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Assessment in anatomy

January 2015
European Journal of Anatomy 19(1):105-124

Authors:

Erich Brenner

Innsbruck Medical University

Andy R. M. Chirculescu

Carol Davila University of Medicine and Pharmacy

Concepción Reblet

University of the Basque Country

Claire F. Smith

University of Sussex

From an educational perspective, a very important problem is that of assessment, for establishing competency and as selection criterion for different professional purposes. Among the issues to be addressed are the methods of assessment and/or the type of tests, the range of scores, or the definition of honour degrees. The methods of assessment comprise such different forms such as the spotter examination, short or long essay questions, short answer questions, true-false questions, single best answer questions, multiple choice questions, extended match questions, or several forms of oral approaches such as viva voce examinations.Knowledge about this is important when assessing different educational objectives; assessing educational objectives from the cognitive domain will need different assessment instruments than assessing educational objectives from the psychomotor domain or even the affective domain.There is no golden rule, which type of assessment instrument or format will be the best in measuring certain educational objectives; but one has to respect that there is no assessment instrument, which is capable to assess educational objectives from all domains of educational objectives.Whereas the first two or three levels of progress can be assessed by well-structured written examinations such as multiple choice questions, or multiple answer questions, other and higher level progresses need other instruments, such as a thesis, or direct observation.This is no issue at all in assessment tools, where the students are required to select the appropriate answer from a given set of choices, as in true false questions, MCQ, EMQ, etc. The standard setting is done in these cases by the selection of the true answer.

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Assessment in anatomy

The Teaching of the Anatomical Sciences Eur. J. Anat. 19 (1): 105-124 (2015)

Erich Brenner

1, 5

, Andy R.M. Chirculescu

2, 5

, Concepción Reblet

3, 5

and Claire Smith

4, 5

Division of Clinical and Functional Anatomy, Medical University of Innsbruck, Innsbruck, Austria,

Department

of Anatomy and Embryology, Faculty of Medicine, Carol Davila University, Bucharest, Romania,

Departamento de Neurociencias, Facultad de Medicina y Odontología, Universidad del Pais Vasco (UPV/EHU), Viz-

caya, Spain,

Anatomy, Brighton and Sussex Medical School, University of Sussex Campus, Falmer, United Kingdom,

and

Members of the Trans-European Pedagogic Anatomical Research Group (TEPARG)

SUMMARY

From an educational perspective, a very im-

portant problem is that of assessment, for estab-

lishing competency and as selection criterion for

different professional purposes. Among the issues

to be addressed are the methods of assessment

and/or the type of tests, the range of scores, or the

definition of honour degrees. The methods of as-

sessment comprise such different forms such as

the spotter examination, short or long essay ques-

tions, short answer questions, true-false questions,

single best answer questions, multiple choice

questions, extended match questions, or several

forms of oral approaches such as viva voce exami-

nations.

Knowledge about this is important when as-

sessing different educational objectives; assessing

educational objectives from the cognitive domain

will need different assessment instruments than

assessing educational objectives from the psycho-

motor domain or even the affective domain.

There is no golden rule, which type of assess-

ment instrument or format will be the best in meas-

uring certain educational objectives; but one has to

respect that there is no assessment instrument,

which is capable to assess educational objectives

from all domains of educational objectives.

Whereas the first two or three levels of progress

can be assessed by well-structured written exami-

nations such as multiple choice questions, or multi-

ple answer questions, other and higher level pro-

gresses need other instruments, such as a thesis,

or direct observation.

This is no issue at all in assessment tools, where

the students are required to select the appropriate

answer from a given set of choices, as in true false

questions, MCQ, EMQ, etc. The standard setting is

done in these cases by the selection of the true

answer.

Key words: Assessment – Knowledge – Skills –

Attitudes – Written exams – Practical exams –

Structured observation – Portfolio – Extended

matching questions – Spotter tests

INTRODUCTION

A series of cooperation programs focused on

education were organized and financed by EU

(1990-2013: Tempus, Erasmus–Socrates, etc.), to

elicit and develop bilateral mobilities of teaching

staff and students (undergraduate and PhD lev-

els), in order to facilitate contacts and develop

partnerships, at both levels. They were designed

to evaluate the competency and professionalism,

as a concrete starting point for ensuring a minimal

compatibility of the education standards, between

EU members and candidates and a common basis

for a valid and equitable European Credit Transfer

System (ECTS), generally accepted in all Europe-

an countries, especially for medics and dentists.

This raises questions of core curriculum or bench-

mark, organization of courses in units, methods of

105

REVIEW

Corresponding author: Erich Brenner. Division for Clinical

and Functional Anatomy, Medical University of

Innsbruck, Müllerstrasse 59, 6020 Innsbruck, Austria. Phone:

+43 512 9003 71121; Fax: +43 512 9003 73112.

E-mail: erich.brenner@i-med.ac.at Submitted: 25 November, 2014. Accepted: 29 December,

2014.

106

Assessment in anatomy

teaching and assessment.

Assessment must ensure a good compatibility

between different schools, in both the same coun-

try and in different countries, as well. The use of

external examiners (largely used in UK and Ire-

land) has to ensure a higher rate of objectivity and

a more constant level of exigency, as well as bet-

ter dialogue and opinion exchanges between insti-

tutions.

From this perspective, a very important problem

is that of assessment, for establishing competency

and as selection criterion for different professional

purposes.

In fact, assessment may be directed toward three

main tasks:

1. the evaluation of achievements in educational

objectives acquired during a whole term or a

short-term intensive course;

2. the evaluation of achievements in educational

objectives acquired during self-learning / train-

ing, according to a recommended curriculum;

3. the evaluation of efficacy of a lecture, confer-

ence, workshop, seminar or whatever – tested

before and after the session.

Assessing the students’ progress in anatomy

does essentially not differ from assessing in other

disciplines. Assessing in anatomy has to obey the

same general parameters as there are objectivity,

validity, and reliability.

Objectivity is of course important. All students

must be assessed the same way, the same diffi-

culty, and without distinction of person. An objec-

tive assessment will be widely accepted by the

students. Objectivity becomes a topic of concerns

when different assessors are satisfied with differ-

ent levels of knowledge, skills, etc. The magic

word for objectivity is standardization. The more

the questions or tasks for the assessment are uni-

fied throughout the assessors and the more the –

expected – answers, actions, or even behaviours

are standardized, the more objective is the assess-

ment. As a matter of fact, there is no totally objec-

tive assessment as each assessment will contain

inherent biases built into decisions about relevant

subject matter and content, as well as cultural

(class, ethnic, and gender) biases.

Validity is an often stressed and repeated term,

which means that an assessment must measure

what was intended to measure with this assess-

ment. Validity refers to how well the assessment

instrument actually measures the underlying out-

come of interest; validity is not a property of the

assessment instrument itself, but rather of the in-

terpretation or specific purpose of the assessment

instrument with particular settings and learners

(Sullivan, 2011). This is important when assessing

different educational objectives; assessing educa-

tional objectives from the cognitive domain will

need different assessment instruments than as-

sessing educational objectives from the psycho-

motor domain or even the affective domain. Validi-

ty itself can be split to four different aspects. The

first of it is the content validity, which means that

the assessment’s content must measure (pre-)

defined educational objectives. The second aspect

is the criterion validity, which means that the as-

sessment’s outcomes (scores) should correlate

with an external reference, or is predictive. The

third aspect is the construct validity, which means

that the assessment corresponds to other signifi-

cant variables, for instance varying backgrounds.

The fourth and final aspect seems quite simple,

the face validity, which means that the item or the-

ory behind makes sense, and it is seemingly cor-

rect to the expert.

Reliability is often intermingled with and misin-

terpreted as objectivity. Reliability means that an

assessment consistently achieves the same re-

sults with the same or a quite similar cohort of stu-

dents when administered repeatedly (Sullivan,

2011). There are several issues influencing an

assessment’s reliability such as ambiguous ques-

tions, inappropriate or incomplete instructions, or

untrained test-takers. This is quite obvious in prac-

tical exams, but is even true in simple-looking mul-

tiple choice questions-exams. A reliable assess-

ment is temporal stable when its repetition within a

short time with the same or a very similar cohort

will produce similar results. A reliable assessment

possesses form equivalence when the perfor-

mance of test-takers is equivalent on different

forms of an assessment based on the same con-

tent. A reliable assessment has internal consisten-

cy when the responses are consistent across dif-

ferent tasks or questions.

Some other aspects of the students’ activity are

now considered as important to be included into

the final marking. Among these additional aspects,

which might be assessed, there are manual skills,

presentation skills (display), writing skills, oral

communication, ethical and professional develop-

ment, position to science philosophy, experimental

design / analysis of scientific literature, data analy-

sis and interpretation, team work ability, individual

initiative, originality, IT competence skills and

many others, which completely lack from some

schools marking criteria for assessment in anato-

my. The use of a Personal Development Planning

(PDP) system and of academic and personal tuto-

rials appears as most recent and attractive ap-

proach. Anyhow, it can be included as one of the

agreed methods of evaluation across EU. Estab-

lishing an Honours degree classification is consid-

ered very stimulatory to increase students’ motiva-

tion for learning performances.

The selection of an assessment instrument is

mainly depending on what the students should

have learned. Indeed it has long been established

that assessment drives learning (Biggs and Tang,

2011). Among the collection of more or less elabo-

rated instruments there are some, which are suita-

E. Brenner et al.

107

ble for testing the students’ achievements in the

cognitive domain, and there are others, which can

be used for testing items in the psychomotor do-

main. The vast number of instruments does also

contain formats suitable for an assessment of edu-

cational objectives from the affective domain.

There is no “golden rule”, which type of assess-

ment instrument or format will be “the best” in

measuring certain educational objectives; but one

has to respect that there is no assessment instru-

ment, which is capable to assess educational ob-

jectives from all domains of educational objectives.

Adopting the best assessment instrument is cru-

cial, in that it needs to link together the aims and

learning outcomes and test appropriately the right

domain, this is termed constructive alignment

(Gibbs and Habeshaw, 1989). To ensure align-

ment a blueprint is constructed in which the learn-

ing outcomes are matched to the examination

mode and the questions asked. Biggs’ (1999)

model of constructive alignment suggested that

when assessment is designed, a three-stage mod-

el should be used:

1) Identify clear learning outcomes that students

can achieve and demonstrate (i.e. what is

achievable for that point of study and from

previous experience).

2) Design appropriate assessment tasks that will

directly assess whether each of the learning

outcomes has been satisfactorily met (can

MCQ or EMQ questions assess if a student

has the knowledge to identify an object?)

3) Design appropriate learning experiences or

opportunities, so that the assessment tasks

are achievable (formative assessments).

In the following, we will use a very simple example,

the glenohumeral joint (GHJ). We will try to estab-

lish educational objectives from the cognitive do-

main, the psychomotor domain, and even the af-

fective domain.

GENERAL PROBLEMS IN ANATOMICAL

ASSESSMENT

The main question in planning anatomical educa-

tion and therein assessment is, what do medical

courses need to assess in students. The main

question is, in fact: “How is the content of anatomi-

cal education defined that a certain medical school

expects its students to learn?” Possible answers

include specific objectives given to the students,

general goals from which students must produce

specific objectives for themselves, and a curricu-

lum composed of core portions and/or extended

(or elective) portions (Chirculescu et al., 2007).

An evaluation of the students’ “core” knowledge

requires an agreed “core” syllabus. For each type

of assessment, this is a compulsory condition. In

this respect, ASGBI produced and published a pro-

posed outline of the core knowledge of anatomy,

as a benchmark that its Education Committee felt

should be expected of medical students and young

doctors (McHanwell et al., 2007). Another ap-

proach was made in the AMEE guide No. 41

(Louw et al., 2009).

All thinking processes must be based on underly-

ing information and the question whether the stu-

dents have that underlying information. When this

question is answered satisfactorily, the next ques-

tion is if the students can use that information in a

logical, deductive, correlative manner in order to

arrive at diagnoses, treatments, management

plans, etc. Finally, the question has to be, whether

the students can show that they know the evi-

dence on which their thinking is based. In relation

to assessment, this means that different tools are

needed for evaluating core knowledge, the exten-

sion of knowledge beyond core, establishing an

Honours degree classification, for establishing

competency, or as a selection criterion for different

professional purposes.

