Anatomy & Forensic Anthropology, Faculty of Life Sciences, University of Dundee, WTB/MSI Complex, Dow Street, Dundee
Correspondence to: Professor Sue Black, Anatomy & Forensic Anthropology, Faculty of Life Sciences, University of Dundee, WTB/ MSI Complex, Dow Street, Dundee, DD1 5EH
SMJ 2005 50(3): 96-98
Abstract
Background & Aims: To document changes in the educational infrastructure of anatomy in Scotland over the past 20 years. To investigate the possible impact of the GMC 1993 recommendations and assess the preparedness of Scottish anatomy to meet the implications of the proposed amendment to the 1984 Anatomy Act. Results: Over the past 20 years in Scotland, the total number of teaching staff in anatomy (full time, part time and honorary) has decreased by over 24%, full time teaching staff numbers have decreased by more than 33% and the number of clinical demonstrators by more than 70%. However, medical student intake has risen by 38% and the overall student number experiencing anatomical teaching (medicine, science and dentistry) has more than doubled, resulting in a current average staff:student ratio of 1:58. Anatomy contact hours between staff and medical students have decreased by just over 60% in the last 20 years. Conclusions: In the last 20 years, contact hours and staffing levels have decreased substantially in Scotland whilst student numbers (medical, science and dental) have increased significantly. On average the anatomical input to the medical curriculum decreased by 28% between 1983 and 1993 but post the GMC initiative, there was a further decrease of 45% resulting in current medical students in Scotland experiencing a 60% reduction in contact anatomy time compared to their peers in the early 1980’s. The decline in anatomical infrastructure is not a reassuring indicator of its ability to meet substantial future demands.
Key words: Anatomy, Scotland, medical curriculum, Anatomy Act, GMC
Introduction
Anatomical studies have played no small part in the advancement of medicine and as a consequence the subject is regarded as the foundation upon which many aspects of medicine and its associated terminology is based, justifying its retained position as a core requirement in the modern medical curriculum. Yet anatomy has neither shied away from, nor indeed been protected from, the demands of change. It has not been immune to competition from subjects that are considered by some medical educators to be more appropriate and/or relevant to the training of the modern Scottish doctor. Understandably therefore, its role within the curriculum has altered over time and anatomy has adapted to best accommodate the shifting requirements of the disciplines that it serves within the constraints imposed by the governing bodies to which it must ultimately respond. Following recommendations in the “Tomorrows Doctors” General Medical Council (1993) publication,1 there was a drive to essentially withdraw from the traditional approach to the undergraduate teaching of anatomy which was perceived as being too heavy on factual content and didactic teaching.
Anatomy in Scotland is now poised on the brink of one of its greatest and most exciting challenges in recent history. The proposed amendment to the 1984 Anatomy Act2 will, for the first time, permit the practice of surgical techniques on bequeathed cadaveric material and this is likely to place unprecedented postgraduate and professional demands on anatomical involvement. Unlike the Human Tissue Act in England and Wales, the Scottish Executive has opted to amend existing legislation rather than implement a new act. This will likely result in a more speedy resolution north of the border with implementation likely to occur well in advance of the situation in England and Wales.
This paper addresses the potential ability of anatomy to play a major role in this new and exciting opportunity in Scotland. To assess this, it is essential that the current status of the subject is addressed through a mapping of recent trends in its operational capabilities. This should construct a realistic picture of its potential ability to respond to the new legislative demands that are likely to be placed on its staff and support infrastructure. This study examines recordable information that, for the first time, permits a charting of the changing face of anatomy in Scotland over the last 20 years. This communication also examines how the provision of education in this subject has changed in the past 20 years, highlighting possible changes that may have arisen in response to the recommendations of the GMC 1993 initiative.
Methods
The data for this study was collected from both the admissions offices and the principal teaching staff of the five Scottish Anatomy Schools within the Universities that offer medical education. Current and retired staff members at the Universities of Aberdeen, Dundee, Edinburgh, Glasgow and St-Andrews were interviewed to obtain the following information pertaining to each of three temporal snapshots of academic years, each separated by a decade - 1983/4, 1993/4 and 2003/4:
•The number and nature of teaching staff involved in gross anatomy teaching (including full time, part time and honorary staff as well as clinical demonstrators).
