The future of anatomy education: Learning from Covid‐19 disruption

Abstract

Back in 1996, the report to UNESCO of the International Commission on Education for the Twenty-first Century highlighted four pillars of education (Delors et al., 1996). These pillars were framed within the context of education throughout life; Learning to Know, Learning to Do, Learning to Live Together, and Learning to Be. 'Learning to Know' emphasizes the combination of having a broad general knowledge with the opportunity to delve deeper into a smaller number of subjects. It also encompasses the ability of learning to learn so that an individual can benefit effectively from learning opportunities. 'Learning to Do' covers the acquisition of various skills and the ability to use these skills appropriately in work and social environments. 'Learning to Live Together' extends out to the understanding of those around us, appreciating interdependence and the need to work together. 'Learning to Be' focuses on maximizing an individual's potential by developing one's personality and competencies in order to act with autonomy, judgment and responsibility. The report also recognized that in the past, formalized education had focused on the development of knowledge, often at the expense of other learning and that we need to shift future education to fully encompass all four pillars by design. Why is this relevant to anatomy education, particularly now? As we deal with pedagogical change, emerging approaches and technologies and assesses the fundamental effects of a health pandemic on the future delivery of anatomy education, these pillars of education can provide an ideal guiding framework in helping to determine what anatomy education will look like in the future, especially in light of the disruption caused by the Covid-19 pandemic, and ensuring that we focus on a more rounded and inclusive approach to learning. Anatomical education has been changing and evolving in a variety of ways over recent decades. Some of these changes are in response to new emerging pedagogical approaches such as moves to a blended learning construct (Pereira et al., 2007; Green & Whitburn, 2016; Khalil et al., 2018), integrated curricula (Evans & Watt, 2005; Klement et al., 2011, 2017), an emphasis on interprofessional learning (Hamilton et al., 2008; Herrmann et al., 2015; Smith et al., 2015) and near-peer teaching (Evans & Cuffe, 2009; Morris et al., 2018; Harrison et al., 2019). The rise of digital innovations has enabled virtual dissection (Darras et al., 2020; Wainman et al., 2021; Duraes et al., 2022), three-dimensional (3D) printing (McMenamin et al., 2014; Smith et al. 2018; Ye et al., 2020), ultrasound (Swamy & Searle, 2012; Smith & Barfoot, 2021; Lufler et al., 2022), gamification (Ang et al., 2018; Rudolphi-Solero et al., 2022; Tan et al., 2022) as well as virtual and augmented reality (Moro et al., 2017; Uruthiralingam & Rea, 2020; Zhao et al., 2020; Jiang et al., 2022) to become common features in many programs. Technology has also started to disrupt the way in which students are assessed with interactive e-assessments being increasingly utilized (Elzainy et al., 2020; Chakrabarti, 2020; Bogomolova et al., 2021). In recent years, there has also been a fundamental recognition that anatomy education needs to be redesigned to play a greater role in preparing learners for practice by helping them to develop a new range of skills and attributes (Roxburgh & Evans, 2021). This includes the explicit incorporation of nontraditional discipline-independent skills (NTDIS) (Evans et al., 2018; Evans & Pawlina, 2020; Lachman & Pawlina, 2020) and professional identity formation (PIF) (Pawlina, 2019; Abrams et al., 2021; Darici et al., 2022) into many anatomy courses with an emphasis on communication (Evans, 2013; Lochner et al., 2020; Yohannan et al., 2022), teamwork (Vasan et al., 2009, 2011; Huitt et al., 2015), critical reasoning (Elizondo-Omaña et al., 2010; Kassirer, 2010; Rajprasath et al., 2020), interprofessional learning (Smith et al., 2015; Zheng et al., 2019; Lochner et al., 2020), and professionalism (Pawlina et al., 2006; Palmer et al., 2020; Khabaz Mafinejad et al., 2021). Overall, such changes and innovations has led to many educators shifting away from an approach that purely focuses on lectures, conventional laboratory practical sessions and time-honored assessments to one that exposes the educator and more importantly the learner to a more varied and multifaceted format and one increasingly aligned to the UNESCO four pillars of education (Delors et al., 1996). The transformative journey that anatomy education has been following has been accompanied by a rise in anatomical scholarship and education-focused research as exemplified by the increasing number and more importantly the quality of publications seen in journals such as Anatomical Sciences Education and the contributions to health-related conferences and symposia. This work has been an active part of the drive for change in, and the continual evolution of, anatomy education and has provided the platform for demonstrating new pedagogies and innovative approaches, allowing effective and assessed practice to be shared and enabling the discussion and challenge of ideas. Importantly, there has been an increasing emphasis on evaluating the effect of teaching interventions on the student learning experience and learning gain. This is essential in providing confidence to