Assessing knowledge – the cognitive domain

The cognitive domain is the best known and

most assessed domain of educational objectives

(Anderson et al., 2001; Bloom et al., 1956; Krath-

wohl, 2002). This cognitive domain comprises at

least two dimensions, the dimension of (possible)

contents and the dimension of the progress, what

a learner should be able to do with the content. [As

a matter of fact, Krathwohl defined a “knowledge

dimension” and a “cognitive process dimension”,

which constitute the cognitive domain (Krathwohl,

2002). In order to use these dimensions for all

three domains, we redefined the “knowledge di-

mension” as the “content dimension” and the

“cognitive process dimension” as the “progress

dimension”.]

The content dimension contains – of course –

factual knowledge, i.e. in our case the knowledge

of anatomical facts and the – medical/anatomical –

terminology. But without knowing what to do with

these facts, it will be impossible to assess the stu-

dents’ learning progress. Another item of the con-

tent dimension is the conceptual knowledge. Be-

sides the factual and conceptual knowledge we

find also procedural knowledge, i.e. the knowledge

of methods or procedures. Finally, the content di-

mension of the cognitive domain contains meta-

cognitive knowledge, i.e. knowledge of the princi-

ples and generalizations, theories, structures, and

abstractions in a certain field.

Using the glenohumeral joint, examples of con-

tents could be:

• factual knowledge: the ligaments of the GHJ

• conceptual knowledge: the principle(s) of a

spheroid joint, with the GHJ as an example

• procedural knowledge: the process to evalu-

ate the range of motion of the GHJ

• meta-cognitive knowledge: an overview of

resources on the GHJ (textbooks, websites,

models, etc.)

108

Assessment in anatomy

It is obvious that these examples per se cannot be

assessed. It is necessary to define, what the stu-

dent should be able to do with these contents.

These activities are described by the progress

dimension. Very basically, a student should be

able to remember different contents. This can be

assessed by any type of assessment targeting on

the recall of facts. Nevertheless, anatomical edu-

cation should or even must not stop with rote

memorization (which is an often heard indictment

against anatomy as teaching object). Thus, stu-

dents should for instance – as the next item on the

progress dimension – comprehend their

knowledge, i.e. demonstrate their understanding of

facts and ideas by organizing, comparing, translat-

ing, interpreting, giving descriptions, and stating

the main ideas. Of course, comprehension is bet-

ter than mere memorization, but there are even

higher levels of progress. The next step is to apply

or use the knowledge, i.e. solve a problem in new

situations by using acquired knowledge, facts,

techniques and rules in a different way. The next

step is to use the acquired knowledge to analyse a

certain problem or question, i.e. examine and

break information into parts by identifying motives

or causes, make inferences and find evidence to

support generalizations. The ability to analyse is a

major prerequisite for clinical reasoning, which it-

self is a major general educational objective in

medical education. A successful analysis enables

the students as the next step of progress to syn-

thesize all available information, i.e. compile infor-

mation together in a different manner by combining

elements into a new pattern or proposing alterna-

tive solutions. Besides the synthesis there is also

the task to evaluate the (available) knowledge, i.e.

present and defend opinions by making judgments

about the quality of information, validity of ideas or

quality of work, in general based on a set of crite-

ria. Such evaluations are important steps towards

evidence based medicine.

Using the glenohumeral joint, examples of pro-

gress could be:

• remember: recall those ligaments, which are

part of the GHJ

• comprehend: compare the range of motion of

the GHJ with the hip joint

• apply: identify those structures (ligaments,

bones, etc.) of and around the GHJ, which

inhibit the abduction of the humerus beyond

90° and mechanisms involved in continuing

abduction over that limit, i.e. understanding

the three steps of arm abduction: initialization,

GHJ abduction proper, increasing amplitude

by rotation of scapula

• analyse: analyse the cause(s) for the much

higher incidence of anterior dislocations of the

GHJ (vs. other types of dislocation)

• synthesize: propose a program for physical

training in order to prevent anterior disloca-

tions of the GHJ

• evaluate: evaluate current treatment options

for dislocations of the GHJ in terms of the pa-

tients’ age and sex; correlate a GHJ-

dislocation with fractures of clavicle or the

humeral neck, differentiate between paralysis

of accessory, axillary or suprascapular

nerves; evaluate pain related to local damage

or referred pain (e.g. gallbladder, heart)

It is obvious that these different levels of progress

in learning cannot be assessed by the same exam-

ination. Whereas the first two or three levels of

progress can be assessed by well-structured writ-

ten examinations – such as multiple choice ques-

tions (MCQ), or multiple answer questions (MAQ),

other – and higher level – progresses need other

instruments, such as a thesis, or direct observa-

tion.

Furthermore, one has to consider the factor time.

There are – and have to be – differences, when

students are tested. Thus assessments might have

three different aims (Sinclair, 1965):

a. to establish the capacity of the students to

acquire knowledge (assessment immediately

on completion of the program);

b. to determine their ability to retain knowledge

(surprise assessment two years later); and

c. to ascertain their capacity to recover their

knowledge in a specified time (assessment of

post-graduate students).

Assessing skills – the psychomotor domain

Similar to the cognitive domain, the psychomotor

domain has a content dimension and a progress

dimension (Harrow, 1972; Simpson, 1971). The

content dimension comprises skills or competen-

cies such as manual skills, perceptive skills, and

psychosocial (or communicative) skills.

Using the glenohumeral joint, examples of con-

tent could be:

• manual skill: perform a closed reduction of an

anteriorly dislocated GHJ, or local anti-

inflammatory / anaesthetic injection / infiltra-

tion

• perceptive skill: assess the GHJ and its sur-

rounding bursae for crepitus

• communicative skill: document a case of suc-

cessful reduction of an anteriorly dislocated

GHJ and write an appropriate physician’s let-

ter

The progress dimension starts with the percep-

tion, i.e. the process of becoming aware of objects,

qualities, or relations. The perception is followed

by the set, a preparatory adjustment or readiness

for a particular kind of action or experience. The

next step is the guided response as an early step

in the development of skill and comprises both

imitation and trial and error. The guided response

is followed by the mechanism, where the learned

response has become habitual. Whereas the

mechanism addresses mainly simple skills, more

complex ones can be addressed as complex overt

E. Brenner et al.

109

response, which resolves uncertainties. Finally, a

skill is at the level of automatic performance. Miller

reduced this progress dimension for clinical skills

assessment to four steps: “knows”, “knows how”,

“shows how”, and “does” (Miller, 1990); actually

with the first two steps similar to the progress di-

mension of the cognitive domain of procedural

knowledge. Another simplified progress dimension

comprises only three steps, (1) imitation, (2) con-

trol, and (3) automatism (Guilbert, 1998).

Using the glenohumeral joint, examples of pro-

gress could be (note that the terms of the progress

dimension have been transformed to verbs):

• imitate: imitate a puncture of the GHJ

• has control: perform a closed reduction of an

anteriorly dislocated GHJ

• does automatically: assess the range of mo-

tion of the GHJ routinely in different subjects

Obviously, educational objectives from the psycho-

motor domain cannot be assessed by multiple

choice questions tests. When testing skills, the

candidate has to perform the skill and the assessor

has to judge the quality of performance, best by

using a standardized score-card. Another option

would be to assess the final outcome of the skill,

i.e. the “product”. When assessing the skill of per-

forming a subcuticular suture, for instance, either

the process of suturing itself can be observed (in a

structured manner), or the suture itself can be as-

sessed.

Another example of assessing communicative

skills is given at Brighton and Sussex Medical

School, where a written communication project

that is directed at writing for a lay audience, was

incorporated as the main coursework element

(Evans, 2007). For this summative assessment, all

students are ‘commissioned’ by the editor of a ficti-

tious newspaper or popular magazine to write a

short lay statement of no more than 500 words in

response to a letter from a member of the public

regarding a defined clinical condition associated

with reproductive or loco-motor anatomy. State-

ments were assessed against a defined set of

marking criteria, which focus on aspects such as

interest, readability and presentation and each

component was classified against an A-E grading

scale.

An element unique to anatomy is its three dimen-

sional nature and this ties together the cognitive

and the psychomotor domain of the subject.

Spatial ability is the ability to perceive, retain and

recognize or reproduce three-dimensional objects

in their correct proportions when they are rotated

in space, translated, juxtapositioned, projected,

sectioned, re-assembled, inverted, re-orientated or

verbally described.

In anatomy spatial ability has been found to be a

good predictor of students’ success in learning

anatomy and examination performance. Spatial

ability might be even more important than the type

of educational materials that are studied (Garg et

al., 2001). It is understood that spatial ability in

anatomy can be trained (Fernandez et al., 2011),

in particular the ability to judge distance (metric

ability), including depth perception. In attempting to

explain this unique element of anatomy the term

‘Touch mediated perception’ (Smith and Mathias,

2010) has been created. Current thinking has not

yet explained how spatial ability and understanding

the three dimensional nature of anatomy can best

be assessed. Having said that three dimensional

understanding is essential in applying knowledge,

as is demonstrated by damage to underlying struc-

tures in surgery where this awareness is lacking

(Ellis, 2002).

Spatial ability is a skill that substantially helps

professional training and exercise of any health-

care career. Spatial ability can be strongly devel-

oped with dissection of human cadavers comple-

mented with the observation of radiological images

and other diagnostic images. Indeed, all these

tasks if practiced together create mental images of

the structure of the body in the person making.

These mental images are essential not only for

surgeons but even more to perform physical ex-

ams and interpret radiological images. We consid-

er that the best method in order to assess the spa-

tial ability and three dimensional understanding of

the students is by structured practical exams and if

possible the exam in the lab of dissections made

by them, which should be explained by the dissec-

tor during viva voce. Portfolio is also a good op-

tion.

Assessing attitudes – the affective domain

The affective domain is the most frightening for

assessors. Nevertheless, also the affective domain

can be analysed for its content dimension and pro-

gress dimension (Anderson et al., 2001; Krathwohl

et al., 1964) and therefore prepared for assess-

ment. That might be particularly important for all

examinations a future physician has to pass, from

the very beginning until her or his final qualifica-

tion.

First of all, there are definition problems for the

content dimension. In general, the content di-

mension describes the way people react emotion-

ally and their ability to feel another person’s pain or

joy. Affective objectives target the awareness and

increase in attitudes, beliefs, mental images, emo-

tions, feelings, and related behaviours.

In contrast to the content dimension, the pro-

gress dimension is easier to define. First of all,

there is the level of receiving, i.e. a phenomenon

of awareness, willingness to hear/see/feel, and

paying selected attention. Without receptivity no

learning can occur. As the next step follows the

level of responding, i.e. there is an active participa-

tion, where the learners attend and react to a par-

ticular phenomenon. This is superseded in the

next step by valuing, where student attaches a

value to an object, phenomenon, or piece of infor-

110

Assessment in anatomy

mation. The next step is organizing, where differ-

ent values, information and ideas are put together

and the student accommodates them within her/his

own mental representations; this is important for

being reflective. Finally, one is internalizing the

educational objectives, when the student holds a

particular value or belief that now exerts influence

on his/her belief and behaviour, so that it becomes

a characteristic, thus building up a value system –

including the targeted educational objectives – that

controls her/his behaviour. A simplified version of

the progress dimension is limited to the steps

“ r e c e p t i v i t y ” , “ r e s p o n s e ” a n d

“internalization” (Guilbert, 1998).

Examples, not directly related to the gleno-

humeral joint, could be:

• receives: listen to others with respect

• responds: assists patients to express their

concerns towards surgery

• values: is sensitive towards cultural differ-

ences (shows value diversity)

• organizes: organizes values into priorities by

contrasting different values

• internalizes: displays a professional commit-

ment to ethical practice on a daily basis

As it is the case with the psychomotor domain, the

affective domain can’t be assessed by simple writ-

ten examinations such as a multiple choice ques-

tions test. This domain can be assessed by either

structured observation formats or feedback for-

mats.