•The number of registered undergraduate medical students as provided by admissions offices. In any one academic year, an anatomy department teaches more than medical students and so the total student number was included to assess teaching burden upon the staff (medical, dental and science students) and calculate staff:student ratios.
•The total number of anatomy lecture, practical and tutorial hours offered to each medical student.
Results
The verbal opinion from the Scottish anatomists was that the prominence of anatomy had declined over the previous 20 years, with the greatest alteration occurring in the 1990’s following the GMC recommendations. Most considered that the major alterations came through lack of investment to recruit and replace staff, a decline in allotted teaching time, a lack of student directed teaching in the dissecting room and a general ‘dumbing’ down of anatomical information. The data presented in Tables I-V largely support these anecdotal impressions.
Table I shows that the profile of the teaching staff has altered significantly in the past 20 years with the greatest reduction in staffing occurring in the number of full time teachers (with 13 teaching posts lost in the past 20 years). Whilst the number of part time teachers has remained constant only the number of honorary staff has shown an increase from two to four over the past 20 years and both of these occurred in one University. The most significant loss in teaching support has come from the 71% reduction in demonstrator posts with five out of the seven remaining posts occurring in one University.
Overall the reduction in available teaching staff represents the loss of 28 teaching positions (41%) over the 20 year period examined by this study. In virtually each category of teacher, the reduction of staff in the 1993/1994 decade was almost double that seen for the previous decade.
Table II shows the educational background of the teaching staff (minus demonstrators). The greatest reduction in staff in the 20 year period has occurred in those who are medically qualified (nine staff posts). When the demonstrator losses are also considered, then out of the 28 teaching positions lost within the anatomy departments, 26 of those relate to medically qualified individuals. Whilst the proportion of scientifically trained staff has marginally increased to present times, the proportion of dental teachers has also decreased and veterinary staff are no longer represented.
Table III shows the numbers of students that were taught in the anatomy departments in Scotland in each of the academic years indicated by these temporal snapshots. In the last 20 years the medical student intake has increased by 38% and the dental intake by 47%. However, the number of science students studying anatomical sciences has increased more than 8 fold from 103 students in 1983 to 887 students in 2003. The largest increase in dental numbers occurred between 1983 and 1993 in response to the decision to increase student intake at that time and also reflects the closure of one of the Scottish dental schools. The most significant increases in student numbers (medical and science) occurred between 1993 and 2003. This effective doubling of student intake, coupled with the reduction in staff numbers has resulted in a virtual trebling of the staff:student ratio from 1:20 in 1983 to 1:58 by 2003.
Tables IV and V show the changes in contact between anatomical teaching staff and medical students in the 20 year period of this study. It is clear from the range of hours dedicated to each of the teaching modes that each University responded in a different way, but this is not for discussion in this communication as only the general pattern throughout Scotland is being considered here. Anatomical input to the medical curriculum in 1983 showed that almost an equal part of the course was given over to lectures (41%) and practical sessions (56%) with a small involvement in tutorials (3%). Whilst the number of lectures decreased by 30%, the practical hours by 27% and the tutorials by 36%, in 1993 the proportions of each teaching mode were still relatively similar. Therefore there is an indication of general downsizing in the subject although it retained a similar teaching format to previous years. However by 2003 following a further 64% reduction in lectures and 44% in practicals, the ratio of lecture to practical time had altered significantly (27% and 58% respectively) with a greater percentage of small group teaching occurring.
Discussion
During the past 20 years, anatomists have been aware of a persistent and accelerating decline in the infrastructural support to their subject. The results of this study confirm that whilst student numbers have continued to rise, staffing levels have decreased significantly and contact time has been seriously eroded which contributes to the ‘dumbing down’ effect as experienced by the teaching staff.
