Abstract
Due to lack of objective data, the benefits of using plastination in combination with wet dissection in teaching gross anatomy are unknown. The aim of this study was to obtain objective evidence from students regarding the effectiveness of combining plastinated specimens (PS) with an established gross anatomy education program at Cambridge University that uses wet cadaver dissection and small-group tutorials. For a complete academic year, a total of 135 PS were used alongside wet cadaver dissections. The PS were also available for small-group tutorials. An anonymous closed questionnaire, using a 5-point numerical-estimation Likert scale, was used to gather information relating to the effectiveness of the PS.
The level of student satisfaction with the combined use of wet dissections and PS was high, although higher (p<.05) for second-year students (98.4%) than for first-year students (95.5%). Students felt the specimens allowed them to see details that were often more difficult to identify in their dissections, for instance nerves. Voluntary use of PS was higher (p<.01) for second-year students (96.9%), who had previously experienced anatomy teaching with cadaver dissection alone, than for first-year students (77.7%). Overall, 97.7% of all students thought that the PS helped them understand and learn anatomy. All students surveyed (100%) recommended the use of PS in the future. Students considered the use of PS in the dissection room combined with wet cadaver dissection to be beneficial when learning anatomy, particularly when combined with their use during small-group tutorials.
With the reduction of time dedicated to gross anatomy, the use of prosections has started to replace classical full-body dissection; this reduces the number of contact hours while still allowing exposure to structures students would otherwise have spent time dissecting.1 However, anatomy is still taught mainly using dissection in combination with physical models developed to support and complement traditional anatomy teaching. Contribution of physical simulators to students' skills and anatomic knowledge development have been investigated for teaching bovine abdominal anatomy,2–4 feline abdominal palpation,5 canine cranial cruciate ligament rupture,6 injecting the jugular vein in horses,7 canine prostate palpation,8 etc. A major limitation of most simulators, models, and textbooks is that they present a single idealized morphology.9 Plastinated specimens (PS) are anatomically accurate, easily handled models that can offer an opportunity to develop a mental map of the body in three dimensions, incorporating normal anatomic variations. PS have been used as a resource to improve the quality of teaching and learning in gross anatomy as well as in other subjects such as pathology.10–12
The plastination method consists of slowly replacing, under vacuum, tissue fluids and a portion of the tissue lipids with a polymer.13 The results are real biological specimens that are clean, dry, odorless, and durable. They can be handled without gloves and do not require any special storage conditions or care. Plastination keeps dissected specimens from deteriorating, thus providing time to prepare new specimens to be added to the anatomic collection. In recent years, plastination has begun to revolutionize the way human and veterinary gross anatomy are presented to students.
The inclusion of PS as a resource in teaching anatomy is now common.14,15 Plastination has been described as the anatomic technique of the century, without which it will be difficult to innovate in anatomy teaching.
The University of Cambridge (UK) has broad experience in teaching and education, and its system is recognized as one of the best in the world. A rigorous student selection process based on academic background and a teaching methodology combining university facilities with college teaching support ensure the success of this higher education system. However, the Department of Physiology, Development and Neuroscience has never used PS to teach anatomy. In comparison, the University of Murcia (Spain) has extensive experience in the design, development, and use of PS in the teaching–learning process of anatomy.16–19 An educational innovation project (covering a complete academic year) was therefore proposed to enable experience sharing between these two universities.
Several papers have evaluated the quality of the learning experience using PS for anatomic teaching.20–22 However, these assessments used plastination in specific practicals only or as a replacement for wet cadaver dissection.
The hypothesis of the present study was that, from the students' perspective, introduction of PS to an established gross anatomy education program using classical methods such as wet cadaver dissection and small-group tutorials would be advantageous to their learning process.
The aim of this study was to examine learners' perspectives by exploring how first- and second-year veterinary students perceived the use of plastinated anatomic prosections, not only during wet cadaver dissection in their anatomy practicals, provided centrally by the university, but also in the small-group tutorials that are an important feature of a Cambridge undergraduate education.
This study was conducted at the Cambridge Veterinary School. It was run throughout the academic year (2014–2015) as part of the established undergraduate curriculum of the first-year program (67 students; Veterinary Anatomy and Physiology [VAP]) and the second-year program (64 students; Veterinary Reproductive Biology [VRB] and Comparative Vertebrate Biology [CVB]). The biological material was processed by the standard S10 method13,23 in the Plastination Laboratory of the School of Veterinary Medicine, University of Murcia.
