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Annals of Anatomy 192 (2010) 373377

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Annals of Anatomy
journal homepage: www.elsevier.de/aanat

A model of horizontal and vertical integration of teaching on the cadaveric heart

Samar AlSaggaf a , Soad Shaker Ali a , Nasra Naeim Ayuob b,c, , Basem Salama Eldeek b,d , Amira El-haggagy a
a

Department of Anatomy, Faculty of Medicine, KAU, Saudi Arabia Department of Medical Education, Faculty of Medicine, KAU, Saudi Arabia Department of Histology and Cytology, Faculty of Medicine, Mansoura University, Egypt d Department of Community Medicine, Faculty of Medicine, Mansoura University, Egypt
b c

a r t i c l e

i n f o

s u m m a r y
This work was performed in a trial to organize the learning process by focusing on the integration of medical education particularly between the three main subjects: gross anatomy, histology and pathology. It was a theoretical teaching draft designed to be implemented with second year students of the Medical school of the King Abdul Aziz University, Jeddah, KSA, in order to overcome disadvantages in traditional teaching. The objectives of this work were to make medical students, at the pre-clinical stage of their medical carrier, alert to diagnosis and handling of clinical problems and to develop their ability to integrate pre-clinical and clinical subjects. Fifty human cadaveric hearts were anatomically and histopathologically examined. This examination revealed six different clinical problems such as pericarditis, myocarditis, cardiac hypertrophy, parasitic infestation, rheumatic heart disease and fatty inltration. The medical students of the second year will be rst introduced to the normal anatomical and histological structure of the heart, then allowed to visualize and examine the specimens of the cadaveric heart both macroscopically and microscopically. They will be introduced to a set of clinical problems through some clinical scenarios and asked to search for the possible etiological factors causing these changes, associated signs and symptoms. Finally they will be asked to present their ndings and interpretations. This paper demonstrated a pathway of self-directed learning in an integrated teaching setting in the medical curriculum using available cadaveric material at a preparatory stage before developing the system-based curriculum. 2010 Elsevier GmbH. All rights reserved.

Article history: Received 6 March 2010 Received in revised form 19 June 2010 Accepted 25 June 2010 Keywords: Integration Cadaveric heart Anatomy Histology Pathology

1. Introduction Understanding is placed between participants rather than being contained in one or the other. Knowledge is not constructed separately in the mind of the knower, but, rather, it emerges; it is co-created during the exchange in an authentic recursive transactive process. Learning and knowing become adaptive responses to continuously evolving circumstances (Mennin, 2010). In the latter part of the twentieth century medical education planners advocated the combination of the disciplines and the organization of integrated learning experiences for students. They called for knowledge and skills from across the disciplines in addressing patient cases, problems and issues. Integration was promoted in teaching and learning approaches rather than assuming that students would somehow integrate their disciplinary knowledge on their own (Dent and Harden, 2005).

Corresponding author. Tel.: +966 530112205; mobile: +20 105608286. E-mail address: nasra-ayuob@yahoo.com (N.N. Ayuob). 0940-9602/$ see front matter 2010 Elsevier GmbH. All rights reserved. doi:10.1016/j.aanat.2010.06.005

Colleagues in a number of academic universities have been discussing ideas intended to foster the rational introduction of integrative medicine into medical education and practice (Dismuke and McClary, 2000; Fortin et al., 2002; Stalburg and Stein, 2002). There are two common approaches in medical education. These are the horizontal and the vertical integrations. In the horizontal approach there is integration between the various disciplines within themselves or each year of the curriculum such as in courses organized on a body systems basis (anatomy, histology, physiology, etc.). In vertical integration there is integration of disciplines taught in different phases or years of the course. The early introduction of clinical skills and their development alongside basic and clinical sciences is a good example of vertical integration (Dent and Harden, 2005). Early exposure to clinical skills was one of the main themes discussed in General Medical Council (GMC) publication of Tomorrows Doctors in 1993. Live demonstrations and audiovisual material were used to demonstrate the content. During early stages of medical study the anatomical cadavers provide good material to deal with horizontal (anatomy and histology), and vertical (pathology) curricula.

