Journal of Anatomy

J. Anat. (2019) 235, pp847--860 doi: 10.1111/joa.13023

The anatomical society core embryology syllabus for

undergraduate medicine
Jane C. Holland,1  O’Shea,3 Jane Stewart,4 Colin Ockleford5 and
Claire Smith,2 Marie
Gabrielle M. Finn6
1
Department of Anatomy, RCSI, Dublin, Ireland
2
Brighton & Sussex Medical School, University of Sussex, Brighton, UK
3
RCSI Health Professions Education Centre, Dublin, Ireland
4
Clinical Education, Newcastle University, Newcastle, UK
5
Lancaster University, Lancaster, Lancashire, UK
6
Health Professions Education Unit, Hull York Medical School, Heslington, York, UK

Abstract
A modified Delphi methodology was used to develop a consensus regarding a series of learning outcome
statements to act as the foundation of an undergraduate medical core embryology syllabus. A Delphi panel
was formed by recruiting stakeholders with experience in leading undergraduate teaching of medical students.
The panel (n = 18), including anatomists, embryologists and practising clinicians, were nominated by members
of Council and/or the Education Committee of the Anatomical Society. Following development of an a priori
set of learning outcome statements (n = 62) by the authors, panel members were asked in the first of a two-
stage process to ‘accept’, ‘reject’ or ‘modify’ each learning outcome, to propose additional outcomes if desired.
In the second stage, the panel was asked to either accept or reject 16 statements which had either been
modified, or had failed to reach consensus, during the first Delphi round. Overall, 61 of 62 learning outcome
statements, each linked to examples of clinical conditions to provide context, achieved an 80% level of
agreement following the modified Delphi process and were therefore deemed accepted for inclusion within
the syllabus. The proposed syllabus allows for flexibility within individual curricula, while still prioritising and
focusing on the core level of knowledge of embryological processes by presenting the essential elements to all
newly qualified doctors, regardless of their subsequent chosen specialty.
Key words: anatomy education; embryology education; integrated curriculum; medical education; syllabus;
undergraduate education.

has a core role in multiple additional specialities (Lee et al.

Introduction
2010; Mascio et al. 2011). Although there is currently no
The Anatomical Society has previously published core anat- consensus, or existing guidelines from regulatory bodies
omy syllabi for a range of health professions, including about the placement of embryological content within the
medicine, which was revised and updated in 2016 (Smith medical curriculum, the time dedicated to this component
et al. 2016a,b), Nursing (Connolly et al. 2018) and Pharmacy averages at around 13–14 h in undergraduate courses and
(Finn et al. 2018). Each of the previous syllabi has focused varies considerably between institutions, ranging from 0 to
on gross anatomy. This paper considers the position of 50 h (Carlson, 2002; Drake et al. 2002, 2014; Heylings, 2002;
embryology within the medical curriculum and presents an Gartner, 2003; Cassidy, 2016). Given these time constraints,
embryology syllabus for use within it. and the lack of a laboratory component in many institu-
Embryology, as a sub-discipline of anatomy, has been tra- tions (Drake et al. 2014), educators are required to make
ditionally considered primarily to be of interest to specific explicit choices about what level of content to retain within
specialities such as obstetricians and paediatricians, but an the core medical curriculum, as opposed to that best
understanding of developmental anatomy and teratology addressed within specialised postgraduate training pro-
grammes. The presented embryological syllabus seeks to
take an outcomes-based approach (Harden, 1999a), to pro-
Correspondence
Jane C. Holland, RCSI Department of Anatomy, 123 St Stephens
vide a core set of learning outcome statements (Harden
Green, Dublin 2, Ireland. E: [email protected] et al. 1999b; Kennedy et al. 2007), prioritising and focusing
on the core level of knowledge of embryological processes
Accepted for publication 1 May 2019
Article published online 20 June 2019 and presentations which is essential to all newly qualified

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848 Core embryology syllabus for undergraduate medicine, J. C. Holland et al.

