Reconsidering laboratory‐based anatomy within the backdrop of digital transformation: Bringing an old practice into a new world

Abstract

For many educators, the connection with the human body is the tenet of anatomical education—a gold standard for which there is no substitute and no alternative for its authenticity (Memon, 2018). As such, the conceptual framework for almost all anatomy curricula is built on chattels of descriptive nomenclature, visualization, physical exploration, and interaction with technologically constructed representations of anatomy such as physical models, low fidelity simulations, three-dimensional (3D) printing, or extended realities (XR, VR, AR, and MR). While established anatomical facts and principles remain the stronghold of anatomical sciences with little opportunity to add to what is already factually known, approaches to teaching and learning, resources, and curriculum design continue to evolve. Despite diversified approaches for teaching and learning of anatomy in medical and other health professions education, its principal goal of providing building blocks to inform clinical practice is incontestable. Two years ago, in May 2020, Anatomical Sciences Education published a special issue on "Covid-19 and Anatomy Education." The editorial in that issue started with a message that resonated throughout all learning institutions worldwide "… move everything online as quickly as possible …" (Evans et al., 2020). The world was under a hold of uncertainty, experiencing a variety of government-imposed social, educational, and structural changes that at its extreme end included closures of education institutions (Ferrel & Ryan, 2020; Smith & Pawlina, 2021). In particular, teaching of the anatomical sciences, which in many institutions has a strong laboratory-based component, was significantly impacted by school closures (Franchi, 2020; Gupta & Pandey, 2020), leaving little choice other then to increase efforts in use of new online collaborative tools, and other screen-to-screen communication technologies to bridge the gap between remote learners and their educational institution (Byrnes et al., 2021; Kurtulmus-Yilmaz & Önöral, 2022). In examining reports on anatomy teaching within the last two years of Covid-19 pandemic through a wide lens of rapid and sometimes chaotic changes in many learning institutions, it is not surprising that many doubts regarding online learning surfaced (Lemoine & Richardson, 2020; Arnett, 2021). These doubts are not unique to anatomy education and are perfectly understandable in the context of why the benefits of online learning are not fully realized by the educators (Arnett, 2021). What began perhaps as stopgap measures, have now found a locus in a transformed model for what could possibly set the stage for the future of cadaveric anatomy—its teaching and learning (Evans et al., 2020). With such significant adjustments in educational strategies in the past two years, it is evident that the Covid-19, pandemic became a catalyst for "disruptive innovation" in anatomy education (Arnett, 2014; García-Morales et al., 2021) instigating global changes at a more rapid rate with long-term impact on learners and educators (Washington, 2019). The term "disruptive innovation" was first coined by Clayton M. Christensen, a professor from Harvard Business School, who analyzed innovations with opportunities to develop within existing markets where a segment of a population's needs were not met by established business practices (Christensen, 1997). Within the business framework, instead of trying to make incremental improvements to an existing product (sustaining innovations), a disruptive innovation, often with fewer resources, leveraged technology to create and increase access to new markets. When applied to the education environment, disruptive innovation represents a break from traditional and well-established educational models of knowledge acquisition. It changes directions, interrupts and replaces existing methodologies, and traditional approaches for knowledge transmission by offering new alternatives for learning (García-Morales et al., 2021). In case of anatomy, disruptive innovation offers virtual transformation of laboratory experience. A parallel construct to the "sustainable business case" for anatomy education prior to the Covid-19 pandemic can also be made. The incumbent anatomy education "product" had not been stagnant, in fact, it had been already undergoing incremental improvements which is well documented by publications in Anatomical Sciences Education journal. The literature demonstrates that many anatomists were revising their anatomy curricula (Klement et al., 2011; Halliday et al., 2015; Klement et al., 2017; Royer et al., 2017), often applying a universal design for learning (UDL) framework for continuous improvement of anatomy pedagogy, technology, and curricula (Balta et al., 2020; CAST, 2022; Dempsey et al., 2022). Since the momentum for change had already been initiated, it was hardly surprising that anatomists intuitively found ways to circumvent the Covid-19 disruption and continue to deliver anatomical education to their learners with as little compromise to learner experience as possible (Harmon et al., 2021; Attardi et al., 2022b). Within this unexpected "Covid-19 natural experimental environment" for innovation, instead of trying to simply import the improved technology, pedagogy and resources in its current state, a greater opportunity arose to reframe, perhaps even challenge the norms of the anatomy teaching and learning establishment toward a reimagined future (Jones, 2020; Maloney et al., 2021). Again, the incursion of submissions and publications in Anatomical Sciences Education journal bears testament to how resourceful, innovative, and creative educators have been in continuing to offer learners the donor experience (Barash et al., 2021; Manzanares-Céspedes et al., 2021). However, despite multiple reported