Repairing the Break – An Anatomical Saga



C. E. Clarkson
Kimerly J. Wilcox


My gaze was fixed upon an egg-sized swelling near the left shoulder of this beautiful golden retriever. The client said her dog had intermittent left forelimb lameness but the referring veterinarian’s radiographs showed no abnormalities. Obviously something was not normal. What was causing the dog’s lameness? Hmmm. Think! Think!

“Well?  So what structures are in this area?” repeated the attending clinician. I knew everyone was waiting for my words of wisdom to break the now deadly silence; after all, fourth-year students should know their anatomy. Several years ago I could have recited all the bones, muscles, ligaments, and nerves in this region. At the time, I knew I needed to remember everything for the test, but now I realize that this is the ultimate test. If only I could remember….


Imagine a class of first-year veterinary students, bombarded with massive amounts of material. Ultimately, without any context to give it significance or immediate reason to retain the information, it quickly fades from their memories once the semester is over. This is the “anatomical saga” - a body of knowledge destined to fade. Or - can we intervene to transform this scenario?  Can we repair this knowledge break? 

A “Success” Story
Over all, the veterinary gross anatomy course has been quite a success story, since first-year students do well on exams (final grade averages of 84-86%), suggesting that this course is an effective learning experience. But, is this really true? 

CVM 6100 Veterinary Gross Anatomy is a core course within the first year of a four-year graduate level program, culminating in a Doctor of Veterinary Medicine degree. This will be the first course in anatomy for most of our students, since it is not a required prerequisite for entry into the program. We cover developmental and gross anatomy rapidly: carnivore (dog and cat) and developmental anatomy for eight weeks, followed by six weeks of ungulate (horse and cow) anatomy, totaling 28 hours of lectures plus 129 hours of laboratory dissection. Two instructors (Clarkson and one other) teach the carnivore and developmental material and a third instructor is responsible for the ungulate portion; all instructors teach laboratories.  The combination of lectures, student dissections, and optional web-based materials (Table 1) provide students with a large variety of learning experiences.


Moodle site:

  • Mediasite Lecture Capture (recordings)
  • Image Gallery (repository for faculty and student dissection images/videos)
  • Clinical Cases for Anatomical Problem-Solving

Veterinary Anatomy Website (http://vanat.cvm.umn.edu)

  • Carnivore Dissection Lab Introductions (with images)
  • Embryology Highlights (Camtasia screencasts)

Self-assessment Tests:

  • Veterinary Anatomy Concept Checker
  • Carnivore Muscle Identification
  • Developmental Anatomy quizzes
Table 1. Selected Veterinary Gross Anatomy Digital Assets

The course’s digital assets are listed in Table 1. The Veterinary Anatomy web site, an extensive, rich resource developed by the College of Veterinary Medicine’s Dr. Thomas F. Fletcher, has been a tremendous resource for our students as well as students from all over the world. In particular, the “Carnivore Dissection Lab Introductions” section (http://vanat.cvm.umn.edu/carnLabs/) is the most heavily utilized with over 42,000 visits in 2011 (Google Analytics). This particular component provides a condensed lab dissection summary, anatomical terms list, instructor commentaries, and actual dissection images with labels that can be toggled on or off, allowing students to test their knowledge.  These lab introductions parallel the required dissection guide textbook (Evans and de Lahunta, 2010) and are commonly used by students to prepare for or review the lab material.  Other resources from the Veterinary Anatomy site listed in Table 1 provide unique ways to learn and options for student self-assessment.

Along with other content and resources, the course Moodle site provides recorded lectures for review, and an image gallery that allows both faculty and students to upload and share their digital images and videos from the labs. Also listed in Table 1 are the “Clinical Cases for Anatomical Problem-Solving,” a new asset and the focus of the following discussion.

Focused Disconnect
Teaching is an extremely gratifying experience; anatomy in particular is fun (I think) and, as mentioned, students perform well in our class and learn the material. However, the opening scenario exposes a serious deficiency in anatomical knowledge retention and retrieval when it is needed most: while problem-solving clinical cases during fourth year clinical rotations. Are we doing something wrong?

Halpern and Hakel (2003) provide a brief overview of research in the area of teaching for long-term retention and transfer. They very logically state that the underlying reason we teach is so that students can transfer their learning to situations they encounter after they leave the educational institution; in this case, so that they can apply their knowledge to the practice of veterinary medicine. For our students, it is easy to lose track of this perspective – the “big picture” - when immersed in the early basic science teachings of year one. Then, each course is focused on content helpful toward understanding the material of a particular discipline - with perhaps little consideration of how students will need to use that knowledge in the future. The “future” begins for most students in the fourth year clinical rotations. As a former practicing veterinarian, I (Clarkson) have been bothered by this approach, but conformed to the prevailing, accepted sentiment that we (basic science instructors) all do our individual parts and it is up to the clinicians to teach the clinical components. In other words, we should remain focused on "our" content and on task. But, is our focus too narrow? How will our students ever develop a bigger picture? In isolation there is some logic to providing a discrete body of base knowledge and some comfort to many who teach the basic sciences that they are not expected to apply the clinical bridge to their material. However, there is a huge flaw in this reasoning, typified by the opening scenario -  the students are not transferring what we teach to the clinical patient. In response, this project represents a model in development to facilitate students’ transfer of anatomical knowledge to the patient, by teaching in context.

Teaching in Context 
In this project, teaching in context involves a guided approach to problem-solving clinical cases that feature anatomical abnormalities. These cases serve as a critical first step toward the transfer of anatomical knowledge to actual clinical patients.   

