changing times, changing training: anatomy teaching in basic surgical training

VIEWPOINTS

Anatomy in Basic Surgical Training

These viewpoint articles voice worries about sur-

gical training in the United Kingdom. Stephen

J. Hanna and Tjun Tang are surgical trainees who

took their medical degrees just before the changes

introduced in response to the General Medical

Council’s directive, Tomorrow’s Doctors. They

express their concerns about the anatomical know-

ledge of surgical trainees. Sara Ramsey also empha-

sises the importance of sound anatomical know-

ledge but gives a different perspective. She is also

a surgical trainee but studied medicine in a new

curriculum. Finally Peter H. Dangerfield, an experi-

enced anatomy teacher and examiner at undergrad-

uate and postgraduate levels, gives more back-

ground and his viewpoint. Although reflecting the

current situation in the United Kingdom, the issues

raised are of international interest. It is hoped that

the viewpoints presented will be of interest to

readers of Clinical Anatomy and deepen discussion

and debate.

Stuart W. McDonald*

University of GlasgowGlasgow, United Kingdom

*Correspondence to: Dr. Stuart McDonald, Laboratory of Anatomy,

University of Glasgow, Glasgow G12 8QQ, UK.

E-mail: [email protected]

Received 13 January 2005; Accepted 14 January 2005

Published online 18 July 2005 in Wiley InterScience (www.

interscience.wiley.com). DOI 10.1002/ca.20121

Reduced Undergraduate Medical Science Teachingis Detrimental for Basic Surgical Training

STEPHEN J. HANNA1*y AND TJUN TANG2

1Oxford Basic Surgical Training Rotation, Oxford, UK2Vascular Unit, Addenbrooke’s NHS Trust, Cambridge, UK

A detailed understanding of the basic sciences, espe-

cially anatomy, is essential for any surgeon. There

has been a recent reduction in the detail of basic sci-

ences taught, at both undergraduate and postgradu-

ate levels, which we believe is detrimental for Basic

Surgical Training.

Until recently, the undergraduate studied the

basic pre-clinical sciences, including anatomy, physi-

ology, biochemistry, and pathology, in great detail.

With the advent of modern courses and the increas-

ing breadth of the curriculum, to include areas such

as communication skills, we have witnessed a drastic

reduction in the volume and depth of teaching in

these subjects. Origins, insertions, nerves supplies,

actions and relations, etc. have fallen by the wayside,

*Correspondence to: Stephen Hanna, c/o 21, Church Road, New-

townbreda, Belfast, Northern Ireland, BT8 7AL, UK.

E-mail: [email protected]

yS. Hanna’s present address is Northampton General Hospital,

Northampton, NN1 5BD, UK.

Received 30 November 2004; Accepted 13 January 2005



VVC 2005 Wiley-Liss, Inc.

Clinical Anatomy 18:465–469 (2005)

to be replaced by what is often a grossly simplified

overview of the subject area. This decline has been

compounded by two factors.

First, dissection has all but disappeared, being

replaced with limited numbers of plastinated speci-

mens, plastic models or computer programmes.

Although these methods are useful adjuncts to

teaching, we feel that they come a very poor second

to well-supervised teaching from a cadaver.

Dissection allows 3D visualisation of the subject

matter and the inter-relationships of anatomical

structures. It also encourages the development of

manual dexterity and an appreciation of anatomical

variation, as seen between different cadavers. The

less obvious benefits of teamwork and an early intro-

duction to death, in a society where we are increas-

ingly insulated from its reality, are of great impor-

tance. This issue has been discussed in some depth

previously (Jones, 1997; Hanna and Freeston, 2002).

Second, there has been a significant reduction in

the number of anatomy demonstrator posts, which

were of enormous value to both demonstrator and

student. For the postgraduate preparing for higher

surgical examinations, this was a vital educational

staging post, permitting some time away from the

significant time constraints of working as a junior

doctor, which could be devoted to learning and revi-

sing the basic sciences. It has also been shown that

anatomy demonstrators have higher pass rates than

average in post-graduate surgical examinations

(Miller and Deal, 1994). The demonstrator was a

particularly valuable asset for the students. They

could display the anatomy, discuss its clinical rele-

vance in relation to what both junior doctors and

consultants do every day. They represented a valua-

ble early link to the clinical world for the undergrad-

uates, thus allowing them to put what they were

studying into a clinical context.

