Anatomical Instruction and Training for Professionalism
From the 19th to the 21st Centuries
JOHN HARLEY WARNER1AND LAWRENCE J. RIZZOLO2*
1Section of the History of Medicine Yale University School of Medicine, New Haven, Connecticut
2Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
For most of the 19th century, anatomists in the United States saw the affective, emotional
aspects of human dissection as salient ingredients in professional formation. Professional-
ism (or ‘‘character’’) signified medical integrity and guaranteed correct professional con-
duct. As gross anatomy came under siege in the late-19th and early-20th centuries,
crowded out of medical curricula by the new experimental sciences, medical educators
rethought what it was that dissecting a human body stood to give medical students. As
they embraced a new understanding of professionalism premised on an allegiance to sci-
ence, anatomists celebrated the habits of mind and sensibility to scientific investigation
that could be acquired at the dissecting table. One consequence was a deliberate distancing
of gross anatomy from the ‘‘art of medicine,’’ and with it a de facto suppression of atten-
tion to the affective components of human dissection. During this period in the opening
decades of the 20th century, the norm of silence about the emotional dimensions of dissec-
tion was set in place. The confluence of various movements by the 1960s and 1970s both
revived attention to the emotional experience of dissection and sparked a renewed discus-
sion about the relationship between the affective components of learning anatomy and the
professional formation of future healers. There is a need to balance the tension between
the ‘‘affective’’ and ‘‘scientific’’ aspects of anatomy, and by extension the tension between
the ‘‘art’’ and ‘‘science’’ of medical practice. One method is to use small-group ‘‘learning
societies’’ as a means to cultivate and meld both dimensions of the professional ethic.
Clin. Anat. 19:403–414, 2006.
C2006 Wiley-Liss, Inc.
Key words: history of medicine; professionalism; anatomy; medical education
Professionalism is an essential quality to instill in
medical students, but is it the purview of anatomy
instructors? With ever decreasing hours allotted to
anatomy courses, instructors barely have time to teach
anatomy. Yet, regardless of their intentions, anato-
mists have always reflected and influenced the profes-
sional ethos of their time.
During the first half of the 19th century, gross anat-
omy held an intellectual centrality to Western medi-
cal science, surpassing anything it enjoyed before or
since. Science meant empiricism, epitomized by sys-
tematic empirical correlation of symptoms observed at
the bedside with lesions found at autopsy. Many med-
ical Americans with scientific aspirations, like their
British and German counterparts, traveled to Paris to
gain the extensive hands-on experience that was diffi-
cult to obtain at home, and labored hard to transplant
the French patho-anatomical model back to their own
countries (Warner, 1998).
We begin with this period in American medicine.
We explore transformations over time in the recipro-
cal influence between approaches to dissection and
concepts of professionalism. Wittingly or not, anato-
mists have played an important role in inculcating an
ethic that balances the ‘‘affective’’ and ‘‘scientific’’
*Correspondence to: Lawrence J. Rizzolo, Department of Sur-
gery, Yale University, PO Box 208062, New Haven, CT 06520-
8062. E-mail: Lawrence.Rizzolo@yale.edu
Received 6 July 2005; Revised 24 October 2005; Accepted 3
Published online 14 April 2006 in Wiley InterScience (www.
interscience.wiley.com). DOI 10.1002/ca.20290
C2006 Wiley-Liss, Inc.
Clinical Anatomy 19:403–414 (2006)
aspects of professionalism. A method is proposed that
encourages students to develop professionalism by
applying its principles to the study of anatomy.
DISSECTION AND THE FORMATION OF
PROFESSIONAL CHARACTER IN THE
In the mid-19th century, it remained possible to
receive an M.D. degree in the United States without
any serious engagement in human dissection (Blake,
1980). Nonetheless, many medical educators main-
tained that dissection should provide a practical foun-
dation for the surgical work that students could antici-
pate in general practice. And dissection brought stu-
dents as close as most would ever come to the
forefront of medical science.
