Surg Radiol Anat (2017) 39:95–101

DOI 10.1007/s00276-016-1713-y

T E A CH I N G A N A T O M Y

Applied clinical anatomy: the successful integration of anatomy

into specialty-specific senior electives
1,2 3,4,5,6 4 6
Helen Morgan • John Zeller • David T. Hughes • Suzanne Dooley-Hash •
7 8 2,6
Katherine Klein • Rachel Caty • Sally Santen

Received: 6 November 2015 / Accepted: 9 June 2016 / Published online: 15 June 2016
Springer-Verlag France 2016

Abstract musculoskeletal medicine, radiology, surgery, and obstet-

Purpose A strong foundation in anatomical knowledge is rics and gynecology. These 4-week courses are all offered
essential for physicians in all fields. Despite this estab- in the spring of the final year of medical school. The course
lished importance, anatomy continues to be primarily curricula, content, and evaluation data are described for
taught only during the pre-clinical years of medical school. each of the courses.
Senior medical students have more mature clinical rea- Results The five electives have been extremely popular at
soning and analytical skills; therefore, advanced anatomy our institution, and all have been consistently filled each
courses have great potential to integrate basic and clinical year by students entering diverse disciplines. Course
sciences to better prepare senior medical students for evaluations have been positive and students specifically
residency. note how these courses allow them the opportunity to
Methods At our institution, five electives have been integrate basic anatomical knowledge into clinical con-
implemented that integrate anatomical education in clinical texts. Students have marked improvement in anatomical
contexts in the fields of emergency medicine, knowledge after completion of these electives.
Conclusions Advanced anatomy courses that integrate
anatomical education with clinical reasoning are important
& Helen Morgan curricular innovations that are popular with students and
[email protected]
lead to important improvements in anatomical knowledge.
1
Department of Obstetrics and Gynecology, University of Anatomists can lead the charge for better integration of
Michigan Medical School, 1500 E. Medical Center Dr., basic sciences into senior medical school curricula.
L4000 Von Voigtlander Women’s Hospital, Ann Arbor,
MI 48109, USA
Keywords Anatomy education Fourth-year medical
2
Department of Learning Health Sciences, University of school Basic science education Accreditation Council
Michigan Medical School, Ann Arbor, MI 48109, USA for Graduate Medical Education Milestones
3
Division of Anatomical Sciences, University of Michigan
Medical School, Ann Arbor, MI 48109, USA
4
Department of Surgery, University of Michigan Medical Introduction
School, Ann Arbor, MI 48109, USA
5
Department of Orthopedic Surgery, University of Michigan A strong foundation in anatomical knowledge is important
Medical School, Ann Arbor, MI 48109, USA for physicians in all disciplines [22]. For example, mus-
6
Department of Emergency Medicine, University of Michigan culoskeletal problems are a leading cause of pain, physical
Medical School, Ann Arbor, MI 48109, USA disability, and outpatient and emergency department visits
7
Department of Radiology, University of Michigan Medical [4, 6, 8]. Anatomic knowledge is likewise becoming
School, Ann Arbor, MI 48109, USA increasingly important with the widespread utilization of
8
University of Michigan School of Public Health, Ann Arbor, sophisticated imaging techniques [13]. Despite its estab-
MI 48109, USA lished importance, there has been a decrease in the number

