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Anatomy is considered to be one of the keystones of undergraduate medical education. However, recently, there has been drastic reduction, both in gross anatomy teaching hours and its context. Additionally, a decrease in the number of trained anatomists and an increase in the costs associated with procuring human cadavers have been noted, causing a diminution of cadaveric dissections in anatomy education.
To address these challenges, there is an ardent need for a pedagogical framework such that anatomy education can be disseminated through active learning principles, within a fixed time frame, using a small team of anatomists and a small number of cadaveric specimens (for live on-site sessions) as well as collaborative learning principles. The latter is particularly important when anatomy education is delivered through distance learning, as is the case currently during the COVID-19 pandemic.
Here, we have blueprinted a pedagogical framework blending the instructional design models of Gagne’s 9 events of instruction with Peyton’s 4-step approach. The framework’s applicability was validated through the delivery of anatomical concepts, using an exemplar from the structure-function course Head and Neck during the normal and COVID-19–mandated lockdown periods, employing the archetype of Frey syndrome. Preliminary evaluation of the framework was pursued using student feedback and end-of-course feedback responses. The efficiency of the framework in knowledge transfer was also appraised.
The blueprinted instructional plan designed to implement the pedagogical framework was successfully executed in the dissemination of anatomy education, employing a limited number of cadaveric specimens (during normal times) and a social media application (SMA)–integrated “interactome” strategy (during the COVID-19 lockdown). Students’ response to the framework was positive. However, reluctance was expressed by a majority of the faculty in adopting the framework for anatomy education. To address this aspect, a strategy has been designed using Mento’s 12-step change management model. The long-term benefits for any medical school to adopt the blended pedagogical framework have also been explicated by applying Bourdieu’s Theory of Practice. Additionally, through the design of an SMA interactome model, the framework’s applicability to the delivery of anatomy education and content during the ongoing COVID-19 pandemic was realized.
In conclusion, the study effectively tackles some of the contemporary key challenges associated with the delivery of anatomy content in medical education during normal and unprecedented times.
Anatomy education is an essential stipulation for medical students, general practitioners, surgeons, and for all those involved in invasive diagnostic and therapeutic procedures [
The COVID-19 pandemic has added to these challenges, as most medical schools have suddenly shifted from face-to-face teaching to distance learning, requiring the design of innovative strategies that will allow for the delivery of remote anatomy education [
One way of effectively addressing these challenges is to design a “student-centered teaching framework” (easily implementable for both face-to-face and distance-learning modalities), where the essential “nuts and bolts” of anatomy can be delivered effectively: (1) within a limited and fixed time frame; (2) using a small team of trained anatomists; (3) using a small number of cadaveric specimens; and (4) by integrating principles of active learning, collaborative learning, feedback, and student autonomy.
Moreover, designing a pedagogical framework alone will not address the challenges of anatomy education. The designed teaching approach needs to be implemented in the delivery of anatomy education and then evaluated. Furthermore, a change management strategy needs to be adopted such that the pedagogical framework is able to initiate a change in pedagogical philosophy in the context of anatomy education.
Here, we outline a pedagogical framework to tackle the aforementioned challenges of anatomy education in a competency-based medical curriculum (CBMC). A pedagogical framework was designed, blending Gagne’s [
The CBMC at MBRU comprises three phases (
The undergraduate medical curriculum at Mohammed Bin Rashid University of Medicine and Health Sciences (MBRU). The curriculum is divided into three phases and spans over 6 years. Note: Each phase of the undergraduate medical curriculum includes integrated courses and builds on the preceding one, such that the curriculum is a “spiral,” and the students repeat the study of a subject, each time at a higher level of difficulty and in greater depth. The phase in which the teaching framework was implemented is indicated with a red arrow.
The structure-function courses are designed to provide students with in-depth understanding of the normal human anatomy and resulting physiological roles, with a focus on essential radiology and basic clinical correlation. The structure-function course Head and Neck where the pedagogical framework was implemented provides students with functional knowledge of the structures of head and neck regions that will enable further understanding of organ system courses in Phase 2 (
In order to design the pedagogical framework, we employed the instructional design models of Gagne [
The individual steps of the instructional plan associated with the pedagogical framework are described below (
Design of the pedagogical framework. The instructional design strategies of Gagne and Peyton were blended to design the framework. The blended steps are also indicated. On the far right, the dissemination of the teaching framework with the sequential steps is shown with the allocated time for each step. The clinical case associated with Frey syndrome and the associated deliverables are shown. The medical image of Frey syndrome was adopted from Prattico and Perfetti [
For the implementation of the instructional plan, the anatomy dissection hall was chosen (
Anatomy dissection facilities at the Mohammed Bin Rashid University of Medicine and Health Sciences. (A) Dissection area showing the dissection stations (each station comprises an adult cadaver placed in the supine position on a removal tray situated on the dissection table); (B) medical imaging and case-based discussion area; (C) and (D) prosection areas.
