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Study of Boneset purchase and use among students of a Medical College in South India

Authors:

Abstract

Introduction - The number of medical seats in India is increasing at an exorbitant pace but the number of bodies donated to the anatomy per student studying is decreasing. To inculcate interest regarding the field of Osteology in the minds of the student a perfect boneset is mandatory. The prescribed curriculum for first MBBS course by MCI does not give any priority to this topic. Experimental-The current study was intended to know about their knowledge & attitude regarding purchase and maintenance of the bonesets. Semi-structured questionnaire was used. Results and discussion- Only 50% of students owned complete boneset. Conclusion- A checklist before purchase needs to be made, and circulated to the students so that they are made aware of the facts. An orientation class needs to be planned before the course starts. The main loop hole in this system that still remains is that the fresh MBBS students will try to seriously understand the worth of this topic only when they become specialists in surgical fields. This research work can transform the student society since now we have to focus on the quality rather than quantity of doctors in India. This study needs to be given wide publicity in every medical, dental and nursing college.
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The Journal of Anatomy. Photon 114 (2014)170-176
https://sites.google.com/site/photonfoundationorganization/home/the-journal-of-anatomy
Original Research Article. ISJN: 2385-4732: Impact Index: 3.67
The Journal of Anatomy Ph ton
Study of Boneset purchase and use among students of a Medical
College in South India
Shruthi Bhat*,
Sagar Borker, Sheela Nayak, Vidyashambhava Pare
KVG Medical College Sullia, Karnataka, India
Article history:
Received: 30 May, 2014
Accepted: 01 June, 2014
Available online: 25 July, 2014
Keywords:
Boneset, Maintain, Osteology, Learning
Corresponding Author:
Bhat S.*
Assistant Professor
Email: drshrubhat@gmail.com
Borker S.
Associate Professor
Nayak S.
Principal
Pare V.
Professor
Abstract
Introduction: The number of medical seats in India
is increasing at an exorbitant pace but the number
of bodies donated to the anatomy per student
studying is decreasing. To inculcate interest
regarding the field of Osteology in the minds of the
student a perfect boneset is mandatory. The
prescribed curriculum for first MBBS course by MCI
does not give any priority to this topic.
Experimental: The current study was intended to
know about their knowledge & attitude regarding
purchase and maintenance of the bonesets. Semi-
structured questionnaire was used. Results and
Discussion: Only 50% of students owned complete
boneset. Conclusion: A checklist before purchase
needs to be made, and circulated to the students so
that they are made aware of the facts. An
orientation class needs to be planned before the
course starts. The main loop hole in this system that
still remains is that the fresh MBBS students will try
to seriously understand the worth of this topic only
when they become specialists in surgical fields.
This research work can transform the student
society since now we have to focus on the quality
rather than quantity of doctors in India. This study
needs to be given wide publicity in every medical,
dental and nursing college.
Citation:
Bhat S., Borker S., Nayak S., Pare V., 2014. Study of
Boneset purchase and use among students of a Medical
College in South India. The Journal of Anatomy. Photon
114, 170-176.
All Rights Reserved with Photon.
Photon Ignitor: ISJN23854732D711825072014
1. Introduction
1.1 Situation of students in India regarding
learning from boneset
During the initial days of entry to medical
college, a student does not get to know finer
details about the way of purchase of bonesets
but it is a must if one has to learn anatomy.
Some of the students manage to procure
bonesets from their elder siblings who have
already finished their first MBBS course; some
procure it from the shops, online from websites
(Quickr.com 2014),
and some from their
seniors. Some of the first MBBS students, who
cannot afford to buy a boneset due to financial
constraints, procure it temporarily from the
library if available, share the set with their
colleagues, or study the muscle attachments or
bone details (Osteology) from
standard textbooks without owning a complete
set.
1.2 Extent of problem in India and Karnataka
There are a total of 63800 MBBS seats per
year in India according to the statistics of
medical college admissions in India out of
which 6005 are in Karnataka itself (MCI India
2014). Very few students are really interested
in medical studies. Most either come to fulfill
their parental expectations or to be considered
in Nobel profession as decided by the Indian
society.