Dissection was also virtually the only moment of
medical education at which hands-on study was pur-
sued systematically in groups. To be sure, they
learned from each other by studying together in their
boarding houses, forming quiz clubs, and exchanging
class notes. But unlike these collaborations or the
practical experience many gained in apprenticeship
before attending medical school, dissection involved a
group process of learning by doing. The collaborative
character of dissection intensified its significance as a
professional rite of passage. Anatomical dissection fig-
ured prominently in ceremonial orations, such as the
inaugural addresses that opened the school year, in
which faculty admonished students that they were at
an inescapably transformative moment in the shaping
of their professional values, integrity, and identity.
Educators recognized that medical training in-
volved not only cognitive but affective components,
and held that both were critical ingredients in mold-
ing professional character. As a period of transition,
medical education was also a time of danger, subject
to both fortifying and corrupting influences. ‘‘You are
now upon that stage of life, when the formation of
character is inevitable,’’ a Memphis Medical College
professor advised his students in 1853. ‘‘Whether the
matter enlists your attention or not, your characters
moulded, for good or evil’’ (Wooten, 1853; Warner,
2001). Human dissection was a catalyst for this moral
transformation. Its practitioners clearly understood
that it was transgressive, conducted on the margins of
legality and conventional morality. Anatomy laws in
the US varied state to state, but through the 1880s, in
some states, human dissection was not legal, and in
some places into the 1910s there was no legal way to
obtain a cadaver (Blake, 1955; Humphrey, 1973; Bla-
and your destiniesbe
keley and Harrington, 1997; Richardson, 2000; Sappol,
2002). ‘‘We know only too well,’’ a Harvard professor
told the 1896 meeting of the Association of American
Anatomists, ‘‘that dissection is an abomination to the
popular mind’’ (Dwight, 1896), while Congressional
debate publicized what a US Congressman called
‘‘the horrors of the dissecting room,’’ ‘‘the savage, soul-
less science of the medical schools’’ (Blake, 1968). At
a time when students often relied on trade of grave
robbers, and sometimes were expected to procure
subjects themselves, the sense of violation that some
students found disturbing was not confined to the dis-
Medical professors warned their students to culti-
vate gentleness as a counterbalance to the hardening
influences of their studies. Records left by students
display acute reflection on the ongoing transformation
in their own sensibilities. ‘‘The study of Medicine
does have a manifest tendency to harden & corrupt
the heart,’’ one young man from Georgia studying
medicine in Philadelphia wrote home to his father in
1853. Spending every evening in the dissecting room,
he reported, ‘‘renders our hearts liable to be corrupted
and hardened,’’ while it tended to ‘‘render the sensi-
bilities Callous, [and] brutalize the feelings’’ (Jones,
1853). As a medical professor cautioned students in
1847, ‘‘anatomy, however indispensable it may be,
tends certainly to freeze up the springs of human feel-
ing, and destroy our sympathy for human suffering’’
(Miller, 1847). Students tended to forget that the
cadaver was more than an object, John Ware warned
Harvard students; yet ‘‘the influence exerted is so
gradual, the change in our habits and feelings is so
insensibly brought about, that we are not aware that it
has taken place’’ (Ware, 1850).
At the same time, some medical professors took
pains to insist that anatomical study did not necessa-
rily tarnish character, and drew attention to its poten-
tial to uplift rather than to degrade. ‘‘The heart is not
hardened, nor the natural sympathies extinguished,
by the exercise of a human art,’’ a Louisville professor
encouraged his medical students in 1838, ‘‘although
the hands may be bathed in blood’’ (Flint, 1838). The
perception that ‘‘the study of medicine has a peculiar
tendency to harden the disposition,’’ a Philadelphia
student urged in his 1840 M.D. thesis, ‘‘The Forma-
tion of Medical Character,’’ made it incumbent on stu-
dents themselves to cultivate an ‘‘affectionate sympa-
thizing spirit’’ (Morril, 1840).
