Anatomy learning and retention among students in a graduate-entry medical course Michelle Machado B.Sc (Hons), M.Sc Thesis submitted in fulfilment of the requirements for the degree of Doctor of Philosophy (Education) College of Arts and Education Victoria University 7 July 2017 Running head: ANATOMY KNOWLEGDE IN MEDICAL STUDENTS i Abstract Anatomy forms the basis of clinical examination and is integral to today’s medical curriculum. Yet, increasingly evident in the literature is feedback from clinicians and surgeons about the perceived lack of anatomical knowledge among recent medical graduates. To understand the issues surrounding student learning and retention of anatomy, a mixed-methods design was utilized to explore medical students’ anatomical knowledge throughout their Bachelor of Medicine and Bachelor of Surgery (MBBS) degree. Students enrolled in the four-year graduate-entry MBBS course at Monash University participated in the study. Participants from the preclinical (Year A) and clinical years (Years B, C and D) sat an online assessment consisting of 60 clinically relevant anatomy multiple-choice and extended-matched questions whose objectives had been previously covered in the preclinical teaching. Altogether, 136 students participated in the study. The results revealed that knowledge of anatomy declined over time and this was significant in the final two clinical years. The drop in anatomical knowledge was not uniform. The regions of anatomy better retained were associated with frequent exposure and reinforcement in the clinical years. Participants cited an intense and time-constrained curriculum, poor integration in the clinical years and rare opportunities for revising and testing anatomy as reasons for the decline of knowledge. The results of this study highlight the need for conceptual coherence at the time of teaching; the importance of vertical integration in providing students with frequent learning opportunities in the clinical years; and, the value of formatively testing students’ knowledge of anatomy throughout the clinical years. ANATOMY KNOWLEDGE IN MEDICAL STUDENTS ii Declaration of Originality I, Michelle Machado, declare that the PhD thesis entitled “Anatomy learning and retention in medical students in a graduate-entry MBBS course” is no more than 100,000 words in length including quotes and exclusive of tables, figures, appendices, bibliography, references and footnotes. The thesis contains no material that has been submitted previously, in whole or in part, for the aware of any other academic degree or diploma. Except where otherwise indicated, this thesis is my own work. Signed: Date: 7 July 2017 ANATOMY KNOWLEDGE IN MEDICAL STUDENTS iii Acknowledgements I would like to thank my supervisors Dr. Margaret Malloch and Dr. Catherine Haigh for their continuous guidance and encouragement throughout this incredible journey. Their scholarly advice, positive and constructive feedback and unwavering support helped me to accomplish this enormous task. I would also like to extend my sincere gratitude to Dr. Bill Haigh, who was a key player in the design and implementation of the online assessment tool used in this research. I extend my sincere gratitude to Assoc. Prof Shane Bullock and my colleagues at Monash University for their moral support and positive reinforcement in helping me complete my thesis. To my husband, Gavin Pinto, thank you for your constant support throughout these years. You always found ways to keep me driven and motivated, even when life threw challenges our way. Without your love and encouragement, I could not have accomplished this. To my daughter, Natalie, I’ve spent many days juggling motherhood and writing a thesis. You are my light and I dedicate this thesis to you in hopes of inspiring you to always strive for what you want, no matter how difficult the circumstances. To my family and my in-laws, I am forever grateful for your encouragement and support you provided me with during those crucial years of balancing motherhood and completing my thesis. I was able to make progress in my thesis through all of the various changes in my life because of the love and support you gave me. So thank you! Finally, to the medical students in the Monash Graduate-Entry MBBS program. Thank you for your time and generosity in participating in this study. Without you all, this thesis would not be possible. ANATOMY KNOWLEDGE IN MEDICAL STUDENTS iv Table of Contents Abstract ............................................................................................................................ i Declaration of Originality .............................................................................................. ii Acknowledgements ........................................................................................................ iii Table of Contents ........................................................................................................... iv List of Figures ............................................................................................................... vii List of Tables .................................................................................................................. ix List of Abbreviations ...................................................................................................... x List of Appendices ........................................................................................................ xii Chapter 1: Introduction ................................................................................................. 1 1.1 Foundation of Research .......................................................................................... 1 1.2 Background and Contextual Base for Research ..................................................... 7 1.2.1 Bachelor of Medicine / Bachelor of Surgery Program in Australia ................ 7 1.2.2 Monash Graduate-entry Bachelor of Medicine / Bachelor of Surgery Program ........................................................................................................... 8 1.3 Purpose, Aims and Rationale for Research .......................................................... 19 1.4 Organisation of Thesis .......................................................................................... 22 Chapter 2: Anatomy: Origins, History and Current Trends ................................... 25 2.1 Anatomy—Importance and Origins ..................................................................... 25 2.1.1 Why is Anatomy Important? ......................................................................... 25 2.1.2 Origins of Anatomy ....................................................................................... 30 2.2 Anatomy in the Twentieth Century—The Early Years ........................................ 35 2.2.1 Traditional Anatomy Curriculum .................................................................. 35 2.2.2 Challenges Associated with the Traditional Curriculum ............................... 38 2.2.3 Early Medical Education Reform .................................................................. 39 2.3 Anatomy in the Twentieth Century—The Past 30 Years and Current Trends ..... 41 2.3.1 Late Medical Education Reform ................................................................... 41 2.3.2 Three Curriculum Formats and Their Instructional Methods ........................ 43 2.3.3 Outcome and Competency-based Education ................................................. 50 2.3.4 Modern Teaching Tools Used in Anatomy ................................................... 55 Chapter 3: Learning and Assessment of Anatomy .................................................... 73 3.1 Learning Approaches and Theories ...................................................................... 73 3.1.1 Theories of Learning ..................................................................................... 73 3.1.2 Adult Learning and Learning in the Workplace ............................................ 77 3.1.3 Approaches to Learning Anatomy ................................................................. 85 3.1.4 Recontextualisation of Knowledge ................................................................ 90 3.2 Assessment ........................................................................................................... 92 3.2.1 Types of Assessment in Anatomy ................................................................. 93 3.2.2 Assessment of Anatomy in the Traditional and Modern Curricula ............... 94 Chapter 4: Anatomy: Current Debates ...................................................................... 98 4.1 Current Debates Surrounding the Modern Anatomy Curriculum ........................ 98 4.1.1 Curriculum Format ........................................................................................ 98 4.1.2 Declining Knowledge with No Vertical Integration ................................... 102 4.1.3 Lack of Core Curriculum and Competency-based Education in Anatomy . 109 4.1.4 Lack of Competency-based Assessments in Anatomy ................................ 112 4.1.5 Learning of Anatomy .................................................................................. 115 ANATOMY KNOWLEDGE IN MEDICAL STUDENTS v 4.1.6 Retention of Anatomy ................................................................................. 118 4.1.7 Anatomy Educators ..................................................................................... 123 4.1.8