Surg Radiol Anat (2010) 32:647–652 DOI 10.1007/s00276-010-0653-1
ORIGINAL ARTICLE
Traditional versus three-dimensional teaching of peritoneal embryogenesis: a comparative prospective study Bassem Abid • Nejmeddine Hentati • Jean-Marc Chevallier • Ali Ghorbel • Vincent Delmas • Richard Douard
Received: 10 November 2009 / Accepted: 8 March 2010 / Published online: 30 March 2010 Ó Springer-Verlag 2010
Abstract Introduction Anatomy teaching is newly boosted by the development of interactive three-dimensional (3D) teaching techniques. Nevertheless, their superiority as teaching aids has never been demonstrated. The aim of this study was to compare 3D and traditional chalk teaching efficiency in terms of student memorization concerning peritoneal embryogenesis. Materials and methods 165 students from the Faculties of Medicine of Sfax (Tunisia) (n = 81) and of ParisDescartes (France) (n = 84) were taught peritoneal embryogenesis either via a 3D technique (interactive DVD ROM) (3D group, n = 85) or via the traditional chalk technique (CL group, n = 80). Both groups were subjected to an evaluation test including 34 questions distributed in six chapters at the end of the course. Results The overall rate of correct answers was higher in the 3D group (65.12 ± 14.88 vs. 49.33 ± 16.17%, p \ 0.001). It was the same for five of the six chapters of B. Abid J.-M. Chevallier V. Delmas R. Douard URDIA Anatomie, Faculte´ de Me´decine Paris-Descartes, Universite´ Paris V, Paris, France B. Abid N. Hentati A. Ghorbel Laboratoire d’Anatomie, Faculte´ de Me´decine de Sfax, Sfax, Tunisia B. Abid N. Hentati A. Ghorbel R. Douard GEFTAC: Groupe d’Etudes Franco-Tunisien en Anatomie Chirurgicale, Laboratoire d’Anatomie, Faculte´ de Me´decine de Sfax, Sfax, Tunisia R. Douard (&) Unite´ de Chirurgie Digestive et Endocrinienne, Hoˆpital Cochin, 27, rue du Faubourg Saint-Jacques, 75679 Paris Cedex 14, France e-mail:
[email protected]
questions excluding the chapter concerning the clinical implications (p = 0.06). There was no significant difference between 3D and CL groups regarding the 20 questions focusing on static phenomena (64.52 ± 27.10 vs. 58.87 ± 23.67%, p = 0.24), but the rate of correct answers was higher in the 3D group for the 14 questions focusing on dynamic phenomena (65.96 ± 20.97 vs. 28.17 ± 24.40%, p \ 0.001). Conclusion The 3D technique is significantly more efficient than the traditional chalk technique for the teaching of peritoneal embryogenesis in terms of short-term memorization and particularly for the assimilation of dynamic phenomena. Medium-term and long-term studies are needed to demonstrate that this benefit has a long-lasting impact. Keywords Anatomy Teaching Computer-assisted teaching Three-dimensional simulations GEFTAC Peritoneal embryogenesis URDIA
Introduction Chalk anatomy teaching is agreed to be a basic technique by all of the anatomists. However, it often takes time for the teacher to learn how to use this teaching technique. Students are supposed to copy down the professor’s anatomy drawings, which helps them to memorize. The faculties were technically equipped with blackboards and chalks. With a view to modernizing this teaching technique, the use of graphic tablets is being developed, but the principles of a teaching based on a succession of static drawings remain usually unquestioned in most universities. Such a succession of static drawings does not seem to really fit for the teaching of dynamic phenomena like organogenesis. The development of three-dimensional and
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virtual reality techniques is liable to be of help for the teaching of the dynamic features in morphological sciences and particularly in anatomy [2, 7]. In 1999, Guttmann [3] had highlighted how three-dimensional reconstructions via the JAVA 3D software had facilitated the teaching of embryo-anatomy and surgery practice. However, these techniques failed to be compared with traditional teaching techniques. Although they have not been evidenced to be more efficient teaching aids, the three-dimensional teaching techniques tend to supersede chalk teaching. This evolution is held to be due to practical reasons (elimination of blackboards, chalk, and dust) and students’ and teachers’ fondness for modernity. The aim of our study was to compare the short-term impact of chalk and three-dimensional techniques regarding the teaching of peritoneal embryogenesis.