After discussion with the staff, a collection of 135 PS from different species—including isolated organs and prosections of specific regions such as body cavities and head, neck, and body sections—were selected to complement the content of 26 practicals. Specimens were accessible during each practical session alongside wet cadavers in the dissection room. The PS selected for each practical were located in a central area of the dissection room and were introduced to the students at the beginning of each session to encourage their use. Outside the practicals, students had free access to the PS in the department's Veterinary Anatomy Museum, where they could be used during tutorial meetings with their supervisors.
Students filled out an anonymous closed questionnaire (Appendix 1) to provide information on the effectiveness of the PS as an anatomic learning resource. The first 10 questions used a 5-point Likert scale. Questions 1 to 5 related to the use of PS during the practicals in the dissection room, and questions 6 to 10 referred to their use after practical sessions and during tutorials. In question 11, they were asked if they would recommend the use of plastination the following year. The questionnaire also included a free-text section that asked students to comment on the use of PS in the future.
Members of the veterinary anatomy academic staff were involved in the design of the project. Although academic staff were not formally surveyed at regular meetings throughout the year, they were able to express their opinions on the value of teaching with PS and on using PS in the future.
Statistical analysis was carried out with SPSS 19.0 software (SPPS Inc). Quantitative data from the questionnaires were analyzed using descriptive statistics and the ANOVA for comparisons of answers between groups (VAP versus VRB-CVB).24 A value of p<.05 was considered significant.
A total of 131 students responded to the questionnaire, with a response rate of 100%. The results obtained for each question in both groups of students (first- and second-year students) are shown in Figures 1 and 2. We present the results of the survey grouped into two blocks of questions, those related to the use of PS during practicals in the dissecting room (questions 1 to 5) and those related to the use of the specimens during tutorial work in the anatomy museum (questions 6 to 10).
Figure 1: Survey results from first-year (VAP) and second-year (VRB, CBV) students
Figure 2: Comparison of answers (mean) of first-year (VAP) and second-year (VRB, CBV) students
* Existence of significant differences at 95% significance level
† Existence of significant differences at 99% significance level
Students were curious and receptive to the use of PS during practical sessions. The use of PS (question 1) during the practicals was voluntary; however, 97% of students used them.
The level of student satisfaction with the plastination experience in the dissection room was high (scores of 4 and 5 for question 2), although higher (p<.05) for second-year students (98.4%) than for first-year students (95.5%), with mean scores of 4.69 and 4.48, respectively (Figure 2).
All students (100%) rated the use of PS in combination with wet embalmed cadaver dissection (question 3) positively (30.5%) or very positively (69.5%).
A majority of students (87%) said they would like to have more PS during wet cadaver dissection in the practicals (question 4). This proportion rose significantly to 96.9% for the second-year students compared to 77.7% for the first-year students, with mean scores of 4.64 and 4.11, respectively (Figure 2).
The possibility of having PS in advance to prepare for the practical sessions (question 5) was important or very important for 76.6% of second-year students and for 52.2% of first-year students, with mean scores of 4.16 and 3.58, respectively (Figure 2). The remainder did not express an opinion for or against their availability.
When analyzing the use of PS after practicals, it should be noted that despite the fact that all students had free access to them in the Veterinary Anatomy Museum, question 6 indicated that only 60% of first- and second-year students had tutorial sessions in the museum, where the specimens were available (museum group). This means that 40% of the students had their tutorials outside the museum (non-museum group) and did not use the specimens (values 1 and 2 to question 6). Our population was therefore further split into these two groups (Figure 3), and we considered the differences between them during the analysis of the results.
Figure 3: Comparison of answers (mean) of the museum group (students who had supervisions with PS; scores of 4 and 5 for question 6) and the non-museum group (students who did not have supervisions with PS; scores of 1 and 2 for question 6)
* Existence of significant differences at 95% significance level
† Existence of significant differences at 99% significance level
A total of 63% of students (53% from the first year and 73% from the second) used PS independently in the museum while preparing for the anatomy exam (scores 4 and 5 for question 8). Students who were given the opportunity to use PS during tutorials were more likely to use them as part of their exam preparation, as shown by comparing the mean scores for independent use between the museum group (3.94) and the non-museum group (2.97) (Figure 3).
Overall, 97.7% of students thought that the PS helped them to understand and learn anatomy (scores 4 and 5 to question 9). This proportion was significantly higher for second-year students (100%) than for first-year students (95.8%), with mean scores of 4.54 and 4.25, respectively (Figure 2).