There are two further complicating issues. First,

the decline in the number of medically qualified

teachers of anatomy, who are in an unrivaled position

to translate anatomy from the books and dissection

room to the bedside and the operating theatre, which

has already been highlighted elsewhere (Miller and

Deal, 1994; Green, 1998). Second, there have been

increasing health and safety concerns regarding the

use of formalin as a preserving agent (Kaufman, 1997).

One of the end results of these changes is that gradu-

ates of the modern courses find themselves facing profes-

sional examinations with a much greater knowledge defi-

cit. Much more has to be learned de novo rather than

simply revised. This problem is compounded by the

declining number of demonstrator posts. In addition, the

mandatory length of Basic Surgical Training is only 24

months. This is an impossibly short time span for the sur-

gical Senior House Officer (SHO) to cover all aspects of

the basic science curriculum and still learn clinical and

operative surgery. Many trainees resort to the often

short-term measure of attending revision courses, hoping

that exam technique rather than a solid foundation in the

basics of the subject, will secure a pass.

It is also important to emphasise that the great

importance of this issue is not limited to the field of

surgery. A sound grounding in all the basic sciences

is essential for nearly all the clinical specialties; the

increasing numbers of interventional procedures

being undertaken by radiologists and physicians

serve to highlight this.

We are concerned that the end result of this com-

bination of reduced undergraduate learning, reduc-

tion in demonstrator posts and shortening of Basic

Surgical Training will be an erosion in standards and

a reduction in the quality of patient care.

We propose that the solution to this problem is to

get ‘‘back to basics.’’ It is imperative that the under-

graduate should learn basic clinical anatomy, which

should then be consolidated by the Basic Surgical

Trainee by means of a demonstrator post. Dissection

of cadavers should play a central role in this. Aspects

of this problem have been highlighted previously

with little apparent effect (Kaufman, 1997; Green and

Raftery, 1999). It is our opinion that those involved in

planning and implementing both undergraduate cur-

ricula and postgraduate examinations should pay seri-

ous attention to this problem before we witness an

inevitable decline in surgical standards.

REFERENCES

Green NA. 1998. Anatomy training for surgeons—a personal

viewpoint. [comment]. J Roy Coll Surg Edinb 43:69–70.

Green NA, Raftery AT. 1999. That this college should sup-

port the maintenance of standards of teaching of basic

medical sciences especially anatomy at both undergradu-

ate and postgraduate levels. Ann Roy Coll Surg Eng

81(Suppl):261.

Hanna SJ, Freeston JE. 2002. Importance of anatomy and dis-

section: the junior doctor’s viewpoint. Clin Anat 15:377–

378.

Jones DG. 1997. Reassessing the importance of dissection: a

critique and elaboration. Clin Anat 10:123–127.

Kaufman MH. 1997. Anatomy training for surgeons—a per-

sonal viewpoint. J Roy Coll Surg Edinb 42:215–216.

Miller S, Neal DE. 1994 Surgical trainees as anatomy demon-

strators. Ann Roy Coll Surg Engl 76(Suppl):187–190.

466 Viewpoints

Changing Times, Changing Training: AnatomyTeaching in Basic Surgical Training

SARA RAMSEY*

Department of Urology, Gartnavel General Hospital, Glasgow, United Kingdom

There is no doubt that Basic Surgical Trainees

require appropriate knowledge of anatomy. Every

year, new trainees are dispatched from theatre to the

library and told not to return until they know the

branches of the facial nerve, muscles of the pelvic

floor, embryology of the gut, insert as appropriate.

This is a rite of passage. In the past, elderly profes-

sors of surgery supposed the lack of anatomical

knowledge was the fault of rock and roll, or the

retirement of their own dear anatomy professor.

Then a document called Tomorrow’s Doctors (General

Medical Council, 2002) put the cat among the

pigeons. Lack of anatomy knowledge is no longer

the trainee’s fault; it is the fault of a new ogre, the

‘‘new curriculum.’’ This is spoken of at great length

in theatre coffee rooms, with those least involved in

its development the most vocal about its failings.

Myths and legends abound—anatomy has been

entirely removed from the curriculum, there will be

20 hr of communication skills a week and these

thoughts are echoed by some of the points raised in

Hanna and Tang’s article (this issue).

