gms | German Medical Science

GMS Journal for Medical Education

Gesellschaft für Medizinische Ausbildung (GMA)

ISSN 2366-5017

Psychosocial aspects of donation and the dissection course: An extra-curricular program with the objective of assisting students confront issues surrounding gross anatomy lab

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  • corresponding author Simone Weyers - Heinrich-Heine-Universität Düsseldorf, Institut für Medizinische Soziologie, Düsseldorf, Deutschland
  • author Thorsten Noack - Heinrich-Heine-Universität Düsseldorf, Institut für Geschichte der Medizin, Düsseldorf, Deutschland
  • author Gerd Rehkämper - Heinrich-Heine-Universität Düsseldorf, Zentrum für Anatomie, Düsseldorf, Deutschland

GMS Z Med Ausbild 2014;31(2):Doc16

doi: 10.3205/zma000908, urn:nbn:de:0183-zma0009081

This is the English version of the article.
The German version can be found at: http://www.egms.de/de/journals/zma/2014-31/zma000908.shtml

Received: October 4, 2013
Revised: January 7, 2014
Accepted: January 27, 2014
Published: May 15, 2014

© 2014 Weyers et al.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by-nc-nd/3.0/deed.en). You are free: to Share – to copy, distribute and transmit the work, provided the original author and source are credited.


Abstract

Background and aim: The dissection course is an essential part of preclinical medical education. At the Medical Faculty of Duesseldorf, an education concept has been developed with the aim, to reflect with students their experiences and to support them in dealing with the donor and preparation. The aim of this paper is to present the concept.

Method: The education concept had a peer group approach. It comprised a lecture, a small group seminar and an online diary as core element. Finally, the concept was evaluated.

Results: Approximately one sixth of students made use of the online diary. Selected entries are presented here. Also, one sixth of students took part in the evaluation. They rated the activity as helpful to prepare for the dissection course.

Discussion: The education concept could be a corner stone of a longitudinal training to promote the adequate encounter with topics such as dying and death.

Keywords: dissection course, psychosocial support


Background and Aim

The course in macroscopic anatomy, generally called the dissection course, is an essential part of the pre-clinical phase of medical education. The dissection course is influenced by the natural sciences, meaning that the dissected structures are analyzed in terms of function according to a cause-effect approach. This can contribute significantly to students “grasping” the structure of the human body. In addition, it can promote teamwork and community, encourage early confrontation with the topics of death and dying and – within the context of appropriate reflection – pave the way for the development of a positive professional attitude [6].

The necessity of the dissection course has been the recurring subject of controversial discussion [4], [6]. This discussion is neither repeated, nor deepened here. In any case, the dissection course is a very significant experience. In a society in which deaths no longer take place within the family, but rather at institutions, many students are confronted with a dead person for the first time in the course. The emotions and attitudes that emerge over long-term contact with the donor’s cadaver are relatively well studied [3]. It is shown that many students attend the course with fears, but also with curiosity and pride, and that most are able to adjust to the unusual situation.

However, many aspects about the adaptation and identification processes must be examined carefully:

1.
The dissection course can promote unfavorable occupational socialization if the students exercise certain, unreflected manners of behaviors in relation to themselves and those around them. An example of this is feelings of guilt that arise in face of the broken cultural taboo, despite the didactic, professional training and general heuristic legitimacy of the dissection course and the voluntariness of the anatomical donation. Another example is a fear of failure that is rationalized and affectively isolated, whereby the development of self-respecting attitudes is inhibited. Such ways of coping increase the probability that patients will become depersonalized and reduced to objects later on when students are practicing medicine professionally [5]. Conversely, the skills needed to form an empathetic relationship with a patient can be encouraged in the dissection course. The student-donor relationship can be made to serve as an example for the future doctor-patient relationship and should be formed accordingly with this in mind.
2.
A small number of students are unsuccessful in coping with the psychosocial demands of the course. These students feel severely stressed over the long term as a result of the dissection course [1], [2]. For some students this even causes them to leave medical school.
3.
Students do not always possess the skills or willingness to sufficiently verbalize their fears and ask for support [8]. Anonymized surveys show that a substantial proportion of students desire stress-prevention measures in parallel with the dissection course [3]. However, such support appears to be seldom offered at German medical schools.

For this reason, during the 2012-13 winter semester an educational concept was developed and offered for the first time at the Medical School of the University of Duesseldorf. The aim was to reflect with students on their experiences and assist them in dealing with the donor and the anatomical preparation.

Reflection took place within the scope of two lecture periods, a small-group seminar and an online journal. Particular value was placed here on sharing within the peer group. In principle, it is the only peer group of students that has the same transgressional experience and shares the same norms that are taboo for the rest of society, such as the cutting up of a dead body. This group can already in itself provide emotional support through the opportunity to share experiences.

