Anatomy teaching in United Kingdom is in crisis, new report says

BMJ 2007; 334 doi: http://dx.doi.org/10.1136/bmj.39080.510394.DB (Published 4 January 2007)
Cite this as: BMJ 2007;334:12.3

Recent rapid responses

Rapid responses are electronic letters to the editor. They enable our users to debate issues raised in articles published on bmj.com. Although a selection of rapid responses will be included as edited readers' letters in the weekly print issue of the BMJ, their first appearance online means that they are published articles. If you need the url (web address) of an individual response, perhaps for citation purposes, simply click on the response headline and copy the url from the browser window.

Displaying 1-8 out of 8 published

Stevie Gamble is quite correct to suggest that history taking is important, I have not suggested otherwise, it provides the basis of clinical medicine; she is sadly incorrect to presume this is what we mean when talking of “communication skills”. Indeed the two subjects were at least when I was a Medical School quite separate, quickly one saw which was important and which was not. I seem to have reassured her in my previous response that such abilities are not superfluous. I would have thought it quite obvious that a great many individuals in everyday life manage quite happily without rigorous training in this modern addition to the medical curriculum. As I suggested previously, it is simply akin to “teaching your granny to suck eggs”.

Is it really justifiable to cut Science teaching, specifically Anatomy but not forgetting those other sciences previously mentioned, to teach students empty notions of “communication skills”?

Similarly I would have thought it obvious that history taking is only of use when combined with (Para) medical training, so perhaps her suggestion that it be carried out by “ward clerks” is rather premature, as well as slightly condescending to people attempting to provide a useful service on the wards.

Again I have nowhere suggested there is a “finite body of knowledge” that is acquired in medical school; indeed I seem to remember specifically addressing the fact that postgraduate education in medicine is more difficult if a thorough Anatomy education is not the basis of undergraduate learning. I have quite clearly suggested that the body of knowledge one needs to acquire is vast, hardly that one can acquire it all. That’s the whole point, one must choose and prioritise, and our priorities are in the wrong place. I doubt very much whether this was the case when TH Huxley was alive or indeed the view of the good Professor, rereading the paper I previously quoted one can see this clearly.

I am sadly at a loss to see the relevance of the paper so quoted, indeed how any of us can know what was and was not taught to individuals when they did or did not attend whichever medical school they did is sadly beyond me. I suspect the evolution of pathogens is taught in medical schools to the benefit of all, this may indeed be different from years past, which one would expect. One can only wonder what benefit for humanity would be evident, if the individuals who authored the paper quoted had instead of studying pathogen evolution, had spent their time at a communication skills workshop?

Science is an open ended progressive subject. I have no doubt education will be different in future years; my concern is that it is currently going in the wrong direction.

I’m glad Mrs Gamble continues in robust health, for which she has Science to thank and the individuals who spend their time attempting to teach it to undergraduate and postgraduate students in increasingly shorter time periods whilst increasingly, time is wasted on superfluous subjects of questionable relevance and benefit.

Competing interests: None declared

Competing interests: None declared

Andy Wood, SHO Ophthalmology

Glasgow

Click to like:

27 January 2007

Andy Wood provides no evidence to support his assertion that: ' All the communication skills needed, can be found in everyday life', nor does he explain why, if this is the case, medical schools have historically devoted large amounts of their students' time to that exemplar of communication with the patient, the medical history. If Andy Wood is right then surely this could be eliminated from medical training without a qualm and left to practise receptionists and ward clerks?

Furthermore, his apparent belief that there is a finite body of relevant knowledge which can be acquired in medical school and then regurgitated at need is, alas, unfounded. There may have been in T H Huxley's day, but the world in general, and human pathogens in particular, has moved on from then. It isn't just that medical knowledge is incomplete; what have been regarded as matters of indisputable fact have been shown to be straightforwardly wrong.

Consider, for example, the situation of the doctors first caring for patients suffering from hypermutating multi-resistant lung infections.(1) Those clinicians had been taught in medical school that, as a question of fact, bacteria couldn't behave like that; the paradigm shift in microbiology was yet to come. It is greatly to their credit that, confronted with an absolute conflict between what they had been taught as fact in medical school, and the evidence, they went with the evidence.

