Medical neurobiologyDo we teach neurobiology in a format that is relevant to the clinical setting.код для вставкиСкачать
THE ANATOMICAL RECORD (NEW ANAT.) 269:99 –106, 2002 SPECIAL ARTICLE Medical Neurobiology: Do We Teach Neurobiology in a Format That Is Relevant to the Clinical Setting? DUANE E. HAINES,* JAMES B. HUTCHINS, AND JAMES C. LYNCH During a period of unprecedented growth in technology that allows imaging of the body in elegant detail, anatomy as a discipline has, in some instances, become marginalized. This may be seen in a reduction of time allotted to anatomy, reduction or elimination of laboratory experiences, or shifting of anatomy teaching to clinical departments. One potential cause of this marginalization is the fact that anatomy is frequently taught in a format that is not useful in, or even applicable to, the clinical setting. At the University of Mississippi Medical Center, the Medical Neurobiology course stresses the functional anatomy of the brain, especially the brainstem, in a format that is directly transferable to the clinical setting. These approaches include (1) using a small neurology book as one of the required texts in the course; (2) extensive use of magnetic resonance imaging (MRI) and computed tomography (CT) as an integral part of the instructional approach; (3) teaching external and internal anatomy of the brain, particularly the brainstem and spinal cord, in a “clinical orientation” that reflects how these central nervous system (CNS) regions are viewed in the clinical setting; (4) teaching nuclei and tracts in images of stained sections and correlating this information with comparable MRI and CT images; and (5) using a large series (75 images) of vascular drawings and clinical cases, all in clinical orientation. The clinical applicability of the basic science information, therefore, is continuously reinforced and extended. It is suggested that teaching anatomy and anatomical concepts in formats that are more obviously useful in, and applicable to, the clinical setting will enhance the value of this basic science in the medical curriculum. Anat Rec (New Anat) 269:99 –106, 2002. © 2002 Wiley-Liss, Inc. KEY WORDS: anatomy; CT; education; imaging; medical curriculum; medical neurobiology; medical neuroscience; MRI; neuroanatomy; teaching INTRODUCTION Dr. Haines is Professor and Chairman of the Department of Anatomy at the University of Mississippi Medical Center (UMMC) and is the Coordinator of the Medical Neurobiology course. His research interests are in the cerebellum and motor systems and in the history of neuroscience. He is currently the President of the International Society for the History of the Neurosciences. Dr. Hutchins is Associate Professor of Anatomy at UMMC, a faculty member in the Medical Neurobiology course, and the Coordinator of the Dental Neuroanatomy course. His research interests are in the cellular and molecular biology of the developing nervous system and neuroprotection in stroke. Dr. Lynch is Professor of Anatomy at UMMC, a faculty member in the Medical Neurobiology course, and the Coordinator of the Graduate Program. His research interests are in the anatomy and physiology of eye movement control. *Correspondence to: Duane E. Haines, Department of Anatomy, The University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216-4505. Fax: 601-984-1655; E-mail: firstname.lastname@example.org DOI 10.1002/ar.10073 Published online in Wiley InterScience (www.interscience.wiley.com). © 2002 Wiley-Liss, Inc. Over the past two decades, developments in imaging technology have revolutionized clinical medicine. The Anatomy as a discipline has allowed itself to become marginalized, partially by its failure to embrace imaging technology and the resulting images that are commonly used in the clinical setting. advent of magnetic resonance imaging (MRI), computed tomography (CT), positron emission tomography (PET), and other methods have pro- vided unparalleled and detailed views of the structure of the human body in health and disease. This revolution has encompassed the generalist physician as well as the specialist. During about the same time frame, anatomy as a discipline, has sometimes been viewed as of marginal or declining value in the medical education process. In other words, although technology has allowed us to look at the structure of the body in images of exquisite detail, the teaching of anatomy (the very essence of these images) has been viewed by some as perhaps less than relevant. This marginalizing of anatomy is reflected in a reduction of time allotted to morphology (as broadly defined), moves to reduce or even eliminate laboratory experiences, and the shifting of anatomy teaching to clinical departments in some institutions. There seems to be an inverse relationship between the clear, present, and necessary value of anatomy in the clinical setting and the 100 THE ANATOMICAL RECORD (NEW ANAT.) view that anatomy should have a less than prominent place in the education of professional students. How can this be