The hardening effect of anatomical study was por-
trayed as particularly dangerous for women medical
students. Concern about brutalization was a serious
issue for both opponents and supporters of women’s
medical education and women practitioners. Cardinal
404Warner and Rizzolo
to the professional identity and legitimacy of the first
generation of women physicians was the assertion that
women had a special aptitude for healing, a conviction
rooted in Victorian gender stereotypes that identified
femininity with refined moral sensibility and special
capacities for caring, sympathy, and nurturing. If ana-
tomical study blunted the moral senses and feelings
of sympathy, accordingly, it could undercut the pillars
that sustained the movement for the education of
women as physicians (Morantz-Sanchez, 1985, 1999;
Critics of the medical education of women, such as
Harvard’s professor Ware, warned that experiences
such as dissection guaranteed what he called ‘‘defile-
ment’’ of women’s ‘‘moral constitution’’ (Ware, 1850).
The advocates of the medical education of women,
for their part, also acknowledged the hardening
potential of experience in the dissecting room, but
countered that properly regarded, anatomical study
could fortify the character and moral sensibilities of
the physician in training. ‘‘We know it has been
objected that familiarity with such subjects as belong
properly to the science of medicine, with anatomy
and kindred studies, cannot fail to injure or destroy
those feelings of delicacy and refinement which add
peculiar luster to the character of women,’’ Emeline
H. Cleveland, professor of anatomy at the Female
Medical College of Pennsylvania, told the students
assembled for her introductory lecture in 1858, a con-
cern she raised only to dispel (Cleveland, 1858). As
she told students at the same school (renamed the
Women’s Medical College of Pennsylvania) a decade
later, enlisting the language and logic of natural theol-
ogy, ‘‘We feel sure that, on the contrary, you have
found the study of Anatomy ‘a hymn in honor of the
creator,’ ... that the study of medicine has but
strengthened your womanly feeling, your reverence
for the divine’’ (Cleveland, 1868; Preston, 1859).
The importance students attached to the shared
group experience of anatomical study is evident in
the rise of a new genre of photography, typically
depicting a small group of students posed in the dis-
section room with a single cadaver, as in Figures 1
and 2. By the 1880s, after technological changes had
made photography widely available, such photographs
proliferated at medical schools across the country
(Terry, 1983). Indeed, this became perhaps the most
common way American medical students chose to
depict themselves together at work. Like other group
portraits, these photographs captured not only particu-
Yale medical students, graduating class of 1902, pose with Dr. Harry Ferris, professor of
anatomy, and their cadaver. Reprinted with permission, Historical Medical Library, Harvey Cushing/
John Hay Whitney Medical Library, Yale University, New Haven, CT.
405 Training for Professionalism
lar moments (however staged) but also social rela-
tions—in this case, between the dissectors and the
cadaver, the lay community they had in some ways
left behind, and the professional fraternity they were
joining. Above all, it was the relationship among the
dissectors themselves that the photographs commem-
orated, underscored in Figure 1 by the inscription of
each student’s name beneath the image (with the
name of their instructor, whose presence sanctioned
the scene). Privileged access to the body marked a
social, moral, and emotional boundary crossing that
conferred new knowledge and reforged sensibilities.
Students acknowledged the emotional intensity of
human dissection in compositions that enlisted dark,
gallows humor—sometimes whimsical and sometimes
darkly sardonic. Photographs of medical students
playing pranks with skeletons, as in Figure 3, often
were set in lodgings or lecture rooms, but pranks with
Pennsylvania students pose with their cadaver
in 1892. Reprinted with permission, Archives
and Special Collections on Women in Medi-
cine, Drexel University College of Medicine,
Women’s Medical College of
Medical College of Pennsylvania clowning with
skeletons, 1895–1896. Reprinted with permis-
sion, Archives and Special Collections on Women
in Medicine, Drexel University College of Medi-
cine, Philadelphia, PA.
Medical students at the Women’s
406 Warner and Rizzolo
a cadaver, as in Figure 4, were restricted to the sepa-
rate, confining space of the dissecting room. Staging
such tableaux was a boast about collective emotional
achievement rather than a gesture of empathy or
respect—a display of collective identity and a vehicle
for emotional release enacted as a group. When the
students shown in Figure 5 painted on the side of
their dissecting table, ‘‘He lived for others, He was
killed for US,’’ it is unlikely that they were confessing
to a crime—even though murder in order to sell the
body for dissection was reported in Baltimore as late
as 1886 (Guttmacher, 1935). Rather, their allusion to
the darkest side of human dissection is better inter-
preted as an acknowledgement of its transgressive
nature and a celebration of this pivotal moment in
their professional formation.
