How Many New Words Do First Year Medical Students Learn

First-year medical students still rely on cadavers to learn beefcake

The six first-year med students approach the tabular array, the place where for the side by side seven weeks they'll spend so much time, it will seep into their dreams. They brace themselves to come across him. Him, their cadaver.

For some, even those who have lost a loved ane, it's the closest they've ever been to a corpse. But soon enough, these students volition spend their days inches away from this man's body, cutting through his pare, peeling back the fat, and trimming away the fascia—those bits of densely woven tissue that encase the body's innards—to encounter his stomach and liver and bones. Soon enough they'll pull on his tendons and watch every bit his toes wiggle in turn. They'll cut his digestive system from esophagus to rectum, making much ado about the smell. They'll hold his eye in their hands, and they'll saw open his skull to remove his brains.

These are the Johns Hopkins Schoolhouse of Medicine students of Table 4D: Sina Famenini, Sara Jones, Ravi Medikonda, Jeremy Applebaum, Nathan Yueh, and Jennifer Qin. One calendar week into med school, they are handed their first patient. He'll teach them more about gross anatomy than they always thought they could absorb in seven weeks. But he'll as well teach them how to care. How to detach. How to work as a squad. A sense of curiosity and discovery. How to navigate the emotions they'll face up when they go fond of a patient but have to put him through the nigh painful experience of his life in gild to brand him well over again.

They unzip the torso purse and slowly peel dorsum layers of plastic tarp and cloth to reveal his pallid, most gray face. They decide to telephone call him but "him." For privacy reasons, they aren't told his name, and a nickname seems disrespectful, as if to minimize who he was when he was living. They give thanks him aloud for the gift he made to their medical education. Famenini grasps a scalpel, holds his breath, and makes the beginning cut.

As they work, the students move from Grant's Dissector, the book that guides them through the twenty-four hours'south to-do listing, to the cadaver, to a calculator screen, back to the cadaver, trying to identify torso parts and figure out what, and what not, to cut. Table 4D is tucked abroad in the last of 4 bays, each of which holds six autopsy tables. Xx-iv bodies in total. Near of the 140 students in the lab are first-year med students, but there are a handful studying biomedical engineering science and a few aspiring medical illustrators. A steady hum of conversation is occasionally interrupted by a cursory mayhem of discovery as the teams work just a few feet from 1 some other.

Some cadavers accept pillows of exposed fat while others, like 4D's, expect emaciated.

Some are tall, some short, some blackness, some white. Some have lungs that prove years of breathing in harsh chemicals. 1, almost the entrance, notwithstanding has a bright pink manicure that looks as though it could accept been done hours earlier expiry. Another is missing his left leg, with a bullet wedged into his skull. The bodies have all been embalmed, and the smell of formaldehyde lingers in the air despite the state-of-the-fine art ventilation system installed in the lab. To a higher place each table hangs a light, much like the one a dentist uses to get a better view of your molars. Below is a pan that catches drippings from the body, such every bit preservatives or fat that has melted nether the lamp; students will ofttimes reuse this "juice," as they call it, to go on the body moist.

Famenini, Medikonda, and Yueh are taking the start shift at the table while their tablemates nourish a session on abdominal imaging. Their cadaver, an elderly human with age spots dotting his skin, lies on the table with a tarp covering his lower one-half. His chest is open, and his rib cage, sawed out a few days earlier, rests atop his face up. Equally they bollix their mode through his belly, at that place are a lot of comments like, "Information technology should be there" and "I think this is information technology." They cutting slowly and advisedly—one time something's been snipped, there's no going back.

"Is that the omentum, or is that … ?" Famenini trails off.

"This is office of the greater omentum," Yueh answers.

"So it goes over from the major curve—the inductive of the stomach folds down and up to the … small intestine," Famenini says.

"Actually, no," Yueh responds, "the greater—this is it. That's non greater omentum."

"Oh yes. Might be lesser omentum," Famenini says.

