Dallas, TX). All data points were aggregated and anonymized by a third party and sent to the primary investigators for further analyses.

This assessment instrument allowed us to investigate these questions: (1) Were there differences in pretest and posttest scores? (2) Did the region of anatomy, radiological modality, or cognitive level of the question have any influence on test results? (3) Did the intervention (radiologically based anatomy resources) increase learning gain?

Statistical analyses

Individual assessment results were scored out of 12 total points. All pretest and posttest results were analyzed, and descriptive statistics were reported, including mean and ± standard deviation (SD). Comparisons of scores between groups were assessed with a Wilcoxon signed-rank test. Statistical significance was set at <0.05 for all statistical tests. Preliminary data sorting was performed using Microsoft Excel 2018, version 16.13 (Microsoft Corp., Redmond, WA, USA) with statistical analysis performed in JMP Pro, version 13.0.0 (SAS Institute, Inc., Cary, NC, USA).

Calculation of learning gain

To calculate absolute learning gain from the pretest and posttest scores, we followed Pickering.[47] Calculating learning gain helps to quantify the difference in acquired knowledge. The normalized learning gain was calculated by dividing the absolute gain by the maximum possible gain. Normalization allowed for comparisons between groups.

Student evaluation

To collect general student feedback about the intervention and to better understand its putative impact, we surveyed learners in their course evaluations at the conclusion of the course. These questions included Did you use the radiology images in the course resources? Were the radiology images helpful? In addition, a Likert-style question was asked “Were the radiology presentations effective?” for each of the presenters in each of the regional topics. The scale was as follows: 1 = not at all, 2 = slightly, 3 = adequately, 4 = very, or 5 = extremely.

 Results



Of 119 eligible learners, a total of 55 participants (46% response rate) volunteered to take both the pretest and posttest in 2016. Of 116 eligible learners, 29 participants (25% response rate) volunteered to take both the pre- and posttest in 2017. The results of the Wilcoxon signed-rank test showed that there was a significant difference (t(54) = 9.98, P < 0.0001) between the 2016 cohort pretest (mean = 13.18%, SD = 8.89%) and posttest (mean = 38.64%, SD = 17.67%) mean scores. There was also a significant difference (t[28] = 10.93, P < 0.0001) between the 2017 cohort pretest (mean = 10.92%, SD = 7.75%) and posttest (mean = 43.96%, SD = 17.38%) mean scores [Table 2]. Learners were most successful when questions were focused on the anatomy of the thorax and abdomen, asked in either MR or CT images, or were categorized in the analyzing level within the taxonomy of cognitive domains [Figure 1]. In addition, there were significant differences based on Wilcoxon signed-rank tests between years in questions related to the cognitive domain of understanding (2016 post: 27.88%, 2017 post: 47.13%), the thorax (2016 pre: 25.46%, 2017 pre: 12.07%), and X-rays (2016 pre: 2.34%, 2017 pre: 7.39%). The absolute learning gain was 25.46 ± 19.07 for the 2016 cohort and 33.05 ± 16.29 for the 2017 cohort. The normalized learning gain was 0.29 ± 0.21 for the 2016 cohort and 0.37 ± 0.19 for the 2017 cohort [Table 2]. Survey feedback from learners indicated that 74.7% of the learners used the radiology images [Figure 2]; 48.3% of the learners rated the radiological images as somewhat helpful and 41.0% rated them as helpful, equating to a combined average of 89.3% [Figure 3]; and on average, the radiology presentations were rated as “adequately effective” (mean rating of 3.2 on a 5-point scale) [Figure 4].{Table 2}{Figure 1}{Figure 2}{Figure 3}{Figure 4}

 Discussion



For our educational intervention, we combined components and methods found in other studies into a larger course-wide initiative, which included involving radiology faculty and residents, anthropologists, and other basic scientists; integrating radiological images and materials into the course lectures, laboratories, and examinations; and implementing the intervention in the first year and first semester of an accelerated preclinical curriculum. The primary aim of our educational intervention was to provide increased radiologic anatomy resources and support to medical students in their first-year preclinical medical school curriculum. Several institutions have implemented and conducted studies on similar, but typically at a much smaller scale, interventions directed at introducing radiology into gross anatomy courses in the first year of medical school.[16],[19],[24],[26],[34] An additional objective of our study was to evaluate how the intervention impacted learners through a pretest/posttest protocol and traditional student feedback questionnaires.

The results of this study suggest that the integration of a variety of radiological resources was an effective intervention and may have contributed to learners' increased knowledge based on the significant increase (P < 0.0001) in learning gain (25.6%–33.1% higher scores) for both the cohorts [Table 2]. Learning gain in other anatomy-related educational intervention studies had absolute learning gain ranges from 10.52% to 47.50% and normalized learning gain ranges from 0.09 to 0.75.[34],[47] Hence, our values are within the range of those reported in the literature in our field. Similarly, other studies saw improvement in pretest and posttest assessments or study-specific assessments that were based on anatomy and the use of radiological imaging.[11],[29] A few programs studies saw improvements in course examinations or final course grades after integrating a variety of radiology materials into their courses,[14],[34],[37],[38] while others saw improvement in general knowledge of radiological modalities or radiology skills.[21],[42] However, it is important to note that not all studies showed improvements in all assessments that were implemented or in course grades.[14],[19],[21],[38]

