by Rick Krupinski
In the 152 years since Moses Gunn arrived in Ann Arbor by stagecoach,
accompanied by a long wooden crate carrying the first cadaver
for study at the new University of Michigan Medical School
indeed for centuries before the School and its peer institutions
were even founded dissection, of animals and of humans,
has been the foremost way of teaching and learning anatomy.
As an autopsy instructs in the specifics of death by allowing
the medical examiner to look inside (the literal
meaning of the word), so has dissection enlightened students
of anatomy throughout history by providing three-dimensional,
palpable experience with the muscles, bones, organs and tissues
that comprise and enable human life.
Whether witnessed from a distance in an amphitheater as instructors
like the legendary Corydon Ford a U-M anatomist renowned
in the early days of the School for meticulous, even elegant,
dissection demonstrated techniques and presented the
internal structures of the human body, or whether performed
firsthand by students themselves, as has been the case in gross
anatomy labs since the late 19th century, looking inside
has been an essential experience fundamental to the study of
medicine, even as the medicine we study has evolved, changed,
and grown more complex. Today, whole fields like bioinformatics
have emerged to effectively unravel and compile the explosion
of new information coming from the ever-expanding frontiers
of medical science.
In just the last 20 years, technological advances have revolutionized
ways of not just looking inside the human body, but also relating
what is seen to physiological function, diagnosis of disease
and subsequent treatment. The evolution of radiological imagery
into precise and dynamic pictures of human structures; the ever-changing
and pervasive presence of computer technology; and new processes
that can preserve anatomical specimens virtually forever have
all contributed significantly to the study of anatomy today.
Relating anatomy to physiology and the actual practice of medicine
is not coincidental, nor is the shift in focus to learning rather
than teaching. As the Medical School undertakes a major curriculum
review, context and methods of learning are helping shape the
future of medical instruction at Michigan. Our goal is
to create a learning environment centered upon helping students
excel as they prepare to care for patients and develop their
professional careers, explains Joseph Fantone, M.D., associate
dean for medical education.
Anatomical knowledge underlies physicians ability
to provide quality care, and providing the why about
what students are learning in context of the patient and of
patient care helps them to become more effective physicians,
he says. Linking physiologic function and clinical findings
with anatomical structure and the pathology of tissues and organs
helps bring relevancy and greater retention to
the study of anatomy overall. Learning effectiveness is driving
medical instruction and revisions to our curriculum.
The lecture is an efficient way of delivering information,
Fantone says, but what do you as the student do with all
that information? How do you know whats relevant, what
facts you really need to know and how they need to be organized
to be effectively applied in the future? Active learning environments
that offer students the chance to apply and test new knowledge
have been shown to be highly effective in promoting student
learning and integration of information, especially when organized
around a specific medical or patient care issue.
Learning Anatomy in the Age
Its a point reinforced by Tom Gest, Ph.D., associate
professor of anatomical sciences and the new Gross Anatomy course
director after Bill Burkel, Ph.D., professor of anatomical sciences,
recently concluded 17 years as course director. With about 170
student contact hours, Medical Gross Anatomy is the largest
course in the Medical Schools offerings. We try
to keep students focused on what they have to know and on the
clinical applications of anatomy. As faculty, we have to look
deeply at every fact we teach. Why are we teaching it? Is it
relevant? If not, we dont encumber students with it,
Gest says. Its our obligation to help students cut
through the enormous volume of information so they understand
what is important.
Photo: D.C. Goings
Gest is largely credited with maximizing use of technology
in gross anatomy, especially digital technology, since he came
to U-M from the University of Arkansas more than three years
ago and began building upon the efforts of Burkel and others.
A lanky, laid-back man with a bushy mustache and traces of a
southern drawl from his Arkansas days, Gest has a varied background
in archeology, anthropology, math and statistics. It is this
unique background combined with his utter love of anatomy that
makes him comfortable with the concept of multiple contextual
bases for learning biomedical, social, cultural and developmental.
He points to the change in educational philosophy to focus on
learning rather than teaching as an important means of encouraging
students to be self-reliant and self-paced in their studies,
a goal very much facilitated by technology.
