RELEVANT REVIEW

Singapore’s Anatomical Future: Quo Vadis?

Eng-Tat Ang,1* Kapil Sugand,2 Mikael Hartman,3,4 Choon-Sheong Seow,5 Boon-Huat Bay,1 Peter Abrahams6 1Department of Anatomy, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 2Department of Surgery, St. George’s Hospital, London, United Kingdom 3Saw Swee Hock School of Public Health, National University of Singapore, Singapore 4Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 5Department of Surgery, Alexandra Hospital, Jurong Health Service, Singapore 6Institute of Clinical Education, Warwick Medical School, Coventry, West Midlands, United Kingdom

The disciplines of anatomy and surgery are not dichotomous since one is dependent on the other. Traditionally, surgeons predominantly taught gross and clinical anatomy. In this review, we examine the context of how human anatomy is taught nowadays. In essence, we discovered that there are certain discernable trends consistently observable between the American and British systems. In Singapore, the British Russell Group first influenced its education landscape but now more so by the American Ivy League. Singa- pore now has three medical schools all offering differing anatomy curricula, which serves as an opportune time for it to consider if there is a best approach given that the practice of surgery is also evolving in parallel. This review discusses the various pedagogies and issues involved, and will serve as a forum and stimulus for discussion. By tweaking the curriculum correctly and the lessons learnt, future doctors and surgeons in training will receive a better anatomical education, not just in Singapore but the world in general. Key recommendations include the use of body painting, clay, plasticine to facilitate the learn- ing of anatomy, and the implementation of a body donation program. Furthermore, stra- tegic mergers with key stakeholders will also ensure the survival of the discipline. Anat Sci Educ 5: 234–240. © 2012 American Association of Anatomists.

Key words: gross anatomy education; undergraduate education; surgical practice; medical curriculum; British education; American education; Singapore

INTRODUCTION edge cannot perform their role proficiently, lest competently. Today, minimally invasive interventions abound, a laparo- The disciplines of anatomy and surgery cannot be separated scopic cholecystectomy if inadequately performed, for from one another. In fact, detailed knowledge of the human instance, could result in postoperative complications such as anatomy is crucial to the work of doctors and certain special- biliary injuries that could endanger the patient’s life (Nagral, ists, especially surgeon and radiologists (Ahmed et al., 2010). 2005). There are also medico-legal consequences that could Historically, surgeons taught their trainees and students, but jeopardize a practicing surgeon’s career, if steps are not taken as their workload and inclination changed, and with more to avoid such related post-operative complications (Ellis, teachers with postgraduate anatomy qualifications joining the 2002; Ellis and Crowe, 2009). Nonetheless, before mastering universities, this is clearly no longer the case. However, it is minimally invasive surgery, trainees ought to be competent still true that surgeons without sufficient anatomical knowl- with gross anatomy before super-specialization (e.g., laparo- scopy, robotic-assisted surgeries) in case the need for conver- sion to open surgery arises (Gogalniceanu et al., 2008; *Correspondence to: Dr. Eng-Tat Ang, Department of Anatomy, Yong Loo Lin School of Medicine, National University of Singapore, MD10, Jime´nez and Aguilar, 2009, Yi et al., 2012). 4 Medical Drive, Singapore 117597, Singapore. Furthermore, students should be aware of variations in an- E-mail: [email protected] atomical structures (Strkalj et al., 2011) both in morphology Received 5 February 2012; Revised 3 April 2012; Accepted 4 April and pathology as a result of trauma, cancer, or inflammation. 2012. It is vital for undergraduate and postgraduate trainees to Published online 4 May 2012 in Wiley Online Library appreciate, recognize, and be familiar with normality. The (wileyonlinelibrary.com). DOI 10.1002/ase.1286 need to understand the subject becomes even more pressing when one considers the emergence of cutting edge imaging © 2012 American Association of Anatomists technology.