Materials and methods A cohort of 165 students, including students from the medical Faculty of Sfax (Tunisia) in the second year of the first cycle of medical studies (n = 81) and students from Paris-Descartes Faculty of Medicine (France) taking a University degree in abdomino-pelvic clinical anatomy (n = 84), were taught peritoneal embryogenesis either by three-dimensional technique (3D group, n = 85), or by the traditional chalk technique (CL group, n = 80). The students were randomly separated into two groups in each of the two faculties. None of the two groups had been taught the subject before and previously informed of the teaching technique used. The peritoneal embryogenesis course included six chapters: (1) emergence of the primitive intestine with its principal segments and their respective vascularisation, (2) development of the posterior mesogastrium focusing on the stomach rotation, development of the spleen, and omental pouch genesis, (3) development of the duodeno-pancreas, (4) development of the common mesentery and the rotation of the mesentery ansa, (5) development of the hepatic bud and the anterior mesogastrium, and (6) clinical implications. The CL group included 80 students (Sfax n = 38, ParisDescartes n = 42) and was taught according to the traditional method using chalk and blackboard (JMC and AG), whereas the 3D group included 85 students (Sfax n = 43, Paris-Descartes, n = 42) and was taught according to the three-dimensional method using three-dimensional illustrations and simulations (BA and RD) (Fig. 1). The 3D group was taught with the aid of a self-manageable interactive multimedia DVD ROM dealing with peritoneal embryogenesis from its earlier stages to the final arrangement of the digestive tract. The DVD was presented by the professor exclusively, and the students were given only one
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Fig. 1 Dilemma of the mesenteric ansa rotation: schematic section or 3D simulation?
learning opportunity. Indeed, this 3D program was not in free access and not yet available on the Web, which made the students unable to use the DVD to learn by themselves. This DVD included 32 simulations among other data (static drawings quite comparable to those made in the chalk group, dissection images and bibliographical references), and had been designed on the occasion of a thesis for medicine doctorate (BA) [1]. Each of the two groups had a 60-min course followed by an evaluation test including 34 shortanswer questions in French language to be answered in 40 min (Table 1). All the questions required short-written answers only with no need for diagrams or diagram-labeling. Twenty questions focused on static phenomena, whereas 14 questions focused on dynamic phenomena. The answers were anonymously collected, and the corrections were made for both groups by a third investigator (NH) using one and the same marking scale. This third investigator was unaware of the origin of the papers (CL or 3D, Sfax or Paris). After the questionnaire had been completed, the two groups received the alternative teaching program to complete student formation. The rates of correct answers for each question, each chapter and for dynamic and static phenomena were compared in each student group (3D or CL). Quantitative variables were compared by Student’s t test, and qualitative variables were compared by chi-squared analysis. Statistical significance was p \ 0.05.
Results The rates of correct answers for the 34 questions in the 3D and CL groups were 65.12 ± 14.88 versus 49.33 ± 16.17% (p \ 0.001), respectively, corresponding to an overall average score of 13.02/20 for the 3D group versus 9.86/20 for the CL group (p \ 0.01). 41.25% of students in the CL group had a score below the arithmetic mean versus 7.5% in the 3D group (p \ 0.01). Distribution of the
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Table 1 Subjects treated and samples of test questions Subjects treated
Samples of questions
Chapter I: Emergence of the primitive intestine
Name the three segments of the subdiaphragmatic primitive intestine Name two organs developing in the dorsal mesogastrium
Chapter II: Development of the posterior mesogastrium
Name the two rotations axes of the gastric bud Name the two vessels limiting the bursae omentalis foramen
Chapter III: Development of the duodeno-pancreas
Name the primitive pancreatic buds Explain the development of pancreatic fascias
Chapter IV: Development of the hepatic bud and the anterior mesogastrium Chapter V: Development of the common mesentery and the rotation of the mesentery ansa
Name the primitive hepatic buds Name the elements derived from the mesenteric ansa
Chapter VI: Clinical implications
Name the types of common mesentery
Name the rotation axis of the mesenteric ansa
group (65.96 ± 20.97 vs. 28.17 ± 24.40%, p \ 0.001). When we compared the rates of correct answers for each of the 14 questions (Fig. 6), the results were significantly better for the 3D group for 13 questions (93%) and not different for the remaining one (7%) (Table 4). There were no significant differences between the Tunisian and French student groups for global results, different chapters, static, and dynamic phenomena in 3D or CL groups (data not shown).
