Abstract
Introduction. Student-driven design of instructional tools within basic sciences curricula in general, and in anatomy in particular, has been shown to be both a positive educational experience for the student developers and a viable way to create quality materials for future courses. We present here a description of a student collaboration arising from participation in an advanced anatomy capstone research project, resulting in the creation of a new dissection protocol for the thoracolumbar junction dorsal primary rami and their branches. Materials and Methods. This project was initiated by two third-year doctor of physical therapy (DPT) students and involved participation from faculty and other DPT students of varying experience levels, in order to pilot and refine the tool over a two-year period. We describe the process by which the tool was developed, from the genesis of the original idea through the piloting stage. Results and Discussion. This collaboration resulted in a new instructional tool to be launched within our first-year DPT gross anatomy labs in 2022. Evaluation of the project through qualitative interviews demonstrated the learning impact on student participants. Conclusions. The success of this project shows the potential for students to be meaningfully involved in instructional tool design. The complete dissection guide, along with photos, is included and will be of particular relevance for medical and health science educators with an interest in orthopedics, neurosurgery, pain management, or physical therapy.
1. Introduction
Student-driven development of instructional tools in medical and allied health education has been increasingly recognized as a valuable way to both engage students in their learning and incorporate end-user perspectives into course design [1, 2]. One way to involve students in this process is through the creation of original instructional materials within the framework of advanced, elective, foundational sciences coursework [3]. Opportunities for advanced anatomy learning through electives or independent study have been shown to be an effective means of integrating anatomy into academic clinical content and as a way to prepare students for clinical experiences [4–6].
In this report, we describe the development of a dissection tool (Table 1) that arose from the work product of an advanced anatomy capstone research project within a Doctor of Physical Therapy (DPT) program. This tool describes two approaches to the dissection of the branches of the dorsal primary rami (DPR) of the spinal nerves. These are clinically relevant structures but are not commonly dissected in an introductory gross anatomy lab course.
The tool described herein was created through a unique collaboration involving four students and two faculty over a two-year period. The planning and execution of the initial dissection was done by two third-year DPT (DPT3) students and was followed by a piloting process of the original dissection guide by a third DPT3 student and completion of tool piloting by a first-year DPT (DPT1) student. Students worked independently with their cadavers to execute the dissection, with as-needed, hands-on faculty support available within the lab as they dissected. Student input was incorporated into the guide at every stage to increase the ultimate usability for our student end-users. Project evaluation entailed in-depth student interviews regarding their perceptions of the value of this process and their roles in the development of the tool (Table 2).
2. Materials and Methods
Authorization for the present research was received from the body donor program that provided our cadaver donors, and exemption from human subjects review was obtained from the Thomas Jefferson University Office of Human Research.
As part of a capstone research project, two DPT students were charged with performing a literature review and independent dissection on a topic of clinical relevance to them. The short-term goal was to create a research poster to use for peer-teaching within the department on their chosen topic. They selected Maigne’s syndrome, a segmental dysfunction of the facet joints at the thoracolumbar junction (TLJ), with secondary referred pain to the ipsilateral iliac crest and buttock regions [7–9]. A literature review on the syndrome, as well as on the anatomy of the DPR and possible dissection approaches, was then conducted during this first semester. The following semester, the students performed a dissection of the T12 and L1 DPR, with as-needed guidance from anatomy faculty, and using a dissection plan they devised themselves, due to a dearth of coverage of these structures in traditional anatomy dissectors. During the third semester, they created a research poster on the project based on their literature review and photos from the dissection. This was presented internally at our institution at an annual student poster day, as well as at the annual meeting of the American Association of Anatomists later that year.
Based on positive feedback from faculty and encouragement from attendees at the anatomy conference, the students were motivated to transform their DPR dissection instructions into a formal dissection guide appropriate for use by other DPT and medical students. In general, our anatomy courses are developed using an approach based on the Analyze, Design, Develop, Implement, and Evaluate (ADDIE) model of instructional design. This intuitive model commonly used in nursing and medical education instructional design [10–12]starts with a baseline student needs analysis, and culminates in a formal evaluation stage. Importantly, it also threads formative evaluation and reassessment into the design and development stages of both course content and instructional materials [10]. We thus found it to be a useful framework for the iterative process by which we planned to create, pilot, and revise the dissection tool.
With faculty guidance, the description of the students’ dissection methods was expanded and adapted into the dissection guide format used by core anatomy faculty within our academic department. This initial guide was piloted with a third DPT3 student who had completed advanced anatomy coursework within the department and worked as a teaching assistant in the DPT1 anatomy lab course. As-needed assistance from the supervising anatomy instructor was provided during this dissection, which took four hours to complete. This student and instructor then revised the dissection guide for clarity and to make it more user-friendly and to allow for completion of the dissection with less faculty involvement. At this time, the dissection instructions were broken down into a basic and an advanced dissection based on available time and the abilities of the dissector. At the end of the third semester, further piloting of the revised guide was conducted with a DPT1 student who had completed the introductory gross anatomy course and who had advanced dissection skills gained through her work as a graduate assistant with anatomy faculty. She was able to perform the basic dissection in two hours, and additional revisions and refinement of the dissection checklist were made based on her feedback, with photos from her dissection added to the final dissection guide.
In the fourth semester, a separate inquiry was conducted by a second faculty member with extensive experience as a qualitative researcher, in order to explore student perceptions about their roles in, and the value of, the project. Three of the four involved students were available to participate in this process and were interviewed separately.