Anat Sci Educ 5:234–240 (2012) JULY/AUGUST 2012 Anatomical Sciences Education Fast-forward to the 21st century, the teaching of human change with the development of the American Anatomy Act anatomy in medical schools has also been transformed (Blake, 1955) and throughout the 19th century, American remarkably. With some exceptions, the modern institutions doctors were travelling to either London or Paris for further are doing away with cadavers altogether (McLachlan et al., medical training. These activities cumulated into the transfor- 2004) whereas the more traditional institutions such as King’s mation of medical education, especially so after the release of College London (KCL), Imperial College London (ICL) in the the Flexner report (Halperin et al., 2010). In particular, United Kingdom, and Duke University in the United States Franklin Paine Mall (1862–1917) chairman of anatomy at are still persevering with dissection (Guttmann et al., 2004; Johns Hopkins Medical School, greatly reformed anatomy McLachlan, 2004; McLachlan et al., 2004; Pawlina and teaching in the United States (Hildebrandt, 2010). However, Lachman, 2004). In Singapore, we are very much at the over the years, with the dwindling of the British Empire, and crossroads as far as anatomy curriculum is concerned, follow- the emergences of American economic power, anatomy edu- ing the setting up of the two new medical schools. These are cation in both countries have somewhat reached a stage (1) Duke University and National University of Singapore whereby neither is the clear leader. Both needed on-going (NUS) Graduate Medical School (Duke-NUS GMS; Williams educational reforms to stay relevant in this modern era. et al., 2008) and (2) Imperial College of London (ICL) and Numerous issues such as the duration of gross anatomy lec- the Nanyang Technological University (NTU)’s Lee Kong tures, embryology teaching, the use of dissections/prosections, Chian School of Medicine (LKCSoM; Ai-Lien, 2011). This and multimedia teaching, et cetera were discussed in recent nation is unique in being exposed to different educational reviews from both sides of the Atlantic (Drake et al., 2009; and health care frameworks before and after it became a sov- Sugand et al., 2010). There appears to be very little uniform- ereign state in 1965. Without going into too much detail, this ity between the different institutions from both continents. shall be discussed in the following section. At the National University of Singapore Yong Loo Lin’s Early Education and Healthcare Policies School of Medicine (YLLSoM), the oldest institution in the in Singapore country, there is now less emphasis on ‘‘hands-on’’ learning of human anatomy compared to a decade ago, primarily due Singapore was once part of the British Empire and got its in- to the lack of human cadavers. This is attributed to cultural dependence in 1965. Its founding fathers were educated in attitudes, and reluctance to donate one’s body for medical sci- British universities and hence its education and healthcare ences. At the Duke-NUS GMS, the curriculum that is largely policies were largely influenced by the UK (Wong and Tay, based on the Duke model (Grochowski et al., 2007) is meant 2005). Medicine was largely based on apprenticeship and to produce clinician scientists to meet the nation’s needs for their previous colonial rulers mentored its early doctors (Tan, research and development (Williams et al., 2008). In this new 1998; Ong, 2005). All these gradually changed when the institution, anatomy is taught in a team-based learning man- United States emerged as a postwar superpower, and policy ner by specialist doctors (Chow et al., 2009). At the newly makers made a strategic move to align itself more with the established Imperial College of London and the Nanyang Americans. Again to the credits of the founding fathers, the Technological University’s LKCSoM, administrators are still system has further evolved to become a hybrid of the two in the process of formulating the basic science curriculum earlier influences, and has developed its unique characteristics since formal intake of students will only take place in the peculiar for its own needs (Callick, 2008). year 2013. It suffices to say that the adopted teaching style is likely to be similar to that of the UK (Ai-Lien, 2011). How- Teaching Human Anatomy ever, it is quite certain that anatomy education will be done In medieval and 18th century Europe, surgeons themselves without dissection (personal communication). taught the subject. Obviously, this has changed considerably Given the above background, the aims of this article are with the appearance of professionally trained anatomists who to: (1) Outline the changing trend in anatomy pedagogy are equally qualified to do the teaching. The major issue between United Kingdom (UK), United States (US) and Singa- relating to the subject has not really changed over time; it is pore, and (2) Stimulate debate and exchange of ideas for cre- still the availability of cadavers for dissection (Bay and Ling, ating an ideal anatomy curriculum for Singapore and other 2007). What has changed is the practice of surgery, and per- developing countries. haps the in-depth understanding of morphology. Despite this, the teaching and learning of human structures by anatomists, trainee surgeons and students will be a perpetually challeng- LITERATURE REVIEW ing process (Sugand et al., 2010) in which the content ought History of Anatomy Education in UK to be continuously reviewed and tweaked. As a scientific sub- and the USA ject, it has arguably stagnated since everything that needs deciphering and understanding, has been systematically dis- In 18th century London, anatomy education was shrouded covered since the days of Herophilus (335 BC–280 BC) and with controversies, as the need for surgical skills improve- Andreas Vesalius (1514–1564) (Bay and Bay, 2010). How- ment and public horror at human dissection went head to ever, the way that this information is visualized, instructed head. Gradually, the situation improved with publicized anat- and applied clinically is a constantly changing process. In the omy lecturing with dissection in London and the Anatomy past and mostly encouraged during the Renaissance, medical Act of 1832 (Lawrence, 1995). Luminaries like John Hunter students in clusters performed hours of cadaveric dissection, (1728–1793) and Henry Gray (1827–1861) laid the founda- learning from their tutors and each other in the process. This tion for anatomy education in Britain. Back in the United was refined to a few students around one dissection table in States, before the declaration of independence in 1776 from contemporary times. However, there is now a de-emphasis on Great Britain, anatomy education closely resembled that in this practice because of a variety of reasons. Such include Europe (Hildebrandt, 2010). Subsequently, things started to decreased funding for anatomy education (Lindor et al.,