U-M medical students have ready access to an array of computer-based
learning tools that allow for individual paces of learning from
their home computers, the Computer Assisted Instruction Lab
and the Learning Resource Center within the Medical School,
and even right alongside dissection tables in the Gross Anatomy
We have one computer terminal for every two dissection
tables, Gest says. If students have questions or
need to review material or dissection technique, they can access
that material right then and there. From the computer,
students can refer to the Medical Gross Anatomy course pages,
find detailed information in the lab manual on the area being
dissected, watch dissection movies, and reference three-dimensional
anatomical models that can be rotated and examined from all
angles, bringing a wealth of information to the dissection experience.
Such learning tools augment rather than replace faculty-student
interaction; Gest and other faculty members work directly with
students in the Gross Anatomy Lab, explaining and discussing
items related to dissection procedures and anatomical structures.
Other Web-based resources available to students of gross anatomy
at Michigan include anonymous medical histories of the cadavers
to bring clinical relevance to anatomical learning (as well
as personal relevance to the cadaver as a unique human individual),
clinical cases related to each dissection component, anatomy
tables and labeled images, practice quizzes even anatomical
crossword puzzles, all as interactive as possible to engage
We have the equivalent of several full books of information
on the Web, Gest says. Students also have access to ATLAS-plus,
a CD-ROM photo atlas presentation (it stands for Advanced Tools
for Learning Anatomical Structures) developed in the early 1990s
by Burkel, Associate Professor of Anatomical Sciences Ted Fischer,
Ph.D., their colleagues and students, using images made during
45 dissections over a three-year period.
And in an exciting technological initiative, the U-M Medical
School is home to a team working on the National Library of
Medicines Visible Human Project, a massive effort to create
complete, anatomically-detailed, three-dimensional, digital
representations of the normal male and female human bodies to
be distributed via high-speed computer networks for application
to a wide range of educational, diagnostic, treatment planning,
virtual reality, artistic, mathematical and industrial uses
around the world. Directed by Brian Athey, Ph.D., assistant
professor in the Department of Cell and Developmental Biology,
the benefits of the Visible Human Project will be enormous for
students and teachers of anatomy, physicians and other health
professionals, and the future direction of gross anatomy learning
The Medical Gross Anatomy course is based upon educational principles
which hold that traditional methods of learning, often passive,
have the lowest rates of retention: lectures, for instance,
carry only a five percent retention rate; reading, just 10 percent.
Active methods, such as teaching others and practice by doing,
result in retention rates of 75-80%. The active methods are
the focus in gross anatomy instruction at Michigan today, and
its not just computer technology that contributes to active
learning and greater retention.
Tom Gest with medical
students Parrish Balcena and Igor Siniakov
Photo: Bill Wood
Peer teaching is a concept implemented by Burkel and continued
by Gest. While half a dissection team of six students
dissects, Gest says, the other half is free to study,
then the dissection half presents to the study half, with one
member responsible for presenting the clinical application.
The roles rotate, and Gest has on-hand eight video cameras so
students can tape themselves presenting for later self-critique.
Presenting medical information to patients and their
families, to colleagues, and to students of the future
is a fundamental skill required of physicians and researchers,
so the taping activity develops communication skills even as
it strengthens retention of gross anatomy material.
We really owe a lot to Bruce Carlson, Burkel says.
As department chair, he supported innovative ideas that
allowed us to move forward, particularly with technology. Without
that support, anatomy instruction at Michigan would have fallen
Burkel speaks from a desk that carries the same impeccable,
neatly-ordered organization characteristic of the gross anatomists.
He retrieves files on a variety of topics with ease, as if the
elegant order of component parts of the human body he studied
and taught for years extends into the external world. Original
airbrush and carbon pencil illustrations of the internal and
external aspects of the human skull hang on the wall next to
him, drawn by medical illustrator William L. Brudon for the
much-respected anatomy textbook, Essentials of Human Anatomy,
which Burkel co-authored with former Chair of Anatomy Russell
Woodburne. Burkel points out that while technology has greatly
aided learning, its also made teaching more difficult,
and he speaks from the perspective of his 35 years at U-M.
