Research articles

By Dr. Patrick M Foye , Dr. Nagaswami S Vasan , Dr. Bart K Holland
Corresponding Author Dr. Patrick M Foye
UMDNJ: New Jersey Medical School, Department of Physical Medicine and Rehabilitation, 90 Bergen St, DOC-3100 Physical Medicine and Rehabilitation, Newark, New Jersey - United States of America 07103
Submitting Author Dr. Patrick M Foye
Other Authors Dr. Nagaswami S Vasan
UMDNJ: New Jersey Medical School, Department of Cell Biology and Molecular Medicine, Medical Science Building, Room G-67, Dept. of Cell Biology and Molecular Medicine, 185 South Orange Avenue, Newark, NJ - United States of America 07103

Dr. Bart K Holland
UMDNJ: New Jersey Medical School, Department of Preventive Medicine and Community Health, Medical Science Building, Room G-671, Department of Preventive Medicine and Community Health, 185 South Orange Avenue, Newark, NJ - United States of America 07103


Undergraduate medical education, Gross Anatomy, Physical Medicine and Rehabilitation, Teaching, Anatomy education, Graduate medical education

Foye PM, Vasan NS, Holland BK. Physical Medicine & Rehabilitation Residents Teaching Clinical Anatomy In The Gross Anatomy Lab: Enhanced Student Performance. WebmedCentral MEDICAL EDUCATION 2011;2(1):WMC001483
doi: 10.9754/journal.wmc.2011.001483
Submitted on: 27 Jan 2011 07:55:45 PM GMT
Published on: 27 Jan 2011 10:45:52 PM GMT


Background: Preclinical curricula in medical schools are moving away from teacher-centered and discipline-based curriculum to an integrated clinical model. Our medical school's Physical Medicine and Rehabilitation (PM&R) resident physicians taught clinical correlations in the gross anatomy lab for first-year medical students. This study assesses, via subjective and objective measures, whether these sessions improved student understanding of musculoskeletal and neuromuscular clinical anatomy.
Design and Methods: PM&R residents taught clinical correlation sessions in the cadaver lab for two afternoons: once at the end of the dissection of the thorax, back and upper extremities, and then again after dissection of the abdomen, pelvis and lower extremities. The sessions were in small group to facilitate interaction. Students' performance on musculoskeletal questions in the National Board of Medical Examiners (NBME) anatomy subject examination was evaluated to assess the effectiveness of this teaching approach. Also, surveys were completed by 288 medical students (out of 351) and also by the residents themselves.
Results: Results indicate that teaching sessions by residents enhanced students’ understanding of human anatomy and, importantly, its clinical application. These educational benefits for students were found via both subjective evaluations by the students themselves as well as being corroborated objectively via external, standardized, national testing (markedly improved scores on the musculoskeletal components of the NBME, p=0.0048). It was also a positive experience for the residents, who learned the material at greater depth and gained valuable teaching skills.
Conclusion: The PM&R residents teaching clinical anatomy to medical students within the cadaver lab educationally benefited both the students and the residents.


