Basic Science

The impact of curricular change on medical students’

knowledge of anatomy

P P McKeown,1 D J A Heylings,2 M Stevenson,3 K J McKelvey,1 J R Nixon4 & D R McCluskey1

Background In recent years, following the publication with those from the student intakes of 1996)98, which
of Tomorrow’s Doctors, the undergraduate medical cur- undertook a new,
systems-based curriculum. To
riculum in most UK medical schools has undergone enhance linear response and enable the use of linear
major revision. This has resulted in a significant models for analysis, all data were adjusted using probit
reduction in the time allocated to the teaching of the transformations of the proportion (percentage) of correct
basic medical sciences, including anatomy. However, it answers for each item and each year group.
is not clear what impact these changes have had on Results The student intake of 1995 (old curriculum)
medical students’ knowledge of surface anatomy. were more likely to score higher than the students who
Aim This study aimed to assess the impact of these undertook the new, systems-based curriculum.
curricular changes on medical students’ knowledge of Conclusion The introduction of the new, systems-based
surface anatomy. course has had a negative impact on medical students’
Setting Medical student intakes for 1995–98 at the knowledge of surface anatomy.
Queen’s University of Belfast, UK. Keywords education, medical, undergraduate ⁄ *stand-
Methods The students were invited to complete a simple ards; curriculum; anatomy ⁄ *education ⁄ standards; Nor-
examination paper testing their knowledge of surface thern Ireland; educational measurement.
anatomy. Results from the student intake of 1995, which Medical Education 2003;37:954–961
undertook a traditional,
old curriculum, were compared

a radical reduction in the amount of didactic teaching

Introduction
allocated to the basic medical sciences, including
In 1993, the General Medical Council (GMC) pub- anatomy. Anecdotal reports from practising clinicians
lished the document Tomorrow’s Doctors.1 This docu- have suggested that medical graduates of the new
ment has had a profound influence on curricular
systems-based courses are limited in their knowledge
development in medical schools across the UK. In of basic anatomy. Concerns have also been raised about
particular, one of the principal recommendations was the reduction in the time available and the lack of
that
the ‘‘core curriculum’’ should be system-based, its suitable staff to teach anatomy.2–5 In view of this, we
component parts being the combined responsibility of undertook a study to investigate the impact of this
basic scientists and clinicians integrating their contri- curricular change on the basic clinical anatomy know-
butions to a common purpose, thus eliminating the ledge of undergraduate medical students at the Queen’s
rigid preclinical ⁄ clinical divide and the exclusive University of Belfast, UK.
departmentally based course.1 (p 23) This has led to

1 Methods
Department of Medicine, Queen’s University of Belfast, Belfast, UK
2
Department of Anatomy, Queen’s University of Belfast, Belfast, UK
3
Department of Epidemiology and Public Health, Queen’s University Curricular background
of Belfast, Belfast, UK
4
Department of Trauma and Orthopaedics, Queen’s University of The medical school at the Queen’s University of
Belfast, Belfast, UK Belfast, where students undertake a 5-year undergra-
Correspondence: Dr D R McCluskey, Department of Medicine, duate course, provided the base for this research. The
Queen’s University of Belfast, Institute of Clinical Science,
Grosvenor Road, Belfast BT12 6BJ, UK. Tel.: 00 44 28 9024 0503
last cohort of students to be taught on the
old
ext 2707; Fax: 00 44 28 9032 9899; E-mail: [email protected] curriculum started in 1995 and graduated in June

