Specialist anatomy: Is the structure of teaching adequate?

BACKGROUND: A knowledge and understanding of specialist anatomy, which includes radiological, laparoscopic, endoscopic and endovascular anatomy is essential for interpretation of imaging and development of procedural skills. METHODS AND MATERIALS: Medical students, specialist trainees and specialists from the London (England, UK) area were surveyed to investigate individual experiences and recommendations for: (1) timing of the introduction of specialist anatomy teaching, and (2) pedagogical methods used. Opinions relating to radiological, laparoscopic, endoscopic and endovascular anatomy were collected. Non-parametric tests were used to investigate differences in recommendations between specialist trainees and specialists. RESULTS: Two hundred and twenty-eight (53%) individuals responded to the survey. Imaging was most commonly used to learn radiological anatomy (94.5%). Procedural observation was most commonly used to learn laparoscopic (89.0%), endoscopic (87.3%) and endovascular anatomy (66.2%). Imaging was the most recommended method to learn radiological anatomy (92.1%). Procedural observation was the most recommended method for learning laparoscopic (80.0%), endoscopic (81.2%) and endovascular anatomy (42.5%). Specialist trainees and specialists recommended introduction of specialist anatomy during undergraduate training. CONCLUSION: Although the methods for specialist anatomy learning are in practice, there is no consensus on timing and structure within the anatomy curriculum. Recommendations from trainees and specialists should be considered so that the existing curriculum can be refined to maximise learning outcomes.

Assessment of anatomical knowledge for clinical practice: perceptions of clinicians and students.

PURPOSE: In anatomy education, assessment may be done by written, practical or oral methods. These are used to varying degrees in UK medical schools with no consensus on the preferred approach. The purpose of this article is to highlight changes to methods of anatomical knowledge assessment utilised in medical schools since the early 1990s and to present recommended methods of assessment according to the level of medical training. METHODS: Medical students, trainees and specialists in the London (UK) area were surveyed to: (1) identify methods experienced in anatomy education at medical school and (2) gather recommendations. Medical student, trainee and specialist responses were compared using non-parametric tests. RESULTS: Two hundred and twenty-eight individuals responded to the survey giving a response rate of 53%. Subjects who graduated before 2005 were assessed significantly more frequently by practical (94.2 vs. 33.3%) and oral (84.5 vs. 13.1%) methods than those whose graduation year was 2005 or later. Subjects whose graduation year was 2005 or later were assessed significantly more frequently by written methods, such as EMQs than those whose graduation was before 2005 (68.7 vs. 25.2%). Practical examination was identified as the most recommended method of assessment in anatomy education by medical students (59.1%), trainees (all stages combined; 54.2%) and specialists (51.7%). CONCLUSION: Practical assessment is recommended over written and oral methods for the assessment of anatomical knowledge. A formal evaluation of the relative benefits and limitations of available assessment tools is required.

Is the structure of anatomy curriculum adequate for safe medical practice?

INTRODUCTION: Anatomy has been considered a core subject within the medical education curriculum. In the current setting of ever-changing diagnostic and treatment modalities, the opinion of both students and trainers is crucial for the design of an anatomy curriculum which fulfils the criteria required for safe medical practice. METHODS: Medical students, trainees and specialist trainee doctors and specialists from the London (England) area were surveyed to investigate the how curriculum changes have affected the relevance of anatomical knowledge to clinical practice and to identify recommendations for optimum teaching methods. The survey employed 5-point Likert scales and multiple-choice questions. Where the effect of training level was statistically significant (p < 0.05), post-hoc analysis was carried out using Mann-Whitney U tests. Significance levels were modified according to the Bonferroni method. RESULTS: Two hundred and twenty-eight individuals completed the survey giving a response rate of 53%. Medical students, trainees and specialists all agreed (mean Likert score 4.51, 4.79, 4.69 respectively) that knowledge of anatomy is important for medical practice. Most of the trainees (88.4%) and specialists (81.3%) used dissection to learn anatomy, but only 61.4% of medical students used this approach. Dissection was the most commonly recommended approach for learning anatomy across all the groups (41.7%-69.3%). CONCLUSIONS: Knowledge of anatomy is perceived to be important for safe clinical practice. Anatomy should be taught with other relevant system or clinical modules. Newer tools for anatomy teaching need further validation before incorporation into the curriculum.

A comparison of skill acquisition and transfer in single incision and multi-port laparoscopic surgery.