Assessing professionalism

Professionalism, as manifested through a com-

mitment to carrying out professional responsibili-

ties, adherence to ethical principles, and sensitivity

to a diverse patient population is coming to the

forefront as one of the six major requirements in all

residency programs (Escobar-Poni and Poni,

2006). Gross Anatomy laboratories, based on ca-

daver dissections, seem to provide the more im-

plicit skills to develop the basic elements of profes-

sionalism that are evaluated during clinical rota-

tions (Escobar-Poni and Poni, 2006); they must be

recognized and consecutively taught in order to

evaluate them. These authors compiled a list of

elements of professionalism commonly accom-

plished and evaluated during gross anatomy

courses with cadaver-instruction (Table 1). They

also suggested a set of tasks and activities, which

can be included as learning objectives that can be

taught, evaluated, corrected, and awarded. These

tasks and activities comprise the creation of a

“clinical anatomy chart”, the compilation of

“progress notes”, the establishing of a “box of ob-

servations and suggestions”, the formal establish-

ing of the “dissecting team”, “peer-teaching”,

“commemorative services”, “interaction with the

relatives of the donors”, “peer review evaluations

on professionalism”, and finally the development of

“self-reflection and journals/portfolios”.

Another example of assessing the development

of the attributes of professionalism was developed

at the School of Medicine and Dentistry of The

Queen’s University of Belfast (Heyns, 2007). An

educational strategy based on role-playing was

developed to engage all students around the dis-

section table. Students received comprehensive

background reviews on professionalism, its attrib-

utes and the identification of such attributes in the

context of the dissection room. Roles, with specific

duties attached, were allocated to each team

member. Circulating academic staff members di-

rectly observed student participation and gave

formative feedback. Students were given the op-

portunity to reflect on their ability to identify the

attributes and reflect on their own and their peer’s

ability to develop and practise these attributes.

OPERATIONALIZATION – FROM EDUCATION-

AL OBJECTIVES TO ASSESSMENT TASKS

Educational objectives consist of an object

(usually a noun) and an action (or verb). The ac-

tion generally refers to the targeted progress di-

mension, whereas the object describes an item of

the targeted content dimension, which students

are expected to acquire or construct (Anderson et

al., 2001). In other words, educational objectives

are a function of an action over an object. In order

to make educational objective more readable,

each objective should be preceded by a – more or

less – general statement such as “the successful

candidate will be able to …” or “the student will be

able to …”.

Our previous examples will therefore be stated in

the following manner.

“The successful candidate will be able to …

...recall those ligaments, which are part of the

GHJ;

...compare the range of motion of the GHJ with

the hip joint;

...identify those structures (ligaments, bones,

etc.) of and around the GHJ, which inhibit the ab-

duction of the Humerus beyond 90°;

...analyse the cause(s) for the much higher inci-

dence of anterior dislocations of the GHJ (vs. other

types of dislocation);

...propose a program for physical training in order

to prevent anterior dislocations of the GHJ;

...evaluate current treatment options for disloca-

tions of the GHJ in terms of the patients’ age sex

and profession;

...imitate a puncture of the GHJ;

...perform a closed reduction of an anteriorly dis-

located GHJ;

...assess the range of motion of the GHJ routine-

ly in different subjects;

...listen to others with respect;

...assist patients to express their concerns to-

wards surgery;

...be sensitive towards cultural differences

E. Brenner et al.

111

(shows value diversity);

...organize values into priorities by contrasting

different values;

...display a professional commitment to ethical

practice on a daily basis”;

An example of intermediate educational objec-

tives for an anatomical dissection class is given in

Table 2 together with their classification and sug-

gestions for assessing.

Of course there has to be a decision: which of

these objectives are valid anatomical objectives,

and which ones are clinical objectives to be allo-

cated to several clinical specialties or disciplines.

This – political – decision should best be made

collaboratively, e.g. by the educational committee,

but when this is not attainable, it must be made

within the discipline of anatomy itself.

Operationalization of educational objectives is

the process of defining a fuzzy concept so as to

make the educational objective clearly measurable

and to test it in terms of empirical observations, i.e.

examinations. In other words, operationalization is

the process of strictly defining variables into meas-

urable factors. In other words, an educational ob-

jective describes who (addressed audience, stu-

dents, etc.) does (activity, behaviour) what

Table 1. Elements of Professionalism commonly accomplished and evaluated during gross anatomy courses with ca-

daver-instruction (Escobar-Poni and Poni, 2006)

•

Accepts constructive feedback and modifies behaviour appropriately

•

Adapts style and content of communication appropriately when regarding each cadaver

•

Adheres to institutional policies and procedures

•

Adheres to local dress code

•

Admits errors and assumes personal responsibility for mistakes

•

Advocates for colleagues

•

Advocates for societal health issues

•

Arrives on time for scheduled activities and appointments

•

Attributes ideas and contributions appropriately to others

•

Balances personal needs and patient care obligations

•

Completes assigned share of team responsibilities

•

Conveys information and answers questions honestly and tactfully

•

Demonstrates appropriate boundaries for inter-professional relationships

•

Demonstrates sensitivity to power asymmetries in professional relationships

•

Discusses colleague-issues without using inappropriate labels or comments

•

Discusses donor-issues without using inappropriate labels or comments

•

Displays compassion and respect for all cadavers even under the most difficult circumstances

•

Engages in informal teaching and learning activities with colleagues as appropriate

•

Facilitates conflict resolution

•

Fulfils all laboratory and non-laboratory responsibilities in a timely manner

•

Improves team effectiveness through motivation and facilitation

•

Intervenes immediately when unprofessional behaviour presents clear and present danger

•

Maintains a positive attitude amidst increased and unanticipated additional work

•

Maintains composure during difficult interactions with colleagues

•

Maintains confidentiality of the cadaver information in public areas

•

Maintains thoroughness and attention to detail

•

Makes valuable contributions during class, rounds, or meetings

•

Offers advice when appropriate

•

Optimizes cadaver comfort and privacy when conducting dissection

•

Provides cadaver information to team members in a timely and effective manner

•

Reacts appropriately to other’s lapses in conduct and performance

•

Requests help when needed

•

Responds appropriately to help a distressed or impaired colleague

•

Serves as knowledge or skill resource for others

•

Signs over and ensures coverage of cadaver duties when unable to fulfil responsibilities

•

Solicits and values input from colleagues when appropriate

•

Takes on extra work when appropriate to help the team

•

Takes steps to prevent repetition of error

•

Teaches and emphasizes tenets of professionalism when appropriate opportunities arise

•

Transmits accurate and detailed information for optimal transition of care

•

Uphold ethical standards in research projects and other scholarly activities

112

Assessment in anatomy

(subject matter, content).

When transforming educational objectives into

assessment tasks we have to add at least a criteri-

on, describing the targeted level of quality: “who

does what how well”. The best would be also to

describe the targeted setting, i.e. the location,

time, amount, equipment, etc.: “who does what

how well in which setting” or “who does what how

well under which circumstances?”

When we want a student to be familiar with the

basic terms of orientation (to be able to use these

terms in a regular manner routinely; “in a regular

manner” = how well, “routinely” = in which setting)

we should not set up questions like “What does

‘distal’ mean?” or “Which axes define the frontal

plane?”, but we should simply use these terms in

the examinations in a regular manner routinely.

One of the most difficult steps in operationaliza-

tion is the scaling of the criteria as indicators of the

targeted level of quality. As an example we will use

the following educational objective: “The student

will be able to perform a closed reduction of an

anteriorly dislocated GHJ.” A possible criterion

would be a demonstration in front of the examina-

tors (assessors). Thus, the assessment task would

for instance be “The student performs a closed

reduction of an anteriorly dislocated GHJ in an ob-

served setting.” Now we have to define the levels

of quality, for instance as a nominal scaled

“correctly”, “partially correct”, or “incorrect”. The

examinators’ rating sheet would therefore contain

a statement like:

The student performs a closed reduction of an

anteriorly dislocated GHJ:

• Correctly

• Partially correct

• Incorrect

We could use an ordinal scale when we want to

test for higher levels of progress, i.e. “very often”,

“often”, “occasionally”, “rarely”, and “never”. Trans-

ferred to our example we have to test of course

our student repeatedly.

The student performs a closed reduction of an

anteriorly dislocated GHJ correctly:

• Very often

• Often

• Occasionally

• Rarely

• Never

Of course we could also establish an examination

setting with a defined number of repetitions and

can establish a ratio scale, for instance “N-times

out of 10”.

The student performs a closed reduction of an

anteriorly dislocated GHJ correctly in N times out

of 10 attempts.

Only when this operationalization has taken

place, one can decide on the appropriate assess-

ment instrument. As a matter of fact, exactly this

process is not observed routinely. Very often, the

assessment instrument is selected before the op-

erationalization and the operationalization is omit-

ted.

Assessment instruments

It is obvious that the students’ learning is influ-

enced and directed by the assessment they will

have to take. The selected assessment strategy

defines, to a huge amount, what students are will-

ing to learn, or as Flexner (1910) stated, “However

the teacher teaches […] the way in which the stu-

dent studies is largely influenced by the examina-

tions” (shortened reprint as: Flexner, 2002). As for

instance multiple choice questions (MCQs) foster

factual knowledge within the cognitive domain,

learning of educational objectives from other do-

mains will be set aside by the students and no one

will ever be able to judge whether they have

achieved the necessary progress in these objec-

tives.

Assessments can motivate students by at least

four distinct factors: (1) the relevance of the as-

sessment, (2) the content of the assessment, (3)

enthusiastic teachers, and (4) group-dynamics.

As a general rule, for each domain an adequate

assessment strategy will have to be used. This

rule is not one without exemption; there are educa-

tional objectives from one domain, which should

be assessed by the principal method of another

domain (Brenner et al., 2003).

Screening the educational literature reveals a

vast number of assessment instruments, some of

them quite similar to other formats, some others

seem quite exotic (Table 3). On the other hand,

anatomists seem to be quite traditional when as-

sessing their students using “specific written ques-

tions”, “(practical) spotter examination”, and

“multiple choice question” examinations, no matter

whether they teach in a traditional curriculum, a

problem-based curriculum, or a system-based cur-

riculum (Heylings, 2002). “Integrated case-based

papers” and “specific written anatomical questions”

are seldom used formats, as is the case with

“vivas”, “worksheets”, and “self-directed projects”.

The most interesting result of this study was a very

limited number of complementary usages of differ-

ent formats. Furthermore, assessment is mainly

targeted for identification of anatomical structures,

much less assessments address the applying or

analysing levels.

Besides the general limited selection of assess-

ment instruments, several other tools have been

developed, for instance the “Think-Tank” (Peel,

1998), or the “three-dimensional multiple choice

test” (Schubert et al., 2009).

Standard setting

Assessment tools may also be classified by a

major difference as there are tools requiring the

(active) production of an answer, a behaviour, or a

product, e.g. written paper(s), structured oral ex-

E. Brenner et al.

113

Table 2. Intermediate educational objectives for anatomical dissection (Brenner et al., 2003).

Domain Educational Objective Classification & Assessment

Cognitive

Students will describe the spatial

construction of the human body.

In order to reach this objective, students will have to apply both factual and con-

ceptual knowledge. Dissection will be used as educational activity, and students

will be assessed by a structured oral examination.

Students will describe and explain

the integration of an organ, organ-

system, etc., into the appropriate

higher system.

Students should be able to analyse their systematic factual knowledge in the

context of the topographical specimen they are creating. This implies that they

are also able to apply their conceptual knowledge of topography. The education-

al activity will be dissection, and students’ achievements will be assessed by a

structured oral examination.

Students will delimit the topo-

graphical regions and cavities of

the human body from each other.

This objective calls for analysis and evaluation of factual knowledge. Additional-

ly, appropriate concepts of limitation of regions and cavities contribute to this

objective. This objective will be taught best by dissection, and assessed by a

structured observation.

Students will demonstrate the

ability to differentiate and exclude

based on concrete examples/

specimens.

This one demands for the evaluation of factual and conceptual knowledge. Dis-

section will be the appropriate educational activity and students will be assessed

by a structured oral examination.

Students will describe and demon-

strate the inner and outer surface-

relief of the human body.

Similar to the previous educational objective, this one fosters the evaluation and

application of factual knowledge. Students should learn this objective by dissec-

tion and they will be assessed by a structured oral examination.

Students will recognize and name

prosected entities/structures of the

human body.