In 2003/4, the average number of contact hours that a Scottish medical student can expect to experience from their anatomy department (151 hours) has dropped below the American average of 167 hours.3 Worryingly, there is no evidence that the decline in anatomical provision to the medical curriculum is slowing down or even approaching a plateau. An identical crisis hit the US in the 1980’s and only now, following serious allegations of basic incompetence is there an appreciation that basic early medical education forms the foundation for the profession. As a result the subject is beginning to display some positive signs for recovery in the US. It is important that if a discernible future exists for anatomy in Scotland then the subject must not be allowed to descend to a level beyond which it is unable to recover.
At the root of many of the issues faced by anatomy is a difficulty in retaining quality recruitment to the profession and this study has shown that within Scotland, it is the posts occupied by medically qualified teachers that are not being refilled. When asked why this should be so, the Scottish anatomists interviewed considered that clinical applicants would not be attracted to pre-clinical salary scales. Equally young science teachers are not being attracted due to limited prospects for career promotion, repetitive small group teaching which can lead to stressful, demoralising and disinteresting working conditions, increasing student numbers, increasing staff:student ratios, a system where lecture based teaching is not advocated and dissection is in decline (only two medical schools in Scotland still offer full body dissection), factual learning is discouraged and there are no Regis chairs of anatomy still in existence to champion the status of the subject. This does not paint a healthy picture for the future survival of the subject or its potential to rise to meet the demands of postgraduate and professional education.
Yet despite all of this, anatomy as a subject is blossoming and attracting more students than ever before. Within the last 20 years it has seen a dramatic increase in the number of science students who wish to study the subject and in a climate where science intake is generally in decline, anatomy admissions are exceeding expectations and courses are heavily oversubscribed. In terms of student numbers and fees attracted this should be sufficient to secure the future of the subject certainly within the science faculties. With no evidence for an impending decline in the trend for such student intake, it can only be anticipated that the numbers of science students seeking an anatomical education will ultimately outstrip the number of medical students within the next decade.
There is no doubt that the infrastructure of anatomical education within Scotland is in decline and that this accelerated throughout the 1990’s at the time of the implementation of the GMC initiative. Whilst it would appear on paper that the universities have ostensibly attempted to implement the GMC recommendations this additional burden was being superimposed on an already weakened subject that was exhibiting decline within the medical faculties. There is now a general view that anatomy may no longer be a necessary core subject for medicine and that it can be condensed further to make way for alternative subjects in the early part of the curriculum. However it must be realised that there is a vast chasm between determining that a subject is not in a fit condition to undertake new, and perhaps even maintain existing responsibilities and inferring that it no longer has relevance. It is an inherently and fatally flawed decision that is made by the educator who cannot comprehend the difference.
Investments in anatomy have been sporadic within Scotland in the past 20 years and although it would not be true to say that there has been no investment it tends to be restricted to isolated incidents. It is highly unlikely that Anatomy in Scotland is in a fit condition to undertake efficiently the rigorous demands of a new initiative without serious investment both from within the Universities and their medical schools but also from governmental sources. The financial success that has arisen from anatomy ’s increased student intake must be reinvested in the infrastructure of the subject if it is to address potential sources for growth and development. Scotland has a narrow temporal window of opportunity to lead the way for an exciting new era in anatomical education but in its current condition this seems unlikely and a tremendous opportunity could be lost unless significant investment is forthcoming.
So with Scottish anatomy about to experience unprecedented professional demands for access to its licensed teaching abilities, the most ironic factor could be that its willingness to accommodate the recommendations of the GMC in the early 1990’s has left it in a mortally weakened condition that could ultimately threaten its survival and therefore its ability to respond to the advances of the very core profession that it has served for so long.
REFERENCES
1 General Medical Council. Tomorrows Doctors: Recommendations on Undergraduate Medical Education. Report of the Education Committee. London: GMC 1993; 1-28.
2 Scottish Executive. Anatomy Act 1984, Consultation on existing provisions and licensing arrangements. Scottish Executive 2004, Crown copyright.
3 Drake RL, Lowrie DJ, Chantal PM. Survey of Gross Anatomy, Microscopic Anatomy, Neuroscience, and Embryology Courses in Medical School Curricula in the United States. The Anatomical Record 2002; 269:118-122.