Dr. Kennedy is professor in the Department of Psychiatry and Behavioral Sciences at Albert Einstein College of Medicine, and director of the Division of Geriatric Psychiatry at Montefiore Medical Center in the Bronx, New York. Dr. Olson is professor in the Department of Anatomy and Structural Biology at Albert Einstein College of Medicine.
Disclosure: Dr. Kennedy is a consultant to Myriad; is on the speaker’s bureaus of Forest and Pfizer; and has received grant support from Forest, Myriad, Novartis, Pfizer, and Takeda. Dr. Olson reports no affiliation with or financial interest in any organization that may pose a conflict of interest.
Please direct all correspondence to: Gary J. Kennedy, MD, Director, Department of Geriatric Psychiatry, MMC, 111 East 210th St, Klau One, Bronx, NY 10467; Tel: 718-920-4236; Fax: 718-920-6538; E-mail: firstname.lastname@example.org.
Numerous medical schools in the United States and abroad have determined that anatomy taught through cadaver dissection is untenable. Concerns for cost effectiveness, educational efficacy, the shortage of trained anatomist teachers, the increasing demand for cadavers, and pressure to convert dissection rooms to research laboratories, all argue for minimizing or eliminating cadaver dissection. However, arguments against dissection tend to ignore the emotional growth students experience in the process. Cadaver dissection prepares them for one of the core dilemmas of patient care, namely, the need to be personally engaged yet clinically detached. This dilemma, traditionally encountered with the first incision in the dissection lab, will persist throughout professional life, and it must be addressed in order to provide humanistic care with scientific objectivity. What follows is one perspective on how to shape students’ self-awareness in the first weeks of dissection. The premise is simply that examination of the cadaver provides the student a unique opportunity to examine the self.
From its origins, human dissection has been an emotionally charged topic.1 Although the morality of dissection for the advancement of medical science is widely accepted,2 the emotional impact on medical students is often ignored.3-5 Failure to provide an avenue for students to discuss their feelings misses a unique opportunity to explore the emotional relationship they will experience with subsequent patients. In addition, it misses a rare educational moment when a confluence of events provokes an openness and vulnerability in which students can reflect and grow. The Albert Einstein College of Medicine in New York City has developed several approaches within the Clinical and Developmental Anatomy Course to facilitate discussions of first-year student reactions to the dissection of a human cadaver. The stated goals for the course focus on a patient-centered approach to learning the basic human anatomy needed to prepare the student for preclinical course work as well clinical experience. Within the course are several opportunities to enhance the students’ capacity for empathy with subsequent patients by addressing empathically their reactions to their cadaver.
For the students’ initial encounter, “Introduction to the Cadaver,” they are asked to perform a physical examination of the body focused on surface anatomy under the supervision of non-anatomist clinical faculty. Students work in teams with one cadaver assigned to a table of four students. For this exercise, the nude cadaver is presented to the students face up, covered by a single shroud. Bed sores and entry wounds for tubes, infusions, and other evidence of invasive procedures are all clearly visible. After the introductory session, the team is required to write an essay describing their findings and speculating on the cause of death and quality of care at the end of life. Next, faculty facilitators not responsible for grading the students meet for 90 minutes with eight students during the second week of dissection for the “Cadaver Conference.” By the time of the conference the student teams will have dissected the back, and begun to work on the chest and most of the chest and thoracic viscera. During the conference, students are encouraged to speak freely of thoughts and feelings that have emerged during dissection. Finally, a memorial service acknowledging the gratitude students owe those who have donated their bodies for dissection is held at the end of the course. Memorial events such as the one held at the Albert Einstein College of Medicine are almost universal practice at medical schools across the US. The other course activities are not. The following describes how the Cadaver Conference facilitates student discussion of their sensory impressions as a prelude to the disclosure of deeper feelings.
The volume of information as well as the pace at which it must be acquired leave the first-year student little time for reflection. As a result, asking students directly to reflect upon their reactions may evoke superficially protective responses. The session begins with brief introductions all around as an ice breaker followed by a purposefully vague description of the goal for the next 90 minutes. Students are reminded that the cadaver is their first patient6 and that the vivid initial impressions can be useful for subsequent encounters provided they have the opportunity for discussion. In some groups a student will seize the leadership with a deeply felt reaction which will propel all the students into the desired openness. More often the students are not prepared for the intensity of their reactions much less the invitation to share them with peers. It is then generally more productive to start with the least intimate perceptions before proceeding to more threatening fears and feelings. At critical junctures the clinical relevance of their reactions is highlighted.