successes, anatomists' discussions still reflect elements of doubt with a petition to "go back to normal," a desire for a subsidence back into the familiarity of the dissection room (Basavanna et al., 2022). Understandably, for courses where dissection was a central curricular objective, impact of disruption was hardest felt. Yet, anatomy educators showed little hesitation in their resolve to endure the physical impediments that challenged the very essence of mainstream cadaveric anatomy education. In the absence of access to physical laboratory learning spaces, the learning of cadaveric anatomy had to take place elsewhere. The students' local, often home environment, substituted the traditional university-based learning space. Learners using mobile devices, computers with online resources, and other devices (i.e., smart phones, tablet computers, gaming platforms, hand-held ultrasounds, and head-mounted displays) navigated their way through the real world of anatomy, dissection, and clinical imaging by contextualizing their learning within their surroundings (Langran, 2022). However, there is a need for a development of the ambient learning space (ALS) architecture (Herczeg et al., 2021), which could integrate all learning applications and would be able to initiate and organize learning activities to guide students in this process. The ALS architecture and associated media platforms need to be constructed as a cloud-based databases to be accessible anywhere and anytime by students (Herczeg et al., 2021). The most drastic adjustment for anatomy educators however was attributed to lost or diminished access of infrastructure to provide students with a hands-on dissection experience (Franchi, 2020). To expound upon, it was not the loss of access to human anatomical data (images, videos, and radiological content) but rather the loss of novice learner driven dissection that endured the biggest incumbrance. Despite the loss of this opportunity, learners prevailed, and learner outcomes appeared to be successfully achieved (Tucker & Anderson, 2021; Chang et al., 2022). So, could it be that a forced disruption is moving us to consider a new perspective for recalibrating the way in which laboratory-based anatomy education is delivered to medical and other health professions students? In writing this editorial, we hope to provide readers with a proposition—one that challenges mainstream thinking as we leverage the established norms built on the use of the body donor, dissection, and the platform for developing non-technical skills also known as nontraditional discipline-independent skills (NTDIS) in anatomy (Evans et al., 2018; Evans & Pawlina, 2020). We think time has come to start deliberating on our past and current practices using body donors. As new cohorts of learners are enrolled in anatomy courses, the future of more enhanced utilization of cadaveric-based anatomy training needs to be considered. As digital capabilities begin to open new doors for superior and more advanced experiences, they should be considered as a valuable tool to meet the expectations of learner needs. In this editorial, discussion of a transformative approach is considered upon the following drivers: (1) Dissection as a tool for learning anatomy; (2) Body donor as a resource for reinforcing anatomical concepts; (3) Anatomy laboratory environment as a platform for non-technical skill (NTDIS) development; and (4) Technology as an asset for diversifying anatomical visualization and student experiences and digital transformation as a way forward. In understanding the current literature and paradigms for thinking about cadaveric-based anatomy education, several established practices and instructive uncertainties need to be elucidated. Despite existing evidence that student dissection affords little if any advantage over study from prosected specimens (Wisco et al., 2015; Aziz et al., 2019; Lackey-Cornelison, 2020) or technologically derived models (Fasel et al., 2016; McMillan et al., 2020; Frithioff et al., 2021), the act of dissection especially for novice first-year medical or other health professions students continues to hold a highly acclaimed position in the teaching and learning of anatomy (McMenamin et al., 2018; Wilson et al., 2019; Basavanna et al., 2022). Its claim, built solely on perceptions of students and teaching faculty appears to be marked by consistent indications of student anxiety, discomfort, and lack of confidence in their ability to meet expectations of high-quality outcomes. In fact, an increasing number of papers describe efforts designed to help students prepare for the stress of learning anatomy before embarking on an anatomy course (Houwink et al., 2004; Iaconisi et al., 2019; Zumwalt et al., 2021; Attardi et al., 2022a), coping with the pressure of performance anxiety during the anatomy course (Bernhardt et al., 2012; Bellier et al., 2020) and develop basic dissection skills using low fidelity activities in preparation for cadaveric-based learning (Yakura et al., 2022). Very few studies suggest that dissection coupled with associated educational activities is an effective pedagogical strategy for learning (Pizzimenti et al., 2016). In the hands of the novice learner, dissection may very well be a double-edged sword intriguing for some, daunting, a limitation for others, valuable in the hands of an expert anatomist and an indispensable tool for those in clinical training, standard practice, and practice innovation. In the authentic anatomy curriculum (Pawlina & Drake, 2016), core knowledge of anatomy is determined by desired clinical competency formulated to build anatomical content within targeted constructs of practice. Within a practice framework, we define "anatomical competency" as it relates to the ability of a surgeon, clinician, or health care provider to assess, interpret and navigate the patient's anatomical terrain to avoid procedural pitfalls and enhance patient outcome. Placed