Through most of the 19th century, then, the affec-
tive, subjective, emotional aspects of human dissec-
tion were seen as part and parcel of teaching and
learning medicine. Even the photographic group por-
traits testified to the pervasive sense that human dis-
section involved intense feelings that should be
openly acknowledged as important ingredients in the
shaping of professional character. If a balance was to
be struck between the hardening and uplifting poten-
tial of human dissection in catalyzing moral transfor-
mation, most agreed that the emotional components
of anatomical study needed to be addressed and sub-
jected to self-reflection, not denied.
THE NEW SCIENTIFIC MEDICINE AND
THE CRISIS OF ANATOMY
A sea-change in what counted as scientific medi-
cine at the turn of the 20th century left leading anat-
omy teachers scrambling to salvage the prestige and
salience of their field. Prompted by newly emerging
canons of professionalism in medicine, they jettisoned
attention to the emotional aspects of dissection and
downplayed the practical role of anatomy as a servant
Medical students playing cards with cadaver, propped up with a lit cigarette in its mouth
(ca. 1890). Reprinted with permission, Steve and Mary DeGenaro.
407 Training for Professionalism
to surgery. Instead, they celebrated the anatomy labo-
ratory as a crucible for molding students’ mental atti-
tudes, reasoning processes, and sensibility to scientific
Gross anatomy came under siege, eclipsed in cur-
ricula by the newer experimental sciences. It was the
most antiquated of the basic medical sciences. It was
also the most distanced from the methods, instru-
ments, and subjects identified with precision, exact-
ness, and the larger cluster of epistemological, profes-
sional, and aesthetic ideals the experimental labora-
tory was made to represent. At the forefront of
scientific medicine, experimentation and rationalism
supplanted empirical observation and symptom-lesion
correlation, while learning by doing became the norm
in laboratory groups. The dissecting room was a site
of epistemological exhaustion, with gross anatomy, as
a Cleveland physician insisted in 1902, ‘‘fixed and
unchangeable’’ (Hamann, 1902).
One response from established anatomy teachers
was a defensive assertion that dissection gave stu-
dents knowledge about structure that was essential to
future practitioners and that the practical value of
anatomy as an applied science meant that its place in
the curriculum should be undiminished, both in hours
and in standing. A response more characteristic of
younger anatomists, however, was to redefine what
constituted ‘‘anatomy,’’ downplaying gross anatomy
and emphasizing developmental biology, embryology,
and histology. At the same time, they also rethought
precisely what it was that the future doctor gained
from cadaver dissection.
Anatomical study, they asserted, should be a bastion
of the new version of scientific medicine that was
growing ascendant (Mall, 1908; Jackson, 1918). New
ideals of science were informing a thoroughgoing ref-
ormation of medical education (through blueprints
such as Abraham Flexner’s 1910 report on Medical
Education in the United States and Canada) and a recon-
struction of professional identity, with mastery of the
new sciences regarded as the best guarantor of right
professional conduct (Warner, 1991). The methods
and habits of mind acquired at the dissecting table,
anatomists argued, offered an important foundation for
making the physician-as-scientist. Redoubled empha-
sis in all areas of medical instruction was placed on
individual experience, learning by doing, as a vehicle
for inculcating the ‘‘scientific method’’ (Ludmerer,
1985, 1999). Anatomists, to be sure, widely complained
that the attention of most students was riveted on
memorizing detail, not the process of thinking they
hoped to develop. Nevertheless, dissection, its defend-
ers insisted, should be seen above all as a vehicle for
instilling those values that distinguished the new pro-
fessionalism of physician-scientists from their prede-
cessors, including an allegiance to objectivity and pre-
Medical students around the turn of the century at an unidentified school with their dis-
secting table inscribed, ‘‘He lived for others, He was killed for US.’’ Reprinted with permission, Dit-
trick Medical History Center, Case Western Reserve University, Cleveland, OH.
