RESEARCH REPORT
Computer-Assisted Learning in Anatomy at the International Medical School in Debrecen, Hungary: A Preliminary Report Gary Kish,1* Samuel A. Cook,2 Gre´ta Kis1 1 Department of Anatomy, Histology and Embryology, Faculty of Medicine, Medical and Health Science Center, University of Debrecen, Debrecen, Hungary 2 Department of Mathematics and Science, Wheelock College, Boston, Massachusetts
The University of Debrecen’s Faculty of Medicine has an international, multilingual student population with anatomy courses taught in English to all but Hungarian students. An elective computer-assisted gross anatomy course, the Computer Human Anatomy (CHA), has been taught in English at the Anatomy Department since 2008. This course focuses on an introduction to anatomical digital images along with clinical cases. This low-budget course has a large visual component using images from magnetic resonance imaging and computer axial tomogram scans, ultrasound clinical studies, and readily available anatomy software that presents topics which run in parallel to the university’s core anatomy curriculum. From the combined computer images and CHA lecture information, students are asked to solve computer-based clinical anatomy problems in the CHA computer laboratory. A statistical comparison was undertaken of core anatomy oral examination performances of English program first-year medical students who took the elective CHA course and those who did not in the three academic years 2007–2008, 2008–2009, and 2009–2010. The results of this study indicate that the CHA-enrolled students improved their performance on required anatomy core curriculum oral examinations (P < 0.001), suggesting that computer-assisted learning may play an active role in anatomy curriculum improvement. These preliminary results have prompted ongoing evaluation of what specific aspects of CHA are valuable and which students benefit from computer-assisted learning in a multilingual and diverse cultural environment. Anat Sci Educ 6: 42–47. © 2012 American Association of Anatomists.
Key words: gross anatomy education; computer-assisted learning; CAL; PBL; human anatomy, international medical school; medical curriculum; English program; clinical anatomical problem solving; Hungary
INTRODUCTION Over the past two decades, pedagogical shifts in medical education have continued to affect what is taught, how it is taught, and when it is taught. Recent medical education reports attribute these transformations, in part, to rapid
*Correspondence to: Dr. Gary Kish, 7 Fairway Drive, Greenland, New Hampshire 03840, USA. E-mail:
[email protected] Received 6 April 2011; Revised 17 June 2012; Accepted 20 June 2012. Published online 26 July 2012 in Wiley (wileyonlinelibrary.com). DOI 10.1002/ase.1303 © 2012 American Association of Anatomists
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technical advances in medicine, evolving methods of medical care delivery, and a better understanding of learning pathways (Brynhildsen et al., 2002; Davis and Harden, 2003; Muller et al., 2008; Cooke et al., 2010; NYAS, 2010). The teaching of basic anatomy knowledge has been challenged by the vast amount of other scientific information medical students need to absorb, a reduction in scheduled anatomy courses, and diminishing faculty to teach gross anatomy (Bergman et al., 2008; Drake et al., 2009; McCuskey et al., 2009). Current medical school anatomy curricula reflect the teaching adaptations that have resulted in increased attention to clinical anatomy, problem-based learning (PBL), and medical imaging (Vidic and Weitlauf, 2002; Brueckner and Gould, 2006; Yiou and Goodenough, 2006; El-Moamly, 2008; Sugand et al., 2010). The very nature of anatomy knowledge needed by today’s clinical physicians may well direct the how, what, and when of anatomy teaching.
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The anatomy that is seen in computer axial tomogram scans (CT scan), magnetic resonance imaging (MRI), ultrasonography, operative endoscopic systems, and computer navigation systems is far different from what can be appreciated in dissecting rooms and anatomy textbooks (Gunderman and Wilson, 2005; Gould et al., 2008). What physicians see and know today is, in large part, based on their familiarity and interpretation of computer-generated images, most notably CT and MRI scans (Rengier et al., 2009). Interest in computer-assisted learning (CAL) in US medical school anatomy departments has increased significantly over the past decade (Shaffer, 2004; Spitzer and Scherzinger, 2006; Sugand et al., 2010). Implementation of CAL encompasses a wide spectrum of teaching methods, software design, and developmental cost (Bryner et al., 2008; Durosaro et al., 2008; Gogalniceanu et al., 2008; Gould et al., 2008; Hisley et al., 2008; Trelease, 2008; Trelease and Rosset, 2008; Greene, 2009; McNulty et al., 2009; Lufler et al., 2010). For some medical schools, the formalization of a CAL program has been inhibited by limited information technology (IT) resources, faculty unavailability, and the cost of such programs (Greenhalgh, 2001; Memon, 2009). In an effort to surmount some of these CAL barriers at the Faculty of Medicine, Medical and Health Science Center, University of Debrecen (UD), Debrecen, Hungary, a low-budget CAL anatomical course, Computer Human Anatomy (CHA), has been developed and taught as an elective course since 2008. The basic tenets of the course have been PBL through the use of computer virtual anatomy cases, with an emphasis on clinical anatomy while limiting expense to the department and the students. The course incorporates teaching methods designed to interest students from a wide range of cultural influences, language backgrounds, and education credentials (Mitchell et al., 2009).