In preparation for the session, students were requested to review the following concepts: (1) boundaries and contents of the parotid region and (2) the structural and functional aspects of the course and distribution of the facial nerve. In addition, for the instructional plan, we decided to use the exemplar of the clinical case associated with Frey syndrome. In line, by reviewing the above concepts, we believed students would be better prepared to tackle the questions accompanying the case.
Learning material in the form of PowerPoint slides, medical images, and reading material pertaining to the above concepts were uploaded to the learning management system [
The steps were tailored employing a “blended” methodology in which Gagne’s instructional model was integrated with Peyton’s 4-step approach (
The instructor applied the “pattern interrupt phenomenon” [
Students were then provided with set learning objectives, which they were expected to achieve at the conclusion of the instructional plan (
Students participated in a group discussion to determine and evaluate the safest dissection approach when resecting the parotid gland. This enabled students to revise concepts related to gross, variational, functional, and living anatomy and helped them appreciate how these contributed to the accurate interpretation of imaging anatomy, safe clinical practice, and successful surgical outcomes. This step touched on the theories of multiple concepts [
Students were then presented with a clinical case (
Principles of steps 2 and 3 of Peyton’s 4-step model was integrated here. Interactive learning was emphasized in this step. The instructor explained the individual steps for the activity (ie, dissection procedure) and provided clarity on the rationale behind it. The instructor then analyzed each step thoroughly, highlighting the essential “dos” and “don’ts” and provided a few practical tips (Peyton’s Principle #2). Students were encouraged to ask questions to clarify any doubts. This was followed by a conceptual phase during which philological and kinesthetic learning styles were encouraged as students were entreated to elucidate each step of the dissection procedure, while the instructor followed the guidelines (Peyton’s Principle #3). Such a practice enabled students to articulate the dissection procedure gradually, concomitantly allowing the instructor to assess their understanding.
This step corresponds to Peyton’s Principle #4. In this step, students were provided with the opportunity to reinforce their learning through performance; therefore, a larger amount of time was allocated to this step. The class was divided into 12 groups (approximately 5 students/group). Each group was assigned a cadaver and a dissection station (5 cadavers in total). In their designated groups, students attempted to perform the dissection procedure of the parotid gland as described by de Ru et al [
In this step, the student groups were also asked to address the questions listed under deliverables in the clinical case of Frey syndrome (
Informative feedback was provided employing Pendleton’s feedback model [
What do you think went well?
What do you think could be done differently?
What could be further improved?
How can this be achieved?
In this step, students prepared a reflective report on their dissection experience and how that experience helped them to better understand the anatomical changes associated with Frey syndrome. The students prepared their report using Gibbs’ reflective cycle framework [
Following submission of the report, students were required to assess a clinical scenario similar to Frey syndrome (namely, facial nerve paralysis) using the sequential steps of the dissection procedure, which they were exposed to earlier [
Currently, with the COVID-19 pandemic sweeping across the globe, many medical schools have switched to the distance learning modality. So, we asked ourselves “Can our teaching framework adapt to this new pedagogical shift?” We have applied this framework again to the structure-function course Head and Neck, this time delivered through distance learning. To apply this framework, we designed an SMA-based “interactome” (
The SMA (social media application) interactome. The dissemination of the teaching framework using SMA during the unprecedented times of COVID-19 is shown. The interactome consists of two aspects, one of which is instructor centric whereas the other is learner centric. Individual steps of the teaching framework attesting to the two aspects in shown. Step 6 is common to both the aspects (indicated by *). The crosstalk between the two aspects is facilitated by SMAs (YouTube and WhatsApp at the Mohammed Bin Rashid University of Medicine and Health Sciences, and also through discussion sessions on the learning management system at the university).
