THE ANATOMICAL RECORD (PART B: NEW ANAT.) 289B:134 –138, 2006 EDUCATION NOTE Study Pace as a Factor That Inﬂuences Achievement in a Human Anatomy Course RODRIGO ENRIQUE ELIZONDO-OMAÑA,* MARÍA DE LOS ANGELES GARCÍA-RODRÍGUEZ, JESÚS ALBERTO MORALES-GÓMEZ, AND SANTOS GUZMÁN-LÓPEZ Determining the optimal conditions for learning anatomy will help medical students to do better in a gross anatomy course. We examined the two types of anatomy courses offered in our institution: slow-paced (SP) and fast-paced (FP) courses, in which the same content is taught in approximately the same number of hours (SP ⴝ 91 hr; FP ⴝ 90 hr), but the duration of each course differed (SP ⴝ 91 1-hr sessions lasting 20 weeks; FP ⴝ 45 2-hr sessions lasting 9 weeks). The objective of this study was to ﬁnd out whether a relationship exists between anatomy course pace and achievement. Two groups of students were tested on their anatomy knowledge both before beginning and after completing either the SP or the FP course. The average difference in scores obtained on the pre- and postcourse tests for each group was obtained and a t-test was used (P < 0.05) to compare the mean score for each group. A signiﬁcant difference was found between group SP and group FP, with the highest achievement obtained by group SP. The pace of the course is thus a factor that inﬂuences achievement. Anat Rec (Part B: New Anat) 289B:134 –138, 2006. © 2006 Wiley-Liss, Inc. KEY WORDS: education; achievement; gross anatomy; anatomy teaching; learning INTRODUCTION During the ﬁrst part of the last century, anatomy courses were considered by some to be too long and often implied learning anatomical details that were irrelevant in clinical practice. During the 1960s and 1970s, the duration of gross anatomy courses Dr. Elizondo-Omaña is coordinator of scholarship recipients for the Department of Human Anatomy, School of Medicine, Universidad Autónoma de Nuevo León. His research interests include morphological characteristics of vascular conduits used as a bypass. Ms. Garcı́a-Rodrı́guez and Mr. MoralesGómez are scholarship recipients of the department. Dr. Guzmán-López is the head of the Department of Human Anatomy at the same institution. His research interests include medical education. *Correspondence to: Rodrigo Enrique Elizondo-Omaña, Departamento de Anatomı́a Humana, Facultad de Medicina Universidad Autónoma de Nuevo León, Ave. Madero y Dr. Aguirre Pequeño s/n. Col. Mitras Centro, Monterrey, Nuevo León, C.P. 64460, Mexico. Fax: 01-52-8183477790; E-mail: rod_omana@ yahoo.com DOI 10.1002/ar.b.20103 Published online in Wiley InterScience (www.interscience.wiley.com). © 2006 Wiley-Liss, Inc. was drastically reduced as the result of the introduction of new subjects into the medical curriculum (Monkhouse, 1992). During the last few years, medical schools in various countries have modiﬁed their curriculum and many others have begun debates concerning modiﬁcation of the same (Pabst and Rothkotter, 1997). One of the factors contributing to these changes is the growing body of knowledge in both the clinical and basic sciences, particularly in the areas of cellular and molecular biology, which has resulted in a considerable reduction in the time dedicated to the study of traditional basic science subjects, including anatomy (Marks and Cahill, 1988). Due to these changes, studies have been carried out to determine the optimum gross anatomy course duration, the content to be presented (Drake, 1998; Bukowski, 2002), and to adjust that content to student needs, taking into consideration that which is most relevant for future clinical practice (Pabst, 1993; Dangerﬁeld, 2000; Kagan, 2002). In the School of Medicine at the Universidad Autónoma de Nuevo León, there is a low passing rate (under 50%) for gross anatomy (Elizondo-Omaña, 2004). At this time, the school’s academic committee is planning to change the curriculum, including a reduction in the time dedicated to the gross anatomy course. In order to show that relationship, we examined the different types of anatomy courses offered at our institution: slow-paced (SP) and fast-paced (FP) courses, in which the same content is taught in the same teaching system. The SP course is for regular students and has 91 class hours taught in 91 sessions (covered in 20 weeks), and the FP course is for repeaters and has 90 class hours taught in 45 sessions (covered in 9 weeks). The objective of this study is to ﬁnd out whether a relationship exists between anatomy course pace and achievement. MATERIALS AND METHODS A longitudinal study was carried out on 130 students divided into two groups (SP and FP) according to the pace of the anatomy course. Both groups were exposed to the traditional EDUCATION NOTE form of anatomy teaching based on lectures. The group SP was formed by 91 regular students who took a 20week-long anatomy course, and the group FP was formed by 39 repeaters (students who previously took and failed the traditional course) exposed to the abbreviated form of the gross anatomy course with a duration of 9 weeks. The SP 20 week course consisted of 91 theoretical class sessions lasting 1 hr/day (a total of 91 class hours). The FP 9 week course was abbreviated to 45 theoretical