408 Warner and Rizzolo
cision and to their moral correlates, such as self-abne-
gation, detachment, and self-denial.
A second prong of this program involved throwing
off baggage that anatomical dissection had inherited
fromthe past, especially
grounded on clinical relevance. Anatomists self-con-
sciously sought to distance dissection from the per-
ception that it was a ‘‘mere’’ applied science: the
‘‘practical,’’ indeed, increasingly was valorized as sec-
ond rate. ‘‘The greatest danger to anatomy, strange to
say, lies in the very fact of its practical importance,’’
Yale comparative anatomist and embryologist, Ross
Harrison, asserted in 1912. ‘‘It is this circumstance
that, in England and America, has threatened, and
even now threatens, to make the science entirely sub-
servient to practice’’ (Harrison, 1913). Insisting on the
rightful place of anatomy as a basic science, anato-
mists turned away from now discounted associations
with the art of medicine.
With this maneuver, rhetoric about the affective
component of dissection as an ingredient in professio-
nal formation to a remarkable extent vanished. Atten-
tion to emotion, to the medical student’s subjectivity
and feelings, became disreputable, professionally sus-
pect, something to be repudiated as part of the quest
to remake anatomical instruction into a buttress for
the new ideals of professionalism.
The language of ‘‘sympathy,’’ moreover, which
some anatomy teachers had once urged students to
cultivate as a counterbalance to the brutalizing influ-
ences of dissection, was further marginalized by its
gendered associations with Victorian feminine senti-
mentalism. And while the term ‘‘empathy’’ was intro-
duced in the late-19th century, anatomy would long
remain aloof from what later developed as empathic
professionalism precisely because of efforts to dis-
tance anatomical instruction from clinical practice
(More, 1994). By the early 1920s, just as the new
Flexnerian model of medical education that gave
pride of place to the experimental laboratory was
fixed in place, photographic group portraits of stu-
dents gathered around their cadaver faded away. The
virtual disappearance of this once ubiquitous expres-
sion of student acknowledgement of the emotionally
transformative character of this intense rite of passage
and reflection on their professional formation was one
indicator of the norm of silence about the affective
aspects of dissection that was established early in the
20th century, what observers decades later (Hafferty,
1991; Dyer and Thorndike, 2000) would note as a per-
sistent feature of dissection room culture. Visual like
verbal commentary on the affective aspects of learn-
ing anatomy were suppressed as one part of the larger
response to the crisis of anatomy as a science.
ANATOMY, EMOTION, AND MEDICAL
SOCIALIZATION AFTER WORLD WAR II
Attention to the emotional components of anatomi-
cal study and their relationship to the grounding of
professionalism re-emerged in the middle of the 20th
century. In the first instance, this came not so much
from medical educators as that from medical sociolo-
gists. Cold War era intellectuals grew increasingly
concerned that training for conformity was breeding
authentic emotion and creative depth out of cookie-
cutter professionals, a specter one sociologist captured
in The Organization Man (Whyte, 1956). Such sociolo-
gists as Robert Merton, Talcott Parsons, and Howard
Becker were intent in disclosing the powerful and
enduring ways that professional training—especially
in medicine—shaped identity and values. During the
1950s, the golden age of medical sociology, the pro-
cesses of medical socialization were subjected to close
scrutiny, as researchers (sometimes collaborating with
psychiatrists in exploring the role of anxiety-provok-
ing experiences) sought to trace out how students
were transformed into doctors (Bloom, 2002).
Sociologists tended to assume that gross anatomy
was a crucial nexus of professional formation, one of
the passages that socialized doctors as a breed apart.
This expectation was reinforced by the public percep-
tion that human dissection must have profound psy-
chological consequences, evident in popular novels.
Yet, in the mid-1950s, sociologists who studied medi-
cal student culture at Kansas observed that the
‘‘trauma’’ students reported experiencing in anatomi-
cal study rested in the massive amount of detail they
were expected to master, not the emotional experi-
ence of dissecting a dead body (Becker et al., 1961).