About half of the students believed that the specimens were a useful aid for their supervisors during small-group teaching sessions (mean scores of 3.31 for first-year students and 3.32 for second-year students, Figure 2). Those students who had not received tutorials in the museum with PS (non-museum group) mostly indicated that they neither agreed nor disagreed (mean score of 2.35, Figure 3). The results of this question (Q10) as well as question 7 are based only on the opinion of the students.
All students surveyed (100%) agreed (25.8% of first-year students, 12.9% of second-year students) or strongly agreed (74.2% of first-year students, 87.1% of second-year students) that they would recommend the use of PS in the following year, with mean scores of 4.87 and 4.74, respectively (Figure 2).
In the questionnaire, 87 students provided free-text comments, focusing on two main themes: (1) the specimens and (2) the learning process.
PS were very positively evaluated in the free-text section, including comments such as “more, they are fantastic”; “use them always, so clear”; “valuable resource”; “they are the best thing ever”; “amazing”; “very useful”; “please get more”; and “love it.”
From analysis of the comments, two aspects of working with the specimens emerged as important for the students: the ease of identifying structures and the ability to show how different structures were spatially related. Student comments included the following: “plastinated specimens make visualizing structures a lot easier”; “more clear, able to identify structures more easily”; “very clear example of anatomy”; “they are excellent for relaying 3D structures”; and “really useful in understanding how everything looks/connects.”
Students frequently commented on the quality and usefulness of the material compared to wet dissections and pots. Students appreciated the combination of wet dissections with PS. The head and neck PS were particularly useful for the students as they allowed them to see details, such as vessels and nerves, that they found difficult to identify during their own dissections. The students also reported that the internal anatomy of dilated hollow organs—such as the ruminant stomach, prosections of canine thoracic and abdominal cavities, and pregnant uteri with attached membranes—were also very valuable. When compared with pots, the ability to physically handle prosections made it faster and easier to understand and learn anatomy; a combination of both was considered the best option. Student comments included the following: “they are useful in having an almost perfect dissection as sometimes vessels are destroyed during wet dissections”; “really, really helpful especially when I've destroyed things in the dissection dog”; “really beneficial often clearer what may be hard to see in wet dissection”; “they are very useful to see things you may miss in practicals”; “good to see a different view of organs”; “so much better than leaky pots”; “much more useful than pots, specially the dissected head ones”; and “a lot better/easier to study than pots.”
The learning environment when using the PS was also a common topic in the free-text comments. Students saw the absence of tutorials in the museum with the specimens as a lack of opportunity for in-depth exploration with their supervisors: “I didn't use them in supervisions but would have liked to”; “haven't used them in supervisions or had supervisions in the museum”; “we don't go to the museum.”
To help independent learning, students suggested specimens be accompanied by labeled images to help them interpret the structures: “labelled photos of them would be helpful alongside”; “fantastic tool, can they be labelled?”
Throughout the year, teachers and supervisors also expressed how useful PS had been. They identified the need to establish a permanent collection in the Veterinary Anatomy Museum. In their opinion, this type of anatomy tool assisted teaching/demonstrations not only in the dissection room when combined with wet cadavers but also during tutorial sessions. PS also allowed for the arrangement of tutorial sessions before practicals to prepare students for wet cadaver dissections and allow them to get more out of the experience.
The role of dissection in anatomy teaching increased during the last half of the twentieth century, resulting in new preservation techniques and anatomic models based on diagnostic imaging.25 One such preservation method, plastination, was developed in 1978 by Gunther Von Hagens in the anatomy laboratory at Heidelberg University,26 and it is currently used in both teaching and research. The use of traditional cadaveric dissection and more modern teaching resources allow for different approaches to teaching anatomy, with aspects of traditional and modern methods being important to the development of practical and theoretical skills.25 However, there remains debate as to which methods or tools foster the most efficient learning experience.27
In our study, PS were used as a teaching resource in veterinary anatomy at the University of Cambridge for the first time. Students found this new tool for anatomic learning very valuable.
The fact that PS could be used outside the dissection room without the need for special conditions made them an ideal tool in tutorials (small-group teaching), which are part of the higher education system of the University of Cambridge. This study demonstrated that students appreciated these specimens beyond the dissecting room. Both students and academic staff considered their use in the tutorial system beneficial.