happening? Anatomy as a discipline has allowed itself to become marginalized partially by its failure to embrace imaging technology and especially the resulting images (such as MRI or CT) that are commonly used in the clinical setting. The structure of the brain or of the body as seen in MRI or CT of a normal individual is simply anatomy in vivo. Unless there is trauma, a lesion, or an on-going pathologic process requiring diagnosis, these are not specifically “clinical” images, just anatomy in vivo. How many times have our colleagues said “I’m not a clinician, why should I have to know MRIs or CTs?” This represents a failure on the part of the anatomist to It behooves us, as anatomists, to use clinical terms whenever possible so that students will have information that is immediately useful when they enter the clinical years. adopt such images as an integral part of their own educational repertoire. MRI or CT are not “clinical images,” these are simply “images” that are used in a clinical setting for a diagnostic purpose and should be used in a basic science setting for an educational purpose. For example, the thalamus is the thalamus whether it is viewed in a brain slice in the lab or in an MRI. The same applies to the medial lemniscus or the substantia nigra in the brain or to the kidney or the esophagus in the gross anatomy experience. The real issue is two-pronged. First, there is a significant reluctance on the part of many basic scientists to enthusiastically embrace, learn, and understand the brain and body as seen in MRI or CT and to use these images in the educational process. This cer- SPECIAL ARTICLE Figure 1. Stained section of the midbrain in the commonly used “anatomical orientation.” The colliculi are “up” in the image and the interpeduncular fossa and crus cerebri are “down.” Reproduced, in a modified form, from Haines (2000) with permission. tainly applies to the appearance of structures within these images as well as to the very important issue of orientation to the image. How do we look at the image, from what direction? What is right and left, anterior and posterior? These are all issues that are of absolute importance in the clinical setting. Yet, they are frequently ignored in basic anatomy courses. Second, there is a failure to stress anatomical concepts and relationships in the basic science instructional setting in an orientation/format that reflects their usage in clinical applications. It is up to us as anatomists to embrace these concepts and images as our own, to realize their powerful value in teaching basic concepts, and to reap the very significant benefits. THE CURRICULUM To a certain degree, basic science courses in medical schools are under what could be broadly described as curriculum change (Drake, 1998; Giffin and Drake, 2000). Although detailing these changes is beyond the scope of this article, some general points merit comment. First, change may be seen in an effort to reduce class hours or to shift hours in the curriculum. The need may be to “capture” some hours from one course/program so as to enhance another that is presumably in need. Second, there may be an interest expressed by a clinical department to see medical students better trained for the clinical years or to have more diversified training within the clinical years. This may result in hours being shifted to better accommodate these perceived needs. Third, there is the expectation from external licensing agencies to keep the curriculum in all of its aspects, current, up to date, and relevant to the needs of the student. This is usually expressed in appropriately diplomatic terms during visits by external reviewers and, if modification is needed, more than ample time is given for change (see Kassebaum et al., 1997). These changes may be exacerbated by the perception that anatomy, as taught in the basic science years, may not be fully relevant to the needs of the medical student in the clinical years. This perception comes from two general directions. First, if a student arrives in a clinical experience without an adequate and relevant basic science knowledge base, the perception is that the basic science program is not adequately preparing the student. No matter how many facts the student may have, if these facts are not useful and in a relevant format, the perception is the fact that the student is ill-prepared. Second, and by far the more important, is that anatomy programs may persist in using some “anatomical” terminology or concepts that are simply not used in a clinical setting. Rather than cling to this somewhat archaic approach, clinical concepts and terminology should be SPECIAL ARTICLE THE ANATOMICAL RECORD (NEW ANAT.) 101 has acquired is not very relevant. Like it or not, clinicians are not going to revert to basic science terminology; it is up to the basic scientists to incorporate as much clinical terminology as is reasonably possible into their instructional efforts. RELEVANCE OF INFORMATION Figure 2. Axial magnetic resonance imaging (T2-weighted) through the