Anatomical Sciences Education JULY/AUGUST 2012 235 2010), lack of cadavers, and promotion of new teaching Separately, over the last 20 years, the subject is increas- methodologies (self-directed learning, TBL, e-learning, etc.). ingly taught in a technology-driven manner (e.g., imaging Furthermore, decreased curricular time allotted to gross anat- and commercial software). One of the new educational aids omy (Drake et al., 2009; Craig et al., 2010) and lack of that we have come to depend on is the application of com- qualified faculty (McCuskey et al., 2005) also contributed to puter and multi-media for anatomy teaching (Bay, 2007; the new situation. Concomitantly, there is an increasing trend Bay and Ling, 2007; Abrahams, 2011). Such include Primal for surgery to move towards minimally invasive approaches Pictures 3D (Primal, 2007), A.D.A.M. Interactive Anatomy such as laparoscopy (Alkhoury et al., 2010). Nevertheless, (A.D.A.M, 2011), and Bracco’s volumetric interactive 3D open procedures must be mastered first so gross anatomy and (Bracco, 2012) representing several commercially available dissection are still very relevant. programs. The availability of such programs to aid the In terms of teaching pedagogy, at the National University teaching of human anatomy is challenging traditional meth- of Singapore YLLSoM, anatomy is taught as a preclinical odology of teaching and learning which is, to perform dis- modular subject with every attempt to integrate with the section on cadavers, coupled with encouraging the students teaching of biochemistry and physiology. The one year’s to learn and appreciate various prosections (embalmed endeavor includes weekly didactic lectures (four–six hours), cadaveric and pot specimens). While it would be an under- practical classes (two hours) to about 280 students, and tuto- statement to say that multimedia has been a valuable assist- rials (two hours) for small groups. Lecturers and tutors always ant for teaching anatomy, it has revolutionized the way attempt to discuss anatomy in a clinically orientated manner knowledge can be reinforced. However, in a recent report, so as to prepare the medical students for their clinical studies. medical students and trainees did not find these programs From the year 2003–2004, dissection was discontinued in this to be especially enticing compared to other established institution, and prosected cadavers were used instead for pedagogies but this will need further validation (Ahmed teaching and demonstration purposes (Wong and Tay, 2005). et al., 2010). Specifically, first year medical students learn their anatomy with prosections supported with computer simulation and imaging modalities (Rajendran et al., 1990; Yip and Rajen- The Practice of Surgery dran, 2008; Lu et al., 2010; Gopalakrishnakone et al., 2011). Furthermore, there is a state of the art anatomy museum that Surgical practice has also evolved considerably since those the students can use for their self-learning ad libitum. This is days when open procedures were the norm. Back then, one in line with what most British medical schools are currently has to touch and see the structures that are operated on offering (McLachlan, 2004; McLachlan et al., 2004; Ahmed before proceeding with either excision, ablation or recon- et al., 2010; Sugand et al., 2010). A review of the literature struction (Mack, 2001). In a recent review done in the suggests that such modern practice may be just as effective United States, there is a significant trend towards the use of (Jones et al., 1978), but contrary views remain (Carmichael percutaneous interventions, angiographic embolization, and and Pawlina, 2004; McLachlan et al., 2004; Older, 2004; endovascular surgery, with corresponding sharp declines in Pawlina and Lachman, 2004; McLachlan and Patten, 2006). major open biliary, aortic, colon, and trauma cases recorded Over at the Duke-NUS GMS, a specially designed curricu- in logs of surgeons and residents from 1993 to 2007 (Eckert lum (Normal Body Course) involving specialist doctors, et al., 2010). Their aspiration was to get the job done teaches anatomy in an integrated manner, together with a efficiently with minimally invasive interventions, so as to clinical system (e.g. alimentary anatomy with gastroenterol- reduce inpatient stay, and return the patient to functional ogy). Interestingly, it begins with a module quiz and ends status as soon as possible (Mack, 2001). Moreover, open with another to allow faculty and students to identify and procedures that are labor intensive, are gradually replaced rectify knowledge gaps (Chow et al., 2009). Furthermore, by robotic intervention in multiple disciplines such as bili- having a smaller enrollment of about 50 students, team based ary, urological, vascular, and colorectal surgery (Mack, learning (TBL) called TeamLEAD is carried out as a form of 2001; Antoniou et al., 2011; Giulianotti et al., 2011; Patel active teaching (Vasan et al., 2008, Vasan et al., 2011). et al., 2011). The idea is for the surgeon to work from a Briefly, TBL entails three phases which are (1) Pre-class prep- remote site away from the patient, using state of the art aration (students are given materials to read and then computer assisted technology to reduce hand tremor and to expected to discuss the key concepts in class), (2) Readiness enhance dexterity, haptic feedback, and motion scaling assurance (multiple-choice questions about the preparation (Mack, 2001). However, the benefits of using robotics work), and finally (3) Application (to apply concepts to labo- to enhance laparoscopic procedures are still contentious ratory and clinical scenarios; Chow et al., 2009). The TBL is since there are reports suggesting advantages between based on the following assumptions; that medical students different platforms used (Garcia-Ruiz et al., 1998; Nguan are a motivated group of learners (Misch, 2002), and that et al., 2007). more learner-to-learner interaction in a group will lead to Given the above technological advancements and the lack active learning (Haidet et al., 2004). At the Duke-NUS GMS, of thorough anatomy education, it is not inconceivable that it successful outcomes have been reported but not without will take longer to train surgeons. This is especially so in issues which have to be further streamlined (Cook et al., Europe, with the European Working Time Directive (EWTD; 2008; Krishnan, 2011). DOH, 2009; Goddard, 2011; Kelly et al., 2011; Simpson On the basis of the above two cited examples alone, it is et al., 2011), which puts legal time restrictions on work. In clear that anatomy lessons can generally be conducted in a di- Singapore, with the practice of medicine and surgery now dactic or active learning manner, both with clinical relevance subjected to the review of the Accreditation Council for to medical practice. However, the question remains as to Graduate Medical Education (ACGME) of the United Sates, which of the above two pedagogies will lead to better critical trainees are required to abide to work-hour limits as well thinking and instill abilities to be a life long learner. (Willis et al., 2009).

