Thursday, September 06, 2007

Dead Man Wasting


Even as I questioned the value of dog labs, I wonder still more about the most hallowed and time-honored tradition of medical school: the dissection of cadavers to which all first-year students are subjected. Because the bodies have been knowingly donated, it's not really an ethical issue, except to the extent that those who've made the gift might have a more exalted view of its value than is accurate. And before I say my piece, I must admit it's just one opinion, from a ways back. I'd hope more recent, and current, students might chime in and set me straight, if that's what is called for.

I'd guess we've all seen classic paintings, like Rembrandt's "The Anatomy Lesson." We've heard of grave-robbers hired on the sly to supply medical schools, of Michelangelo becoming one himself to facilitate his artistry; and we know the extent to which these dissections have been carried out, more or less in the exact way, for centuries. So in pushing yourself through the portal into the anatomy lab, you feel as if you're entering a space hallowed by history; taking up a challenge and a charge handed down by people willing to risk their freedom to advance science. Maybe more than anything I can think of, you're stepping into the past. Unlike, say, those who re-enact wars, or who sail on resurrected galleons, this is more than play. It's not make-believe. This is becoming what was, experiencing exactly (sort of) what the pioneers of our field felt, and did. In a couple of important ways, though, it's also a great deal less.

Much as I might have liked to be wearing the flowing clothes, the fuzzy collars and broad hats of Rembrandt's vision, it was rubber gloves and plastic aprons. If I'd imagined being in the thrall of a master lecturer and demonstrator, it was in fact a bunch of clueless students trying to follow written instructions, wrestling alone and together with their conflicted thoughts, working out who'd do what, with a lab assistant sometimes wandering by. (Was that a smirk on his face?) As far from life-like as they could be, the tissues reeked of formalin, and were leathery and hard, belying and opacifying the mystery they held. Or had held. And they were greasy. There's not much to be gained from the process of finding one's way through, by dissecting such unnatural material, spending lots of time getting there and often missing a turn. To the extent that there's knowledge to be revealed, in a preserved cadaver it's in the arriving there, not in the travelling. And marvelous and awesome as is living anatomy, what's revealed in a cadaver is a wooden shadow; as removed from real as a dried and pressed flower is from a bloom.

There was a need to acknowledge the gift this person had made, and there was a desire to turn away from it. To look at the face; simultaneously to absorb and to erase. Tightened, tanned, transmogrified, the body had already been dehumanized more than our dissection would do; still, in making the first strokes of the knife, there's an inward voice saying, "Sorry... sorry... sorry."

Is it like removing the sword from the stone? There's a sense in which this feels like a rite of passage, a symbolic qualification for being allowed to learn the long-guarded secrets. If you faint, if nausea overtakes you, if you can't get past the sense of transgression, you ought not be here. So it seems. Does it harden you? Or soften you up? For most, it's the first encounter with a real live dead body. There's fear of how you'll react, of embarrassing yourself. Some students have ceremonies of thanks to the person who gave their gift. Whom's it for? Is it being actual sensitive, or see-me-sensitive? To the extent that this dissection is ritual, we respond with ritual. We dance with the corpse, and it dances with us. So it raises a question: is it necessary?

In my view, there's only so much -- not much -- that you can get from working with stiffened sinews and pickled pieces. The anatomy I really needed, the relevant relationships I began to understand as a surgeon, I got in the operating room. Or in the basement: I participated in autopsies of unpreserved bodies, and the ones on patients of mine were infinitely more emotional -- and instructive and useful and important -- than that work as a first-year student. The sequence seems wrong: if such dissection is to be done, it ought to be by those more knowledgable and honed. Absent context, it can become clutter. Cardiologists need to have the experience of holding a heart in their hands (and to see one beating in the operating room); how much more meaningful to do it later in the process. As students, it's like a White House document dump: too much information, no hooks on which to hang it. Even books, with their diagrams and plastic overlays provide more understanding once you figure out what it is you need to know. And now, of course, 3-D imaging and computer programs allow interactive and highly effective work.