Of course, had they pursued Andy Wood's approach I probably wouldn't be alive to argue with him…

Ms Stevie Gamble

1. Hypermutation Is a Key Factor in Development of Multiple- Antimicrobial Resistance in Pseudomonas aeruginosa Strains Causing Chronic Lung Infections María D. Maciá, David Blanquer, Bernat Togores, Jaume Sauleda, José L. Pérez, and Antonio Oliver1 Antimicrobial Agents and Chemotherapy, August 2005, p. 3382-3386, Vol. 49, No. 8 http://aac.asm.org/cgi/reprint/49/8/3382

Competing interests: None declared

Competing interests: None declared

Stevie Gamble, retired HMIT

EC2Y 8BL

Click to like:

17 January 2007

Mr Gamble can rest assured that I do not think that communication is superfluous, nor have I anywhere in the above letter suggested that it is. Neither have I suggested anywhere one should not communicate with patients, rather I have suggested that the medical Undergraduate and Postgraduate curriculum is limited in time. What is important is producing doctors who know what and how to prescribe and surgeons who know what and how to cut and not spend time teaching one’s granny to suck eggs. That limited time is better spent teaching the important sciences of Anatomy, Physiology, Pharmacology etc.

Or to quote T H Huxley, “I entertain a very strong conviction that any one who adds to medical education one iota or title beyond what is absolutely necessary, is guilty of a very grave offence.”

All the communication skills needed, can be found in everyday life and it is a “grave offence” to waste such time in the curriculum. One can only wonder at the “wry puzzlement” of one who thinks that knowing the human body in detail is not a pre-requisite for medical or surgical practice. I believe vets no longer need to know the Anatomy of horses, although they may be able to whisper to them!

References. Huxley T H On Medical Education (1870).

Competing interests: None declared

Competing interests: None declared

Andy Wood, SHO Ophthalmology

Glasgow

Click to like:

Andy Wood's conviction that communication skills are relatively unimportant to doctors provokes a degree of wry puzzlement; after all, just how does he envisage doctors taking medical histories, providing diagnoses, prescribing therapy and generally advising patients, other than by communicating with them?

The bacteria which colonise my lungs are very good at communicating with each other; fortunately my lung consultant is very good at communicating to me the risks and benefits of therapy to undermine that communication. It seems ironic that, at a time when huge tranches of research are being done on cell-to-cell communication in human pathogens, some doctors feel that communication with humans is superfluous.

Stevie Gamble

Competing interests: None declared

Competing interests: None declared

Stevie Gamble, retired HMIT

EC2Y 8BL

Click to like:

The article by Dobson (BMJ 2007;334:12 (6 January)), draws attention to current crisis in Anatomy teaching in the UK. Over the past decade there appears to have been a move away from the teaching of sciences in the preclinical years of the medical undergraduate curriculum. The result has been a cohort of undergraduates graduating with little or diminished Anatomical knowledge.

For future surgeons this means he or she has to learn from scratch what previously had been common knowledge or being required to know less to pass postgraduate exams. For those specialists in less surgically orientated fields, one may suppose this does not matter, but radiologists and cardiologists to name just two routinely use Anatomical knowledge, which may be lacking in the current educational climate.

The upside of these circumstances is that if a lack of anatomical training leads to a patient being harmed, one may call on this same cohort of young doctors to explain, why. The ultimate explanation being that they were learning how to “communicate” rather than learning the structure and physiology of their patients bodies. Which I’m sure will provide comfort to the afflicted and bereaved, although I’m less sure how successful this will be as a defence in court.

Isn't it time we as a profession stopped accepting change for changes sake and returned to what we should be good at, that being preparing the next generation of Doctors for their careers appropriately.

Teaching Anatomy is more important than teaching communication skills.

Competing interests: None declared

Competing interests: None declared

Andy Wood, SHO Ophthalmology

Glasgow

Click to like:

11 January 2007

The summary by Dobson of the article in Surgery by Andrew Raftery places emphasis on the 'recent... increase' in surgical claims to the MDU citing damage to underlying structures, presumambly because of anatomical misjudgement or lack of knowledge. However the source for these data in the Raftery report is cited as an article by Harold Ellis in which I could find no such corroboration. The inference seems to come from a 2000 article by Goodwin in the British Journal of Surgery dissecting the causes of MDU claims. However in this article Goodwin makes it clear that: "The commonest reason for compensation was damage to underlying structures (32 per cent), a figure similar to that noted in an 8-year review first performed in 1998". In other words, there was no dramatic increase between 1990 and 2000, and unless there is a further published source, there has been no evidence of a dramatic increase in such claims recently, In fact, in many medical schools in the 90's, anatomy was alive and well, and taught by dissection. So we must be careful how we attribute effects to causes, especially when the effects themselves may be difficult to trace.