1.3 A few words about bones
Bones are rigid organs that serve various
functions in the human body including
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mechanical support, protection of soft organs,
blood production (from bone marrow), etc.
Bone is a very complex tissue: strong, elastic,
and self-repairing (Warwick et al., 1973).
1.4 Consequences of the current problem
Improper application of medical knowledge can
have serious repercussions on the future as
this may be the reason for creating a whole
cohort of ill equipped doctors lacking
appropriate surgical skills. Some of the
anatomical knowledge that is carried forward
from generations to generations is threatened
by this ultramodern internet era where virtual
memory is more relied upon than factual one.
There are very few centers in the world that
manufacture bone like moulds artificially for
purpose of use by medical students. They are
expensive and not as accurate as a natural
bone.
2. Justification of the Study
2.1 Damages to bones
The art and knowledge of maintenance of bone
sets among first year MBBS students is also
found to be far from satisfactory. Moreover the
students are not taught about this in their
curriculum. Damages during their minimum
one year of use per student might be due to
gnawing by animals, ants, fungus, chemical
injury etc. Bones could also be damaged due
to mishandling, creating artificial foramina
using a candle or incense stick as used
frequently in India for prayer, or sharp objects
like thorns, sticks, or compass. This might be
deliberate or due to stress of the first MBBS
course. The tender adolescent first MBBS
student’s age group cannot be held
responsible for these mishaps, which are minor
according to them (Bhat et al., 2013). The
research was needed since the students are
usually misguided by their seniors that
bonesets are not mandatory they are not good
for health or are scary. There is no proper
guidance on this particular issue to them. Bone
sets are sold at exorbitant costs illegally due to
shortage of cadavers. Students in grave need
have to share the bonesets or borrow them
from the medical college laboratory. These
days there are websites where a student can
buy as well as sell bonesets online. This
research is significant since this check list will
be applicable to all the students which include
medical as well as dental, nursing colleges
around the world for use. This study will act as
a benchmark for further research on the topic
thus it will act as a milestone in research in this
topic.
2.2 Objectives of the research
To assess the knowledge and attitude of first
MBBS students regarding purchase and use of
the bonesets for learning anatomy, and to
prepare a checklist to ease the issue.
2.3 Brief summary of work plan
KVG Medical College Sullia is located 90 Km
from Mangalore along the Mangalore Mysore
highway, in a hilly region in Karnataka, India.
The annual admission is of 100 MBBS
students. The students are admitted in the
month of July- August every year. The first
MBBS course is of 1 year, but the actual
reading time given to the students is hardly 10
months. The proposal for the current study was
written in May 2012 followed by ethical consent
in the month of June 2012. The data was
collected in February 2013 i.e. after 6 months
of their entry in MBBS course. This period was
chosen to find the current nature of purchase
and maintenance of bonesets and to suggest
appropriate modifications if need be. Data was
entered in the month of March 2013, analyzed
and interpreted in April 2013. We then
requested all the study participants to get their
bonesets to the Department of Anatomy so
that they can be examined by the author. Final
report was submitted in May, 2013.
3. Experimental
3.1 Study design and setting
It was a cross sectional study done at KVG
Medical College Sullia, Department of
Anatomy. A cross sectional study was done at
a single point in time. The college has an
intake capacity of 100 seats per year. Out of
these 70 students consented to participate. 30
students had their own personal reasons for
nonparticipation. We did not interrogate further
into this areas since we thought that they may
not be comfortable for students.
3.2 Sample size inclusion and exclusion
criteria of the participants
Data collection was done from a total of 70
study participants who were willing to
participate. The rest 30 students were not
willing to participate were excluded from the
data collection. The authors did not try to find
the reasons for non response among them.
3.3 Study tool used
A questionnaire was administered to the
students of first MBBS course with some semi-
structured and structured questions. This
included questions which pertained to both
purchase as well as maintenance of bonesets.
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3.4 Data entry and analysis
The data was entered in SPSS version 19
software and analysis involved percentages,
proportions, and Chi-square test of
significance.
