AND Martin Schlaud

Reinhard Pabst

Thomas Tschernig

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EDUCATION NOTE
Emotional Reactions of Medical Students to
Dissecting Human Bodies: A Conceptual
Approach and Its Evaluation
THOMAS TSCHERNIG,* MARTIN SCHLAUD, AND REINHARD PABST
In recent years, the medical curric-ulum has been changed in manyinstitutions worldwide. New con-
cepts such as problem-based or evi-
dence-based learning have conse-
quences for teaching anatomy (Drake,
1998). Various papers have been pub-
lished, for example, on the effects of
self-directed learning on teaching
anatomy (Peplow, 1990), small group
case-based learning programs (Han-
sen and Krackov, 1994; Peplow,
1992), multiple choice testing in anat-
omy (Nnodim, 1992), or using com-
puterized representations of anatomy
(Rosse, 1995; Walsh and Bohn, 1990).
Dissection has also been compared
with prosection (Nnodim, 1990). In
other articles, the hours available for
teaching anatomy have been com-
pared between medical schools in
Great Britain, and aspects of teacher
training for anatomists have been dis-
cussed (Fitzgerald, 1992).
One aspect, however, has seldom
been discussed (Putz, 1999) and has
rarely been the subject of scientific
interest. How do we prepare our
young medical students to touch and
dissect a human body? Irrespective
of whether it is the classical dissec-
tion course or problem-based learn-
ing using prosected material, it will
probably be the first time that stu-
dents will come into close contact
with a dead body and thus be con-
fronted with issues of dying and
death. Articles on this topic have
been published in journals but not
often read by anatomists (Bertman
and Marks, 1985; Horne et al., 1990).
In our experience, the vast majority
of first year medical students have
seldom had contact with dying rela-
tives or friends, nor have they actu-
ally seen a dead person.
About 15 years ago, Lippert (1985)
asked the provocative question: How
humane is human anatomy and to
what extent will the behavior of a
medical student during dissection
influence his/her future attitude to
patients? The corpse has no name
for the student and need not be
asked for permission before major
organs are cut. Is the corpse, there-
fore, not more like a guinea pig than
a person with individual character-
istics? Babad and Kedar (1999) enti-
tled their contribution to a recent
congress “How to remain sensitive
without becoming vulnerable: Medi-
cal students coping with reactions to
dissection.”
The two aims of this short article
were to describe our concept to in-
tegrate the topic of death and dying
into the curriculum of gross anat-
omy and to present the results of a
questionnaire on this topic distrib-
uted to students at the end of their
first semester.
INTEGRATED CURRICULUM OF
TEACHING GROSS ANATOMY
Annually, the Medical School of Han-
nover enrolls approximately 350 first
year medical students. In contrast to
nearly all other faculties in Germany,
gross anatomy starts immediately at
the beginning of the first semester
with a unique concept. A topic is dealt
with in lectures in one week, followed
by dissecting this region the next week
and a seminar in living anatomy deal-
ing with the same area, whereby the
students identify the structures on
each other partly using ultrasound
equipment. In parallel, clinicians
present patients twice a week with dis-
eases of the part of the body just
learned. This basic concept has been
described before (Pabst et al., 1986).
In the very first week the topics of
dying, death, and postmortem signs
are dealt with in the lecture hall and
an embalmed body is demonstrated at
the end of this lecture. The following
week, students go to the dissecting
room to see and palpate the corpse
(four to five students per corpse). Af-
ter one hour, groups of about 20 stu-
dents meet with an anatomist in a
seminar room, where they talk about
expectations and fears with respect
to dissecting a human being. The
students are stimulated to talk about
their emotions within their group
and not suppress them throughout
the course.
The anatomist plays a
critical role in initiating a
balanced attitude to
death and dying in
trainee medical doctors
Drs. Tschernig and Pabst are on the fac-
ulty of the Department of Functional and
Applied Anatomy at the Medical School
of Hannover in Hannover, Germany. Dr.
Schlaud is with the Department of Epi-
demiology and Social Medicine at the
Medical School of Hannover.
*Correspondence to: Dr. Thomas
Tschernig, Centre of Anatomy 4120,
Medical School of Hannover, 30623
Hannover, Germany. Fax: 49-511-532-
2948; E-mail: tschernig.thomas@mh-
hannover.de
THE ANATOMICAL RECORD (NEW ANAT.) 261:11–13, 2000
© 2000 Wiley-Liss, Inc.
QUESTIONNAIRE AT THE END OF
THE FIRST TERM
An anonymous questionnaire was dis-
tributed to the students after the first
half of the dissection course (after
four months). Several questions were
asked about coping with the initial
contact and dissecting a human body.
Differences were calculated between
male and female students and differ-
ent age groups: up to 21 years (imme-
diately after leaving school) vs. over
22 years (mainly students who en-
tered medical school after some other
vocational training, e.g., nurses). A
further question dealt with the behav-
ior of fellow students and another
asked whether they would have been
interested in talking about problems
of death and dying during the semes-
ter.
The response rate was 97%; 52% of
which were female students. There
were no significant differences be-