During the eight-week carnivore anatomy portion of the course (Clarkson's main teaching component), three anatomical problem-solving clinical case scenarios are posted and responded to entirely within the course Moodle site. Key questions guide students' case processing, requiring them to (1) recognize the problem (a critical first step to problem-solving), (2) recall the anatomy of the region (knowledge retrieval), and (3) justify how an alteration of that anatomy could contribute to the clinical signs, thus applying anatomical knowledge within an appropriate future context. Answers and explanations are posted in Moodle following a pre-determined deadline for each case.

Case example:
A two-year-old intact male Labrador retriever is brought to your practice with a history of acute disuse of the right rear leg. The owner is unaware of any traumatic precipitating cause for this lameness. On examination of the right knee the joint feels “loose,” - the tibia (lower leg) can be pushed slightly forward (past the end of the femur), and the knee can be pushed slightly outward (laterally).  Neurological examinations were within normal limits.

After reading the case, students are prompted to respond to the following questions without consulting outside resources (for your reference answers are provided in parentheses):
  1. List the problems. (Right rear leg lameness and laxity of the right knee joint.)
  2. List the anatomical structures you would consider as you try to determine the cause of the reported symptoms. After each item briefly explain how it could relate to the clinical case.  (Based on the information given in the scenario, abnormalities detected in the right knee are a potential cause for the observed lameness. Damage to the following ligaments could contribute to the abnormal knee movement noted in the scenario: (1) a cranial cruciate ligament tear would allow the tibia to slide forward with respect to the femur and (2) a tear in the lateral collateral ligament would allow the knee to be pushed more laterally than normal.) 

Cases are staged to correspond to students’ current knowledge of carnivore anatomy, with each case increasingly more difficult; they earn up to one bonus point per case for correctly identifying the actual "problem" presented by the patient and the anatomical structures that might be involved. At the time of this writing, 200 students (two consecutive student cohorts) have had the option to respond to the clinical cases; the majority of students chose to participate. The case scenarios are designed for student practice and self-assessment as they apply their knowledge of anatomy within the context of a clinical case. The current text-based cases will be expanded in the future to include radiographs, MRI, CT scans, and patient images to demonstrate anatomical abnormalities that the students must then identify. The commonality of all these interventions will be to offer insight to the student regarding their abilities to (1) identify problems and (2) recall anatomical structures relevant to these problems in a clinical context.

Findings
Problem identification within the cases has resulted in an interesting set of student responses that seemed dependent on the exact phrasing of the question. For example, Case 1 asks the following question: What is the problem(s)? Case 2 provides the following prompt: List the problem(s). Student responses to Case 1 often resulted in an attempt to conjecture a diagnosis, while Case 2’s statement, “List the problem(s)” produced the desired student response of listing the clinical problems, e.g., lameness, swelling, etc. This was an accidental question variation that may unintentionally have led to different kinds of student responses, although it is difficult to determine if the difference is due to learning what was expected after the first case. Future iterations will provide clearer instructions to avoid misinterpretations.

The recall of anatomical structures item (the second question related to the clinical cases) has also resulted in some interesting findings.  For example, one case scenario describes a dog with intermittent pain on extension of the right shoulder plus a soft swelling in the cranial (towards the head relative to the) shoulder region. When prompted to list potential anatomical structures that may be involved with the clinical problem, the majority of students named specific muscles in the shoulder region. Very few students mentioned the muscle tendons, tendon sheaths, or ligaments as potentially involved structures. The answer in this case was in fact a torn biceps brachii tendon sheath that resulted in leakage of synovial (joint) fluid, hence the soft swelling cranial to the shoulder. Why were students so focused on muscles, even though very little muscle tissue is present in this specific region? This may be explained by the many hours spent dissecting and identifying muscles; although a muscle’s tendon attaches it to the bone, often students don’t take great care in uncovering these attachments.

In summary, these findings and others, drawn from student responses to the clinical case scenarios, will be used to inform future course interventions (e.g., additional targeted Moodle-based clinical cases, web-based learning exercises, and improved lab instructions) to reinforce learning the important structures that students are unknowingly overlooking. In addition, the cases provide students with critical opportunities to learn their anatomy in context, facilitating the retrieval of that knowledge within a similar, future context, the real-life anatomical problem solving of clinical patients. It is our hope to follow these students and assess their performance in the fourth year clinics.

Acknowledgement
I would like to thank the Faculty Fellowship Program (Office of Information Technology) and the individuals involved for providing the needed support and guidance to begin to understand this problem and work towards better long-term student outcomes.

References
Howard E. Evans and Alexander de Lahunta, Guide to the Dissection of the Dog (St. Louis, MO: Saunders Elsevier, 2010).

Diane F. Halpern and Milton D. Hakel, “Applying the Science of Learning To the University and Beyond: Teaching for Long-Term Retention and Transfer,” Change 35(4) (2003): 36-41.



  

Christina E. Clarkson <clarkson@umn.edu>
Christina E. Clarkson, DVM, PhD is an Assistant Professor in the Department of Veterinary and Biomedical Sciences, I teach several courses within the veterinary curriculum. Within these efforts my ultimate goal is to optimize the student learning experience; pedagogical research and technology continue to provide intriguing ways in which to strive for this outcome.
 
Kimerly J. Wilcox Ph.D.<wilco001@umn.edu>
I am an academic technology consultant in OIT’s Academic Technology Professional Services and also work in several OIT faculty development programs. I have been involved in managing the Faculty Fellowship Program since its inception and continue to be delighted to be able to work with talented instructors such as Tina Clarkson.