The Design of New Teaching Model of Neuroanatomy to Prevent Neurophobia in Preclinical Medical Students.
John Yung-Sung Cheng, MD
研討會名稱 : 六維立體虛擬實境影像國際研討會 99 年 11 月 6 日 台北醫學大學 台北
Background:
Neurophobia, being described as “a fear of the clinical neurosciences”, is a longstanding problem among preclinical medical students. The lack of knowledge in the complexity of neuroanatomy is regarded as one of the most important reasons. Therefore, a new teaching model of neuroanatomy was developed.
Summary of work:
We combined traditional method and contemporary virtual reality technologies to design this new teaching model of neuroanatomy, including anatomical atlas sketch, pretest and posttest of reading brain computed tomography scans, and teaching with dextroscope.
During July 2009 and July 2010, fifty-five medical students in Taipei Medical University Hospital were enrolled in our study.
Summary of results:
The significant improvement between the mean scores of pretest and posttest was observed.
Questionnaire results revealed that most of the students express strong positive attitude toward learning in dextroscope, and the teaching model of neuroanatomy. Moreover, they also showed more confidence on learning neuroanatomy after being taught with dextroscope.
Conclusion:
A carefully designed teaching model of neuroanatomy could possibly help medical students to overcome neurophobia. Besides, dextroscope is a friendly learning environment of virtual reality.
Take-home messages:
The traditional method of teaching neuroanatomy could be integrated with new virtual reality technologies to innovate a curriculum of the future.
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Introduction
Anatomy has been the fundamental medical knowledge for centuries since renaissance, but the teaching of anatomy is facing significant challenges in recent years. A great leap in the development of digital medical images has provided new ways to see through the structure of the human body. With the rapid advances in information technology, the role of diagnostic radiography in anatomy education is expanding [1]. Many reports had pointed out the potential roles of digital medical images to enhance the teaching and learning of anatomy [1,2].
However, there is a developing debate on methods of teaching anatomy. The use of cadaver dissection is still a traditional and important part in the Anatomy course for medical students. But, could it be totally replaced by computerized anatomy resources, (including diverse software and websites)?
Rapid evolution of three-dimensional images technologies has made virtual environments (VEs) possible in recent years. The applications of virtual reality (VR) on health care are diverse, including surgical planning and simulation, medical education, patient simulator, psychological assessment, rehabilitation, bronchoscopy, et al [4]. The applications of virtual reality (VR) in surgery include anatomy education, preoperative planning and simulation, and assessment of surgical skills.
The results of applications of VR techniques in preoperative planning and simulation are promising, especially for laparoscopic surgery and neurosurgery [4,5,6]. The task performance in simulator is strongly correlated to daily surgical performance [7]. The implementation of VR in anatomy education also has great potential, but could it influence the learning of reading skills of diagnostic images for medical students?
Moreover, the role of virtual reality (VR) in the teaching of anatomy is revolutionary and with great potential [3,4]. Since the Visible Human Project (VHP) launched by the US National Library of Medicine in 1988[11], it allowed the developments of various VR 3-D models. The most renown is the Visible Human 3D Anatomical Structure Viewer (EPA Lausanne) [12].
3-D visualization of clinical diagnostic images allows a deeper understanding of spatial relationships between deep structures that hardly can be achieved by other teaching methods [4].
Taking brain neuroanatomy as an example, trainees thus can see the sophisticated and delicate neural structures by dynamic dissections from various directions with the help of VR.
VR definitely improve the learning of anatomy. But, could the VR techniques influence the learning of reading skills of radiological anatomy (diagnostic images) for medical students?
Radiological anatomy is totally different from gross anatomy. Medical images are another representation of gross anatomy, and anatomy knowledge gathered from dissections always needs being translated into cross-sectional views of clinical images [11]. That is why students often feel frustrated while reading cross-sectional clinical images (such as, brain computed tomography scans) at the first moment.
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Therefore, appropriate learning scaffolds are needed as the bridges of knowledge among those different representations of anatomy.
The learning of reading brain computed tomography (CT) scans is a critical step in studying clinical neuroscience, but it seems to be a major obstacle to medical students. The most difficult parts are lack of the acquaintance of medical terms and 3-D concepts of neuroanatomy.
Therefore, we are developing a new model of teaching clinical neuroanatomy for preclinical medical students. The teaching model includes sketch of atlas of neuroanatomy, self-directed learning of reading brain computed tomography (CT) scans, and implement of dextroscope. We are in the hope to teach gross anatomy in the context of clinical setting.
Sketch is an unique skill commonly used in medicine, and it is especially important in the training of surgery. Students have to recognize what structures they are going to sketch, and allocate them in a proper position after knowing the spatial relationship between neural structures. Sketch could help students to recall the unfamiliar and difficult neuroanatomical terms, and restructures 3-D concepts of neuroanatomy inside students’ minds.