"No, lesser is this," Yueh says, pointing.

The clock is ticking. Past Friday, Famenini needs to know this data by heart (or, well, by stomach). Information technology's his plough to requite a rapid-burn down 15-infinitesimal presentation, complete with Q&A, on everything they've dissected this week.

Today, med students accept detailed medical atlases and 3-D visualization software that signal out every muscle and nerve and os. As technology advances, so exercise educational tools, with ever more realistic and advanced representations of the human being body. Simply cadaver dissection remains an essential office of medical school education in the United States. Why is that? What practice students get out of the experience that can't be had through software and hands-on patient experience?

Chris Ruff is the director of the Johns Hopkins Center for Functional Beefcake and Evolution. Like near who teach anatomy at Johns Hopkins, Ruff is an anthropologist, specializing in the evolution of man skeletal beefcake over the terminal vi one thousand thousand years. Information technology makes sense for anthropologists to teach the course, he says: Clinicians or retired surgeons, for instance, have probable spent then many years specializing in 1 area of the human body that they won't be able to respond the wide range of questions students volition take as they work. To incorporate those specialists' armory of expertise, students attend lectures and become hands-on demonstrations from clinicians on things like imaging or pathology.

For more than than 30 years, Ruff has watched as students spend their showtime weeks of med school in the anatomy lab. He doesn't get sentimental about what the course represents—his goal is to ensure students get out armed with information more than than a memorable experience—and winces when people telephone call dissection a med school initiation or rite of passage. However, he acknowledges its significance. It'south a once-in-a-lifetime feel shared by very few people, most of whom are in the same line of work. "There has been a trend over the years for this to be seen as an initiation or something like that, something yous have to get through," Ruff says. "And in a sense, it is. Information technology is something that well-nigh no one except medical people do, then yous are kind of part of a order past having done it. Only that's not the reason we're doing it. It's to learn something that you lot're going to utilize all the time, and that, at least in our stance, you can't learn whatever other manner every bit finer. It just makes and then much more than of an touch on. Even if people did almost as well on written tests by reading a book and looking at a estimator, I don't think they'd exist as good doctors without this experience."

When Maryland's medical schools demand bodies, they call Ronn Wade, the manager of the Maryland Country Anatomy Lath besides as of the Anatomical Services Division at the Academy of Maryland School of Medicine. Wade grew upwardly in a family unit-owned funeral home, directs mortuary continuing instruction classes, is a licensed funeral managing director, co-directed a research project to replicate Egyptian mummification, and oversees the distribution of the state's bodies for medical inquiry. Over the past four decades, he has simplified donor forms, inverse and clarified laws, and publicized the option of body donation to people making finish-of-life arrangements. Today, Maryland leads the nation in card-conveying body donors. "Maryland is a fiddling fragmentary land," he says, "and for u.s. to have well-nigh 80,000 people walking around with donor cards, that's a lot." The number of bodies that come to the Anatomy Lath goes upwards ii to 3 percent each twelvemonth, he says. In fact, Maryland gets then many donors that the Anatomy Lath often helps other states that take supply-and-demand problems.

The lath gets its bodies in one of two ways: Either the person has filled out a short form willing his or her body to donation, or the deceased becomes a "donor by circumstance," every bit Wade calls it. In those cases, either the family unit could not be reached or they're unable to have custody of the body for financial or logistical reasons (they tin't beget a funeral, or the family lives out of state, for instance). After 72 hours, it legally becomes the responsibility of the lath, an entity within the Maryland Department of Health and Mental Hygiene, to have command of the body. "The issue is, I accept a person here who the paramedics could train on, that I have no pending claim on, that can help them learn to salve people's lives," Wade says. "Or, I can agree off on it and the trunk's going to slowly decay away." It becomes a public health result at that point, he says, so he opts to employ the bodies in the way that does the most proficient.

