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Anatomy Tour Time.

Introduction

Alabama State University is an historically black university (HBCU) located in Montgomery, Alabama. The school has an occupational therapy program leading to a Master of Science degree in Occupational Therapy and a physical therapy program leading to a Doctor of Physical Therapy degree. Gross anatomy is a foundational course for both programs. Although the content itself is not difficult to understand, the vast amount of material presented in the course is daunting. For many students, the learning expectations make the course difficult to pass. At ASU, the majority of students who did not complete the physical therapy program received a grade of "C" or lower in gross anatomy. Students who receive four "Cs" or a single grade of "D" or "F" while in the program are dismissed from the graduate school. To improve student grades, two changes were made during the first semester of the physical therapy program in 2009: the Anatomy Tour Time, a reciprocal peer teaching event during which the students demonstrate their dissection to their classmates, was incorporated into the gross anatomy lab and tutors--available, but optional, in the past--were mandated for students with exam grades lower than 80%.

Peer teaching has become an established methodology for actively engaging students in learning gross anatomy. Techniques employed include formal presentations to first year students by second year students (Youdas, Hoffarth, Kohlwey, Dramer, & Petro, 2008), and prepared presentations given by first year students to their classmates (Hendelman & Boss, 1986; Krych, A.J, et al., 2005; Yeager & Young, 1992). Bentley and Hill (2009) described a reciprocal peer teaching method in which one half of the students came to lab prepared to dissect and demonstrate the dissection to the other half of the class who did not arrive until after the dissection was completed. Students acting as peer teachers have reported that the situation gave them more confidence in their knowledge and in their ability to teach others (Hendelman & Boss), an important skill for graduates of allied health programs, and that they learned more as teachers than as learners (Krych, et al). One complaint of students was inadequate teaching from their peers (Bentley & Hill).

In this paper, a unique method of peer teaching initiated in the ASU Department of Physical Therapy is described. This method, which engages all students in peer teaching during each laboratory session, incorporates repetition--an important element in memorization--during each lab period, allows the students to see the normal anatomic variations of the structures they are dissecting, and ensures that the peer-taught information is accurate.

Methods

Gross anatomy in the Department of Physical Therapy is an eight-week course taught in the first semester. The class meets on Monday, Tuesday and Thursday with two hours of lecture in the morning and four hours of lab in the afternoon each day. Two doctorally trained anatomists teach the course to a class ranging in size from 23 to 33 students. The body below the head and neck is studied and dissected in this course. The head and neck are covered in the neuroscience course during the subsequent semester. Students in the physical therapy program dissect the entire cadaver, but emphasis is placed on the extremities and the back with particular detail to the musculoskeletal, cardiovascular, and nervous systems.

The morning lectures cover the region to be dissected in depth. Traditionally, the afternoon lab consisted of four hours of dissection. Four students formed a lab group that was assigned to a cadaver table for the duration of the semester. Each lab group was organized into two pairs, one for each side of the cadaver. One student in each pair was the dissector while the other, non-dissecting student acted as the reader. The reader directed the dissection by reading the instructions from a published dissection manual and showing appropriate illustrations from atlases. During the lab sessions, the paired students alternated, with one student acting as the dissector while the other was the reader, so a student dissected during every other lab session.

The laboratory session was modified by the author (course director) by decreasing the dissection time from four to three hours and replacing the final hour of dissection with tours during which students rotate around the room to see all of the cadavers. Initially, in 2008, the tour event consisted only of students rotating among the tables to view the other students' dissections at the end of each class period. In 2009, the tours were formalized and activities were designed for the readers.