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Curricular change and anatomy knowledge • P P McKeown et al. 955

examinations, which have an identifiable anatomical

Key learning points practical component, and include both integrated, case-
based, short-answer questions and a multiple-choice
The surface anatomy knowledge of medical stu-
paper. Students have to pass the examination overall,
dents undertaking the new, systems-based course
but there are no sanctions for any student who fails the
is significantly less that that of those who under-
identifiable anatomical component. As part of the
took the traditional curriculum.
curricular change, dental and medical students share
Vertical integration occurs in the systems-based the same basic core course for the first 2 years.
course.
This study centred on knowledge of surface Assessment of clinical anatomy
anatomy. It is not clear whether similar findings
The student intake of 1995, which graduated in 2000,
apply to other basic medical sciences.
was assessed using a short examination paper (Appendix)
prior to the Final MB examination. This paper assessed
their knowledge of the surface anatomy of the limbs and
2000. Since 1996, all student cohorts have been taught abdomen. Using the same examination paper, the
on a systems-based curriculum revised in light of student intake of 1996 was assessed twice, first during
Tomorrow’s Doctors. Year 4 and again prior to the Final MB examination.
The 1995 intake undertook a course with 2nd MB The student intakes of 1997 and 1998 were also
(the preclinical end-of-course examination) at the end assessed using an abbreviated paper (abdomen only) at
of 1Æ5 years of study. The curricular objectives of this the end of Years 3 and 2, respectively. The papers were
course had already been reduced so that they were marked blindly by 1 author (DMcC), using templates
more clinically orientated and students had on average prepared from Grant’s Atlas of Anatomy.6
12 hours of anatomy teaching per week. Students had a
regular weekly embryology lecture, a lecture and
Statistics
practical in histological anatomy and 8 hours of gross
anatomy practicals per week, including specific surface To enhance linear response and enable the use of linear
anatomy classes. The curriculum was completed with a models for analysis, all data were adjusted using probit
short compact course on neuroanatomy lasting transformations of the proportion of correct answers for
approximately 12 hours, which ran in parallel to a each item within each year group. In rare cases of 100%
comprehensive gross anatomy revision programme. correct response, the probit equating to 1–1 ⁄ 2 n was
Overall scheduled interactive teaching totalled imputed where n was the number of respondents. The
384 hours, with a final end-of-course
must pass transformed data were then analysed using general linear
anatomy examination. models with question and year as main effects. Residual
In comparison, the new, systems-based course, plots were made and these confirmed that normality and
which started in 1996, provides integrated teaching of equality of variance assumptions held. Post hoc tests
basic medical sciences alongside clinical training, using modified t-tests on differences between years of
centred on body systems rather than on specific subject intake were performed and Duncan’s range test was
areas. Clinical skills teaching commences in the second used to examine for homogeneous subsets.
semester of Year 1 and involves tutorial-based sessions
both in the Clinical Skills Centre and with patients in
Results
hospitals and general practices. The anatomical input
to this integrated course is based on a total teaching The anatomy paper was answered by 165 ⁄ 208 (79Æ3%)
time of 183 hours. It consists of a separate histology of the 1998 intake (Year 2 medical and dental
programme over 2 years (totalling 61 hours) and gross students), 83 ⁄ 180 (46Æ1%) of the 1997 intake (Year 3
anatomy over 1Æ5 years (with an average of 3Æ25 hours medical students), 129 ⁄ 149 (86Æ6%) of the 1996 intake
per week, a total of 116 hours, including 6 hours of (Year 4 medical students), 130 ⁄ 148 (87Æ8%) of the
neuroanatomy, limited surface anatomy and virtually 1996 intake and 95 ⁄ 166 (57Æ2%) of the 1995 intake (as
no embryology). The histology programme is enhanced Year 5 medical students). The abdominal data were
with additional classes in an integrated introductory summarised according to organ position (Fig. 1) and
pathology course used to highlight normal structure organ size (Fig. 2). Data pertaining to surface anatomy
and introduce principles of pathology. The anatomical of the limbs are also shown (Fig. 3). Overall, the
assessment is carried out through end-of-semester anatomy knowledge for both limbs and abdomen was

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956 Curricular change and anatomy knowledge • P P McKeown et al.