class sessions lasting 2 hr/day (a total of 90 class hours). Both groups had access to laboratory sessions (dissection), to a bone room, and to a virtual room. These three auxiliary resources were optional. As a part of each course, students also took three examinations and a ﬁnal global examination and received passing or failing grades. Those evaluations were not taken into account in this study. The textbook for both groups was Anatomı́a Humana (Human Anatomy) by Lockhart et al. (1965). In our teaching format, the teacher interacts with students during the class, asking them to explain some topic to the rest of their classmates while the teacher guides and complements students’ exposition. Both groups were given a survey and two tests, one upon starting the course (pretest) and another upon ﬁnishing the course (posttest). The survey consisted of 10 questions for group SP and 13 questions for group FP. One test was applied twice (preand posttest) in each group and it consisted of 30 multiple-choice questions appropriate to the study plan in effect. There were three questions, randomly selected for each of the 10 areas of study, e.g., head and neck, upper limb. The separate pre- and posttests were used rather than the actual course examinations so that the group teacher would be blinded as to the questions in the test, thereby avoiding biased coaching toward the pre- and posttests used to compare SP and FP groups. All subject areas were covered with the same amount of questions for both groups. The tests were scored on a 30-point scale. The pretest was used to establish a baseline for the groups and also to determine the initial difference between them. The posttest was used to determine the im- THE ANATOMICAL RECORD (PART B: NEW ANAT.) 135 TABLE 1. Demographic characteristics of students in group SP High School Female Male Age SD Frequency Technical Private Public 17.17 17.77 16-30 0.8 2.1 46 45 n ⫽ 91 4 6 10 10 13 23 32 26 58 provement of the students from baseline. Achievement was deﬁned as the difference between the average scores obtained on the posttest and pretest. The data obtained were placed in a database and processed in Microsoft Excel. Descriptive statistics were applied for the information derived from the survey. The achievement (difference in mean scores obtained on the pre- and posttests for each group) was analyzed with a t-test (P ⬍ 0.05). RESULTS Demographic characteristics of the survey are as follows. registered in other semesters taking subjects for the ﬁrst time as regular students. Many FP students (35.89%) did not use any available auxiliary resource. The most used was the bone room, which was used by 30.76% of the students. The virtual room and laboratory had very low attendance, with attendance percentages of 5.12% and 17.94%, respectively. The average number of hours spent by an FP student in the bone room was 3.8 hr. Use of the other resources (virtual room and laboratory) averaged less than 1 hr per FP student. Group SP The demographic characteristics of group SP are shown in Table 1. The auxiliary resource most used was the laboratory in which 100% of the SP students did an average of four dissections. The average amount of time invested in dissection per student was 3 hr a week. The SP student had to dissect and identify required structures as per directions in the dissection manual. The bone room was used by 94.50% of the students and the virtual room was used by 74.75% of the students. The average number of hours of use per SP student of the bone room was 16 hr and of the virtual room was 5.9 hr. Group FP The demographic characteristics of group FP are shown in Table 2. Students in group FP took gross anatomy for a second time as repeating students (Fig. 1). Seventeen FP students took only the anatomy course for 9 weeks, while the other 22 FP students were simultaneously registered in other courses, including courses for repeating students in other subjects. Of these students, only 11 were found Pretest and Posttest The average scores obtained from the pretest and posttests for both groups are shown in Table 3. There was a signiﬁcant difference (P ⬍ 0.05) between the SP and FP pretests, and students in group FP performed better than those in group SP. There was no signiﬁcant difference (P ⬍ 0.05) between the SP and FP posttests, even though students in group FP did better than group SP. There was a statistically signiﬁcant difference (P ⬍ 0.05) in achievement between both groups, with SP students exhibiting higher achievement than FP students. DISCUSSION Gross human anatomy is one of the basic subjects within the medical curriculum. In a survey answered by medical residents in which an attempt was made to establish the importance of anatomical knowledge in their training as doctors, the gross anatomy course was thought to be indispensable and highly relevant (Pabst and Rothkotter, 1997). 