This targets the evaluation of factual knowledge. Whereas it seems that this

objective is imminent in anatomical dissection, it has to be stated explicitly. In

order to achieve this objective, students will use dissection as proper education-

al activity and they will be assessed by a structured oral examination.

Students will describe and demon-

strate the layer-sequel in the con-

struction of the regions and cavi-

ties of the human body.

The description of the layer sequel of the human body is a clear application of a

conceptual knowledge. Students should achieve this educational objective by

dissection, and present their achievements by a structured oral examination.

Students will discuss systematic

fundamentals, especially course

and function, in the synopsis of

the structures of a region or cavity.

We map this to the application of conceptual knowledge. The proper educational

activity will be dissection and the appropriate assessment will be a structured

oral examination.

Students will describe and explain

the interaction of organ-systems.

In order to achieve this, students will have to apply and analyse a profound con-

ceptual knowledge of the function of organ systems. Dissection should be the

proper educational activity, and assessment will be made by a structured oral

examination.

Students will demonstrate as well

as describe the different regions

and cavities of the human body,

their content, their function, and

their borders.

In contrast to the first objective, here an analysis of conceptual knowledge is

demanded. Students will have to integrate concepts of systematic anatomy,

topography, function, etc. The educational activity used will be dissection, and

assessment will be made by a structured oral examination.

Students will describe and demon-

strate important 'spreading-streets'

of infections.

Achievement of this necessitates the analysis of conceptual knowledge. The

educational activity will be dissection, and achievements will be assessed by a

structured oral examination.

Students will recognize, under-

stand, demonstrate and document

the individual peculiarities and

variations in the construction.

This comprises both the evaluation of the conceptual knowledge of anatomical

variability, and – to some extend – a distinct communicative skill. Students

should achieve this educational objective by dissection, and their achievements

will be assessed by their portfolio.

Students will learn by mutual

learning and explaining each oth-

er.

Mutual learning and explaining address the meta-cognitive knowledge of learn-

ing processes. We want the students to gain the competence to evaluate these

processes or knowledge, respectively. Students therefore will have to work as a

group together – of course with supervision by the teacher. Assessment will be

done by structured observation.

114

Assessment in anatomy

Table 2 (Cont). Intermediate educational objectives for anatomical dissection (Brenner et al., 2003)

Domain Educational Objective Classification & Assessment

Psychomo-

tor

Students will handle selected

(surgical) instruments appropriate.

Similar to the previous objective, this objective addresses a clinical skill. Again,

we want the students to gain at least control of this manual skill. Therefore, the

usage will first be demonstrated and then trained by application in the process of

dissection. This skill will be assessed by structured observation.

Students will acquire tactile skills.

It targets a professional competence and maps clearly to the psychomotor do-

main. Any enhancement of the students’ tactile skills can address the reproach

that nowadays medicine uses laboratories and machines too extensively. We

want the students to acquire real automatism in this manual (and also percep-

tive) skill. The proper educational activity should be dissection and assessment

will be made by structured observation.

Students will handle specimens

and instruments carefully.

Besides the necessary attitudes, we focus on the manual skill of handling instru-

ments and specimens. It should be learned by dissection and will be assessed

by structured observation.

Students will observe, feel and

describe.

The main target of this educational objective is the clinical skill of perception. We

want the students to achieve a high level of automatism in this important profes-

sional competence. It goes beyond the mere tactile skill addressed previously. It

will be taught by dissection, and assessed by a structured observation and the

students’ portfolio.

Students will describe and demon-

strate the spatial relationships of

anatomical structures to each

other within a certain region or

cavity, but also beyond their bor-

ders.

Whereas the previous one requires a manual skill, this educational objective

targets the control of a – verbal and non-verbal – communicative skill. The ap-

propriate education activity is dissection, and students will be assessed by a

structured observation.

Students will implement an appro-

priate documentation of their own

activities.

This utilizes meta-cognitive knowledge, but mainly targets the psycho-social –

communicative – skill to document all activities of the students themselves.

Therefore, the students will have to manage a portfolio as a product of group-

work, which will be finally assessed.

Students will manage and imple-

ment an exact documentation.

This one is quite similar to the previous objective. The major difference is the

content to be documented: whereas in the former the content of documentation

is the students’ own activities, this objective targets all other entities, such as

special findings, external influences, etc., which can contribute to a full imagina-

tion of the cadaver dissected. As a patient’s file is compiled by different physi-

cians, etc., students are intended to set up and manage a portfolio as a group.

Students will incorporate them-

selves into a team by appropriate

work, especially by transmission

of knowledge, cooperate, lead and

solve conflicts.

This is a quite difficult one to classify as it comprises factual, conceptual, and

meta-cognitive knowledge of group-dynamics and knowledge-transfer, as well

as the psycho-social skills to apply these entities of knowledge. Seen from an-

other point of view, it addresses several entities of professionalism such as the

commitment to professional competence and responsibilities. As for this paper,

we classify this educational objective to the domain of professionalism. Students

should learn by dissection and will be assessed by structured observation.

Students will recognize and docu-

ment deviations from the healthy,

‘normal’ condition.

This educational objective is meant to be mainly a psychomotor skill, which uses

of course conceptual knowledge. The educational activity will be dissection, and

assessment is accomplished by the students’ portfolio.

Affective

Students will demonstrate select-

ed medical techniques, such as

several forms of local anaesthe-

sia, coniotomy, trepanation, tooth

extraction, punctures, and palpa-

tions.

The human cadaver used in anatomical dissection is a good tool for training

several medical techniques. Students should at least gain control for these clini-

cal skills. Selection of techniques has to be done carefully and only techniques

should be used, which are relevant for a general practitioner. The selected tech-

niques will be taught by initial demonstration and following exercise during dis-

section. The students will be assessed by a structured observation.

Students will find and demonstrate

anatomical structures within a

region or cavity, without damage

to other structures within.

Whereas others may consider this educational objective to map into the cogni-

tive domain, we want the students to apply their factual and conceptual

knowledge in the sense of a manual or tactile skill: students should acquire con-

trol of the clinical skill to find and demonstrate anatomical structure by dissec-

tion. We will assess the students by a structured observation.

E. Brenner et al.

115

aminations, structured observations, viva voce,

etc., whereas others require (just) the selection

from given answers (e.g. true-false, MCQ, EMQ,

etc.). These two forms may be combined. This

means that in some circumstances, both the prac-

tical & theoretical steps of an examination might be

first discursive answers, and secondly structured

assessment tools, or vice versa.

This distinction is important in terms of standard

setting. Standard setting is most important for

gaining reliability. In other terms, all assessors

must agree on a common, consolidated set of rat-

ing and scores for the answers, behaviours, or

properties of the students’ products. It is in effect

demarking the cut off between acceptable and not

acceptable (Norcini, 2003).

In anatomy standard setting is frequently em-

ployed to define the pass mark of anatomical

knowledge. However, it is not suitable for associat-

ed skills and attitudes. As described by Cohen-

Schotanus and van der Vleuten (2010) in a de-

tailed analysis of the examination results in medi-

cal schools in the Netherlands, there is no gold

standard in standard setting. In anatomy, criterion-

based methods have tended to be preferred. Both

the Angoff (1971) and Ebel (1972) methods are

commonly used in medical education

(Bandaranayake, 2008), although the suitability of

such a specialized panel of anatomists for Angoff

has not proved to be as reliable as a modified Ebel

(Cohen-Schotanus and van der Vleuten, 2010). A

further problem with both these methods is the

gathering together of a suitably large cohort of

people sufficiently well informed about how anato-

my fits into the overall course structure and aspira-

tions. Anecdotally (and there does not appear to

be any published information on this) the variance

among the expert assessors is sufficiently great to

Domain Educational Objective Classification & Assessment

Psychomo-

tor

Students will express them pre-

cisely and clear orally as well as in

writing by practical application of

the medical and anatomical termi-

nology in clinical and scientific

context.

This communicative – psycho-social – skill is intended to the level of automatism

as we consider it to be a crucial skill in the medical profession. The main educa-

tional activity will be dissection, accompanied by the students’ group-work. This

skill will be assessed by a structured oral examination for the oral part and by

the portfolio for the written part.

Students will respect the dignity of

the dead person.

This objective addresses an attitude, which the students should internalize.

Achievements should be gained both by dissection and group-work. This group-

work should be the planning and implementation of any sort of commemoration.

We will leave it to the students’ decisions, which form of commemoration they

will chose, a – religious – service, a recital, or whatever they want. Assessment

will be made by structured observation, and the students’ are asked to add the

materials used for preparation and implementation, e.g. letters, programs, etc.,

to their portfolio.

Students will demonstrate an

appropriate commitment with

death.

The demonstration of a commitment is behaviour from the affective domain. We

target on the concept of death and dying, which we consider to be an important

professional competence. By dissection we want the students at least to gain

response to this educational objective. Assessment will be made by structured

observation.

Students will show, keep and

justify behaviours in the contact

with the deceased.

Whereas the required behaviour from the previous objective targets death in

general, this one focuses mainly on the behaviours with and towards the specific

cadaver, with which the students work actually. The educational activity will be

dissection. Additionally, students should compile in group-work a set of behav-

ioural rules to be applied in the lab. Assessment will be accomplished both by

structured observation and the students’ portfolio.

Students will demonstrate respect

and honesty towards academic

and non-academic personnel.

This can be seen either as attitude or as behaviour. In contrast to the next edu-

cational objective, which focuses on the inter-personal relations more generally,

this objective addressed the reproach that “doctors” behave condescending

against other health professionals. As the curriculum is output-oriented, we con-

sider it as a behaviour, which – of course – must be taught mainly by demon-

stration and role-modelling and we will assess the achievements by structured

observation.

Students will obey and justify

behaviours in the contact with

patients, colleagues, etc., as for

instance with respect, tolerance,

cleanness, and (self-) discipline.

We want the students to internalize these behaviours, which are also crucial for

medical professionalism. There will be no special education activity – beside

dissection – and assessment is done by structured observation as well as the

portfolio.

Affective

Table 2 (Cont). Intermediate educational objectives for anatomical dissection (Brenner et al., 2003)

116

Assessment in anatomy

render the whole process of questionable value.

Data gathered at the Winter Meeting of the Ana-

tomical Society in 2011 at Cardiff, in a workshop

conducted on anatomy assessment with 71 anato-

mists participating, when asked about their use of

standard setting it was revealed that the predomi-

nant method used by anatomists was Angoff

(38%) followed by Hofstee (15%) and the Fixed

Method Percentage (12%), though the new Cohen

method (Cohen-Schotanus and van der Vleuten,

2010), which uses the performance of a top group

of students as a measure of the relative difficulty of

the assessment, was used in Dutch schools and in

one UK school.

This is no issue at all in assessment tools, where

the students are required to select the appropriate

answer(s) from a given set of choices, as in true-

Paper-based Patient-based Teacher-/Peer-based

•

(Modified) Essay Ques-

tions Test

•

Multiple Choice/Answers

Questions Test

•

Tag/Spotter Test

•

Thesis and Project

•

Publications/Conference

Papers

•

Progress Test

•

Patient Surveys

•

Short Answer Questions

•

360° Evaluation Instrument

•

Application Test

•

Appraisal Technique

•

Assessment of Performance

∗

Checklist Evaluation

∗

Global Rating

∗

Assessment Panels

•

Direct/Practice (structured) Observation

•

Direct observation of procedural skills

(DOPS)

•

Key Feature Problems / Examinations

•

In-Basket Exercise

•

Objective Structured Clinical Examination

•

Objective Structured Long Examination

Record

•

Simulations and Models

•

(Standardized) Oral Examination:

∗

Patient based long case

∗

Patient based short case

•

Simulation based Assessment:

∗

Simulated Patient Examination

∗

Standardized Patient Examination

∗

Simulated Surgeries

•

Patient Management Problem

•

Peer Evaluation:

∗

Medical Team

∗

Multi-disciplinary

•

Practical Examination

•

Rating Scales

•

Recall (Oral) Examination:

∗

Chart-Stimulated

∗

Video-Stimulated

•

(medical) Record (case note) Review

•

Record of Practice:

∗

Critical Incidence Technique

∗

Portfolios

∗

Procedure, Operative, or Case Logs

•

Structured Interviews

•

Structured Trainer’s Report

•

Triple Jump Exercise

•

Video Assessment

•

Vivas:

∗

Unstructured (Question firing)

∗

Structured Oral Examination

•

Clinical evaluation exercise (mini-CEX)

false questions, MCQ, EMQ, etc. The standard

setting is done in these cases by the selection of

the “true” answer(s). Problems arise, when there is

not a single best answer; and even more, when

the second best answer is also true and was not

intended as “true” answer by the question’s author,

but found post-hoc as “true” answer by the exami-

nees.