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Pathology and anatomy are both sciences contributing to the foundations of a successful medical career. In the past decade, medical education has undergone profound changes with the development of a core curriculum combined with student selected components. There has been a shift from discipline-based teaching towards problem-based learning. Both anatomy and pathology are perceived to have suffered from this educational shift. The challenge is to introduce methods of learning for these subjects into an integrated student-centered curriculum (Wood et al., 2010). The heavy penalty of not concentrating on sufcient anatomy education will inevitably lead to incompetent anatomists and healthcare professionals, leaving patients to face dire repercussions (Sugand et al., 2010). Traditionally, undergraduate medical education is divided into pre-clinical and clinical education; with basic sciences dealt with during the rst 3 years and clinical sciences in the next fourth, fth and sixth years. Teachinglearning activities consist of lectures, seminars, group discussion and laboratory exercise (Rees and Sheard, 2002). Indeed, this was what was actually applied in the medical college of KAU. The gross anatomy core course was taught during the second and third years. The histology core course was taught during the second year. The pathology core course was taught during the third year. Gross anatomy and histology courses were focused exclusively on the students acquisition of basic components of normal anatomical and histological specimens. Little is done to promote higher levels of pre-clinical learning. This work was a theoretical teaching draft designed to be implemented on second year students, of the Medical school of the King Abdul Aziz University, Jeddah, KSA, in order to overcome the disadvantages of the traditional teaching methods. Recently, the curriculum has been shifted from discipline-based to system-based one. So this study has not been applied as it is, instead it was modied to form a cardiovascular module which is being taught to the second year students of the developed curriculum. The authors prefer to publish this teaching draft as it could be helpful to others who are unsatised with traditional discipline-based teaching of basic sciences and are willing to change it. 2. Subjects and methods Fifty cadaveric male and female hearts were collected from the dissecting laboratory of the medical college of King Abdulaziz University. Hearts were chosen for their abnormal anatomical appearance either in size, consistency and color. Hearts with abnormally looking pericardium, myocardium, valves and associated blood vessels were included. These specimens were photographed. Selected regions of suspected pathology were re-xed in 10% neutral buffered formalin; parafn sections were cut at 10 m and stained with hematoxylin and eosin (Bancroft and Gamble, 2007). Apparently normal specimens were examined in same way and were used for comparison. Abnormal histopathological ndings were described, compared to normal ones and illustrated. The second year students, around 150, will be selected for implementation of this study. They will be introduced to the normal anatomical and histological structure of the heart by one or two lectures given by the course instructor in the auditorium. The students then will be divided into small groups, 20 students each; one tutor will be assigned for each group. Tutors are demonstrators or staff members of either the anatomy or pathology department. The tutors will adopt the principles of self-directed learning, through tutorials, in four stages. In the rst stage the tutor will present a case history of the related pathological diagnosis to the students and discuss with them the learning objectives of the related disciplines (anatomy, histology, pathology and related clinical presentation). At this stage the student will go to the dissection room and histology lab, during the practical sessions. They will be

divided into subgroups of ve students. Each student will have the chance to inspect and manipulate real cadaveric heart specimens wearing gloves and under supervision of a tutor. They will be allowed to examine routinely stained slides prepared from the same specimens. In the second stage, the students will have the opportunity to do research for the related learning objectives. At the third stage the students will come back, present and discuss the results of their research. The tutor will help them by asking some cognitive questions to relate knowledge of each discipline to the studied case history. At the fourth stage the students will perform presentations or seminars for 15 min to present their knowledge and understanding of the studied case history then the tutor will provide them with constructive feedback. 3. Results The students will be introduced to the normal gross and microscopic structure of the heart and will be allowed to examine and manipulate the specimens and slides frequently to be familiar with the normal heart (Figs. 1 and 2). The materials will be presented in a systemic way with respect to the three anatomical layers of the heart namely: pericardium, myocardium and endocardium. Fig. 3 shows a cadaveric heart with thickened adherent epicardium (the outermost layer of cardiac wall). There was a yellowish brin deposit lending what is called a bread and butter appearance. Fig. 4 shows the histopathological appearance of this

Fig. 1. A cadaveric heart showing normal appearance.

Fig. 2. A photomicrograph of the specimen in (Fig. 1) showing a longitudinal section of normal cardiac muscle bers (H&E 200).

Fig. 3. A cadaveric heart showing the bread and butter like appearance of pericarditis (arrows).

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Fig. 4. A photomicrograph of the same specimen in Fig. 3 showing hyaline appearance of brous connective tissue in the subepicardium (stars). There are congested blood vessels (BV) (H&E 100).

Fig. 8. A cadaveric heart appears enlarged. The thick right ventricular wall shows yellowish coloration (fatty inltration).

