Active Learning Exercises in the Anatomy Lab to Review Radiologic Anatomy

1. Active Learning Exercises in the Anatomy Lab to Review Radiologic Anatomy Ann Zumwalt, Ph.D., Department of Anatomy & Neurobiology Rebecca Lufler, Ph.D., Department of Anatomy & Neurobiology Kitt Shaffer MD PhD, Department of Radiology

2. Outline • Context of our project Traditional medical school curriculum • Objectives of the project • Radiological Anatomy lab Design Examples • Discussion Insights from our experience Applicability of our approach to a broader context

3. Context Med School Curriculum Year 1 • Gross Anatomy • Biochemistry • Physiology • Histology • Other courses dealing with applied clinical skills

4. Context Med School Curriculum Year 1 • Gross Anatomy • Biochemistry • Physiology • Histology • Other courses dealing with applied clinical skills Year 2 • Microbiology • Pathology • Pharmacology • Health Law • Other courses dealing with applied clinical skills

5. Context Med School Curriculum Clinical years Assorted required clerkships (Pediatrics, Obstetrics & Gynecology, Psychiatry, Family Medicine, Surgery, Medicine, Neurology, Radiology, Geriatrics) Electives to explore these or other fields more intensely.

6. Context - Summary Anatomy is traditionally taught near the beginning of medical school Studies have shown that students demonstrate relatively poor retention of this material, despite its relevance to their subsequent clinical education and work. In this project, we established a new educational session during the radiology clerkship that revisits anatomy knowledge and principles that are relevant to that clerkship. Incorporating radiology into first year anatomy courses is not uncommon.

7. Context • Logistics: • Required clerkship for all medical students (3rd & 4th years) • Four weeks long • Approximately 20 students per block Radiology Clerkship “…The course is comprised of didactic lectures, departmental conferences, small group sessions on evidence-based imaging, case review sessions, and clinical observations in general radiology, pediatric imaging, musculoskeletal imaging, neuroradiology, abdominal and pelvic imaging, thoracic imaging, breast imaging, nuclear imaging, and neuroradiology.” -Clerkship overview, BUSM Radiology dept

8. Objectives Radiology Clerkship • The objectives of this project were to: • Reinforce anatomical concepts the students learned in their first year

9. Objectives Radiology Clerkship • The objectives of this project were to: • Reinforce anatomical concepts the students learned in their first year • Demonstrate the clinical applicability of this knowledge

10. Objectives Radiology Clerkship • The objectives of this project were to: • Reinforce anatomical concepts the students learned in their first year • Demonstrate the clinical applicability of this knowledge • Demonstrate the anatomical basis for difficult concepts in radiology, e.g: • 3D anatomical relationships when viewed in 2D • Rationale for interventional radiology procedures

11. Design Radiological Anatomy Lab All students in the clerkship assemble in the anatomy lab for two hours. Four work stations Each group spends ~20 minutes at a station, completes the exercises and answers questions then rotates to the next station. Class reconvenes at the end to discuss the lessons of the four stations

12. Design Station 1 Layout of Room Station 2 Station 4 Station 3

13. Design • Station 1 • Basic anatomy • Radiological images of relevant anatomy Layout of Room • Station 2 • Model building • Clinical procedure • Practice with clinical instruments, if applicable • Station 4 • Ultrasound (US) station • Radiology residents teach the students how to use the US and how to interpret images • Station 3 • Model building • Computer station • Radiological images / movies relevant to the procedure

14. Station 1 – Shoulder & Hip Musculoskeletal Imaging Examples

15. Examples Station 1 – Shoulder & Hip Musculoskeletal Imaging

16. Stations 2 & 3 - Femoral Triangle & Subclavian Region Examples

17. Stations 2 & 3 - Femoral Triangle & Subclavian Region Examples Example questions from worksheet: • How would you locate the femoral vein to place a femoral line? • If you are attempting a femoral artery access for angiography and go too far lateral, what structure is at risk? • Where it the most restricted region for a subclavian catheter, where it is most likely to be pinched by skeletal structures? • After completing Stations 2 and 3, please answer the following question: • Why is the femoral artery preferable to the axillary artery or carotid artery for vascular access to the aorta for angiography?