3.5 Intervention done
A checklist was made for ready reference for
the students so that it could ease the issue of
purchase and maintenance of the bones
among students in future. The students who
were identified to have incomplete or damaged
bonesets were requested to get them to the
Department of Anatomy and they were
repaired by using beeswax by the authors.
4. Results
4.1 Background characteristics of the study
population
A Total of 70 1
st
year MBBS students were
interviewed. 30 refused to participate. Their
ages ranged from 18-21 years. 30 were males
and rest females. Out of these 70, 67 (95.7%)
owned their own bonesets in the first 15 days
of their course. 3 students who did not possess
the bonesets shared it with their roommates.
4.2 Students with complete boneset
Thus out of 70 study subjects only 50.7% of
the students owned complete half boneset.
The Operational definition of a “Complete half
boneset” that was taken for the study was ‘A
boneset which included at least -1 human skull
with mandible, 1 humerus bone, 1 radius bone,
1 ulna bone, 1 clavicle, 1 sternum, 1 scapula, 4
ribs, 2 cervical vertebra, 4 thoracic vertebra, 2
lumbar vertebra, 1 femur, 1 tibia, 1 fibula, 1
patella, 1 sacrum, 1 pelvic bone (Hip bone)’.
For the purpose of this study we have
classified bones as major (main important) and
minor bones. The major bones were as
mentioned above. The ear ossicles, carpal and
tarsal bones were considered to be minor
bones for the study purposes as their absence
is common.
34/67 (50.7) students owned a complete half
boneset of a correct shape size and contour.
The rest had broken or damaged bones.
Table 1: Completeness of bone sets and the type
new and old
Complete
boneset In complete
boneset Total
New bone
set 5 5 10
Old
boneset 29 28 57
Total 34 33 67
Table 1 state that the completeness of the
boneset is not statistically linked to the type of
the boneset new or old. Sometimes the bones
of two or more different dead bodies are mixed
in one set to make it complete. Out of the 33
incomplete bonesets 28 (84.8%) were deficient
in main bones like long bones.
4.3 Knowledge regarding purchase of
bonesets
30% of the students (21) did not know that one
had to purchase bonesets right at the start of
the academic term. They got to know it within
15 days of the beginning of the class. Out of
the 70 students, 49 students knew that
bonesets could be purchased from their
seniors, attenders, shops etc. But the rest 21
did not have any clue whatsoever. 73.5% of 49
students knew that seniors would sell them a
set, 8.2% knew that attenders would sell them
a set, 10.2% knew that sets could be
purchased from the shops or online. 40
students (59.7%) have taken the opinion from
other person before buying the boneset. 27
students did not consult any other person
before purchase. Out of these 40, 36 students
consulted an MBBS doctor before purchase of
the set.
Table 2: showing the difference between the cost of
purchase and the ideal cost thought by the students
Cost of
purchase Cost thought
to be ideal
No % No %
1500-2500 36 53.7 40 59.8
2500-3500 17 25.4 20 29.8
3500-4500 13 19.4 7 10.4
>4500 1 1.5 0 0
Total 67 100 67 100
Table 2 shows that at least 7 students thought
that they could have purchased the boneset at
a lower price.
Table 3: Criteria considered prior to purchase by
those who had already purchased the bonesets.
Number of
students % (n=67
students)
Damage to bones 60 89.5
Number of bones 53 79.1
Color of bones 14 20.89
Varnish 16 23.8
Foul smell 27 40.2
Others 5 7.4
Table 3 states that most of the students looked
for damage of bone contour and the number of
bones. 65% prefer new bonesets over old. 35
students answered correctly why they
preferred old or new bonesets correctly. 61.2%
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answered that the bones which were marked
gave good guidance in studies as compared to
the fresh bones. 87% of the students told that
they used to store bones in a cool and dry
place in a polythene bag. This can only be
confirmed by visiting the places of storage
which is outside the purview of this research
paper.
4.4 Knowledge regarding use/maintenance of
bonesets
Out of the total 70 students who participated
41.45 (29) used the boneset once a week that
too only those bones which were questioned
about in the Osteology demonstration and viva
voce exams were used during that week.