The following sections of the paper describe the educational concept and the sequence of the activities. In the section addressing the results, selected entries from the online journal are presented, as are the evaluation results of the educational concept. Finally, the pilot project is discussed critically.


Method

Lecture and seminar

Both prior to the first hours in the anatomy lab and approximately seven weeks later, a lecture period was integrated into the concurrent anatomy lecture series. During the first lecture, the students were initially requested to take a few minutes to silently address the following questions: “What do you know about the dissection course and from whom? What are your expectations?” Following this, the students discussed these aspects in buzz groups. After this reflection phase, a short presentation was given on anatomical donation at the Medical School of the University of Duesseldorf. Along general lines, the motives for anatomical donation were presented, the process was described starting with the initial contact through to transfer and storage of the body, and some facts and figures about the university site were given.

On the same evening the interdisciplinary team of educators offered a seminar, in which the students could address the topic of death and dying independently of the dissection course. Using self-reflection, buzz groups and class discussions, the students described their personal experiences. The lecturers supplemented these reflections with sociopsychological aspects, for instance concerning the social changes involving death. On the next day, the students attended the dissection course for the first time.

Online journal

Over the coming days and weeks the students wrote their journal entries. An instrument was added to the e-learning platform of the University of Duesseldorf allowing students to voluntarily and anonymously respond to the following questions at two different points in time – directly at the start of the course and three weeks later:

  • Which emotions did you feel before the course started or while it was underway and why (e.g. pride, curiosity, interest, repulsion, fear, disinterest, disgust)?
  • Which experiences during the course were emotionally meaningful for you and why?
  • How would you describe your relationship with the cadaver you are preparing?
  • How have the experiences in the course to date affected your daily life (e.g. perception of other people, daily routine, personal hygiene, dreams and daydreams)?
  • Which reactions have you witnessed in your fellow students to date? Were there similarities, differences?
  • How have the experiences in the course influenced your choice of career?

Questions were also asked about sex, professional experience in the health system and student consent to use the entries. The individual entries were not visible to other students.

The analysis and presentation of the journal entries was not done in the context of a scientific study. Rather, statements which appeared to be typical were identified as being potentially representative of the peer group. Within the context of providing socio-emotional support, these quotes were to make it clear that the individual impressions represented collective experiences – that the students were not alone.

Since only a few entries were written at the second point in time, the analysis and presentation of these entries did not take place. During the second lecture seven weeks later, the selected journal entries were presented and discussed (see Results).

Evaluation

At the end of the second lecture, the students were requested to make suggestions for developing this educational concept by leaving a sheet of paper with their comments in the room. Again, statements that appeared to be typical were identified and discussed as part of the internal review process.


Results

Journal

The online journal formed the core of this extra-curricular activity. Of the total of 393 students in the dissection course, 67 (17%) participated in the first few days. Corresponding to the sex distribution in the student cohort, female students were over-represented (49 women vs. 14 men, 4 missing values). Likewise, the students without professional experience in health system were in the majority (52 vs. 13 with experience, 2 missing values).

The presentation and discussion of the journal entries during the lecture was done using the main questions listed above and by visually projecting the original texts (here in cursive), which were then supplemented with explanations by the lecturers as follows:

a) Attitudes and expectations before the dissection course began

A third of the students who kept the journal (n=22) reported excitement prior to the course which then quickly abated. Nine students expressly described this part of medical training as a privilege.

Example: “I had always looked forward to the dissection course and was very excited right before it began. I was a little frightened that I wouldn’t be able to handle the situation, but it turned out to be very different from what I expected: of course, it was strange at first to dissect a dead person, but then it very quickly became normal and my curiosity prevailed from the very start anyway!”

b) Emotionally meaningful events at the start of the dissection course

Several students (n=10) reported about the extraordinary nature of the moment in which the cadaver was unwrapped and on the challenge of making the first eye-contact with the donor.

Example: “Unwrapping the donor was a very significant moment, for it was the moment in which we became acquainted with the body that will accompany us over the coming months of our studies and indirectly help us to acquire our skills and understand human anatomy.”

For few (n=4) however, only the beginning of the course was associated with excitement, after that interest was more predominant. Though the complaint was also made (n=1) that too little time was devoted to “adjusting to the course”. The social support of the assigned dissection groups was highlighted by several (n=4) as being especially important.

c) Relationship to the cadaver

In regard to the cadaver, the full spectrum of responses spanning from distance to closeness was described, ranging from a matter-of-fact and impersonal position all the way to frequent preoccupation or partial identification with the dead person.

Example: “I would say that we are still strangers. I would really like to know, how old she was, why she signed up to donate, and how she died.”