18. Station 4 – Ultrasound Imaging of Neck and Upper Extremity Examples

19. Station 4 – Ultrasound Imaging of Neck and Upper Extremity Examples

20. Examples Transjugular Intrahepatic Portosystemic Shunt (TIPS) Interventional radiologists use image guidance to make a tunnel through the liver to connect the portal vein (the vein that carries blood from the digestive organs to the liver) to one of the hepatic veins (three veins that carry blood away from the liver back to the heart). http://www.keepingyouwell.com/CareAndServices/InterventionalRadiology/LiverFailureTIPS.aspx Maleux, G. et al. Am. J. Roentgenol. 2007;188:659-664 http://www.radiologyinfo.org/en/info.cfm?pg=tips

21. Station 1 – Gross Anatomy of Portal System (vascular drainage to liver) Examples

22. Station 2 – Practice TIPS Procedure & Seldinger Technique Examples Seldinger technique tools

23. Station 3 – Imaging of TIPS procedure Examples http://web.me.com/kitt_shaffer/Anatomy_Year_3_4/Topics.html

24. Station 4 – Ultrasound Imaging of Neck and Upper Extremity Examples

25. Discussion Feedback Suggestions for improvement “Allowing more time and adding spine anatomy could be helpful for visualizing posterior elements (oblique vs. lateral c-spine views).” [timing, materials, topics] “Maybe some landmarks for subclavian lines?” We seem to be meeting our objectives “Musculoskeletal anatomy is very confusing on radiograph, so this station was excellent.” “Really enjoyed the session. Great to have some 3D models to learn from and connect to the 2D images. As a 4th year, I very much needed the reminder when it came to the anatomy!” “Man, it felt like going back to high school/college again - a good, conductive, interactive learning environment. First time I can say I've had a learning experience like this in medical school (which is indeed VERY SAD).”

26. Discussion Analysis, Insights, Future directions Principles of Adult Learning and recommended teaching practices Adults often have a problem centered approach to learning Show immediately how new knowledge or skills can be applied to current problems or situations; use participatory techniques such as case studies and problem-solving groups http://online.rit.edu/faculty/teaching_strategies/adult_learners.cfm

27. Discussion Analysis, Insights, Future directions Principles of Adult Learning and recommended teaching practices Adults often have a problem centered approach to learning Show immediately how new knowledge or skills can be applied to current problems or situations; use participatory techniques such as case studies and problem-solving groups Adults have years of experience and a wealth of knowledge Use open-ended questions to draw out students' knowledge and experiences; provide many opportunities for dialogue among students http://online.rit.edu/faculty/teaching_strategies/adult_learners.cfm

28. Discussion Analysis, Insights, Future directions Principles of Adult Learning and recommended teaching practices Adults often have a problem centered approach to learning Show immediately how new knowledge or skills can be applied to current problems or situations; use participatory techniques such as case studies and problem-solving groups Adults have years of experience and a wealth of knowledge Use open-ended questions to draw out students' knowledge and experiences; provide many opportunities for dialogue among students Adults need to feel self-directed Expect students to want more than one medium for learning and to want control over the learning pace and start/stop times http://online.rit.edu/faculty/teaching_strategies/adult_learners.cfm

29. Discussion Analysis, Insights, Future directions Principles of Adult Learning and recommended teaching practices Adults often have a problem centered approach to learning Show immediately how new knowledge or skills can be applied to current problems or situations; use participatory techniques such as case studies and problem-solving groups Adults have years of experience and a wealth of knowledge Use open-ended questions to draw out students' knowledge and experiences; provide many opportunities for dialogue among students Adults need to feel self-directed Expect students to want more than one medium for learning and to want control over the learning pace and start/stop times Adults tend to be less interested in survey types of courses and more interested in straightforward how-to Focus on theories and concepts within the context of their applications to relevant problems; orient the course content toward direct applications rather than toward theory http://online.rit.edu/faculty/teaching_strategies/adult_learners.cfm

30. Discussion Analysis, Insights, Future directions Principles of Adult Learning and recommended teaching practices Adults often have a problem centered approach to learning Show immediately how new knowledge or skills can be applied to current problems or situations; use participatory techniques such as case studies and problem-solving groups Adults have years of experience and a wealth of knowledge Use open-ended questions to draw out students' knowledge and experiences; provide many opportunities for dialogue among students Adults need to feel self-directed Expect students to want more than one medium for learning and to want control over the learning pace and start/stop times Adults tend to be less interested in survey types of courses and more interested in straightforward how-to Focus on theories and concepts within the context of their applications to relevant problems; orient the course content toward direct applications rather than toward theory Adults have increased variation in learning styles (individual differences among people increase with age) Use a variety of teaching materials and methods to take into account differences in style, time, types, and pace of learning http://online.rit.edu/faculty/teaching_strategies/adult_learners.cfm

31. Discussion Analysis, Insights, Future directions Strengths Weaknesses Pedagogy / Andragogy Students are only able to participate one time (one topic, no longitudinal reinforcement) Active learning Review / “springboard” of knowledge More efficient focus on the clinically relevant points Difficult to test outcomes Collaboration / cross-talk between students; between fields (anatomy & radiology) Future Directions More topics Incorporate cadaver station Assess effectiveness Logistics Flexibility with time, scheduling, staffing Inexpensive materials

32. Discussion Translation to other fields…