Fig. 9. A photomicrograph reveals accumulations of fat cells in the perivascular connective tissue, separating muscle bers (H&E 50). Fig. 5. A photomicrograph showing degenerated cardiac muscle bers separated by inltration of polymorphonuclear leucocytes (H&E 500).

Fig. 6. A photomicrograph showing myocardial degeneration with plasma cells (1), macrophages (2), dense granules (3), and lymphocyte (4) inltration between the cardiac muscle bers (H&E 200).

case presented by sub-epicardial brous thickening and the presence of congested blood vessels. The term pericarditis was used in both pathological and clinical courses to describe inammation of the outer cardiac layer (Robbins et al., 2001). Pericardial disease is a common disorder seen in varying clinical settings and may be the rst manifestation of an underlying systemic disease. It may be due to multiple causes (Mookadam et al., 2009). Students will be asked to research these possible causes for their clinical presentation. The presented cadaveric specimens in (Figs. 57) showed one of the possible pathological changes in myocardial layer of the heart which is inammation. Myocarditis is the term given to inamma-

tion of myocardium; its diagnosis is very difcult in living patients and is often found at autopsy. Clinically it may give rise to fever, chest pain, tachycardia or arrythmias (Danish, 2002). The students will be asked to search for and differentiate between the two types of inammatory reactions (acute and chronic) using histopathological sections (Figs. 5 and 6). Non-infectious inammatory reactions like rheumatic fever are characterized by the formation of Aschoff bodies in cardiac brous septa (Fig. 7). The specimen presented in Fig. 8 shows a thickened cardiac wall, the color of the muscles indicate the presence of fat. Microscopic examination revealed an accumulation of fat cells in the perivascular connective tissue separating cardiac muscle bundles (Fig. 9). The muscles looked atrophied owing to compression. The pathological term given to such changes is fatty inltration. Such conditions are seen in alcoholic, hypertensive and obese patients (Sharma and Sharma, 2006). The specimen presented in Fig. 10 shows an enlarged cadaveric heart, there are marked trabeculation of ventricular and papillary muscles and narrowing or stenosis of the valve. Histopathologically, cardiac bers appear large and irregular, their nuclei became vesicular indicating cellular hyperactivity, some bers show tiny vacuolization (Fig. 11). Cardiac hypertrophy is usually associated with chronic hypertension or valvular stenosis (Leslie et al., 2001). The specimen presented in Fig. 12 shows a small-sized heart with a brownish yellow appearance. Marked accumulation of solidied fatty tissue was observed along the course of coronaries. Histopathological studies were interesting; it revealed the presence of parasitic cysts among or within cardiac bers (Fig. 13). Cardiac

Fig. 7. A photomicrograph showing degenerated cardiac bers inltrated with lymphocytes, macrophages and Aschoff cells (arrow head) (H&E 200).

Fig. 10. A cadaveric heart with left ventricle opened. It shows an increase in ventricular trabeculation, hypertrophy of papillary muscles. The aortic valve has been exposed and appeared narrow, with white patches on the ventricular side.

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Fig. 11. A photomicrograph of same specimen in Fig. 13 showing large cross sectioned cardiac bers with large and vesicular nuclei (cardiac hypertrophy) (H&E 200).

Fig. 15. A photomicrograph of the specimen in Fig. 14 showing multiple homogenous vegetations (V) (H&E 100).

Fig. 12. Cadaveric heart shows deposition of fat along the coronary arteries. The heart is apparently small in size.