Early introduction of clinical material (vertical integration) in the first year of undergraduate medical education is increasingly being recognized as a very important way to help medical students bridge the gap between basic sciences and clinical practice [1-4]. Typically this is done via clinical Preceptorships, problem-based learning or clinical correlation lectures. Incorporating clinical material into gross anatomy courses seems to be associated with improved scores on standardized National Board anatomy examination [5]. But little has been published on the role of adding actual resident physicians and clinicians to the teaching program specifically within gross anatomy cadaver labs.
Meanwhile, teaching and learning of rehabilitative care in most medical schools lags behind medical education in other areas [6, 7], which is unfortunate since increased exposure to the specialty of PM&R in medical school has been shown to introduce numerous benefits for neuromuscular and musculoskeletal education and for the specialty of PM&R [8, 9]. To assist medical schools in their efforts to improve how their students are being educated about musculoskeletal conditions, the Association of American Medical Colleges (AAMC) and a panel of musculoskeletal experts developed learning objectives for undergraduate medical education [7]. Concerned about the lack of musculoskeletal teaching in undergraduate medical education at the Harvard medical school, clinicians and anatomists teamed up to introduce musculoskeletal curriculum in their classes [10].
To fill the desire to have actual clinicians teaching students directly within the cadaver labs, collaboration was formed between faculty in our gross anatomy course and in our department of PM&R. Physiatry (PM&R) is well suited for teaching clinical anatomy since physiatrists have expertise in evaluating and treating neuromuscular and musculoskeletal conditions. The goal was to institute a program in which PM&R residents teach first year medical students within the cadaver labs, in a structured small group format [11,12]. The residents have much more clinical experience than students, but they are still close enough to their own undergraduate medical education to remember what level of understanding is being mastered at the first year medical student level. Further, by using physicians who were at the resident level, it was hoped that the students would easily relate to them and thus foster an open, interactive format. The small group sizes were similarly intended to allow more individual questions and answers. Since gross anatomy at our medical school is taught and learned primarily by cadaver dissection (65% of course time), the cadaver lab seemed to be the ideal setting for these educational sessions, so that the students could be taught clinical topics via the actual cadavers that the students were dissecting.
The goal of this study was to assess the value of using PM&R residents to teach clinical anatomy to first year medical students.
The outcomes of this educational program were measured by student performance in the NBME subject examination on the musculoskeletal questions, and written surveys and oral interviews with the students and residents.

