Pandemic-Era Digital Education: Insights from an Undergraduate Medical Programme.

The undergraduate medical programme at Newcastle University (NU) includes a fundamental 'Essentials of Medical Practice' (EOMP) phase comprising the first 2 years of study. This period is designed to support entrants in their transition from further education into the advanced study and practice of clinical medicine. The anatomical sciences of gross anatomy, histology and embryology, and life sciences including physiology, pharmacology and genetics are key disciplines taught within the integrated case-based EOMP curriculum. Learners apply basic science knowledge to clinical scenarios during training in practical examination, communication and reasoning skills. Within the modern pedagogic landscape, the development and introduction of technology-enhanced learning strategies have enhanced the provision of remote learning resources in pre-clinical education. However, the emergence of COVID-19 has resulted in widespread technological challenges for educators and learners, and has raised pedagogic, logistical and ethical concerns. Nonetheless, the pandemic has produced favourable conditions for the creation of valuable digital visualisation strategies for learning and teaching, and for developing and modernising universal approaches to remote education. Here, we describe our technology-enhanced adaptations to COVID-19 across the domains of teaching, learning and academic support for pre-clinical learners studying basic life sciences and clinical skills. Moreover, we outline research-informed digital visualisation solutions to pandemic-era challenges and reflect upon experiences gained within our own educational context. In doing so, we provide insights into the impacts and successes of our interventions. While providing a record of unprecedented contemporary circumstances, we also aim to utilise our observations and experiences of COVID-19 pedagogy when developing ongoing strategies for delivering curricula and futureproofing educational practice.

Exploring Visualisation for Embryology Education: A Twenty-First-Century Perspective.

Embryology and congenital malformations play a key role in multiple medical specialties including obstetrics and paediatrics. The process of learning clinical embryology involves two basic principles; firstly, understanding time-sensitive morphological changes that happen in the developing embryo and, secondly, appreciating the clinical implications of congenital conditions when development varies from the norm. Visualising the sequence of dynamic events in embryonic development is likely to be challenging for students, as these processes occur not only in three dimensions but also in the fourth dimensions of time. Consequently, features identified at any one timepoint can subsequently undergo morphological transitions into distinct structures or may degenerate and disappear. When studying embryology, learners face significant challenges in understanding complex, multiple and simultaneous events which are likely to increase student cognitive load. Moreover, the embryology content is very nonlinear. This nonlinear content presentation makes embryology teaching challenging for educators. Embryology is typically taught in large groups, via didactic lecture presentations that incorporate two-dimensional diagrams or foetal ultrasound images. This approach is limited by incomplete or insufficient visualisation and lack of interactivity.It is recommended that the focus of embryology teaching should instill an understanding of embryological processes and emphasise conceptualising the potential congenital conditions that can occur, linking pre-clinical and clinical disciplines together. A variety of teaching methods within case-based and problem-based curricula are commonly used to teach embryology. Additional and supplementary resources including animations and videos are also typically utilised to demonstrate complex embryological processes such as septation, rotation and folding.We propose that there is a need for embryology teaching in the twenty-first century to evolve. This is particularly required in terms of appropriate visualisation resources and teaching methodologies which can ensure embryology learning is relevant to real-world scenarios. Here we explore embryology teaching resources and methodologies and review existing evidence-based studies on their implementation and impact on student learning. In doing so, we aim to inform and support the practice of embryology educators and the learning of their students.

A Novel Cadaveric Embalming Technique for Enhancing Visualisation of Human Anatomy.

Within the discipline of anatomical education, the use of donated human cadavers in laboratory-based learning activities is often described as the 'gold standard' resource for supporting student understanding of anatomy. Due to both historical and educational factors, cadaveric dissection has traditionally been the approach against which other anatomy learning modalities and resources have been judged. To prepare human donors for teaching purposes, bodies must be embalmed with fixative agents to preserve the tissues. Embalmed cadavers can then be dissected by students or can be prosected or plastinated to produce teaching resources. Here, we describe the history of cadaveric preservation in anatomy education and review the practical strengths and limitations of current approaches for the embalming of human bodies. Furthermore, we investigate the pedagogic benefits of a range of established modern embalming techniques. We describe relevant cadaveric attributes and their impacts on learning, including the importance of colour, texture, smell, and joint mobility. We also explore the emotional and humanistic elements of the use of human donors in anatomy education, and the relative impact of these factors when alternative types of embalming process are performed. Based on these underpinnings, we provide a technical description of our modern Newcastle-WhitWell embalming process. In doing so, we aim to inform anatomy educators and technical staff seeking to embalm human donors rapidly and safely and at reduced costs, while enhancing visual and haptic tissue characteristics. We propose that our technique has logistical and pedagogic implications, both for the development of embalming techniques and for student visualisation and learning.