MATERIALS AND METHODS The objectives of this preliminary study are to determine if the CHA course influences student anatomy core curriculum performance. Additionally, the study data are intended to serve in the future as foundations for identifying what components of the course are valuable in teaching anatomy to multinational medical students and which UD individual students can benefit the most from CAL. The research protocol was reviewed by the Dean of the Faculty of Medicine at the UD and has met with his approval under the ethical standards of the university.
Required Gross Anatomy Curriculum at the University of Debrecen’s Faculty of Medicine UD medical students are required to complete two semesters of gross anatomy (core curriculum), which begin in the second semester of the first year. During the first semester of anatomy (the focus of this study), musculoskeletal anatomy is taught in three five-week long blocks: upper limb, lower limb, and back/skull. Successful completion of this semester earns the student five credits of the 360 credits necessary to obtain the doctor of medicine degree (Matesz, 2007). Gross anatomy classes are divided into two groups: one for English-speaking students and the other for Hungarianspeaking students. The English language program and HunAnatomical Sciences Education
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garian language program anatomy curricula are identical in format and time framework and are taught by the same bilingual native Hungarian staff. During the first semester, students have a total of 54 gross anatomy contact hours, including six hours of lectures and 48 hours of gross anatomy dissection laboratories which have a student/instructor ratio of 30 to 1. The two-hour, twice-a-week dissection sessions begin with didactic instructor discussions followed by student dissection. Unscheduled student access to the cadaver laboratory is restricted to two four-hour sessions the week prior to examinations. In gross anatomy, mid-term examinations are exclusively oral (viva voce) examinations. The format of these examinations has been developed over the past 25 years by senior instructors in the Department of Anatomy. Using faculty collaboration and postexamination Delphi exercises (Linstone and Turoff, 1975), the oral examinations are kept uniform in content. At the end of each five-week block, the oral examinations are administrated by the faculty in the dissection room. Each student selects a topic envelope from a question box containing 14 anatomical topics taught during the five-week section. After a five- to 15-minute period of preparation, the student is asked to answer topic questions while stationed at the appropriate cadaver dissection or skeleton. The students are graded on a scale of 1 to 5 with 15 fail and 5 5 excellent with 2 and above corresponding to passing grades. These grades are used as the metrics of anatomy performance in this study.
Elective Courses As defined in the UD bulletin, students are required to accumulate 54 elective course credits (15%) from the total 360 graduation credits over their six years of study. Elective courses are demarcated to be ‘‘closely related to a basic subject, but the information is to be more detailed, and include material not dealt with in the frame of the compulsory courses’’ (Matesz, 2007). The CHA course is one of these courses and the first anatomy CAL course offered at this school.
The Elective CHA Course Design Since 2008, CHA has been offered as a two-credit elective course given in the first 11 weeks of the spring semester. The course is taught in English by a single instructor. The CHA syllabus runs in parallel to the anatomy core curriculum course, specifically the anatomy of the upper and lower limbs. CHA differs substantially from the required core course because of its reliance on computer-generated anatomy, emphasis on cross-sectional anatomy, and inclusion of clinical anatomy. On completion of the course, students can expect to acquire an understanding of medical digital imaging, gain better computer navigation skills, develop cognitive skills specific to computer anatomy, and learn to value the pathways of clinical anatomy problem solving. The course schedule consists of nine lectures, eight weekly computer laboratory sessions, a final examination, and a closing session of examination review for a total of 20 contact hours. To receive the two elective credits, students must attend seven of the nine lectures, six of the computer laboratory sessions, and obtain a 2 or above (15 fail and 5 5 43
excellent with 2 and above corresponding to passing grades) on the final CHA multiple choice examination. Subject matter is delivered through weekly lecture presentations and instructor-assisted laboratory sessions keyed to the lecture topics. Laboratory computers have the capacity to accept scrollable CT and MRI DICOM files, are equipped with interactive software anatomy programs designed to guide users through the CT and MRI case studies, and are connected to the internet to view ultrasound, radiology, and anatomy education sites. Since 2007, the virtual human dissector (VHD), an anonymous copy-protected collection of CT and MRI DICOM image files, and the free Human Anatomy Online website have remained the primary modules and teaching tools of the course. Additional proprietary computer anatomy programs are in development, and a few of them are available for student access (Kish, 2012a). Student surveys indicate that 90% of the students in the course use the VHD and other free online programs primarily or exclusively during their laboratory sessions. A UD first-year medical student in the English program, the subject of this report, embarks on the two semesters of anatomical studies in the spring semester of his/her first year of