2011; 33: 7880

SHORT COMMUNICATION

Learning surface anatomy: Which learning approach is effective in an integrated PBL curriculum?
SAMY A. AZER
King Saud University, Saudi Arabia

Abstract
Background: Understanding surface anatomy and surface markings are integral for introducing clinical sciences. Aim: This study aimed to assess which learning approach is effective in learning surface anatomy. Method: First-year medical students were randomly assigned into two groups and asked to complete an MCQs quiz covering surface anatomy of the abdomen ( pre-test). Each student worked on his/her own in each group. Group A students (n 70) were then provided with a reading material and two images of the abdomen printed on A4 size paper. Students were asked to study the reading material and use the image of the abdomen to draw and label the surface anatomy of six abdominal organs. Group B students (n 74) were provided with the same reading material but were asked to answer short-answer questions. After 45 minutes, the reading material and answers were collected from both groups and students performance was compared using the same sets of MCQs ( post-test). Results: Students from both groups showed significant improvement in their post-test scores compared to their pre-test scores. Also the means for paired samples were significantly higher in Group A compared to Group B. A small number of students in both groups scored 2 in the pre-test and failed the post-test. Conclusion: While both techniques improved students scores; learning by drawing surface anatomy of abdominal organs showed higher scores.

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Introduction
Surface anatomy is an integral component of medical curricula and aims at preparing students for clinical sciences. Several learning and teaching approaches have been described to enhance students understanding of surface anatomy, for example interactive computer multimedia, lectures, small group learning and practical classes, seminars and videos (Evans & Cuffe 2009; Sum Shin et al. 2009; Smith & Mathias 2010). Recently, body painting sessions have been described as an innovative approach to learn surface anatomy. In these sessions, students familiarise themselves with the surface markings and subsequently paint full organs at the site of their projection on the body surface (Op Den Akker et al. 2002; McMenamin 2008; Finn & Mclachlan 2010). Body painting usually requires peer volunteers, artists models or simulated patients (Aggarwal et al. 2006) to offer such opportunities to other students to learn by drawing on their skin. Although there is evidence that students enjoy learning various aspects of anatomy in such sessions (Op den Akker et al. 2002), it might be difficult to find enough volunteers. Also using artists models or simulated patients might be costly, and might not be practical for self-access learning or revision before examinations. This work examined learning surface anatomy by using two different approaches learning from a text and using

Practice points
. Learning surface anatomy and surface markings by drawing or writing short answer questions improves students performance in post-test. Scores were higher when students used drawing during learning. . Students with a poor performance in both tests require further assessment.

knowledge learnt to outline the surface anatomy and surface markings of major abdominal organs by drawing (visual spatial learning) versus learning from a text and answering short-answer questions (verbalabstract learning).

Aim
This study aimed to assess which learning approach is effective in learning surface anatomy.

Methods
Background
First-year medical students, at the Universiti Teknologi MARA, participated. The medical curriculum is integrated hybrid

Correspondence: S. A. Azer, Department of Medical Education, College of Medicine, King Saud University, P. O. Box 2925, Riyadh 11461, Saudi Arabia. Tel: 9661-4699178; fax: 96614699174; emails: azer2000@optusnet.com.au; sazer@ksu.edu.sa

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ISSN 0142159X print/ISSN 1466187X online/11/0100783 2011 Informa UK Ltd. DOI: 10.3109/0142159X.2011.530704

Learning surface anatomy

PBL curriculum. Students at the time of conducting the study were about to be introduced to the Gastrointestinal Module. No ethical approval is required for the study. The Faculty Executive Committee has endorsed the training workshop, Becoming an Effective Learner and related studies.

Discussion
This study demonstrated that the use of drawing to outline the surface anatomy of the abdomen improves significantly the students performance in a post-test. Although a similar improvement is observed in students learning by writing short-answer questions, scores were higher in the group using drawing. This is in line with the notion that approaches to learning correlate positively with the quality of learning. Successful learning of anatomy requires a balance between memorisation with understanding and visualisation. Interrelationships between these strategies for learning anatomy are essential for deep learning (Pandey & Zimitat 2007; Quitadamo & Kurtz 2007). Students who used drawing commented that the use of drawing while learning from a text required a lot of concentration (57%), lateral thinking (31%), and making an alignment between what they understood from the text (60%) and how to transfer knowledge into drawings outlining abdominal structures (63%). This experience helped them to deepen their understanding (92%). Students who used short-answer questions believed that the experience helped them to memorise the factual knowledge related to a particular organ (70%). The results show improvement of students scores in the post-test immediately after the learning session is over. It is important to note that what works best in the long-term perspective cannot be directly concluded from this study. Further follow-up studies are in place to study the long-term impacts of such strategies on students learning of surface anatomy, for example after 56 days. Regarding the small group of students in both groups who scored 2 in the pre-test and failed the post-test, it is difficult to speculate on an explanation for these outcomes. Further follow-up study aiming at testing the use of these learning strategies in supporting students learning is in progress.