Interdimensional Travel: Visualisation of 3D-2D Transitions in Anatomy Learning.

Clinical image interpretation is one of the most challenging activities for students when they first arrive at medical school. Interpretation of clinical images concerns the identification of three-dimensional anatomical features in two-dimensional cross-sectional computed tomography (CT) and magnetic resonance imaging (MRI) images in axial, sagittal and coronal planes, and the recognition of structures in ultrasound and plain radiographs. We propose that a cognitive transition occurs when initially attempting to interpret clinical images, which requires reconciling known 3D structures with previously unknown 2D visual information. Additionally, we propose that this 3D-2D transition is required when integrating an understanding of superficial 2D surface landmarks with an appreciation of underlying 3D anatomical structures during clinical examinations.Based on educational theory and research findings, we recommend that 3D and 2D approaches should be simultaneously combined within radiological and surface anatomy education. With a view to this, we have developed and utilised digital and art-based methods to support the 3D-2D transition. We outline our observations and evaluations, and describe our practical implementation of these approaches within medical curricula to serve as a guide for anatomy educators. Furthermore, we define the theoretical underpinnings and evidence supporting the integration of 3D-2D approaches and the value of our specific activities for enhancing the clinical image interpretation and surface anatomy learning of medical students.

Integrating 3D Visualisation Technologies in Undergraduate Anatomy Education.

Anatomy forms the basis of clinical examination, surgery and radiology and it is therefore essential that a fundamental understanding of the key concepts, structures and their relationships is gained by medical and healthcare students during their undergraduate training. Anatomy involves the study of three dimensional entities relating to the human body itself and its constituent structures. In our experience, the appreciation of 3D concepts is one of the most demanding areas for medical student learning of anatomy (ben Awadh et al. 2018, unpublished observations). The ability to interpret 3D anatomical features in 2D cross-sectional clinical images can be troublesome, while the dynamic nature of embryological development is a further challenge.The aim of introducing technology enhanced-learning (TEL) approaches into our practice is with a view to enhancing undergraduate medical student learning of clinically relevant anatomy. Here we will explore the importance of visualisation and visual learning in anatomy as a scholarly basis for the integration for TEL approaches. We will then describe examples of visualisation technologies that are currently being implemented within the School of Medical Education at Newcastle University based on a research informed understanding of how students learn anatomy. We will consider the available evidence that supports best practice, identify limitations where they arise, and discuss how these visual 3D learning technologies can be effectively utilised as adjuncts and self-directed resources to supplement more established approaches to undergraduate anatomy education.

Everyone can draw: An inclusive and transformative activity for conceptualization of topographic anatomy.

Anatomical drawing traditionally involves illustration of labeled diagrams on two-dimensional surfaces to represent topographical features. Despite the visual nature of anatomy, many learners perceive that they lack drawing skills and do not engage in art-based learning. Recent advances in the capabilities of technology-enhanced learning have enabled the rapid and inexpensive production of three-dimensional anatomical models. This work describes a "drawing on model" activity in which learners observe and draw specific structures onto three-dimensional models. Sport and exercise sciences (SES, n = 79) and medical (MED, n = 156) students at a United Kingdom medical school completed this activity using heart and femur models, respectively. Learner demographics, their perceptions of anatomy learning approaches, the value of the activity, and their confidence in understanding anatomical features, were obtained via validated questionnaire. Responses to 7-point Likert-type and free-text items were analyzed by descriptive statistics and semi-quantitative content analysis. Learners valued art-based study (SES mean = 5.94 SD ±0.98; MED = 5.92 ± 1.05) and the "drawing on model" activity (SES = 6.33 ± 0.93; MED = 6.21 ± 0.94) and reported enhanced confidence in understanding of cardiac anatomy (5.61 ± 1.11), coronary arteries (6.03 ± 0.83), femur osteology (6.07 ± 1.07), and hip joint muscle actions (5.80 ± 1.20). Perceptions of learners were independent of both their sex and their art-based study preferences (p < 0.05). Themes constructed from free-text responses identified "interactivity," "topography," "transformative," and "visualization," as key elements of the approach, in addition to revealing some limitations. This work will have implications for anatomy educators seeking to engage learners in an inclusive, interactive, and effective learning activity for supporting three-dimensional anatomical understanding.