123
of hours devoted to were all implemented as a a curriculum focuses on
anatomy, which is usually response to the need for n common emergency
only taught during the pre- increased anatomical and d medicine pro- cedures, the
clinical years of medical musculoskeletal education relationship of critical
school [7]. Fur- thermore, in the medical school c anatomical structures, and
there is concern that curriculum. All five o procedural skills (Table 1).
medical students are courses are offered in the n The topics are first
t
entering the clinical years spring of the final year of discussed in lecture, and
e
ill prepared to transfer medical school just prior then reinforced both in the
n
anatom- ical knowledge to to students entering t anatomy and simulation
clinical scenarios [12]. In residency. We will laboratory settings. The
addition, stu- dents are describe the course anatomical dissections
All of the courses
failing to retain anatomical curricula and content, and supplement the clinical
emphasize the correlations
knowledge from the pre- evaluation data for these context for these
between anatomical
clinical years during their five courses. procedures.
concepts and clinical
clinical clerkships [10,
applications. The content
16]. Applied clinical
for each of these courses
Accordingly, there is M was created by both the anatomy: the
great potential to improve a physician and anatomical musculoskeletal
the delivery of anatomy t faculty course directors. system
education in medical e
school curricula. There is r This course was created
Applied clinical
increasing recognition of i with the goal of presenting
anatomy:
the importance of inte- a mus- culoskeletal
emergency
grating basic sciences, l anatomical concepts
medical
such as anatomy, into the s within the framework of
procedures
later parts of the medical clinical application. It is
school curriculum [9]. a co-taught by a basic
This course was designed
Cadaver dissection [11] n science fac- ulty from the
to prepare students for a
and other forms of d Division of Anatomical
career in emergency
anatomical instruction [5] Sciences and clinical
medicine, as well as other
have been utilized to faculty from the
m specialties that involve
integrate anatomical Department of Orthopedic
e procedural skills and
education in clinical Surgery. Fac- ulty from
t resuscitations. The course
contexts. multiple clinical
h provides focused
Developmentally, senior departments including
o instruction and guided
students have more mature anes- thesiology,
d practice of psychomotor
clinical reasoning and rheumatology, and
s and clinical decision-
analytical skills [19]. physical medicine and
making skills to strengthen
The purpose of this rehabilitation teach
C knowledge acquisition and
paper is to describe the sessions in this inter-
o retention of clinically
successful integration of disciplinary course that
u relevant medical pro-
anatomy into senior was first implemented in
r cedural skills and
medical student elec- tives s 2006. Each topic has
resuscitation. It is co-
at our institution. Five e lectures and anatomical
taught by a basic science
electives have been imple- data related to common
faculty from the Division
mented in the fields of c orthopedic problems,
of Anatomical Sciences
emergency medicine, u followed by a session
and clinical faculty from
musculoskeletal medicine, r incorporating the physical
the Department of
radiology, surgery, and r exam.
Emergency Medicine,
obstet- rics and i and was first
gynecology. These 4-week c Applied clinical
implemented in 2009.
courses all integrate u anatomy: anatomy
The
anatomical education in l meets radiology
clinical contexts. They a
The purpose of this course
is to review pertinent riculum utilizes multiple
clinical anatomy using modalities of teaching,
common radiology including anatomical
modalities that are sessions, to prepare
employed in daily practice medical students for the
by primary care and Accreditation Council of
subspe- cialty physicians. Graduate Medical
This course is the newest Education
of the senior electives, and
was first offered in 2015.
It is co-taught by a basic
science faculty from the
Division of Anatomical
Sciences and a clinical
faculty from the
Department of Radiology.
The course has a
multidisciplinary approach
with faculty not only from
Radiology and the
Department of Anatomy,
but also from orthopedic
surgery, otolaryn- gology,
emergency medicine,
pathology and
neurosurgery. The
curriculum is structured to
emphasize a case-based
approach to radiology and
pertinent clinical anatomy
uti- lizing small group
sessions. The mornings
are spent in case-based
sessions, and the afternoon
sessions are a combination
of anatomical dissections
in the lab with
demonstration of common
procedures, simulation
training on high-fidelity
phantoms, and time in
the radiology reading
room for students to apply
their knowledge.

Advanced
clinical skills
course in
obstetrics and
gynecology

This course was designed

to prepare senior medical
stu- dents for obstetrics
and gynecology
residencies. The cur-
Surg Radiol Anat (2017) 39:95–101 97

Table 1 Anatomical topics and their clinical correlations for each of the five anatomical electives offered to fourth-year medical students at the
University of Michigan
Course Anatomical topics Clinical correlations