2 second
Probit (% correct)

third
1 fourth
final - new
0
final - old

-1

ascending
left kidney

bifurcation
spleen

pancreas
bladder
caecum

left ovary
liver

stomach

of aorta
colon
Figure 1 Abdomen: organ position. Summary of results for all years.

best for those students who had completed the old be more discriminatory than those that received very
curriculum. On the basis of the abdominal anatomy high ratings.
questions alone and looking at all years, the difference When we included the questions on limb anatomy,
in years was significant at P < 0Æ01. This level of thereby reducing the examination to Years 4 and 5 (old
significance was maintained when just the final year and new curricula), the difference between cohorts was
performance of students on the old and new curricula greater (P < 0Æ001) and each cohort was different from
were compared (P ¼ 0Æ009). Post hoc tests revealed all others. Year 5 (old curriculum) performed best,
that this difference could be explained sufficiently by followed by Year 5 (new curriculum), with Year 4
the much better performance of old curriculum Year 5 performing worst.
students compared to all others. Questions that Notably, the same cohort of students was represented
received a mid-range correct response rate tended to in the data from the fourth and final years of the new

3
Probit (% correct )

2 second
third
1 fourth
final - new
0
final - old

-1
ascending

bifurcation
left kidney
pancreas
left ovary

stomach
bladder
caecum
spleen
liver

of aorta
colon

Figure 2 Abdomen: organ size. Summary of results for all years.

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Curricular change and anatomy knowledge • P P McKeown et al. 957

Probit (% correct) 3

2
fourth
1 final - new

0 final - old

-1
ulnar nerve

median nerve

radial nerve

common femoral

anterior superior iliac

sciatic nerve
olecranon

tibial tubercle
deltoid

dorsalis pedis
nerve

spine
Figure 3 Limbs. Summary of results for fourth, final (new curriculum) and final (old curriculum) years.

curriculum and their improvement was significant Monkhouse recommended that undergraduate anat-
(P ¼ 0Æ002). It was reassuring for staff to note the omy teaching should be aimed at those disciplines for
performance of Year 2 students who had just comple- which postgraduate training does not include anatomy
ted their course on the abdomen, as they performed as teaching, for example, undifferentiated doctoring and
well or occasionally better than final year students when general practice.2 More recently, Haase identified the
it came to organ size, although for this group of important issue of deciding what from the vast stores of
questions a formal statistical test shows no significant anatomical knowledge was most directly and clinically
difference across all years. However, they were notice- relevant to an undifferentiated doctor.9 However, there
ably weaker in surface positioning of the same organs; has been no pedagogical research to establish which
within this group of questions there was significant teaching approach ) dissection or demonstration clas-
difference between years, with Year 5 of the old ses using prosected anatomical specimens ) provides
curriculum emerging as the clear winner, although the better learning forum for anatomy.10,11
there is no significant difference between all other years. Similar concerns have been expressed about junior
The data for students on the new curriculum clearly doctors’ level of knowledge of acute medicine and it has
demonstrates that knowledge of surface anatomy was been recommended that medical schools incorporate
normally acquired during the later clinical years of appropriate training into undergraduate curricula.12
study. Performance on the limbs was more uniform The teaching of anatomy (not only in the UK) faces
except for the questions relating to the radial nerve and challenges that relate to changes in medical curricula
tibial tubercle, perhaps reflecting the emphasis placed and in the academic background of staff in what were
on these structures in the later clinical years. once traditional anatomy departments.3,4,13,14 In many
departments in the UK, teaching relies on part-time
clinical teachers, with fewer full-time teachers with
Discussion
clinical experience. In the past, anatomy departments
The GMC document Tomorrow’s Doctors has had a also relied on part-time teachers, who were enthusiastic
profound effect on curricular design, leading to a major young surgeons in training, learning anatomy for their
reduction in the importance of anatomy teaching in higher examinations. They provided superb role models
most UK medical schools. Various authors, arguing for undergraduate students and enhanced the learning
that anatomical knowledge provides the structure on environment in many ways. However, following chan-
which other medical disciplines sit, have challenged this ges to postgraduate training requirements, there has
erosion of teaching in medical schools.7,8 In 1992, been a great reduction in the availability of these young

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958 Curricular change and anatomy knowledge • P P McKeown et al.