Transforming musculoskeletal anatomy learning with haptic surface painting.

Anatomical body painting has traditionally been utilized to support learner engagement and understanding of surface anatomy. Learners apply two-dimensional representations of surface markings directly on to the skin, based on the identification of key landmarks. Esthetically satisfying representations of musculature and viscera can also be created. However, established body painting approaches do not typically address three-dimensional spatial anatomical concepts. Haptic Surface Painting (HSP) is a novel activity, distinct from traditional body painting, and aims to develop learner spatial awareness. The HSP process is underpinned by previous work describing how a Haptico-visual observation and drawing method can support spatial, holistic, and collaborative anatomy learning. In HSP, superficial and underlying musculoskeletal and vascular structures are located haptically by palpation. Transparent colors are then immediately applied to the skin using purposive and cross-contour drawing techniques to produce corresponding visual representations of learner observation and cognition. Undergraduate students at a United Kingdom medical school (n = 7) participated in remote HSP workshops and focus groups. A phenomenological study of learner perspectives identified four themes from semantic qualitative analysis of transcripts: Three-dimensional haptico-visual exploration relating to learner spatial awareness of their own anatomy; cognitive freedom and accessibility provided by a flexible and empowering learning process; altered perspectives of anatomical detail, relationships, and clinical relevance; and delivery and context, relating to curricular integration, session format, and educator guidance. This work expands the pedagogic repertoire of anatomical body painting and has implications for anatomy educators seeking to integrate innovative, engaging, and effective learning approaches for transforming student learning.

Multimodal Three-Dimensional Visualization Enhances Novice Learner Interpretation of Basic Cross-Sectional Anatomy.

While integrated delivery of anatomy and radiology can support undergraduate anatomical education, the interpretation of complex three-dimensional spatial relationships in cross-sectional and radiological images is likely to be demanding for novices. Due to the value of technology-enhanced and multimodal strategies, it was hypothesized that simultaneous digital and physical learning could enhance student understanding of cross-sectional anatomy. A novel learning approach introduced at a United Kingdom university medical school combined visualization table-based thoracic cross-sections and digital models with a three-dimensional printed heart. A mixed-method experimental and survey approach investigated student perceptions of challenging anatomical areas and compared the multimodal intervention to a two-dimensional cross-section control. Analysis of seven-point Likert-type responses of new medical students (n = 319) found that clinical imaging (mean 5.64 SD ± 1.20) was significantly more challenging (P < 0.001) than surface anatomy (4.19 ± 1.31) and gross anatomy (4.92 ± 1.22). Pre-post testing of students who used the intervention during their first anatomy class at medical school (n = 229), identified significant increases (P < 0.001) in thoracic cross-sectional anatomy interpretation performance (mean 31.4% ± 15.3) when compared to the subsequent abdominal control activity (24.1% ± 17.6). Student test scores were independent of mental-rotation ability. As depicted on a seven-point Likert-type scale, the intervention may have contributed to students considering cross-sectional interpretation of thoracic images (4.2 ± 1.23) as significantly less challenging (P < 0.001) than comparable abdominal images (5.59 ± 1.14). These findings could have implications for how multimodal cross-sectional anatomy learning approaches are implemented within medical curricula.

Focused Multisensory Anatomy Observation and Drawing for Enhancing Social Learning and Three-Dimensional Spatial Understanding.