At the time I went there, my medical school was the leader of a revolution; it broke the timeless tradition of curricular structure. For ever, it had been anatomy, physiology, pathology, pharmacology, lined up in sequence and out of sense. Where I went, they'd just rearranged into teaching by system: cardiovascular, for example, including the anatomy, physiology, pathology, organized in ways to make it meaningful. So the old-fashion dissections were out of synch, and therefore out of use to a much larger extent than at other schools. We did, in other words, much less in the cadaver lab than our contemporaries. In hearing of that, at first I worried that I'd come out unprepared, anatomologically. It was almost embarrassing to reveal to college friends at other med schools how little time I'd spent doing the dissections and taking the tests that they and our forebears had done. But it's clear to me now my time was better spent. And whereas I do think all doctors need a working understanding of the anatomy of all systems, it needn't be -- and in fact isn't -- those first-year dissections which provide it. I'd go so far as to say that, other than imparting a sense of having walked over the same coals as everyone else, the first-year cadaver lab is over-rated and under-important.

33 comments:

Buckeye Surgeon said...

I agree doc. I don't remember much of anything from gross anatomy lab other than goofing around for 2 hours a day with equally immature, uncertain labmates. The experience had ZERO impact on my decision to become a surgeon; if fact, it merely strengthened my initial resolve not to be a surgeon. I passed the exams not by spending all night looking at the tangled, formaldehyde-laden mess in our corpse, but, rather, by memorizing the beautifully, lucidly rendered images in the text book. If anything, the gross lab is perpetuated as some sort of right of passage, as you mention. It lets you know "you're really in medical school."

Interestingly, as a senior surgical resident, our program introduced a gross anatomy lab tailored toward surgical anatomy. Now this was much more useful. Head and neck anatomy suddenly made sense. Learning complicated abdominal vascular exposures was practiced and mastered. It's all about timing. The corpse can be a wonderful tool, in the right situation.

#1 Dinosaur said...

Agree 100%.

ER's Mom said...

I can't add anything other than I agree as well.

I remember our corpse's thyroid was in his chest. But otherwise, I remember very little from those days.

DC Med Student said...

Looking back at my post on the subject, it looks like I partially agree with you. While I learned a lot just by studying Netter's beautiful renderings, I had to see and feel the structures in the cadavers to really understand the spatial relationships. I do feel that a good 3-D computer program would have worked for me, but not for all of my classmates. Some really did need to see and touch to get it.

We were told by one of the deans that they had looked into going to a 3-D computer program instead of cadavers, but found that schools that had tried it went back to using cadavers because of lower student performance. I don't remember him mentioning any names.

I like the idea of the the gross anatomy lab tailored toward surgical anatomy mentioned by Buckeye Surgeon. I think first year anatomy lab would have been better if there were less students per tank and had an instructor that could stay and guide us through each of the dissections. It was hard to keep a professor at your tank because everyone needed help. Very few had done this before and no one wanted to mess it up.

rlbates said...

Another in agreement with you. What I remember most about anatomy lab is the feelings you mention and the smell. I got much more out of the anatomy dissections I got to do as a fellow. As Buckeye put it, it made much more sense then--there was context.

MedFriendly said...

Well, any thoughts I had about donating my body to science have now completely gone out the window.

Dominic A. Carone, Ph.D.
Founder and Webmaster of MedFriendly.com and The MedFriendly blog.

Justine Hemmestad said...

The concept of using cadavers as being archaic is understandable, with a great connection between historical paintings and detachment. Thank you for this insight.

Shauna said...

I had decided (a long time ago) to give my brain to the local brain bank (I have MS), and the rest of me can go to where it's needed and can be used. What's left goes to the med students.....I have always known that cadavers are subject to some tom-foolery; med-students are human, too, I think. At our local med school, though, there is a once a year memorial and committal service for those who donated their bodies. It is attended by the med students, faculty, and families of the deceased. A touching tribute I am told. And that works for me......but not until my time has come, please.

David said...

Nice essay. I so agree with you. I am often astounded at physicians' deft knowledge of anatomy. I always ask myself how they could have learnt that from a cadaver. I believe that medical school instruction, thankfully, has become more intuitive and encouraging of students' imagination and critical thinking. I believe we are going in the right direction. Thank you once again for your mindful comments on the subject.

Rob said...

Eloquent as always, Master Sid.

My main memory from Anatomy was riding on the L in Philadelphia on my way home from Med School and thinking: "If only these people around me knew. I just cut a dead person's leg off." It was a surreal experience which had more the feel of an initiation than a learning experience.