OBJECTIVES: Single incision laparoscopic surgery (SILS) offers a scar-less approach to cholecystectomy. We conducted a cadaveric randomized crossover study to compare the novice learning curves for multiport laparoscopic cholecystectomy (LC) and single incision laparoscopic cholecystectomy (SILC), and to investigate the acquisition of transferable skills. PARTICIPANTS: Twenty medical students were randomized into SILS or LC groups. METHODS: After baseline assessment and cognitive learning modules, groups completed 5 cadaveric porcine cholecystectomies in their designated modality, followed by one using the other approach. Performance was assessed using a validated surgical assessment device (ICSAD) and by expert video analysis with generic and procedure-specific rating scales [modified global rating scale (mGRS) and procedure-specific rating scales (PSRS)]. RESULTS: Analysis of the first case revealed significant differences between LC and SILS groups for time-taken (median 46.00 vs 68.19 min, p = 0.019), and path length (216 vs 348 m, p = 0.034). Intergroup analysis of the remaining group cases showed no difference for any of the performance metrics. Outlying performance of the 4th case in the LC group rendered learning curve comparison unviable. At crossover, performance of the SILS group on their LC compared with the 5th LC performed by the LC group showed no significant difference. However, comparing the LC group's SILC to the 5th SILC performed by the SILS group showed significant difference for all performance metrics (p < 0.05). CONCLUSIONS: This study suggests that the difference between novice performance for SILC and LC becomes negligible after the first procedure. Furthermore, dedicated SILC training appears to develop competencies for both SILC and LC, therefore its addition to the early surgical curriculum is likely to extend the access of SILC to patients without reducing multiport laparoscopic skill acquisition.

A high fidelity model for single-incision laparoscopic cholecystectomy.

Single-incision laparoscopic surgery (SILS) is a safe approach for cholecystectomy, with the potential to minimise the iatrogenic trauma sustained from the operation. However, a number of reports show SILS to be technically challenging and as such there is expected to be a significant learning curve for expert surgeons adopting the new technique, as well as for junior surgical trainees. There are inherent risks to patient safety associated with practicing and developing new skills in a real-life theatre environment. However, thus far, there have been no realistic SILS training models available. We tested the feasibility of conducting SILS cholecystectomies on a cadaveric porcine model with standard operating equipment, which may provide a platform to facilitate safe training and assessment protocols. In this paper we provide an account of the training model technique, and review the literature surrounding SILS training and performance evaluation.

A minimally invasive approach to undergraduate anatomy teaching.

Anatomy is one of the cornerstones of medical education. Unfortunately, sufficient evidence has accumulated to suggest a worldwide decline in the resources and time allocated to its teaching. Integration of anatomy with clinical medicine has been frequently advocated as the solution to this academic crisis. Consequently, new ways of harnessing clinical relevance to the teaching of anatomy must be sought to make it applicable to contemporary clinical practice. Human cadavers have been used to teach laparoscopic skills to surgical trainees for some time. More recently, centers in the United States have piloted the use of minimally invasive techniques in the teaching of anatomy to undergraduates. We believe that the use of laparoscopy on human cadavers may also be used to complement the teaching of anatomy to United Kingdom and European medical students. This would not only familiarize students with the topography and morphology of human anatomy, but also with the concept of manipulating anatomical structures to achieve a clinical outcome. Other benefits include improved three-dimensional orientation, increased dexterity, and development team-working skills amongst students. A UK feasibility study is currently underway.

Hypoxia augments gelatinase activity in a variety of adenocarcinomas in vitro.

BACKGROUND: Hypoxia within solid adenocarcinomas and protease up-regulation has been independently implicated as poor prognostic indicators in a variety of tumor types. The authors hypothesize that Matrix Metalloproteases (MMP) are up-regulated in direct response to a hypoxic environment. MATERIALS AND METHODS: Colonic (SW1222), breast (MDA-MB231), and pancreatic (PSN-1) tumor cell lines were exposed to hypoxia (1% oxygen/94% nitrogen/5% carbon dioxide) for periods of up to 24 h. Reaction to a hypoxic environment was determined via invasion across a Matrigel-coated 8-microm Transwell filter. Activity of MMP 2 and 9 was assessed using gelatin zymography. Expression of tissue inhibitor of metalloproteases 1 (TIMP-1) was quantified using ELISA (Biotrak). Correlation between protease expression and invasive capacity was determined using a specific gelatinase inhibitor (MMPI; Calbiochem). RESULTS: All tumor lines demonstrated augmented invasion over 72 h (P < 0.01 all groups). Concomitant significant increase in MMP 2 and 9 activity was observed in the SW1222 and PSN-1 lines. MDA-MB231s showed increase in MMP 9 expression and in a unidentified 103-kDa gelatinase (P < 0.001). The hypoxia-augmented invasion was attenuated by the addition of a specific gelatinase inhibitor confirming interdependence. CONCLUSIONS: Hypoxia induces an increased invasive capacity via gelatinase up-regulation without loss of cell viability. This suggests a mechanism explaining the poorer prognosis seen in patients with protease-secreting solid adenocarcinomas.