236 Ang et al. Perspectives for the Future of Lerner College of Medicine, Bristol, Newcastle and Warwick Anatomy Education Medical Schools and Royal College of Surgeons, England; Drake, 2007; Ahmed et al., 2010; Kerby et al., 2011). That Other educational competencies such as communication being said, the ‘‘open ‘‘ method of teaching anatomy using skills, medical ethics and law, genetics, and the biomedical prosections should not be discarded entirely, but with research agenda have gained more attention and significance adjuncts such as ultrasound, trocars insertion with laparo- over time. These are now vying for more time from medical scopic procedures and learning to orientate monitors. What- students and residents (Riegert-Johnson et al., 2004; Kanna ever the future holds, it suffices to say at this stage that all et al., 2006; Bay and Ling, 2007). Furthermore, disciplines trainees should be encouraged to take up the role of demon- such as surgery and radiology, which are dearly married to strators in anatomy education, as is happening at KCL, UK anatomy have also evolved considerably, with the emergence as part of the curriculum for core surgical trainees (Older, of ‘‘key-hole’’ interventions and the ever sophistication of 2004; Abdalla, 2011). imaging techniques (Epstein, 2002; Goh et al., 2005; Chara- Body painting to teach clinical anatomy as pointed out by lampaki et al., 2006). Against this background, is the current studies (Op Den Akker et al., 2002; McMenamin, 2008; Finn method of teaching anatomy still relevant? More pertinent to and McLachlan, 2010) can also be useful in developing spa- surgical practice, is there still a need for surgeons to know tial awareness. In addition, other methodologies such as the ‘‘gross anatomy’’ to the expected standard in the past? Since use of clay modeling alone (Myers et al., 2001; Motoike there is now minimal manual handling of organs, is there et al., 2009; Oh et al., 2009) or in conjunction with animal really a need for them to use cadavers to understand the carcass dissection (DeHoff et al., 2011), plasticine (Naug gross morphology of organs? Yes, to the latter two points, as et al., 2011), and low fidelity simulation (Chan, 2010; Chan the trainees are still expected to deal with either distorted and Cheng, 2011) could all be harnessed to help with anat- view, or inverted feel of the operated site via the minimally omy education. There should also be clinically orientated invasive approach. Instead of the previous rigors of descrip- training for the students to identify of surface markings as tive anatomy, there is now an increasing need to appreciate this forms the basis of thorough physical examinations, and practical spatial awareness instead, to have a sense of depth appropriate clinical skills (Rizzolo et al., 2011). If medical perception, and the ability to see things from different angles students are unwilling to partake in the above exercise due to as seen on a monitor. The challenge for the students and cultural or religious reasons, it is also recommended that pro- trainees is to try to make that connection between what they fessional models and simulated patients be invited to facilitate see in two-dimension (2D) to what is happening in three- the learning process. dimension (3D). Failing to do so will result in post-op com- In summary, it is important to realize that anatomy teach- plications such as cases of unnoticed perforations (Dozois, ing is a human activity and as such no amount of technology 2008; Gogalniceanu et al., 2008). This is important because would be able to take over this role completely. It is also im- the take-up rate for minimally invasive procedures is likely to portant to note that one size will never fit all and surgical go up since there is evidence to suggest that it is less danger- trainees will need to have a deeper understanding of the anat- ous (Mamidanna et al., 2011). This is perhaps where medical omy in their own specialty. This will also be different from simulation will have a bigger role to play in future. In robotic the needs of a professional career anatomist. surgery at least, no longer does the surgeon need to handle the organs to be operated on, hence the question if the pres- Body Donation Program ent way of teaching the subject is still relevant? Perhaps, it should be done in a simulation laboratory whereby proce- The greatest hurdle for the medical students and trainees to dures can be practiced on animal carcasses and cadavers learn their anatomy via cadaveric dissection is the acute lack instead. It is therefore recommended that anatomists work of cadavers. Here at National University of Singapore YLL- more closely with professionals from the arts or computing SoM, we are in the process of instituting a body donation departments to produce high quality educational visual aids program, but there are numerous contentious and challeng- to relate anatomical structures with their function. ing issues to overcome linked to religion and society. There At present, the suspicion is not many younger surgeons is therefore a need to engage all faiths and to ensure donors’ will have the experience and courage to open up the abdo- wishes are fulfilled. This will come at considerable cost if all men or any part of the patient if the need arises. This is logistical needs are to be met. Furthermore, Singaporeans because they lack the training and the opportunity as an are conservative and not many are accustomed to donating undergraduate to do dissection. In a recent review, due to a their bodies for medical sciences and research. At the lack of anatomy training in undergraduate years, surgical moment, the Ministry of Health (Singapore) releases trainees are disadvantaged in their early phase of training, unclaimed bodies for medical and educational purposes, and and hence there should be focus on core clinical anatomy NUS YLLSoM is one of the recipients (Abu Baker, 2011). In (Standring, 2009). It is therefore imperative that the teaching the United States, body donation programs have already of anatomy should involve input, ideas, and perspectives been well implemented (Pawlina et al., 2011) and the Duke- from clinicians (surgeons and radiologists) to stay relevant to NUS GMS is in fact importing cadavers into Singapore to clinical practice (Purkayastha et al., 2007; Ahmed et al., fulfill their needs for education. In summary, this is an issue 2010). Dissection is also now used far more often by the that is not peculiar to Singapore and is faced by other devel- trainees and specialists in their later studies compared to oping countries as well (Anyanwu et al., 2011). We draw medical students (Ahmed et al., 2010). This highlights the inspiration from other Asian cultures that have conducted preferential method of dissection over prosections (Ahmed theprogramswell(e.g.,Korea,Thailand,andTaiwan)and et al., 2010; Kerby et al., 2011), especially for post-graduate believe that these issues are not insurmountable (Kao and surgical study where dissection rooms using fresh frozen Ha, 1999; Winkelmann and Gu¨ ldner, 2004; Lin et al., 2009; cadavers is now becoming more common (Cleveland Clinic Park et al., 2011).