When a body is bound for the Anatomy Board, the procedure goes something like this: If the person is an organ, middle, or tissue donor, the local organ procurement arrangement takes annihilation that could exist used. Wade then gets a call and sends out a mortician to choice up the remains. Information technology's brought back to the Beefcake Board, housed in the basement of the University of Maryland Schoolhouse of Medicine, where Wade and his crew look over the torso to meet if there'south any evidence of HIV, hepatitis, tuberculosis, or other chancy infection. If the torso doesn't present any dangers, they decide how it can best be used. A body that is extremely heavy or alpine, for example, makes a poor cadaver because information technology will exist too cumbersome to motility or might not fit on the dissection table. If a trunk has been ravaged by cancer, its beefcake will have been so altered it won't be a skillful pedagogy tool for med students. Too, if information technology has had several organs removed for donation. Those bodies tin be used for other medical training—a plastic surgeon practicing a new technique or a paramedic learning to intubate—and tin can meet up to eight to 10 uses each.

Of the 2,500 bodies that came to the lath last twelvemonth, just 400 were suitable for use every bit a cadaver, according to Wade. Those bodies were embalmed and then distributed to medical schools including the Academy of Maryland; Johns Hopkins University; and the Uniformed Services University of the Health Sciences in Bethesda, Maryland. Mail-dissection, they are cremated, placed in neatly labeled black urns, and returned to Wade's office. If the family requested the ashes, they are returned. Otherwise, they go to the Beefcake Board's gravesite in Sykesville, Maryland, where a statewide memorial service is held each June. (Students at Johns Hopkins hold their ain private memorial service later the course ends as well.)

Sometimes, Wade gets calls from the family members later on. "People call. 'I just want to know what my mom was used for,'" he says. "So I'll look on the calendar schedule and I'll run into all the programs that are going on that she would accept been in. I'll say, 'Let'due south see. We had an orthopedic programme, nosotros had plastic surgery, at that place was emergency medicine and paramedics.' And it's very comforting." Sometimes, he says, he gets to tell them that their loved one finally made it to med school.

In fall 2015, a few of the start-year students planning a memorial service for the cadavers proposed a more permanent monument at Johns Hopkins for those whose bodies are donated. They formed a student group named Hum-An, brusque for Humanistic Anatomy, and are working with Schoolhouse of Medicine leadership to create a memorial garden next to the edifice that houses the beefcake lab.

"It occurred to us that information technology's a very transient experience," says Anna Goddu, Hum-An co-chair, as she stands in the proposed space for the public garden on the backyard west of the Armstrong Medical Education Building. "The whole thing is this intense seven weeks where you spend hours a twenty-four hour period with your cadaver, and so after 7 weeks, of a sudden they're but sort of gone. And the memorial service is a wonderful tribute, and I think an of import 1, but information technology'southward besides just a moment. There'south no existent sort of permanent mark of this experience that opened your medical educational activity, no recognition that over many years, there are generations of people who have contributed to our didactics in that mode."

Hum-An collaborated with the school to install an 18-human foot-wide labyrinth in the grass for walking and reflection. Two benches will seat a group of 5 or six, the typical size of each lab group. Wind chimes, a birdbath, and a plaque will go most an arbor. Hum-An members helped support this year's anatomy students, besides, filling them in on what to await, offering advice on how to become through the course, and passing on their memorial service plans. "This year, on the first solar day of Beefcake, as I was walking toward the edifice, I was like, There are 24 people in there," Goddu says. "Twenty-four actress people. I felt this extra presence in the building. In that location'due south this deep, deep sense of gratitude and amazement toward these people whose bodies were donated."

Midway through Anatomy, the students have started to trust their instincts more and divvy upward the twenty-four hour period's to-do list rather than watch nervously equally 1 person applies scalpel to pare. The cadaver lies face down on the table, the skin removed from his legs to reveal atrophied muscles. The bits of pare and fat that speckle the table don't seem to faze anyone.