an anticipated six-year medical school experience. During the opening plenary departmental lecture, students are advised that CHA is offered as an elective course in which (1) all aspects of the course are taught in English, (2) each lecture is given twice weekly to accommodate student schedules, and (3) the weekly one-hour small group computer laboratory sessions are designed for PBL exploration of computer anatomical programs, clinically generated CT and MRI scans, and ultrasound files. The student is directed to the CHA website that has been designed as a resource for the course format, with weekly updates on lecture topics, laboratory and examination schedules, and medical website information (Kish, 2012b). This website has limited value to any student not registered for the CHA course due to password protections of lecture summaries and PBL questions. Student queries and CHA website monitoring indicate that the majority of the CHAS went to the website only during the laboratory sessions and the week prior to the CHA examination. The format of the CHA sessions has a distinct neuromuscular anatomy foundation: the brachial and lumbar plexuses are presented as the basics in understanding the limbs as integrated functioning units. In response to student requests, each year the lectures contain more clinical case presentations. Beginning in 2009, a clinical case study was added at the end of each lecture. These clinical problems serve as the focal point of the weekly laboratory sessions. These problems range from nerve deficits in the limbs, limb trauma, and shoulder/pelvic mismatch dystocia to altered gait patterns, all of which are linked to basic anatomy. An example of a clinical anatomy problem would be the presentation of an automobile accident that causes life-threatening pelvic fractures and a tear of a branch of the superior gluteal artery. In the laboratory, the students are presented with a normal pelvic MRI and a pelvic MRI demonstrating the fractures and hematoma that might occur as the result of the auto accident. The students are asked to compare each MRI to the VHD, identifying the fractures, the superior gluteal artery, and soft tissue distortions. This process requires the students to scroll through multiple images until they can identify the structures in the coronal, sagittal, and axial plane images. Image problem-solving quizzes are given at five-week intervals. An example of a quiz question would be to identify a highlighted muscle on a sagit44
tal section of a shoulder MRI. The student and his computer partners are instructed to distinguish the muscle in the frontal, sagittal, and axial views. Once recognized, the student assignment remains to recreate, step by step, the brachial plexus diagram (Romm and Chu, 2005), trace the motor nerve supply from nerve root(s) to the muscle, and finally identify on the separate myotome chart the specific joint motions that are controlled by the selected muscle (Kish, 2012c). The computer laboratory sessions are limited to nine students and offered six days a week. The final CHA grade is based on the composite results of CHA laboratory quiz performance and a written CHA multiple-choice examination. The underlying themes of the CHA revolve around thinking through problems and developing a clinical reasoning approach to anatomy learning that can be applied to a wide range of anatomical topics. The CHA course does not include cadaver dissection, direct preparation for mid-term oral examinations, or tutorial assistance outside the classroom.
CHA Course Expenditures Expenditures for the course include (1) purchase of anatomical software for use in the computer laboratory, (2) development of the CHA website, (3) creation of anonymous MRI and CT scans and arthroscopic and ultrasound videos, (4) rental of internet image programs and computers, (5) website subscriptions and instructor textbooks. Excluding services provided by the UD (Internet TI cable access) and the Anatomy Department (office supplies, printing resources, secretarial IT services, and instructor stipends), expenditures amounted to a startup cost of $10,057 in 2006–2007 and a yearly expense of $1,500. There is no extra cost for the CHA course to the students.
The Student Groups The first-year English program medical student performances were studied. Only those students who successfully completed the first semester gross anatomy course of study were included in this study. These selected students were divided into two groups: medical students who enrolled in the elective CHA course (CHAS) and those medical students who did not enroll in the course (NCHAS). The two groups were tracked during the 2007–2008, 2008–2009, and 2009–2010 academic years. This cohort of studied individuals totaled 921 English program students from 39 countries: 571 NCHA students and 350 CHA students. A majority of these students were from Israel (16%), Nigeria (14%), Norway (10%), Saudi Arabia (7%), Sweden (9%), South Korea (6%), Iceland (6%), the United Kingdom, Canada, and the United States (5%), and Vietnam (5%). Student enrollment in the elective CHA course varied from year to year and country by country. Other students eligible to take the CHA course, such as Hungarian program students, dental students, and senior students, were not included in this study. Grade averages on the first two gross anatomy mid-term core curriculum oral examinations, which tested students’ knowledge of upper and lower limb anatomy, were collected for CHAS and NCHAS. These two metrics were chosen as the measures of anatomy knowledge, as all students must successfully take them to proceed in their studies and are independent of the CHA curriculum. The core curriculum instructors were blinded as to the content and format of the CHA elective course. Likewise, the Kish et al.