Anatomical Sciences Education JULY/AUGUST 2012 237 Mergers and Strategic Collaboration first year medical students at the National University of Singapore. Anatomy education worldwide is undergoing major transfor- BOON-HUAT BAY, M.B.B.S., Ph.D., is a professor of mation due to an array of issues including professional, ethi- anatomy and Chair of the Department of Anatomy at the cal, and financial (Drake et al., 2009). All these are happen- Yong Loo Lin School of Medicine, National University of ing in the midst of further integration with other basic science Singapore, Singapore. He teaches gross anatomy to first year and clinical disciplines (e.g., cellular biology, surgery, and medical students and has research interest in cancer biology. oncology) into larger departments (Collins, 2008). It has been PETER ABRAHAMS, M.B.B.S., F.R.C.S., F.R.C.R., D.O., proposed that a merger with a clinical department (surgery) is a professor of clinical anatomy at Warwick Medical would better ensure survival for anatomy (Fasel et al., 2005). School, University of Warwick, Coventry, West Midlands, Departmental mergers or downgrade aside, it is imperative United Kingdom. He is currently leading an active career that anatomy professors remain active advocates and cham- within postgraduate teaching and research. pions for thorough anatomy education in the medical schools. The society as a whole will benefit from it when institutions produce competent doctors and surgeons. ACKNOWLEDGMENTS Acknowledgements are due to the following people whom Dr. CONCLUSIONS Eng-Tat Ang have had meaningful conversations; Dr. Yuk- Man Kan (Alexandra Hospital, Singapore), Prof. Davies, (Im- We do not know if there will be a shift back to dissection perial College London, UK), Mr. Laurie Wiseman, founder of rooms in Singapore (and other countries). A review of this Primal Pictures (UK) and Prof. Wojciech Pawlina (Mayo nature has been attempted in the past in the United Kingdom Clinic, USA). Dr. Eng-Tat Ang is particularly grateful for the (Older, 2004) but has not been done in this part of the world. AMDA fellowship, MOH (Singapore), as it provided time to What is peculiar of Singapore is the fact that we now are gather his thoughts and reflect on them while in London, UK. straddled between two contrasting educational cultures, that of the British and the Americans. The national education framework was first aligned to the British but is now increas- LITERATURE CITED Abdalla S. 2011. The role of anatomy demonstration for surgical trainees. Ann ingly leaning towards the numerous lucrative benefits of R Coll Surg Engl 93:S60–S62. American standards. More resources and financial incentives Abrahams P. 2011. Aspects of Anatomy. Coventry, UK: University of Warwick. are attracting more students to the latter than British compet- URL: http://itunes.apple.com/us/app/aspects-of-anatomy/id422032949?mt58 ing universities. [accessed 24 March 2012]. Abu Baker J. 2011. About 6 Elderly S’poreans die alone each month. The In addition, competition from computer-based learning Straits Times, Newspaper, Monday, 30 May 2011. p B1. Singapore Press (multimedia programs and the Internet) has become increas- Holdings Ltd., Singapore. ingly popular, and will inevitably affect the future of anatomy A.D.A.M. 2011.A.D.A.M. Education. A.D.A.M. Interactive Anatomy Online - education. The teachers of the subject should also aim to Student Version. A.D.A.M., Inc., Atlanta, GA. URL: http://www.adameduca tion.com/aiaonline_student.aspx [accessed 20 February 2012]. inspire the students and trainees to keep up lifelong learning Ahmed K, Rowland S, Patel V, Khan RS, Ashrafian H, Davies DC, Darzi A, and not attempt to overload the students in a limited time Athanasiou T, Paraskeva PA. 2010. Is the structure of anatomy curriculum frame. Despite all the arguments, what is certain is the fact adequate for safe medical practice? Surgeon 8:318–324. that good knowledge of anatomy is essential for good clinical Ai-Lien C. 2011. Creating Dr Right—The Straits Times Special Report on NTU’s Lee Kong Chian School of Medicine. The Straits Times, Newspaper, practice (Older, 2004; Ahmed et al., 2010). Saturday, 5 March 2011. p D6–D7. Singapore Press Holdings Ltd., Singapore. Alkhoury F, Martin JT, Contessa J, Zuckerman R, Nadzam G. 2010. The impact of laparoscopy on the volume of open cases in general surgery training. NOTES ON CONTRIBUTORS J Surg Educ 67:316–319. Antoniou GA, Riga CV, Mayer EK, Cheshire NJ, Bicknell CD. 2011. Clinical ENG-TAT ANG, B.Sc, P.T., Ph.D. is a lecturer in the Depart- applications of robotic technology in vascular and endovascular surgery. J Vasc Surg 53:493–499. ment of Anatomy at Yong Loo Lin School of Medicine, Anyanwu GE, Udemezue OO, Obikili EN. 2011. Dark age of sourcing