Bridges are waiting to be built: Delivering point‐of‐care anatomy for everyday practice

The traditional role of an anatomist in medical education is to design the learning environment for medical students. To accomplish this anatomists transform their laboratories into a setting where students acquire fundamental anatomical knowledge and nontraditional discipline-independent skills necessary for future training (Gregory et al., 2009; Evans and Pawlina, 2015). However, over the last three decades, the time allocated to anatomical sciences education has been progressively reduced in curricula worldwide in an effort to change to a more integrated/student centered educational approach (Drake et al., 2009, 2014). At the same time, the anatomical science knowledge base has not shrunk and students are still expected to master this information in less time. Amazingly, evidence shows that medical students still grasp and retain core principles of anatomy knowledge in medical school despite these challenges (McBride and Drake, 2016). Anatomy educators know what is at stake if these challenges become too great. Retention of anatomic knowledge is critical for clinical practice. In the surgical and radiological specialties, anatomical information may influence efficiency and effectiveness of targeted clinical outcomes. When we teach not only the information to be learned but the applicability, transportability, and relevance of that very information to clinical practice, we promote its retention and retrieval in “real life” (Pawlina and Drake, 2016; Pawlina and Lachman, 2017). After this year's American Association of Anatomists meeting in Chicago, we exchanged emails with one of our colleagues from Canada. He was shocked at the high number of deaths attributed to medical errors in the United States. From a presentation at the annual meeting, he had learned that estimates of annual deaths from medical errors in the United States are on the rise. In 1999, the Institute of Medicine reported that approximately 44,000–98,000 deaths each year could be attributed to medical errors (Kohn et al., 1999). Five years later, a report from the Agency for Healthcare Quality and Research Patient Safety Indicators in the Medicare population estimated the number of deaths attributable to medical errors to be 195,000 (HG, 2004). James (2013) using a weighted analysis provided an incidence range of 210,000–400,000 deaths a year associated with medical errors among hospital patients. In 2016, an article in the British Medical Journal reported the mean calculated death rate from medical errors to be around 251,000 per year (Makary and Daniel, 2016). These authors concluded that medical error is the third leading cause of death in the United States. Our colleague was concerned that the steady increase in medical errors might be related to the curricular revisions taking place in medical schools over the last 30 years. A terrifying hypothesis! He was even more troubled by this phenomenon which seemed to be worsening in spite of the fact that we now have academicians whose entire careers are concerned with “improving” medical education. Thus, should the question at the forefront of our collective professional conscience be: Why have curricular changes in medical schools not reduced the number of deaths linked to medical errors? There are several reports suggesting a link between a student's anatomy knowledge and the quality of their future medical practice (Ellis, 2002; Hanna and Tang, 2005; Ahmed et al., 2010). There is also literature to suggest that if anatomy is not adequately taught then a students’ anatomy knowledge may be below the minimum standard of what is considered necessary for safe medical practice (Waterston and Stewart, 2005). But these articles are largely conjecture and we can find no solid evidence that medical errors are linked directly to anatomy education. And yet some suspect a connection, and when discussing the state of healthcare, which appears to be growing less safe by the decade, we feel responsible in a way to reflect on how our influence on students might at the very least make them more aware of what is at stake when they gather around the bodies in our laboratory to learn. This is not learning for learning's sake or to pass the exam—this knowledge is meant to protect the safety of future patients. As we have said, the question that we should be asking is what can we as anatomy educators contribute to improving the quality of health care and patient safety? Also, what is the best way to deliver anatomical knowledge to improve the practical skills of health care providers so as to make an impact on these two factors? We want our students to see their limitations—their knowledge and skill deficit early in training—as a gap they must continuously work to build a bridge across—so that on graduation, they and all the stakeholders who will benefit, patients at all, may ferry safely to the other side. As our graduates enter clinical training and continue into clinical practice, they will need to periodically refresh their anatomical knowledge to improve their skills or when they are faced with challenging procedures or difficult cases. While learning resources are widely accessible on the Internet, in a busy practice, finding the time to search for this information is often challenging and impractical. We believe there is a gap here we as anatomists can and should fill. In general, anatomists, are rarely involved in the direct training of practicing physicians, and only a few of us regularly participate in the Maintenance of Certification or Continuing Medical Education courses in our teaching institutions. Ideally, anatomists should be more actively involved in the point-of-care delivery of targeted anatomical information to physicians who need it in real time—in the clinics, on the wards, in the operating rooms, and in radiology reading rooms. We believe this could be accomplished via a variety of potential encounters (face-to-face, electronic, and virtual) to complement practicing physicians’ specific procedural skills and to improve their surgical/clinical confidence. There are several examples of point-of-care anatomical knowledge delivery recently created by teams of anatomists and clinicians. We are aware of a community of dermatologic surgeons and procedural dermatologists who use such a model. Their process started from a needs assessment, which identified gaps in anatomical core knowledge conducted through the membership of two professional dermatology societies: the American College of Mohs Surgery and the American Society for Dermatologic Surgery. They developed objectives designed to provide highly specific snippets of anatomical knowledge to improve micrographic surgeons’ confidence in the performance of Mohs procedures. Together, anatomists and surgeons used a collaborative team approach to select clinical cases with anatomic teaching points (i.e., danger zones, safe zones, and functional impairments). In preparing for this project, an anatomist conducted a detailed clinical literature review surveying existing resources and identifying areas where anatomical knowledge relevant to those performing Mohs procedures could be augmented and clarified. A simulation was designed for dermatologists to perform dissections of fresh frozen cadaveric models focusing on identified cosmetic subunits of the face, specifically in the anterior and posterior triangles of the neck, also in the superficial anatomy of the upper limb with emphasis on the nail unit. These dissections were videotaped in real time and were edited into clips of layer-by-layer dissections of cadaveric regions to emphasize learning points relevant to real clinical cases. Various possible patient defects were recreated on the cadaver to mimic challenging anatomy and the dissection of these difficult cases were made into short video sequences to address specific concerns related to Mohs' resections and repairs. Both dermatology societies allocated time within their annual meeting to feature these anatomy-based sessions (Lachman and Russell, 2017). The presentations were co-delivered by an anatomist and a clinician as a case-based discussion of anatomical concepts relevant to dermatologic surgeons. Short video segments were used to explain anatomical relationships and highlight important structures potentially in danger of injury in the surgical field. This material is now available to all members of the organizations via webinar (ACMS, 2017). Evolving a system for point-of-care delivery of anatomical information relevant to professionals who most need it is crucial for continuing medical education initiatives in the basic sciences. Perhaps, while the role of the anatomist as educator of medical students is diminishing, a change which seems inevitable, the role of the anatomist as continuing educator of the practicing health care provider has room to expand. Perhaps this is the best way to address the gap in quality of education and quality of medical care delivered. In the era of authentic learning, the onus for creating educational point-of-care content that improves patient care is on the anatomist. There are so many bridges waiting to be built. Wojciech Pawlina, M.D.* Department of Anatomy Mayo Clinic College of Medicine and Science Mayo Clinic Rochester, Minnesota Richard L. Drake, Ph.D.* Cleveland Clinic Lerner College of Medicine of Case Western Reserve University Cleveland Clinic Cleveland, Ohio

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