doctors, regardless of their subsequent chosen specialty. previously published core syllabus for medical students
The aim of this study is to seek knowledge about a specific (Smith et al. 2016a,c) and one (C.O.) was part of the author-
subject from relevant stakeholder groups in order to ing team for the original medical undergraduate core-syl-
develop consensus for a core embryology syllabus for labus publication (McHanwell et al. 2007) from which this
undergraduate medical students. This information will aid strand of research developed that was cited in the influen-
educators when constructing and implementing their curric- tial 2009 ‘Tomorrow’s Doctors’ report of the GMC (GMC,
ula, including learning outcomes, activities and aligning to 2009).
assessments. It is also intended to aid students in their learn-
ing, providing a clear outline as to what is expected of them
Study design
as they progress through their medical curriculum.
The Delphi method is a structured methodology for This study consisted of four distinct phases; (1) pre-screen-
establishing consensus on subjects used to determine colle- ing, (2) Delphi round 1, (3) Delphi round 2, (4) post-screen-
gial knowledge from experts; this is knowledge where ing syntax editing. Setting a level of consensus for a Delphi
there exists a shared, implicit understanding of a subject by varies within the literature (Ab Latif et al. 2016) but typi-
experts, but which may not be verbalised or spoken about, cally ranges from 70 to 100%. The teaching of embryology
and the Delphi method makes this implicit knowledge can vary in both volume and design from institution to
explicit (Dalkey et al. 1969; Moxham et al. 2014; Smith et al. institution, mostly either fully or partially integrated and
2016c; Humphrey-Murto et al. 2017). There is no standard systems-based, but consensus was set at 80% to account for
approach and thus considerable variations of the method this variability (McBride & Drake, 2018).
are described throughout the literature (Boulkedid et al.
2011), but it is typically characterised by a series of inquiry
Identification of the Delphi panel
rounds to obtain the individual judgements and opinions
of a group of experts on the issue under review (Powell, Experts were identified for the Delphi panel by inviting
2003; Moxham et al. 2014). For example, one approach nominations from members of both the Anatomical Society
begins with a tabula rasa, with no pre-existing content or Council and the Education Committee. The aim was to iden-
assumptions, and all panel participants are solicited for tify 15–20 individuals for the Delphi process across a spec-
options through a series of open-ended questions, eventu- trum of expertise including: anatomists, embryologists and
ally focusing down to achieve consensus through multiple practising clinicians (Campbell et al. 1999; Akins et al. 2005;
rounds (Hasson et al. 2000). Another form, which is a modi- Boulkedid et al. 2011; Moxham et al. 2014). Nominees were
fication from the original, starts with the initial generation required to meet one of two criteria: (1) an academic with
of items for inclusion by a core group, whether from modi- responsibility for teaching embryology within an under-
fication of existing materials or a review of the relevant lit- graduate medical curriculum, with a minimum of 5 years’
erature and evidence base (Smith et al. 2016c; Humphrey- experience or (2) an active clinician who both practised
Murto et al. 2017; Finn et al. 2018). within a specialty requiring a knowledge of embryology
and had educational experience of an undergraduate medi-
cal curriculum (i.e. clinical lecturer or professorial role).
Methods and Analysis
Forty-seven nominees were identified by this process from
across the UK and Ireland (Fig. 1). Three nominees were
Ethics
found to be uncontactable by the e-mail addresses identi-
Ethical approval for this study was obtained from both the fied, and so 44 individuals were invited to take part in the
Research Ethics Committee of the Royal College of Surgeons Delphi study (Dalkey et al. 1969) of whom 17 invitees partic-
in Ireland (reference RCSI-REC1085) and the Ethics Commit- ipated in the first Delphi round, and 18 invitees in the
tee at Hull York Medical School (reference 17 08). second.

Construction of the research group Pre-screen – initial outcome screening before Stage 1

The research group included all of the present authors. Four Prior to commencing this study, there were no previously
of the researchers participated in this study due to their published embryology syllabi composed of learning out-
roles as anatomists, with specific experience of teaching come statements available to use as a starting point. Thus,
anatomy and embryology to undergraduate medical stu- we began this process by developing learning outcome
dents (G.F., J.C.H., C.O., C.S.) and on postgraduate training statements drawn primarily from syllabi of the co-authors’
courses (J.H., C.O., C.S.). Two authors (M.O’S., J.S.) were institutions (Figs 2 and 3). Fifty-nine outcomes were derived
selected due to expertise in Delphi methodology but were from the RCSI undergraduate medicine syllabus, with an
not involved in the revision of any anatomical content. additional four outcomes added from the Brighton and Sus-
Three of the authors (G.F., C.S., J.S.) had worked on the sex Medical School. A further four outcomes were then

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 Core embryology syllabus for undergraduate medicine, J. C. Holland et al. 849

Fig. 1 Delphi panel members; inclusion criteria, identification, invitation and participation.

added following a review of the literature available to the used, and also to identify potential gaps in the syllabus
authors at that time (Smith et al. 2016a; Fakoya et al. 2017). (Fig. 3). During these discussions, inclusion of 23 outcomes
These steps were undertaken by the research team in order was confirmed with no alterations, and a further 26 out-
to minimise the risk of omitting relevant content, to reduce comes were modified in some minor way, such as the
unnecessary rounds of refinement during the Delphi rounds rephrasing of an action verb, to ensure they would be easily
by removing the obviously irrelevant, or duplicated, out- understood and comply with the principles of writing clear
comes from the a priori set, and to ensure that the out- learning outcomes. For an additional eight outcomes, while
comes were written and phrased in line with current best the content of the outcomes was deemed relevant, discus-
practice (Kennedy et al. 2007). sions resulted in more major modifications to the learning
This set of 67 learning outcomes statements was systemat- outcome statement for clarity (Fig. 3). During the course of
ically reviewed and discussed by the content experts within these teleconference discussions, an additional five learning
the research group (G.F., J.H., C.O., C.S.) to ensure consensus outcome statements were proposed, debated and then
and consistency with regard to phrasing and terminology inserted to cover content not encompassed by the a priori

Fig. 2 The key stages of the Delphi process (Finn et al. 2018).

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850 Core embryology syllabus for undergraduate medicine, J. C. Holland et al.

Fig. 3 Formulation and modification of learning outcome statements during the development phase.

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 Core embryology syllabus for undergraduate medicine, J. C. Holland et al. 851