Discussion Fig. 2 Diagram showing the distribution of the student scores (/20) for each group
student scores in each group is shown in Fig. 2. The results for the different questions are shown in Fig. 3 confirming the superiority of the 3D group. The results for the different chapters are presented in Table 2 and Fig. 4. Results were significantly better in the 3D group for all the chapters except for the chapter entitled ‘‘Clinical implications’’. Assimilation of the static phenomena For the 20 questions focusing on static phenomena, the rates of correct answers in each of the two groups were not significantly different (3D 64.52 ± 27.10 vs. 58.87 ± 23.67% CL, p = 0.24). When comparing the rates of correct answers for each of the 20 questions, the 3D group results were significantly better for six questions (30%) and were not significantly different for the remaining 14 (70%) (Table 3; Fig. 5). Assimilation of the dynamic phenomena For the 14 questions focusing on dynamic phenomena, the rate of correct answers was significantly higher for the 3D
Anatomical knowledge of qualifying doctors has been recently reported to be below an acceptable level [5, 12, 16]. Such findings are due to a cut in the anatomical learning programs observed in most western countries. The current trend is to shorten the anatomy course to cope with the expanding time required for the teaching of other basic scientific subjects. Learning anatomy probably needs to be deeply reformed to adapt to this new age [8, 10]. Since Vesalius in 1542, anatomy teaching has been based on dissection [6]. Nevertheless, the role of cadaver dissections has always been under debate for philosophical, religious, ethical, and more practical reasons related to the scarcity of available subjects. Dissection seemed to have been abandoned by many institutions, but most of them have reestablished it as the cornerstone of their anatomy course even in the most modern learning programs [8, 9, 11, 13]. In recent studies, Patel et al. [8, 10] demonstrated that a majority of professional anatomists are still in support of the use of human cadaveric dissection. However, the new teaching techniques (3D reconstructions) appear to be an additional medium of interest. Thus, Uhl et al. [8, 9, 15], consider this new teaching tool as supplementary to cadaveric dissection even though it will never supersede the real dissection and its tactile sensations. Patel et al. [8, 10, 13]
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Fig. 3 Comparative diagram of percentages of right answers obtained by students of both groups for each question. The 3D curve demonstrates better scores in this group (CL traditional teaching group; 3D three-dimensional teaching group)
Table 2 Comparative overall average scores for each of the six chapters 3D group Correct answers (%)
CL group Correct answers (%)
p value
Chapter 1: Emergence of the primitive intestine
94.11 ± 2.23
84 ± 11.36
\0.01
Chapter 2: Development of the posterior mesogastrium
75.29 ± 16.89
52.1 ± 33.67
\0.01
Chapter 3: Development of the duodeno-pancreas
65.88 ± 25.80
46.71 ± 24.71
\0.01
Chapter 4: Development of the common mesentery
59.34 ± 20.96
42.71 ± 18.86
\0.01
Chapter 5: Development of the hepatic bud
49.17 ± 22.14
21.16 ± 14.36
\0.01
Chapter 6: Clinical implications
29.41 ± 4.7
21.85 ± 13.66
0.06
Fig. 4 Comparative diagram of percentages of right answers for each chapter
also demonstrated that most of professional anatomists are inclined to favor multi-modal teaching programs often comprising practical lessons using cadaveric dissection by the students, prosection, lessons using living and radiological anatomy, workshops, literature analysis, and computer activities using 3D imaging software and new imaging techniques [13]. The development of computer-assisted programs used these new techniques for the teaching of more and more clinically oriented anatomy. The benefit of
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these new 3D techniques is unquestioned even though it has not been compared to traditional methods. The 3D techniques’ main advantage lies in their unique availability (intranet, internet, and DVD exchange), which allows the students to use again and again the DVD-ROM to revise and better understand the lesson. Nevertheless, lessons by anatomy professors are now filmed in Paris-Descartes University which makes traditional chalk lessons as easily available as modern 3D teaching aids. Despite these
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Table 3 Comparative average scores for the 20 questions focusing on static phenomena Static phenomena Question numbers
3D group Correct answers (%)
CL group Correct answers (%)
p value
1
94.11
78.75
\0.01
2 3
95.29 94.11
80 70
\0.01 \0.01
4
96.47
92.1
0.35
5
90.58
86.2
0.22
6
89.41
87.7
0.34
7
83.52
80.2
0.03
8
77.64
73.5
0.16
9
83.52
76.25
0.12
10
83.52
70
0.01
12
50.58
55
0.28
15
55.29
51.4
0.03
18
57.64
53.75
0.30
19
55.29
48.75
0.20
22
29.41
23.7
0.46
26
32.94
33.75
0.45
27 30
43.52 18.82
38.3 22.5
0.09 0.28
32
24.70
18.75
0.17
33
34.11
36.8
0.17
Italic values indicate p \ 0.05