The concept that multisensory observation and drawing can be effective for enhancing anatomy learning is supported by pedagogic research and theory, and theories of drawing. A haptico-visual observation and drawing (HVOD) process has been previously introduced to support understanding of the three-dimensional (3D) spatial form of anatomical structures. The HVOD process involves exploration of 3D anatomy with the combined use of touch and sight, and the simultaneous act of making graphite marks on paper which correspond to the anatomy under observation. Findings from a previous study suggest that HVOD can increase perceptual understanding of anatomy through memorization and recall of the 3D form of observed structures. Here, additional pedagogic and cognitive underpinnings are presented to further demonstrate how and why HVOD can be effective for anatomy learning. Delivery of a HVOD workshop is described as a detailed guide for instructors, and themes arising from a phenomenological study of educator experiences of the HVOD process are presented. Findings indicate that HVOD can provide an engaging approach for the spatial exploration of anatomy within a supportive social learning environment, but also requires modification for effective curricular integration. Consequently, based on the most effective research-informed, theoretical, and logistical elements of art-based approaches in anatomy learning, including the framework provided by the observe-reflect-draw-edit-repeat (ORDER) method, an optimized "ORDER Touch" observation and drawing process has been developed. This is with the aim of providing a widely accessible resource for supporting social learning and 3D spatial understanding of anatomy, in addition to improving specific anatomical knowledge.

Negative-feedback regulation of FGF signalling by DUSP6/MKP-3 is driven by ERK1/2 and mediated by Ets factor binding to a conserved site within the DUSP6/MKP-3 gene promoter.

DUSP6 (dual-specificity phosphatase 6), also known as MKP-3 [MAPK (mitogen-activated protein kinase) phosphatase-3] specifically inactivates ERK1/2 (extracellular-signal-regulated kinase 1/2) in vitro and in vivo. DUSP6/MKP-3 is inducible by FGF (fibroblast growth factor) signalling and acts as a negative regulator of ERK activity in key and discrete signalling centres that direct outgrowth and patterning in early vertebrate embryos. However, the molecular mechanism by which FGFs induce DUSP6/MKP-3 expression and hence help to set ERK1/2 signalling levels is unknown. In the present study, we demonstrate, using pharmacological inhibitors and analysis of the murine DUSP6/MKP-3 gene promoter, that the ERK pathway is critical for FGF-induced DUSP6/MKP-3 transcription. Furthermore, we show that this response is mediated by a conserved binding site for the Ets (E twenty-six) family of transcriptional regulators and that the Ets2 protein, a known target of ERK signalling, binds to the endogenous DUSP6/MKP-3 promoter. Finally, the murine DUSP6/MKP-3 promoter coupled to EGFP (enhanced green fluorescent protein) recapitulates the specific pattern of endogenous DUSP6/MKP-3 mRNA expression in the chicken neural plate, where its activity depends on FGFR (FGF receptor) and MAPK signalling and an intact Ets-binding site. These findings identify a conserved Ets-factor-dependent mechanism by which ERK signalling activates DUSP6/MKP-3 transcription to deliver ERK1/2-specific negative-feedback control of FGF signalling.

Twelve tips for implementing artistic learning approaches in anatomy education.

This article was migrated. The article was marked as recommended. To enhance learning and maximise student satisfaction while simultaneously optimising costs and resources within the modern context and environment of integrated anatomy education, it is vital that innovative methods of delivering learning and teaching are considered for implementation into medical curricula. The development of learning processes including observation, visualisation, haptic reasoning and visuospatial ability are strongly associated with the use of artistic approaches. In addition to being crucial for medical student learning of anatomy and other life sciences, such skills are also relevant for training in surgery, clinical observation and diagnosis. The twelve tips outlined here have been identified with the intention of providing guidance for anatomy educators aiming to incorporate innovative creative and artistic approaches into their own teaching practice within medical curricula. These proposals are underpinned by educational theory and recent research that has investigated artistic learning methods in medical education. Recommendations are also based on our personal experiences from both the undergraduate student point of view as well as the academic educator perspective with respect to the usage of creative and artistic learning approaches in anatomy education at Newcastle University.

Concluding Commentary. Life Sciences in an Integrated Medical Curriculum: Continuing the Conversation.