set. Nine outcomes were deemed to have content similar participant information sheet and link to the online survey.
to, or related to other learning outcome statements, and so The consent form was built into the survey and completion
were merged. While debating the relevance of this content, of the Delphi process was taken as implied consent. The
there was some discussion as to whether contextual clinical Delphi survey was open for a total of 8 weeks to maximise
information, or examples of congenital conditions, should participation, with e-mail reminders sent at 2, 4 and
be included within the learning outcome statements, or 6 weeks. Delphi panel members were asked to consider the
whether this unnecessarily increased the specificity of the learning outcomes within the draft syllabus and asked to
statements and the complexity of their phrasing; a decision consider each statement and decide whether it should be
was made to keep the phrasing of the learning outcomes included in the revised Embryology Core syllabus and, if so,
statements clear and comprehensive and, instead, to incor- in what form. Panel members were asked to accept (with-
porate specific examples or contextual information within out modification), reject or accept with suggested modifica-
an associated appendix (Finn et al. 2018). Furthermore, the tions (if a modification was proposed, panel members were
research team explicitly discussed and agreed upon the use asked to write the modification in the open comment text-
of the term fetal, as opposed to foetal, and the use of the box) was also available at the end of each section of the
term embryonic as opposed to embryological (Boyd & draft syllabus so that participants could propose additional
Hamilton, 1967). In total, 62 learning outcome statements learning outcomes for consideration. Seventeen panel
were drafted and refined during this pre-screening phase, members (39% of invitees) responded, providing a total of
and then forwarded to the panel of stakeholders for the 137 free-text comments (Table 1).
first round of this modified Delphi process for their expert Analysis and decisions were undertaken using the pro-
review and response (Figs 2 and 3). tocol developed by Smith et al. for the Core Anatomy
Syllabus (Smith et al. 2016c). All submitted free text com-
ments were reviewed and assigned to one of the follow-
Generation of the survey
ing categories (Table 1): Supportive (S), Contextual (C),
The 62 learning outcome statements were entered into Sur- Modify (M), Amend Typographical Error (ATE), Question
vey Monkey (Survey Monkey, Palo Alta, CA, USA) using an (Q), Negative/not important (N) and Not Relevant (NR).
RCSI (Health Professions Education Centre) Account. Within No learning outcome statements were rejected at this
the survey, participants were initially presented with a con- phase. All learning outcomes achieving a consensus level
sent form, which they were required to read and agree to of over 90% were accepted outright. Learning outcomes
before then continuing to proceed on to the rest of the sur- achieving a consensus level of between 81 and 90% were
vey. Next, instructions for completion of the survey and con- accepted but were modified if there were suggestions
tact information for the research team were included that might increase the level of agreement. All suggested
ahead of the outcomes for consideration. In addition, there modifications were reviewed using the rules developed
were four demographic items. Participants were asked to by Smith et al. for the Core Anatomy Syllabus (Smith
indicate their institution, their principal role and whether et al. 2016c) and discussed (following collation and
their institution specifically teaches developmental embryol- anonymisation) among the research team (J.H., C.S., G.F.)
ogy and, if so, whether this was as a stand-alone module, (Table 2).
or integrated throughout a systems-based curriculum. This
information was recorded to describe the range of expertise Stage Three: Delphi Round Two
within the panel. Learning outcomes were presented in sec- The revised syllabus was recirculated to the Delphi panel-
tions (one focused on terminology, the remaining nine on lists, in the same manner as for Delphi Round One, being
body systems). For each of the learning outcomes, check open for a total of 8 weeks followed by e-mail reminders
boxes were provided for the panel members to record their after 2, 4 and 6 weeks (Fig. 2). Members were asked to
decisions at each of the two stages. Text-boxes were pre- review 16 learning outcome statements and associated clini-
sented with each outcome to enable panel members to cal context examples which had not yet reached consensus
record their suggested modifications. Following each sys- in the first round, and to either accept these learning out-
tem, a free-text box was also provided for panel members comes without modification or reject them outright. The 46
so that they could, if they wished, record the reasons for learning outcomes which achieved consensus during Delphi
their decisions or any other comment relating to the out- Round One were included in the survey, so that panel mem-
comes being reviewed. Prior to the survey being made live, bers could identify them as being part of the syllabus and
the data-collection form was checked and piloted by the identify potential gaps or duplication, but no further input
research team. was sought regarding their inclusion (Smith et al. 2016c).
However, free-text comments were still permissible for all
Stage Two: Delphi Round One 62 learning outcome statements, and 225 were received
Participants who had been identified as potential panel (Table 1). Potentially, some minor amendments (other than
members were emailed an invitation to participate, a accept/reject) that could be considered in response to

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852 Core embryology syllabus for undergraduate medicine, J. C. Holland et al.

Table Examples of free-text comments

Delphi Round One Delphi Round Two

Comment
classification n = 137 Example(s) n = 225 Example(s)

Supportive (S) 14 182

• All of the above are extremely relevant • Yes
to clinical practice, e.g. prescribing in • Accept
pregnancy, ectopic and miscarriages, • Essential for O&G and paediatrics
understanding multiple pregnancies,
prenatal screening and infertility
• All of this very important in paediatrics
and neonatal. Essential for the
understanding of cardiac problems at
birth
Contextual (C) 10 4
• We also use cut-off of viable/non- • This is not specific to embryology
viable (i.e. < 23 weeks or thereafter) as • Maybe the actual stages of
working in neonatology spermatogenesis not in depth, just
• Point 25 is, in my view, troublesome know causes of low and azoospermia
knowledge that is very challenging to and treatment – this would be taught
teach well. by a clinician and not require in depth
• This is becoming increasingly difficult knowledge
to teach as time pressures in the
curriculum increase
Modify (M) 102 22
• Avoid use of twisting spiral which • Not clear what ‘main stages’ are from
over-eggs it! simply need to refer to outcome alone. Name stages in
modified segmental pattern of outcome or ‘Describe stages of
dermatomes due to flexion of limbs, spermatogenesis’
though different in UL and LL • Modify
• Clinical context – anal atresias • Additional clinical context: derivatives
of neural crest
Amend 6 2
Typographical • Primitive not primative • Spelling mistake on metastases
Error (ATE)
• It is neurulation not neuralation • Small typo noted – 2) at end of clinical
context
Question (Q) 5 5
• I know very few students (and • Do you mean genetic conditions
academics) who truly understand this. I associated with sexual differentiation?
wonder if we should provide the basic • Epigenetic factors may be beyond the
principles of peritoneal development, scope of the course?
and just describe the lesser sac in the • Surely the significant clinical context is
adult? understanding the innervation of the
• What do you mean by brain barriers? diaphragm and the sequelae of cervical
spinal injury?
Negative/not 0 6
important • This would be part of an O&G
curriculum not needed within an
embryological curriculum
• Not a priority.
• Not so sure that detailed explanation
around syndrome/non syndrome
needed at undergraduate level
Not relevant 0 4 N/A