Anonymous said...

I go back to my local med school for a couple of days each year when they are dissecting the pelvis. I really enjoy it. I feel that I get to review the anatomy for myself with a freedom that is not available in a live person and I get to try to teach the students something about what is important about the anatomy, why the relationships and the structures are important. Sure it isnt the same as a fresh or live person but there is still value in the experience.

prairie mary said...

It seems that both computer simulations and pickled cadavers have the potential to de-humanize the human body. But I've read accounts of conferences (always some nice place with good golf courses) where salesmen and demonstrators bring coolers of parts: arms, pelvises, whatever, so as to show new techniques and tools. And then there is that weird display of plasticized bodies that travels the country. I think that the human body, which we see bared far more now in ads and media than we ever did before, is a culture-wide issue as much as a medical issue.

Prairie Mary

Bruce said...

Sid, thanks for shining light where there is not enough. Many good points. Can I dissent a little?

I attended a packed "Ethics of Human Dissection" lecture given to our M1 students a couple of weeks ago and will spend a few afternoons volunteering in the lab during the upcoming head and neck dissections. My observation is this: the students take the cadaver lab VERY seriously...this is another human being, after all. The faculty take the experience very seriously and are distraught if the students don't take full advantage of this incredible opportunity.

Certainly, years from now, the M1 students won't remember specifics of the dissection experience. Using that logic, they won't remember much of the Biochemistry or Pharmacology, either. Anatomy has the advantage that it won't change very much over their lifetimes. The Immunology I learned in medical school 30 years ago was basically all wrong.

Still, the students are really just learning how to learn. Their academic loads are overwhelming. To rapidly learn anatomy, many students will have to hold it in their hands, draw it out, cut it in ways that they will never be able to again, and examine it from every angle. If they end up as surgeons, they will learn it over and over again until it is second nature. However, even as surgeons, they will never be able to transect the aorta or lift out the brain with impunity like they could as a student to see and touch the attachements and hidden secrets.

On another level, the students, who just a month ago were lay people, are now irretrievably tied to their newly chosen profession by this experience. No one who has had the privilege of studying the muscles, organs, and fibers of another person is left completely unaltered.

Finally, having physicians, particularly surgeons, volunteer in the anatomy lab provides the students with their first tentative links between a pre-clinical subject and illness. As Dr. Anonymous points out, it enriches both student and teacher.

So, put me in the (apparently small) camp that supports the vital importance of human dissection, even if our students (and we) do not learn as much from it as did Vesalius and Michelangelo. Too much of a comment, and perhaps I do protest too much. Still, after spending several years helping in our anatomy lab, I can't help but think that it is a valuable watershed experience for our soon-to-be colleagues.

Thanks again, Sid.

Aggie Sarah said...

As a current medical student (I'm three weeks deep in gross!) I've found that it isn't doing the actual dissection that helps me learn, it is sitting with an already dissected body, poking around, looking for landmarks, learning the actual 3-D relationships between all the parts. Pictures, like in the beautiful netter, give an idealized picture of what the body looks like. I think real bodies are necessary for the learning process (as is an EXCELLENT teaching team, of which I think my school has, but I think that has more to do with the fact the blind can't lead the blind in figuring out where a tiny artery is), but I don't think student led dissections are the way to go.

Greg P said...

I remember during a plastic surgery rotation in med school having the opportunity to watch a radical neck dissection by Dr. Arthur James at OSU. I remember this as the most marvelous anatomy lesson I have ever seen, first of all because he was a meticulous surgeon who tied off (this was pre-bovie) every little bleeder, and as he operated he pointed out all sorts of structures and their anatomical relationships as well as the clinical importance in connection with the dissection. It's something that should have been preserved on videotape for instructional purposes.

Greg P said...

Something else:
I saw Korperwelten (Body Worlds) in Munich when I visited there a few years ago.
It's quite an amazing thing, and for those who can appreciate it, these are some incredible dissections -- I had no idea one could dissect out such small nerves and other structures.
It's a controversial display for a number of reasons, clearly sensationalist in the posing of the various specimens, and in the end clearly a commercial enterprise.
While I could see the scientific benefit of this effort, one could make a digitized and annotated DVD of these specimens which could be much more instructional and allow on-demand use at appropriate times. One thing the public may not know is how often a surgeon may do a review of the surgical anatomy before an important tricky procedure, but there is a huge difference between the visual/mental surgical anatomy in the OR and that of the cadaver or Gray's Anatomy.