Rene ´e Fox, a student of Parsons, had already con-
cluded from a collaborative study of Cornell that med-
ical students regarded emotion in the dissecting room
as something to be overcome, a step in the develop-
ment of ‘‘detached concern,’’ a concept she formu-
lated in 1951 and that circulated among sociologists
before she first used it in print in 1963 (Fox, 1957;
Becker et al., 1961; Fox, 1988). Fox, with psychiatrist
Harold Lief, observed that students were reluctant to
discuss their feelings about dissection, convinced that
they needed to approach anatomy ‘‘in an objective sci-
entific way.’’ Weathering the ordeal in this manner
Lief and Fox maintained was a valuable catalyst in
transforming the student’s sensibilities into those of a
well-adjusted doctor (Lief et al., 1960; Lief and Fox,
1963; Maguire, 1985).
A driving force in moving attention to the emo-
tional components of anatomical dissection from the
realm of medical sociologists to that of medical educa-
409Training for Professionalism
tors was the broader assault mounted in the 1960s and
1970s on the medical profession, its values, and its
putative failure to foster humane patient care. The
attack came from many fronts: liberal Democrats
seeking health care reform in the face of AMA resist-
ance; civil rights activists targeting segregated hospi-
tals; consumer activists suspicious of ‘‘the medical–
industrial complex;’’ feminists denouncing abuses of
medical authority; and medical students decrying a
dehumanizing system of training. One message these
critiques shared was that medical schools were culpa-
ble in the pervasive failings of medical professional-
ism. Critics increasingly insisted that while scientific
expertise was necessary for medical competence, it
was far from sufficient as a foundation for making
humane doctors (Rothman, 1991; Warner, 1995;
Brandt and Gardner, 2000; Rogers, 2001). Clinical
care, the structure of medical training, and inequities
in the health care delivery system received the lion’s
share of reformers’ attention. But by the 1970s, anat-
omy also captured the attention of critics rethinking
the grounding of professionalism—both recent medi-
cal graduates reflecting on ‘‘how to stay human in
medicine’’ (Reiser, 1973) and faculty concerned with
‘‘humanizing the student–cadaver encounter’’ (Black-
well et al., 1979).
By the late 1960s, terms such as ‘‘dehumanization,’’
which once had belonged to the rhetoric of the radical
left, had been taken up by organizations such as the
AAMC (Rogers, 2001). One educator called in 1965
for curricula that offered ‘‘learning experiences which
will develop in the student population a behavioral
guished by ‘‘gentleness, kindness, empathic consider-
ation, and other qualities of the humanitarian’’ (King,
1965). ‘‘We are told that we neglect the teaching of
human values and the art of medicine,’’ physician
Edmund Pellegrino noted in 1974; ‘‘that the patient
care we provide in our teaching hospitals and clinics is
itself dehumanizing’’ (Pellegrino, 1974). Opportuni-
ties, he urged, ‘‘must be provided for students to
express their feelings of conflict and anxiety,’’ assert-
ing that ‘‘affective learning has the goal of making a
humane and compassionate practitioner.’’
Other forces specific to anatomy also called atten-
tion to the affective components of dissection. Gross
anatomy again was under siege in crowded curricula,
with time for dissection rechanneled into expanding
areas of molecular medicine and into psychosocial
dimensions of medicine and medical humanities,
which made explicit bids to address and allay concerns
about dehumanization (Callahan and Gavan, 1968;
Crafts, 1965, 1968; Aziz and McKenzie, 1999; Rizzolo,
2002). The emphasis of instruction had been on anat-
omy as ‘‘a science in its own right,’’ as one participant
in an AAMC teaching institute devoted to anatomy
put it in 1955, as a way ‘‘to train the student in basic
principles of observation, deduction and interpreta-
tion’’ (AAMC, 1956). Amidst calls for relevance, how-
ever (Moffatt and Metcalf, 1972), anatomy was
approached less as a field of science taught for its own
sake and more for its relevance to clinical practice,
drawing attention to how values acquired at the dis-
secting table were transferred to the bedside (Rizzolo,
2002; Guttmann et al., 2004; Pawlina and Lachman,
2004; Peck and Skandalakis, 2004).