Design and Methods

The subjects in this study were first year medical students, and the course was taught in the first semester. The class sizes varied from 170-176 and all the students were taking anatomy for the first time. The average GPA and MCAT of the entering class were comparable each year, and compared similarly to the national average (Table 1), thus showing that incoming students had academically similar baselines for years both with and without our resident teaching sessions. The course format, teaching syllabus and the faculty who participated in the teaching were the same in the years studied.
The Gross Anatomy course was offered for a 15-week period and was divided into three units: thorax, back and upper extremity (5 weeks), head and neck (4 weeks), and abdomen, pelvis, perineum, and lower extremity (6 weeks). Approximately sixty five percent of the course time was spent on cadaver dissection in small groups. The remainder of the course included embryology, basic anatomy and clinical correlation and radiographic anatomy lectures provided by faculty. The PM&R residents taught musculoskeletal clinical teaching. Attendance in the laboratory was mandatory, and four students were assigned to each cadaver. Each laboratory session started with a brief pre-laboratory presentation by anatomy laboratory instructors who were all basic scientists. The faculty to student ratio was 1 to 22.
To supplement the teaching by anatomy faculty, the PM&R residents taught clinical correlation sessions twice during the course, once at the end of the dissection of the thorax, back and upper extremities (unit 1), and again at the end of the dissection of the abdomen, pelvis and lower extremities sessions (unit 3). The clinical teaching sessions were intentionally placed at the end of the dissection units, to maximize the educational benefit by having the students familiar with the basic anatomy and thus ready for the bigger picture of clinical correlations. Also, having the cadavers already dissected allowed the clinicians’ time to be used for demonstrations using the cadavers, rather than actually doing dissections. In order to maintain uniformity of subject matter discussed, residents were given material and clinical conditions (clinical vignette in some instances) for teaching the students. PM&R attending physicians reviewed with the residents the subject matter to be covered, appropriate cases and scenarios to be discussed and explained. Attendings also taught the residents how to conduct an interactive small group session, maintain collegial atmosphere and role modeling. In addition, PM&R attending physicians were themselves involved in teaching a limited number of small groups and overseeing student instruction by residents.
The residents and overseeing attendings spent the morning among themselves teaching and reviewing the dissection of the body region to be covered that afternoon for the first year medical students. In the afternoon, for 3-4 hours, the 7-10 senior (postgraduate year four) residents provided hands on teaching and spent an hour with each small group of 12-16 students per group, reviewing basic anatomy and providing clinical correlation. The cadaver provided a valuable tool to explain and demonstrate many clinical points and presentations. The visual exhibition of nerves and plexus on the cadaver helped the residents to demonstrate and teach how a nerve injury or impingement could occur, as well as the clinical manifestations. Students were taught how to clinically test for nerve injuries, e.g. via assessing what muscles might become weak or atrophied, what sensory distribution might become numb, what muscle stretch reflexes might become diminished, and what provocative maneuvers could be performed (e.g. Tinel’s sign to reproduce dysesthesias via tapping over a superficial nerve), etc. The residents also demonstrated how various muscle groups function on a joint, and how injury to muscles, tendons or ligaments and degenerative joint diseases affects range of motion and movements. Simultaneously, students were also exposed to basic rehabilitation protocols for such cases.
The student performance on the musculoskeletal questions in the NBME subject exam was statistically analyzed to assess the effectiveness of teaching musculoskeletal and neuromuscular clinical correlation to understand basic anatomy. Our outcome measures included student scores on the NBME exam since it is a nationally standardized and normalized test and an excellent external, objective measure. From the item analysis provided by the NBME, we have selected items that are relevant to thorax, back and upper limb, and abdominopelvis and lower limb, since the residents taught only these regions. The results generated would compare the performance of our students to national average. We have included items of thorax and abdominopelvis in the analysis since lesions in these regions also affected the neuromuscular systems of the limbs.
At the end of the semester, a written survey was distributed to the students to assess the clinical correlation teaching received from the residents. The survey utilized a Likert Scale to score students’ level of agreement with 16 statements, with the level of agreement scored 1-5, with 1 meaning “hardly at all”, 2 meaning “to a small degree”, 3 meaning “to a moderate degree”, 4 meaning “to a considerable degree” and 5 meaning “to a very high degree”. The 16 items are listed within Table 3. Students were also encouraged to provide additional narrative comments.
The students' performance on the NBME subject exam (presented in Table 2) were collected during two consecutive academic years with resident participation and also during the two subsequent academic years when the residents did not participate in clinical correlation teaching. Except for the resident participation, the teaching program was the same in all the years studied.
The student survey results presented in Table 3are the combined responses from 288 out of 351 students (response rate of 82%). The results were tabulated using Microsoft Excel software, which allowed us to perform descriptive statistical analysis.
The 16 items in the survey (Table 3 ) were categorized into four domains: 1. Students’ understanding of the overall anatomical knowledge in clinical context, patient evaluation, treatment planning and patient management, 2. Clinical relevance of musculoskeletal structures, clinical manifestations of nerve, musculoskeletal or ligamentous injuries, and clinical testing of such injuries, 3. The resident’s enthusiasm, ability to communicate knowledge, present material at appropriate level and role models, and 4. Enhancement of student interest and awareness of PM&R as a specialty.
The residents answered a shorter questionnaire (Table 4), and were requested to provide narrative comments regarding their experiences in teaching first year medical class.
Further, one author conducted a semi-structured one-on-one resident and student interviews, which lasted approximately 10 minutes. The interviews were voluntary, mostly focused on obtaining further comments regarding the topics covered in the questionnaire. The only new question raised to both residents and students during this interview was how this resident teaching could be improved. The interview was done to gain perspectives of the students and residents in improving clinical teaching.