In the 2009 lab sessions, readers not only directed the dissection, but became more actively involved in the dissection process by collecting and organizing information on the structures which had been exposed on their cadavers and by quizzing the dissectors on the structures being dissected. During each lab period, the dissector showed the reader the structures as he/she exposed them and the reader gathered information on each structure obtained from the textbook, atlases, and/or lecture notes. The information exchange between reader and dissector reinforced the material presented during the morning lecture. Approximately an hour and a half before the end of the lab, the two readers at each table consolidated their notes on dissected structures from both sides of the body. When each group was ready, one of the instructors verified the structures located and the information collected. During the final hour of lab, after all tables had been checked by the instructors, the readers disseminated the information they had gathered by acting as tour guides for their classmates. One of the two readers at each table remained with the cadaver, acting as the first tour guide, while the other reader joined the dissectors, who rotated from table to table around the lab as tourists. The tour guide at each table pointed out the dissected structures, told something about them (such as attachments and innervation of muscles, branches of arteries, etc) and quizzed the tourists. They were given 3 to 5 minutes per table depending on the particular dissection. After the tourists completed the tour, they returned to their own tables. The readers then switched places so that the reader who circulated around the room as a tourist the first time took over the role of tour guide, while his/her partner took the second tour. The dissectors could use this time to clean their instruments and to review the material or could choose to take the tour again.

At the end of the 2009 semester, the success of the program changes was evaluated by comparing student outcomes of the current class with previous classes, and by student evaluation of Anatomy Tour Time as an educational technique. Although a single grade is received in the course, to detect any change in lab scores, the lab grades for each student were calculated separately for this evaluation. Overall grades for the course and grades for the lab portion were analyzed by Student's t-test (two-tailed, 0.05 a). Comparisons were made between grades for 2009 (formalized lab tours) and 2008 (non-structured tours), between 2009 and 2007 (no tours), and between 2008 and 2007. For evaluation of student perceptions of the tours, brief questionnaires prepared by the course director were distributed at the end of a lecture session. Students anonymously completed the questionnaires after class and turned them in to the class president who bundled them and left them with the course director. The questionnaires consisted of nine questions in which students evaluated the tours on a Likert scale ranging from 1 = strongly disagree to 5 = strongly agree. Questions fell into three categories related to [1] preparation for the tours while acting as a reader, [2] taking the tours as a tourist, and [3] acting as tour guide. In addition, students were asked to provide any other feedback that would increase the effectiveness of the tours for future students.

Results

Since the inception of Anatomy Tour Time, the pass rates for both the lab portion of the course and the overall course have increased as summarized in Table 1. In 2007, before the tours were utilized, only 88% of students passed the gross anatomy course, with only 79% receiving an average passing grade on the lab exams. In 2008, when an informal tour was introduced at the end of each lab session, the pass rate for the course increased to 91% while the pass rate for the lab portion improved to 88%. In 2009, when the formalized tour time with information gathering objectives for readers was implemented, 100% of the class passed the gross anatomy course and 91% passed the lab portion. When comparing 2009 to 2007 grades, analysis of both the lab grades and the course grades showed a statistically significant improvement (P=0.01 and P=0.005 respectively). There was no significant difference between either the 2009 vs. 2008 or the 2008 vs. 2007 grades for overall grades or for lab grades.

All of the first year physical therapy students completed the questionnaire at the end of the summer 2009 term. The results are shown in Table 2. The results of the questionnaire indicate positive student perceptions of tours in the anatomy lab. The majority of students responded that all three aspects of the tours (preparing for the tours while acting as the reader, taking the tours as a tourist, and acting as the tour guide) were beneficial.

Preparing for the tours while acting as the reader: 20 students (87%) responded that preparing for the tours helped them focus on the day's dissection while a smaller majority (57%) thought that preparing for the tours decreased the amount of time they needed to spend studying at home. Only 1 student responded that preparing for tours was a "waste of time".

Taking tours as a tourist: 22 of the 23 students (96%) responded that the repetition involved in going to all the dissection tables, and thus listening to the information 5 times, helped them to learn the material. The same number of students thought seeing all of the cadavers helped them to understand the normal anatomic variations found in the population. Interestingly, 4 (17%) thought the time could be better spent dissecting.

Acting as tour guide: 22 students (96%) responded that the repetition of giving the tours and discussing the structures with the tourists helped them to understand the material. Twenty students (87%) felt more confident in their knowledge of the material after giving the tours while 21 (91%) felt more confident in their ability to teach others.