3. Results
3.1. Dorsal Primary Rami Dissection
Instructions for completion of the dissection are provided in Table 1, with explanatory photos of key steps and structures contained in Figures 1–5. The advanced dissection includes branches of the T12 and L1 DPR and can be performed by upper level medical or health sciences students or by highly motivated and skilled first-year students working under the supervision of anatomy faculty. It involves demonstration of the medial and lateral branches in their entirety up to and including the superior cluneal nerves (SCN), the mamillo-accessory ligament (MAL), and the branches to multifidus (MF) and the facet joint. This advanced dissection can take up to 4 hours even when performed by a skilled anatomist. A less complete, basic dissection, will expose most of the pathways of the medial and lateral branches, without preserving the SCNs or the MAL, and can be accomplished by a novice in less than 4 hours.
3.2. Qualitative Evaluation of Student Roles in Project
A detailed summary of the themes that emerged from our evaluation is contained in Table 2. During the interview process, it became clear that the experiences of the three students were widely divergent and separated both in time and by the different tasks and responsibilities they assumed or had been assigned. Three distinct student roles were thus identified: the originator, the reviser, and the end-user. Within the context of these different roles, four common themes emerged from the three interviews as follows: (1) the dissection itself was challenging; (2) both the dissection and the process of developing the tool had educational value; (3) the dissection itself was clinically relevant; and (4) participation in the process was both demanding and personally satisfying.
4. Discussion
The project described here combines a number of desired goals in anatomy teaching: student involvement in anatomy-related research; use of dissection for peer-to-peer teaching; and the application of anatomy knowledge to real world clinical scenarios. This multiyear project resulted in a lasting instructional tool, namely, a dissection guide for a clinically relevant dissection that had not been seen previously in the literature.
Anatomy dissectors routinely make only cursory reference to the DPR, and the existence of the branches of the DPR is all but ignored [13–16]. This is in spite of the fact that they are relevant to certain types of back and neck pain, including pain arising from facet joint arthropathy [17–19] and Maigne’s syndrome [8, 20]. The DPR’s potential clinical relevance is further demonstrated when one considers the role of the multifidus (MF) muscle in the etiology of low back pain (LBP). This deep stabilizer of the spine is innervated segmentally by the medial branches of the DPR and has been shown in a number of studies to atrophy in the presence of nonspecific LBP [21–23]. Furthermore, iatrogenic injury to the medial branches of the lumbar DPR during spinal surgeries [24, 25], causing denervation of the MF muscle, will also lead to MF atrophy and has been identified in failed back surgery syndrome [26]. A deeper understanding of the anatomy of the DPR and their branches is relevant to both medical and health sciences students. Spinal surgeons, pain management physicians, and anesthesiologists are particularly in need of a deeper understanding of the detailed anatomy of this structure in order to safely perform surgeries, corticosteroid injections, and radiofrequency ablations. Physical therapists also need to be familiar with the anatomy of the DPR in order to recognize potential underlying etiologies related to these nerve lesions in their patients with LBP, and to develop evidence-based treatments.
Based on the feedback we received during follow-up interviews with the students involved in the project, it is clear that they found it worthy and felt that they personally benefitted from their participation. In particular, they believed that the process was challenging and had educational value, and that the dissection was clinically relevant. They also felt excited about their role in the project and expressed an appreciation for the value of dissection in the learning process. They did, however, feel that, due to the complexity of the dissection and the advanced skills required to expose delicate structures without damaging them, this dissection may not be appropriate for all first-year students.
The ADDIE model was a useful framework to guide the creation of our dissection guide. In particular, the ongoing revision of materials based on student feedback and experiences, which are a hallmark of the ADDIE approach [27], led us to pilot and refine the tool with DPT students of different skill levels. The detailed descriptions of the varying roles of our student collaborators contained in Table 2 highlight how the involvement of each student was built on the work of their peer(s) to achieve a cohesive final end product. ADDIE also supports a type of curation of instructional design that targets different student expertise levels, which guided our team to create two forms of the dissection: the basic and the advanced.
The dissection guide created as a part of this project is unique when compared to existing anatomy instructional materials. Firstly, it covers an area of gross anatomy dissection largely absent in existing resources such as Grant’s Dissector [14]. Secondly, it provides two tiers of instructions to meet the needs of the differing ability levels of the students who might be working with the tool. Finally, the instructions within the tool were developed and refined using feedback from our target audience of anatomy students to ensure that they were student-centered, appropriate, and user-friendly.
5. Limitations
The time required to develop the tool and pilot it over multiple semesters mandated that the involved students be highly motivated and committed to seeing the project through to a completion extending well beyond their graduation date. Additionally, the temporary move to virtual anatomy instruction in 2020 due to the Covid-19 pandemic prevented piloting of this tool with a large cohort of first-year DPT students. Future refinements of the tool are planned, including introducing it as a voluntary dissection in the gross anatomy lab for DPT1 students at our institution matriculating in the summer of 2022.
6. Conclusions
Student engagement in the development of instructional tools, such as this dissection guide, is feasible and appropriate, and the process can be rewarding for the involved students. A clinically relevant product can be created that is both useful and that fills a gap in available course materials. Ongoing, periodic reassessment of the tool can ensure that it continues to meet the changing needs of students enrolled in both health sciences and medical school anatomy courses.
Data Availability
The data are available through application to the corresponding author.
Disclosure
Authorization for the present research was received from the body donor program that provided our cadaver donors, and exemption from human subjects review was obtained from the Thomas Jefferson University Office of Human Research. No funding was received for this research.
Conflicts of Interest
The authors declare that they have no conflicts of interest.