The efficiency of the pedagogical framework in knowledge transfer was investigated by comparing the performance of students in the summative assessment of the Head and Neck course across three cohorts (
Performance of students in the summative assessment of the Head and Neck course across three cohorts: (A) cohort where the course was delivered on-site using traditional didactic pedagogy; (B) cohort where the course was delivered on-site using the blended pedagogical framework with incorporation of dissection sessions; and (C) cohort where the course was delivered using the blended pedagogical framework, with integration of the social media application interactome during the COVID-19–mandated lockdown period. Note: the performance of the students was better when the pedagogical framework was implemented in the delivery of anatomy education.
Cohort and range of % score | Students, n (%) | |
|
|
|
|
31-41 | 2 (3) |
|
41-51 | 3 (5) |
|
51-61 | 12 (21) |
|
61-71 | 22 (38) |
|
71-81 | 16 (28) |
|
81-91 | 3 (5) |
|
|
|
|
42-53 | 6 (10) |
|
53-64 | 8 (14) |
|
64-75 | 22 (38) |
|
75-86 | 19 (33) |
|
86-97 | 3 (5) |
|
|
|
|
55.7-65.7 | 10 (18) |
|
65.7-75.7 | 14 (25) |
|
75.7-85.7 | 14 (25) |
|
85.7-95.7 | 18 (32) |
In the present work, our focus was on the design and implementation of the pedagogical framework. An elaborate evaluation of the perceptions of students toward the pedagogical framework is still pending and will be addressed in our future work. The evaluation presented here is only preliminary.
The pedagogical framework was evaluated informally following Pendleton’s approach [
The pedagogical framework was received positively by the students, who exhibited enthusiasm in both organizing and in participating in the event. Key points of note are as follows:
Students from different academic backgrounds effectively functioned as a group.
The reading habits of students improved significantly following their participation in the activity due to the increase in depth and content of the questions posed by the students during discussion. This observation is in line with the findings of Miner et al [
Student autonomy was augmented, as many of them prepared concept/mind maps to correlate their understanding of the delivered concepts to their clinical significance.
Specific limitations that students believed need to be addressed are as follows:
The time allocated for discussion (Step 6 in the instructional plan) was insufficient. The way to overcome this insufficiency is to integrate SMA into the delivery of the specific steps of the instructional plan, especially the ones that entail collaborative learning, similar to one of our previous studies [
Students had difficulties accessing specific journals with regard to Step 6 of the instructional plan (since the institution didn’t have a subscription to these resources). One of the ways to side-step this limitation is to encourage students to refer to articles in open access journals of repute.
Formal student feedback for the Head and Neck course was obtained by using an institution-approved questionnaire for the cohorts where the pedagogical framework was implemented. The feedback for the course indicated that students expressed satisfaction with the instructional plan employed in the course; 79% (44/56) of students in both cohorts where the pedagogical framework was implemented strongly agreed with the highest grading score “extremely satisfied.” The majority of students (81/114, 71%) in both of the cohorts where the pedagogical framework was implemented indicated in open-ended comments that the instructional plan that was integrated into the Head and Neck course should be implemented across all structure-function courses in anatomy education, and if possible, especially in practical sessions involving dissection or discussion of clinical scenarios. Further, while evaluating the reports of the students, the instructor found that most students, while reflecting on their experience with regards to the instructional plan, identified that the pedagogical framework augmented their knowledge of anatomy pertaining to the session learning objectives, as well as helped them understand the clinical relevancy of the concepts.
In this study, we have blueprinted a pedagogical framework blending Gagne’s 9 events of instruction and Peyton’s 4-step teaching approach, and employed the framework in the dissemination of anatomy education both during normal and COVID-19–mandated periods. The framework was positively received by the students, who recommended its integration across all structure-function courses in Phase 1. Based on this feedback, the director of Phase 1 (YB) and the instructor who implemented the pedagogical framework (NN) approached other instructors in other structure-function courses to encourage the adoption of this framework. However, initial discussions indicated that instructors were reluctant to adopt the framework as it entailed elaborate modifications to their teaching approaches, which involved conformist strategies employed in anatomy education. However, this observation is not unique to our institution, and similar barriers have been encountered in medical education [
Accordingly, we decided to design a change management approach to integrate the pedagogical framework across all structure-function courses. This design involved the use of Mento’s change management model. We selected this model since it was previously used successfully to initiate change in pedagogical philosophy to implement active learning strategies in the medical curriculum, specifically in biochemistry and molecular biology courses [
In addition, the benefit of the pedagogical framework being adopted by a medical school can be elaborated using Bourdieu’s Theory of Practice [
The fact that our pedagogical framework requires only a limited number of cadaveric specimens is pivotal, especially for medical schools in the Middle East where religion may play an imperative role in the number of cadavers available for dissection (Naidoo et al, unpublished data). Although Elamrani and colleagues [
Apart from the above, body donation programs in many countries are also affected by local and political history [
Conventionally, anatomy is often perceived as an uninteresting, labor-intensive discipline, taught using surface-learning strategies and rote memorization [
Guidelines outlining the activities and timeline corresponding to each step of Mento’s change management model for the integration of a blended Gagne-Peyton instructional model in all structure-function courses.
