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Clinical Anatomy Taught Through Surgery

Every medical student has to take anatomy, but only a lucky handful of fourth-years get a spot in the Clinical Application of Anatomy course offered in August.

What makes the class different from a typical anatomy course is that it goes beyond simple identification. Instead, students discuss and perform clinical and surgical procedures as a means to study anatomy. Surgical faculty and residents and anesthesiologists, in addition to anatomists and radiologists, teach the lectures and labs.

“It is anatomy as you are going to see it in a clinical setting,” said Trudy Van Houten, an HMS clinical instructor in radiology and director of the course. In the labs, the students perform procedures from a range of specialties, using radiology along with dissection as tools for learning. As a fourth-year course, the class also achieves the goal of longitudinal learning, enhancing what is taught in the first-year anatomy class.

“The approach is very different from a classical, anatomic perspective versus a surgical perspective. They are almost exact opposites,” said Kitt Schaffer, HMS associate professor of radiology and director of the first-year Human Body course. In the typical anatomy course, a wide section is opened in a cadaver so students can view as much as possible, but in a surgical procedure, the smallest incision possible must be made. Once the procedure is complete, the students make a bigger cut so they can see surrounding anatomy.

The course started in 1997, after surgical faculty found that the anatomy courses, typically taken in the first year, were not adequately preparing clerkship students, interns, and residents. William Silen, then chief of surgery at Beth Israel Deaconess Medical Center, was among the faculty who approached Van Houten about designing a new anatomy elective. Van Houten was previously involved in the development of the first-year anatomy elective.

Notable faculty have since participated, including Michael Zinner, De-partment of Surgery chair at Brigham and Women’s Hospital, who taught a session on abdominal surgery last summer. Silen has also remained involved.

“Part of the success of the course is that instead of trying to find a surgeon who has the time to be the director of the course, which they don’t, we’ve been able to create cameos,” said Van Houten. It also gives clinicians a welcome opportunity to teach, she said, noting that clinicians often call asking how they can take part.

Students also must do a presentation, which includes a demonstration in the lab. Some students have invented new approaches to procedures that were not as successful as they could be, said Van Houten. “[The projects] are incredibly ingenious and fun to do,” she said.

The course has proven to be extremely well-received by students. “It is one of the most popular, if not the most popular, elective at Harvard,” said Shaffer. “Students are so lucky to be able to spend time with these superstar doctors that they would maybe never meet otherwise.”

Ziad Obermeyer, a fourth-year student who took the course, realized that he had not absorbed all he could have from the first-year anatomy course during an emergency department rotation in his third year. Faced with a patient, a young girl, who had a lacerated arm, he could not remember the local geography and was unsure of what might have been damaged. He said he found the clinical anatomy class to be much more useful.

“The approach of the continuing anatomy course was to emphasize the practical aspect, starting from how anatomical knowledge is applied and working backwards from the goal to the details. This made everything so much more relevant—suddenly it became crucial to know not only the one path of a vessel traditionally described in textbooks, but also the three common anatomical variants,” Obermeyer said. “Essentially, we were no longer learning for a test, but for real life.”

Van Houten said that the course, which she also helped develop at Boston University, is the first of its kind among medical schools; representatives from Yale visited the class last summer to investigate instituting a similar course. Shaffer said those involved with the HMS course hope to expand it and offer it two or three times per year.