Nevertheless, these are minor problems in com-

parison to the problems arising from un-

standardized assessment items, where the exami-

nees are required to produce an answer, behav-

iour, a product, or something else actively. For

comparison, a multiple answer question and an

identical question for a (structured) oral examina-

tion is given:

Therefrom several problems arise, which need

Table 3. (incomplete) survey of different assessment instruments used in medical education

E. Brenner et al.

117

for consent:

a. In the oral exam question, which answers

are allowed for being true? In this case, the

student might not respond “articular recess”,

but might use the term “axillary recess” or

even “recessus axillaris”. The “capsular liga-

ments” might be replaced by “glenohumeral

ligaments”, and even the labrum might be

responded as “glenoid labrum”. Obviously all

these answers are true for the GHJ. All asses-

sors will easily agree that this set of expected

answers [articular recess|axillary re-

cess|recessus axillaris], [capsular liga-

ments|glenohumeral ligaments|Ligg. gleno-

humeralia], and [labrum|glenoid la-

brum|labrum glenoidale] will be rated as

“correct”. In other cases, it might be more diffi-

cult to get consent on a standardized set of

expected answers.

b. How are true and false answers rated? This

question has to be answered for both the

MAQ/MCQ and the oral question. When

MCQs/MAQs are administered in a general-

ized setting, these issues are predefined by

the administration. For the written version with

predefined answers, there is general agree-

ment that each answer contributes to the total

score. Thus an un-marked “true” answer is

equally wrong than a marked “false” answer,

whereas a marked “true” answer is equally

right than an un-marked “false” answer. In

oral exams, this gets more complicated, be-

cause of the fact that all expected answers

are only “true” answers. Thus, consent has to

be achieved how unspoken missing “true”

answers should be handled and rated. Addi-

tionally, consent has to be achieved whether

the assessor is allowed for inquiring for a

missing answer (“Don’t you think that there is

something missing?”) or not.

c. How should the whole question be rated?

In the written setting of MAQs/MCQs exams,

this issue is often predefined by the admin-

istration, or the software for analyse the scor-

ing sheets. There is general agreement that

one question can be rated either “correct” or

“incorrect” as a whole. The question arising

here is, if “incomplete” answers, i.e. a mixture

of answers rated “true” and “false”, might be

rated “partially correct”. With this “partially

correct” scoring, there is a logical problem: (a)

when a “true” answer is marked, it is logically

“true”, (b) when a “true” answer is not marked,

it is logically “false”, (c) when a “false” answer

is not marked, it is logically “true”, and (d)

when a “false” answer is marked, it is logically

“false”. Logically, “true” and “false” is “false”.

Thus, if even one answer is marked wrongly,

the whole conjunction or construct is “false”.

In MCQs, this is quite simple: the question is

“true” only, when only the expected “true” an-

swer is marked, and not more (as these are

obviously “false”). In MAQs, it is also simple

from a logical point of view: the question is

“true” only, when all expected “true” answers

are marked, neither more nor less. Neverthe-

less, there are several assessors, who are

willing to give partial ratings for incomplete

answers, with neglecting that each missing

“true” answer is also “false”. This might be

administered based on a general consent of

all assessors involved.

d. In oral examinations, exactly this issue is

heavily discussed between assessors and

scrutinized by the examinees. Having no com-

mon consent on this question among the as-

sessors bates the assessments reliability. The

logically recommendation would be: (a) “when

the student responds incompletely (with or

without inquiring), i.e. doesn’t reproduce all

expected ‘true’ answers, the whole question is

rated ‘false’”, and (b) “when a student in-

cludes a ‘false’ answer to her or his response,

the whole question is rated ‘false’”.

e. How should the rated questions be

scored? There is a difference between rating

and scoring, as rating means that the asses-

sor rates the answer either “true” or “false”. By

this, he gets an answer whether question it-

self, the logic conjunction, is answered “true”

or “false”. Finally, this rating has to be trans-

formed to scores.

In MCQ/MAQ-examinations, in general there

is such a high number of questions that all

questions are scored identically with exactly

one score (or point). Of course, there is the

possibility of weighting, i.e. a subset of ques-

tions is considered more important than other

ones, and is therefore awarded with higher

scores. In this case, of course no partial

scores should be assigned. In oral examina-

tions, this step is not always done, especially

when the whole assessment’s result has to be

transformed to grades (depending on the

MAQ Oral examina-

tion

Question

Which of the following option-

al structures can be found in

the glenohumeral joint?

(a) Articular disc

(b) Articular recess

(d) Labrum

(e) Meniscus

Which optional

structures can

be found in the

glenohumeral

joint?

Expected

Answer

Which of the following option-

al structures can be found in

the glenohumeral joint?

 (a) Articular disc

⌧ (b) Articular recess

⌧ (c) Capsular liga-

ments

⌧ (d) Labrum

 (e) Meniscus

The optional

structures of the

glenohumeral

joint are an

articular recess,

capsular liga-

ments, and a

labrum.

118

Assessment in anatomy

grading system used; A-E, 1-5, 1-6, etc.).

Nevertheless, it is as simple as with MCQs/

MAQs, and each question is assigned a

score. All questions together result in an over-

all examination-score, which can afterwards

be transferred or recalculated to grades.

There is just one limitation: the whole exam

must at least contain as many questions as

grades …

Standardisation for oral examinations is therefore

quite easy, when all steps are made in accordance

and in common agreement of all involved asses-

sors. Of course, even more sophisticated and

structured forms of standardized oral examinations

might be developed (see below).

Written exams

Even in written exams, questions might match

different levels of the progress dimension. A good

description of different types of questions is given

by Chollet et al. (2009):

“Four question types were possible: memoriza-

tion, pathway, spatial, and analytical (Question

Type). Memorization questions were those ques-

tions that required a student to recite a fact (e.g.,

True/False: CN I is responsible for olfaction). Path-

way questions required students to trace the path

of blood or a nerve (e.g., trace the path of blood

from the appendix back to the heart). Spatial ques-

tions required the student either to describe the

spatial relationship of one structure to another

(e.g., True/False: The subclavian vein is anterior to

the anterior scalene muscle) or to identify the indi-

cated structure in a diagram. A question was clas-

sified as analytical if it required the student to solve

a problem that required significant integration of

material. Analytical questions were often present-

ed as clinical scenarios (e.g., A patient presents

with shoulder pain. Explain how this might be relat-

ed to inflammation of the gallbladder).”

Multiple choice questions (MCQ)/ multiple an-

swer questions (MAQ)

Literature on multiple choice questions is legion.

Thus we will strictly present a short overview of the

structure.

An optimal MCQ starts with a stem. This stem

introduces the candidates with the topic of the

question, and gives all, but not more than, the in-

formation necessary. This stem can also be an

image, or a clinical vignette. Images could be

schematic drawings, photographs, images from

different imaging modalities such as ultrasounds, x

-ray/ plane radiographs, CTs, MRIs, or diagrams,

for instance an electrocardiogram. The clearer the

information given is, the less misinterpretations of

the proper question will occur.

The stem is followed by a genuine question

(with a question mark!), or a distinct request. The

question or request has to make unmistakable

clear, what the candidate should do with the infor-

mation given in the stem supported by his own

knowledge. In the case of the MCQ, the candidate

will have to make the decision to mark the appro-

priate answer.

The question is followed by a set of possible an-

swers. In the case of MCQs there is just one

“correct” choice, the “singe best answer”, the oth-

ers – in general four – “wrong” choices are distrac-

tors. In the case of multiple answer questions

(MAQs), there are more than one “correct” choice;

on the other hand, MAQs should at least contain

one “wrong” choice.

The construction of the “wrong choices”, the dis-

tractors, is very important for the quality of the

question. The term “possible” is the first and most

important feature of an answer or distractor; this

very choice has to be a possible answer to the

question asked. Statements such as “none of the

above” are inappropriate choices, as they aren’t

answers to the question asked. Furthermore, the

answers should be similar in terms of provenance,

for instance the same system, topographical re-

gion, or they are all clinical treatment options, diag-

noses, etc. All choices, the “correct” and the

“wrong” ones, must be of similar length. Questions

writers tend to elaborate the “correct” choice while

disregarding the distractors, resulting in the fact

that the longest answer is very often the correct

one. Another cues for wrong answers are absolute

statements (“always”, “never”, etc.), therefore such

terms should be avoided. The authors should be

aware that even grammar or the gender of terms

might be cues. In general:

1. Avoid interpretation problems (semi-

quantitative terminology, mingled cause and

effect, ambiguous terminology)

2. Test facts, avoid testing opinions

3. Test only one aspect per question

4. Avoid hints and cues

5. Use short and clear sentences

6. Use semantically un-ambiguous terms

7. Avoid negations

8. avoid nonsense alternatives (fillers)

9. avoid two-in-one alternatives

10. make sure alternatives are mutually exclusive

Now some examples derived from the GHJ.

Synovial joints may have different optional struc-

tures.

Which of the following optional structures can be

found in the glenohumeral joint?

a. Articular disc

b. Articular recess

c. Capsular ligaments

d. Labrum

e. Meniscus

The expected correct answers for this MAQ would

be (b), (c), and (d). The choices (a) and (e) are in

fact also optional structures of a synovial joint, but

can’t be found in the glenohumeral joint. Of course

this question asks for mere rote memorization.

Mr. Doe shows up in your office. He complains

E. Brenner et al.

119

that he feels some pain in his left shoulder. The

onset was some days ago when he had to work in

his garden and cut off some branches of a tree.

When you examine Mr. Doe’s left shoulder, you

find that he is unable to abduct the left arm fully.

The measured range of movement (add/0/abd) is

30°-0°-65°.

Which of the following muscles of the gleno-

humeral joint might be damaged?

a. infraspinatus muscle

b. subscapularis muscle

c. suprascapularis muscle

d. teres major muscle

e. teres minor muscle

Extended matching questions (EMQ)

Extended matching questions are a set of ques-

tions (two or more), which use a common list of

answers, which is not restricted in length. This for-

mat is now used on many licensing and certifica-

tion examinations, as well as intramural tests at

many medical schools. In contrast to other ques-

tion types, this list of common answers precedes

the individual questions. It is indispensable that all

these common answers are completely unique and

free of any cueing. Their sequence starts with a

general introduction or theme, followed by the

question or lead-in (mostly formulated as request)

that gives the students instructions on what to do.

These parts are followed by the list of answers.

The response option includes one correct answer

for each question, and other possible responses

as distractors. It is the main characteristics of

EMQs that this list of possible answers can pertain

to any number of independent test items or ques-

tions. There is no restriction on the number of

times a given answer may be correct. Several

stems, in most cases more or less complete clini-

cal vignettes, complete an EMQ. Therefore they

are quite difficult to construct; furthermore, there is

only few examination software capable to use this

question format.

The following patients all suffer from muscular

weakness and sometimes from pain. Please

choose the most likely affected nerve form the list

below:

a. suprascapular nerve

b. axillary nerve

c. radial nerve

d. ulnar nerve

e. median nerve

A 54 year old patient complains about difficulties to

turn a key. He can’t remember an accident but re-

ports an extensive tennis match.

A 42 year old woman complains that she has

difficulties to dress her hairs.

An older patient complains that he increasingly

drops his pint.

EMQs shall overcome some of the criticisms lev-

elled at the use of multiple-choice questions to test

factual and applied knowledge. Among the ad-

vantages to using EMQs:

• Themes aid the organization of the examina-

tion.

• As questions are written in themes or general

topics it allows for writing many questions for

that theme.

• Good questions provide a structure designed

to assess application of knowledge rather

than purely recall of isolated facts (which is

not only true for EMQs!).

• The approach to writing these questions is

systematic, which is very important when sev-

eral people are contributing questions to one

exam.

