Medical students interacting with the families of donors they are dissecting?
Dr Ernest Talarico concedes that some may consider this “a little bit bizarre”.
However, Dr Talarico, Associate Director of Medical Education at Indiana University School of Medicine-Northwest, believes it is a model that can help students develop key competencies, among other positives for both students and families.
It is “a big shift” from traditional protocols, he recognises.
“Traditionally, students may get an ID number for an anatomical donor and their cause of death, and that is all they would receive,” Dr Talarico tells the <em><strong>Medical Independent (MI)</strong></em>. “But in our programme, we try to put our students in contact with the family of those patients — we call them ‘first patients’ — that they are dissecting in the laboratory. We do this early on. It usually begins with a letter or email and then develops into more of that, or phone calls, or other contacts.”
As Dr Talarico confirms, some donors have consented to the involvement of their families in communications pertaining to the programme, following their death, while others may not have explicitly done so. However, in the latter case, if the family itself wants to share information on the donor, this is permitted.
<img src=”../attachments/facdee4b-8ce0-4852-9054-bd23897f54b5.JPG” alt=”” /><br /><strong>Dr Ernest Talarico of Indiana University School of Medicine-Northwest</strong>
As all donors consented to donate their body to the programme, with the intent of helping the development of medical students, Dr Talarico indicates that he does not consider the interaction with families as an ethical dilemma.
Occasionally, a family may choose not to participate, he says, and this is fully respected by the university.
The families, for their part, want to feel secure that their loved ones are being treated with dignity and respect — and Dr Talarico believes the system at the medical school offers further confirmation of this. For students, the method fosters professionalism and compassion, he posits.
The protocol is outlined in a paper written by Dr Talarico and published in the journal Clinical Anatomy in 2013 (‘A Change in Paradigm: Giving Back Identity to Donors in the Anatomy Laboratory’).
Information from families can augment medical knowledge about the donor, while exposing medical students to grieving relatives can enhance the skills and competencies of future physicians, it argues.
There are a number of guiding principles, including strong emphasis on the cadaver as the ‘first patient’, a concept encouraged at many medical schools.
Another principle is ‘treating the total patient’, which commits students to using all that they learn from their ‘first patients’ to understand the medical and non-medical factors that contribute to a patient’s total wellbeing and quality of life.
Preparation of an ‘autopsy report’ is another aspect. According to the paper, students perform a full-body examination as part of an autopsy report that they will develop throughout the course of dissection. Investigations can be augmented with the application of knowledge and information gained from family contact.
This information — like a history taken by a physician — is added to this report using anatomical and medical terminology, states the paper.
<h3>Letters to families</h3>
Early in the anatomy course, students write letters to the families of their donors (with the permission of the State of Indiana Anatomical Education Program and donors and/or donor families), “thus beginning ongoing correspondence that constructs the stories of past lives, humanises the ‘cadaver experience’ and enables student doctors to learn more about the lives of those who gave the ultimate gift of self to help others”.
Students are extensively counselled by the faculty regarding their professional and ethical obligations and letters are reviewed and discussed with students prior to contact with family members, according to the paper.
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The families, for their part, want to feel secure that their loved ones are being treated with dignity and respect
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“If any question or situation arises that might pose an issue, the students defer to faculty. Evidence of this comes from an example in which family members requested medical advice regarding their own cancer risk because their loved one passed away secondary to a rare, deadly cancer. In this case and a few others that have occurred, faculty resolved the issue with family members with the involvement of students to promote their learning of professional and ethical competencies.”
<h3>Medical records</h3>
Typically, says the paper, families forward medical records, narratives, photographs and videos, allowing students to learn about the medical history, life and family relationships of the donors.
In its conclusion, it noted that medical students are treating their donors not as anonymous cadavers, but rather as their very first patients. Students learned not just about anatomy and how their patient died, but had an opportunity to learn how he or she lived by communications and meetings with the family. Students also had an opportunity to conduct a medical history, complete detailed autopsy reports and radiological examinations, and ask questions of the donor’s loved ones.