ACA: musculoskeletal system Anatomy of the shoulder, axillae, arm, Surgical approaches for clavicle, humerus, cubital tunnel
elbow, forearm, wrists and hands release, Dupytren’s contracture
Upper extremity (UE) radiology
Physical exam of the shoulder and hand
UE entrapment and compartment syndromes
UE joint injections
Anatomy of the lower extremity (LE), Physical exam of the hip and knee
foot, ankle LE entrapment and compartment syndromes
Surgical approaches to the hip
Below knee amputations
Anatomy of the spine Physical exam of the spine
Physical medicine and rehabilitation (PM&R) considerations
EMG imaging
Spine imaging
Anesthesiology and pain management
Anatomy of the neck and chest Needle thoracentesis, chest tube placement, cricothyroidotomy,
tracheostomy
ACA: emergency medical Anatomy of the thorax, heart, lungs Resuscitation and trauma evaluation Radiology of
procedures and mediastinum. Anatomy review emergency medical procedures Simulation lab:
of cardiovascular system
airway procedures, IV placement,
pericardiocentesis, thoracentesis
Anatomy of the head and neck Radiology of head and neck and emergency neuroradiology
Sedation
Simulation lab: head, eyes, ears, nose, throat (HEENT)
procedures, suture and wound closure
Anatomy of the spine Fractures, dislocations and reductions
Common pain syndromes, PM&R considerations
Anatomy of the lower extremity (LE) Compartment syndrome
Anatomy of the upper extremity (UE) Brachial plexus
Anatomy of the gastrointestinal (GI) Radiology of GI and genito-urinary systems
tract
ACA: radiology Anatomy of the heart and lungs X-ray and CT of the chest
Chest pathology (pneumothorax, hemothorax, effusions,
tamponade, fractures, congestive heart failure, pneumonia,
oncology, and trauma)
Simulation lab: thoracentesis, vascular access
Anatomy of the GI/GU Imaging of the GI and GU tract
Abdominal pathologies (liver, ascites, gall bladder, large and
small bowel, renal stones, abscesses, hemorrhage, and
oncology)
Simulation lab: paracentesis
Anatomy of the UE Brachial plexus
Imaging of UE: bone and joint pathologies
Anatomy of the LE Imaging of LE: bone and joint pathologies
Compartment syndromes
Anatomy of the spine Imaging of the spine
Simulation lab: Lumbar puncture
Anatomy of head and brain Imaging of head and neck
Neuro-spine pathologies: herniated nucleus pulposus, stenosis,
trauma, oncology, stroke, cerebral palsy
Table 1 continued
Course Anatomical topics Clinical correlations
Advanced clinical skills in Abdominal pelvic anatomy Operative anatomy: Bilateral tubal ligation,
obstetrics and gynecology salpingo-oophorectomy, total abdominal hysterectomy
Perineal anatomy Operative anatomy: laceration and episiotomy repair
Surgery resident prep course Head and neck anatomy Operative anatomy: cricothyroidotomy, tracheostomy, central
line placement; Simulation model: cricothyroidotomy,
central line placement, intubation
Vascular anatomy Operative anatomy: femoral artery exposure, below knee
amputation, above knee amputation, central venous line
placement
Thorax anatomy Operative anatomy: chest tube placement, thoracotomy,
pericardiocentesis; Simulation model: chest tube placement
Abdominal anatomy Operative anatomy: exploratory laparotomy, bowel resection
and anastomosis, cholecystectomy, appendectomy
Musculoskeletal anatomy Operative anatomy: fasciotomy of lower extremity, above knee
amputation, below knee amputation, inguinal hernia repair,
skin lesion excision