This article was migrated. The article was marked as recommended. In our opening editorial, we contrasted the time devoted to delivering the Life Sciences curriculum, as a part of medical training, with the limited attention given to it within the medical education literature ( Jennings & Keenan, 2017). In our experience, there are also few opportunities to present and discuss Life Sciences at medical education conferences and perhaps within the wider medical education community. We therefore started this conversation to provide a forum for consideration of the integration and delivery of Life Sciences teaching within medical curricula.

Improvements in anatomy knowledge when utilizing a novel cyclical "Observe-Reflect-Draw-Edit-Repeat" learning process.

Innovative educational strategies can provide variety and enhance student learning while addressing complex logistical and financial issues facing modern anatomy education. Observe-Reflect-Draw-Edit-Repeat (ORDER), a novel cyclical artistic process, has been designed based on cognitivist and constructivist learning theories, and on processes of critical observation, reflection and drawing in anatomy learning. ORDER was initially investigated in the context of a compulsory first year surface anatomy practical (ORDER-SAP) at a United Kingdom medical school in which a cross-over trial with pre-post anatomy knowledge testing was utilized and student perceptions were identified. Despite positive perceptions of ORDER-SAP, medical student (n = 154) pre-post knowledge test scores were significantly greater (P < 0.001) with standard anatomy learning methods (3.26, SD = ±2.25) than with ORDER-SAP (2.17, ±2.30). Based on these findings, ORDER was modified and evaluated in the context of an optional self-directed gross anatomy online interactive tutorial (ORDER-IT) for participating first year medical students (n = 55). Student performance was significantly greater (P < 0.001) with ORDER-IT (2.71 ± 2.17) when compared to a control tutorial (1.31 ± 2.03). Performances of students with visual and artistic preferences when using ORDER were not significantly different (P > 0.05) to those students without these characteristics. These findings will be of value to anatomy instructors seeking to engage students from diverse learning backgrounds in a research-led, innovative, time and cost-effective learning method, in the context of contrasting learning environments. Anat Sci Educ 10: 7-22. © 2016 American Association of Anatomists.

The role of 3D printing in anatomy education and surgical training: A narrative review.

This article was migrated. The article was marked as recommended. Recent expansions in the development and availability of three-dimensional printing (3Dp) have led to the uptake of this valuable and effective technology within the modern context of medical education. It is proposed that 3Dp is entirely appropriate for the creation of anatomical models for purposes of teaching and training due to the ability of this technology to produce accurate 3D physical representations based on a processed data set acquired from sources including magnetic resonance imaging (MRI) and computed tomography (CT). When investigating the currently available educational research with respect to 3Dp, it is important that the best evidence supporting the practical and theoretical benefits of this technology in teaching and training can be identified, while any obstacles to the effective implementation of 3Dp can also be determined. Here, literature describing recent primary research with respect to the capability and utility of 3Dp in anatomy and surgery have been explored in a narrative review. The impact on resources of implementing this technology within medical education have also been investigated. In order to emphasise wider applications in medicine, the role of 3Dp in medical practice and research have also been examined. To identify recent literature appropriate for this review published up to March 2017, suitable search terms were determined and applied using PubMed and results were judged against an established checklist. The research identified was then allocated with respect to the agreed topic areas of anatomy education, surgical training, medical usage and medical research. A student partnership approach was utilised for this review and the focus of the work was driven by undergraduate students in collaboration with anatomy and medical educators. Preliminary findings from this narrative review support the implementation of 3Dp in anatomy education and surgical training as a supplement to traditional learning approaches.

Negative feedback predominates over cross-regulation to control ERK MAPK activity in response to FGF signalling in embryos.

Expression of the gene encoding the MKP-3/Pyst1 protein phosphatase, which inactivates ERK MAPK, is induced by FGF. However, which intracellular signalling pathway mediates this expression is unclear, with essential roles proposed for both ERK and PI(3)K in chick embryonic limb. Here, we report that MKP-3/Pyst1 expression is sensitive to inhibition of ERK or MAPKK, that endogenous MKP-3/Pyst1 co-localizes with activated ERK, and expression of MKP-3/Pyst1 in mice lacking PDK1, an essential mediator of PI(3)K signalling. We conclude that MKP-3/Pyst1 expression is mediated by ERK activation and that negative feedback control predominates in limiting the extent of FGF-induced ERK activity.