“In this way, they learn not only about the anatomy and the signs and results of illness, but also about the roles of physician and family in patient care”.
The paper includes positive feedback from students and families. But Dr Talarico acknowledges that the ‘added element’ of the programme, involving engagement with families, demands appropriate preparation.
“We talk with students about it, we counsel them, and our students are pretty much okay with that — they consider it an honour and a privilege to be able to learn more about that individual and answer some of the families’ questions.”
<h3>Donation programmes</h3>
In Ireland, five of the six medical schools have body donation programmes. The exception is the University of Limerick Graduate Entry Medical School, which does not accept donated cadavers. A UL spokesperson explains anatomy learning is supported by use of “high-quality anatomical models, living anatomy, radiological scans and the latest e-learning resources. Technological developments with three-dimensional and large-scale display systems enable highly-detailed anatomical study both in the school’s facilities and on the students’ own computers.”
The level of information shared with students, on the donors, varies slightly between the colleges.
At NUI Galway, medical students are generally informed only of standard details concerning the donor, such as age at death and the cause of death, as stated on the donor’s Death Certificate.
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Students are couselled on appropriate behavious, such as resisting the possible temptation to use black humour
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Mr Alexander Black, Lecturer in Anatomy at the University’s School of Medicine, tells <em><strong>MI</strong></em>: “If the donor themselves has given any information regarding past surgeries or medical interventions on their donor form, students may also be given this information. They are not given the name of the donor.”
The programme at Indiana University School of Medicine-Northwest is “interesting”, says Mr Black, but “it may be worth noting that there are many differences in a first-year medical class between Ireland and the USA”.
Medical students in the US, for example, already hold a degree before they can study medicine, so they are several years older than the majority of medical students in Ireland. Therefore they “may be better equipped in terms of emotional maturity to deal with the personhood of an anatomy donor”.
He adds: “It may also be important to note that American medical schools tend to be very well served in terms of financial support for such programmes, which necessitate large numbers of staff… ”
<h3>Irish culture</h3>
“Irish culture with regards to death and burial is also significantly different. Indeed, it is only within the last few decades that donating one’s body to a medical school has gained a level of social acceptance as an alternative to a traditional wake immediately followed by final internment.”
At NUI Galway, students meet the families of the donors once a year at a special Memorial Service. However, they are not given information regarding which donor is related to which family.
Mr Black explains: “This student-led service is organised by [the students] with the steering support of one member of Anatomy staff and one member of the University Chaplaincy. It offers students a chance to personalise their experience of cadaveric dissection by giving their thanks to the families of donors in person — particularly at the reception held following the service.”
In respect of preparing students for cadaveric-based learning, Mr Black says a lecture-based induction has been developed following research into the psychological and psychometric reactions of students to cadaveric dissection programmes. “This research was instigated due to concerns that a minority of students were observed having adverse reactions to this pivotal element of the curriculum.”
Broadly similar structures are in place at the other Irish universities running body donation programmes. Prof John F Cryan, Chair of the Department of Anatomy and Neuroscience at UCC, informs MI that “personal information” supplied to students on donors is limited to the fact that they come from the Munster region.
An induction programme emphasises the privilege involved in participating in a cadaveric-based anatomy teaching course. Every two years, a student-led Thanksgiving Service is held, attended by students, relatives of donors and staff of the Anatomy Department and School of Medicine.
At Trinity College Dublin, an orientation programme is run for students prior to beginning dissections. Ms Siobhan Ward, Chief Technical Officer at the Department of Anatomy, explains that this includes a walk-around the dissection theatre and the 12 student work stations before the donors are present. Students are counselled on appropriate behaviour, such as resisting the possible temptation to use black humour.
Language is important — it is ‘incisions’, for example, not ‘cutting’, outlines Ms Ward.