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Table 2 Rules developed by Smith et al., for the Core Anatomy Syllabus (Smith et al. 2016c)

1 If all, or the majority of, comments suggest a particular change, then the learning outcome will be modified accordingly.
2 If contradictory comments are being made, then discussion between the research team members will be used to decide which
changes should be adopted and which rejected. The basis of these decisions should be ensure clarity and reduce repetition.
3 In situations where one comment is felt by the research team to be especially apt, even if no other panel members’ comments
match, then this single comment could be used to modify a learning outcome.
4 Where a panel member makes a comment regarding inconsistency in terminology relating to a small number of learning
outcomes, then the research team will discuss whether this inconsistency should be addressed across the whole syllabus and
changes made.
5 Anatomical terminology follows the guidelines laid out in Terminologia Anatomica (1998).
6 All decisions are recorded.
7 These rules are applied, recognising that all changes will receive further scrutiny in Stage 3. Where any change results in lower
levels of consensus being achieved, then the research team will restore the original learning outcome.

comments at this stage included removal of any duplicate requesting removal or simplification of the outcome state-
content, and correction of grammatical or typographical ment and others suggesting that more detail be included
errors. (Fig. 4).

Delphi Round Two results

Post-screen – final proofing post Delphi
Sixteen learning outcome statements were put to the Del-
The final step in this process was a review by the research phi panel for final review, as they either had not reached
group of the final list of learning outcome statements to the 80% acceptance rate in the first Delphi round and/or
ensure that no typographical or grammatical errors existed had been modified following feedback from Round 1, and
in the final draft (i.e. tetraology/tetralogy, outlline/outline). members were asked to either simply accept or reject these
statements. Forty-four invitations were sent to the panel
nominees; 18 nominees participated, providing responses
Results
and comments. The 46 learning outcomes which achieved
consensus during the first Delphi round were included so
Delphi panel demographics and participation rates
that panel members could identify them as being part of
Seventeen nominees participated in the Delphi panel dur- the syllabus (Fig. 4). However, free-text comments were still
ing Round 1, and 18 in Round 2. The majority of respon- permissible for all 62 learning outcome statements, and 225
dents to Round 1 and Round 2 were primarily identified were submitted (Table 1). At this stage, 15 of the 16 learn-
either as anatomists (n = 10), or clinicians (n = 9), from ing outcome statements were accepted, with one rejection,
across the UK or Ireland, with most institutions teaching resulting in a total of 61 learning outcome statements
embryology within integrated (systems-based) curricula. included in the final syllabus (Figs 3 and 4), along with sug-
gestions for clinically relevant contextual information
(Table 3).
Results for each Delphi stage
Figure 2 provides a summary of the overall number of
learning outcomes reviewed at each stage of syllabus devel- Discussion
opment and the number of outcomes retained following
The Anatomical Society is the first to combine an outcomes-
each of these stages.
based approach with the rigour of a structured Delphi
methodology (Harden, 1999a; Kennedy et al. 2007; Mox-
Delphi Round One results
ham et al. 2014). The utilisation of a Delphi methodology
Sixty-two learning outcome statements were put to the Del-
throughout this process, with consultation across diverse
phi panel for review during this first round. Forty-four invi-
stakeholder groups, ensures this syllabus should strike a bal-
tations were sent to the panel nominees; 17 nominees
ance of being both inclusive of all necessary core content,
participated, providing responses to the learning outcome
while retaining the flexibility to be generally applicable
statements, including suggesting additions and/or modifica-
across varied educational contexts and institutions (Mox-
tions, and contributing a total of 137 free-text comments
ham et al. 2014). One potential limitation of the study is
(Table 1). Nine learning outcomes statements achieved a
that of the panel size, with 17 and 18 respondents to Delphi
lower level than the pre-agreed consensus level of 80%; of
Rounds One and Two, respectively. Nonetheless, the priority
these, six were modified (Smith et al. 2016c), with three
of a Delphi is to ensure that participants or panel members
remaining unchanged, as comments and suggestions for
are chosen because of expertise in their field; when then
modification were contradictory, with some panellists

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854 Core embryology syllabus for undergraduate medicine, J. C. Holland et al.

Table 3 Contextual information to support the integration of outcomes into the curriculum