Sid Schwab said...

Bruce: Your comment comes from one much more currently involved and is much appreciated. How great it would be (and would have been) to have had an expert such as you helping each group of students with a particular area of dissection. (In fact, it makes me think I should contact the local med school to see if they'd like help with the abdomen.) My perspective, at this point, is one of great distance. In my post I said "the sequence seems wrong." Yet I don't suppose it's temporally possible to have gross anatomy happen at a time when it's more relevant. As it is, whereas there's lots of ordeal and amazement -- and I do recall being thrilled and amazed -- there's also much in the way of lost opportunity because of when it occurs in schooling.

Again, thanks for your really thoughtful comment. I wish I'd had surgeons helping with my dissections back then. I'm sure that if I did, I'd have written something much different now.

Beach Bum said...

Thank you for an interesting and thought provoking post. My own thoughts on this subject, written while I was taking Gross Anatomy last semester, seem to mirror yours in some respects.

I have a couple of thoughts:

For a variety of reasons during our head-and-neck block, we didn't have enough bodies for each group to dissect. The professors did a handful of dissections, and we learned from these. Our class average was significantly higher than for the rest of the semester, when we were doing our own dissections. I do think there is something to be said for students being given more guidance. And in addition, when students are busy trying to get a dissection finished, in my experience they may be less likely to actually learn the anatomy. They may end up with good dissection technique, but not have spent as much time actually learning the material.

I do think that the Gross Anatomy experience does provide a rite of passage into the medical profession, in a way that a "White Coat Ceremony" can't or often doesn't. That being said, I agree with you about issues such as timing, and focus. I enjoyed the experience, and learned easier when the professors emphasized the clinical importance of what we were learning.

At least one Canadian medical school doesn't do cadaveric dissections for their first year medical students. The stereotype (for what it's worth) of surgical residents from that school is that they need remedial anatomy training to bring them up to the same level of knowledge and confidence as their peers.

Thanks again.

Kathleen said...

Hey Doc! Just wnated to let you know my daughter read your book. When I asked her what she thought, she chuckled at what she getting herself into! :) I'm finally getting my xplant! I report to MN on the 2d for pre-op, Table date is the 8th! :) Thank you for everything, Kathleen

TBTAM said...

I alsways felt that anatomy should be taught while one is on surgical rotations, and not at the beginning of medical school...

Health Train Express said...

Sid, I meant to say mazeltov regarding your wedding anniversary.

I think your perspective as a surgeon is a bit biased since you have worked with anatomy so much as you progressed through training and worked with living tissues.

However for many who become internists, pediatricians, radiologists, psychiatrists, this may be their "unique" exposure to anatomy.

I agree it is a right of passage which creates a certain camaderie amongst the M1s...It too is a bit overpowering, and yet it is one of the few remaining experiences early on that does set us apart in our early innocence and naivety of altruism, before we are bludgeoned and labelled as "providers", licensed as "physician providers" by the Department of Consumer Affairs here in California via the Board of Medicine....

I still remember my cadaver's name (which is a violation of HIPAA law which did not exist back then. Someone had forgotten to remove the toe label (his name was Russel......

I remember vividly starting in the axilla where I was totally confused and overwhelmed trying to figure out the "wiring"....it was an experience as physicians we all need to keep us "humble" at this great creation of life....whether one thinks it was created or evolved...what a masterpiece!!
I also remember being told by my early mentors that we would not understand what it was we were seeing and that later the individual pieces would come together. Perhaps from a pedantic point of view the process was a bit convoluted. However it made you "work" at it to get it, and later on the pieces did assemble in my brain.

For those unfamiliar with Koperwelten, they can find information at:

http://link.brightcove.com/services/link/bcpid1078960718/bclid1078573149/bctid1044920714 I also remember at the time our anatomy lab was on the top floor (5th floor) of a very old civil war building in Washington DC at GWU.
At the time a nearby skyscraper was just being occupied adjacent to our open windows....Quite a few secretaries were "shocked" when they saw us sawing, chopping and dissecting our cadavers. We were supposed to draw our shades and close the windows but at the time in D.C. the A/C was inadequate. I am sure the odors drifted into their spaces.