Student opinion about this method of teaching was to be assessed in focus group discussions with the students and respective course evaluation questionnaires. It included parts for evaluation by the tutor, teaching and learning methods, and learning resources as well as the learning objectives that formulated to be learned by the students. The students performance was designed to be evaluated through theoretical and practical exams. The theoretical exam includes both a written and a selected response questions e.g. structured essay, type-A multiple choice questions (MCQ) and extended matched questions (EMQ). All these were designed to test not only recall but also higher levels of cognition e.g. understanding, application and synthesis. The student performance results will be compared to those of the students taught by the traditional methods of the previous years. 4. Discussion This study represented a model of application of self-directed learning to facilitate understanding of cardiac anatomy, histology, pathology and related clinical presentation of the studied hearts through an integrated teaching and learning approach. It uses cadaveric heart specimens to help demonstrate these methods. Recently a study was done to determine the prevalence of pathology in 12 donor cadavers in the dissecting room of the Bute Medical School-University of St. Andrews. This study conrmed that cadaveric dissection provides an excellent opportunity for the integration of anatomy, pathology, and clinical medicine into the early clinical training of undergraduate medical students. The identication of disease in a cadaver provides an excellent introduction to the gross features of a disease process, but does not substitute for the detailed study of a process later in the curriculum (Wood et al., 2010). Anatomy has historically been a cornerstone in medical education regardless of nation or specialty. Until recently, dissection and didactic lectures were its sole form of teaching (Sugand et al., 2010). Recently, the interest of many medical educators has been focused on curriculum reform to introduce early pre-clinical skills in the rst 2 or 3 years of medical studies (Issenberg and Mc Gaghie, 2002; Lam et al., 2002). Stanford et al. (1994) and Erkonen et al. (1992) tried to use a cardiac computer-based program to enhance cadaver dissection in teaching cardiac anatomy to rst year medical students. However, they stated that although using ultra fast computed tomography (UFCT) videotape of heart improved image testing performance, it should not replace dissection for teaching cardiac anatomy. One of the objectives of this design is to encourage the learners to be good observers, besides attracting them for more reading in related clinical problems. Small break groups in which students are exposed to standardized related clinical cases in the hospital could be also organized (Barry, 2002; Issenberg and Mc Gaghie, 2002). Boon et al. (2002) found that medical students of the second year of the Pretoria medical school, South Africa, recognize the

Fig. 13. A photomicrograph of specimen in Fig 12 showing encysted parasite within Purkinje bers probably Toxoplasma gondii (H&E 100).

bers either showed atrophy, or hyaline degeneration most probably due to parasitic toxins. Available literature pointed to possible involvement of cardiac tissue in parasitic infections. Although parasites were intracellular, their presence seldom leads to conspicuous signs or symptoms and cases of death due to the cysts were most probably related to toxoplasma. However, diagnosis must be conrmed by clinical, serological and histopathological investigation (Patrat-Delon et al., 2010). The specimen presented in Fig. 14 showed a cadaveric heart with whitish thickened patches in the endocardium near the valve region. Vegetations on endocardial surface were observed in histopathological examination (Fig. 15). These vegetations are usually associated with endocarditis or inammation of the inner layer of the cardiac wall. Vegetations are amorphous masses of brin and fused platelets and sometimes entangled bacteria in instances of bacterial endocarditis, in such instances it may be friable leading to septic emboli (Fowler and Durack, 1994).

Fig. 14. A cadaveric heart opened to show whitish thickened patches in the endocardium near the valvular region (arrow).

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importance of anatomy as the basis for clinical examination when exposed to an appropriately integrated presentation format. Naga Rani (2002) wanted to know what students say about the early clinical exposure at B.P. Koirala Institute of Health Sciences, Nepal. He found that more than two-thirds of students thought that the new design improved their understanding of the anatomical basis for future clinical knowledge, being stimulated to do further reading on the given subject. Lam et al. (2002) and Vidic and Weitlauf (2002) found that students enjoyed change from traditional basic sciences classroom teaching to pre-clinical skill sessions, getting an impression of what it is like to be a doctor, and feeling better prepared for their clinical studies in later years. Naga Rani (2002) agreed that early clinical exposure through integration of basic science disciplines (organ system teaching) besides clinical orientation (clinical posting) once (1st year) or twice (2nd year) in a hospital enhanced students condence in responsibility towards interaction with patients. In conclusion, the mission of this work was not to present pathological ndings compared to normal ones, but rather to provide an educational design of highest quality coupled with a more integrated presentation of knowledge. Also to capture the students imagination, develop creativity, critical thinking and skills needed for future their later clinical work would result in doctors who are better trained in integrating basic sciences with clinical skills. 5. Recommendation As the curriculum in King Abdulalaziz University medical school had been shifted to an integrated system-based one, the team developing this work did not get the chance to implement its proposal. However, it still hopes for better use of available materials and methods, in any medical school, to design an integrated curriculum that facilitates gaining information, and helping students to conceptualize rather than memorize and encouraging them to integrate basic science concepts and principles into future clinical practice. An important issue when applying the new curriculum is to look forward and analyze the positive and negative effects of the curriculum. Action can then be taken to improve the design or to weaken the case against the proposal. Acknowledgments The authors are grateful to Dr. Khadra Soliman, department of Pathology, Faculty of Allied Sciences, KAU, for her help in histopathological examination and reporting and Fawzia Nayeem, technician in Biology department and all other technicians in the anatomy department for their technical support. The authors are also grateful to Wajdan Aleryani and Saad AlHusaini technicians

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