Learning
Outcome Clinical context/condition/procedure/system

Anatomical terminology
1 Frequently used when describing relationships
2 Important for understanding 2-dimensional images of 3-dimensional structures
3 Essential terms and definitions for embryology and congenital conditions; principles of teratology, including
infectious and environmental
Gametogenesis to placentation
4 Non-disjunction, translocations or deletions (Down’s syndrome; Klinefelter’s syndrome)
5 Contraception, infertility, assisted reproduction (IUI, GIFT, IVF, ICSI)
6 Infertility, assisted reproduction (IUI, GIFT, IVF, ICSI)
7 Contraception; multiple pregnancies
8 Ectopic pregnancy; contraception; placental morphology and adherence
9 Germ cell layers
10 Umbilical cord morphology and development
11 Placental morphology and adherence
12 Oxytocin and myometrial contractility; steroids and uterine perfusion; placental transfer of drugs
13 Placental morphology and abnormalities; multiple pregnancies; inspection of afterbirth (cotyledon retention,
cordal vessels); hydatidiform moles
14 Oligohydramnios and polyhydramnios; amniocentesis; rupture of membranes; pulmonary hypoplasia
Trilaminar disc and early embryonic period
15 Situs inversus; caudal dysgenesis
16 Spina bifida;
17 Vertebral fusions; hemivertebrae; scoliosis
18 Pericardial, pleural and peritoneal cavities
Musculoskeletal system
19 Micromelia; syndactyly; club foot
20 Bone age; epiphyseal pathology (i.e. fusion, fracture, slipped)
21 Innervation; muscular agenesis (i.e. pectoralis major)
22 Clinical examination
23 Abnormalities such as meromelia, phocomelia, polydactyly; teratogenicity (e.g. thalidomide)
Cardiovascular system
24 Haemopoeisis
25 Malrotation & dextrocardia
26 Ventricular and atrial septal defects;
27 Tetralogy of Fallot; co-arctation of the aorta; transposition of the great vessels; aortic arch remnants and variants;
28 Patent ductus arteriosus
Respiratory system and diaphragm
29 Bare area of the liver and implications for metastases
30 Diaphragmatic hernias
31 Tracheo-oesophageal defects (fistula, atresia)
Gastrointestinal system
32 Endodermal intestine; vitelline fistula
33 Implications for metastases; mesenteric ischaemia; abdominal pain
34 Pyloric stenosis or atresia
35 Lesser sac anatomy; epiploic foramen (of Winslow)
36 Accessory spleen
37 Mesodermal and endodermal components within the liver; biliary atresia; variable biliary tree anatomy
38 Pancreas divisum, annular pancreas, variable anatomy of the duodenal papillae
39 Duodenal and intestinal atresias; malrotations; omphalocele; gastroschisis
40 Meckel’s diverticulum; vitelline fistula; vitelline cyst
41 Cloacal abnormalities (fusion, fistulae)
42 Contrasting histological and anatomical features; anal atresias
Genitourinary system
43 Renal dysplasia, agenesis, polycystic kidneys
44 Pelvic kidneys; horseshoe kidney
45 Undescended testes; maldescended testes; testicular tumours; infertility

(continued)

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Table 3 (continued)

Learning
Outcome Clinical context/condition/procedure/system

46 Duplex ureters
47 Uterine malformations (bicornis; bicornis unicollis; didelphys)
48 Patent urachus; urachal cyst or fistula; exstrophy of the bladder
49 Hypospadias; epispadias; environmental oestrogens and anti-androgens; congenital adrenal hyperplasia;
ambiguous genitalia
50 Turner syndrome; disorders of sexual development
Head and neck
51 Branchial cysts and fistulae
52 Microglossia; macroglossia; ankyloglossia (fusion of lingual frenulum)
53 Thyroglossal cyst or fistula; pyramidal lobe
54 Cleft lip; cleft palate
55 Coloboma; Persistent pupillary membrane (PPM)
56 Congenital hearing loss, both syndrome and non-syndrome
57 Physical examination of fontanelles; microcephaly; craniosynostosis; meningocele; hydrocephalus diagnosis
Central nervous system and endocrine system
58 Facial development; adrenomedullary cells; pigment cells; Hirschsprung’s disease; carcinoid (neuroendocrine
tumours)
59 Spina bifida; anencephaly
60 Hydrocephalus; anencephaly; toxicity; transfer of drugs
61 Parathyroid glands; activation of HPG axis; minipuberty; ectopic or accessory adrenal tissue

identifying experts at the intersection of education and As an academic and clinical Obstetrician and
such a specialised discipline as embryology, this can be a Gynaecologist I am very concerned about the
small, select field. The panel members within this study met reduced teaching in Embryology and its long term
rigorous inclusion criteria, with representation from both implications
career anatomists and clinical colleagues. Furthermore, the
Although developmental or embryological syllabi have
final number of panel members compares well when con-
been previously published (Leonard et al. 2000; Fakoya
sidering previous reviews of Delphi studies which report
et al. 2017; Das et al. 2018), the number of components
that a median of 17 individuals (range 3–418) are typically
within each of these means that they are incredibly detailed
invited to participate as panel members, with median
and granular, essentially listing all possible processes; the
response rates typically around 88–90% (Boulkedid et al.
syllabus published by Fayoka et al. is a list of over 250
2011).
topics, while Leonard et al. list over 700 (Leonard et al.
Embryology as a separate sub-discipline and course has
2000; Fakoya et al. 2017). Although that published by Das
largely been superseded by integrated systems-based mod-
et al. for the Liaison Committee for Medical Education
ules within many curricula, primarily delivered via large
(LCME) and the Commission on Osteopathic College Accred-
group lectures, with an average of 14 course hours
itation (COCA), is written in the form of learning outcome
(McBride & Drake, 2018). The time that can be devoted to
statements, aims and competencies, it is still extensive, with
teaching embryology within current curricula is limited,
over 200 primary or secondary level outcomes (Das et al.
having reduced rapidly between 1955 and 1973, and
2018). However, we know from the literature that the aver-
remaining at or under an average 20 h since (Gartner, 2003;
age teaching time for embryology in most curricula is only
Drake et al. 2009; McBride & Drake, 2018). Conversely, our
13 or 14 h – so how many institutions truly have time to
understanding of related aspects such as genetics and epi-
teach all 700 items on the list (Heylings, 2002; Drake et al.
genetics has advanced substantially, and fetal surgical inter-
2014)? What should they include, and what should they
ventions, both open and fetoscopic, are rising (Carlson,
omit from these lists if needing to “cut their cloth” to the
2002; Chirculescu & Morris, 2008; Deprest et al. 2010; Drake
allotted time? So, the aim of the Anatomical Society has
et al. 2014; Cassidy, 2016). Educators are required to make
been to develop a syllabus of learning outcome statements
explicit choices about what content to retain and what may
advising on what is absolutely core for undergraduate stu-
be omitted, and a number of our panel members specifi-
dents to know. The clinical correlates may or may not be
cally commented on time constraints with regard to teach-
used as examples of each of these processes, allowing for
ing of embryology within their own programmes.