cadav- National University of Singapore, Singapore. He teaches gross ers in developing countries: A Nigerian survey. Clin Anat 24:831–836. anatomy and histology to first year medical and life science Bay BH. 2007. Can computer-aided instruction effectively replace cadaver based students. He is also involved in elementary bedside teaching learning in the study of human anatomy? National University of Singapore, Centre for Development of Teaching and Learning (CDTL) Brief 10(3). URL: at the hospital. http://www.cdtl.nus.edu.sg/brief/v10n3/sec4.htm [accessed 15 March 2012]. KAPIL SUGAND, B.Sc. M.B.B.S., is an Academic Founda- Bay BH, Ling EA. 2007. Teaching of anatomy in the new millennium. Singa- tion Doctor, researcher, author and Board Representative for pore Med J 48:182–183. South Thames Deanery and is currently a surgical trainee at Bay NS, Bay BH. 2010. Greek anatomist Herophilus: The father of anatomy. Anat Cell Biol 43:280–283. Kingston Hospital and St. George’s London NHS Healthcare Blake JB. 1955. The development of American anatomy acts. J Med Educ Trust, London, UK. 30:431–439. MIKAEL HARTMAN, M.D., Ph.D., is an assistant profes- Bracco . 2012.Bracco AMT, Inc. Leading the World in Advanced 3D Visualiza- sor in the Saw Swee Hock School of Public Health and the tion. Bracco AMT, Inc, Princeton, NJ. URL: http://www.dextroscope.com/ Department of Surgery at the National University of Singa- about.html [accessed 20 February 2012]. Callick R. 2008. The Singapore Model. The American. 2008: May–June. pore, Singapore. He teaches general surgery and epidemiology American Enterprise Institute, Washington, DC. URL: http://www.american. to medical students. com/archive/2008/may-june-magazine-contents/the-singapore-model/article_print CHOON-SHEONG SEOW, M.B.Ch.B., M.D., F.R.C.S., is [accessed 5 March 2012]. a consultant surgeon at the Department of Surgery at the Carmichael SW, Pawlina W. 2004. Loose lips sink ships. Acad Med 79:1002. Chan LK. 2010. Pulling my gut out: Simple tools for engaging students in gross Alexandra Hospital, Jurong Health Service and a visiting con- anatomy lectures. Anat Sci Educ 3:148–150. sultant to the Department of Surgery, National University Chan LK, Cheng MM. 2011. An analysis of the educational value of low-fidelity Health System (NUHS) in Singapore. He teaches anatomy to anatomy models as external representations. Anat Sci Educ 4:256–263.

238 Ang et al. Charalampaki P, Filippi R, Welschehold S, Perneczky A. 2006. Endoscope- Kanna B, Deng C, Erickson SN, Valerio JA, Dimitrov V, Soni A. 2006. The assisted removal of colloid cysts of the third ventricle. Neurosurg Rev 29:72–79. research rotation: Competency-based structured and novel approach to Chow PKH, Soh CR, Tay SM, Cook S. 2009. An integrated approach to learn- research training of internal medicine residents. BMC Med Educ 6:52. ing anatomy, physiology and micro-anatomy: A clinician-based system at Kao T, Ha H. 1999. Anatomy cadaver ceremonies in Taiwan. Zhonghua Yi Shi Duke-NUS Graduate Medical School Singapore. SGH Proc 18:84–90. Za Zhi 29:175–177. Collins JP. 2008. Modern approaches to teaching and learning anatomy. BMJ Kelly BD, Curtin PD, Corcoran M. 2011. The effects of the European Working 337:a1310. Time Directive on surgical training: the basic surgical trainee’s perspective. Ir J Cook S, Puthucheary J, Kamei RK. 2008. Is it learning or is it a prelude to Med Sci 180:435–437. cheating? JIAMSE 18:55–59. Kerby J, Shukur ZN, Shalhoub J. 2011. The relationships between learning Craig S, Tait N, Boers D, McAndrew D. 2010. Review of anatomy education outcomes and methods of teaching anatomy as perceived by medical students. in Australian and New Zealand medical schools. ANZ J Surg 80:212–216. Clin Anat 24:489–497. DeHoff ME, Clark KL, Meganathan K. 2011. Learning outcomes and student- Krishnan KR. 2011. 7th College of Physicians lecture: The changing face of perceived value of clay modeling and cat dissection in undergraduate human medicine, medicine: Past, present and future. Ann Acad Med Singapore anatomy and physiology. Adv Physiol Educ 35:68–75. 40:201–203. DOH. 2009. Department of Health. What is the European Working Time Directive? Lawrence SC. 1995. Anatomy and address: Creating medical gentlemen in Department of Health, London, UK, URL: http://webarchive.nationalarchives.gov.uk/ eighteenth-century London. Clio Med 30:199–228. 1/www.dh.gov.uk/en/Managingyourorganisation/Workforce/Workforceplanningand Lin SC, Hsu J, Fan VY. 2009. ‘‘Silent virtuous teachers’’: Anatomical dissection development/Europeanworking timedirective/DH_077304 [accessed 20 February in Taiwan. BMJ 339:b5001. 