hemisphere and midbrain. Note that the colliculi are “down” in the image and the interpeduncular fossa and crus cerebri are “up.” This “clinical orientation” is 180 degrees from that shown in Figure 1. embraced and used in the basic science instructional setting. There are numerous cases of terminology mismatch between the basic and clinical settings. For example, anatomists describe a “horizontal plane” of the brain as a line passing through the long axis of the hemisphere from the frontal pole to the occipital pole. To the clinician, this is the “axial plane”—the term “horizontal” is not used. Another example is the segment of the anterior cerebral artery between the internal carotid artery and the anterior communicating artery. In anatomical terms, this is the “precommunicating part of the anterior cerebral artery”; but to the clinician, this is simply “A1” (Yasargil, 1984). Anatomical terminology is good, universally accepted, and very useful. However, it behooves us, as anatomists, to use clinical terms whenever possible so that students will have information that is immediately useful when they enter the clinical years. If students arrive at the clinical years with terminology that does not flow seamlessly into the clinical environment, they may be perceived as not being well-prepared (see Charles et al., 1999, for related comments). Indeed, students themselves may not feel well-prepared. By inference, the basic science information the student Obviously, the goal of all instructors is to provide relevant information. Indeed, all instructors believe they are providing relevant information, when, in fact, that may not actually be the case. In fact, some information may be presented in a way that complicates its integration into subsequent learning experiences in the clinical setting. There are two general ways to de- The problem of presenting anatomical information in a useful format is an ongoing problem faced by instructors as well as those agencies preparing national standardized examinations. termine whether or not the information presented is relevant. These are by content and by format. Course content is rarely the issue. The vast majority of anatomy courses contain current, correct, and reliable information. Indeed, most instructors regularly update their lectures to include new ideas, discoveries, novel uses of the information, or simply to try out a better way of getting the facts across. So, content is usually not the problem. This leaves format. If information is factually correct, then it should be presented in a format that enhances its application to a specific clinical problem or learning situation. If the information is in a form that precludes its direct and unencumbered application in a clinical setting, the perception may be that the informa- tion is not very useful. In this case, fact is not at issue; but the perception of how useful (or not useful) the fact is becomes the truth. THE MAIN QUESTION: NEUROBIOLOGY AS THE EXAMPLE The question posed in the title of this paper actually has two parts. The first could be, “Are we, as instructors, providing correct information in our medical neurobiology or neuroscience courses?” The answer is clearly “yes” in most cases. For example, all courses cover, to varying degrees and by using a variety of methods, the structure and function of long tracts, cranial nerves, degenerative diseases, vascular patterns and lesions, a wide variety of clinical cases/examples, and the range of other facts that make the educational experience fruitful. Content, in most cases, is not really a problem. The second part of the question could be, “Are we presenting anatomical information in a format that is directly applicable to, or useful in, the clinical setting?” The answer to this question is largely “no.” Although the Figure 3. View of the base of the brain, with brainstem removed at the midbrain level. This image is the gross brain in “clinical orientation.” Note the striking similarity of this view with that of the MRI (Figure 2) at a comparable level, particularly the midbrain and immediately adjacent hypothalamic structures. Reproduced, in a modified form, from Haines (2000) with permission. 102 THE ANATOMICAL RECORD (NEW ANAT.) Figure 4. Stained section of midbrain in “clinical orientation.” Comparing this image with Figure 1 illustrates one important problem. In this figure (and in Figure 2) the observer’s right is the patient’s (and image’s) left and the observer’s left is the patient’s (and image’s) right. This sidedness is absolute in axial and coronal planes in magnetic resonance imaging and computed tomography and in stained sections presented in a clinical orientation. However, in “anatomically oriented” stained sections, as in Figure 1, sidedness is not clear, because there are no universally accepted and used standards. Laterality of deficit is extremely important in the diagnosis of the neurologically impaired patient. Therefore, correct laterality should be stressed and learned from the start. Reproduced, in a modified