The Australian
Senior doctors fear today's medical graduates lack basic knowledge about how the body works. Megan Howe reports
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May 06, 2006. DISSECTION of the human body was once a rite of passage for medical students – a test of their nerve, their skill and their anatomical knowledge.
But the remarks made by some of today's students while observing autopsies have forensic pathologist Dr Peter Ellis worried about the way medicine is now being taught.
"Students say 'what organ is that – oh, is that what a spleen looks like'," he says.
"I'm a bit horrified that students within one year of becoming qualified doctors have not seen what (organs) they are supposed to be feeling for."
The concerns raised by Dr Ellis, clinical senior lecturer in pathology at the University of Sydney and director of the department of forensic medicine at the Institute of Clinical Pathology and Medical Research at Westmead, are at the heart of a row about anatomy teaching that has polarised the Australian medical fraternity.
While older doctors spent countless hours as students dissecting cadavers, some of today's doctors will graduate having never done a single dissection.
At medical schools worldwide, anatomy teaching has been cut back to make way for the explosion of knowledge in fields like pharmacology, genetics and biochemistry – and the introduction of subjects like communication skills into a crowded curriculum.
While he supports the broader curriculum, Dr Ellis is not convinced students can fully appreciate the structures of the human body without having dissected it.
"They don't hold a heart and see the chambers and see what the vessels looks like, so that when they put a stethoscope on someone's chest to listen for a heart murmur, they are able to picture in their mind what those things look like," he says.
"You can learn that from a book, but when you have got a resource available – and that resource is the human body – it seems crazy not to give medical students access to that material. There is nothing like seeing and touching something to learn."
Associate Professor Barry Oakes, a former anatomy lecturer at Monash University, says he retired in 2002 because of the "appalling state of affairs" regarding the lack of anatomical teaching within Monash's undergraduate course, which was cut from six to five years in 2002.
"Undergraduates have been disempowered from basic anatomy," he says. "You can't make an adequate clinical diagnosis unless you have an understanding of where the body parts are and how they are put together and how they work." He demonstrates his point with a mechanical analogy. "Would you take your car to a mechanic who does not know where all the parts of the engine are?" he asks.
"That is what 'modern' undergraduate medical education is producing: physicians who do not know in detail where all the body parts are, but can tell you in some detail about the metallurgical composition of the hard-facing of the crank shaft."
Last year, several of Australia's leading medicos took up the cause for teaching basic sciences at a conference entitled "Rescuing medical education", run by the Australian Doctors' Fund. The ADF later issued a public statement, calling on the deans of medical schools to ensure that "all medical students receive a comprehensive practical education in anatomy, physiology, microbiology, biochemistry, pharmacology and pathology as an essential requirement and foundation of their medical education and hence reverse the downgrading of these basic medical sciences". They also demanded students be exposed to dissection as an essential part of their medical education. The then Federal Education Minister, Brendan Nelson, pledged his department would review medical education in Australia.
The ongoing review is investigating how well undergraduate medical education prepares graduates for their work as interns and to meet the requirements of postgraduate training in future medical careers.
Professor Lindon Wing, chair of the Committee of Deans of Medical Schools and a member of the review steering committee, believes there is no need for today's students to have the same level of anatomy knowledge as when he was a student.
"There is absolutely no doubt that a medical student does not need the detailed level of anatomical knowledge that was thrust down my throat in 1962 and 1963," he says.
The University of Western Australia's associate dean of teaching and learning in the faculty of medicine, Professor Paul McMenamin, agrees. He stresses that the university is no longer aiming to produce a medical "jack of all trades".
Rather, he says the Australian Medical Council, which accredits medical degree courses, requires the university to produce medical graduates who can work safely, under supervision, in an intern environment.
The anatomy component of the WA university's medical degree was reduced from about 350 to 250 hours in a curriculum revision in 2000.
While a popular, optional dissection course is on offer for those students with a particular interest in it, Professor McMenamin says students largely work with prosected specimens of body parts.
"There are lots of other ways of teaching anatomy that are far more interesting than spending hours cleaning away fat to see one or two small features," he says.
Professor Chris Briggs, deputy head of anatomy and cell biology at the University of Melbourne, say medical students do 130 hours of anatomy, including dissection, in their first two-and-a-half years. That compares to approximately 600 hours of anatomy in the curriculum 30 years ago.
While he believes it would be a "major disadvantage" if students never engaged in dissection, he says anatomy can be taught in a variety of other ways including studying prosected specimens – where organs, limbs or other body parts are already removed and prepared for study, using new imaging techniques and through electronic alternatives such as Anatomedia, developed by the University of Melbourne. which allows students to virtually dissect body parts.
"I think the objective of the current undergraduate course is to provide students with a thorough grounding in the principles and concepts of anatomy," he says. "I'm not sure that it is necessary for undergraduate students to know every minute detail."
After all, most medical graduates will face another three or so years of training in their chosen speciality after they graduate – although they usually work in the hospital system as undifferentiated doctors for two or three years first. Some never do further training.
Professor John Collins, dean of education at the Royal Australasian College of Surgeons, says you'll get as many opinions on the issue of the teaching of anatomy as people you ask. "Older surgeons, who did two years in anatomy rooms, will all tell you that younger people have grossly inadequate anatomy," he says. "Myself, I wasted an enormous amount of time in anatomy rooms and having to learn it again as a surgeon."
He argues that graduates don't need to have handled organs, but do need a grasp of functional "living anatomy" – much of which can now be gained through imaging, telescopic techniques and computer-based "virtual dissection".
At the centre of the debate sit the students.
Australian Medical Students Association president Teresa Cosgriff, in her fourth year of medicine at Melbourne University, says some students are concerned they are not being taught enough anatomy or being exposed to enough dissection. However, she believes dissection is only a useful learning tool when well guided and supervised. "One student told me he felt like he had just mutilated the perfect opportunity because he didn't know what he was doing," she says.
While she admits she hasn't found dissection particularly useful, Cosgriff says she would still elect to do dissection if it was optional. "It's something students expect. You go into medicine naive, straight out of school, and you expect to have experiences working with specimens."
At the University of Sydney, Associate Professor Chris Roberts, director and assistant dean of the faculty of medicine, says the students graduating today are every bit as skilled as those of yesteryear.
"We've got good evidence that our graduates are just as competent as those from 'traditional' courses," he says.
Professor Wing, dean of Flinders University medical school in SA, also stresses there is no substantial evidence to support claims graduates are missing vital knowledge.
Rather, he says the "publicly strident" lobby group fighting the anatomy cause simply can't accept that students are not being taught exactly the same way they were.
"There has been a major revolution in medical education in Australian in the last 15-plus years," he says. "Every medical course has changed markedly and a number of new medical courses have come on stream. All are subject to a very, very rigorous level of accreditation and peer review based on best international practice. The whole issue is, what is the balance of knowledge that someone needs to have when they come out of medical school?"