2012]. Lindor KD, Pawlina W, Porter BL, Viggiano TR, Grande JP, Barrier PA, Swan- Dozois EJ. 2008. Laparoscopic anatomy for medical students. Anat Sci Educ son JA, Buman KF. 2010. Improving medical education during financially chal- 1:135. lenging times. Acad Med 85:1266–1268. Drake RL. 2007. A unique, innovative, and clinically oriented approach to Lu J, Li L, Sun GP. 2010. A multimodal virtual anatomy e-learning tool for anatomy education. Acad Med 82:475–478. medical education. Lect Notes Comput Sci 6249:278–287. Drake RL, McBride JM, Lachman N, Pawlina W. 2009. Medical education in Mack MJ. 2001. Minimally invasive and robotic surgery. JAMA 285:568–572. the anatomical sciences: The winds of change continue to blow. Anat Sci Educ Mamidanna R, Burns EM, Bottle A, Aylin P, Stonell C, Hanna GB, Faiz O. 2:253–259. 2012. Reduced risk of medical morbidity and mortality in patients selected for Eckert M, Cuadrado D, Steele S, Brown T, Beekley A, Martin M. 2010. The laparoscopic colorectal resection in England: A population-based study. Arch changing face of the general surgeon: National and local trends in resident Surg 147:219–227. operative experience. Am J Surg 199:652–656. McCuskey RS, Carmichael SW, Kirch DG. 2005. The importance of anatomy Ellis H. 2002. Medico-legal litigation and its links with surgical anatomy. in health professions education and the shortage of qualified educators. Acad Surgery 20:i–ii. Med 80:349–351. Ellis H, Crowe A. 2009. Medico-legal consequences of post-operative intra- McLachlan JC. 2004. New path for teaching anatomy: Living anatomy and abdominal adhesions. Int J Surg 7:187–191. medical imaging vs. dissection. Anat Rec 281B:4–5. Epstein NE. 2002. A review of laminoforaminotomy for the management McLachlan JC, Bligh J, Bradley P, Searle J. 2004. Teaching anatomy without of lateral and foraminal cervical disc herniations or spurs. Surg Neurol 57: cadavers. Med Educ 38:418–424. 226–233. McLachlan JC, Patten D. 2006. Anatomy teaching: Ghosts of the past, present Fasel JH, Morel P, Gailloud P. 2005. A survival strategy for anatomy. Lancet and future. Med Educ 40:243–253. 365:754. McMenamin PG. 2008. Body painting as a tool in clinical anatomy teaching. Finn GM, McLachlan JC. 2010. A qualitative study of student responses to Anat Sci Educ 1:139–144. body painting. Anat Sci Educ 3:33–38. Misch DA. 2002. Andragogy and medical education: Are medical students Garcia-Ruiz A, Gagner M, Miller JH, Steiner CP, Hahn JF. 1998. Manual vs internally motivated to learn? Adv Health Sci Educ Theory Pract 7:153–160. robotically assisted laparoscopic surgery in the performance of basic manipula- Motoike HK, O’Kane RL, Lenchner E, Haspel C. 2009. Clay modeling as a tion and suturing tasks. Arch Surg 133:957–961. method to learn human muscles: A community college study. Anat Sci Educ 2:19–23. Giulianotti PC, Coratti A, Sbrana F, Addeo P, Bianco FM, Buchs NC, Anne- chiarico M, Benedetti E. 2011. Robotic liver surgery: Results for 70 resections. Myers DL, Arya LA, Verma A, Polseno DL, Buchanan EM. 2001. Pelvic anat- Surgery 149:29–39. omy for obstetrics and gynecology residents: An experimental study using clay models. Obstet Gynecol 97:321–324. Goddard AF. 2011. Progress on the European Working Time Directive (EWTD) and new deal negotiations. Clin Med 11:420–421. Nagral S. 2005. Anatomy relevant to cholecystectomy. J Minim Access Surg 1:53–58. Gogalniceanu P, Madani H, Paraskeva PA, Darzi A. 2008. A minimally inva- sive approach to undergraduate anatomy teaching. Anat Sci Educ 1:46–47. Naug HL, Colson NJ, Donner DG. 2011. Promoting metacognition in first year anatomy laboratories using plasticine modeling and drawing activities: A Goh BK, Chui CH, Yap TL, Low Y, Lama TK, Alkouder G, Prasad S, Jacobsen pilot study of the ‘‘blank page’’ technique. Anat Sci Educ 4:231–234. AS. 2005. Is early laparoscopic appendectomy feasible in children with acute appendicitis presenting with an appendiceal mass? A prospective study. Nguan C, Kwan K, Al Omar M, Beasley KA, Luke PP. 2007. Robotic pyelo- J Pediatr Surg 40:1134–1137. plasty: Experience with three robotic platforms. Can J Urol 14:3571–3576. Gopalakrishnakone P, Lu J, Sun GP, Abeykoon A, Newton Fernando ON, Oh CS, Kim JY, Choe YH. 2009. Learning of cross-sectional anatomy using Cheok AD. 2011. A multimodal virtual anatomy learning tool for medical clay models. Anat Sci Educ 2:156–159. education. In: Proceedings of the 2nd International Conference on Society Older J. 2004. Anatomy: A must for teaching the next generation. Surgeon and Information Technologies (ICSIT 2011); Orlando, Florida, 2011 March 2:79–90. 