Dextroscope (Volume Interactions, Ltd., Singapore) is a virtual reality system for preoperative planning and simulation of surgery. Patient-oriented and fused medical images are presented stereoscopically and the fused images can be manipulated freely from various dimensions. Some degree of simulation of bone drilling and brain retraction can be implemented in the dextroscope. With the help of dextroscope, students can trace vascular and neural structures in dynamic serial images, and further establish a deep understanding of the spatial relationships between individual structures.
This new model of teaching clinical neuroanatomy definitely encourage students to learn clinical neuroanatomy in a more interesting and promising way. However, we also want to see if we could improve the learning of reading skills of brain computed tomography (CT) scans with the help of dextroscope ? Part of the aim of our study is to see if VR can improve students’
confidence of reading brain CT scans.
What is Neurophobia?
Neurophobia is described as “ the fear of clinical neurosciences ”. It is a worldwide phenomenon among medical students[13].
Neurological diseases is becoming more and more popular. Brain computed tomography (CT) scans gave become a regular and screening scans for diagnosing neurological problems.
Learning to read brain CT scans is the crucial first step to learn clinical neurosciences.
However, atlas in anatomical textbooks and brain CT images are different representations of neural structures. Medical Students’ memory battery for neuroanatomy is very poor. Students have difficulty to have far transfer of anatomical knowledge, which was learned years ago.
Therefore, an integrated program is needed to path the ways for the learning of basic and radiological neuroanatomy. The aim of this study was to evaluate the impact of dextroscope on
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the learning of radiological neuroanatomy, and to verify that if virtual reality simulator, dextroscope, could help the learning of reading brain computed tomography scans.
Methods
Sixty-five preclinical medical students in Taipei Medical University Hospital were enrolled in this study. All of the successive students rotate in the department of neurosurgery for two weeks, and they are divided into two groups. The implement of dextroscope is used as a treatment for the students of the group one.
Thirty-five students are in the group one, and the timetable of teaching activities is as the following. On day1, and day 2 of the rotation, students are asked to sketch atlas of basal ganglia and brain stem, and the terms of neuroanatomy structures will be indicated. Then they need to complete a self-study brain CT scans test (including fifty questions), as the pretest, during the first week rotation, and their answers will be discussed with teacher on the 8th day. Dextroscope will be taught for one hour on day 5 and another hour on day 13 of the rotation. The post-test of brain CT scans is held on day 13 after the teaching of dextroscope finished.
Thirty students are in the group two, and the timetable of teaching activities is as the following. On day1, and day 2 of the rotation, students are asked to sketch atlas of basal ganglia and brain stem, and the terms of neuroanatomy structures will be indicated. Then they need to complete a self-study brain CT scans test (including 50 questions), as the pretest, during the first week rotation, and their answers will be discussed with teacher on the 8th day. The post-test of brain CT scans is held on day 13. Dextroscope will be taught for one hour, as salvage instruction, only after the post-test of brain CT scans being finished.
Learning attitude questionnaire and self-confidence questionnaire are completed after the rotation. Degree of satisfaction is divided into five grades.
The fifty questions of pretest of brain CT scans include thirty questions of neuroanatomy and twenty basic clinical questions. Full score of the fifty questions is one hundred.
The composition of the fifty post-test questions is slightly different from the pretest’s. Seven advanced clinical questions are added, and they are deployed to indicate the problem-solving ability of students. Therefore, the fifty post-test questions are composed of twenty-six questions of neuroanatomy, seventeen basic clinical questions, and seven advanced clinical questions. Full score of the post-test is also one hundred.
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Results
Table 1. Results of sixty-five students.
Mean SD Rate of correct
Answers
Pre-test 71.29 8.4 Full mark : 100
Post-test 89.91 6.3
Clin. A (7tests) 8.46 2.42 60%
Clin. B (17tests) 31.94 2.74 94%
Anat. (26tests) 49.24 3.47 95%
E.S. (Cohen’s D): 2.53 : huge effect size.
Table 2. Results of different groups.
Treatment Pretest score
Post-test score
Score Increment Group one With Dextroscope
(35 students)
71.9 90.0 18.1
Group two Without Dextroscope (30 students)
66.8 87.9 21.0
Discussion
Besides cadavers and dissecting room, there are emerging methods of teaching gross anatomy with the generalization and advance of computer technology [1,2,3,4]. But, could cadaver dissection be totally replaced by computerized anatomy resources? Biasutto et al. (2006) argued that there were no objective and scientific data to prove the superiority of computerized resources over cadaver dissection, and demonstrated that the best way of teaching anatomy is the combination of cadaver dissection and computerized materials [2].