It is generally accepted that PS are of great value as resources for anatomic teaching and learning,13,14,20,22,26,28 and therefore many institutions now use PS for teaching undergraduate anatomy. However, very little research attention has focused on how undergraduate students perceive the use of PS. To our knowledge, this is the first study evaluating PS as part of an established undergraduate curriculum in combination with other classical anatomic resources such as cadaver dissections, pots, and lectures. Latorre et al.20 investigated how veterinary and medical students improved their knowledge using PS, but they focused on a specific practical session rather than a whole anatomy program. Fruhstorfer et al.22 surveyed the views of first-year graduate medical students on the use of PS as a replacement for wet cadaveric specimens. During our study, students had a full program of wet dissection of cadavers in combination with PS and other tools such as pots and radiographs.
Wet cadaver dissection is time-consuming for students as well as for academic staff. Most first-year veterinary students are inexperienced and hesitant in their dissection, and they are concerned about accidentally damaging their specimen. During dissections, students often waste time waiting for one of the instructors to verify the identification of structures before continuing with their dissection.29 In our study, students were able to combine different resources during practicals. Previous studies have demonstrated that blended or multimodal learning based on didactic teaching, problem-based learning, cadaveric dissection, and the use of prosections is more effective than traditional teaching.30,31 In this sense, tools such as simulators,2,4,6–8 anatomic models,32 and virtual models33,34 are effective aids that complement traditional teaching, increasing the confidence, knowledge, and ability of students.
The use of PS helped students understand and identify the structures that needed to be respected during dissection. Many students reported that the PS were important in identifying structures during dissection and understanding the three-dimensionality of these structures. Previous studies have reported improvement of student dissection skills when using additional instructional support from computers in gross anatomy.35 Students need to use both traditional and modern techniques to acquire skills and anatomic knowledge.25 It should be noted that in other studies using only PS, the majority of students articulated their concerns about the discontinuation of wet dissection.22
Most students in our study welcomed the PS and said they would like to have more of them. However, the results varied between first- and second-year students. The second-year students assigned higher ratings to the experience of learning with PS than the first-year students. Their responses were influenced by the fact that they had completed the VAP course the previous year, when PS were not available, and so they were able to compare learning anatomy with and without PS. This clearly affected the results in the survey. Some second-year students commented that PS would be even more useful for first-year students (“very good for first year stuff”; “they are incredibly useful, I think would have helped even more in 1st year”) due to the high number of anatomy practicals in the VAP course. The proportion of students who wanted more PS during dissection practicals was 20% higher for students in the second year than those in the first. Similarly, the number of second-year students who said they would like to have these specimens available before the practicals was 25% higher.
The availability of PS in the anatomy museum gave students the opportunity to prepare for practicals in advance; by allowing students to visualize a specific dissection, they had a better understanding of how the dissection was to be performed in the practical. Second-year students, who had not had this advantage during the previous year, rated this as particularly useful.
Since PS can be easily handled, they help students see the three dimensions of the structures in detail. However, the rigidity of some PS10,23 still makes it necessary to combine their use with the wet cadaver dissection. Nevertheless, more flexible PS are now becoming available for some hollow organs such as lungs and gastrointestinal tracts.36–38
Previous studies suggest that plastination should not replace the traditional learning method of hands-on dissection of wet cadavers.10 In our study, the use of PS combined with wet cadaver dissection was rated very important by those students who had previous experience learning anatomy with cadaver dissection alone. Supporting this, a study by Fruhstorfer et al.22 reported that students who learned anatomy using PS alone expressed concerns about the lack of opportunity to carry out wet cadaver dissection. Therefore, our study supports the view that students prefer a combination of both teaching methods.
As previous authors have indicated,10 the use of PS is not restricted to the dissection room; PS can be used in the museum or any lecture room, and this was an important factor in our study for tutorial work after practicals. Time spent by University of Cambridge students in small-group tutorials is very high compared with other universities; therefore, in morphological subjects such as anatomy, it is important to have high-quality resources available during tutorials. The context in which anatomy is taught makes a difference to student perceptions of learning. Local curriculum factors are important in creating an enabling learning environment.39 All teachers and supervisors who used PS during this study said the specimens facilitated their teaching during the tutorials and indicated that they would like to have more specimens. Some teachers suggested the possibility of creating small collections of PS within the colleges. The same opinion was reflected in the student survey.