27–30. International Institute of Informatics and Systemics (IIIS), Winter Ong BK. 2005. One hundred years of the teaching of medicine in Singapore. Garden, FL. URL: http://www.iiis.org/CDs2011/CD2011IMC/ICETI_2011/ Ann Acad Med Singapore 34:108C–113C. PapersPdf/EB387OJ.pdf [accessed 31 March 2011]. Op Den Akker JW, Bohnen A, Oudegeest WJ, Hillen B. 2002. Giving color to Grochowski CO, Halperin EC, Buckley EG. 2007. A curricular model for the a new curriculum: Bodypaint as a tool in medical education. Clin Anat training of physician scientists: The evolution of the Duke University School of 15:356–362. Medicine curriculum. Acad Med 82:375–382. Park JT, Jang Y, Park MS, Pae C, Park J, Hu KS, Park JS, Han SH, Koh KS, Guttmann GD, Drake RL, Trelease RB. 2004. To what extent is cadaver dis- Kim HJ. 2011. The trend of body donation for education based on Korean section necessary to learn medical gross anatomy? A debate forum. Anat Rec social and religious culture. Anat Sci Educ 4:33–38. 281B:2–3. Patel CB, Ragupathi M, Ramos-Valadez DI, Haas EM. 2011. A three-arm (lap- Haidet P, Morgan RO, O’Malley KJ, Moran BJ, Richards BF. 2004. A con- aroscopic, hand-assisted, and robotic) matched-case analysis of intraoperative trolled trial of active versus passive learning strategies in a large group setting. and postoperative outcomes in minimally invasive colorectal surgery. Dis Colon Adv Health Sci Educ 9:15–27. Rectum 54:144–150. Halperin EC, Perman JA, Wilson EA. 2010. Abraham Flexner of Kentucky, his Pawlina W, Lachman N. 2004. Dissection in learning and teaching gross anat- report, medical education in the United States and Canada, and the historical omy: Rebuttal to McLachlan. Anat Rec 281B:9–11. questions raised by the report. Acad Med 85:203–210. Pawlina W, Hammer RR, Strauss JD, Heath SG, Zhao KD, Sahota S, Regnier Hildebrandt S. 2010. Lessons to be learned from the history of anatomical TD, Freshwater DR, Feeley MA. 2011. The hand that gives the rose. Mayo teaching in the United States: The example of the University of Michigan. Anat Clin Proc 86:139–144. Sci Educ 3:202–212. Primal Pictures. 2007. Primal Pictures.com. 3D Human Anatomy Software. Pri- Jime´nez AM, Aguilar JF. 2009. Laparoscopy: learning a new surgical anatomy? mal Pictures Ltd, London, UK. URL: http://www.primalpictures.com/ [accessed Anat Sci Educ 2:81–83. 20 February 2012]. Jones NA, Olafson RP, Sutin J. 1978. Evaluation of a gross anatomy program Purkayastha S, Paraskevas P, Darzi A. 2007. Make surgeons more active in without dissection. J Med Educ 53:198–205. teaching anatomy at all levels. BMJ 334:110.

Anatomical Sciences Education JULY/AUGUST 2012 239 Rajendran K, Tan CK, Voon FC. 1990. Computer graphics in the teaching and Vasan NS, DeFouw DO, Holland BK. 2008. Modified use of team-based learn- learning of anatomy. J Vis Comm Med 13:49–52. ing for effective delivery of medical gross anatomy and embryology. Anat Sci Riegert-Johnson DL, Korf BR, Alford RL, Broder MI, Keats BJ, Ormond KE, Educ 1:3–9. Pyeritz RE, Watson MS. 2004. Outline of a medical genetics curriculum for in- Willis RE, Coverdill JE, Mellinger JD, Collins JC, Potts JR III, Dent DL. 2009. ternal medicine residency training programs. Genet Med 6:543–547. Views of surgery program directors on the current ACGME and proposed Rizzolo LJ, Rando WC, O’Brien MK, Garino A, Stewart WB. 2011. Effective- IOM duty-hour standards. J Surg Educ 66:216–221. ness of a shortened, clinically engaged anatomy course for physician assistant Williams RS, Casey PJ, Kamei RK, Buckley EG, Soo KC, Merson MH, students. Anat Sci Educ 4:64–70. Krishnan RK, Dzau VJ. 2008. A global partnership in medical education Simpson C, Cottam H, Fitzgerald JE, Giddings CE. 2011. The European work- between Duke University and the National University of Singapore. Acad Med ing time directive has a negative impact on surgical training in the UK. Surgeon 83:122–127. 9:56–57. Winkelmann A, Gu¨ ldner FH. 2004. Cadavers as teachers: The dissecting room Standring S. 2009. New focus on anatomy for surgical trainees. ANZ J Surg experience in Thailand. BMJ 329:1455–1457. 79:114–117. Strkalj G, Spocter MA, Wilkinson AT. 2011. Anatomy, medical education, and Wong WC, Tay SS. 2005. The teaching of anatomy: The first hundred years human ancestral variation. Anat Sci Educ 4:362–365. (1905–2005). Ann Acad Med Singapore 34:72C–78C. Sugand K, Abrahams P, Khurana A. 2010. The anatomy of anatomy: A review Yi F, Jin WS, Xiang DB, Sun GY, Huaguo D. 2012. Complications of laparo- for its modernization. Anat Sci Educ 3:83–93. scopic cholecystectomy and its prevention: A review and experience of 400 Tan CC. 1998. Rethinking medical education. Singapore Med J 39:273–276. cases. Hepatogastroenterology 59:47–50. Vasan NS, DeFouw DO, Compton S. 2011. Team-based learning in anatomy: Yip GW, Rajendran K. 2008. SnapAnatomy, a computer-based interactive tool An efficient, effective, and economical strategy. Anat Sci Educ 4:333–339. for independent learning of human anatomy. J Vis Comm Med 31:46–50.

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