Table 1. First Semester Pre-anatomy Medical Science Grade Averages (MSGA) for Students Participating (CHAS) and Nonparticipating (NCHAS) in the Computer Human Anatomy (CHA) Course
Participating students (CHAS)
Academic year
Nonparticipating students (NCHAS)
a
P-value
Number of students
MSGA (6SD)
Number of students
MSGA (6SD)
2007–2008
65
3.83 (60.83)
215
3.84 (60.77)
0.885
2008–2009
122
3.70 (60.74)
217
3.61 (60.68)
0.481
2009–2010
163
3.88 (60.72)
139
3.60 (60.84)
0.007
All 3 years
350
3.81 (60.75)
571
3.70 (60.76)
0.071
a
P-value calculated by two-sided Wilcoxon-Mann-Whitney test; the grading scale is as follows: 1 5 fail, 2 5 pass, 3 5 fair, 4 5 good, 5 5 excellent.
CHA instructor does not participate in the development, formatting, or administration of these oral examinations. The science aptitude and readiness of each student was measured by the cumulative grade averages of the first semester compulsory medical science courses: Biophysics, Biostatistics, and Medical Chemistry. The 350 CHAS students included in this study met the CHA lecture and laboratory attendance requirements and took the CHA final examination.
Statistical Analysis A Wilcoxon-Mann-Whitney (WMW) nonparametric test was used to compare oral examination scores over the grouping variable CHA. To perform these tests, (1) independence of data must be reasonable, (2) data must be ordinal, and (3) one must assume, under the null hypothesis, that the distribution of each population is the same. It was assumed that students performed independently of each other. Oral examination scores were on a 1 to 5 ordered scale, and it was assumed that there was no difference in the population when testing if one population had larger values than another. Statistical analysis was performed using the software package R, version 2.15.0 (R Foundation, Vienna, Austria).
RESULTS Pre-anatomy Students’ Performance Baseline To examine the science aptitude and readiness of students in each group, the pre-anatomy medical science grade averages (MSGA) were compared as a baseline for student ability. In 2008 and 2009, there was no significant difference in the grades of CHAS students versus NCHAS students in a twosided WMW test (P 5 0.88 and P 5 0.48). In 2010, the CHAS did have significantly better scores (P < 0.01). These results are summarized in Table 1. In 2010, the CHA enrollment rose to 163, constituting 54% of first-year medical students. In that year’s CHA group, 48% of the students were from Asia and the Middle East, in contrast to 20% in 2008 and 22% in 2009. In that third year, the anatomy oral examination grades of the CHA students were lower than the preceding two year’s CHAS, whereas this 2010 group’s first semester primarily written MSGA was the highest of all groups measured (Table 1). Anatomical Sciences Education
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The Performance of CHA Versus Non-CHA Students on Core Anatomy Examinations Data for three years of the core anatomy oral examination results were collected from 2008 to 2010. A total of 921 English program students took the fifth- and tenth-week oral examinations (280 in 2008; 339 in 2009; and 302 in 2010). As indicated in Table 2, 350 of these students completed the elective CHA course (65 in 2008; 122 in 2009; and 163 in 2010). Between 2008 and 2010, collected and distributed data indicated that CHAS students performed better on the two oral examinations than the NCHAS. A WMW test was performed on all students over the three-year span, as well as on each year. On comparison of CHAS students versus NCHAS students over the course of the study, students who were enrolled in CHAS had significantly higher scores on both the fifth-week examination (Pvalue < 0.001) and the tenth-week examination (P < 0.001). In 2008, there was a significant difference between CHAS students and NCHAS students on both the fifth-week examination (P-value < 0.001) and the tenth-week examination (P < 0.001). In 2009, there was a significant difference between CHAS students and NCHAS students on both the fifth-week examination (P-value < 0.001) and the tenth-week examination (P < 0.001). In 2010, CHA students continued to score higher than non-CHA students; however, the difference was nonsignificant. The fifth-week examination result difference was not significant (P 5 0.27). The difference in the results of the tenth-week examination was not significant (P 5 0.35). The averages, standard errors, and WMW P-values of all these examinations are summarized in Table 2. The grading scale for the oral examination is as follows: 1 5 fail, 2 5 pass, 3 5 fair, 4 5 good, 5 5 excellent.
DISCUSSION The results of this study indicate significantly better performance in the mainstream anatomical curriculum of the CHAS in comparison to NCHAS as measured by two markers spaced over 10 weeks of anatomy while the elective CAL course was taught. Considering the large study groups evaluated over a period of three years, the results suggest an association 45
Table 2. Performance of Students Participating (CHAS) and Nonparticipating (NCHAS) in the Computer Human Anatomy (CHA) Course on Core Anatomy Oral Examinations
Academic year
Examination
2007–2008
Fifth week
Participating students (CHAS)
Fifth week
Fifth week
Number of students
Grade average (6SD)
65
3.62 (60.15)
215
2.81 (60.10)