Step | Mento’s model of change | Activity to facilitate/implement the change | Timeline |
1 | The idea and its context |
Preliminary results from the HNSFa course in Phase 1, semester 2, showed that the blended instructional model of pedagogy facilitates better learning in UMEb. The idea is to integrate the blended instructional model throughout all structure-function courses in semester 2 of Phase 1. |
N/Ac |
2 | Define the change initiative |
Present to concerned stakeholders the following: What are the attributes of the blended teaching approach of Gagne and Peyton? Benefits of the blended instructional model of Gagne and Peyton Planning of the teaching approach Successful case studies of the blended instructional model (eg, results of this study) |
4 weeks prior to course initiation |
3 | Evaluate the climate for change |
Assess the necessary resources, prior knowledge of stakeholders, and technological proficiency required to successfully implement the blended instructional model in the structure-function courses through SWOTd analysis. |
4 weeks prior to course initiation |
4 | Develop a change plan |
Work with the technology-enhanced learning (TEL) and Smart Learning Hub (SLH) teams at MBRUe to develop a faculty development plan to train stakeholders on the strategies to implement the blended instructional model of Gagne and Peyton in structure-function courses. |
3 weeks prior to course initiation |
5 | Find and cultivate a sponsor |
Schedule meetings with MBRU academic leadership (dean/associate deans/departmental chairs, phase directors) to inform them about the benefits of the blended instructional model and the resources required. |
3 weeks prior to course initiation |
6 | Prepare your target audience |
Organize faculty development workshops in collaboration with the TEL and SLH teams to inform stakeholders about Circulate nano-lectures on active learning to stakeholders over WhatsApp. |
2 weeks prior to course initiation |
7 | Create a cultural fit |
Create linkage between students’ learning approaches and the blended teaching approach to explain to concerned stakeholders |
2 weeks prior to course initiation |
8 | Develop and choose a lead |
Create an informal lead team consisting of the course coordinator and instructors of the HNSF course and digital advisors from the TEL and SLH teams, such that they can guide and encourage stakeholders to implement the blended teaching approach in the structure-function courses (at least 9 blended teaching sessions over 5 weeks). |
1-5 weeks into the course |
9 | Create small wins for motivation |
Identify the stakeholders who successfully integrated the blended teaching approach into their courses and request them to present their experiences in this effort to the MBRU academic leadership and other concerned stakeholders. |
4-5 weeks into the course |
10 | Constantly and strategically communicate the change |
During the whole transformation process: Create a “learning community” such that stakeholders can learn from each other about strategies to successfully implement the blended teaching approach in pedagogy. Try to address hurdles that are faced by stakeholders in their endeavours by communicating the change process to sponsors |
1-5 weeks into the course |
11 | Measure the progress of the |
Refer to the updated pedagogical techniques of the concerned courses to appraise the number of teaching sessions where blended teaching was implemented. Evaluate the attitude of stakeholders toward blended teaching following the transformation initiative using an ADKARf framework. Assess the performance of the students in the structure-function courses to identify if blended teaching was beneficial over the traditional method. Obtain student feedback to assess students’ perceptions toward blended teaching. |
6 weeks into the course following midterm assessments |
12 | Integrate lessons learned |
Using a reflective framework conduct an After Action Review to: Map the transformation process Identify hurdles that need to be tackled such that blended teaching can be successfully integrated in other courses |
6 weeks into the course following midterm assessments |
Other notes |
Preparatory time for implementing the transformation: 4 weeks Time required for implementing/assessing the transformation: 5 weeks Total study duration (preparation + implementation + assessment): 9 weeks |
aHNSF: Head and Neck structure-function course.
bUME: undergraduate medical education.
cN/A: not applicable.
dSWOT: strengths, weaknesses, opportunities, and threats.
eMBRU: Mohammed Bin Rashid University of Medicine and Health Sciences.
fADKAR: awareness, desire, knowledge, ability, reinforcement.