Head of Anatomy Department at TCD, Dr Nick Mahony, further informs <em><strong>MI</strong></em> that it is underlined to the students that the donor is their ‘first patient’. As he notes, the Medical Council has developed <em>Guidelines for Medical Schools on Ethical Standards and Behaviour appropriate for Medical Students</em>. Professionalism is a huge aspect of these guidelines and “that starts with the first patient,” he says.
In respect of sharing donors’ personal details, since 2010 Trinity has also provided students with the donor’s first name, in addition to their age and recorded cause of death.
This change was instigated following research undertaken by Ms Ward, which involved feedback from student and staff workshops.
She says the fact that donors are known by their first names “really resonates” with families, who have regarded it as “very positive”.
Dr Mahony adds that sometimes relatives of donors bring in x-rays and medical notes, although this takes place informally.
The availability of a dedicated family room is noted as important. When a donor is received by the Department at the Trinity Biomedical Sciences Institute, next of kin may accompany the coffin to the relatives’ room. It is also a space where families can gather on anniversaries or special occasions. Ms Ward often reassures families that their relative is nearby, residing just on the other side of the wall.
Every two years, Trinity holds the Act of Remembrance and Thanksgiving for those who have donated their bodies for medical education and research at the College.
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<h3>A gift of education: Figures on donation in Ireland</h3>
Some 308 human donor bodies were donated to the five medical schools that operate body donation programmes, from 2012 to 2014 inclusive.
The statistics were released to <em><strong>MI</strong></em> following requests under Freedom of Information legislation and related to registered donors who died during these years.
Between 1 January 2012 and 9 February 2015, some 571 people registered to donate their bodies for anatomical study at Trinity College Dublin. In the years 2012 to 2014 inclusive, some 48 bodies were received for anatomical study at the College, with one body declined due to “unexpected pathology”. Donors whose bodies were received in this period ranged in age from early 40s to mid-90s.
At the RCSI, between the years 2012 and 2014 inclusive, some 94 bodies were received for anatomical study, with donors ranging in age from early 20s to over 100. One donor had to be declined there due to “unexpected pathology”.
At UCC, during the same period, there were 66 bodies donated. However, four donor bodies had to be declined during these years. Two bodies were declined because of “poor preservation due to severe arteriosclerosis”. In another case, there was a delay in transfer to UCC post-death, while another instance involved “pronounced jaundice”. The age of donor bodies received during these years ranged from mid-40s to over 100.
UCD informs <em><strong>MI</strong></em> that up to 1,200 donors are currently enlisted on its programme, noting that a more precise figure would take an “extensive review of decades of paperwork”. From 2012 to 2014, 46 bodies were donated for anatomical study, with one declined due to having undergone major surgery. Deceased donors ranged in age from mid-40s to over 100.
At NUI Galway, during the same period, 54 donor bodies were received and all were suitable for anatomical study.
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<h3>‘Rite of passage’ is of huge import for medical students</h3>
The vibrant, tidy illustrations of tomes such as <em>Gray’s Anatomy</em> and <em>Netter’s Atlas</em> detail the wondrous story of human anatomy. But they cannot reveal it in all its glory.
Many within medicine regard the journey into the dissection lab as an integral aspect of accruing — and retaining — anatomical knowledge. It is also an exercise laced with potent symbolism.
“It was a rite of passage — and we knew it was a rite of passage,” reflects Mr Pishoy Gouda, final-year medical student at NUI Galway, of his first dissection lab. “It was one of the things that distinguished us, as medical students, and we were all looking forward to it but were also a bit wary. It wasn’t something you went into lightly and the staff didn’t take it lightly either.”
The realisation that the donor had gifted their body so that students could learn was important, he says, and thus one needed to “get over” distractions that might inhibit this.
As a learning tool, Mr Gouda feels that the cadaver experience cannot, at present, be adequately replaced by multimedia systems.
<img src=”../attachments/458e60c0-8990-45bc-810d-1eb4262af43d.JPG” alt=”” /><br /><strong>Mr Pishoy Gouda, NUI Galway</strong>
In the US, Dr Talarico at Indiana University School of Medicine-Northwest concurs that technology has not reached the point whereby cadaver-based learning or cadaver dissections or prosections can be discarded.