In general, increasing students' awareness of and exposure to these resources may be a benefit to their long-term clinical training. Our data suggest that most learners correctly answered questions when provided with images from the core body regions (e.g., thorax and abdomen), which may be indicative of a better understanding of organs versus the extremities (including the joints like the shoulder and knee) and pelvis. This may be due to prior experience (premed courses, clinical experience, etc.). Learners performed better when questions included more anatomical context (i.e., several structures in the region of interest were visible). These types of questions met the “analyzing” level of cognitive taxonomy. Based on the results, learners showed overall higher levels of cognitive processing ability entering the course in both the years (e.g., analyzing) but showed the largest improvements in lower level processing questions (e.g., remembering and understanding) [Figure 1]. These results could be indicative of the students' abilities when they enter medical school and how quickly they can process information. It was also found that questions with MR and CT images appeared to be more well received. This could be because they often included more anatomical context. In addition, the majority of students considered the resources provided useful and beneficial [Figure 2] and [Figure 3] but wanted more direction and time with these resources, as has been found in similar studies.[19],[21]

Curricular change is slow moving, and evidence-based best practices are still emerging in this genre of educational initiatives, although the integration of radiology into medical curricula has been taking place for several decades now.[16],[19],[24],[34] It is apparent that accreditation bodies and academic and educational administration are focused on increasing exposure to clinically oriented content and early clinical experiences, as well as providing learners increased access to clinicians. We believe that our intervention and efforts provide an additional resource and basic guide to implement an educational intervention based on integrating radiology more explicitly in a medical gross anatomy course. As our participants were year one and semester one students, they gained valuable exposure to anatomy in a radiological context. The pretest/posttest assessments indicate that not only they learned general anatomy and concepts but also learners' gained knowledge of anatomy in radiological imaging modalities. This can help them to become more comfortable with orienting themselves in images, finding landmarks, and recognizing what tissues and structures look like in X-ray, CT, or MR. Exposing learners to these important, although challenging and sometimes uncomfortable, learning experiences early in their training will help them when they are faced with more difficult and stressful tasks later. The process of learning difficult concepts can be important in developing skills for life-long learning. Overall, the results from our study not only allowed us to improve the integration of radiology into gross anatomy but also assisted our faculty in understanding if there are gaps in the coverage of anatomical concepts and find links to clinical concepts while working with radiologists.

Limitations

There are limitations of this study, including relatively low response rates, especially in the 2017 cohort. Since the posttest occurred near the end of the semester, many students were overwhelmed with other responsibilities and the impending holiday break. There was also potentially selection bias among students who voluntarily took part in the pretest/posttests. These individuals may have already had more experience and confidence in their skills with radiological images. During any course, there are many variables that can alter how the course progresses, and our courses and this intervention could have been influenced by many variables that could not be controlled (e.g., differences in presentations, awareness of a new intervention, and communication with other cohorts, etc.). In additiona, due to only one iteration of the posttest, we were not able to determine long-term retention, but we hope to implement longitudinal assessments in the future. Finally, although this was a single institutional study, it would be interesting to now collaborate and implement this type of intervention in other medical schools.

Future directions

The results and feedback from this intervention have helped in the continued development of course resources, established a proof of concept, and have allowed us to set a foundation for more fully developing the use of imaging not only in medical student anatomy courses but also in other anatomy courses that use the gross anatomy laboratory. These efforts have led to the use of postmortem cadaver-specific CT scans in the medical gross anatomy course. The outcomes of this latter phase, which is part of a larger endeavor in radiology integration, will be reported in a future publication. Many discussions during this intervention also included ideas about introducing more early and meaningful clinical experiences in our courses, including the use of handheld ultrasound by our students and the introduction of table-side procedural anatomy (e.g., intubation, intravenous placement, etc.).

 Conclusions



We introduced a series of radiological anatomy presentations by radiologists and augmented our lectures, laboratory dissector, laboratory practicals, and lecture examinations with radiological images; all while implementing the intervention in an accelerated medical curriculum. This study contributes to the growing area of research that supports the integration of clinical faculty and clinically relevant applications into traditional basic science courses. There was a statistically significant improvement between pretest and posttest scores on radiological anatomy assessments. This study suggests that when made available to students, the radiological resources were helpful to their learning, were used by most students, and allowed them to become more comfortable with radiological imaging and anatomy prior to their clerkship years. These results allow us to improve the integration of radiology into our gross anatomy courses, assist our faculty in understanding if there are gaps in the coverage of anatomical concepts but also share these findings with other institutions considering this type of intervention.

Acknowledgments

The authors wish to thank the gross anatomy instructors for their support and assistance with the project in the gross anatomy course: Daniel Schmitt, Kirk Johnson, Christine Wall, Angel Zeininger, Sara Doyle, JD Pampush, Gillian Moritz, Gabriel Yapuncich, James Campbell, Paul Morse, Craig Wuthrich, Arianna Harrington, Bernadette Perchalski, and Rachel Roston. Radiologists Erik Paulson (Chair, Radiology Department), Caroline Carrico, Stephen Preece, Michael Malinzak, Dorothy Lowell, Nathan Hull, Benjamin Wildman-Tobriner, Joshua Zeidenberg, Neal Viradia, and Linda Gray were integral for clinical perspectives and content and in supporting these educational efforts. Mr Joseph Cawley from the Office of Curricular Affairs provided technical support. Mrs. Kristin Dickerson and Dr. Diana McNeill from Duke AHEAD provided logistical and creative support. Several leaders in education at Duke University School of Medicine provided financial, material, and logistical support – Assistant Dean for Basic Science Education Matthew Velkey, Associate Dean for Curricular Affairs Colleen O'Connor Grochowski, and Vice Dean for Education Edward Buckley. Material in this manuscript was previously presented as a poster and abstract at the 2018 American Association of Anatomists Conference.

Financial support and sponsorship

Financial support was provided by Duke University School of Medicine and Duke AHEAD.

Conflicts of interest

There are no conflicts of interest.

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