Table 2 shows the performance of students on the musculoskeletal questions in the NBME exam for years 1 and 2 when the residents participated in teaching, and years 3 and 4 when the resident participation was discontinued. In 1 and 2, when the residents contributed to the teaching program, our students' average scores in both affected subject units exceeded national average scores by at least 10 points. In each year and subject unit, this difference in the mean was compared to the national score was found to be statistically significant at the 0.05 levels, according to t-tests. Subsequently, in years 3 and 4, in the absence of resident teaching, our students' scores never exceeded national averages in either subject areas, and were usually below them. The overall comparison between the years with versus without residents' involvement, in terms of performance being superior to the national average, was statistically significant using Fisher's exact test, p=0.0048. The number of items tested under each anatomical area was generally the same from year-to-year.
The 16 items in the survey were categorized into four domains (Table 3). The results of the first domain indicate that clinical correlation sessions taught by the PM&R residents enhanced students’ understanding of how basic anatomy is important in various aspects of patient evaluation, care and management (mean of 4.45 ± 0.66). In isolating the items in the first domain that relate to linking of clinical situations to basic anatomy, and knowledge of anatomy in patient evaluation the vast majority of the students gave high marks in these areas (mean 4.56 ± 0.62). Similarly, most of the students came away from the sessions appreciating the importance anatomic knowledge in patient care and management (4.51 ± 0.62).
The results of the second domain clearly indicate that the residents described and demonstrated clinical relevance of musculoskeletal structures, clinical manifestations of nerve, musculoskeletal or ligament injuries, clinical testing of such injuries (mean of 4.45 ± 0.59).
The results of the third domain clearly indicate that the PM&R residents were accessible, enthusiastic, encouraging, and able to communicate knowledge (mean of 4.49 ± 0.72). Further analysis of the items showed an important outcome. The majority of the students indicated that the residents effectively communicated knowledge at an appropriate level (mean of 4.54 ± 0.57). Most students indicated that the residents were excellent role models and demonstrated high professional standards and interpersonal skills (mean of 4.59 ± 0.54).
Overall, the students predominantly responded that the teaching by residents was extremely valuable (mean of 4.56 ± 0.65). Prior to the interaction with the residents, a high proportion of the students had little or no awareness of the field of PM&R (mean of 1.45 ± 0.83). Not only did the sessions provide initial PM&R exposure for many students, but also a substantial number of students replied that the sessions kindled their interest in the field (mean of 3.41 ± 1.09).
The results of resident questionnaire (Table 4) indicated that the residents learned more by teaching the sessions than they would have by just attending them (mean 4.75 ±1.39). Most residents indicated that medical students’ questions prompted them to perform further reading or inquiry into topics (mean 3.38 ± 1.06). Residents deliberately altered their presentations of anatomy/clinical material for the first year medical student level (mean 4.38 ± 0.92). Although not asked to do so, many residents made conscious efforts to discuss PM&R as a career choice (mean 4.5 ± 0.35).
Semi-structured interviews: During semi-structured interviews with residents and students, the topic mostly focused on obtaining students' impressions on this educational format, e.g. being taught by residents, learning with peers in an interactive setting, clinical application of anatomical knowledge, use of cadavers and prosected specimens during the teaching, and suggestions for improvement. Students indicated that the residents incorporated a number of relevant clinical cases as examples, presented materials at an understandable level, and were also willing to learn from the students. Students also mentioned that working with teachers whose training is not so far advanced beyond their own helped the students to be more open in discussion, and participate more without feeling intimidated. The cadaveric material allowed the residents to demonstrate various mechanisms of injury, to visually ‘act out’ patient clinical presentations, and to teach differential diagnosis. Regarding areas for further improvement, numerous students suggested reducing the number of students in each small group and increasing the amount of teaching time allotted for the residents.
The interviews with residents mostly focused on their experience in teaching the first year students. The residents expressed personal benefit from teaching, indicating that it provided them an opportunity to review basic anatomy and relate them to function. Some residents indicated that learning to simplify the material to the first year student level provided practice at simplifying presentations that they would give to patients when educating them about their diagnoses. The residents echoed the students’ suggestions for improvement, feeling that it would be ideal to have smaller groups of students per resident, and more overall teaching time, to allow them to provide more cases to reinforce anatomical correlation.
In addition to answering the survey questions, the residents were asked to provide written narrative comments about the sessions. Quotes from the residents included the following: ”I used words that a first year medical student would understand, and covered conditions that related to the anatomy they were learning”; ”I explained physical examination and maneuvers as they related to the anatomy, demonstrating on the cadavers”; “I described clinical injuries and used cadavers to show their mechanisms of injury”; “This was a worthwhile experience in every way, and the teaching program itself is excellent, and I wish I had such an experience back when I was a student.”