27.1% (19) used them once in 15 days and
27.1% used it once a month. 87.1% of the
students washed their hands before and after
using bones. The other 12.9% did not bother
much about the hand washing. 57/67 students
own an old bonesets out of these 57, 36
students bonesets had markings on it.
Table 4: Reasons for bone damage thought by the
students during use
Ways of damage to
bones No %
Marking by sharp
objects 28 41.7
Acid, spirit, water or
moisture 12 17.9
Fungus 23 34.33
Ants 17 25.3
Animals 9 13.4
Oxidation by air 3 4.4
Table 4 shows that still the knowledge
regarding the damages done to bones is
lacking among the 1
st
MBBS students. Only
41.7% of students thought that sharp objects
could damage the bones. There is no mention
of rats, cats, or other animals, damaging the
bones. Many of such animals especially cats
are are kept as pets by medical students in the
college. This ignorance could prove to be
hazardous.
Table 5: Perfectness of boneset
Students with near
perfect boneset Students with reasonably
acceptable boneset Students with badly
damaged bones of
the boneset
Total
Number 25 20 2 47
% 53.1 42.5 4.4 100
Out of the two students who had damaged
bone sets one scapula was badly damaged.
The damage was repaired with the help of
wax.
4.5 Services rendered to the students during
the course of the study
The students were then requested to bring
their bonesets and the following findings were
observed. Out of the total 67 students who
possessed the bonesets 47 students brought
their bonesets to the department and got it
examined by the first author. The authors
repaired them free of cost and returned them
to the students. Thus Zero budget intervention
proved to be quite effective in inculcating
interest in the subject as well as respect for the
department in the minds of students.
A thorough Checklist was then made which
included Dos and Don’ts regarding the
purchase and use of bonesets. It included
keeping away from pets, rodents, fungus,
humidity, water, cleaning regularly with a clean
cotton cloth, correct price of purchase, regular
varnish, and storage in a cool dry place. The
check list is still being circulated among
students of KVG Medical College. A follow up
study is planned to know the cost benefit
analysis of this checklist among the future
batch of medical students.
5. Discussion
5.1 Storage of bones
The place where bones are stored should not
be liable to abrupt swings in humidity and
temperature. Relative humidity should
generally be in the middle range (35-70%) and
should not be allowed to rise above 85%.
Excessive humidity may result in mould
growth; especially in damp buildings.
Extremely low humidity may cause cracking or
flaking of bone; especially in centrally heated
buildings. Storage should not be done under
direct sunlight since UV rays damage bones.
The storage environment should not be too
cold. Rodents and other pests should not be
allowed to enter the storage place. Appropriate
health and safety regulations must all be
complied with. Human bones do not pose any
particular health and safety threats. (Lammy et
al., 2005; Ahrndt et al., 2013) but they must be
handled with utmost care and respect (Tandy
et al., 2007)
5.2 Innovation in the present study
The recent trends towards minimal access
surgeries, necessitates the perfect knowledge
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of relations of anatomical structures with
regards to the corresponding bones. In-depth
knowledge of anatomical structures is now
considered to be absolutely essential to the
success of an operative intervention (Pawlina
et al., 2004). No such study has been done in
any medical college in India on such an
important topic so far as the author’s
knowledge goes. Some of the basic concepts
in anatomy like, nutrient foramen are directed
away from to the growing end of the bone, line
aspera is present in the posterior surface of
femur etc. may not be visible if the bones are
used year after year without proper care. It is
hypothesized that first year MBBS students
who use the bonesets often do not have
adequate knowledge about their maintenance
as bonesets get damaged/undergo wear and
tear, which is also proved in the current study.
This is doubly troubling as visual impact of
foramens and ridges proves to be the best
available information for the students even
today. Most of the students fail to understand
the negative impact of the artificial ridges or
false foramina on them. Heavy penalty of not
concentrating on sufficient anatomy education
will inevitably lead to incompetent anatomists
and health care professionals, leaving patients
to face dire and resentful repercussions has
also been confirmed (Sugand et al.,2010).
There are no special demonstrations
prescribed in the curriculum by the Medical
Education in India targeting this particular
issue.