teachers and today their replacements are either retired whereby Year 2 students were better at identifying
clinicians or those looking to add a new dimension to organ size but not position, can be explained by the
their career.5,15 The increasing number of non-medic- reduction in teaching time, with the loss of surface
ally qualified staff, whose main interests are focused on anatomy classes, the content of which was expected to
basic research rather than clinical anatomical teaching, have been picked up by clinical teachers. To enhance
has further changed the profile of teachers and their the impact of surface landmarks, staff have increased
approach to the subject.16 the emphasis on surface landmarks both in gross
These changes in staffing occurred at the time of anatomy and in basic clinical skills teaching. In addition
transition from the old to the new curriculum and may to this, it has been proposed that the facility for
partially explain the impact noted in the data presented. compensation across subjects should be reduced in
Pertinent to this was the sudden loss of the additional order to ensure that students learn to an acceptable
input from young clinicians, resulting in substantially standard in all aspects of the curriculum.
fewer teachers with clinical experience in each class of There are several limitations to our study. Firstly, the
the new curriculum. This has now been addressed with percentage of students who completed the examination
the introduction of significant numbers of experienced was low for the intakes of 1995 and 1997, resulting in a
clinicians. In addition, a review of anatomy teaching weaker data set than desirable. Secondly, the assess-
has been carried out and the curriculum refined to ment only tested the factual knowledge of limited
produce an agreed core set of learning outcomes. aspects of surface anatomy and used a paper-based
Medical imaging, in particular MRI and CT, has assessment rather than clinical patients; indeed, this
resurrected cross-sectional anatomy as a curricular factual knowledge is only 1 component of medical
imperative; similarly, the frequent need for vascular education, as we also expect our students to develop
access has made understanding the vascular relation- problem solving and critical analysis skills.
ships an important educational objective. Marks7 com- An often overlooked core element of anatomical
mented that:
Anatomy, the structural basis for life, teaching concerns the development and practice of
provides a unique and necessary perspective on the
medical communication skills, through the teaching
human body from the molecular to the macroscopic. A and use of the terminology that makes up the language
solid foundation in anatomy is the best preparation for of medicine.18 This was retained in our curriculum
an effective physical examination and for safe, efficient design to encourage students, through their study of
basic clinical procedures. (p 343) Elsewhere, Pabst anatomy, to learn how to orientate and describe normal
reported that medical students, at the end of their structures (and hence abnormal structures) and then to
undergraduate clinical training at the Medical School of accurately communicate this information to other
Hanover, considered gross anatomy to be a keystone of professionals. Such skills are best developed through
their clinical courses; these students also indicated that the small group work and self-directed learning that
they would have liked further specialised dissection occur through either dissection or well constructed
courses during the clinical curriculum.17 demonstration classes, a key goal of the curricular
Our results show that the clinical anatomical know- construct. Through the use of the cadaver, we were also
ledge (as assessed by our particular examination) of able to raise emotional issues that some students had
students who undertook the old curriculum was better not yet had to face. The issue of how these should be
at the end of the medical undergraduate course than addressed has been discussed elsewhere.19,20 However,
that of students on the new, systems-based course. it should be remembered that the anatomy laboratory
However, it was evident from the assessment scores of provides a learning experience for the student that the
Year 5 students on the new curriculum that anatomical teacher can use to explore wider issues that relate to
knowledge was accumulated throughout the medical medical practice. For example, the issue of death is
course, reassuringly suggesting that vertical integration often faced by students for the first time in anatomy and
had taken place. Over the period of the introduction of various pathologies observed through dissection allow
the new curriculum, anatomy staff had observed a the teacher to explore how the disease may have
reduction in the degree of effort put into learning by a affected the patient’s lifestyle. Hence, the student is
proportion of students. Whilst the majority of students able to integrate anatomy knowledge into the wider
were able to gain a sound level of anatomical know- context of medical practice. This approach has been
ledge, staff believe that the change in assessment facilitated in our medical school, through the introduc-
procedures, which now allow for compensation tion of senior or retired surgeons to the anatomical
between subjects, contributed to the effect documented room, in order to create a bridge between basic surface
by the data presented. The discrepancy within the data, anatomy and clinical practice.