• The extended list of answers allows the inclu-

sion of all relevant options, and therefore re-

duces the opportunity for students to 'guess'

the correct answer.

• EMQs were found to be more discriminating

than two and five option versions of the same

questions resulting in a greater spread of

scores, consequently resulting in higher relia-

bility.

Medical students previously familiar with the one-

from-five type of question (MCQ) do relatively

poorly the first time they are faced with the new-

style EMQs, probably because at least some of

them are still working in the “eliminate the distrac-

tors” mode. On the assumption that students will

adopt whatever mode of working gives them the

best chance of passing the examination, EMQs

that require the students to use and evaluate data

with the aim of making a deduction, i.e. using

(clinical) vignettes, then this is what they will do.

Spotter/tag tests

In a tag or spotter test, the students have to pass

different stations with pre-dissected/prosected

specimens, where several structures are “tagged”,

and to work on relating tasks. The questions con-

cerning to the stations and their tagged structure

have to be answered on an exam-sheet or its elec-

tronic equivalence. There are used SAQs (short-

answer questions) usually, occasionally MCQs are

used. Very often the tag or spotter test is used

simply to assess the identification of the tagged

structures, thus being an assessment of remem-

bering factual knowledge (Winkelmann, 2007).

Besides the identification, sometimes a further

question is added to the targeted structure. This

may be derived from the system, topography, func-

tion, development, clinical reference, etc.

(Adamczyk et al., 2007). Besides the mainly sim-

ple form of a spotter, more sophisticated versions

have been developed (Schubert et al., 2009). Jus-

tifications for using spotter style assessments in-

clude that they:

• are aligned to three dimensional spatial un-

derstanding

120

Assessment in anatomy

• can test relations of structures to each other

• can test ability to identify similar structures

e.g. nerves

• are aligned to learning through touch

• can be related to clinical applications

• can test an appreciation for anatomical varia-

tion

• may be linked to imaging

• can require production of knowledge

When seen in its simplest form, the spotter/tag test

is just a modified written exam with either MCQs or

SAQs. The tagged specimens serve as initial trig-

ger or stem for the corresponding questions. The

real specimen can be replaced by its image. One

could imagine that two tests with literally the identi-

cal questions, one presenting the specimens as

stems and the other presenting the specimens’

images as stems, will achieve identical results;

when not, the assessment does not assess what it

is intended to measure. Any differences in results

might be biased by the setting itself.

Spotter questions can also be included as a sta-

tion in an Observed Structured Clinical Examina-

tion (OSCE), or integrated into a wider practical

assessment including other disciplines. As well as

OSCEs, Objective Structured Practical Examina-

tions (OSPEs) have been proposed as an effective

modality for assessing the practical aspects of

anatomy (Yaqinuddin, 2013). It is suspected that

different models of this have emerged under alter-

native names as the next generation of ‘spotters’.

The spotter has been criticized for testing low

levels of knowledge (Yaqinuddin et al., 2013). Alt-

hough this may be true for a spot such as ‘Identify

this structure’, where testing is at the level of sim-

ple recall, modifications could move such a ques-

tion into a higher taxonomy order. Of particular

interest is that key action words associated with

anatomy are used in spotter style assessments,

and that these can be aligned to the taxonomy or-

ders. The word ‘Identify’ is frequently associated

with the Remembering level. ‘Describe the func-

tion’ is associated with Comprehension, whereas

phrases such as ‘Damage to X causes…’ are as-

sociated with Applying and ‘What clinical condition

is associated with...?’ with Analysing. There are

few examples of ‘create’ (synthesize) but as this

involves bringing components together, it may be

more suited to clinical scenarios and OSCEs; fur-

ther work will elucidate if anatomy and clinical

skills are aligned and truly integrated. Anyhow, it is

often simple to increase or decrease a level as

appropriate.

Oral exams

Structured oral examination (SOE)

A structured oral examination (SOE) is a special

form of a Viva (JCEM, 1997). SOEs are individual

assessments. Their main targets are educational

objectives from the cognitive domain, except ob-

jectives assigned to the meta-cognitive knowledge

(e.g. “learn by mutual learning and explaining each

other”). A structured oral examination should be

structured by both the number of questions and

the rating scale for each item. Of course, for each

question the appropriate steps of standard setting

must be passed through.

An example of the first author’s institution should

enlighten this. In the topographical dissection

course, students have to take – among other items

contributing to the final score – five structured oral

examinations (SOEs). Each of these SOEs com-

prises three items. It is proposed that one item

should deal with the recent major topic (e.g. intes-

tine, heart, etc.), another item with the examinee’s

specimen; whereas the topic of the third item will

be open to the assessor’s decision. Each item it-

self consists of three questions. The first question

of each item is either to name a shown structure or

show a named structure. This initial question is

considered mandatory, such a student not able to

show or name the structure under question, has

failed this whole item. When the initial question is

answered correctly, the first score is assigned and

followed by two consecutive questions, one of

them dealing with the anatomical context

(vascularisation, innervation, topographical rela-

tions to other structures, etc.) and the other deal-

ing with either anatomical or clinical contexts. Each

question is assigned, if answered appropriately,

one additional score. Thus, each item can be

awarded with up to three scores, and the whole

SOE sums up to a maximum of nine scores, with a

pass/fail level of six scores. This seems quite com-

plex, but the assessors are supported by a con-

venient rating sheet:

Assessment

X Date: Assessor:

Item 1: 0 1 2 3

Item 2: 0 1 2 3

Item 3: 0 1 2 3

Total

Score: 0 1 2 3 4 5 6 7 8 9

Table 4.

All five SOEs will result in a maximum of 45

scores (and a minimum of 30 scores); with a total

maximum of 72 scores for the whole course. The

other scores can be achieved by the structured

observation of the student’s collaboration (max. 6

scores), the structured observation of the dissect-

ed specimen (max. 15 scores), and the portfolio

(max. 6 scores).

These proposed SOEs should not be mixed up

with a standardized oral examination, which is de-

fined as a type of performance testing using real or

at least very realistic patient cases with a trained

physician examiner questioning the examinee

(ACGME and ABMS, 2000). The SOEs were se-

lected for their advantage of checking that a stu-

E. Brenner et al.

121

dent’s verbal and mental ability matches the ability

demonstrated in written form (JCEM, 1997), such

as in the summative and integrative assessment at

the end of the second term, but also in the portfo-

lio. As these students sat for a written exam

(MCQs) on systematic anatomy already, we chose

this form of an oral examination, which also allows

for following up a student’s answers and assessing

the depth of knowledge as well as assessing atti-

tudes (JCEM, 1997). On the basis of the selection

of the qualification-profile (‘The student is able to

communicate precisely and clearly in clinical and

scientific context orally as well as written’), and

under consideration of the facts that the ‘big exam-

inations’ are written assessments and the written

expressiveness should be examined in the dissec-

tion lab by the portfolio, at least one oral assess-

ment must be implemented. The students must be

able to express themselves clearly also in ‘stress-

situations’.

The reliability of this assessment strategy should

be quite good as the initial questions of each item

are standardized, the answers are likely to be with-

in a specified range and the number of questions

in total is quite high for an oral examination form.

The validity of SOEs hinges upon the precise

level of ‘structure’ used. The more structured and

more closed the questions, the less will be the op-

portunity to assess the student’s attitudes and

knowledge as a coherent whole (JCEM, 1997).

Online assessments

An example is the Oxford “live” experiment: a

qualification intensive course 8 hours a day for 3

weeks of Principles of Clinical Anatomy, each

week ended with an evaluation test. The online-

assessment of the students’ progress led to the

following conclusions (Morris and Chirculescu,

2007):

1. Students have repeatedly commented that, by

the end of the course, they felt that they had

acquired the anatomical knowledge neces-

sary to examine patients with confidence.

2. In each year, 4-6 students have scored >90%

in each of the three weeks.

3. With on line assessment, inter- and intra-

examiner variability is completely eliminated.

4. Marks for the cohort of students and also for

each individual part of each question are

available within minutes of the end of the ex-

amination. This means that ‘rogue’ questions

can be immediately spotted to facilitate deci-

sions on re-sits/vivas.

5. More importantly, the relative difficulty of each

part of each question is quantified and a bank

of questions of known difficulty will enable the

creation of more robust assessments in the

future.

6. Student feedback was very positive in all the

3 years passed (2004-2006), despite the fact

that the course comes just one week after

their final preclinical Medical Science exami-

nation.

7. Having seen the results, external examiners

have requested that on-line assessment is

used for all preclinical core examination.

8. Always, the best score was related to the 1

week, and the poorest to the 2

week exami-

nation test.

Practical exams

By exposing the spotter / tag tests as a special

form of a written exam, where the tagged speci-

men forms the stem of the question, there is a

shortcoming of real practical examinations, the

more when we are searching for a structured ver-

sion. Searching the literature for “anatomy” and

“practical exam” reveals only few usable descrip-

tions of practical examinations. In most cases,

these “practical exams” were mere spotter / tag

tests in some quite interesting modifications (eg.

Cundiff et al., 2001).

We can only suppose that this is due to the fact

that no appropriate educational objectives have

been formulated. When the focus is only on

knowledge, the worst on a low step on the process

dimension (mere memorization), there is indeed no

need for a practical examination.

A practical examination is an examination, in

which the examinee is asked to do, to perform a

certain task, especially manually. When we, for

instance, want our students to comprehend the

composition and structure of a certain bone, then a

task for a practical examination could be to re-

assemble a scattered bone. When you ask, if this

clinically relevant, ask your traumatologist … Anat-

omy could provide a “sheltered workshop” in ad-

vance of clinical reality. When we want our stu-

dents to apply their knowledge of the range of mo-

tion of the GHJ, the task should be an ROM-test of

a subject, either a co-student or a simulated pa-

tient (or even a real patient). Of course, such a

task should be accompanied by appropriate verbal

analysis of normal and/or pathological findings.

For dissection, the most obvious task for a practi-

cal examination would be the request to dissect a

certain structure within a certain time.

Structured observation

Structured observations are individual assess-

ments and can observe (1) the student’s active

contributions (e.g. Heyns, 2007), (2) their work’s

product, the dissected anatomical specimen, (3)

selected medical techniques, or for instance the

anatomical basics of selected clinical skills, on a

predefined and easy rating scale. The reliability of

structured observations depends on the clear defi-

nition of the rating scales used. A high number of

single observation-events will contribute to a high

reliability. The validity of this instrument in total

should be acceptable as both process and out-

come (product) are assessed.

122

Assessment in anatomy

In the first author’s setting, structured observa-

tions are made on the student’s active collabora-

tion and their specimen. In general, the student’s

active collaboration is continuously observed by

the staff. The structured observation is recorded

once a fortnight in the student’s file with a score of

0 or 1 for each observation.

Even the student’s product in the dissection lab,

the dissected specimen, can be monitored for as-

sessment purposes. For this structured observa-

tion, both the dissection-technique of the student,

and – essentially – the product, the specimen it-

self, should be evaluated. Of course, the respec-

tive difficulty of the region dissected, but also the

quality of the specimen has to be accounted for.

A rating scale could for instance comprise of four

levels: 0–1–2–3, with 0 being “insufficient”, 1

“satisfactory”, 2 “good”, and 3 “outstanding”. Of

course, these levels have to be defined more

clearly by common consent of all assessors.

“Insufficient” dissection can be defined as a speci-

men, where the student has not at all exposed all

those major structures (such as the main nerves of

a plexus, a major vessel, etc.), which should have

been dissected according to the dissection plan, or

has cut apart one or more of these major struc-

tures. The specimen might be “satisfactory”, when

the major structures are exposed in general, but

incomplete in respect of the target region itself or

adjacent regions. A “good” specimen can be de-

fined by a complete exposure of all major struc-

tures and most of the minor structures within the

target region and appropriate connection with oth-

er adjacent regions. Finally, an “outstanding” spec-

imen should go (far) beyond the common require-

ments for a student’s dissection, such as a com-

plete exposure of all major and minor structures

within the target region and appropriate connection

with other adjacent regions, combined with a com-

plete removal of connective tissue where appropri-

ate; the specimens should look like an image of a

photographical atlas. Of course, there has to be a

list of major and minor structures …

Portfolio

The portfolio could be either a single student’s

product or a group assessment where all students

working on one cadaver will have to contribute.