Shifting attitudes toward death and funerary practi-
ces from the 1950s to the 1970s, and a move toward
donated body programs, also contributed to these
changes in the affective experience of human dissec-
tion and the attention it received from anatomists. By
the mid-1950s, in both the US and UK there was a
serious cadaver shortage, and in the UK the idea of
donation was raised with increased frequency. Jessica
Mitford’s American Way of Death (Mitford, 1963), a
widely read expose of the funeral industry, signaled a
cultural turn toward cremation, something earlier and
more pronounced in the UK, and during that decade
medical schools started deeded body programs. By
1967, of 82 surveyed medical schools in the US and
Canada, 9% had entirely donated cadaver supplies,
while 6% had none donated; 24% had more than half
donated; and 76% had less than half (Smith, 1969).
Passage of the Uniform Anatomical Gift Act in 1968
was a crucial watershed in the social origins of the
cadavers who filled American dissecting rooms (Dal-
ley et al., 1933; Sadler et al., 1968).
‘‘Detached concern’’ became a lightning rod for
criticism of how medical education taught students to
suppress emotion. Beginning in the 1970s, feminist
and critical social theorists challenged the desirability
and possibility of maintaining complete detachment
between subject and object (More, 1994). Medical
sociologist Frederic Hafferty followed Fox’s lead two
decades later by observing a class of first year stu-
dents, and concluded that in the anatomy laboratory
students quickly learned to adopt the mantle of emo-
tional detachment by outwardly suppressing their
inner experience. What Lief and Fox had reported as
‘‘an unwritten law’’ against discussing feelings about
dissection (Lief and Fox, 1963) Hafferty recounted as
‘‘feeling rules’’ (Hafferty, 1991) that discouraged any
open discussion or display of emotional upset. In his
study of ‘‘the emotional socialization’’ of medical stu-
dents, however, Hafferty contended that whatever
adaptive value there might be in silence about feel-
ings and an outward posture of detachment, ‘‘training
for detachment’’ was purchased at too high a price.
410Warner and Rizzolo
Self-consciously cultivated respect for the cadavers
was one means of chipping away at established norms
of socialization and acculturation. Memorial services
held at the end of the anatomy course began in the
UK as early as 1965, and in the US by the early 1970s,
signaling an important change in students’ sensibility
to their cadaver (Susan Lawrence, University of Iowa,
personal communication). This shift in medical stu-
dent culture coincided with a surge in public and pro-
fessional interest in death and dying, marked by the
publication of Elisabeth Ku ¨bler-Ross’s widely read
book (Ku ¨bler-Ross, 1969), which informed initiatives
to use students’ experience confronting and dissecting
a cadaver as a springboard to exploring these newly
resonant topics. By the late 1970s, and more so into
the 1980s and 1990s, students’ emotional response to
gross anatomy had again captured the attention of
many medical educators. By the turn of the century,
the focus was not merely on how to humanize an
emotion-laden experience in ways that avoided the
risk of dangerous detachment, but also on how the
affective experience of human dissection could be
harnessed as a positive ingredient in professional for-
mation (Blackwell et al., 1979; Penney, 1985; Gustav-
son, 1988; Horne et al., 1990; Dickinson et al., 1997;
Dinsmore et al., 2001).
THE ROLE OF PROFESSIONALISM IN THE
MODERN ANATOMY COURSE
Over the last 150 years, the normative statements
of anatomists and clinicians alike reflected a dynamic
tension that favored either the affective or the scien-
tific aspects of professionalism. With the swings of
that pendulum, anatomists strove to maintain their
position in the curriculum by redefining their role in
tune with the trends in medical professionalism. Once
again anatomists find their position threatened (Aziz
et al., 1999; Dyer and Thorndike, 2000). The knowl-
edge base of the other basic sciences continues to
expand and more clinical activities continue to be
added to the ‘‘basic science’’ years. Students need to
be evermore prepared to understand therapies that
are grounded in molecular and cellular biology. Classi-
cal anatomy courses are labor- and time-intensive, and
many clinicians feel anatomy courses dwell on
unnecessary detail. Accordingly, deans of education
look to shorten anatomy courses to make room for
other priorities (Drake et al., 2002; Heylings, 2002).