within the Dreyfus classical five-stage model of skill acquisition (Dreyfus & Dreyfus, 1980), the novice learner would be identified as a learner with little to no background in anatomy, limited understanding of the anatomical landscape, terminology and a system for interpreting anatomy and without background or prior experience in clinical practice. These markers apply to the average undergraduate, first-year medical, dental, or other health profession novice learner. While we must acknowledge that many learners today at this stage may indeed have some level of undergraduate exposure to anatomy, their lack of practice experience and insufficient depth of cadaveric-based knowledge will remain compounded by the challenge of using dissection, as a primary tool for learning a new subject. No study to date has succeeded in providing any empirical evidence to support the notion that novice learner driven dissection is the most effective tool for learning anatomy or that the first-year medical anatomy dissection experience informs future surgical prowess. Wilson et al. (2018) meta-analysis of anatomy laboratory pedagogies, present evidence to support the notion that true long-term retention of anatomical knowledge is a result of prolonged engagement with the material; an aptitude built through multiple interactions with anatomical data, application of clinical knowledge and the process of dissection for the anatomically competent. As a gold standard for anatomy education, the human body donor remains unrivaled in its instructional capacity. An excellent prosection surpasses simulated or synthetically created anatomical models through its ability to present real anatomy, variations of anatomy, and pathological or surgical alterations of anatomy (Pather, 2020). Its superiority as a teaching and learning tool however is only as formidable as the anatomy is demonstratable. While standard anatomy atlases, videos and software applications provide outstanding productions constructed from dissected material (Netter 3D, 2018; Netter, 2019; Agur & Dalley, 2020; Acland, 2022; Anatomy.TV, 2022), the everyday anatomy laboratory is an undependable space where clear demonstration of anatomy is influenced by the adeptness of the dissector, the dissection technique and exposure, the status of the donor, the tools used for visualization, and the learners point of view. As technology continues to outpace pedagogy and health care practice moves toward a data driven, visually directed platform, intentional instruction. This approach involves the integration of technologically aligned tools that serve twofold objectives: (1) to enhance the learning experience and (2) to reduce the learning curve. The days of straining to appreciate broad field, single angle (dissector's) view; passing off more difficult areas of dissection as "nice-to know but don't worry about it" strategy; acceptance of forced satisfaction with unrepeatable opportunities to view smaller but significant anatomical structures or the helplessness that comes with the understanding that the dissection process will by consequence disrupt possibly destroy earlier dissected structures may no longer be necessary. Perhaps not now, perhaps not even in the near future, but the certainty of change and the influence that creatively applied digital technology and the virtual platform can offer to existing ways of practice is resonant and will inevitably reorganize the stronghold of the cadaver laboratory. Meeting this challenge will almost certainly depend on how anatomists will engage in a paradigm shift, combine technology, dissection, and instructional approaches to enhance the learner's experience of anatomy. The continually increasing focus on promotion of non-technical skills in anatomy education (Evans et al., 2018; Evans & Pawlina, 2020; Lachman & Pawlina, 2020; McDaniel et al., 2021) lends credence to the fact that early introduction of non-technical skills from aviation industry have positive impact on its advancement during clinical training (Pal et al., 2018; Collins & Wisz, 2020). In fact, if nothing else, a growing body of anatomists believe that the most impactful learning within the anatomy laboratory is associated with and emanates from the demonstration of non-technical competencies found in attributes of professionalism, professional identity formation, teamwork, communication and the ethical standards, and reflection that comes from acknowledgment of death and dying (Escobar-Poni & Poni, 2006; Lachman & Pawlina, 2006; Pawlina, 2006; Jones, 2019; Kumar Ghosh & Kumar, 2019; Parker & Randall, 2020; Shiozawa et al., 2020; Abrams et al., 2021; Greene & Scott, 2021; Cline et al., 2022). Loss of this laboratory experience is often seen as a forfeiture in the learner's journey resulting in instructor hesitance in venturing out of this realm. While the transitional landscape of the anatomy laboratory provides ideal opportunities for growth, the recognition of non-technical attributes is pervasive across the longitudinal curriculum. If meaningful influence on its development comes from intentional demonstration within the learning environment (by both learners and instructors) then perhaps this would hold true even across platforms. In considering non-technical skill associated activities outside the anatomy laboratory it is important not to identify the virtual platform as a stand-in or substitution for the traditional classroom. The virtual platform is an independent pedagogical space that requires independent mechanisms and skills to work within its capabilities. Across the digital interface, communication, teamwork, professionalism, and a conscious recognition of the gift of body donation when intentionally driven into the curriculum, are no less impactful to the learner. Learning activities that draw on building blocks for non-technical skills attainment can be built into virtual frameworks as synchronous, asynchronous, and independent reflective