educators, institutions, accrediting bodies as well as learners that what is being introduced is pedagogically sound and evidence-based. In early 2020 an unexpected disruption to the provision and evolution of anatomical education intervened. The declaration of the Covid-19 pandemic in March 2020 caused a primary global health concern and by May 2022, there were over 518 million confirmed cases of Covid-19 and over six million deaths reported globally (Wang et al., 2020; WHO, 2022). The pandemic has had a profound effect across society, leading to far-reaching health, geopolitical and economic consequences. The education sector was far from immune to the pandemic with many countries initially implementing nationwide closures of schools, colleges and universities, with others under severe restrictions (Evans et al., 2020; Smith & Pawlina, 2021). For most anatomy educators, delivery of teaching had to shift rapidly to remote and online learning as opportunities for face-to-face teaching was all but removed (Evans et al., 2020; Papa et al., 2022). The challenge faced by many educators was far from trivial as although anatomy education had embraced new approaches including digital innovation as detailed above, face-to-face interaction and practical-based learning opportunities were still, quite appropriately, the mainstay of many anatomy courses. Apart from the governmental and institutional imposed constraints, which included restrictions in access to cadaveric and other materials, educators were faced with a shortage of resources and appropriate platforms for online teaching, a lack of time to make changes, and for many, an unfamiliarity with some of the available technologies. This was compounded by questions around how to convert materials and approaches for online, which approach to use, what technology to focus on and of course how to assess students. Despite the challenges, anatomy educators responded quickly, effectively and often innovatively. The changes seen demonstrated the richness of talented staff, the ability to be agile in responding to the needs of learners as well as dealing with the pace of change (Alkhowailed et al., 2020; Byrnes et al., 2021; Kapoor & Singh, 2022). The pandemic led to range of new or adapted approaches, often digitally-based, to be introduced into the curriculum to replace or adapt existing approaches in order to meet the perceived limitations of remote delivery. In some cases, this involved expanding the reach or extent of an existing approach or assets while for others the introduction of totally new interventions was required. Whichever the case, a great deal of time, effort, and commitment on behalf of educators and other staff was required as well as additional or differentiated resourcing. Digital interventions included live streaming of dissection and other practical demonstrations via anatomy studios (de Carvalho Filho et al., 2021), provision of virtual dissection (e.g., Anatomage, Sectra, etc.,), live and recorded lectures and dissections, the comprehensive use of video conferencing platforms (e.g., Zoom, Microsoft Teams etc.,) for synchronous and asynchronous delivery, and more effective use of learning management systems. Three-dimensional virtual applications and atlases became more widespread and new learning interfaces and platforms were introduced to support approaches such as simulation, and gamification. Other changes included the inclusion of more interactive formative assessment opportunities, online approaches to summative assessment and use of artificial intelligence (AI) in grading. Publications in the literature in the last two years confirm that a range of changes in anatomical education delivery were implemented and assessed world-wide (Brassett et al., 2020; Longhurst et al., 2020; Pather et al., 2020; Cheng et al., 2021; Harmon et al., 2021; Attardi et al., 2022; Özen et al., 2022). Perceptions, performance, satisfaction and well-being of students in the Covid-19 imposed online curricular environment emerged as a frequent theme for many publications (Cuschieri and Calleja Agius, 2020; Franchi, 2020; Srinivasan, 2020; Harrell et al., 2021; McWatt, 2021). Educators shared their experiences, best practices, and recommendations regarding digital transformation of anatomy teaching (Cuschieri & Calleja Agius, 2020; Pather et al., 2020; Böckers et al., 2021; Thom et al., 2021); as well as discussed issues and concerns related to teaching faculty (Patra et al., 2020, 2021). Scientific reports were published from a number of different anatomy programs and disciplines (Darici et al. 2021; Singal et al., 2021; Yoo et al., 2021; Al-Alami et al., 2022; Mahdy & Sayed, 2022) with some authors exploring their vision how the post-Covid anatomical sciences education might look like in the future (Jones, 2021; Ross et al., 2021; Lachman & Pawlina, 2022). Overall observations from these reports and others suggest that in terms of positive outcomes the shift in approach resulted in a significant driver to migrate to an online environment, the development of a range of new resources, a faster pace of pedagogical change, the introduction and learning of new technologies and a more personalized learning experience for students. However, a number of report outcomes point to a range of problem issues such as a lack of learner engagement, issues with assessments, difficulties with online access, learner isolation, and concerns over mental health and