The students aren't given any information about their cadaver, so, for now, they invent their ain. (They'll acquire his age and crusade of expiry on the last mean solar day.) "I similar to remember he was a family homo, that he really took care of his family and worked hard," says Famenini. "At that place's no basis of me saying that, only that'southward only the feeling I get from this person." As he peels away the skin on the human being's heel, which is now in stirrups, Famenini says, "We've been trying to think most what he did when he was alive. I'1000 thinking truck commuter." "Or Information technology—a desk job," counters Medikonda. They wonder what kind of sedentary lifestyle could accept been responsible for his poor muscle definition.

Wade says students become more intimate in some ways with their cadaver than his or her partner had been in life. They tin wait at a mailman'due south shoulder and see the wear and tear from carrying a heavy bag every day. They tin even tell if the person was correct- or left-handed. And yet, when students are aptitude over the table, six inches away from his leg, squeezing his nerves, veins, and arteries to attempt to differentiate each one, they're more concerned with anatomy than empathy. It takes seeing his mitt or, equally they learned, accidentally thumping his caput while turning him over on the table, to snap that idea back into their minds. In that location's a constant back-and-forth. Zoom in, zoom out. Man, teaching tool.

"It's important to recall that our cadaver was a living person at one time and had his own successes and failures and family and a personality and a life," Applebaum says. "That's very important to maintain when yous're working with your cadaver because you want to show respect for their remains and recognize that the donation is i of the nigh of import gifts they've ever given. You want to remember that it was a person and a patient. But when you're going through the autopsy and proceeding through the body, information technology just feels very compartmentalized. We're looking at the legs and item muscle structures without recognizing, 'Oh yep, this is the leg of a person.' You get into the mindset of only having to work. You take your list of muscles and arteries and structures that you need to find, and you're so hyperfocused on that. And then in that location's a glimpse of the face or something, and you but finish and pause for a minute and call up what you're doing and why you're doing it, and it just becomes so much more important in that moment."

Some question whether cadaver dissection makes sense anymore. As schools push to contain more than clinical experience earlier on, can't the same cognition exist gained from working with actual living patients? Isn't most 24-hour interval-to-solar day anatomy gleaned from medical imaging anyway? And with advances in engineering science, is dissection worth the time, money, and effort?

In 2004, the journal Anatomical Record invited kinesthesia members from four medical schools to nowadays their case. John C. McLachlan, and so a professor at the Peninsula Medical School in the Great britain, argued that "modern 3-D reconstruction and imaging methods give views of the internal structures … that can be superior to those observed during autopsy." He wrote that forgoing autopsy in favor of clinical experience allows students to first encounter patient death in a much more natural setting and is less likely to cause desensitization. Some other author, Kimberly S. Topp with the Department of Anatomy of the University of California, San Francisco, proposed prosection—professionally pre-dissected bodies—equally an alternative to basic classroom dissections.

Technology advances make a cadaver-free medical education more possible with each passing yr. In the 1990s, the National Library of Medicine's Visible Human Project created anatomical, iii-dimensional representations of a murderer from Texas and a housewife from Maryland past slicing, scanning, and photographing cantankerous sections of each trunk. In Korea and Cathay, more than contempo versions of the U.S. project give fifty-fifty more detailed, higher-resolution images. In 2015, a scientist from Tampa went on the TV prove Shark Tank to pitch to investors his $40,000 image of Syndaver, a constructed human cadaver that mimics real man tissues and organs in non just appearance but feel. And Silicon Valley startup Anatomage has created products including the Anatomage Table, a life-size visualization tool that uses the images from Korea, amidst other sources, on an iPad-like display. Kris Thomson, director of applications for the Anatomage Table, says the $70,000 product is a deal for smaller institutions, including community colleges and physical therapy or physician assistant programs. Instead of paying for a lab, ventilation system, prep fees, disposal fees, and and then on, the schools tin can purchase the product ane time and use it for years. For comparison, information technology cost $17,500 to operate the Johns Hopkins anatomy lab terminal yr alone. Anatomage'southward products are too helpful for students who, say, have an allergic reaction to the chemicals used in embalming.