(ACGME) intern milestones competencies. These compe- Course evaluations and knowledge assessments
tencies include knowledge of abdominal and pelvic anat-
omy. A faculty from the Division of Anatomical Sciences The three Applied Clinical Anatomy courses utilize pre-
teaches cadaveric dissection on the topics of pelvic viscera, and post-course assessments on physical examination,
pelvic vasculature and nerves, and perineal anatomy. Fac- anatomical knowledge, and radiology. Questions for these
ulty and house officers from the Department of Obstetrics three assessments come from a question bank comprised of
and Gynecology facilitate 8 h of fresh cadaver intern-level questions created by the American Association of Anato-
procedures. mists (AAA), from Bernstein et al. [6] and from a question
bank co-developed by one of the course directors (JZ). The
Surgery resident prep course Advanced Clinical Skills Course in Obstetrics and Gyne-
cology utilizes pre- and post-course assessments of
The objective of this course is to prepare senior year anatomical knowledge that was developed by the faculty
medical students for residency in a surgical specialty. This from the Division of Anatomical Sciences. Means for the
course utilizes many components of the American College pre-and post-course assessments were compared utilizing
of Surgeons/Association of Program Directors in Surgery/ paired t tests. The Surgery Residency prep course is not
Association of Surgical Education Resident Prep Cur- currently utilizing an assessment of anatomical knowledge
riculum [1] and includes senior medical students who in its course. Improvements in anatomical and procedural
have applied for residency positions in general surgery, knowledge following the operative anatomy week have
vascular surgery, cardiothoracic surgery, and plastic sur- previously been described from this course [21]. IRB
gery. Anatomy is included in this course with a combi- exemption was obtained from our institution for all aspects
nation of didactic lectures, simulation sessions, and of this paper.
human cadaver dissection taught by surgery and anatomy
faculty. The focus of the didactic lectures includes applied
clinical anatomy as it relates to common operative pro- Results
cedures encountered during the first years of surgical
residency (Table 1) and includes cadaver dissection dis- Evaluation of the courses is based on three levels of the
playing normal anatomy relevant to these surgical pro- modified Kirkpatrick’s evaluation pyramid [14]. The five
cedures. The operative anatomy week is the primary courses have been extremely popular electives at our
anatomy component of the curriculum in which students medical school. The three Applied Clinical Anatomy
perform operative procedures on fresh cadavers. The electives have been taken by 154 students going into
procedures are proctored by surgery and anatomy faculty diverse specialties including emergency medicine, internal
in groups of three to four students. Students perform each medicine, pediatrics, anesthesia, and radiology. The Sur-
procedure with a focus on anatomic clinical relevance as gery Resident Prep course has been taken by 135 total
it relates to the procedure. students since 2008. This course has been reserved only for
Table 2 Student comments from evaluations for each of the five anatomical electives offered to fourth-year medical students at the University of
Michigan
Course Comments

Applied clinical anatomy: emergency medical Excellent review of anatomy

procedures
Having this focused, clearly relevant anatomy class after M3 and m4 years is really
helpful
Reviewing basic science helps to solidify clinical experience and knowledge
Probably most beneficial class of my four years in medical school
Applied clinical anatomy: the musculoskeletal Great opportunity to relearn critical anatomy
system Course was excellent and I have relearned a lot of the detailed anatomy
that I have not utilized since the first year
The best I have taken in medical school and the most useful for residency
Excellent course and building upon anatomical knowledge and how it relates
to clinical applications
Course was excellent and I have relearned a lot of the detailed anatomy
that I have not utilized since the first year
Applied clinical anatomy: anatomy meets radiology Great correlation between radiologic modalities and gross anatomy
It is a great opportunity to learn about anatomy after having a very limited exposure after
M1 year
The format of this class had multiple methods of subject matter reinforcement that helped
solidify concepts related to anatomy and radiology. I highly recommend this class to
everyone
Great mix of everything-dissection, radiology, pathology, anatomy and clinical skills
Surgery resident prep course Amazing! One of, if not the, best rotation of medical school for those interested in
surgery
Outstanding rotation. I feel much better prepared for residency after taking this elective
Best month of entire medical school. Very well done
Advanced clinical skills in obstetrics and gynecology This elective was extremely valuable in providing practical knowledge and skills
for soon-to-be Ob/Gyn interns. I feel much better prepared to begin intern year,
and really appreciate the opportunity to this elective
Hands down, this was the most productive rotation I’ve taken in medical school!
All specialties should offer a rotation like this. AMAZING!