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856 Core embryology syllabus for undergraduate medicine, J. C. Holland et al.

Fig. 4 Development and modification of learning outcome statements and clinical context amendments during Delphi rounds One and Two. [Col-
our figure can be viewed at wileyonlinelibrary.com]

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 Core embryology syllabus for undergraduate medicine, J. C. Holland et al. 857

flexibility between curricula, while still providing some students upon graduation, to demonstrate a basic level of
guidance or suggestions should course directors wish to competence in the embryology:
expand on outcomes in more detail. For those who have
the time and desire to incorporate more extensive embry-
Anatomical terminology
ological content into their curricula, perhaps as student-
selected modules, would be advised to revert to the previ- 1 Define the anatomical terms cephalic/cranial, rostral/
ously published syllabi in these circumstances. caudal, anterior/ventral and posterior/dorsal in rela-
During the course of the study, the research team explic- tion to embryology
itly discussed variant terminology, such as foetal vs. fetal. 2 Describe the following basic anatomical planes: axial/
While the use of terms such as fetal and fetus is more gram- transverse/horizontal, sagittal and coronal
matically correct upon exploring their derivation from Latin 3 Define the following terms: gamete (pre-embryo),
and the historical records on this matter (Boyd & Hamilton, embryo, fetus, trimesters of pregnancy, teratogen,
1967), the use of anatomical terms such as oesophagus dif- mutagen
fers according to geographical location. So, while we have
adopted the use of terms such as haemopoeisis (vs. he-
mopoeisis or haematopoiesis) and oesophagus within our Gametogenesis to placentation
syllabus, these may be modified according to local use and 4 Explain the process of gametogenesis in males and
grammar. Additionally, while there were a few edits in the females, and how common consequences of abnor-
two Delphi phases with regard to the action verbs utilised mal gametogenesis such as non-disjunction, translo-
in the learning action statements, individual institutions cations or deletions occur
may wish to tailor these for internal consistency within their 5 Describe the main stages, and hormonal control, of
local context, when embedding them within their curricula. follicular development and ovulation within the ovar-
Alongside this provision of a core set of learning outcome ian cycle
statements, we have also developed a list of relevant clinical 6 Describe the main stages of spermatogenesis
conditions, linked to each outcome, which may be used as 7 List the processes and phases of fertilisation, cleavage
optional examples to introduce clinical context during and zygote development up to and including blasto-
teaching activities, appropriate to individual institutional cyst formation
curricula (Finn et al. 2018). Regulatory frameworks such as 8 Describe blastocyst implantation and trophoblastic
the GMC outcomes for graduates require an understanding invasion of the uterine endometrium, with regard to
of basic sciences and the ability of a doctor to translate that placental development and function
knowledge into clinical practice (GMC, 2009). The embryol- 9 Describe the two layers (epiblast, hypoblast) and the
ogy syllabus is designed with this in mind, to enable junior specified cavities (amniotic, exocoelomic/primitive
doctors to be able to underpin common conditions that yolk sac) of the early conceptus
have embryological origins. 10 Describe the development of the chorionic (extra-
While the vast majority of our learning outcome state- coelomic) cavity, secondary yolk sac and umbilical
ments were retained by the panel, albeit with some modifi- cord
cations, the one learning outcome that was rejected was 11 Summarise the development and endocrine function
that of venous embryology; while some adult remnants are of the placenta in the first, second and third trime-
visible and relevant to (and thus covered by learning out- sters of pregnancy
comes on) fetal circulation, for minutiae regarding subcardi- 12 Describe the functional anatomy of the uterine and
nal vein development, while interesting for specialists fetal-maternal circulation and the placental ‘barrier’
wishing to gain insight into renal venous asymmetry, time is 13 Explain how abnormalities of implantation and pla-
perhaps better spent on more clinically relevant priorities. cental development occur
Thus, the following syllabus allows for flexibility within indi- 14 Discuss the structure and role of the amnion and
vidual curricula, while still prioritising and focusing on the amniotic fluid
core level of knowledge of embryological processes and
presentations which is essential to all newly qualified doc-
tors, regardless of their subsequent chosen specialty. Trilaminar disc and early embryonic period
15 Describe the embryonic process of gastrulation and
The Anatomical Society core embryology the origin of the new germ layer (mesoderm) formed
syllabus for undergraduate medical students during this process
The Anatomical Society and the expert Delphi panel of 16 Explain the embryonic processes of neurulation, and
anatomy and medical educators recommend that the fol- the development of the neural tube and neural crest
lowing learning outcomes should be achieved by all cells