136 THE ANATOMICAL RECORD (PART B: NEW ANAT.) EDUCATION NOTE TABLE 2. Demographic characteristics of the students in group FP High School Female Male Age SD Frequency Technical Private Public 18.1 18.8 16-25 1.109 1.868 22 17 n⫽ 39 1 5 6 6 5 11 15 7 18 Student’s Demographic Characteristics: The Survey The characteristics of our student population in the ﬁrst year of their medical training differ widely in comparison to those observed in other countries. In medical schools in Canada, the age range of students starting their medical studies is from 20 to 24 years and 51.1% of the population is female (Dhalla et al., 2002). In medical schools in the United States, the average age is 25.6 years (Dinsmore et al., 2001) and 49% of the population is female (Barzansky and Etzel, 2003). In our study, the average age in group SP was 17.5 years, and the gender showed a slightly female predominance (50.54%). Group FP had an average age of 18.5 years and was predominantly female (56.40%). The difference in ages between the groups studied is due to the fact that group SP includes only students in their ﬁrst semester and group FP consisted of students in their second or third semester. The difference in the average age observed in this study with respect to that observed in other medical schools is explained as follows: upper middle education (high school) in Mexico lasts 3 years for private and technical schools, while in public schools it lasts 2 years. In addition, in Mexico there are no medical school requirements for premed college courses such as those found in the United States or Canada. For that reason, the majority of our students in professional education enter medical school after an abbreviated high school education and without the beneﬁt of a college education. Most Mexican medical students are thus only 17 years old, an age that is much lower than that in other countries. The above factors probably inﬂuence the low achievement observed in the gross anatomy course. We must remember that anatomy is a basic science and, in our present curriculum, it is studied in its entirety in the ﬁrst year of medical studies. As Miller (2000) says, it represents a totally different way of learning for young students, as it implies the learning of concepts that they have never been exposed to previously. The course format used for teaching the subject of anatomy is quite varied in different medical schools throughout the world and there are even multiple forms of teaching it within each school. In our school, courses (slow and fast) consist of daily theoretical classes taught by physicians with graduate degrees, as well as laboratory sessions during which human cadavers are dissected. In addition, students have optional auxiliary resources provided by the department: a virtual room and a bone room (Elizondo-Omaña et al., 2004). The way in which class content is reviewed, the hours dedicated to dissection, and the auxiliary resources used for that purpose also have an inﬂuence on student achievement. The traditional teaching model of anatomy was originally based on faculty instruction, usually in a lecture setting, and student discovery in laboratory. This offers low integration of areas of study (Drake, 1998) and places the student in a receptive situation, in which he memorizes concepts that he does not necessarily understand. In our teaching model, students of both groups were randomly asked to explain some topics regarding the subject of anatomy in each class session. We think that a student’s class participation is important since it promotes active learning. They need to understand and keep in mind (in an organized fashion) the topic in order to explain it to the rest of their classmates and show mastery of the topic to the teacher. Pretest and Posttest Group SP had an average score of 7.3 on the pretest in a 30-point scale. Students in this group had never taken a human anatomy course, except those who studied in technical medical high schools (10/91). In group FP, the average score on the pretest was 10 in a 30-point scale. The higher FP pretest scores were probably because they have a higher level of knowledge since they had already taken a previous slow paced anatomy course in the School of Medicine (which they failed), and/or because prior exposure to this form of testing may have given them greater skill at answering these kinds of test questions. The pretest intention was to establish a precise baseline level of knowledge from which to determine the progress of students’ learning. Regardless of differences in average pretest scores, when subtracted from the posttest score, it allowed an independent measure of each group’s progress Figure 1. Academic situation of students in group FP. EDUCATION NOTE THE ANATOMICAL RECORD (PART B: NEW ANAT.) 137 TABLE 3. The scores obtained by the students in both groups. Achievement was deﬁned as the subtraction between post-test and pre-test averages Group SP Group FP Pre-test Post-test Achievement 7.3 (⫽3.47) 10 (⫽4.34) 13.49 (⫽3.74) 15.28 (⫽3.79) 6.18 (⫽4.83) 4.87 (⫽5.62) (achievement) without bias from prior medical school gross anatomy course exposure. However, as some students in both groups had already taken anatomy courses as part of their academic training in high school, we believe that use of pretest scores subtracted from posttest scores was a helpful tool for measuring only achievement. In the posttests, the average score obtained by group SP was 13.49 in a 30-point scale, which is lower than the 15.28 average