This was a great post that draws us all together from the beginning of our careers to where you and I stand today

Bongi said...

from a personal point of view, dissection was great and useful. yes, you had to get the stuff from the books first, but thereafter, if you dived into a cadaver to verify and 3-d-ify your knowledge it was so worthwhile (for me at least). our dissections were done under the watchful eye of anatomy lecturers, some of whom had been in the department for about 20 years. they were fountains of knowledge and would jump in to help us at the slightest provocation.

the new curriculum pretty much (but not completely) scrapped dissection. i really think the students today have a clear deficit in their anatomy knowledge.

just my view though. these thoughts are not meant to be taken as actual medical advice.

Harry said...

The med school I'm starting teaches anatomy by prosection, with the option to dissect.

I was seriously considering to use one of my optional choices for dissection but I am now not so sure...

Sid Schwab said...

Harry: don't let the rantings of an old man deter you. I'd suggest talking to people who run the lab, or who've taken it, and see how it'll work. If there's direct and readily available guidance, dissection is more meaningful. Still, assuming you have time to handle and get a grasp (literally) of the relationships, prosection would seem to provide what you need.

Mike said...

I'm not a surgeon, but I like the fact that I did Gross Anatomy. It was useful in innmuberable ways, even to the disingenuous here (including the author) who just prattle about learning from books being enough. That's not reality. It's easy to sit in hindsight and proclaim that the whole thing was a drag, just like elementary school students who think math will never be useful. C'mon. Getting your hands on nerve sheaths, seeing that blood vessels aren't so big and juicy as in Netter, learning that muscle looks like a shriveled up steak, rubbing the fat until it melts to get the deeper structures. How would I know this stuff otherwise?

Sid Schwab said...

Mike: I can't tell if you're serious or not. The first words say yes, the last say no. Nor am I sure you read what I actually said. So I won't write a comment.

makeminetrauma said...

Sid, Wow, I never suspected cadaver labs might go out of "style" or fall way to 3-d computer programs. I also never suspected that there would be anyone who would not benefit from a cadaveric dissection.
You have opened my eyes but not taken away my resolve!

http://intraoporate.blogspot.com/2007/09/say-it-aint-so.html

MMT

makeminetrauma said...

http://intraoporate.blogspot.com/2007/09/say-it-aint-so.html

makeminetrauma said...

Okay, I give up, thought I was a real smarty pants-figuring out how to post my link. After all, it was underlined and highlighted just like a real link, but alas, it doesn't work! Here's hoping people will cut and paste. And now, I will quit cluttering your comments with my shameless self-promotion!

MMT (again)

jb said...

Respectful disagreement here also. My anatomy lab, in the 1970s, was reverential, and the always present faculty and assistants made sure that there was no fooling around. As a surgeon, it was my introduction to anatomy, and as said above, for the non-surgeons, may be the only hands-on exposure to true "internal medicine" that they ever had. One of my senior students electives was as a teaching assistant in the gross lab, and it was here that I really learned anatomy, before beginning my internship.

I agree that spacing the gross anatomy lab experience out through the basic and clinical science years would nave been better, but not practical.

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Dr. Rob Oliver said...

I think there's a lot I took away from gross anatomy that you just can't get from not having put the time in the lab in. It's certainly not the most efficient way to learn, but it teaches you a certain discipline which is lost with computer sims. I think the same of histology. Learning to use a scope and handle slides teaches you alot of respect for the method versus just looking at static archived atlas images (as increasingly being done)

I would highly recommend Dr. Bob Ackland's 6 volume DVD video atlas of anatomy which is a 3-d "disection" of function anatomy. It's won a bunch of awards and is used in many places for teaching. Dr. Ackland was one of my Plastic Surgery professors at the University of Louisville and was one of the founders of microsurgery in Europe 30 years ago.

Anonymous said...

"(In fact, it makes me think I should contact the local med school to see if they'd like help with the abdomen.)"

I definitely think you should. Throughout my anatomy course, we had many specialists come through and point out what they thought was relevant. I found it quite helpful. Many of the things you've said in your blog are things that I wish a surgeon had told us in anatomy, because it certainly helps fill in some details of the big picture.