5.3 Reason for price rise elsewhere and in the
current study setting –Demand and supply
problem
Most of the parents who own a nursing home
or hospital, at least in India want their
offspring’s to pursue medicine as a profession.
Due to higher demand for medical education,
zooming number of seats in medical colleges,
mushrooming of new medical institutions, it
has become a distant dream for every
institution to meet the ever increasing demand
for these bonesets. The prices of the sets are
souring sky-high due to acute shortage of
cadavers and are predicted to go higher up if
body donations to medical education do not
keep up in pace. It is a herculean task to
procure the bonesets especially in district of
Dakshina Kannada where 7 medical colleges
each of 100-150 seats and equal number of
dental, nursing colleges exist. Each complete
skeleton for the museum cost 40000-45000 Rs
in the market. There are several ways to
produce bones by the Medical colleges from
dead cadavers after converting them into
skeletons by burying. There are many legal
and ethical issues of transportation of human
bones from one place to another, the
discussion of which is out of context of this
paper. Approximately a boneset of a good
quality costs 3000-4000Rs in the current study
setting. If middlemen are present then the cost
even goes higher. If students purchase it at a
higher price they then even sell it for a higher
than price they purchased it for (Table 2). This
price rise worries the authors. According to the
authors this will surely inculcate business
attitude in the minds of students during their
first MBBS course itself. They may thus start
equating human remains as object of profit.
This sort of mentality is horrendously
dangerous for the medical fraternity. It is very
deplorable state which can be prevented by
various interventions proposed in the study.
Bonesets are also required by dental students,
nursing students’ anthropologists, and students
of other paramedical courses. In short, the
supply demand position of bonesets is highly
unsatisfactory at least for today. The study of
bones is essential for every discipline of
medicine be it Ayurveda, Unani, allopathic,
homeopathy as well as veterinary medicine.
The protuberances, nutrient foramina,
prominences, sutures in the skull and grooves
of the nerves cannot be exactly replicated
artificially and natural undamaged bones are
the only tools to learn these features. From the
bones we can assess the age, sex, race, and
ethnicity as well as differentiate them as
human and non-human. Craniometry,
pelvimetry etc. can give us a broad overview of
the skull capacity and pelvis shape
respectively. We can also assess the
approximate stature by using anthropometric
formula from the length of long bones as well
as skull. We can also assess the type of face
from the complete bony details by using
computers software. Thus its usefulness in
Forensic Medicine is also beyond doubt.
5.4 Factors which determine bone preservation
Factors which determine bone preservation,
both intrinsic and extrinsic, may act dependent
or independent upon each other. Intrinsic
factors include the chemistry, size, shape,
structure, and density of bone, along with
pathological changes to bone structure.
Extrinsic factors include ground water, soil
type, temperature and air, along with the
nature of local flora and fauna, method of
burial and human activity (Dent et al., 2004).
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5.5 Message to global audience students and
anatomists
Globally people should pledge to donate their
bodies after death to Medical colleges for
dissection and learning purposes. This will
reduce the demand and supply problems in the
field of anatomy. Globally for the medical
students message is that we should store the
bonesets properly so that future generation of
doctors can learn it correctly. Bonesets should
be ideally purchased from lab assistants or
anatomy departments of respective medical
college or after the opinion of a trained
anatomist at the start of the 1
st
year MBBS
course to understand the subject of Osteology
thoroughly, as it forms the basis of all surgical
knowledge. It should be returned back to
department every year for varnish and repair.
Anatomists must make a register which needs
to be maintained in the department itself
regarding the sale and purchase of the
bonesets. A workshop or lecture by a qualified
anatomist from the anatomy department before
purchase could equip the prospective buyer
with adequate knowledge regarding its
purchase and maintenance. A checklist before
purchase needs to be made, and circulated
among the students and their parents so that
they are made aware of the facts prior to
purchasing it. Such studies should be done in
other medical colleges also to know the impact
of such a novel intervention on the minds of
budding medical freshers.