wellbeing, restricted interaction between educators and students, staff exhaustion, and rushed curriculum planning (Cecilio-Fernandes et al., 2020; Sani et al., 2020; Pokryszko-Dragan et al., 2021). The absence of hands-on practical experience was seen as the major disadvantage for students. Learning from such outcomes is important for individual educators, course leaders, institutions as well as the discipline of anatomy education. The results of the transition to remote and online anatomy learning provision should be actively used to shape future direction and identify where efforts should be focused. As has been noted, it is impressive the way in which anatomy educators have responded to the challenges of teaching in the midst of the Covid-19 pandemic, but as identified above, what about the effects on future provision? What long-term disruption might or should the period of the pandemic have on the design and delivery of anatomical education? It would certainly be a missed opportunity if we simply returned to way things were done and did not respond to the questions that have been posed during the pandemic, or failed to build on, use and adapt the innovations and approaches that have been used in the past two years or so. Therefore, determining how we provide anatomy education in the future should be influenced by the disruption of the pandemic and the opportunities identified. Disruption is not new and has been shown to be a trigger for innovation and change but also a threat for those areas that fail to respond effectively or in a timely manner. In the business world, disruptive innovation "is a process whereby a smaller company with fewer resources is able to successfully challenge established businesses and is gradually moving upmarket to challenge the industry leaders" (Christensen, 1997; Christensen et al., 2015). There are a number of classical examples of disruptive innovation in business such as the fall of Blockbuster and the rise of Netflix, the introduction of Uber and its effect on the taxi transportation industry, the closure of Borders bookstore as a result of its failure to transition to digital and online publication. Likewise, some innovations also fail to make the desired impact such as Google Glass, the Theranos health start-up and the Ford Edsel. And that is the point, some disruptive innovations succeed, and others do not but what they all have in common is that they challenge our thinking and enable us to critically assess ideas and concepts, which can lead to change or affirmation of the efficacy of current approaches. How does this relate to education? Disruption, both large and small has been a congruent element of education for centuries. Whether it has been the transition of the slate to paper to the screen, or chalk to the pen/pencil to the keyboard, or perhaps more fundamental changes to the approach to teaching such as the appearance of the Khan Academy, the flipped classroom or introduction of massive open online courses (MOOCs). Whatever the disruptive innovation in education, the importance is that they disrupt the norm. The impact that innovations have in the educational field can be brief or longer-term and can be influenced by global changes in teaching strategies, systematic efforts for change, or at a local level such as a new intervention by an individual educator. Some of these innovations therefore start out small but can go on to have national or global influences in teaching pedagogy, academic development and learning opportunities. Despite challenge and disruption, some existing approaches have stood the test of time, at least up until now such as the lecture or for anatomy education, cadaveric dissection. However, dissection may undergo some adjustments in the future, especially for novice undergraduate anatomy students in order to maximize the students' experience and their knowledge gain from using the precious gift of the human body (Onigbinde et al., 2021; Lachman & Pawlina, 2022). How to respond longer term to the disruptive influences the pandemic has thrown upon anatomy education needs appropriate consideration and requires a robust assessment of the changes, innovations and interventions introduced. This includes primarily the impact on student learning of the approach, but also the financial, logistical and strategic viability that will enable a sustainable change to be made. There has been an abundance of contributions to the anatomical education literature since the start of the pandemic and as seen, these have largely focused on sharing details of implemented practices, and discussions and commentaries on the challenges and opportunities faced by students and educators, often informed by analyses that include the results of surveys and focus groups. Such reporting has been insightful and valuable but has yet to focus specifically on the effects on learning gain and long-term viability. There is a growing need for more in depth and systematic evaluation of the interventions and innovations used during this disruption in order to appropriately inform the efficacy of changes to practice and influence future decision making (including limiting future threats to delivery), which often sits outside the remit of the individual educator or course leader. There is a danger that some approaches or innovations become embedded into the course provision without appropriate evaluation with potential downstream consequences on learning, student