form, from Haines (2000) with permission. information may be factually correct, the format in which the information is presented is, in certain important instances, clearly not applicable to the clinical setting. Students are left holding a block of facts that they may have difficulty figuring out how to turn into useful/helpful information. The whole problem of presenting anatomical information in a useful format is an ongoing and contemporary problem faced by instructors as well as those agencies preparing national standardized examinations. It is especially a problem in neurobiology when teaching the anatomy of the brainstem in the axial plane, one of the three principal planes in which the brain is imaged in the clinical environment. This problem is illustrated here using the midbrain as an example, although it is applicable to all parts of the brainstem and to the spinal cord in the axial plane. When basic scientists, be they anatomists or other neuroscientists, teach the structure of the midbrain, it is common to illustrate the colliculi as “up” in the image and the interpeduncular fossa as “down” (Figure 1). This is an “anatomical orientation”— one that has been used for many decades when teaching the structure of the brainstem (see any contemporary textbook). Unfortunately, this is not the way the midbrain is viewed in the clinical setting. When the brain is imaged in vivo in the axial plane, such as in MRI or CT, the colliculi are “down” in the image and the interpeduncular fossa is “up” (Figure 2); this is a “clinical orientation,” the standard view in radiology. Considering how brain images are used in the clinical setting, one can argue that the “anatomical orientation” is actually upside-down and the “clinical orientation” is right-side up. SPECIAL ARTICLE Consequently, facts learned in a basic science course that stresses “anatomical orientation” may be transferred to images in the clinical setting (clinical orientation) only with significant difficulty and potential confusion. Medical students rarely see the brainstem or the spinal cord in an “anatomical orientation” once they get into their clinical years. Consequently, the positions of nuclei and tracts, the distribution of vascular territories, and many other facts learned in the “anatomical orientation” are not easily transferred to images of the same portion of the brainstem when seen in MRI. This transformation from anatomical to clinical orientation requires (1) a 180-degree degree rotation (or flip) of all structures, (2) a rotation of somatotopy in some tracts and nuclei and of vascular territories, (3) flipping anterior and posterior, and (4) potential confusion of what is right/left in the anatomical orientation vs. what is right/left in the clinical orientation (see Figures 1 and 4). Indeed, the student may very well conclude that the basic science information he/she learned in a course that stresses anatomical orientation is simply not very applicable to the clinical experience. In the medical neurobiology course taught to first year medical students at University of Mississippi Medical Center (UMMC), we have recognized this problem and, for several years, have presented anatomical information (nuclei, tracts, vasculature, clinical cases) in a format that reflects, as Figure 5. The midbrain in “clinical orientation” showing clinically important tracts and cranial nerve nuclei in color. Reproduced, in a modified form, from Haines (2000) with permission. SPECIAL ARTICLE THE ANATOMICAL RECORD (NEW ANAT.) 103 Figure 6. The midbrain in “clinical orientation” showing a variety of labeled structures and a lesion (shaded area). Note that structures/fibers involved in the lesion are not labeled, thus requiring the student to more actively participate in analyzing the lesion. Right (R) and left (L) sides of the patient may or may not be indicated. closely as possible, the way the brain is viewed in the clinical setting. We use several approaches. First, in addition to a text and atlas, we require a basic clinical neurology book. After a survey of several potential candidates (we focused on approximately six to eight books in the 200- to 300-page range and consulted with our neurology colleagues), we settled on a book (Donaghy, 1997) that meets our criteria of short chapters (most are three- to six-pages long), covers a variety of clinical topics, has nice illustrations, and treats clinical topics at a level appropriate to the general M1 audience. There are assigned readings in, and test questions taken from, this source. Second, we emphasize gross brain structures and slices in an orientation comparable to how that part of the brain will be seen in clinical images. For example, in a basal view of the cerebral hemispheres, frontal lobes are up and occipital lobes are down (Figure 3). Incidentally, if the brainstem is removed at the level of the midbrain, this orientation automatically puts the midbrain in a clinical orientation (compare Figure 3 with Figure 2). When looking at a coronal brain slice, we draw