Origin of non-cardiac endothelial cells from an Isl1+ lineage.

The cardiovascular system consists of many cell types with distinct embryonic origins. Cells from an Islet1 (Isl1)-expressing progenitor population make a substantial contribution to the developing heart. We reasoned that cells derived from Isl1-expressing progenitors might contribute more widely to the cardiovascular system. We show that cells derived from an Isl1-expressing progenitor lineage make a wide contribution to the systemic vasculature and that embryos conditionally deficient for Rac1 within this cell population develop defects in the non-cardiac vasculature. These data define new roles for Isl1 in the developing embryo and demonstrate a contribution of Isl1-expressing progenitors to vascular endothelium in vivo.

FGF signal transduction and the regulation of Cdx gene expression.

Cdx homeodomain transcription factors play important roles in the development of the vertebrate body axis and gut epithelium. Signaling involving FGF, wnt and retinoic acid ligands has been implicated in the regulation of individual Cdx genes. In this study we examine the requirement for FGF-dependent signal transduction pathways in the regulation of Cdx gene expression. In the amphibian Xenopus laevis the earliest expression of Cdx1, Cdx2 and Cdx4 is within the developing mesoderm. We show that a functional FGF signaling pathway is required for the normal expression of all three amphibian Cdx genes during gastrula stages. We show that FGF stimulation activates signaling through both the MAP kinase pathway and the PI-3 kinase pathway in Xenopus tissue explants. However, our analysis of these pathways in gastrula stage embryos indicates that the MAP kinase pathway is required for Cdx gene expression, whereas the PI-3 kinase pathway is not. We show that FGF and wnt signaling can interact in the regulation of Cdx genes and during gastrula stages the normal expression of the Cdx genes requires the activity of both pathways. Furthermore, we show that wnt mediated Cdx regulation is independent of the MAP kinase pathway.

A consensus Oct1 binding site is required for the activity of the Xenopus Cdx4 promoter.

Cdx homeodomain transcription factors have multiple roles in early vertebrate development. Furthermore, mis-regulation of Cdx expression has been demonstrated in metaplasias and cancers of the gut epithelium. Given the importance of Cdx genes in development and disease, the mechanisms underlying their expression are of considerable interest. We report an analysis of the upstream regulatory regions from the amphibian Xenopus laevis Cdx4 gene. We show that a GFP reporter containing 2.8 kb upstream of the transcription start site is expressed in the posterior of transgenic embryos. Deletion analysis of the upstream sequence reveals that a 247-bp proximal promoter fragment will drive posterior expression in transgenic embryos. We show that 63 bp of upstream sequence, that includes a consensus site for POU-domain octamer-binding proteins, retains significant promoter activity. Co-expression of the octamer-binding protein Oct1 induces expression from a Cdx4 reporter and mutation of the octamer site abolishes activity of the same reporter. We show that the octamer site is highly conserved in the promoters of the human, mouse, chicken, and zebrafish Cdx4 genes and within the promoters of amphibian Cdx1 and Cdx2. These data suggest a conserved function for octamer-binding proteins in the regulation of Cdx family members.

Cloning and expression of the Cdx family from the frog Xenopus tropicalis.

The caudal-related (Cdx) homeodomain transcription factors have a conserved role in the development of posterior structures in both vertebrates and invertebrates. A particularly interesting finding is that Cdx proteins have an important function in the regulation of expression from a subset of Hox genes. In this study, we report the cloning of cDNAs from the Cdx genes of the amphibian Xenopus tropicalis. Xenopus tropicalis is a diploid species, related to the commonly used laboratory animal Xenopus laevis, and has attracted attention recently as a potential genetic model for animal development. The Xenopus tropicalis cDNAs, Xtcad1, Xtcad2, and Xtcad3, show between 88 and 94% sequence identity with their Xenopus laevis orthologues. This finding corresponds to between 90 and 95% identity at the level of derived amino acid sequence. We also present a detailed description of Xtcad1, Xtcad2, and Xtcad3 expression during normal development. In common with the Cdx genes of other vertebrates, the Xenopus tropicalis Cdx genes show overlapping and dynamic patterns of expression in posterior regions of the embryo through the early stages of development.