5.6 Future possibilities that the next
researchers need to explore
The future researchers need to explore the
reasons for shortage of bonesets in the
medical colleges and newer ways to
scientifically and legally procure them.
Conclusions
The current study states that we need to
improve the knowledge of students regarding
purchase and use of bonesets. We also need
to inform them about the list of bones which
are present in a complete boneset prior to
purchase. We need to change their attitude
regarding storage of bones so that the bones
are not subjected to damages. We need to
teach them about the importance of hygiene
and hand washing practices before and after
handling bones.
Research Highlights
The knowledge regarding purchase of
bonesets among medical students is poor.
30% of the students did not know that one had
to purchase bonesets right at the start of the
academic term
Out of the 33 students who had
incomplete bonesets 28 (84.8%) bonesets
were deficient in main bones like long bones.
The medical students are not
competent enough to maintain and store the
bonesets properly.
The medical students do not practice
any hygienic hand washing practices before
and after use of bonesets. Only 87.1% of the
students washed their hands before and after
using bones
Limitations
The current study has taken into consideration
a small study population which might have
influenced the study findings. Also there was a
30% non-response rate which might have also
introduced a non-response bias in the study.
These could have been taken care of by taking
a large sample from different medical colleges
in India.
Funding and Policy Aspects
This is a zero budget study. There were no
funds received from any organization for the
study. The people need to be made aware that
donating the body for the purpose of medical
college dissections is a social service to the
medical fraternity. Hence body registry for
donation should be made possible by the local
government and nongovernmental
organizations. The current policy of voluntary
donation of dead body needs to be amended
in such a way that funding for awareness
regarding body donation is generated from the
Government as well as NGOs.
Authors’ Contribution and Competing
Interests
There are no conflicts of interest from all
authors.
1. Dr Shruthi Bhat Assistant Professor in
Anatomy KVG Medical College Sullia
Karnataka India First author- Idea, data
collection, data entry, analysis, manuscript
preparation, data analysis, report writing,
editing.
2. Dr Sagar Borker- Associate Professor in
Community Medicine KVG Medical College
Sullia Karnataka India Co- Author - Idea, data
collection, data entry, data analysis,
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176
manuscript preparation, data analysis, report
writing, editing.
3. Dr Sheela G Nayak- Principal AND
Professor in Anatomy KVG Medical College
Sullia Karnataka India Manuscript Editing 4. Dr
Vidyashambhava Pare- Professor in Anatomy
KVG Medical College Sullia Karnataka India
Editing the manuscript.
Acknowledgement
We would like to thank MBBS students of 2013
batch for cooperating in giving the data. We
also thank the teaching and non teaching staff
of Anatomy Department, Management of KVG
Medical College for their support and
guidance.
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Anatomy has historically been a cornerstone in medical education regardless of nation or specialty. Until recently, dissection and didactic lectures were its sole pedagogy. Teaching methodology has been revolutionized with more reliance on models, imaging, simulation, and the Internet to further consolidate and enhance the learning experience. Moreover, modern medical curricula are giving less importance to anatomy education and to the acknowledged value of dissection. Universities have even abandoned dissection completely in favor of user-friendly multimedia, alternative teaching approaches, and newly defined priorities in clinical practice. Anatomy curriculum is undergoing international reformation but the current framework lacks uniformity among institutions. Optimal learning content can be categorized into the following modalities: (1) dissection/prosection, (2) interactive multimedia, (3) procedural anatomy, (4) surface and clinical anatomy, and (5) imaging. The importance of multimodal teaching, with examples suggested in this article, has been widely recognized and assessed. Nevertheless, there are still ongoing limitations in anatomy teaching. Substantial problems consist of diminished allotted dissection time and the number of qualified anatomy instructors, which will eventually deteriorate the quality of education. Alternative resources and strategies are discussed in an attempt to tackle these genuine concerns. The challenges are to reinstate more effective teaching and learning tools while maintaining the beneficial values of orthodox dissection. The UK has a reputable medical education but its quality could be improved by observing international frameworks. The heavy penalty of not concentrating on sufficient anatomy education will inevitably lead to incompetent anatomists and healthcare professionals, leaving patients to face dire repercussions.
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