"I do feel like the technology is improving more and more each year," Thomson says. "I know our visual quality is leaps and bounds amend than information technology was just a couple of years ago. I think more than and more than people are starting to recognize that and move away from merely the cadaveric studies." All the same, he says that while the Anatomage products, which also include a iii-D printed torso, can cover much of what students learn in conventional anatomy labs, there is nonetheless value to dissection. "Information technology's difficult to replace the feeling of beingness around an actual body, an actual person," he says. "Information technology would be very difficult to take a virtual platform of whatsoever sort supervene upon that feeling."

Ruff, who spends his mornings moving from tabular array to tabular array in the Johns Hopkins beefcake lab's offset bay, reiterates that there'southward something about the easily-on process of dissection—the sense of discovering each organ's location for oneself, of identifying abnormalities in your specific cadaver's trunk—that can't be replicated. Diagrams in books or in a digital simulation tin can requite you an thought of where things should be, but they're often idealized and oversimplified. The drawing might show the muscles or the bones or the cardiovascular organization, but rarely will you see all of the above on ane folio. And it's nigh impossible to get the level of detail (or messiness) that you'll come across in the flesh. They're helpful educational tools for reviewing systems after the fact. "But for really learning it and seeing it for the first time," he says, "information technology'southward like looking at a movie of someone hiking through the Thousand Coulee versus actually hiking through the Grand Canyon.

"You don't get that 3-dimensional feel. Yous don't become the texture, the variation, the reality of what bodies are similar, without the cadaver. And also, just the procedure of finding things … it's very concrete, very structural, geometric, spatial. Y'all but don't get an appreciation for that otherwise."

Toward the end of the course, the cadaver'south skin has been peeled from his face up; the meridian of his head, cleanly sawed off, sits on the table every bit a dish for his encephalon. 1 of the concluding things students will have to do this week is disarticulate the caput—chisel away at the spinal column to separate caput from neck.

They're tired. When the students exit the lab most days, they grab lunch, then study until effectually ten p.m., taking a brief intermission for dinner. They estimate that they spend thirty to 40 hours a week studying for this ane class. Fifty-fifty now, every bit they're fastening colored paper clips to marker the arteries in the neck, they're quizzing each other for the final exam. The number of mnemonic devices the students repeat is boundless; Tom, Dick, and Harry, for example, refers to the lodge of ankle tendons from anterior to posterior: tibialis posterior, flexor digitorum longus, flexor hallicus longus. Tom, Dick, and very nervous Harry takes it a pace further to include artery, vein, and nerve. Every one time in a while, someone goes to the whiteboard adjacent to the body to draw a nerve construction.

Famenini thinks dorsum to twenty-four hour period one, when they were told the cadaver would be their first patient. "And information technology became a cliché and flew over my head. How could a cadaver exist our showtime patient? I did feel that dichotomy of, How could going through someone'due south body in a very systematically violent way, kind of dismembering them, literally, how could that teach u.s. empathy and agreement of a patient? Withal, every bit I've gone through and gained a much better appreciation of the complexity—the internal planning of the human body—I've kind of seen how different things have to all piece of work together to work right, how things have to get wrong on the inside to requite a patient pain or discomfort, or how some problems that could be summarized in one clinical term, similar 'centre assail,' could have ramifications. Information technology'south definitely given me a deeper appreciation of the inner workings of the homo body and how they all work together to brand someone'due south life go on."

Subsequently the test, the students will get a couple of pieces of information. Age: 93. Crusade of expiry: vascular dementia and hypertension. They'll say goodbye to the lab and their cadaver. A few weeks later, they'll hold a memorial service, where they might sing songs or read poems. And and so they'll move on to the side by side course, and the next one. Merely as they learn almost the kidneys or the lungs or the heart, it'southward his they'll picture.

Jeanette Der Bedrosian is acquaintance editor of Johns Hopkins Mag.