Occasionally (n=6) the hypothesis was formulated that a relationship with the cadaver, meaning establishing a closeness, was counterproductive. In a very distanced manner, one person described the dissection of the fatty tissues as disgusting and saw themselves at a disadvantage in comparison with other students who dissected the slim cadavers. A third of the students (n=22) expressed gratitude and respect in relation to “their” donor.

d) Effect on daily life

A third (n=23) of those surveyed were of the opinion that the dissection course did not influence their daily routine. Other students reported practicing more frequent personal hygiene (n=8) and changes in eating habits (n=2). Shameful thoughts were had about the similarities primarily between older people in the students’ environments and the donors (n=3).

Example: “One visits death – each day in a new way. And death visits me, too. It doesn’t close the door behind itself when I leave the lab. It follows me and brings along what I would really rather leave behind in the lab. […] Death follows me in my dreams. But it also prods one to confront death in a different way than one otherwise would.”

e) Perception of the reactions of fellow students

Several students (n=5) described great respect for the cadaver and the activity of anatomical preparation. The situation was perceived as exceptional. Fear of failure (fear of the unknown, fear of not being able to bring oneself to do something, of not meeting the challenge) were frequently addressed (n=22). In the case of some, these fears predominated; some handled the situation very objectively (n=21), while others looked forward to the “prepping” (n=9). A number (n=9) described the removal of subcutaneous fat and the fixation smell as negative experiences.

Example: “I already have previous occupational training during which I often came into contact with dead people. Most of those in my dissection group are a bit younger and don’t have any experience yet with dead bodies. What we share is that we all have respect for the donor and are wholeheartedly involved. What I noticed as we unwrapped the donor is that none of us showed any inhibitions.”

f) Professional motivation

Of the 67 journal entries, two-thirds (n=44) give the impression that the course positively influences the student’s professional commitment. The course was viewed as psychologically and physically demanding, but also as a challenge to grow. The complexity of the body was described by some (n=9) as fascinating. One person expressed the fear of later injuring these complex structures through medical carelessness.

Example: “Up until now the experiences in the course have shown me that I have chosen to pursue the right career and that this is really what I want to learn and what I am interested in. However, at times the amount of information leads me to kind of doubt if I am really up to meeting the demands.”

g) Other comments

One person explicitly evaluated the practical work of dissection and preparation as helpful in learning the anatomical structures. Three students expressly desired more psychosocial and ethical offerings connected with the dissection course and pointed out a potentially greater need among future first-semester students who, as a result of shortened secondary schooling, will be even younger.

Evaluation

The feedback from the students (n=60) about the educational concept outlined here was overall very positive. The students who participated in the evaluation unanimously found the program to be very helpful in preparing for the dissection course. Many suggested expanding the program and making it a requirement, for instance as part of a seminar. Many students criticized that the scheduling was inconvenient, since around the same time there was subject matter to learn and tests to take, so that they were not able to participate to the extent that they wished.


Discussion and Outlook

The educational concept described here aimed at providing a setting for joint reflection with students on the experiences they had in the dissection course and to provide support in dealing with the donor and the preparation of the body. This paper presents the process and selected results and evaluations.

It must be pointed out that the limited number of participating students does not allow for any generalized statements. In addition, the group possibly shows a distortion in that primarily the particularly troubled students took advantage of the program wishing to profit from it in terms of relief.

It can, however, be stated that the student journal entries in general underscore the evidence mentioned in the beginning. Initially, stress is predominant, but adjustment occurs rapidly. Sporadically, students reported of a hard to handle burden as a result of the dissection course. In these cases, professional help should be offered immediately.

Using their own journal entries, students could be clearly shown how difficult it is to regulate between objective distance and an empathetic, yet fear-inducing closeness to the donor – a problematic issue that will accompany the students throughout their education and later when they assume their professional roles as clinically active physicians. Studies and personal medical experience show the current need of students and beginning professionals for assistance in dealing with the topic of death and dying and how inadequate the support from experienced colleagues has been to date [7]. This should be counteracted with an early integration of reflective activities and coping strategies during medical education.

Ideally, the extra-curricular offering described here could, after post-pilot phase optimization, form the start of a reflection and learning spiral that runs through the degree program from dissection course to bedside and deathbed attendance in order to promote an adequate and, in a positive sense, professional handling of the topic of death and dying.

The evaluation by the students underlined the need for such programs to accompany the dissection course and the necessity of convenient and meaningful curricular scheduling.


Acknowledgement

We wish to thank Fatjon Ndregjoni and Kathrin Heper for helping with data processing.


Competing interests

The authors declare that they have no competing interests.


Approval

Approval was granted by the ethics committee at the Medical School of the Heinrich-Heine-Universität.


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