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Curricular change and anatomy knowledge • P P McKeown et al. 959

In summary, our results provide evidence that the 4 Malamed S, Seiden D. The future of gross anatomy teaching.
medical students who undertook the new, systems- Clin Anat 1995;8:294–6.
based course did not have the same level of knowledge 5 Ger R. Basic surgical training 4: American and British scenes
compared. Clin Anat 1996;9:173–4.
of surface anatomy as those students who undertook
6 Agur AMR, Lee MJ. Grant’s Atlas of Anatomy. 10th edn.
the old curriculum. Smith and Poplett recently high-
Baltimore: Lippincott, Williams & Wilkins 1999.
lighted deficiencies in junior doctors’ knowledge of
7 Marks SC. Information technology, medical education and
basic aspects of acute care.12 It is therefore important anatomy for the 21st century. Clin Anat 1996;9:343–8.
that UK medical schools examine the impact of these 8 Paalman MH. Why teach anatomy? Anatomists respond. Anat
curricular changes on outcome measures to ensure that Rec 2000;261:1–2.
the quality of our medical graduates remains high and 9 Haase P. The challenges of teaching an old subject in a new
expected clinical skills are not lost. world – a personal perspective. Clin Invest Med 2000;23:81–3.
10 Dinsmore CE, Daugherty S, Zeitz HJ. Teaching and learning
gross anatomy: dissection, prosection or
both of the above.
Contributors Clin Anat 1999;12:110–4.
PMcK, DH and DMcC were primarily responsible 11 Monkhouse WS, Farrell TB. Tomorrow’s doctors: today’s
mistakes? Clin Anat 1999;12:131–4.
for the writing of the manuscript. MS performed the
12 Smith GB, Poplett N. Knowledge of aspects of acute care in
statistical analysis. KMcK, JN and DMcC designed
trainee doctors. Postgrad Med J 2002;78:335–8.
the study and were responsible for data collection. 13 Willan PLT, Humpherson JR. Profiles of applicants for junior
DH has recently moved to the University of East faculty posts to teach anatomy in the UK: changing popula-
Anglia. tions of candidates. Clin Anat 1999;12:272–6.
14 Heylings DJA. Anatomy 1999–2000: the curriculum, who
teaches it and how? Med Educ 2002;36:702–10.
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18 Ellis H. Teaching in the dissection room. Clin Anat
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19 Nnodim JO. Preclinical student reactions to dissection, death
1 General Medical Council. Tomorrow’s Doctors. Recommenda- and dying. Clin Anat 1996;9:175–82.
tions on Undergraduate Medical Education. London: General 20 Dinsmore CE, Daugherty S, Zeitz HJ. Student responses to
Medical Council 1993. the gross anatomy laboratory in a medical curriculum. Clin
2 Monkhouse WS. Anatomy and the medical school curricu- Anat 2001;14:231–6.
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960 Curricular change and anatomy knowledge • P P McKeown et al.

Appendix

SURFACE ANATOMY OF THE ABDOMEN:-

Please draw (to scale the following organs):

1. Liver 6. Pancreas
2. Spleen 7. Stomach
3. Caecum 8. Left Kidney
4. Left Ovary 9. Ascending Colon
5. Bladder 10. Bifurcation of Aorta

Costal Margin

Inguinal Ligament

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Curricular change and anatomy knowledge • P P McKeown et al. 961

SURFACE ANATOMY OF THE ARM AND LEG

On the diagrams provided draw and/or mark with an arrow the following structures:

Upper Limb

Deltoid muscle
Ulnar nerve at the elbow joint
Median nerve at the wrist
Olecranon process
The radial nerve in the upper arm

Lower Limb

Sciatic nerve
Common femoral nerve
Anterior superior iliac spine
Position of dorsalis pedis pulse
Tibial tubercle

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