Fig. 5 Diagram showing the absence of superiority of 3D for static phenomena teaching
improvements, anatomy teaching in most of the medicine faculties is still mainly based on dissection and also on blackboard drawings by teachers using chalks. The aim of our comparative study based upon the teaching of a dynamic phenomenon (peritoneal embryogenesis) was to assess the differences between the results obtained via the traditional chalk technique and the results subsequent to the use of three-dimensional simulations and reconstructions. The comparisons between the 3D and CL groups were achieved at three levels: (1) overall score average, (2) average scores for each of the chapters treated, and (3) average scores for
Fig. 6 Diagram showing the superiority of 3D for dynamic phenomena teaching
each of the 20 questions focusing on static phenomena and for the 14 questions focusing on dynamic phenomena. Taking account of the overall score average, the average score of the CL group was found to be significantly below the arithmetic mean versus 13.02 in the 3D group. When detailing the results and taking each chapter apart, the 3D technique yielded results significantly better regarding either the rate of correct answers or the score average. When comparing the results between the six chapters, 3D was more efficient for each chapter except for the chapter focusing on clinical implications. This chapter is mainly based on static phenomena, which seems to corroborate 3D specific superiority regarding dynamic phenomena. Indeed, there was no significant difference between the two groups concerning the 20 questions relating to any static phenomenon including surgical implications, and the results of the 3D group was significantly better in only 30% of these 20 questions (Table 3; Fig. 5). On the contrary, the 3D technique proved to be significantly more efficient for the teaching of dynamic phenomena such as the rotation of umbilical ansa or the formation of the omental pouch. For this group of 14 questions, the results in the 3D group were significantly better for 13 out of the 14 questions (Table 4; Fig. 6). Such findings mean that using static illustrations for the teaching of dynamic phenomena hampers the student’s understanding. At the time when several reports have been published in support of new techniques for teaching surgery and particularly laparoscopic surgery [4, 14], the efficiency of this type of techniques for teaching anatomy still remained to be demonstrated. To the best of our knowledge, no comparative study has ever been published to assess traditional versus three-dimensional impact for the teaching of organogenesis and anatomy. Our study points to the superiority of the 3D techniques for the teaching of dynamic phenomena and demonstrates that these techniques are efficient teaching aids and particularly useful for the teaching of embryogenesis, which precludes dissection and only allows to use static illustrations. Interestingly, embryogenesis is the very same type of a dynamic process, and proves to be of paramount importance to understand
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Table 4 Comparative average scores for the 14 questions focusing on dynamic phenomena Dynamic phenomena Question numbers
3D group Correct answers (%)
CL group Correct answers (%)
p value
11
67.05
11.25
\0.01
13 14
95.29 47.05
7.5 7.5
\0.01 \0.01
16
47.05
20
\0.01
17
95.29
68.75
\0.01
20
92.94
76.25
\0.01
21
78.82
63.2
23
48.23
21.25
\0.01
24
75.29
33.75
\0.01
25
63.52
30
\0.01
28
56.47
13.75
\0.01
29
80
1.25
\0.01
31
47.05
30
\0.01
34
29.41
10
\0.01
0.06
Italic values indicate p \ 0.05
the adult’s anatomy and pathology. The three-dimensional type of teaching technique can open the way to an e-learning program specifically designed for medical students. The traditional teaching should not be abandoned until the new techniques have been assessed to be more efficient. In addition, a longer-term evaluation of the memorization is required to further validate these techniques at the time of the evidence-based medicine. Such long-term results will allow to determine if the reproduction of drawings, which is part and parcel of the traditional teaching, contributes to the student’s memorization or if the immediate understanding via dynamic 3D imagery is sufficient for the principles of a phenomenon to be memorized. It will also be necessary to assess the impact of a free access to DVD-ROM and subsequent benefit for the students.
Conclusion The teaching of the peritoneal embryogenesis via threedimensional imagery proves to be significantly more efficient as compared with the traditional teaching via static
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chalk drawings. The superiority of 3D technique is higher for dynamic phenomena. Medium- and long-term studies are required to ascertain that the immediate memorization benefit is long-lasting. Acknowledgments The authors would like to thank Pierre Ratier for his help in the preparation of manuscript and for constant support.
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