particular attention to the rostral surface of the slice; the viewer’s right is the left side of the brain slice and would be the left side of the patient’s brain in MRI. When looking at an axial brain slice, we draw attention to the inferior surface of the slice as this is how the axial MRI is viewed. In all of these ap- proaches, anatomy is not compromised (in fact, it is enhanced) and emphasis is placed on (1) correlating how important gross brain anatomy is to the clinical experience, and (2) stressing how the brain is viewed in images in the clinical setting. As one integral part of this approach, we extensively use MRI and CT images in correlation with gross brain slices to teach brain anatomy both external and internal. We emphasize how the brain appears on MRI scans in all three planes and repeatedly reinforce how knowledge of normal brain anatomy is essential to understanding the abnormal brain. In this regard, we use MRI and CT images as equal (and in some cases more important) partners with brain slices, gross brain, or im- ages of stained sections to teach basic anatomical principles as applicable to the clinical neurosciences. Third, stained sections of the brainstem are presented in the orientation seen in axial MRI images, i.e., posterior (dorsal) down and anterior (ventral) up (Figure 4, compare with Figure 2). Internal vascular patterns, nuclei and tracts (and their somatotopy), and many other relevant facts are presented in the manner in which these vascular patterns and structures are seen in the clinical setting (Figures 5 and 6). Once the internal structures of the midbrain are learned, they can easily, and without modification, be transferred to their proper location within an MRI of the midbrain. The student is not required to learn the “anatomical” view and then rotate it to a “clinical” view; the brainstem and its contents are learned in the clinical orientation from the very start. A particularly poignant example of how information presented in an anatomical orientation can be quite confusing in the clinical setting concerns the spinal trigeminal tract and nucleus of the medulla oblongata. When the medulla is presented in anatomical orientation the ipsilateral side of the face is somatotopically represented upside-down in the spinal tract and nucleus; ophthalmic input is in the lower part of the tract as it appears in the image, and mandibular input is in the upper part. However, when the medulla is presented in a clinical orientation the face is right-side up; the ophthal- Figure 7. The midbrain is “clinical orientation” showing the general arrangement of vascular territories. The major vascular territories are indicated by the shaded areas; students have the opportunity to identify the vessels serving these areas. Right (R) and left (L) sides of the patient, or posterior (P), may or may not be indicated. 104 THE ANATOMICAL RECORD (NEW ANAT.) mic input is in the upper part of the tract as it appears in the image and the mandibular input is in the lower part. There are many other examples of how information presented in an anatomical orientation can be confusing to the student when they are expected to rotate it to a clinical orientation. Fourth, we provide a series of vascular drawings (11 images) and clinical case studies (64⫹ images) that are all presented in a clinical orientation, be it axial, coronal, or sagittal (Figures 6 and 7). These drawings and case studies build on how the anatomy is taught, directly transfer anatomical information to a clinical example, and repeatedly emphasize important clinical concepts such as laterality, how deficits relate to lesions, and blood supply. These clinical examples and vascular illustrations are used throughout the course, are fair game for test questions, and are presented in a format that requires student participation in solving the problem. Presenting clinical examples in an appropriate orientation not only correlates with how the anatomy is presented but, more importantly, correlates with lectures given by clinicians in which MRI or CT images are used. This overall approach serves two additional goals. For one, it allows and even encourages cross-correlation between basic science and clinical issues at any point and at any level in the course. We have found that clinicians are more eager to stress the value of the anatomical information when they see anatomy being presented in a format that is clinically relevant. Another spinoff is that students who may, on their own or with faculty encouragement, visit radiology, neurology, neurosurgery, or other clinical departments will immediately see that what they are learning in their medical neuroscience course is something that they can take down the hall and apply directly to a clinical question. WILL WE CONFUSE THE STUDENT? When the topic of teaching the structure/function of the brainstem or fore- brain in a clinical orientation is discussed, a typical reason for not doing so is, “It will confuse the student”. This is certainly a valid concern. Would