The portfolio documents are distinct products of

the students’ work. It can be used for direct

presentation of performance. The portfolio can as-

sess the students’ skills in team-work and docu-

mentation, the usage of different sources of infor-

mation (old and new media), ethical aspects, as

well as self-assessment (reflection).

Based on the selection of different items of the

general educational objectives – under considera-

tion of the respective parts and key-requirements –

we recommend that all students working on one

cadaver should produce and manage a common

portfolio as group.

The portfolio documents distinct products of the

students’ work. It can be used for direct presenta-

tion of performance. The portfolio combines tech-

nical as well as general achievements, for example

excerpts from books, learning-diaries, other ele-

ments chosen by the students and/or negotiated

with the teacher, project-reports, case studies, etc.

The portfolio for the dissection lab should have to

comprise the following obligatory items:

• An initial and ongoing description of the

corpse, with an exact description of the find-

ings without diagnosis, and without influence

by ‘norms’. This will train the students’ skills in

observation, examination and documentation.

This item is quite similar to the “clinical anato-

my chart” (Escobar-Poni and Poni, 2006).

• A documentation of the dissection itself (who

dissected what when with which result;

"progress notes" as proposed by Escobar-

Poni and Poni, 2006);

• A documentation of the implementation of

selected techniques (clinical skills, such as

spinal puncture, etc.);

• A documentation of the usage of instruments;

• A documentation of the individual peculiarities

(norm-variations, varieties, abnormalities

[either congenital or acquired] etc.), and even-

tual pathological changes (tumours, fractures,

etc.) of the corpse, supplemented by findings

from ‘new’ and ‘old’ information-technologies

(part of the "clinical anatomy chart" proposed

by Escobar-Poni and Poni, 2006); and finally

• An ongoing self-evaluation of the student’s

own performance (in the sense of a reflec-

tion). The students can include not only their

own behaviour in a specific circumstance, but

can also write about the behaviours of others

(Escobar-Poni and Poni, 2006).

• Optionally, the students might insert further

documents, for instance the documentation of

their commemoration service. Optional sup-

plements will of course be honoured with ad-

ditional scores.

The appraisal takes place for the entire group to-

gether. Each participant of the group will get the

same score. The main focus of the evaluation is

set towards tidiness, wholeness, and correctness

regarding content and terminology. The good news

is that it might stimulate mid-level and border-line

students to improve their learning performances.

The bad news is that it can either encourage some

students to stay apart and passively benefit of the

others’ work or make the performant and ambitious

students, if indulgent - to work harder or if exigent -

to exclude some members of the team from doing,

not to spoil nor to decrease the level of the group’s

work, in order to avoid decrease of the team per-

formance and global evaluation.

The reliability of this instrument in general is

quite low, since the range and individuality of dif-

E. Brenner et al.

123

ferent portfolios will decrease the level of reliability

between different assessors. Therefore, this instru-

ment should limited to about 10% of the maximum

score. Nevertheless, such a portfolio is high on

face and content validity.

Students’ Self-directed Learning and Assess-

ment

'Doughnut Rounds'

'Doughnut Rounds', are self-directed learning

approaches, which involve four to seven medical

students and or residents. They choose the read-

ing material as a group and are expected to formu-

late 12 questions based on the week's readings.

They pose these questions to their colleagues in a

'game show' format. In this scenario, the attending

teacher/lecturer has only to bring the doughnuts

and to act as a moderator during the session.

(Fleiszer et al., 1997)

Donut rounds are at least as good as lectures in

imparting factual knowledge and may provide a

selective advantage to weaker students (Bulstrode

et al., 2003).

CONCLUSION

There is much diversity concerning the assess-

ment of anatomical knowledge, skills, and attitudes

in medical and dental courses and there needs to

be agreement about the best strategies and meth-

odologies to be pursued to ensure consistency,

reliability, (clinical) validity, and standardisation

across the European medical and dental sectors.

Therefore, the development of a European-wide

clinical- and research-oriented integrated curricu-

lum of Anatomical Sciences (Gross Anatomy, His-

tology and Embryology) for medical students is a

major need, which should help also to achieve a

unitary evaluation system.

ACKNOWLEDGEMENTS

We gratefully thank Tracey Wilkinson, Jo Bishop

and John Morris for their valuable input on stand-

ard-setting.

REFERENCES

ACGME

AND

ABMS (2000) Toolbox of Assessment

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uate Medical Education ACGME), and the American

Board of Medical Specialties (AMBS). http://

www.acgme.org/Outcome/assess/Toolbox.pdf. ac-

cessed 11-06-2003.

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Spot(ters) the difference: Bringing traditional anatomical examinations online

Article

Full-text available

Jul 2023
CLIN ANAT

The COVID‐19 pandemic caused a shift in anatomy education forcing institutions to find innovative ways to teach and assess online. This study details the development of an online spotter across multiple modules that allowed students to sit the examination at home whilst still maintaining the integrity of the assessment. The online spotter consisted of individual, Zoom calls between students and examiners whereby slides with images and questions were screen shared. To examine the viability of this spotter in non‐lockdown scenarios several parameters were considered. Mean marks were compared to traditional versions and Pearson's r correlation coefficients were calculated between online and traditional spotters and between online spotters and overall performance in anatomy modules. A survey was carried out to determine the students' view of the assessment. Pearson's r was between 0.33 and 0.49 when comparing online spotters to the traditional format, and between 0.65 and 0.75 (p < 0.01) when compared to a calculated anatomy score. The survey indicated overall student satisfaction as 82.5% reported that it was a fair way to test their knowledge and 55% reported the same or lower levels of anxiety when compared to traditional spotters. However, there was nothing to indicate that the students preferred this format over laboratory‐based spotters. These results indicate that this new exam format would be useful for small cohorts who are undertaking online or hybrid courses, or in circumstances when running a full spotter is too costly, and represents a fair and robust way to assess practical anatomical knowledge online.

Interprofessional Anatomy Education: Its Significance, Challenges and Recommendations

Article

Full-text available

Jun 2024

Interprofessional education (IPE) is increasingly recognised as essential for preparing healthcare professionals to work collaboratively in interdisciplinary teams. In the realm of anatomy education, integrating IPE offers unique opportunities to enhance students' understanding of the human body and its clinical relevance while fostering essential teamwork and communication skills. This commentary underscores the pivotal role of IPE in anatomy curricula, highlighting its capacity to cultivate collaboration among students from various healthcare disciplines and enhance patient care by equipping students to apply anatomical knowledge in interdisciplinary settings. Through interprofessional learning experiences, students develop critical thinking skills and gain a deeper understanding of how anatomy knowledge and skills are translated into patient care, fostering effective problem-solving and clinical reasoning within collaborative teams. Despite the potential benefits, challenges such as curricular integration, logistical barriers, faculty resistance, assessment complexity, resource constraint, and variations in institutional cultures and policies, must be addressed to effectively implement IPE in anatomy education. Overcoming these challenges involves prioritising interdisciplinary collaboration, establishing interdisciplinary curricular models, promoting interprofessional relationships, developing innovative assessment strategies providing faculty development opportunities, and addressing resource constraints. By addressing challenges and implementing recommendations, institutions can create meaningful learning experiences that enhance students' abilities to work effectively in interdisciplinary teams and improve patient care outcomes.

Master students’ perception and attitude on methods of anatomy teaching and assessment, Khartoum, Sudan 2014–2020

Article

Full-text available

Feb 2025
BMC Med Educ

Background Medical education relies heavily on anatomy as a fundamental component. Irrespective of their specific field of expertise, it is undeniably essential for doctors to possess a comprehensive grasp of anatomical principles. Teaching and obtaining knowledge of anatomy are highly important and challenging disciplines for both educators and learners. The aim of this study was to assess the perception and attitude towards the methods used for teaching and assessing anatomy among postgraduate students. Methods A descriptive cross-sectional study was conducted on three consecutive cohorts of anatomy master students. The data collection process employed a semi-structured questionnaire, and the data analysis was carried out using the IBM Statistical Programme for Social Sciences version 24 (SPSS 24). Results There was a total of 44 participants who filled out the questionnaire. Among them, 90.9% chose dissection room sessions as the most effective approach for attaining the necessary learning outcomes. Practical dissection was found to be the most successful educational method in terms of stimulating attention (81.1%), offering enjoyment (70.5%), boosting information retention (65.9%), and ensuring satisfaction (59.1%). Of the study participants, 72.7% of the participants hold the belief that the practical dissection test is the most efficient method for evaluating the designated learning goals. The utilisation of multiple-choice questions proved to be highly beneficial in facilitating good comprehension of anatomy and served as the optimal means for evaluating one’s knowledge among 63.6% of the students. Conclusions Overall, the majority of students held positive views regarding the efficacy of cadaveric dissections in all their forms for transferring knowledge about anatomy. The most effective evaluation procedures were the utilisation of multiple-choice questions and the implementation of the spotter test.

Transformative Medical Education: The Role of E-Pads in Revolutionizing Examinations Processes in Medical School

Article

Full-text available

Aug 2024

Muhammad Zulfiqah Sadikan

Electronic pads (E-pads) in medical education and examination revolutionize pattern schemes and enhance better learning methods. This review addresses E-pad implementation in medical school examinations, which mainly focuses on the usefulness of this technology, including its capacity to enable easy assessment, improve interactivity and engagement, make automatic exams that adapt to user personality and feedback, maintain data security, and to ensure accessibility and inclusivity during assessments. E-pads enlighten the assessment process by providing ease of digital test administration, and standardization of format and grading processes, hence delivering an efficient and consistent output. Interactivity features such as touchscreen interfaces combined with incorporating multimedia elements in the app arouse the engagement, understanding, and comprehension abilities of the learners. Learners' progress is met with adaptive testing algorithms that adjust the examination to their performance levels. In return, learners are supported by feedback mechanisms that create personalized learning paths. Next, E-pads can tackle issues with data security by encryption protocols and remote invigilating tools. Also, the usability of personalised accessibility features provides equality in access to college students with disabilities. Moving ahead, emerging technologies in E-pad will contribute to continuous improvement by integrating advanced features for autonomous item generation and adaptive testing. Through the extension of the potential of E-pad technology, medical educators can create more vibrant and inclusive examination conditions, and in addition, uplift the traditional way of education, so that the students can stand their ground towards modern healthcare practice.

A comparison of 1‐ versus 3‐month regional anatomy exposure on learning outcomes of undergraduate medical students

Article

Full-text available

Aug 2024
CLIN ANAT

Regional anatomy teaching forms a cornerstone of undergraduate medical education. Owing to an increase in teaching and learning content throughout the medical curriculum in recent years, contact hours and overall course durations in anatomy are under review worldwide. This study aimed to assess whether shortening the course content duration impacts learning gain and the ability to identify anatomical structures correctly. Undergraduate medical students of the Johannes Kepler University Linz (JKU; n = 310) and at the Medical University of Graz (MUG; n = 156) participating in regional anatomy courses were included. Whole body regional anatomy courses, including hands‐on dissection and accompanying lectures, were delivered over one or three months. Course content and examination mode were kept consistent, while the duration of knowledge delivery was one or three months, respectively. Objective structured practical examinations (OSPE) were then carried out on prosections for the neck, thorax, and abdomen. 3‐month course exposure resulted in significantly higher OSPE scores for the neck (49 vs. 37%), thorax (65 vs. 54%), and abdomen (65 vs. 45%), respectively. Further evaluation of the utility of different embalming types yielded higher 3‐month scores in the neck and thorax regions with Thiel‐embalmed tissues and thorax and abdomen regions in ethanol‐glycerin‐embalmed tissues. Course exposure over a more extended period, like three months, appears to be highly beneficial.