The ethos of the new undergraduate curriculum

in medicine, pioneered in Maastricht and Montreal,

is to develop individuals with a thirst for knowledge

and self-directed learning. A series of carefully

planned clinical problems forms the basis and struc-

ture of courses that require students to actively

search for information. We are entering a time of

professional revalidation and continuing medical

education where these skills of self-directed learning

will be necessary throughout our careers.

Despite what has been claimed, anatomy is still

present in the new course. It is the format and the

timing that has changed. An integrated course pro-

vides clinical experience from the first day and anat-

omy is taught with a variety of prosections, dissec-

tion, and computer models. Exposure to the operat-

ing theatre, radiological imaging, and diagnostic tests

shows students anatomy in real life, in real time, and

illustrates the importance of the subject. Anatomy

teaching in association with clinical work will be

more relevant to the student than tales from a dem-

onstrator. Early clinical experience also helps foster

respect for the patient as a person, something

achieved less readily with a cadaver on the slab.

Surely the branches of the facial nerve are better

demonstrated by the ENT surgeon in theatre, and the

coronary circulation during angiography, rather than a

poor attempt at dissection where most of the struc-

tures end up in the ‘‘scraps’’ bowl. Of course cadaveric

anatomy teaching provides early exposure to the skills

of sharp and blunt dissection, but there is a great deal

more to surgical technique and manual dexterity than

this alone. The skills of tailoring and dress-making

may improve manual dexterity for stitching techni-

ques, but it is not argued that junior surgeons should

have an apprenticeship with a seamstress!

Recently, those who teach on the local Basic

Surgical Skills course have noticed that the laparo-

scopic surgery session has taken significantly less

time for the trainees to become comfortable with

the skills. Laparoscopic surgery is increasingly more

common and less open surgery will be the inevita-

ble result. The next generation of surgeons, raised

on computer games, will find the hand–eye coordi-

nation and dexterity of laparoscopy easier than

ever.

Although the reduction in learning time for lapa-

roscopic work may be anecdotal, objective evidence

exists to defend the changing curriculum. Studies at

Maastricht (Prince, 2003) have shown similar levels

of knowledge in basic sciences between traditionally

taught students and those of the new curriculum,

despite popular opinion to the contrary. It seems

there is a significant degree of cramming before tra-

ditional examinations, with an associated degree of

retrograde amnesia. When students were asked to

rate their confidence in their answers (Last, 2001),

however, the new curriculum students were much

less confident, although no less correct. This still

*Correspondence to: Sara Ramsey, 12B Burnbank Gardens, Glas-

gow, G20 6HB, UK. E-mail: [email protected]

Received 8 February 2004; Accepted 20 January 2005



467Viewpoints

requires explanation and could lead to problems

with negatively marked examinations.

The altered undergraduate curriculum has faults

and I am in complete agreement with Hanna and

Tang (this issue) that these flaws are more evident

during post-graduate studies, whether Basic Surgical

Training, or a medical rotation. Students and trainees

need to know the basics of science to apply their

knowledge with confidence to clinical work.

I also agree that 2 years of Basic Surgical Training

is a short period of time to learn clinical and opera-

tive surgery when shift systems are the norm. There

is also increasing emphasis on critical care as part of

basic training that, when coupled with a demonstra-

tor post as suggested, would further reduce surgical

experience. Funding and availability of the anatomy

demonstrator post for every trainee would be further

practical problems.

Despite the flaws, the new undergraduate curricu-

lum and altered senior house officer training should

produce more rounded doctors, with a greater enthu-

siasm and range of abilities to continue learning

throughout their careers. Though formal anatomical

dissection may be consigned to the mists of time,

there is no reason to suppose there should be an

‘‘erosion of standards’’ in clinical and applied anat-

omy. The need is for a solid foundation of applied

anatomy as an undergraduate, which can be built on

as a post-graduate trainee. At the same time, greater

emphasis on communication and ethics within both

undergraduate and post-graduate training should cre-

ate better surgical care for patients.

REFERENCES

General Medical Council. 2002. Tomorrow’s doctors. http://

www.gmc-uk.org/med_ed/tomdoc.htm [accessed 12/1/04].

Last KS. 2001. Basic science knowledge of dental students

on conventional and PBL courses at Liverpool. Eur J

Dent Educ 5:148–154.

Prince KJ. 2003. Does problem based learning lead to

deficiencies in basic science knowledge? Med Educ 37:15–

21.

