The COVID-19 pandemic in Canada has had widespread consequences for the organization of health care services and medical education more broadly. In many cases, this education was simply halted: clinical clerks were pulled from the hospitals, exams were deferred, and elective placements were cancelled. However, as the need to train physicians remained constant, other components of the curriculum were adapted or repurposed and delivered online. One of the most interesting changes was that many schools that previously placed an emphasis on learning anatomy through cadaveric dissections moved this curriculum online. In this blog post, I reflect on anatomy (informed by my own lived experience) and what is lost, preserved, and gained when the study of the body proceeds without the presence of a physical body.
Anatomical Knowledge A logical place to start with a question of pedagogy is epistemology. How is knowledge of anatomy produced, understood, and translated to new generations of physicians? Cadaveric dissections emphasize the value of tactile knowledge (Kuriyama, 2006; Gunderman, 2005). It is an inherent assumption that there is something to be gained from squeezing vessels to feel for a hallow lumen or from manipulating a skeleton in three-dimensional space. Proponents would maintain that learning about anatomical theory is a poor facsimile of the dissection experience. This is perhaps analogous to Latour’s (1987) notion that there is a discordance between the knowledge of a phenomenon, as it is experienced, and the written, papered form of that knowledge, when it is abstracted for purposes of dissemination.
Comparatively, few resources have extolled the potential virtues of digital avenues for learning anatomy (and where they have, it has generally been as an adjunct – see for example: DiLullo et al., 2006; O’Bryne et al., 2008; Jaffar, 2012; Lewis et al., 2014; Chakraborty & Cooperstein, 2018). While this can take many forms, one worth highlighting is the rise of apps designed for a variety of devices, such as “Essential Anatomy.” These apps try to replicate the exploratory nature of anatomy by allowing users to layer structures/organ systems and manipulate them for ideal vantage points. In contrast to cadaveric samples in which structures tend to have similar colours, images on apps can not only be colour coded, but labelled. The temporality is also altered: tedious tasks such as removing skin or fascia can be accomplished in a split second, whereas potentially destructive tasks (i.e. removing structures altogether) can be performed and subsequently undone. For example, in the picture below, I layered the arterial and digestive system, hid the omentum, faded the small intestines to reveal the posterior vessels, and clicked on a specific artery for the app to identify.
The Individual Behind the Body What is the difference between the body lying in a medical school’s anatomy lab all year and the virtual body that exists in perpetuity on these apps? In a literal sense, the answer lies with the anatomy itself. Apps like Essential Anatomy have two bodies: male and female. What you see with each option is ‘textbook’ anatomy. Conversely, what you learn through cadaveric dissections is that there are seemingly endless derivations. Some are expected – i.e. certain traits that are present in stable percentages of the population – while others are unique to your cadaver. In fact, some of them might be related to the reason that this individual is now a cadaver and not still alive.
And herein lies a significant difference between these two bodies: cadavers are inevitably intertwined with mortality. Students are not typically given many details about the cadaver beyond age, sex, and cause of death (if known). Yet those details alone link the cadaver with a life – one that has been lived and is now over. This fact may frequently be lost on eager medical students trying to gain mastery over a complicated discipline in a very limited amount of time. Nevertheless, most students will admit to having a ‘moment’ at some point during the curriculum. Most commonly, this is when students are tasked with dissecting the face, but other areas include the brain, genitals, and hand/foot – consider, for instance, the visual essay ‘Pink’ (Stephenson, 2012), where the protagonist dissects much of her cadaver, but finally unwraps the lower limb to reveal pink nail polish. This association is controversial. Some view it as a necessary exercise in gaining respect for human life – as one of my tutors told me, “Your cadaver is your first patient.” Others think it teaches students to compartmentalize and separate the person from the body. Most lie somewhere in between, struggling to reconcile the need to gain anatomical knowledge with the need to reflect thoughtfully on the life behind that anatomy (e.g. Pennisi, 2008; Cancino, 2014; Mollica, 2016). These tensions are unlikely to be replicated in digital forms of anatomy without significant redesigns in curriculum – and whether they ought to be is a different question.
Anatomy as a Rite of Passage Scholars have long portrayed medical education as a time of liminality that is mediated by rites of passage, often with the effect of shaping the trainees’ growing personal and professional identities. This research is often centred around the trials and tribulations of clinical work (in Canada, clerkship and residency), from morning rounds to 26-hour shifts (e.g. Apker & Eggly, 2004; Monrouxe, 2010; Brooks and Bosk, 2012). However, in the pre-clinical realm, anatomy can be considered its own rite of passage – and indeed, for many students, it will be their first rite of passage (Gunderman, 2005; Godeau, 2009). While students will not have clinical responsibilities for two years (and will not be staff physicians for anywhere from 6-10 years), successfully completing the anatomy curriculum is an early milestone. Among other things, it proves that a student can accept the inherent mortality of the situation and also, put simply, that they’re not too squeamish (as Godeau said, “dissection separates... those who have managed to control their senses from those who did not succeed). Of course, aspects of this rite of passage are preserved in a virtual curriculum; after all, learning the material is proof of a student’s determination and capacity for rote memorization. However, part of the rite is certainly tied to the physical, ritualistic act of dissecting – of spending six hour removing the skin from a cadaver’s face despite the limited educational value, or of working with delicate structures and not damaging them. As with the previous section, this function of anatomy is likely incapable of translating to digital modalities.
Concluding thoughts Medical pedagogies are constantly changing, irrespective of external forces like the COVID- 19 crisis. Amidst this change, dissections are, in some ways, a vestige of traditional medical education – an epistemology in their own right dating back not only to currently-practicing physicians, but to antiquity. Intuitively, bringing this curriculum online would sacrifice the hands-on learning of in-person dissections, but there are digital alternatives (apps, VR, and even more) that may replace this embodied experience. However, doing so may sever the humanistic and ritualistic elements of anatomy from the pure ascertainment of knowledge – for better or worse.
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