The characteristics of PS allow them to be used to study anatomy independently. Time for self-teaching with the specimens should therefore be provided. It has been shown that if students have no access to PS outside formal teaching hours, they find it difficult to assimilate their learning, and they express concerns about the limited time available with the specimens.22
In our study, we found that students' independent use of these resources increased when they had previously used PS with their supervisors. However, students, mainly from the second year, who had seen PS in practicals but not in tutorials, used them for self-study in the museum. These same students indicated it would be useful to provide diagrammatic interpretation of the different structures of the specimens to help encourage independent learning.
Second-year students had previously studied anatomy without PS; this was useful in our study, giving us a strong indication of the ideal combination of resources for learning anatomy. Previous assessments of plastinated resources have been limited by students' inexperience with wet cadaveric specimens.22
In a previous study, we showed that PS not only aided anatomic teaching but also improved student knowledge20; however, in that study, plastination was used only in one or two practicals in specific subjects such as veterinary anatomy, human anatomy, and veterinary surgery, and so the evidence was limited.
One limitation of the present study is that it measured student perceptions but not any quantitative improvements to their learning. Therefore, validation studies are necessary to determine whether the use of plastinated specimens during the complete preclinical veterinary anatomy curriculum improves student knowledge. It would be interesting to correlate any improvement in student anatomic knowledge after pre-clinical PS use with their subsequent progress in clinical subjects. In this context, it is worth remembering the importance of the use of PS and transparent-sheet plastinated sections as valuable resources for training in clinical subjects, bridging the gap between anatomy and clinical practice.16,28,40–42 Plastinated gastrointestinal tracts have also been used for endoscopy training to reduce the learning curve for these minimally invasive exploration techniques.36,38,43,44
The students felt that the use of PS in both the dissection room and the anatomy museum helped them learn and understand anatomy. They recommended it as a resource in combination with wet cadaver dissection.
PS were greatly appreciated by students as a tool during the anatomy practical program and during the small-group tutorials.
ACKNOWLEDGMENTS
This work is a result of the internship (19597/EE/14) funded by the Seneca Foundation's Agency for Science and Technology in the Region of Murcia, under the “Jiménez de la Espada” Program for Mobility, Cooperation and Internationalization.
We wish to thank Dr. Jonathan Holmes (Affiliated Lecturer, Director of Studies at Queens' College, Cambridge); Dr. John Brackenbury (Lecturer since 1984 and fellow of Wolfson College, Cambridge); Dr. Gavin Jarvis (Lecturer since 2012 and fellow of Selwyn College, Cambridge); Dr. Colin Roberts (Affiliated Lecturer and Director of Studies at Sidney Sussex College, Cambridge); and Mr. Roger Tattersall (Technician in Veterinary Anatomy, Cambridge) for their assistance during practicals and tutorial work.
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Many thanks in advance for taking part in this survey. Your responses will be anonymised and your data will be securely stored in accordance with the Data Protection Act.
| 1–Strongly disagree | 2–Disagree | 3–Neither agree nor disagree | 4–Agree | 5–Strongly agree | |
|---|---|---|---|---|---|
| 1. I have used the pastinated organs during anatomy practicals. | □ | □ | □ | □ | □ |
| 2. I am satisfied with the experience of using plastinated specimens. | □ | □ | □ | □ | □ |
| 3. I believe plastinated specimens usefully complement wet cadaveric specimens in teaching anatomy. | □ | □ | □ | □ | □ |
| 4. I would like to have more plastinated specimens as a reference during anatomy dissection in the practicals. | □ | □ | □ | □ | □ |
| 5. I would like to have plastinated specimens available before the practical to prepare for it in advance. | □ | □ | □ | □ | □ |
| 6. I have used the plastinated specimens with my supervisor during our supervisions in the anatomy museum. | □ | □ | □ | □ | □ |
| 7. I think my supervisor would like to have more plastinated specimens available. | □ | □ | □ | □ | □ |
| 8. I have independently used the plastinated specimens in the anatomy museum while preparing for the anatomy exam. | □ | □ | □ | □ | □ |
| 9. Plastinated specimens have helped me understand and learn anatomy. | □ | □ | □ | □ | □ |
| 10. Plastinated specimens helped my supervisor teach anatomy. | □ | □ | □ | □ | □ |
| 11. Would you recommend the use of plastinated specimens next year? | □ | □ | □ | □ | □ |
| 12. Any comments about the use of plastinated specimens in future? |
Thank you for participating in this survey.