Twenty years ago, he says, Gross Anatomy consisted
of about 45 lectures divided among six or seven faculty members.
Lectures changed little from year to year, so there wasnt
a lot of preparation involved. Now were constantly struggling
to keep information current and preparation is ongoing. I just
spent six weeks on four anatomy movies for four days of the
Gross Anatomy course.
When I studied anatomy, Burkel reflects, the
field of molecular biology didnt exist. We knew much less
of biochemistry than we know now. Anatomy becomes smaller in
light of explosions of progress in other areas. As a result,
what was at the beginning of the 20th century a two-year course
has now been distilled to the first semester of medical training.
One begins to understand why helping students figure out what
they need to know has become so crucial over the course of the
revolution in teaching and learning strategies for gross anatomy.
Overall, Gest adds, we have one of the strongest
programs in gross anatomy, with a long tradition of innovative
teaching. There are lots of anatomy Web sites and instructional
software, to be sure, but what distinguishes Michigan is that
focused learning takes place in the most advanced way possible,
with maximum use of technology. You can have a thousand links
in your Web site, but are they providing what students need
to know? At Michigan, were focused tightly on what students
need to know to become the best physicians and researchers possible.
Last year we experienced the highest grade point average
in Gross Anatomy in 10 years and student satisfaction was the
third highest its been in 10 years. In characteristic
understatement Gest concludes, This seems to indicate
that were effective and not going in the wrong direction.
Radiology is at the center of medicine, says Reed
Dunnick, M.D., the Fred Jenner Hodges Professor of Radiology
and chair of the U-M Department of Radiology. It will
be used by virtually all physicians over the course of their
careers. The language of anatomy is the language of radiology.
Dunnick oversees a busy department of more than 100 faculty,
and hes proud of its participation in the gross anatomy
curriculum. We just dont learn well from flat, two-dimensional
pictures. Radiological images show three-dimensional shape and
form and relativity to other structures much more clearly and
The field of radiology has come far since Wilhelm Conrad Roentgen,
a physics professor at the University of Wurzburg in Bavaria,
took the worlds first X-ray, of his wifes hand,
in 1895, but most of the distance has been traveled since the
1960s. Until then, fever of unknown origin was a
bedrock diagnosis for unsuspected tumors or chronic infections
that plain X-rays simply werent able to detect, and exploratory
surgery was the best way of seeing for oneself inside a living
patient. Contrast materials helped, as did stereoscopy (two
images of the same structure from different perspectives) and
fluoroscopy (continuous viewing of an internal structure by
transmission of X-rays to evaluate dynamic events, like breathing,
swallowing, and blood flow, akin to a movie in real time).
But all that began to change in the 1970s. Use of barium and
barium-plus-air for contrast had already led to finer X-ray
detail for the bodys hollow organs (such as the esophagus,
stomach, small bowel and colon), but it was the development
of ultrasound, which uses high frequency sound waves instead
of ionizing radiation, that was the first big leap forward.
Ultrasound produces images that can be viewed on a television
monitor, taped with a videocassette recorder, or recorded on
radiographic film or photographic paper.
The 1980s saw the advent of computed tomography (CT) scans,
which use thin X-ray beams that rotate around the patient to
gather information that is collated by a computer to create
an image of the internal structures of the patients body,
like a slice, showing the relative location of the structures
in cross-sectional orientation. The resulting images can be
stored on a computer disk or magnetic tape or printed on radiographic
film. Magnetic resonance imaging came to the forefront in the
1990s; strong magnetic fields cause hydrogen atoms in the body
to produce radio waves that make the MRI image. As with CT scans,
computers create cross-sectional images of the patients
body that are particularly useful for examinations of the brain
and spinal cord because of the images detail.
Photo: Martin Vloet
One of the most promising recent developments in radiology
is positron emission tomography (PET), which examines the metabolic
activity in various structures of the body, such as the heart
and blood vessels, and is becoming especially helpful in staging
cancers and detecting Alzheimers Disease.