tween female and male students or
between “younger” and “older” stu-
dents. In Table 1 the main results are
shown. For the vast majority of stu-
dents, step-by-step contact with the
dead body and the discussion in sem-
inar groups that followed, was posi-
tive. The answers given on the behav-
ior of fellow students were surprising;
during the course we often discussed
the topic, but heard no complaints. In
the anonymous survey, however,
roughly every fourth student was an-
noyed at times by the behavior or at-
titude of other students. Table 2 illus-
trates whether the topic of death and
dying should have been dealt with
more often. About 40% were inter-
ested and 11% were not sure. Answers
varied greatly about the need to talk
and with whom.
ETHICAL AND MORAL
DEVELOPMENT OF MEDICAL
STUDENTS IS INFLUENCED BY
ANATOMISTS
In the discussion of modern medical
curricula, several theories have been
put forward. However, not many sci-
entifically based “outcome studies”
are available. In questionnaires dis-
tributed to students during their final
year working on the wards (Pabst,
1993), at the end of their curriculum
(Pabst and Rothkötter, 1996), or to
doctors at the end of their residency
time in hospitals (Pabst and Rothköt-
ter, 1997), gross anatomy was always
ranked among the most clinically rel-
evant parts of the undergraduate cur-
riculum. In studies on ethical environ-
ment and personal development
(Feudtner et al., 1994), medical ethics
(Feudtner et al., 1994; Hojat et al.,
1995), and the moral development of
medical students (Self et al., 1993),
such aspects were found to have a fun-
damental impact on medical students.
In our system, the seminars follow-
ing the initial encounter with the
corpse seemed to be an important op-
portunity for medical students to
share feelings and fears. By talking it
over, means of coping could be shared
among students. Horne et al. (1990)
reported that those students who had
had the prior experience of a dead
human body wanted more contact
with anatomy department staff to dis-
cuss emotional aspects of human dis-
section.
Anatomists are often the first teach-
ers in the curriculum who need to be
aware of ethical problems (Bertman
and Marks, 1985; Horne et al., 1990;
Putz, 1999). More attention should be
paid to the first encounter with
corpses, and students should be of-
fered the opportunity to discuss their
emotions. Many students mentioned
they could not talk about these prob-
TABLE 2. Interest in repeated discussion of death and dying
Would you prefer to speak about death and related topics repeatedly during the
course?
No Yes Unsure
50% 39% 11%
With whom would you prefer to speak about death and related topics? (% of all students; multiple answers
possible)
Student tutor Anatomist Clinician Clergy Other
15% 10% 23% 10% 5%
TABLE 1. The main results of the questionnaire
Was it helpful to attend a demonstration of the corpse in the lecture hall?
Helpful No positive effects Negative
72% 27% 1%
Was it helpful to attend a seminar after the first encounter with the corpse in the dissection hall?
Helpful No positive effects Stressful
67% 32% 1%
Is the attitude to, and treatment of, the corpse by other students correct?
Correct Varies Incorrect
75% 23% 2%
12 THE ANATOMICAL RECORD (NEW ANAT.) EDUCATION NOTE
lems with family or even closest
friends, who tend to find such topics
embarrassing. Anatomists should not
only teach young medical students the
structure and function of organs, but
also provide a role model for how fu-
ture doctors will deal with their pa-
tients.
As a consequence of this study, we
approached a Protestant and a Catho-
lic member of the clergy. They are
eager to integrate the problems of
death, dying, and the dissection
course in a devotion for the student
parish and are also available if stu-
dents wish to speak to them on these
topics. Furthermore, at the beginning
of the autumn term a colleague from
the department of transplantation
surgery was invited to give a talk on
determining brain death, organ trans-
plantation, and the decision to be-
come an organ donor, which was fol-
lowed by a discussion.
CONCLUSIONS
Despite curriculum changes, the un-
dergraduate medical student’s first en-
counter with a human corpse will still
be in anatomy. Our questionnaire
documented the need to prepare stu-
dents for the psychological and phys-
ical reactions they may experience
during the dissection course. The con-
cept of introducing the students step
by step to this situation was graded
“very helpful” by the majority of stu-
dents for coping with dissecting a hu-
man body. About 40% expressed a de-
sire for repeated discussion with
student tutors, anatomists, clinicians,
or clergy. Alternative approaches to
discussing these topics should be of-
fered. Emotional issues during hu-
man dissection should not be ne-
glected, but addressed repeatedly. The
anatomist plays a critical role in initi-
ating a balanced attitude to death and
dying in trainee medical doctors.
ACKNOWLEDGMENTS
We thank M. Peter for preparing the
tables and S. Fryk for secretarial help
and correction of the English text.
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EDUCATION NOTE THE ANATOMICAL RECORD (NEW ANAT.) 13


Emotional reactions of medical students to dissecting human bodies: A conceptual approach and its evaluation

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Emotional reactions of medical students to dissecting human bodies: A conceptual approach and its evaluation

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