Medical Science Teaching Needs StrongerSupport from Universities and a Better

Career Structure for Anatomists

PETER H. DANGERFIELD*

University of Liverpool, Liverpool, United Kingdom

This article is an observation on an issue that has

been raised since the early 1990s when changes to

undergraduate curricula and post-graduate training

came into place.

In the United Kingdom, the surgical colleges with-

drew recognition of time spent as staff in anatomy

from career progression and also removed a require-

ment for trainees to spend at least six months in acci-

dent and emergency medicine. This led to the loss of

many demonstrator posts within university anatomy

departments that were combined with Accident and

Emergency positions. This has resulted in many

medical schools now having minimal demonstrator

coverage. Such support that is available is provided

frequently by science graduates studying medicine or

undertaking a poorly paid Ph.D.

Additionally, the changes in the undergraduate

medical curriculum, driven by the General Medical

Council’s directive Tomorrow’s Doctors (General

Medical Council, 1993, 2002), resulted in radical

redefining of undergraduate courses, cutting down

on factual content and inclusion of more social

science.

Concurrent with the above changes, the Univer-

sity sector was entering a phase of financial difficulty

and focussing more and more on the Research

Assessment Exercise, and staff with high ratings.

Even now, with the pressure on fees and income,

the lack of support and limited funds released for

*Correspondence to: Peter H. Dangerfield, Director Phase 1,

University of Liverpool, Sherrington Buildings, Ashton Street,

Liverpool, L69 3GE, UK. E-mail: [email protected]

Received 19 January 2004; Accepted 13 January 2005



468 Viewpoints

teaching as opposed to research is still a major issue

for medical and dental education. Sadly for anatomy,

many of the best teaching staff were not high

research contributors and many retired or left, with

no replacements, leaving a core subject emasculated

and almost in its death throes. Additionally, the

financial remuneration for medical graduates who

might consider entering anatomy is now running at

about 50% of the salary of a consultant, hardly an

attractive proposition. Pragmatically, with increased

numbers of students to educate and less medical

academic staff in the university sector (Council of

Heads of Medical Schools, 2004), medical courses

have moved away from traditional sciences into ear-

lier clinical contact, inter-professional education and

more community-based learning, relying more and

more on NHS staff to do the teaching. Cadavers

have also become less easy to acquire through dona-

tions, costs of preservation have risen, and many dis-

secting rooms have been replaced by learning

centres, the best of which are state of the art envi-

ronments. Clinical skills education in medical

courses, however, has also focussed on anatomy as

well as individual competencies.

Hanna and Freeston (2002) comment on the

effect this is having on basic surgical training and

the Membership of the Royal College of Surgeons

(MRCS) examination. Changes ahead are not going

to make it easy to rectify this issue, with the intro-

duction of the Foundation Year, in which registered

doctors in their first year at SHO grade will need to

spend time in a range of specialties, including gen-

eral practice. After this, the rush to get on to the

basic surgical training programme, obtain an MRCS

(or equivalent if this changes), and enter the Special-

ist Registrar grade becomes a priority.

What can be done? First, the surgical colleges

need to address the issue of basic sciences and clini-

cal anatomy by pressing for more medical input into

the education at undergraduate and post-graduate

levels. If education in the subject is viewed as

important, then some method of devising a contract

for staff that releases them from the strictures of the

RAE but rewards them on a par with their NHS

staff is essential. Students who have an interest in

interventionalist careers such as surgery need sup-

port in anatomy with direction to clinically-based

learning and professional informed support from

educators who have clinical experience. Although it

has been suggested that retired surgeons could

undertake this, a proper career structure can be the

only realistic solution.

Considerable debate is current concerning funding

streams for undergraduate medical and dental educa-

tion. Perhaps serious consideration should be given

to reviewing this in the context of the need for good

basic anatomy for surgery and for other disciplines.

REFERENCES

Council of Heads of Medical Schools. 2004. Clinical academic

staffing levels in UK medical and dental schools. London:

Council of Heads of Medical Schools.

General Medical Council. 1993. Tomorrow’s doctors. London:

General Medical Council.

General Medical Council. 2002. Tomorrow’s doctors. London:

General Medical Council.

Hanna SJ, Freeston JE. 2002. Importance of anatomy and dis-

section: the junior doctor’s viewpoint [comment]. Clin

Anat 15:377–378.

469Viewpoints

changing times, changing training: anatomy teaching in basic surgical training

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