students entering the fields of general surgery, vascular Students have marked improvement in anatomical
surgery, cardiothoracic surgery, and plastic surgery. Of knowledge after completion of these five courses. Pre- and
note, many other students have expressed interest in this post-course knowledge assessment results are presented in
course but have not been able to enroll due to lack of Table 3. For the three Applied Clinical Anatomy courses,
available space. The Advanced Clinical Skills in Obstetrics the numbers reported are the means and standard devia-
and Gynecology course is reserved for students applying in tions for the Anatomy Knowledge component of the pre-
obstetrics and gynecology residencies, and has been taken and post-course assessments. The results reported for the
by 44 students since 2013. Of note, 46 students have Advanced Clinical skills in Obstetrics and Gynecology
entered obstetrics and gynecology residencies since 2013, course are the means and standard deviations for the
and only two of these students elected not to take the Anatomy knowledge assessments.
course. As a measure of dissemination, the implementation and
The course evaluations (learner satisfaction) for these analysis of these five courses have provided academic
courses have been extremely positive. See Table 2 for scholarship opportunities for the faculty involved. The
student comments from the five electives. Students faculty have published manuscripts about curriculum
specifically noted how these courses allowed them the development [15, 20], musculoskeletal knowledge [18],
opportunity to integrate basic anatomical knowledge into and procedural knowledge improvement [21]. There have
clinical contexts. Many students commented on how these also been numerous abstract presentations pertaining to
electives were the best courses in their medical school these five courses at Anatomical, Medical Education, and
experience. Subspecialty-specific National Meetings.
Table 3 Mean scores achieved on knowledge assessments for three of the anatomical electives offered to fourth-year medical students at the
University of Michigan
Course Pre-coursec Post-coursec P value
Applied clinical anatomy: emergency medical procedures 45.95 ± 12.77 77.78 ± 11.60 \0.001
(data available for years 2010–2013, n = 47)a
Applied clinical anatomy: the musculoskeletal system 56.93 ± 14.60 89.50 ± 8.86 \0.001
(data available for years 2009–2013, n = 40)a
Advanced clinical skills in obstetrics and gynecology 67.33 ± 18.19 80.67 ± 16.59 \0.001
(data available for years 2013–2016, n = 36)b
a
Data are from the Anatomical Knowledge component of the Knowledge Assessment used in the Applied Clinical Anatomy courses
b
Data are from an Anatomy Knowledge Assessment that was created uniquely for the Advanced Clinical Skills in Obstetrics and Gynecology
course
c
Data reported as mean ± standard deviation

Discussion importance of anatomy, and of anatomical faculty, in

medical education. There have been calls to restore the
This paper describes how anatomy has been successfully relationship between anatomist and surgeon [17], and our
integrated into clinical preparatory electives for fourth-year courses demonstrate a successful model of partnership
medical students. Our five electives have been consistently between ana- tomists, clinicians, and surgeons.
filled, for many years, by students entering diverse disci- During this time of significant curricular change in
plines. The course evaluations have been very positive, medical education, many medical schools are working to
with many students explicitly stating in their evaluations integrate the basic sciences into clinical applications. There
that these were the best courses of their medical school is increasing recognition that the tradition curricula of
experi- ence. Students had marked improvement in 2 years of pre-clinical education followed by 2 years of
anatomical knowledge after completion of these electives. clinical course work need to be updated [9]. In addition, the
It is worth noting that students in all five electives had ACGME Milestones Project [2] initiated a formal recog-
relatively low pre-test scores, which provides additional nition of the need for medical schools to better prepare
evidence that students need a review of anatomical their senior medical students for residency competencies.
knowledge at the senior level of their medical school The importance of anatomical knowledge is specifically
experience. Students who took these electives can begin delineated in many of the specialty milestones. Applied
their residency careers with stron- ger bases of anatomical Clinical Anatomy courses can be well poised to success-
knowledge. fully integrate anatomical sciences into clinical preparatory
We are in the process of planning multiple additional senior electives. These courses can successfully reintro-
electives that build on this successful model of incorpo- duce anatomical education to senior medical students who
rating anatomy into clinical contexts for senior medical are able to integrate the anatomical knowledge as it applies
students. An Applied Clinical Anatomy for Geriatric to patient care. This suggests that anatomists can lead the
Patients will be offered in the future at our institution. This charge for better integration of basic sciences in medical
course will likely attract many medical students who are school curricular innovations.
entering non-surgical subspecialties. The further need to
develop additional courses speaks to the importance of Acknowledgments The authors wish to thank Ms. Sarah Block for
her assistance with manuscript preparation, and Dr. Clifford Craig and
anatomy in virtually all specialties of medicine.
Dr. Tamara Stein for their valuable contributions to course and cur-
It is important to acknowledge and recognize that these ricula development and teaching.
courses can be very labor intensive. Faculty need to
organize, implement, teach, and create new and innovative Compliance with ethical standards
curricula for senior medical students. The Applied Clinical
Conflict of interest The authors report no conflicts of interests.
Anatomy electives involve approximately 130–140 class-
time hours for the primary anatomical faculty (JZ). Student
comments about the anatomical faculty involved in the
courses have been extremely positive. Students appear to References
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