The primary benefit of using radiological images in gross
anatomy study is that we can demonstrate anatomy in a living
patient and directly relate that anatomy to physiological function
and disease to show students why they need to know these
things, says Katherine Klein, M.D., assistant professor
of radiology, who participates in presenting the radiological
content of the Gross Anatomy course. That increases both
motivation to learn and retention of whats studied.
Photo: Gregory Fox
Marilyn Roubidoux, M.D., associate professor of radiology,
serves as course director for the radiology lectures in Gross
Anatomy and also serves on the Medical Schools curriculum
review committee. She has worked, at Gests behest, to
build more radiological imagery and content into Gross Anatomy
lectures and Web-based course materials. In the first week of
the course, she and Klein present the radiology-anatomy correlation
lecture, providing in-depth, highly visual information using
multiple examples of anatomy and how they correlate to structures
seen with plain films, CT, MRI, Ultrasound, PET scans and nuclear
medicine. Included are descriptions of each radiological modality
from the perspectives of history, physics and how each image
Its not just radiological technology that has improved
gross anatomy instruction, its technology in general,
says Roubidoux. Large screens for electronic presentations
like PowerPoint mean we can share with a whole roomful of students
images and movies that show, three-dimensionally and in living
patients, physiological movement and function. A smaller
form of the PowerPoint radiology lecture is placed on the Anatomy
Web site where students can refer to it prior to the lecture,
or later, for review.
With the entire field of radiology moving to digital technology
meaning electronic storage, use and transfer of images
teaching and learning opportunities are not restricted
to time and place, Dunnick says. These changes truly
are revolutionizing the field of radiology and its role in diagnosis,
as well as its role in learning gross anatomy.
It used to be that diagnosis had about 90 percent of its
basis in the clinical history and physical examination of the
patient, adds Klein. Now radiological examination
accounts for a large portion of diagnoses, and that portion
continues to grow.
The next big development in radiological technology, according
to Dunnick, is fusion imaging, a process that puts the best
of two worlds into a single image more precise than ever before.
Weve just purchased a CT/PET scanner, the combined
technology of which will eliminate warping, a problem
that can occur with slight changes in position as successive
images are taken. Positional changes can make it more difficult
to pinpoint an area its as if the area has moved
or migrated, which of course it has not. With a CT/PET scanner,
both techniques simultaneously capture their images while the
patient is in a single position, yielding a single three-dimensional
view of the same area that is more comprehensive, thanks to
two spectacular technologies, than anything weve seen
Preserving Anatomical Specimens Virtually Forever
Beneath a large reproduction of the classic painting Anatomy
Lesson of Dr. Nicholaes Tulp by Rembrandt van Rijn, and
alongside models of the brain and a photograph of the Medical
Schools most beloved and illustrious neuroanatomist, Elizabeth
Crosby, Roy Glover, Ph.D., associate professor of anatomical
sciences, sits in scrubs and lab coat reviewing the history
of establishing North Americas largest plastination laboratory
at the U-M Medical School. It is Glover, who came to U-M in
1968, who not only established the lab but has also directed
it since its completion in 1989.
Photo: Paul Jaronski
Plastination, he explains, is a method of
preserving anatomical specimens so that they retain their flexibility
and natural appearance and are at the same time protected during
repeated handling and study. Invented in the late 1970s
by German polymer chemist-turned-anatomist Gunther Von Hagens,
the plastination process essentially removes tissue water from
the specimens and replaces it with a liquid silicone polymer.
Because the process uses acetone, a highly explosive and flammable
chemical, Occupational Safety and Environmental Health regulations
require that every laboratory be explosion-proof.
One of the most crucial steps in the plastination process, Glover
explains, involves replacing the acetone within a specimen,
under vacuum, with a curable silicone polymer; once the specimen
is completely impregnated with the polymer, the polymer is hardened.
Finally, after specimens are cured, trimmed, tagged and entered
into the laboratory database, they are ready to be studied
by U-M medical and dental students as well as undergraduate
health science students. Since the Plastination Laboratory is
a cost-for-service facility, it also prepares specimens for
other medical and dental schools, for museums, for hospital
training programs, and for many other health-related organizations.