exercises (Shiozawa et al., 2020; Abrams et al., 2021). To continue what had been achieved in the last decade, anatomy instructors must forge ahead to lay the foundations for non-technical skills learning opportunities within the next iteration of interacting with cadaveric donors on the virtual and digital platform. The emergence of digital health brings with it a bank of literature rich in multidisciplinary and cross field experiences. Advancements in anatomical sciences education has benefitted in the past from adoption of practice models intrinsic to the business and aviation industries (Pal et al., 2018; Collins & Wisz, 2020). In this light, could it be worth exploring already existing constructs that offer (1) Protocols for face-to face interaction in digitally connected classrooms; (2) Frameworks for synchronous videoconferencing instruction via digital networks of learning and instructional teams (Schmitt & Eilderts, 2018); (3) Immersive learning experiences within the experiential learning model (Dunne & McDonald, 2010; Hendricks et al., 2018); (4) Simulation systems that offer augmented experiences designed for learner development of cultural competency (Qin & Chaimongkol, 2021; Maar et al., 2022); or (5) Artificial intelligence-based generated virtual human characters (metahumans) and assets (de Borst & de Gelder, 2015; Stein & Ohler, 2017) to increase anatomical proficiency within the clinic. Perhaps, consider that such archetypes may in fact offer greater propensity for non-technical skill development in the virtual platform (Kwong et al., 2019; Papalois et al., 2022) and that such a platform may indeed offer opportunity to advance the evolving social agenda, reinforce responsibilities toward diversity equity and inclusion and provide wider outreach in our efforts to improve. Within the backdrop of Covid-19 pandemic driven disruptive innovation, the "digital transformation" driver had already emerged as a fulcrum for change. In literature, the digital transformation, is defined as a "change in how a business or company uses digital technologies, to develop a new digitally aligned model to extract more out of and bring more value to the organization" (Verhoef et al., 2021). In the field of anatomical sciences education, efforts to transform can be seen in the increasing market of commercially driven virtual resources mostly aimed at providing alternatives for cadaveric laboratory-based anatomy (i.e., virtual dissection tables or 3D anatomy visualization platforms with removable tissue layers options). These resources have established strong holds within academic curricula and have become significant platforms for engaging with virtual cadaveric anatomy. For laboratory-based programs, however, the influence of these products will continue to dwell within their supplemental capital and in the presence of the cadaveric instruction model will risk falling short in their ability to present authentic anatomy. The point of this reflective question therefore is not to initiate a debate around what delivers the best anatomy but rather how can the best anatomy be leveraged from a well-established teaching and learning model whose potential appears to have been waived by the trepidation that comes with attempting to upend a tradition. Given that digital transformation is known to be multidisciplinary in its construct it may be feasible to apply its model to reforming the approach to cadaveric anatomy by exploring elements of digital transformation from a business perspective (Berman, 2012; Verhoef et al., 2021) within a relevant and relatable context. Variety of the extrinsic and intrinsic drivers (motivators and disruptors) that play an important role in anatomy teaching and the anatomy learning space that should be considered are: the access to cadaveric tissue and donor programs, alignment of skills (i.e., dissection, reasoning, communication, etc.,) with knowledge (anatomical competency), appropriate use of scarce resource (donor material), availability of new tools and technology 3D platforms, digital learner need for curricular and learning, in and of commercially In the of a digital transformation strategy in its and of the transformation and not in the digital technology et al., the of a process and of its business model is associated with several (Verhoef et al., 2021) to establishment of in the of and cadaveric experiences, anatomy experiential learning or technology driven curriculum with opportunity to and data and tools for open access and and driven and clinical The anatomy curriculum is to an that is built from an of empirical and data that instructional design with learner needs. As a anatomy to date remains an basic of health professions education. Its to inform learning and its propensity for advancement of its understanding and application that it will not within an of digital or by any other requires a toward that will serve to a with an appropriate for the next of its there is in or the disruptive innovation on by the Covid-19 pandemic has already how cadaveric anatomy is and without the of novice driven dissection and with demonstration of anatomy that is and (Harmon et al., 2021; Attardi et al., 2022; Pawlina, 2022). toward this change and toward this change is to the that anatomists will in the academic Perhaps, we may indeed to that the for a to past practice at the intrinsic of the unexpected that from the may be more Perhaps, the time has come to past to be that the changes in clinical practice have approaches to cadaveric anatomy and that dissection has a place that the advanced and expert learner that efforts toward transformation will result in outreach and more advanced capabilities. We at the of change and within our the opportunity to take the best from the best forward. The human body will remain the gold standard for teaching and learning of anatomy—its within a digital future is on the from the

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