There are three major applications of virtual reality (VR) on health care: anatomy education, simulation of operation, and radiology education.
The application of virtual reality (VR) has led anatomy education into different horizon [3,4,7]. Through interactive 3-D graphics, students can explore internal structures in various dimensions. Anatomical structures are represented in dynamic images, and it allows trainees to trace all kinds of tissues from multiple viewpoints [4]. Therefore, students can attain a deeper understanding of spatial relationships between different structures that cannot be achieved by other teaching methods.
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The simulation of operation in virtual reality (VR) environments has been introduced successfully in recent years, especially in laparoscopic surgery and neurosurgery [4,5,6,8,9,10].
With the advances of endovascular techniques and radiosurgery, there are more alternative methods of treating cerebral aneurysms or skull base tumors. The decrease of open operative cases is making young neurosurgeons more difficult to develop their surgical skills [8]. VR technologies provide a no-risk environment for preoperative rehearsal, and it allows residents to simulate operation preoperatively. Therefore, neurosurgeon can somehow keep experienced in those rare and complicated surgeries with the implement of VR technologies.
Nonetheless, virtual reality is never like actual surgery. It allows some degree of rehearsal of bone drilling, brain retraction, and simulation of possible trajectory and probable difficulties encountered during operation. However, all of this advantages are the initial steps of performing surgery. In real life, the unpredictability during actual operation is more challenging. The experience in computerized simulator could not offer similar tactile and emotional training from the real world experience.
Significant progresses in medical imaging in recent years have enhanced the potential role of radiology over anatomy education. Since the introduction of Visible Human Project (VHP) by National Library of Medicine (NLM) in 1988[11], digital diagnostic images can be processed in various ways. Medical images are restructured in 3D style, and it has made virtual reality resources available for radiology education. Students now can see the structures in a more comprehensive way, and spatial relationships between structures could be realized nearly without any limitation. But, could the VR techniques improve the learning of reading skills of clinical images, ex. brain CT scans, for trainees?
The design of our new teaching model for neuroanatomy adopted sketch (the traditional learning method) and dextroscope (VR technology) to facilitate students’ learning of reading brain CT scans. From our preliminary results, there are no differences of average marks and improvement between study and control group. The treatment for this teaching model, dextroscope, seems to have no role on the learning of reading brain CT scans. However, based on the primitive results of the learning attitude questionnaire and self-confidence questionnaire, students do feel direct help and deeper understanding of spatial relationships between structures from the teaching of dextroscope, and they also show more confidences on the following learning of clinical neuroscience.
The significant improvement between the mean scores of pretest and posttest was observed.
Questionnaire results revealed that most of the students express strong positive attitude toward learning in dextroscope, and the teaching model of neuroanatomy. Moreover, they also showed more confidence on learning neuroanatomy after being taught with dextroscope.
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Conclusion
Our new teaching model for neuroanatomy seems to enhance the learning of reading brain CT scans. A carefully designed teaching model of neuroanatomy could possibly help medical students to overcome neurophobia. Besides, dextroscope is a friendly learning environment of virtual reality. Therefore, the traditional method of teaching neuroanatomy could be integrated with new virtual reality technologies to innovate a curriculum of the future.
References
[1] Miles, R.A. (2005). Diagnostic imaging in undergraduate medical education: an expanding role. Clin Radiol., 60(7):742-5.
[2] Biasutto S.N. et al. (2006). Teaching anatomy: cadavers vs. computers? Ann Anat., 188(2):187-90.
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[8] Anil S.M. et al. (2005). Virtual 3-dimensional preoperative planning with the dextroscope for excision of a 4th ventricular ependymoma. Minim Invas Neurosurg 50: 65 – 70
[9] Wong G.K.C. et al. (2007). Craniotomy and clipping of intracranial aneurysm in a stereoscopic virtual reality environment. Neurosurgery 61:564–569
[10] Kockro R.A. et al. (2009).Virtual temporal bone: an interactive 3-dimentional learning aid for cranial base surgery. Neurosurgery 64[ONS Suppl 2]:ons216–ons230
[11] Visible Human Project (VHP)page of the NLM: (http://www.nlm.nih.gov/research/visible/)
[12] Visible Human 3D Anatomical Structure Viewer (EPA Lausanne):http://visiblehuman. epfl.ch/applet3D.php [13] Zinchuk A.V. et al. (2010). Attitudes of US medical trainees towards neurology education: "Neurophobia" - a
global issue. BMC Medical Education, 10:49
台灣醫學 2014 年 18 卷 6 期 51 (台灣醫學 Formosan J Med 2015;19)
緒言
通訊作者聯絡處：張俊彥，北市中正區南昌路一段 108 號 9F-1。E-mail: [email protected]