Study design
Students were randomly assigned into two groups and asked to complete an MCQs quiz (15 questions, all Single Best Answer Questions) covering surface anatomy of the abdomen. Students performance in the two groups was compared using the same sets of MCQs before and after completing learning tasks. The learning tasks for Group A (n 70) were: (i) learn surface anatomy from a text, (ii) use the image of the abdomen to draw the subcostal and transtubercular lines and vertical lines through midpoint of each clavicle; (iii) identify the nine zones of the abdomen and (iv) use a second image of the abdomen to draw the following abdominal organs: the liver, the fundus of the gallbladder, the stomach, the duodenum, the pancreas, the abdominal aorta and its bifurcation into two iliac arteries. To complete these tasks, students used images of the abdomen printed on A4 size papers. The learning tasks for Group B (n 74) were: (i) study the same text, and (ii) answer short-answer questions related to the tasks required from Group A. In both groups, each student worked on his/her own to complete the task and answer the MCQs quiz.

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Post-test discussion
Following the post-test, students in each group were asked to discuss a key question, In what way was the learning strategy of help to them? A written response was also collected from students.

Analysis
Students scores for each assessment, before and after completion of the learning tasks, were pooled. The mean change in response () after completion of the appropriate learning task was compared. The means for the two protocols were then compared using non-paired Students t-tests (twotailed). Declaration of interest: The author reports no conflict of interest. He is the only author of this article. Part of this article was presented orally at ANZAME annual conference in 2009.

Notes on contributor Results

Students from both groups showed significant improvement in their post-test scores compared to their pre-test scores (Group A, 10.07 3.49 versus 5.97 2.09, r 0.762, p 5 0.001; and Group B, 8.18 2.35 versus 6.39 1.96, r 0.629, p 5 0.001). Also, the means for paired samples were higher in Group A compared to Group B (4.10 2.35 versus 1.79 1.89, p 5 0.001). No significant difference is found between the pre-test scores in Groups A and B ( p 0.184) and no differences were found between students on the basis of gender. A small number of students in both groups scored 2 in the pre-test and failed the post-test.
SAMY A. AZER, MB, BCh, MSc, PhD, Med, FACG, MPH, is a Professor of Medical Education and Head of Curriculum Development Unit, Department of Medical Education, College of Medicine, at King Saud University, Saudi Arabia. During this study, he was a Professor of Medical Education and Chair of the Medical Education Research and Development Unit at the Universiti Teknologi MARA, Malaysia.

References
Aggarwal R, Brough H, Ellis H. 2006. Medical student participation in surface anatomy classes. Clin Anat 19(7):627631. Evans DJR, Cuffe T. 2009. Near-peer teaching in anatomy: An approach for deeper learning. Anat Sci Educ 2(3):107112.

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Finn GM, Mclachlan JC. 2010. A qualitative study of student responses to body painting. Anat Sci Educ 3(1):3338. McMenamin PG. 2008. Body painting as a tool in clinical anatomy teaching. Anat Sci Educ 1(4):139144. Op Den Akker JW, Bohnen A, Oudegeest WJ, Hillen B. 2002. Giving color to a new curriculum: Body painting as a tool in medical education. Clin Anat 15(5):356362. Pandey P, Zimitat C. 2007. Medical students learning of anatomy: Memorisation, understanding and visualisation. Med Educ 41(1):714.

Quitadamo IJ, Kurtz MJ. 2007. Learning to improve: Using writing to increase critical thinking performance in general education biology. CBE Life Sci Educ 6(2):140154. Smith CF, Mathias HS. 2010. Medical students approaches to learning anatomy: Students experiences and relations to the learning environment. Clin Anat, 23(1):106114. Sum Shin D, Seo Park J, Lee S-B, Lee S-H, Chung J, Chung MS. 2009. Surface model of the gastrointestinal tract constructed from the visible Korean. Clin Anat 22(5):601609.

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