close

Вход

Забыли?

вход по аккаунту

?

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:
dhaines@anatomy.umsmed.edu
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.
Документ
Категория
Без категории
Просмотров
0
Размер файла
546 Кб
Теги
relevant, forma, teach, neurobiology, clinical, settings, neurobiologie, medical
1/--страниц
Пожаловаться на содержимое документа