teaching the structure of the brainstem and forebrain and systems neurobiology in a clinical orientation actually confuse the medical (or for that matter any professional) student? Three points bear directly on this issue. First, the vast majority of medical students have not had a neuroscience or neurobiology course before entering medical school. They have certainly not had a course on the human nervous system with a significant clinical focus and with lectures given by neurologists, neurosurgeons, or other clinicians. Most undergraduate neuroscience courses emphasize basic principles using animal models. For the large part, these are excellent introductions to the nervous system and students who take such courses are usually at an advantage when they get into a medical neurobiology course. However, when these students enter medical school, they do not have a detailed knowledge base on the human nervous system from which they can “get confused.” Furthermore, MRIs, CTs, or PET scans that do appear in undergraduate textbooks almost always are presented in a clinical orientation. Second, although most medical students have not had formal training on the structure and function of the human nervous systems, quite a few may have an impressive knowledge base through their work experience. In fact, many medical schools give preference to applicants who have demonstrated their interest in medicine by working in a job that exposes them to various aspects of medicine as a career. Consequently, these students may be more in-tune with some of the subtleties of clinical medicine. For example, medical students who worked in the emergency room, in a health care clinic, a physician’s office, or as an emergency medical technician for several years know, to varying degrees, how the brain (and body) is viewed in MRI or CT. If medical students with such prior experiences are taught that the colliculi of the midbrain are up and the interpeduncular fossa is down in the image (anatomi- SPECIAL ARTICLE cal orientation, Figure 1) they may very well know from their prior experience that the brain is not viewed this way in the clinical setting. When students see that the colliculi are down and interpeduncular fossa up in the MRI presented by the clinician (see Figure 2), they may question the notso-relevant approach of the basic science professor. In this scenario, the basic science information is regarded as not directly applicable to the clinical situation and the overall value of the information, and possibly the course, is diminished. Third, medical students are an empty vessel waiting to be filled with useful information that is relevant to the clinical years and beyond. If students are told “. . . this is how you will see the midbrain in the clinical setting. . .” they will absorb the information, believe it, and not for a second be confused or question its validity. Students want and need information that will help them in their clinical experience. They do not want to learn irrelevant information, only to find out that it has to be relearned before it is useful in the clinical setting. WHO IS CONFUSED? It is our experience that students are not confused by a clinical approach to neuroscience. Students cannot be confused when they have no basis from which confusion can arise or when their prior experiences may have already given them a baseline concept of how the body is represented in images used in the clinical setting. Indeed, when the basic neuroscientist teaches that the colliculi are up and, in the next hour, the clinical neuroscientist shows that the colliculi are down, guess which instructor is perceived as providing the most relevant and useful information? In fact, it may be the basic science faculty who are confused. This is certainly understandable; many of us received our education before the advent of MRI or CT. We were taught that posterior/dorsal was up and anterior /ventral was down. Period. However, the factors that influence how we acquire and impart information have changed profoundly; it is up to the faculty to adjust to the change. It is up to the faculty to develop methods to SPECIAL ARTICLE impart information that is maximally useful to students when they get to the clinical years. The argument on the part of faculty that “I can’t do it that way, it’s upside down to me, it’s confusing, it’s backwards, I didn’t learn it that way, I’m not a clinician” is specious. If it is difficult for the faculty to teach the nervous system in a clinical orientation, with their many years of experience and specialized training, what must it be like for the student to learn the brainstem upside down (anatomical orientation) then be expected, on their own and with only one semester or quarter of exposure, to rotate the brainstem images 180 degrees to a clinical orientation before they can be used in the clinical environment? This failure to teach brain anatomy, particularly that of the brainstem and spinal cord, in an orientation appropriate for the clinical experience feeds directly into the