Bourdieu’s Theory of Practice. The figure elaborates on three intimately related concepts: field, capital, and habitus. The text box in blue elaborates how Bourdieu’s Theory of Practice when applied to the current context demonstrates the benefit of the teaching framework being adopted by a medical school. The concept of the figure was derived from Brosnan [
Reflecting on our pedagogical framework against Harden’s integration ladder [
In recent times, anatomy teaching has undergone a paradigm change from “instructor-centered” to “student-centered” approaches [
During the mandated COVID-19 lockdown, we were able to implement the pedagogical framework through SMA integration. This further attests to the versatility of our teaching framework, which can be tailored according to the demands of a given situation. Of course, the detailed analysis with regard to students’ perception of this distance learning adoption of our pedagogical framework is still pending and will form the basis of our future studies.
Although our pedagogical framework has several inherent benefits as discussed above, it also has several limitations. Our pedagogical framework integrates only real dissection. However, studies have indicated that integrating real dissection and radiology using 3D image postprocessing tools provides a more enriching learning experience, as such a pedagogical strategy imparts familiarity with imaging and image postprocessing techniques and also improves anatomical understanding, radiological diagnostic skills, and 3D appreciation [
The dissemination of this pedagogical framework requires extensive instructor preparation, which may not allow instructors to adopt it, especially instructors who teach anatomy using conventional strategies. Our proposed change management framework may aid in mitigating this limitation.
The pedagogical framework integrates the precepts of peer-assisted learning (PAL) in several steps. However, this may be disadvantageous for some students, many of whom may feel they would learn better when they relate to the instructor. Additionally, students learning in a group can encounter problems, especially if they find themselves working with members in a group with whom they are not keen on collaborating. Furthermore, students working in a group may veer away from the point of an exercise and discuss irrelevant topics of interest. These aspects may be effectively addressed by involving peer tutors in the dissemination of the teaching framework.
Our framework was implemented in only one structure-function course, that too in the delivery of anatomy teaching. However, implementation of this framework across all structure-function courses may lead to cognitive overload [
A typical cohort at MBRU has 50 to 70 students. Dissemination of our pedagogical framework was successful with limited student numbers. However, many medical schools have 150 to 200 students in a cohort, and there is a possibility that this pedagogical framework may not work as effectively in such large cohorts. This may be because organizing group-based activities required for the implementation of the pedagogical framework with a larger cohort may be challenging.
Implementation of the framework requires instructor(s) to be conversant with the theoretical underpinnings of the instructional design models that were employed in blueprinting the framework. This may not be the case for all medical schools, especially the ones who use adjunct or part-time faculty members for the delivery of anatomy content. One way to address this gap will be to organize Continuing Professional Development modules for anatomy instructors, where the advantages of integrating the framework in anatomy teaching and the theoretical foundations of the framework can be elucidated.
In this study, we have provided the initial evaluation of our pedagogical framework. However, the detailed evaluation of this framework is still pending. This also raises the question, “What evaluation model will be best-suited to appraise the framework?” Our framework predominantly employs PAL at multiple steps, which functions on the theoretical foundation of social and cognitive congruence [
In conclusion, in this study we have delineated a pedagogical framework to teach anatomy during normal and unprecedented times, blueprinted using a blended approach exercising the instructional design strategies of Gagne and Peyton. The designed strategy integrates active learning principles and initiates a shift from the “sage on the stage” to “guide on the side” mode of delivery. Additionally, we have demonstrated the use of this framework in the successful delivery of anatomy concepts in a structure-function course in a CBMC both during normal and COVID-19 lockdown periods. Although our framework was well received by students, anatomy instructors at our medical school were reluctant to adopt the framework (a challenge that others may also face). To counter this, we propose a strategy designed using the change management model of Mento. We have also elaborated on the benefits to a medical school that adopts the pedagogical framework, which have been explicated through the use of Bourdieu’s Theory of Practice. We firmly believe that the delineated pedagogical framework will allow instructors to efficiently and effectively deliver concepts in anatomy education using cadaveric dissection or through the effective use of clinical scenarios, in a limited span of time, which will not only benefit students but will also be advantageous for the medical school.
PowerPoint presentation used in the delivery of the instructional plan.
Approaches and Study Skills Inventory for Students
competency-based medical curriculum
Mohammed Bin Rashid University of Medicine and Health Sciences
peer-assisted learning
social media application
None declared.