Anatomy Reconfigured

by Eve Jacobs

To "steady the hands" of 180 freshman medical students as they begin their dissection of a human cadaver is no small undertaking. Over the years, NJMS professor Nagaswami Vasan, DVM, PhD, has witnessed an array of reactions to the task at hand, many of them incredibly intense. Following their first few sessions in the gross anatomy lab, students are often shaken and wrestle with thoughts of their own mortality and that of their loved ones, he says. Witnessing a cadaver "up close and personal" may make death and dying real to many students for the first time.

And that is just the beginning. In less than four months, Vasan and teaching partner David DeFouw, PhD, both of whom have been awarded numerous Golden Apples by their students, will shepherd this group through their emotional roller-coaster ride as well as what has traditionally been one of the hardest courses academically in the four-year medical school curriculum. And it's certainly one of the courses they can least afford to fail. All of their subsequent learning about health and disease will be based on a basic understanding of how the human body is constructed and how it functions, which they can only learn here.

This is the challenge that greets Vasan anew every year as each freshman medical school class steps up to the plate, but it's a challenge that calls to his heart. Even after almost 30 years doing this job and doing it well, he is always looking for a better way.

In fact, just five years ago, Scribner published a 272-page book entitled Body of Knowledge by Asbury Park Press reporter Steve Giegerich detailing his observations after spending an entire semester with the medical students around Vasan's gross anatomy dissection tables. The book received critical acclaim from many sources, including Publisher's Weekly and Library Journal . There has even been some talk lately about a made-for-TV movie, or series, based on the riveting action in this lab.

The book follows one group of NJMS students as they work on "their" cadaver for the 15-week class. All have since graduated from NJMS with their MD degrees. The writer focuses on each individual's reactions and the group's dynamics as the four would-be-doctors work at their dissection, a task that is both emotionally and mentally demanding. The students, many of whom have never held a scalpel, must cut into human flesh, carving out the organs, bones, muscles, joints, ligaments and tendons, of their anonymous cadaver.

Giegerich tells readers the background of the donated corpse. He was a man by the name of Tom Lewis, a public school administrator in New Jersey , who had a strong commitment to furthering science and a willingness to put that belief on the line. The journalist records the students' struggles, particularly their hesitation on having to cut into a human face, a kind-of "sacred ground" that they perceive as housing the personality.

It's clear that Vasan welcomed the reporter and photographer Noah K. Murray into this classroom because he has his teaching of gross anatomy "down to a science." There probably is no one more aware of the difficulties of teaching and learning the material than this professor. During his three decades of trying to maximize the students' grasp of the subject matter and their scores on national proficiency exams, he has continuously modified his approach. His open door policy and quick response to comments sent by students via email has let them know he values their insights and puts them to good use.

So why, in 2004, would this longtime NJMS faculty member introduce a whole new way of teaching such a pivotal course?

Well, first and foremost may be Vasan's abiding interest in the teaching process itself. He was elected to the inaugural class of UMDNJ Master Educators in 2000, served as the Guild's president in 2002-2003, has been awarded 10 Golden Apples by NJMS students, and has been nominated every year for this award, and just this past spring was accepted to be a Harvard Macy scholar. He's one of the first faculty members from NJMS to attend this international program, he says proudly, where he is learning "how to lead change."

Leading change seems to be in Vasan's blood. In 1982, he introduced the "structured lab review," which is still in use, as well as the "mock practical," learning tools enabling students to better prepare themselves for the practical and exam. For those needing additional help, he initiated tutorials and also has spent innumerable evening and weekend hours in the lab. No student "suffers" alone. On becoming the course director in 1996, he introduced more radical changes. After attending clinics and morning rounds at UMDNJ-University Hospital for two years, he felt equipped to revamp the entire gross anatomy curriculum, retaining only the clinically relevant material, and reshaping its presentation to "reach" these future doctors. In other words, this is a teacher who has never been content to rest on his laurels.

His current and most radical departure "Team-Based Learning" was initiated in 2004. What he discovered in his classroom-laboratory is that students learn more when they are challenged to teach themselves. He's certainly not the only proponent of this kind of teaching approach but he may be the first to try it out in a course as critical to the medical students' success. He made the decision to refashion a course historically considered to be "an intimidating nightmare" and the "make-it or break-it course" for first year medical students, into one that is still tough, but manageable. A less confident teacher or one less proficient in leading change would probably not have risked it.