© 2019 Anatomical Society

858 Core embryology syllabus for undergraduate medicine, J. C. Holland et al.

17 Outline the process of mesodermal differentiation, derivatives, and name the mesenteric attachments
and the subsequent development of somitomeres and blood supply to each part
and somites 34 Describe the development of the stomach and its
18 Describe embryonic folding and the development of musculature, and identify abnormalities of develop-
the intraembryonic, or coelomic, cavity, and discuss ment such as pyloric stenosis or atresia
the consequences and significance of this process 35 Describe the development of the greater and lesser
omenta and explain how rotation of the stomach
contributes to the formation of the omental bursa
Musculoskeletal system
(or lesser peritoneal sac)
19 Describe the germ layers and steps involved in limb 36 Describe the development of the spleen and explain
development its haemopoietic function in the embryo
20 Compare and contrast the processes of endochondral 37 Describe the origin of the liver bud and the develop-
and intramembranous ossification of bone ment of the liver, biliary tree and gallbladder.
21 Explain how limb muscles develop and migrate to 38 Describe the formation of the pancreas and its ducts,
the limb buds, and how these muscles then become from ventral and dorsal buds
positioned with respect to dorsal and ventral surfaces 39 Explain the development of the midgut, including
of the limbs physiological herniation, rotation and retraction
22 Describe the formation and pattern of the upper and 40 Describe the role of the vitelline duct in midgut
lower limb dermatomes development and how it may abnormally
23 Identify some of the more common congenital limb persist and pathologically present in the neonate
abnormalities and explain how they occur. or adult
41 Describe the division of the cloaca with regard to the
development of the hindgut and upper anal canal
Cardiovascular system
42 Compare and contrast the origins, development and
24 Identify the sites of haemopoeisis in the embryo, associated features of the upper and lower sections
including during the yolk sac, hepatic and myeloid of the anal canal
periods
25 Summarise how the primitive heart tube develops
Genitourinary system
into the adult, four-chambered heart
26 Describe the normal processes of atrial and ventricu- 43 Outline the stages of development of the urinary sys-
lar septation, and explain the development, physiol- tem within the embryo, including pro-, meso- and
ogy and clinical presentation of conditions such as metanephros
septal defects or patent foramen ovale 44 Describe the development and ascent of the kidneys
27 Describe the normal development and potential con- and the clinical conditions that may arise from
genital malformations of the conus cordis, truncus abnormal development
arteriosus and aortic arches 45 Describe the processes of sex differentiation and
28 Compare and contrast the pre-and postnatal circula- gonadal development within the male and female
tions, and explain how these changes at birth occur embryo, including ovarian and testicular descent
46 Compare and contrast the development of the meso-
nephric and paramesonephric ducts in males and
Respiratory system and diaphragm
females
29 Describe the septum transversum and name its 47 Explain the development of the paramesonephric
derivatives in the embryo and adult duct and uterine development in the female, and the
30 Describe the development of the diaphragm and main abnormalities that may occur
explain how congenital defects and hernias occur 48 Describe the roles of the allantois and cloaca with
31 Describe the embryonic development of the trachea, regard to urogenital embryology, and explain how
oesophagus and lungs abnormal development of these structures may lead to
conditions such as patent urachus or internal fistulae
49 Describe development of the external genitalia and
Gastrointestinal system
perineum in males and females and how common
32 Summarise how embryonic folding leads to forma- abnormalities occur
tion of the primitive gut tube, and describe its com- 50 Outline the major chromosomal, genetic and epige-
munication with the yolk sac netic factors influencing sexual differentiation and
33 Identify the three parts of the primitive gut tube determination, and explain how genetic conditions
(foregut, midgut and hindgut) and their adult are diagnosed and treated