The Utility of Anatomy Assessment in Preclinical Undergraduate Medical Curriculum: A Scoping Review Protocol

Article

Full-text available

Mar 2024

Anatomy has been taught predominantly in the preclinical years. However, little guidance exists for medical educators in designing appropriate assessments of anatomy knowledge. In general, medical schools implement and determine their own curricula and methods of assessment. The purpose of this scoping review is to examine the breadth of literature regarding the utility of anatomy assessments, which will be reported whether they have been investigated in terms of validity, reliability, practicality, feasibility, cost-effectiveness, and educational impact in the included resources. This scoping review will be conducted using the Joanna Briggs Institute (JBI) scoping review guideline, and its protocol is outlined to systematically map the utility of anatomy assessments in preclinical undergraduate medical curricula over the past 20 years. Primary data will be searched from relevant studies, review articles, and grey literature sources between 2002 and 2023. The resource searching will be performed using the three-step search strategy, namely review search, study selection, and evidence charting, which will involve four electronic databases and two independent reviewers. As secondary research, this review does not require ethical approval. The review will not only permit better comparisons of anatomy assessment and foster meaningful evaluation of both medical students and teaching establishments to take place in the anticipation of ensuring the constructive alignment in anatomy education but also produce important information on the quality of anatomy assessment in the context of the undergraduate medical curriculum. The findings will be disseminated through journals and conferences targeting anatomy educators worldwide.

Online anatomy education during the Covid‐19 pandemic: Opinions of medical, speech therapy, and BSc Anatomy students

Article

Full-text available

Apr 2023

With the emergence of the Covid‐19 pandemic in 2020, it was difficult to predict if the “cadaveric‐based (golden) standard” of teaching anatomy would be possible in the unforeseeable future. This forced traditional anatomical teaching and learning practices to be transitioned to remote online platforms. This study explored the opinions of anatomy students (n = 51), on their online learning experience of anatomy during the Covid‐19 pandemic. A mixed methods approach using a descriptive, exploratory study design was conducted, by use of an online survey. The survey consisted of a six‐point Likert scale and was assembled into four sub‐categories. Likert scale options ranged from; strongly disagree, to strongly agree, and not applicable. Results obtained seem to tally with expectations, indicating an adequate theoretical course component with room to improve practical online teaching. Most participants had a positive perception of the theoretical course content, duration, and platforms of communication. Virtual classes were simple to navigate with few technical difficulties experienced by the participants. Students also noted having access to sufficient study material, videos, and additional online material. Overall, more than half of all participants reported adapting well to the remote learning environment, however, the greatest challenge experienced highlighted a sense of deprivation from the lack of cadaver exposure and hands‐on instruction. This research highlighted the effects of the pandemic on the modality of anatomy education and how it affected students. Although anatomy is multi‐modal, it can be concluded that it is possible to achieve academic success by using online learning methods.

Multiple Mini Viva as an Online Assessment Tool for Postgraduate Anatomy Programme: The USM's Experience Amidst COVID-19 Pandemic

Article

Full-text available

Dec 2022

Assessment is fundamental to student learning as it shapes student learning behaviour. Designing a holistic assessment is a demanding task because it involves evaluations of both cognitive and non-cognitive competencies. The unprecedented outbreak of COVID-19 has led to many changes in the assessment practice of higher education institutions. To ensure the sustainability of education provision to all students, assessment activities in higher education institutions are mainly conducted through online platform, and the task becomes more challenging. Hence, we introduce a new holistic assessment method, the multiple mini viva (MMV), that is used in the assessment of the Master of Science (Clinical Anatomy) programme in Universiti Sains Malaysia. The MMV was adopted from the framework of multiple mini interview that is commonly used for the student selection process in medical and allied health sciences programmes. This form of assessment was first implemented to address the drawbacks of the classical viva voce, and it could assess students' cognitive skills, including various interpersonal competencies such as communication skills, critical thinking and professional behaviour. In this article, we describe the practice of the classical face-to-face and online MMV with regard to its purpose, process, advantages and challenges. The implications and suggestions for the future practice of anatomy assessment are also elaborated.

The cognitive structure of gross anatomy knowledge in physiotherapy students

Article

Full-text available

Oct 2024

Allan Besselink

Cognitive structures are the mental representation of domain knowledge and its organization. A preliminary investigation of the cognitive structure of gross anatomy knowledge was conducted on physiotherapy students. The criterion‐related validation study examined two data modeling strategies (multidimensional scaling and Pathfinder networks) as potential visual and quantitative representations of cognitive structure. Two criterion standards were used: expert cognitive structure (concurrent) and the student's unit grade (predictive). The raw data for both data modeling strategies were generated from an online survey of paired comparisons of 20 anatomical structures and concepts relevant to musculoskeletal clinical practice. Convenience sampling was used to recruit first‐semester physiotherapy students (n = 31), gross anatomy course instructors (n = 4), and domain experts (n = 3) who completed the online survey. The results indicated moderate‐to‐high effect sizes, regarding the level of agreement (reliability, accuracy, and association) between student and expert cognitive structures. Multiple regression analysis was performed to examine the potential relationships with unit grades. Six predictor variables accounted for 68.9% of the variance in unit grade, indicating a large effect size. The results provide preliminary evidence of concurrent and predictive criterion‐related validity for using data modeling strategies to represent cognitive structure in this knowledge domain and population. Further research is indicated to assess the potential impact of this innovative use of data modeling strategies for cognitive structure mapping on gross anatomy education, adaptive learning, and competency‐based education, leading to the long‐term development of expertise.

Integration of physiology in a curriculum on human structure: a snapshot of the cardiovascular block

Article

Full-text available

Jul 2023

With the gradual shift from discipline-based to competency-based medical education, the integrated curriculum has become a popular model for connecting basic science and clinical content in undergraduate medical education. Despite its popularity, there are concerns that important physiological concepts are not adequately addressed. We describe the spiral integration of physiology content in the 5-week Cardiovascular block of our Homeostasis course at the Zucker School of Medicine. We also describe our approach to incorporating physiology into an integrated, constructed response, short-answer assessment format. Our approach to spiral integration consists of rotating lab stations that highlight the distinction between normal and abnormal states, linked with appropriate clinical interventions. Physiology is at the core of integration in any curriculum and the basis of all applied fields of medicine, hence our approach is that teaching structural relationships would not be valuable without consideration of its functions, which can then be utilized in discussion of clinical presentations, imaging, and relevant pathologies. Likewise, our integrated assessments require the students to compose their answers to the questions from scratch, which creates a shift in mode of students’ preparation from rote memorizations to more cognitive processing that enhances critical thinking.

What is an Objective Structured Practical Examination in Anatomy?

Article

Full-text available

Apr 2013

Muhammad Zafar

Assessing teaching-learning outcomes in anatomical knowledge is a complex task that requires the evaluation of multiple domains: theoretical, practical, and clinical knowledge. In general, theoretical knowledge is tested by a written examination system constituted by multiple choice questions (MCQs) and/or short answer questions (SAQ). The assessment of practical knowledge (three-dimensional anatomical concepts) involves oral, spot, or objective structured practical examinations (OSPE). Finally, the application of anatomical knowledge to patients is tested mainly through objective structured clinical examinations (OSCE). The major focus of this study is the OSPE. Although many schools challenge students using this tool in practical examinations in the early phase of the curriculum , the true meaning of OSPE is frequently forgotten and it becomes, in reality, a spot examination. This article, for the first time, describes how the concept of the OSPE has evolved and is currently being used to assess the practical domain of anatomical knowledge in a problem-based curriculum at Alfaisal University College of Medicine. In addition, it describes the main differences from the spot examination, which is normally used in traditional medical curricula. The authors believe that the OSPE remains the most efficient tool to assess the practical aspects of anatomical knowledge in a system where basic knowledge is integrated with the clinical or functional part of anatomy. However, this contention only holds true if the OSPE process revolves around structured objectives. Anat Sci Educ 6: 125–133.

Das Fähnchentestat als neue Prüfungsform im Fach Anatomie an der Ludwig-Maximilians-Universität München

Article

Full-text available

Jan 2007

A strategy towards professionalism in the dissecting room

Article

Full-text available

Oct 2007

Marise Heyns

The teaching and cultivation of professional-ism is an integral part of medical education as professionalism is central to maintaining the public's trust in the medical profession. Tradi-tionally professional values would have been acquired through an informal process of socialisation and observation of role models. Recently, however, medical educators have accepted the responsibility to explicitly teach and effectively evaluate professionalism. A comprehensive working definition of the term professionalism and a universally agreed list of the constituent elements of professionalism are currently debated. The School of Medicine and Dentistry of The Queen's University of Belfast uses an approach of self-directed learning for teaching anatomy, and students are given the opportu-nity to learn anatomy from human dissection. Self-directed learning teams have been found to be underutilised as educational strategies and presented an opportunity to utilise the first year dissection room teaching environ-ment to nurture the development of the attributes of professionalism. An educational strategy based on role-playing was developed to engage all students around the dissection table. Students received comprehensive back-ground reviews on professionalism, its attrib-utes and the identification of such attributes in the context of the dissection room. Roles, with specific duties attached, were allocated to each team member. Circulating academic staff members directly observed student participa-tion and gave formative feedback. Students were given the opportunity to reflect on their ability to identify the attributes and reflect on their own and their peer's ability to develop and practise these attributes. This strategy indicated that small group learning teams in the dissection room utilise widely accepted principles of adult learning and offer an opportunity to create learning activities that will instil in students the knowledge, values, attitudes and behaviours that characterise medical professionalism. Anatomy faculty have a responsibility to nur-ture and exemplify professionalism and play a significant role in the early promotion and inculcation of professionalism. It remains imperative not only to assess this strategy but also to create opportunities for critical reflec-tion and evaluation within the strategy.

Medical Education in the United States and Canada: a report to the Carnegie Foundation for the Advancement of Teaching. Cited by Ludmerer K. Understanding the Flexner Report

Article

Jan 2010
ACAD MED

A. Flexner

The classification of educational objectives in the psychomotor domain

Article

Jan 1972

E.J. Simpson

The role of the anatomist in communicating Anatomy to a lay audience

Article

Oct 2007

D.J.R. Evans

The ability to communicate with the public is one of the essential tools by which an anatomist can enhance knowledge and understanding within the general population. Unfortunately, up until recently few scientists or health-care professionals have received much training in communicating science to a non-specialist audience, a surprising situation given the increasing demand from the public for more knowledge about health and science. The co-ordinators of undergraduate curricula have responded somewhat by increasing the time devoted to developing oral communication skills, however the ability to communicate by written means has not been widely explored. At a new medical school in the UK, we have introduced an assessment component directed at using the creation of lay statements as a strategy for providing accessible anatomically related information for a particular audience. Students were asked to respond to a letter from a member of the public regarding one of a number of clinical conditions by composing a short piece for a fictitious newspaper. When marked against a set of criteria, results showed that students had produced effective articles very much directed at the particular chosen audience. Students found the experience challenging yet one that enhanced their written communication skills and gave them the chance to think about what information to communicate. Overall this study demonstrates that such an assessment format is an effective way for students to start to develop professional competence through critical thinking and self-reflection and provides an opportunity for appreciating the skills necessary for adapting the written-word for a non-specialist audience.

The Assessment of Clinical Skills/Competence/Performance

Article

Sep 1990
ACAD MED

G.E. Miller

A core syllabus in anatomy for medical students - Adding common sense to need to know

Article

May 2015

A satisfactory knowledge of topographical anatomy is one of the key foundations of safe and effective medical practice. Existing curriculum guidelines in the UK and Ireland from bodies including the General Medical Council, the Medical Council of Ireland and Scottish Doctors do not provide detailed guidance on curriculum content in respect of individual subjects. This paper describes a core syllabus in anatomy developed by the Anatomical Society of Great Britain and Ireland detailing the level of knowledge that we believe should be the minimum expected of a recently-qualified medical graduate in the UK and Ireland about to embark upon their two year Foundation training.

On Medical Education in the United States and Canada

Article

Jul 2002
B WORLD HEALTH ORGAN

Abraham Flexner

Medico-legal Litigation and its Links with Surgical Anatomy

Article

Aug 2002
Surgery

Harold Ellis

You do not have to be a member of our profession to be aware of the massive increase in recent years of medico-legal claims against surgeons in this country. Indeed, it seems that every day the newspapers report some new and sensational ‘surgical disaster’. The hard facts speak for themselves. A report from the National Audit Office last year showed that the bill for medical negligence faced by the National Health Service amounted to £2.6 billion, double the amount paid out in 1997. In addition, there was an estimated liability of a further £1.3 billion related to negligent episodes that were likely to have occurred, but for which claims had not yet been received. The report pointed out that the rate of new claims per thousand finished consultant episodes rose by an incredible sevenfold between 1995–6 and 1999–2000.