This sweeping transformation has already yielded positive results. But with the same quantity of material to be learned, and the same difficult dissections to be performed, what is so very different?

"The number one change has been that there are no more anatomy lectures," Vasan explains. "Now students act as teachers for their teams."

Vasan himself handpicks each team. First he assigns four students to each dissecting table and then combines two tables to make teams of eight. While these groups could be assembled randomly, he explains, they are far more successful if the experiences of the members are very varied. "I mix mature and young people, women and men, students with differing work experience and those from different ethnic backgrounds. The group will fail if its members have all had similar experiences," he states.

Why does this matter when learning human anatomy? The course director explains that through the group's discussions, these students will learn differential diagnosis. Being able to identify body parts is the easy part of the lesson, he contends. More important is the development of critical thinking skills to take that knowledge to the next step.

"Students will learn how to discuss a problem, taking into account varying perspectives, and to think things through to a satisfactory end," he says.

The class of 180 students meets for three hours of dissection time three times each week. That constitutes 65 percent of the course time. "That has not changed," says Vasan. Each of the team-based sessions which have taken the place of the lectures lasts 90 to 120 minutes.

Students are given a hefty reading assignment and learning issues that must be completed before each class; and each class kicks off with a quiz. "This provides for continuous self-assessment and "fast tracking," he says.

If a student is falling behind, Vasan says it becomes apparent immediately. "I can pull that student out and ask what's going on," he explains. "In most cases, the student is studying the wrong way. I can put the student back on the right track very quickly."

He says that his data has shown that students whose performance on weekly quizzes is consistently "borderline" will be in the lower percentile by the end of the class. "Now we will approach those students early and tell them where they are lacking," he states.

Although classes this large often have a dozen facilitators to make small group learning effective, Vasan says proudly that in this course, there are just two. He and DeFouw are always present in the TBL sessions and each "visits" half of the teams spending a few minutes with each during every session. The facilitator observes the group dynamics, assesses if the team is doing okay, refocuses team members if the group is off-base; and might give them a "one-minute lecture," which the course director calls "micro-teaching."

"The team must arrive ready to critically discuss what they've read," he says. Fifteen percent of a student's grade in this course will come from his "team effort," according to the anatomy teacher.

Exams are given five times during the semester. When the exams are taken away, explains Vasan, the team assembles to discuss each question, arriving at a group answer. "The conversations are really intense," he says. "Team members discuss why an incorrect answer is wrong. There is a lot of teaching going on during those sessions."

Perhaps one of the more critical elements of team-based learning in gross anatomy is peer evaluation. Students critique each other five times during the course on punctuality, preparedness, contribution to the group, respect for each other and flexibility (considering other points of view). If a student is not contributing enough, according to the team report, then one of the facilitators will talk with him.

Communication, communication, communication. Vasan has demonstrated that when the communication lines are opened between students and facilitators, and students and their fellow students, "no one should fall behind."

The feedback on this new approach has been "outstanding," he says. Students learn quickly that there is a limit to one person's knowledge, and that team members have to talk with each other and rely on each other. "It teaches future doctors to work as a team," he says. "Memorization no longer works. Team members are forced to think critically."

Vasan does admit that the course is a lot of work for the two facilitators, who are responsible for the success of all 180 students. Every week the students' data is input in Excel, he says, so that the facilitators can chart each student's performance.

What has become apparent is that when the data from 2002 and 2003 (when gross anatomy was taught traditionally) is compared with the 2004 and 2005 data, the students are doing much better now. National test scores are rising, too.

"Medical students are competitive," Vasan says. "So when they see it works for one course, they figure why not try it in other classes as well."

Next year the gross anatomy teacher will work with the biochemistry faculty at NJMS to initiate team-based learning in that course. And other medical schools across the country are asking for his help, too.

Vasan does not take these successes lightly. He knows that teachers are tested even more strenuously than those they teach and that an A+ from students is hard-earned and a very sweet thing.