© 2019 Anatomical Society

 Core embryology syllabus for undergraduate medicine, J. C. Holland et al. 859

Akins RB, Tolson H, Cole BR (2005) Stability of response charac-

Head and neck teristics of a Delphi panel: application of bootstrap data
51 Describe the development of the pharyngeal arches, expansion. BMC Med Res Methodol 5, 37.
Boulkedid R, Abdoul H, Loustau M, et al. (2011) Using and
and name both the normal adult derivatives and
reporting the Delphi method for selecting healthcare quality
potential clinical abnormalities (i.e. cysts or fistulae) indicators: a systematic review. PLoS ONE 6, e20476.
that may result from abnormal development Boyd JD, Hamilton WJ (1967) Foetus – or Fetus? BMJ 1, 425–425.
52 Describe the formation of the tongue, including Campbell SM, Hann M, Roland MO, et al. (1999) The effect of
mucosa, muscles and innervations panel membership and feedback on ratings in a two-round
53 Describe the development of the thyroid gland, asso- Delphi survey: results of a randomized controlled trial. Med
ciated structures and developmental abnormalities Care 37, 964–968.
Carlson BM (2002) Embryology in the medical curriculum. Anat
such as thyroglossal cyst or fistula
Rec 269, 89–98.
54 Explain palatal and facial development, and identify Cassidy KM (2016) Embryology in medical education: a mixed
the various forms of cleft lip and palate that may methods study and phenomenology of faculty and first year
result from abnormal fusion of the embryonic facial medical students. Faculty of the University Graduate School in
processes partial fulfillment of the requirements for the degree Doctor
55 Describe the embryonic development of the eye and of Philosophy in the Department of Anatomy and Cell Biol-
related extra-ocular structures, and explain how con- ogy, Indiana University.
Chirculescu A, Morris J (2008) The curriculum in anatomy for
ditions such as coloboma may develop
medical students: UK and Irish responses to the ASGBI ques-
56 Describe the embryonic development of the ear, tionnaire. J Anat 213, 348.
from ectodermal and endodermal origins, and sum- Connolly SA, Gillingwater TH, Chandler C, et al. (2018) The
marise how conditions such as congenital deafness Anatomical Society’s core anatomy syllabus for undergraduate
may arise nursing. J Anat 232, 721–728.
57 Describe the development of the fetal skull and the Dalkey NC, Brown BB, Cochran S (1969) The Delphi Method: An
functional significance and use of the fontanelles in experimental Study of Group Opinion. Santa Monica: Rand
Corporation.
physical examination.
Das M, Claeson KM, Lowrie DJ, et al. (2018) A guide to compe-
tencies, educational goals, and learning objectives for teach-
ing human embryology in an undergraduate medical
Central nervous system & endocrine system education setting. Med Sci Educator 28, 417–428.
Deprest JA, Devlieger R, Srisupundit K, et al. (2010) Fetal sur-
58 Describe how neural crest cells migrate from the neu-
gery is a clinical reality. Semin Fetal Neonatal Med 15, 58–67.
ral tube, and outline the functional roles that they
Drake RL, Lowrie DJ, Prewitt CM (2002) Survey of gross anat-
perform in their target destinations (cranial, trunk, omy, microscopic anatomy, neuroscience, and embryology
cardiac and vagosacral). courses in medical school curricula in the United States. Anat
59 Describe spinal cord development and neural tube Rec 269, 118–122.
defects Drake RL, McBride JM, Lachman N, et al. (2009) Medical educa-
60 Outline the development of the primary brain vesi- tion in the anatomical sciences: the winds of change continue
to blow. Anat Sci Educ 2, 253–259.
cles and the blood-brain barrier (prosencephalon,
Drake RL, McBride JM, Pawlina W (2014) An update on the sta-
mesencephalon and rhombencephalon)
tus of anatomical sciences education in United States medical
61 Describe the development of the endocrine glands schools. Anat Sci Educ 7, 321–325.
(e.g. pituitary, adrenal) Fakoya FA, Emmanouil-Nikoloussi E, Sharma D, et al. (2017) A
core syllabus for the teaching of embryology and teratology
to medical students. Clin Anat 30, 159–167.
Acknowledgements Finn GM, Hitch G, Apampa B, et al. (2018) The Anatomical Soci-
ety core anatomy syllabus for pharmacists: outcomes to create
This project was supported and funded by the Anatomical Soci-
a foundation for practice. J Anat 232, 729–738.
ety. The authors wish to express their gratitude to everyone
Gartner LP (2003) Anatomical sciences in the allopathic medical
involved, especially the anatomy and medical educators who
school curriculum in the United States between 1967–2001.
participated as Delphi panellists from higher education institu-
Clin Anat 16, 434–439.
tions across the United Kingdom and Ireland in developing the
GMC (2009) Tomorrow’s Doctors; Outcomes and standards for
recommended syllabus.
undergraduate medical education. [Accessed 11/12/2018].
Harden RM (1999a) AMEE Guide No. 14: outcome-based educa-
tion: part 1 – An introduction to outcome-based education.
References Med Teach 21, 7–14.
Harden RM, Crosby JR, Davis MH, Friedman M (1999b) AMEE
Ab Latif R, Mohamed R, Dahlan A, Nor MZM (2016) Using Del-
Guide No. 14: outcome-based education: part 5-from compe-
phi technique: making sense of consensus in concept mapping
tency to meta-competency: a model for the specification of
structure and multiple choice questions (MCQ). Educ Med J 8,
learning outcomes. Med Teach 21, 546–552.
89–98.

© 2019 Anatomical Society

860 Core embryology syllabus for undergraduate medicine, J. C. Holland et al.

Hasson F, Keeney S, McKenna H (2000) Research guidelines for McBride JM, Drake RL (2018) National survey on anatomical
the Delphi survey technique. J Adv Nurs 32, 1008–1015. sciences in medical education. Anat Sci Educ 11, 7–14.
Heylings DJA (2002) Anatomy 1999–2000: the curriculum, who McHanwell S, Davies D, Morris J, et al. (2007) A core syllabus in
teaches it and how? Med Educ 36, 702–710. anatomy for medical students – Adding common sense to
Humphrey-Murto S, Varpio L, Gonsalves C, et al. (2017) Using need to know. Eur J Anat 11, 3–18.
consensus group methods such as Delphi and Nominal Group Moxham BJ, Plaisant O, Smith CF, et al. (2014) An approach
in medical education research. Med Teach 39, 14–19. toward the development of core syllabuses for the anatomical
Kennedy D, Hyland A, Ryan N (2007) Writing and Using Learning sciences. Anat Sci Educ 7, 302–311.
Outcomes: A Practical Guide. Cork: University College Cork. Powell C (2003) The Delphi technique: myths and realities. J Adv
Lee NK, Kim S, Jeon TY, et al. (2010) Complications of congeni- Nurs 41, 376–382.
tal and developmental abnormalities of the gastrointestinal Smith CF, Finn GM, Stewart J, et al. (2016a) The Anatomical
tract in adolescents and adults: evaluation with multimodality Society core regional anatomy syllabus for undergraduate
imaging. Radiographics 30, 1489–1507. medicine. J Anat 228, 15–23.
Leonard R, Hoos P, Agur A, et al. (2000) A clinical anatomy cur- Smith CF, Finn GM, Stewart J, et al. (2016b) Letter to editor: a
riculum for the medical student of the 21st century: develop- new core gross anatomy syllabus for medicine. Anat Sci Educ
mental anatomy. Clin Anat 13, 17–35. 9, 209–210.
Mascio CE, Pasquali SK, Jacobs JP, et al. (2011) Outcomes in adult Smith CF, Finn GM, Stewart J, et al. (2016c) Anatomical Society
congenital heart surgery: analysis of the Society of Thoracic Sur- core regional anatomy syllabus for undergraduate medicine:
geons Database. J Thorac Cardiovasc Surg 142, 1090–1097. the Delphi process. J Anat 228, 2–14.

© 2019 Anatomical Society