“I don’t think there really is a substitute for the physical part of the dissection, the feelings of the muscles, nerves and arteries and veins, the examining of the anatomy and the anatomical relationships. A computer software programme will show you one thing; it will not show you the differences of anatomy and anatomical variation, whether they are normal variations or whether they are abnormal as a result of some pathology or disease process.”
No two donors are anatomically the same, he says, and software programmes are frequently not going to show that.
Internationally, however, cost factors, availability of new technologies, time demands on curricula and cadaver shortages have seen many colleges move away from dissection and cadaveric-based learning and reduce the time spent on anatomical tuition.
A 2010 paper in the <em>Education in Medicine Journal</em> (‘The Role of Traditional Dissection in Medical Education’, Hassan et al) noted that resources for teaching anatomy had made giant leaps due to advances in technology, information and imaging tools.
Anatomists had been polarised into two “belief systems”, according to the paper: “The modernists, who regard the cadaver dissection as obsolete and dispensable, and the traditionalists, who think that dissection is the keystone of anatomy education.”
The paper stated that some educationalists argued that the shift away from a descriptive “cadaver-orientated anatomy” to a “clinically-trimmed, computer-orientated anatomy” may not be positive as regards the assimilation and sustenance of core knowledge.
It argued that the “psychovisual, tactile, multi-sensory stimuli that are part of a dissection ritual leave an indelible mark on the observers’ minds and aid retention of anatomic data among its learners”.
It concluded that cadaver dissection and modern technological resources should complement one another, strongly warning against the abandonment of the former.
Furthermore, a paper published in Anatomical Sciences Education in 2014 (‘Human Cadavers vs Multimedia Simulation: A Study of Student Learning in Anatomy’, Saltarelli et al) found that the human cadaver laboratory “offered a significant advantage over the multimedia simulation programme on cadaver-based measures of identification and explanatory knowledge”.
Dr Alistair Hunter, Senior Lecturer and Academic Manager of the Dissection Room at the Department of Anatomy, King’s College London (KCL), tells <em><strong>MI</strong></em> that, sadly, many UK medical schools no longer facilitate dissection. However, KCL has retained its dissection programme and considers it highly important.
As Dr Hunter outlines, dissection makes anatomical tuition more memorable — it encourages recall; it requires students to manage stress; facilitates teamwork; and harnesses the skill of clinical detachment.
In the UK, declining time spent on anatomical tuition for medical undergraduates, including loss of dissection programmes, has particularly disquieted the surgical community, he says.
“There is a huge rumpus, which has been going on for the last five or six years. There was a meeting at the Royal College of Surgeons (England) a few years back, it was called ‘Cruellest Cut of All — Anatomy in the 21st Century’ and that was a conference that was set up to get a feel for the true extent of the loss of anatomy and to try and promote its retention.”
As he notes, postgraduate institutions are left “picking up the pieces” when confronted with graduates of medicine with insufficient knowledge of anatomy.
“The amount of time given over to anatomy in the curriculum has dropped hugely over the last decade [in medical schools]. I think now the postgraduate departments are beginning to recognise there is a major, major problem in this,” he says.
Dr Hunter says research within departments of anatomy/molecular biology are important, but increasingly the time spent on teaching anatomy, and ensuring it is taught effectively, is diminishing.
Meanwhile, feedback from Irish colleges indicated that they regarded dissection and cadaveric-based learning as indispensable.
As Prof Cryan at UCC remarked: “Although we use different teaching methods for the instruction of anatomy — including cadaveric-based, anatomical models, IT-based, radiological imaging — which complement each other, we find that there are areas where cadaveric-based anatomy teaching has advantages over other methods.”
These areas include the cadaver as ‘first patient’; anatomical variation lacking in models; the opportunity for students to visualise and feel structures and the 3D relationship of structures within the body; and the fact that a cadaveric-based course gives students the experience of cutting through layers of the body to locate clinically-important structures.
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