Discussion

Anatomy Tour Time is a unique laboratory experience that benefits the students in four ways: 1) by keeping the students attentive to the progress of the dissection, 2) by providing repetition in seeing and hearing about the dissected structures for both the tour guides and the tourists, 3) by acquainting the students with normal anatomic variation, and 4) by providing students with experience in teaching others, a skill that will be needed when they become clinicians.

As in most gross anatomy labs, one cadaver is shared by several students so every student does not get to dissect during every lab period. Providing teaching methodologies that engage and provide learning opportunities for the non-dissecting students has been an ongoing concern at ASU. In the past, the non-dissecting anatomy students often appeared bored and inattentive to the dissection, sometimes carrying on conversations that had nothing to do with anatomy. The Anatomy Tour Time keeps the students who are acting as readers involved with the dissection by researching valid information on the structures as they are dissected and sharing their findings with the dissectors. Having specific responsibilities that occupy their time during the laboratory session has kept the students on topic and reduced their inattention. The majority of students indicated on the questionnaire that preparing for the tours while serving as readers helped them to focus on the day's dissection. Discussions about the dissection that occur between the readers and dissectors help both to integrate the information from the lecture with the structures seen in the cadavers. Additionally, students who know they will have to demonstrate the cadaver dissection to their classmates are more rigorous in proper identification of the dissected structures during the lab period, rather than waiting until near an exam to learn them. One student wrote on the questionnaire that being the tour guide "forced me to learn the material" for the day.

Anatomy Tour Time reinforces learning from initial memorization to applying the information to a clinical context, and helps students acquire skills that will be needed as clinicians. The first step in building the anatomical knowledge required for clinical reasoning is memorization of relevant material. Repetition is a key component in the process of memorization (Mondria & Mondria-DeVries, 1994). As students move from table to table they are exposed to information on the same structures, but with different emphasis, as each tour guide leads them through the dissection. When they act as tour guides, students become thoroughly familiar with their own cadavers and the information regarding the dissected structures. To ensure that structures have been correctly identified and that supporting material is correct, the information is presented to one of the instructors prior to the tours. This also gives the student teachers a practice session which can increase confidence in their knowledge of the material.

In addition to the knowledge gained by the repetition during the tours, teaching one's peers has been shown to be an effective means of learning. By working in reader-dissector pairs, students alternate between the roles of researcher/teacher and learner. Students working in pairs, in which the students rotate roles as teacher and learner, have been shown to score significantly higher on achievement tests (Goldschmidt & Goldschmidt, as cited in Bonwell & Eison, 1991). Annis' study (as cited in McKeachie & Svinicki, 2006), in which students read a passage and then taught it to another student, showed that peer teaching resulted in better learning than when students were simply taught the passage.

Peer instruction also provides the students with teaching experience they can use when educating their patients. In a questionnaire on skills in clinical practice sent to practicing physical therapists, 99% of responding therapists either agreed or strongly agreed that teaching is an important skill in the practice of physical therapy. Yet only 34% of the responders indicated that they had received some instruction in teaching as part of their physical therapy education. Sixty-six percent indicated that they had used "trial and error to develop competence in education" (May, 1983). By instructing their peers in a non-stressful environment, students develop the teaching skills and confidence they will need in clinical practice.

Seeing a variety of cadavers helps students to see variation, and this will carry over into their clinical experiences. Students exposed to only one cadaver and atlases of "perfect" specimens do not appreciate the anatomic variations commonly seen in the human population. This is important in transferring anatomical knowledge to their patients.

Student perceptions of Anatomy Tour Time were favorable. A majority of students indicated that the anatomy tours were beneficial in all areas described above. A single student thought the tours were not beneficial and should not be mandatory.

Statistical analysis showed a significant improvement in both overall course grades and lab exam grades of students in the 2009 class when compared with the 2007 class, which did not utilize lab tours. Although not

statistically significant, the increase in course and lab pass rates for the 2008 class suggests that even informal tours may help to improve anatomy grades.