The American Cancer Society, for example, has made effective
use of slices of plastinated healthy, cancerous and emphysemic
lungs in its anti-smoking campaign.
Plastinated specimens are permanent, dry, odorless and
non-toxic, Glover explains. Specimens can be predissected
to display underlying structures or, after processing, can be
sliced to show a variety of different cross-sectional views.
As with cadaver dissection, plastinated specimens afford the
student the opportunity to examine important internal structures,
with the added benefit of being reuseable and portable. They
can be used for learning in many settings and passed around
among students during classroom presentations or even
in the Gross Anatomy Lab to inform their own dissecting work.
Most specimens come from the U-M Anatomical Donations Program
and are harvested, with appropriate permission, from elderly
Since the specimens are real, and because it is illegal to sell
body parts, plastinated specimens are leased long-term by customers
that request them, and the U-M Plastination Laboratory tracks
and monitors the location and condition of specimens on loan
throughout the world. Most of the specimens, however, remain
right at U-M where they comprise a specimen library from which
they can be made available to different groups of students,
including graduate students in the School of Art and Designs
Program in Biomedical Visualization, formerly known as Medical
Pharmacy student Jim Miller
Photo: Bill Wood
Undergraduate anatomy students at U-M do not have the
benefit of a laboratory experience, Glover says. Now
they are able to access module boxes which contain plastinated
anatomical specimens, informational cards which include highlights
about the specimens, and a self-test, which they can take to
a quiet location in the library and study independently. These
students can now see and appreciate things that they otherwise
would be asked to understand either from textbook readings or
from lecture notes.
The use of plastinated specimens not only makes student
learning more efficient but also can save teachers valuable
curricular time. For example, the hand and the foot are usually
not thoroughly dissected in Gross Anatomy Lab because the work
is difficult and time-consuming. The study of plastinated dissected
hands and feet presents an ideal solution to this problem. Specimens
of both healthy and diseased organs can also be made available
to students so that anatomy can be more readily related to pathology
The U-M plastination library contains nearly 2,000 specimens
that are catalogued and available for study. And recently, the
laboratory designed and implemented the use of equipment that
now allows for the plastination of entire cadavers. Seven such
cadavers have already been plastinated and plans are underway
to do many more, both for the U-M and for its customers. Work
of this kind has been done in only one other laboratory in the
What about dissection?
Where do these recent technological innovations leave that
classical foundation of anatomical learning and teaching, the
dissection of human cadavers? Opinions are mixed. Ironically,
two of the leaders of innovations in U-Ms gross anatomy
curriculum, Gest and Glover, believe that dissection will remain
a crucial experience in learning anatomy. They believe that
despite advances in technology, and though cadavers present
tougher textures than do living tissues and in colors that arent
true, the firsthand, three-dimensional anatomical learning experience
of dissection cant be duplicated as a learning tool even
by the most sophisticated technology. The radiologists, on the
other hand, predict the demise of dissection in gross anatomy
courses, perhaps as soon as within a few years.
People learn in different ways, Joe Fantone says.
There is something about the tactile experience for some
learners, the three-dimensional in situ observation,
that works very well for them.
In many ways the cadaver also represents a students
first patient, a valuable dimension to learning that helps students
gain respect and responsibility and provides opportunities for
them to learn in the integrated biomedical, socio-behavioral
and clinical contexts in which all patients live their lives.
In the debate, one thing is clear: Michigans strength
in gross anatomy is currently derived from its maximum combined
use of all the learning methods currently available, with all
the benefits they offer, as well as the expertise and technical
support represented by the Visible Human Project and innovations
in imaging technology. Beyond the educational opportunities
such projects themselves present is the considerable ability
of the people who make those projects happen and the
dedication and imagination that is brought to bear on students
day-to-day learning of the fundamentals of medicine and patient
care en route to becoming the next generation of highly trained
physicians and medical scientists.
For more information:
U-M Medical School Division of Anatomical Sciences: www.med.umich.edu/anatomy
U-M Visible Human Project Team:
National Library of Science Visible Human Project:
U-M Department of Radiology:
The Visible Human Project