experience or sustainability. Likewise, some interventions are likely to be dismissed as a continuing approach as they were seen as a temporary measure or appeared less effective at the time of first use. Appropriate evaluation of such approaches is still needed to determine whether the approach (and all the work that went into it) in fact has longer-term potential and might highlight adaptations and refinements that could be made to improve or transform efficacy. A focus on multi-modal approaches to evaluation including an emphasis on effectiveness, learner satisfaction, staff impact, value/cost and learning gain is therefore essential in order to properly assess the substantive value of making changes that will underpin the makings of a future approach. The Covid-19 pandemic has provided an unexpected experimental environment for testing educational innovations in the anatomical sciences and the opportunity to scientifically evaluate the outcomes of these as well comparing against the effectiveness of pre-Covid-19 provision. This will help to ensure that the level and quality of scholarship in anatomy education also benefits. If we return to the opening message of this editorial and the four pillars of education (Delors et al., 1996), how do these inform the design and rollout of a future approach to anatomical education? The pillar of 'Learning to Know' suggests the need to maintain a continuous focus on anatomical knowledge and understanding in order to secure a student's solid academic base, but also providing better opportunities for learners to be able to critically analyze and research. This can be enabled through a range of teaching approaches delivered as part of a holistic curriculum. This pillar also recognizes the need for more attention on enabling the capacity for learning to learn and preparation for life-long learning. Anatomy often appears as an early subject in many health education programs, and as such needs to do more in supporting students in preparing to be effective learners. The lessons outlined above, particularly those related to guiding learners, if implemented effectively and in a student-centered way would be enabling of this. The 'Learning to Do' pillar focuses on the acquisition of various skills and the ability to use these skills and the knowledge learned appropriately in work and social environments. For anatomy this would focus on the ability of students to develop a range of technical and related skills through face-to-face and simulated laboratory opportunities and use these to apply to their knowledge to clinical cases and environments. While this is embedded in many current anatomy curricula, the emergence of new pedagogies and technologies provides exciting and potentially more enabling opportunities for students to learn and apply knowledge and skills. A transformation in the approach to assessment as outlined in lesson five is also essential so that students learn what is expected, where their learning gaps are and the importance of focusing on application of knowledge and skills. 'Learning to live together' is a pillar that relies on, amongst other things, the ability to communicate, resolve conflict and be aware of and respond appropriately to cultural sensitivities. The emergence of NTDIS in anatomy education provides a focus for ensuring that we provide students with a wider learning opportunity that will prepare them appropriately for their future role in clinical practice. This relies on being able to integrate these skills into a holistic curriculum, using appropriate learning technologies and pedagogies, supporting and guiding students as they develop and using assessment as a tool for learning. The final pillar, 'Learning to be' embraces the need to develop self-esteem, emotional intelligence and higher-level critical thinking. Within anatomy this can be achieved through a more explicit focus on professionalism, and the development of professional identity. The incorporation of PIF pedagogies and NTDIS within a holistic anatomy curriculum therefore provides effective opportunities to achieve this. The ability to touch on all these aspects within the anatomy curriculum requires effective planning and design and one which generates a balanced, appropriately loaded approach that supports rather than hinders the learner. It is important that anatomy education is not developed in isolation from other disciplines and instead ensure appropriate integration is achieved. By using the recent evolution in pedagogies as well as the current pandemic disruption we can also learn from and inform other disciplines. Simply going back to the way things were done before Covid-19 is a missed opportunity for anatomy education to enhance the experience for learners, incorporate lessons learned from this unexpected experimental Covid-19 environment and build on the recognized foundations as a discipline that is continually evolving in its approach. Much of what is suggested in the five lessons presented or captured within the four pillars of education will not be a surprise or new to many educators, but we all have a responsibility to bring these elements together to frame a future anatomy education provision post the pandemic and one that provides the opportunity to reset expectations, increase learning gains, personalize the student learning experience, enable and empower educators and lead to change in anatomical sciences education.

Topics & Concepts