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March 6, 2002

The Changing Role of Dissection in Medical Education

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JAMA. 2002;287(9):1180-1181. doi:10.1001/jama.287.9.1180-JMS0306-4-1

No other curricular component has figured as prominently as anatomy in modern medical education. While the most basic purpose for dissection (to learn structure and function) has not changed since its introduction into the curriculum centuries ago, the attitudes of medical educators toward dissection have evolved according to the particular societal and professional demands of their time.

During the Middle Ages, theologians and philosophers considered the material world (including the frail human frame) to be fleeting and unimportant compared to eternity, and the body was therefore not a focus of rigorous study. Anatomical dissection, in particular, was culturally construed as desecration and thus prohibited. In the 15th century, however, a small cadre of French and Italian university professors—inspired by the humanist rediscovery of the ancients – began to use cadavers to illustrate lectures from ancient Greek and Latin texts.1,2 In science and medicine, as in sculpture and painting, the Renaissance inaugurated a period of renewed interest in the human body and human potential in this world. Prior to the mid 16th century, however, anatomical dissection was not physically performed by professors or students of medicine. The professor lectured from a chair elevated above the cadaver while lowly barber-surgeons demonstrated various structures at the professor's command. Students were completely passive—they engaged the dissected body only through their eyes and their ears, never with their hands.3

Occasionally, exceptional students might inhabit the role of the barber-surgeon in demonstrating structures for the lecturer. One such student, Andreas Vesalius (1514-1564), became so enthusiastic about dissecting that he continued to dissect as a professor and insisted that his students do likewise. Vesalius' most important book, De Humani Corporis Fabrica (On the Structure of the Human Body), drew on the most recent techniques in illustration and helped solidify his pedagogical innovation. Anatomy, through Vesalius and his successors, became the fulcrum of a major shift in medical education away from the study of ancient Greek and Latin texts and toward direct observation. For these Renaissance medical educators, the dissected cadaver became the definitive text and the students' own observations became a source of authoritative knowledge about the human condition.4

Although anatomy was not a static field for the following 350 years, the next major shift in thought about medical education occurred around the end of the 19th century, this time with its epicenter in the United States. In the early 1870s, leading US medical schools initiated reforms that brought medical faculty under the direct control of the university and formalized teaching relationships with major hospitals. These reforms, epitomized by the legendary Flexner Report in 1910, also included dramatic curricular reforms. Students were expected to enter medical school with a substantial background in the sciences and to apply the scientific method to their medical studies and clinical exercises. A major conceptual component of this application was the development of problem-solving skills, and innovative professors advocated for curricula that would teach students not only the retention of anatomical facts but also the ability to reason from structure to disease.5

While the early 20th-century shift in medical education was not as essentially centered on anatomy as the Renaissance reforms, dissection still played a central role. It was seen as a place to begin schooling students in the "scientific" method of reasoning, from evidence to theory and back again. Educators feared that a student who could not reason would become a "shoemaker physician who drives into ruts and cannot get out of them."6 This concern was a byproduct of the dogmatism that plagued medical thought for much of the 19th century, as well as the desire of medical educators to distance themselves from the two dominant dogmas of "empiricism" and "rationalism." Empiricists had insisted that theory had no relevance in medical practice—whatever treatment appeared to cure a particular patient had to be embraced, even if the mechanisms underlying the cure were completely unknown. At the opposite extreme of practice, rationalists maintained that the only effective treatments were those derived directly from systematic theories of diseases. The new breed of "scientific" medical educator sought to combine both direct observation and theory while avoiding the "ruts" of dogmatic thought.7

One example of this new breed of educator was Franklin Mall, an anatomist at Johns Hopkins University, the flagship institution for progressive reform in medical education at the time. Professor Mall did not lecture to his students on how to dissect nor did he encourage the use of dissectors; instead he encouraged students to devise their own methods while he circulated around the room, answering questions as they arose. Although the teachers and students at Hopkins did not represent the situation at most medical schools of the time, this pairing of active learning and scientific reasoning with anatomical dissection was the ideal championed by educational reformers like Flexner.

Another result of these reforms and standardization movements was the desire to scrutinize the product of hospitals and health care for accuracy.8 Clinical pathology filled this need by allowing physicians to work backwards from the cadaver to determine whether diagnoses and treatments during life had accurately matched the patient's illness as confirmed through postmortem examination. Given that autopsy (derived from the Greek "autopsia," seeing for oneself) became the yardstick by which all diagnostic and therapeutic efforts could be measured, it made more sense than ever to emphasize dissection as a critical part of a physician's education.

As medical technology flourished over the following decades, however, the autopsy lost its centrality as the definitive measure of clinical accuracy. By the last quarter of the 20th century, sophisticated imaging techniques and molecular biological assays became more common than postmortem examinations9 and drew concepts of disease into increasingly abstract models. In contrast to Renaissance thinking, the body was no longer the text but rather the object of machines and procedures that produced authoritative knowledge about the body. Disturbed by the tendency of technology to reduce patients to their diseases, educators sought to place "humanistic" values at the fore of medical education in the late 20th century.10 While objectification of patients certainly occurred without the aid of technology, the radical advances in medicine that occurred after World War II raised unprecedented questions about the appropriate limits of scientific medicine—indeed, the bioethics and medical humanities movements were born largely out of such concerns.11,12 In response to such societal concerns that modern medical care could dehumanize patients, medical educators sought creative ways to emphasize humanistic values in the curriculum. The use of cadavers for teaching humanistic values is one example of this response and represents a "new" role for dissection in medical education. Thus, changes in the instructional approach to the anatomy lab have included trends toward emphasizing death and dying during the dissection experience and towards consideration of the patient-physician relationship.13,14 While the process of dissection still provides students the opportunity to utilize the human body as an authoritative text for mastering structural knowledge and to develop active learning skills, these new curricular changes attempt to emphasize and nurture humanistic attitudes and behaviors toward human bodies, dead or alive.

It would, however, be inaccurate to infer that anatomical dissection in medical schools has been reduced to a scientifically unimportant component of modern curricula that is retained only for its ability to occasion reflection on humanistic values. On the contrary, the remapping of many curricula into organ-based systems has facilitated the return of students to the anatomy lab at multiple points during the educational experience to study and explore different areas of the body. Furthermore, the development of sophisticated computerized learning aides has allowed for greater integration of clinical material such as radiographs, computed tomography, and magnetic resonance imaging. Although these changes have effectively reduced the amount of time spent on dissection, many students and educators still believe that the physical procedure of dissection develops a spatial and tactile appreciation for the fabric of the human body that cannot be achieved by prosections or computerized learning aides alone.

The attitude toward dissection in medical education has shifted according to the prevailing social norms and professional demands of each time period considered here, but these changes are not necessarily signs of declining relevance.15 Today, anatomical dissection in American medical education combines the ideals of the profession in the new millennium: acquisition of scientific knowledge and skill balanced by the development of humanistic attitudes and behaviors.

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