The Anatomy Tour Time was one of two strategies implemented to improve grades in 2009. In the past free, optional tutoring has been available for students. In 2009, the tutoring was mandatory for all students with an average score less than 80%. Although the mandatory tutoring may have affected student grades, in the past the majority of students with low grades took advantage of the optional tutoring. A second limitation to the validity of this study is the possible differences in student demographics, GPAs, and GREs which were not taken into consideration.

Results of this pilot study indicate that reciprocal peer teaching through anatomy tours is a simple but effective way to increase student involvement in the gross anatomy lab, increase retention as indicated by improved exam scores, and expose the students to multiple cadavers during each lab period. At Alabama State University, Anatomy Tour Time will be continued in the physical therapy gross anatomy course and integrated into the occupational therapy course.

References

Bentley, B.S. & Hill, R.V. (2009). Objective and subjective assessment of reciprocal peer teaching in medical gross anatomy laboratory. Anatomical Sciences Education, 2, 143-149.

Bonwell, C.C. & Eison, J.A. (1991). Active learning: creating excitement in the classroom. ASHI-ERIC higher education report no. 1. Washington: The George Washington University School of Education and Human Development.

Hendelman, W.J. & Boss, M. (1986). Reciprocal peer teaching by medical students in the gross anatomy laboratory. Journal of Medical Education, 61, 674-680.

Krych, A.J., March, C.N., Bryan, R.E., Peake, B.J., Pawlina, W. & Carmichael, S.W. (2005). Reciprocal peer teaching: students teaching students in the gross anatomy laboratory. Clinical Anatomy, 18, 296-301.

May, B.J. (1983). Teaching: a skill in clinical practice. Physical Therapy, 63:1627-1633.

McKeachie, W.J. & Svinicki, M. (2006). McKeachie's Teaching Tips. Boston: Houghton Mifflin.

Mondria, J.A & Mondria-DeVries, S. (1994). Efficiently memorizing words with the help of word cards and "hand computer": theory and applications. System, 22:47-57.

Yeager, V.L. & Young, P.A. (1992). Peer teaching in gross anatomy at St. Louis University. Clinical Anatomy, 5, 304-310.

Youdas, J.W., Hoffarth, B.L., Kohlwey, S.R., Kramer, C.M. & Petro, J.L. (2008). Peer teaching among physical therapy students during human gross anatomy: perceptions of peer teachers and students. Anatomical Sciences Education, 1, 199-206.

Mary Beth Downs, Ph.D.

Associate Professor

Department of Physical Therapy and Occupational Therapy

Alabama State University
TABLE 1
Summary of gross anatomy strategies and outcomes

                2007       2008               2009

Tutoring        Free,      Free, optional     Free, mandated for
                optional                      students with
                                              average score <80%

Anatomy Tour    No         Showing cadavers   Formalized with
Time                       to classmates      objectives for
                           at the end         readers followed
                           of each lab        by tours
                           period

Course pass     88%        91%                100%
rate

Lab pass rate   79%        88%                91%

TABLE 2
Student responses to reciprocal peer teaching questionnaire

                                 Disagree or             Agree or
                                  Strongly     Neutral   Strongly
                                  Disagree                 agree

Acting as a reader:

Preparing for the tours helped        2           1         20
to focus on the day's
dissection material

Preparing for the tours               8           2         13
lessened the amount of time I
needed to study at home
because I learned the material
during the lab period

I feel that preparing for the        18           4          1
tours was a waste of my time

Being a tourist taking the
tours:

Taking the tours has helped me        1           0         22
learn the dissected structures
through repetition

Taking the tours helped me to         1           0         22
understand the normal anatomic
variations found in different
people

Taking the lab tours was a           18           1          4
waste of time that could be
better spent dissecting

Acting as tour guide:

Giving tours helped me                1           0         22
understand the material
through repetition and by
discussing the structures with
the "tourists"

Giving the "tours" made me            3           0         20
more confident in my knowledge

Giving the "tours" made me            1           1         21
more confident in my ability
to teach others
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Author:Downs, Mary Beth
Publication:Journal of the National Society of Allied Health
Geographic Code:1USA
Date:Jan 1, 2010
Words:3225
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