The results show that having PM&R resident physicians teach first year medical students in gross anatomy cadaver labs is educationally valuable and offers several apparent benefits. The student performance on the musculoskeletal NBME questions improved. This could be due to a combined effect of improved analytical ability, reinforcement by examples of common clinical cases, and clarifying misconceptions. A prior study addressing poor musculoskeletal education in first year curriculum used physical therapy students to teach common cases of shoulder and knee pain. The study found that this helped to bridge between basic anatomy content and physical examination skills [12].
The small group format we used establishes a collegial rapport between the students and residents, and among students themselves, thus fostering a favorable environment for interactive learning. Furthermore, in small group settings being led by residents, the students felt less intimidated, and more open to asking questions than with larger groups. Residents are not so far advanced beyond the student level as to forget or lose touch with the students’ level of understanding. Within the setting of small, informal groups, the residents indicated that they were able to quickly assess the level of students’ comprehension and then intentionally modify their teaching to the appropriate level. Meanwhile, the students indicated that the residents were effective at doing so. The majority of the students indicated that the clinical correlation sessions presented by the residents communicated knowledge effectively at an appropriate level. Further, although the students have ample lab time in small groups with non-clinical faculty throughout the course, the students indicated that the sessions with clinicians (residents) added substantial additional benefit.
Students were excited to be able to learn from clinicians, who could share first hand experiences of how the anatomy was relevant to direct patient care, thus inspiring the students to learn the material. Students appreciated the residents’ enthusiasm and saw the residents as role models. The narrative comments from the students were all positive. Many students stated that they learned a lot in such a short time. Other comments included the following: “tied in a lot of anatomy with the clinical situations”; ... “hands-on learning was the best part in incorporating the knowledge of anatomy to clinical application”; ..... “they made the sessions interactive so that we were not left out”; ..... “it made us think rather than just listen”; .... “the residents taught so well that it helped me to get honors on the final exam.”
But the sessions benefited not only the students. The residents found that in teaching, they learned more themselves. The residents not only learned more of the anatomy, but they also honed their ability to explain medical conditions to those with less medical knowledge, a skill that is clinically important for patient education. Such abilities are important, since communication skills in PM&R are an important component of physician-patient relationships. [13]
On the departmental level, the PM&R department invested substantial time and effort to support and coordinate these sessions. Also, the department reallocated the senior residents from their clinical rotations so the residents could teach at these sessions. But the results indicate that the department reaped significant benefits, via creating a very positive image among first year medical students, most of whom had never before even heard of the field of PM&R. Prior studies have shown that knowledge of PM&R by medical students is often “marginal”, [14] but students who have such knowledge of the field have been shown to be much more likely to refer patients to PM&R. [15] Although the residents in our sessions were not instructed to discuss PM&R as a general field, many students indicated that their interest in the field was increased. Some of these students eventually entered PM&R residency training programs.


The results of this study indicate that utilizing PM&R residents to teach clinical correlations in the gross anatomy cadaver lab is an effective educational approach. Residents enhanced students' understanding of the anatomy and, importantly, its clinical application. The student performance in the NBME subject examination showed marked improvement. It was also a positive experience for the residents, who learned the material at greater depth and learned valuable teaching and communication skills. Other anatomy programs may wish to consider adopting a similar approach.


Joel A. DeLisa, MD, MS, PM&R Chairman, provided the PM&R faculty and residents for these teaching sessions, and has demonstrated consistent support of medical education for our students and residents. PM&R faculty members Boqing Chen, MD, PhD, and Todd P. Stitik, MD, provided educational oversight of the PM&R residents in the laboratory. Susan V. Watson, MA, assisted with preparing the conference presentation of a prior, incomplete version on this topic. The Department of Cell Biology and Molecular Medicine provided the course time and cadavers for these sessions. The Institutional Review Board approved this study. A preliminary version of the material included in this manuscript was presented (in partial, incomplete form) at the annual meeting of the American Association of Anatomists, and communicated as ‘work in Progress’ in Academic Medicine.
All three authors of this study are part of the Stuart D. Cook 'Master Educator Guild' of the University of Medicine and Dentistry of New Jersey, whose encouragement and support we acknowledge.


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