The first perception the students will have of the cadaver is visual. As a result, the facilitator begins by asking, “Who among you have seen or touched a dead body before the anatomy course?” Most students have done neither. However, they have performed a physical examination of the cadaver so that the next question focuses on their first glimpse of the body which the facilitator will call “the person” thereafter. The students are asked to describe what they saw, more specifically, “What was the gender, age, race, and condition of the body?” Students are asked if they have seen the hands, face, or genitals, each a more intimate part of the anatomy. These questions give permission for the students to voice their natural curiosity despite initial reservations. Some describe the appearance as “unreal or not human” or note that surgical scars, entry wounds for embalming fluids, bed sores, or compression of soft tissues due to positioning have distorted the anatomy. They are also asked again to speculate on the cause of death and state of the person’s care at the end of life. They are asked to determine whether the nails are manicured, the scalp hair is recently cut or dyed, or the appearance of the hands offers clues to the person’s work or self-care. In one instance, the person’s finger nails had been manicured shortly before death but the toenails “were in terrible shape.” In another, the boundary between dyed and natural hair color was nearly an inch. The hands of one of the bodies were heavily calloused prompting one student to say, “He must have worked hard right up to the end.” These observations allowed students to project themselves into the person’s immediate history to promote identification and lessen the interpersonal distance. Students are also asked how they left the body at the end of the initial dissection. In the initial stages of dissection with the body relatively intact, students are more meticulous in repositioning the cadaver’s anatomy prior to covering it with a shroud. When asked why, students generally respond it is simply matter of respect. This provides the clinically relevant observation that no matter what condition of the patient, living or dead, likable or not, admirable or not, the physician’s stance must always be one of respect. Starting with these more passive observations sets the stage for their responses to actual dissection.
The facilitator’s next line of inquiry starts with, “At your table, who made the first incision? Why were you chosen to be the first?” Students who have already identified themselves as future surgeons often initiate the dissection. However, on occasion a student will take the scalpel to overcome self doubt or embarrassment, saying that is easier to do it than to watch. The student who made the first cut is asked to describe the experience. “Was the flesh tough or difficult to incise? Was the force needed to retract the skin from the back greater or lesser than expected? Was a finger-sized stab wound opened to provide a better grip on the skin for retraction to reveal the anatomy below the surface?” Most students find the dissection of the back physically arduous. One mentioned, “When I first started it was really slow and I did not want to mess it up, but the instructor said I had to move along and not be so cautious. Then I got really into it; it was like I was just hacking away to get down to the spine. It was a little creepy.” Another student mentioned, “I was [dissecting] okay until I reached the scalp. It actually gave me a chill when I cut into the hair line.” Here the student is touching on the dread of inflicting harm, but also the latent sadism that doing so may be a source of delight. Yet, physicians are expected to enjoy their work and be proficient even if it means causing pain or disfigurement in order to prevent agony or death. Students are warned that no patient wants a surgeon who lacks confidence, is tentative, or is squeamish about making an incision.
Students are then reminded that this same push and pull, take action but do no harm, will recur throughout their professional lives. Sharing a dreaded diagnosis such as cancer, dementia, or terminal illness invariably distresses the patient and is unpleasant for the physician. But doing so in a skillful manner provides the patient and family a platform both to grieve and to act. To be an ongoing source of stability for patient and family unsettled by their realization of mortality is one of the more satisfying moments in medicine. Further, a seasoned, empathic physician can provide the leadership needed by the other members of the healthcare team as well. Confronting death in the person of a cadaver is the student’s first professional encounter with death and dying.7-9 The goal of the discussion, then, is to help students become aware of their own fears of death as well as fears of the inevitable errors in technique or judgment which they will commit.
Olfactory and Gustatory Dimensions of Dissection
The facilitator should ensure that no one in the group remains silent. Smell is a particularly effective sensation with which to elicit participation. Invariably, the students become animated when discussing smell. Most often the smell of the preservative receives the most discussion. When asked, “How did you manage to work on the person despite the smell?” most students, especially those who were first to make an incision, describe becoming habituated as concentration to the task at hand absorbs their attention. Others express an abiding revulsion which is present at the start of every class. However, asking how the odor is managed after class brings a wider range of responses. Some students retreat to their apartments, which are across the street from the anatomy room, to bathe and shampoo immediately after the dissection. For others, discarding their apron and washing their hands is sufficient. Some will admit to remembering the smell even when they know their clothing as well as their person has been thoroughly cleansed. Some will wear the same apparel to every dissection to contain fears of contamination. Asking questions about smell inevitably leads to a discussion of how dissection has affected appetite. Some leave class ravenous after the manual effort and prolonged standing at the dissection table. Others experience a temporary loss of appetite or forgo the consumption of meat.
Added to the sight, smell, and feel of the cadaver is the sound associated with the procedures to free up bony parts of the anatomy using a Striker saw. A laminectomy performed during the early dissection assignments to view the spinal cord can provoke a noticeable reaction. One student was surprised by the amount of effort required to cut through the lamina. But the snap heard as the lamina was successfully sectioned was startling. The event made the student pause. “That was the first time it really got to me,” reflected the student. Thus, inquiring about the sound of the procedure also provides an opportunity to uncover complex feelings. The pause of self awareness is something to nurture rather than avoid.
Disavowals and Emotional Blunting
When shared among table mates, the sensory perception and emotional experiences promote openness and acceptance. However, equally important are expressions to the contrary by students who disavow strong feelings. There will be some who legitimately question the value of dissection to their individual careers. Even for them, hearing fellow students discuss the intense reactions can be enlightening. On rare occasions, students will deny strong reactions or even any reaction despite the facilitator’s questions. At times, students will form protective pairs to keep the discussion superficial by rationalizing emotional reactions as limited to the group setting and thereby artificial. This may well keep threatening feelings out of awareness, but is precisely what the conference is meant to prevent. Rather than allowing blunting to be a group norm, it may be helpful for the facilitator to express disappointment or surprise that what is usually an intense experience has eluded them. This normalizes the expression of feelings and allows the remaining students to continue the discussion uninhibited.