obtained by group FP on the same scale. Based on the posttest alone, it can be assumed that group FP had better absolute knowledge of the subject than group SP; however, this score does not consider the degree in which the anatomical knowledge improved once the courses were completed (i.e., achievement). Achievement The most important factor in our study was to determine achievement according to our operational deﬁnition (the difference obtained by the subtraction of pretest average from posttest average scores). This revealed that the achievement for group SP was 6.18 points, which is signiﬁcantly higher (P ⬍ 0.05) than achievement for group FP, which was 4.87 points. This signiﬁcant difference in achievement indicates that the slow-paced course likely provided a better learning environment for acquiring new anatomical knowledge than the fastpaced course. In both anatomy courses (slow and fast), the content covered was the same, the way of presenting this content was very similar among the groups, and the tests applied for evaluating student achievement were identical. The only difference between groups was the number of sessions during which the content was presented, 91 for group SP and 45 for group FP. In spite of this, the number of theoretical class hours was practi- cally the same (group SP, 91 hr; group FP, 90 hr), while the number of course days was lower for group FP. We therefore conclude that the pace of the course was the most likely factor accounting for the difference in achievement. This is in agreement with McKeown et al. (2003), who observed better achievement in courses that last longer. In 2002, Drake et al. did a survey to learn about the composition of courses in different medical schools in the United States and found that of the 83 schools answering the survey, in most of them (72%) the duration of gross anatomy courses was found in the range of 126 to 200 total hours (mean ⫽ 167 ⫾ 39 hr). It was also found that the percentage of the course hours dedicated to the laboratory was 34% to 89%. In 40% of schools surveyed (33/83), laboratory work represented 70% or more of the total course hours. In ﬁve schools in the United States, the anatomy course had a duration of 101 to 125 hr, and anatomy courses lasted less than 100 hr in only four schools. Reidenberg and Laitman (2002) reported that the anatomy course in their medical school consists of 140 hr, including dissections, lectures, and group discussion. In our medical school, the time spent in anatomy laboratory is only about 30 hr and students have the option of spending additional time outside of ofﬁcial class hours going to the bone room or virtual room. At the end of the long course, most of the students spent approximately 120 –130 hr learning anatomy (90 hr in required lectures, 30 hr in required anatomy laboratory, and some additional hours in other optional resources). Although Muller (1984) suggests that the curriculum in medical schools should reduce the number of hours dedicated to lectures, our study shows that it is not advisable to reduce any of the time dedicated to anatomy learn- ing. An alternative option would be to increase the number of hours spent in the laboratory doing dissections (bringing this number closer to the U.S. average of 70% of the total course hours) and requiring use of the currently optional additional resources (bone and virtual rooms). This would reduce the proportion of the course devoted to lectures while adding the beneﬁt of more hands-on learning. We must remember that changes in the curriculum must be based on the principle that modifying educational programs must improve the quality of subjects taught in the medical profession (Drake, 1998), not the opposite. Study Limitations There are other factors that were not speciﬁcally tested in this study, which could inﬂuence the student’s achievement, such as interest in anatomy and motivation to learn. The FP groups is likely to have a larger proportion of students (compared with the SP group) exhibiting a lack of interest and low motivation, as evidenced by their failing grades in the initial slowpaced course. Thus, we would expect lower achievement scores in the FP group. These two variables were not measured with a speciﬁc test, but there are two indications that low motivation and lack of interest occurred: the FP group students had a negative experience in the past course, and the record of attendance to optional activities was lower in FP students. While this study has shown that course pace was a signiﬁcant factor affecting achievement, it is possible that these additional two variables may have also played a role in lowering achievement of the FP group. In order to identify the speciﬁc contributions of each variable, a future study should be conducted in which naive students (i.e., no prior anatomy training) take the fast-paced course and are compared with naive students in the slowpaced course. Likewise, repeaters (i.e., students who failed anatomy) should also be tested in a second attempt at the slow-paced course and compared with repeaters taking the fast-paced course. Course pace is a factor that inﬂuences achievement. 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