Competing interests: None declared

Competing interests: None declared

Brian C Jolly, Professor

Monash University, Australia 3800

Click to like:

Roger Dobson quotes surgeon Andrew Raftery, “Reform is being driven by enthusiasm for change rather than by a rational response to the shortcomings of the traditional curriculum.” He is writing about the teaching of anatomy but, shorn of the last half of the sentence, is the problem with much that has happened in the last few years, and not just in medicine: “Reform is being driven by enthusiasm for change rather than by a rational response.”

No rule dictates that change is necessarily for the better.

Competing interests: None declared

Competing interests: None declared

Neville W Goodman, Consultant Anaesthetist

Southmead Hospital, Bristol, BS10 5NB

Click to like:

Dear Sir,

The article in the BMJ News section by Roger Dobson[1] has brought to light what many clinicians feel have felt to be true for many years now. Medical students’ curricula have had to be expanded for the addition of many different disciplines, however at the expense of the traditional subjects such as anatomy and physiology. As a result the basic building blocks for entering into acute, procedural based disciplines, such as surgery have also become weaker. Indeed there are medical schools in the UK that have done away with dissection suites and even medical schools that do not teach anatomy as a subject to undergraduates. The traditional model of didactic lectures and dissection also had its problems. Much of the anatomy that we were required to learn was esoteric and never used in the clinical setting. Maintaining and running a dissection suite needs staff, has health and safety issues and has considerable costs and learning anatomy from books is far from ideal. But at least this provided a system by which the core of anatomical knowledge was learnt and tested to a high standard at least once. Operative anatomy is rarely taught at an undergraduate level but is especially imperative to be understood prior to starting out on a surgical career particularly with the remits of patient safety, however if the foundations are weak then building from there is a difficult task. With more healthcare delivery being planned to be provided in the community and diagnostics and even minor procedures possibly being performed in primary care and by primary care physicians in the future, surely anatomy should be taught soundly to all medical students with a view that most clinicians will need to know clinical and procedural anatomy.

There has to be a balanced approach. Surgeons should be more involved in the teaching of anatomy and integrated with the anatomists and also other clinical specialists such as anaesthetists, gynaecologists and radiologists to provide a multi-speciality approach. The ownership of the dissection room should not be just to those that teach anatomy but have not used their anatomical knowledge for clinical benefit. The practicalities of maintaining large numbers of cadavers has to be balanced with cost, utilisation and usefulness of the teaching methodology adopted. New technology (such as web based learning, 3-D anatomical packages and virtual prosections) should be embraced as an adjunct to traditional methods. Ultimately, if more time and money is not spent on anatomy for students then their knowledge will always be weak. For this to be achieved there must be a shift in the medical school curricula and anatomical knowledge should be retested at clinical levels, perhaps with end of specialty examinations and a surgical anatomy component of finals. Until there is one standardized examination for all medical students in the UK, this will not be possible. Similarly for post graduates if there is not the same emphasis on learning anatomy and rigorous testing, then this will continue to mean that those that gain membership to the Royal College of Surgeons may have less anatomical knowledge to those in the past. If the UK is to produce high quality surgeons of the future then the surgeons of today must be more actively involved in teaching, reinforcing and planning anatomy teaching at both undergraduate and post graduate level.

Mr. Sanjay Purkayastha, Specialist Registrar, General Surgery

Mr. Paraskeva Paraskevas, Senior Lecturer in Surgery & Consultant General Surgeon.

Professor Sir Ara Darzi, Professor of Surgery.

Academic Surgical Unit, St. Mary’s Hospital, London & Department of Biosurgery and Surgical Technology, Imperial College, London, UK

References: 1. Dobson R. Anatomy teaching in United Kingdom is in crisis, new report says. BMJ. 2007 Jan 6;334(7583):12

Competing interests: None declared

Competing interests: None declared

Sanjay Purkayastha, Specialist Registrar

Mr. Paraskeva Paraskevas, Senior Lecturer & Consultant Surgeon, Professor Sir Ara Darzi, Professor of Surgery.

Academic Surgical Unit, St. Mary's Hospital, London W2 1NY

Click to like:

THIS WEEK'S POLL