Shame and Authority
In contrast, some groups will dwell on difficult emotions as though they were mourning the loss of innocence rather than exploring a professionally important phenomenon. One student found herself in tears in her apartment after the first dissection, saying, “How could we do this? This could have been someone’s mom. I know we need to learn but it just does not feel right.” Indeed, the legitimacy of dissection has been questioned both before and after the 1832 Anatomy Act which allowed English hospitals to receive unclaimed dead bodies for dissection.1 At the Albert Einstein College of Medicine, many of the cadavers are provided by donors who have bequeathed their bodies for medical education. However, an equal and often greater number are donated annually by the decedent’s family members or estate executor. Thus, most cadavers used at the college of medicine are obtained without the informed consent of the living individual. This is most often the case for cadaveric organ donation as well. Nonetheless, this lack of prior permission is distressing for students already unsure of their “right” to dissect.
As a result, some students will continue to minimize contact with the body. The question, “Has everyone had a chance to make an incision?” helps students, such as the one mentioned above, to disclose their reasons. A more provocative question is, “How do you justify the mutilation of this person?” Here, the clinically relevant point is that dissection is a privilege performed so that others, not just the students, may benefit. It is a reminder that the moral authority of their profession is based on beneficence.
Alternatively, for groups stuck in their own mourning, it may be helpful to reflect, “Yes, these are inconvenient feelings, but was there nothing about the dissection that you enjoyed? Did not anybody have fun?” This often serves to uncover the students’ pride in newly acquired skills or an appreciation for the feel of anatomy that was absent from texts or Websites. Students will also mention the fascination of discovery. It also reminds students that cadaver dissection is only one among many of the challenges they will embrace to become effective, mature physicians. Mastering the work of dissection will facilitate mastery of the emotional work involved in patient care—both the successes and failures.
Humor can create a protective distance from threatening reality but risks loss of sensitivity. One student admitted that for a moment he found himself too detached. As the heart was being excised from the chest cavity he humorously imagined passing it like a football. His ability to share this with the team added to rather than detracted from his moral stature. His insight had brought him closer, not farther, from the person, and closer to his classmates as well. He had, in effect, apologized to the cadaver and his classmates. The facilitator used the opportunity to reflect that when an error occurs, an apology delivered directly and without excuses more often sustains than ruptures the doctor-patient relationship. Patients can be remarkably forgiving, but not of sarcasm, indifference, or abandonment. Given the power, complexity, and cost of modern medicine, knowing how to apologize is a critical skill.
One student recalled being asked by a friend who was not a medical student what the dissection experience was like. The student welcomed the opportunity to discuss his feelings away from his instructors and classmates. However, as he began to describe his feelings, he became aware that his friend seemed distant, unable to relate to the experience. Similarly, patients will ask for personal information or express genuine concern when the physician cannot conceal the effects of personal illness or loss. Yet, the physician is responsible for maintaining a working distance that keeps the patient close without crossing the boundary of using the patient to meet the physician’s personal needs. Personal questions most often indicate a need to know what doctors think of their patients rather than what doctors think of themselves. Without the student’s example of the friend who could not relate, the boundary concept would have seemed little more than an ethical abstraction.
Finally, when asked, most students do not consider donating their bodies for dissection. Though for some this is the result of religious precepts, it is more often not the case. Throughout the session, the facilitator has sought to examine the boundary between the cadaver and the student in an effort to pave the way for a more empathically effective stance toward their patients. Yet, no matter how much they may identify with the cadaver, rarely do they identify themselves as future donors.
This column has focused on only one pedagogic technique and does not offer experimental evidence of beneficial outcomes associated with the experience. However, student evaluations of the experience are positive. One student commented at the end of the conference, “I never knew there was so much to this.” Another had a morbid fear of how she would respond to dissection, which seized her from the first moment she read her acceptance letter from the college of medicine. Two years later, during her clerkship, she told the facilitator how much she appreciated the opportunity to confront her fears in an open, non-judgmental arena. Admittedly, the sensitivities evoked by this technique may easily be blunted by overwork, cynical attendings, or clinical rotations that do not promote an empathic environment. In addition, there is no shortage of events during the clerkships that bring to light the dilemma of sustaining clinical detachment while remaining emotionally engaged. Yet, the intensity of the experience occurring as it does in the first year of medical education uniquely captures the duality and boundaries of patient care. For the patient’s sake, the physician cannot afford to be emotionally overwhelmed or unable to act. A physician paralyzed by fear or doubt has effectively abandoned the patient. Yet, unfeeling detachment is impersonal and unlikely to inspire trust. However anatomy is to be taught in the evolving medical school curriculum,10-13 student dissection provides a rare avenue to promote clinician self awareness and improve patient care. Dissection of the cadaver provokes an examination of the self. PP
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