hands of those who may perceive anatomy as something less than relevant. WHAT ABOUT GRADUATE STUDENTS? The argument can be made that students in anatomy or neuroscience graduate programs should not have to learn brain structures in a clinical orientation. After all, they are not going to practice medicine, are they? Actually, a small number of students receiving graduate degrees in neuroscience do go on to attend medical school. Furthermore, several foreign graduate students who have the equivalent of the MD degree from their own country will finish their graduate program and eventually enter clinical medicine in the United States. Beyond these more immediate issues is the simple fact that graduate students receiving doctorate degrees in neuroscience may very well find themselves on the faculty of a medical institution. They may be teaching students who will be entering a clinical practice. It would seem that such young faculty should not only have the knowledge base, but just as important, the philosophical bent, to instruct the medical student in a relevant format. The former graduate student, now as a new faculty member, must also be THE ANATOMICAL RECORD (NEW ANAT.) 105 sensitive to the impact of two national organizations on the process of educating medical students. These are the Liaison Committee on Medical Education (LCME) and the National Board of Medical Examiners (NBME) (see Kassebaum et al., 1997, 1998). Although these organizations do not establish educational policy at medical schools, their expectations influence how we do our job. For example, the LCME encourages an emphasis on the clinical relevance of the basic sciences and an introduction of clinical information (as broadly defined) early in the educational process. The NBME uses clinically oriented ques- MRI, CT, and other similar images should be incorporated into the anatomy curriculum and used to teach fundamental anatomical concepts. tions that rely on correct clinical terminology for a given situation and certainly a fundamental understanding of how the nervous system (and for that matter the entire body) appears in MRIs or CTs in the clinical environment. PERCEPTION IS KEY If a student perceives that a piece of information is not useful in the clinical setting, that perception becomes their truth, and the information is, indeed, not useful. Students may have facts and information, but in a format that they cannot fold into a clinical experience. Therefore, the students perception is that they have to start all over once they get to the clinical years. Students may believe that it is easier to learn anatomy all over again in what they believe to be a useful format than to attempt to modify a previously acquired knowledge base that does not meet the requirements of the clinical setting. Students should not be required/expected to make modifications in their basic science knowledge base that they do not know how to make or are ill-prepared to make. Furthermore, it is not the responsibility of clinical faculty to revisit extensive amounts of basic science information, but rather it is the responsibility of basic science faculty to present basic science information in a format that effectively prepares the student for the clinical setting. If students get information in their basic science courses that are directly transferable to the clinical setting, their perception is that this “clinical” information came from the basic science course. This perception clearly enhances the value of the basic course and what it has to offer in the mind of the medical student. For example, why should third-year courses in radiology, surgery, neurosurgery, neurology, or orthopedics, get credit, in the students mind, for teaching in vivo anatomy by using MRI and CT? This credit should go to the first-year anatomy courses. STUDENT FEEDBACK The teaching of medical neurobiology at UMMC with a particular emphasis on presenting anatomy and systems in a clinical orientation has been applied to the entire class each year. All students were exposed to the same educational opportunities and took the same examinations. Consequently, it is not feasible to conduct “before” and “after” analyses or to test students in parallel programs, one stressing a clinical orientation and one not stressing a clinical approach. In some instances, it has been suggested that different instructional pathways may not result in notable differences in USMLE Step I scores (Way et al., 1999). Although the feedback we have received is anecdotal, we believe it is important because it is voluntary and it reflects the perception of how wellprepared the students believe they are for their clinical neuroscience experience. This input, primarily from M3 and M4 students, is summarized as follows. First, we received more, and more enthusiastic, feedback on our new approach than we received in prior years. Students reported that their basic neurobiology course contained helpful information (“. . .it [the clinical expectation] was just like you 106 THE ANATOMICAL RECORD (NEW ANAT.) told us it would be. . .”) that proved to be very useful in their clinical years. Second, students reported that they felt prepared to view and understand MRI and CT and to actively participate in the diagnosis of neurologically compromised patients. Third, students noted that they believed they now have a knowledge base to which appropriate clinical information could be added. Fourth, students commented that images of brain in MRI or CT were not new to them in their clinical years, that they had “seen it before” and felt generally well-prepared and comfortable with MRI and CT images. They noted that laterality— what’s left versus what’s right—was not a problem. Fifth, on several occasions, M3 and M4 students as well as those working with local neurosurgeons between their M1 and M2 years indicated that they received compliments from clinicians on their level of preparedness. The positive and enthusiastic response from students suggests to us that the “clinical orientation” approach provides useful and relevant information that is retained longer, more easily reviewed, and more rapidly recalled. The students perceive themselves as being well-prepared, in all respects, for the clinical experience. This interpretation is consistent with the view that students who learn anatomy in conjunction with radiologic images learn more information and retain it longer (Erkonen et al., 1992, de Barros et al., 2001). One of the more interesting results of this educational experiment was related to the senior author by the Chairman of the Department of Neurology at UMMC. He indicated that all nine members of the graduating class of 2002 (currently M4s) who are in- SPECIAL ARTICLE terested in neurology as a career specifically stated that their interest stemmed from their experience in the first-year Medical Neurobiology course. thank Ms. Lisa Boyd for library work, Ms. Katherine Squires for typing, and Mr. Bill Buhner, Director of Computer Graphics at UMMC, for assisting with the images. CONCLUSIONS LITERATURE CITED It is essential that anatomists, especially those teaching neuroscience and gross anatomy, recognize the significant value of, and aggressively use, MRI, CT, and other similar images as an integral part of their educational armamentarium. Such images should be incorporated into the anatomy curriculum and used to teach fundamental anatomical concepts. It is essential to make the basic science learning experience as relevant as possible to the clinical setting. This includes, when possible, using MRI and CT, clinical terms and/or phrases, and clinical concepts in their proper framework. It is especially important to teach basic anatomy in orientations that reflect how the brain and body is viewed in images in the clinical setting. It is not enough to simply provide facts and hope that students can adapt these facts to a clinical situation; facts must be provided in a useful and relevant format. Basic scientists cannot expect clinicians to adopt basic science terminology, concepts, or techniques. It is the responsibility of the basic scientist to capture clinical terms, concepts, and images and to present this information as an integral part of the basic science educational experience. ACKNOWLEDGMENTS Figures 1, 3, 4, and 5 of this article are reproduced, in a modified form, from Haines (2000) with permission from Lippincott Williams & Wilkins. We Charles PD, Scherokman B, Jozefowicz RF. 1999. How much neurology should a medical student learn? A position statement of the AAN undergraduate education subcommittee. Acad Med 74:23–26. de Barros N, Rodrigues CJ, Rodrigues AJ Jr, de Negri Germano MA, Cerri GG. 2001. The value of teaching sectional anatomy to improve CT scan interpretation. Clin Anat 14:36 – 41. Donaghy, M. Neurology. New York: Oxford University Press. 1997. Drake RL. 1998. Anatomy education in a changing medical curriculum. Anat Rec (New Anat) 253:28 –31. Erkonen WE, Albanese MA, Smith WL, Pantazis NJ. 1992. Effectiveness of teaching radiologic image interpretation in gross anatomy. Invest Radiol 27:264 – 266. Giffin BF, Drake RL. 2000. Gross anatomy of the head and neck and neuroscience in an integrated first-year medical school curriculum. Anat Rec (New Anat) 261: 89 –93. Haines DE. 2000. Neuroanatomy: An atlas of structures, sections and systems. 5th ed. plus CD-ROM. Baltimore: Lippincott Williams & Wilkins. Kassebaum DG, Cutler ER, Eaglen RH. 1997. The influence of accreditation on educational change in U.S. medical schools. Acad Med 72:1128 –1133. Kassebaum DG, Cutler ER, Eaglen RH. 1998. On the importance and validity of medical accreditation standards. Acad Med 73:550 –564. Way DP, Biagi B, Clausen K, Hudson A. 1999. The effects of basic science pathway on USMLE Step I scores. Acad Med 74:S7–S9. Yasargil MG. 1984. Microneurosurgery. I. Microsurgical anatomy of the basal cisterns and vessels of the brain, diagnostic studies, general operative techniques and pathological considerations of the intracranial aneurysms. Stuttgart: Georg Thieme Verlag. p 1–371.