Advances in computer simulation and diagnostic
imaging suggest alternatives to dissection that may be
more effective and require less time. Despite the per-
ception that anatomy is less important, residency and
clerkship programs suggest students are under-pre-
pared with respect to anatomy (Cottam, 1999; Dicap-
rio, 2003). Together, the sense is that essential anat-
omy, lost in the trivia, cannot be recalled when stu-
dents reach the clinic. In turn, this leads to the
perception that anatomy courses are too long, yet fail
to get the job done. To address these concerns, anato-
mists need to redefine their roles to serve the new
demands of an evolving medical school curriculum.
In our effort to redefine our anatomy course, we
aim to break the pendular swings between the affec-
tive and scientific aspects of professionalism. We hope
to balance this dynamic tension by fostering the atti-
tudes of empathy, respect, and humility while inte-
grating them with the attitudes of scientific inquiry
and evidence-based medicine.
A concern in modern medicine is that emotions
will interfere with objectivity. This view is challenged
by psychiatrist and philosopher Jodi Halpern in her
book, From Detached Concern to Empathy (Halpern,
2001). Halpern values the role that empathy plays in
enabling science-based medical practice. In her view,
an empathic connection with the patient allows the
clinician to obtain a more complete, accurate history
and description of the present illness, to better under-
stand the needs and goals of the patient and to
increase the likelihood of patient compliance with
Anatomists can begin to develop the skills needed
by the objective, yet empathetic, clinician. As a first
step, anatomy can lead clinical students to explore
and address their own emotions. Because the dissec-
tion lab presents emotional challenges in a scientific
setting, we suggest the dissection lab is well-suited to
begin integrating the diverse professional attitudes of
service. These include the attitudes of knowledge,
scientific inquiry and interpretation of data along with
the attitudes of empathy, respect for cultural diver-
sity, and self-reflection. Earlier, we described our ini-
tial efforts, which focused on the affective aspects of
professionalism (Rizzolo, 2002). For the core of that
program, we found it very helpful to refer to the stu-
dent’s cadaver as their ‘‘donor’’ rather than their ‘‘first
patient.’’ Many students, physicians, and chaplains
were uneasy with the latter characterization, because
students would not cure this ‘‘patient’’ or ease ‘‘their’’
cadaver without making it whole again. Further, the
cadaver has no voice, in sharp contradiction to the
value now placed on listening to the patient’s story,
and encouraging participation in decision-making, as
constitutive parts of the doctor–patient relationship.
By contrast, students readily accepted ‘‘donor,’’
because it constantly recalled the gift and the trust
that the donor placed in the student. This subtle shift
411 Training for Professionalism
in focus inspired students to articulate reflections on
life, disease, and mortality during the course and at a
year-end service-of-gratitude. In the current report,
we describe how we have built on that early program
to create a structure that engages more of the class
and brings both affective and scientific attitudes of
medical professionalism to bear on anatomy instruc-
Despite the stated goals of past and present anato-
mists, two powerful forces distract students from
achieving either the scientific or affective goals. First,
students continue to be confronted with large masses
of detail to master in very little time. Memorization
continues to compete with the development of ana-
tomical concepts and problem solving, thereby under-
mining the attitudes of scientific inquiry. Second, stu-
dents fear appearing ignorant in front of others. Con-
sequently, instructors wait for exams to learn about
their effectiveness, and students lose opportunities to
learn from one another (Rizzolo et al., in press). When
brought together in a focus group to discuss learning
strategy, many students were surprised and grateful to
learn of the diverse strategies and resources that other
individuals or dissection teams used to solve common
problems (Rizzolo, unpublished data). Without a team
approach, students also lose a venue to explore emo-
tional responses to their work.
We are finding that these destructive forces can be
mitigated by actively and continuously facilitating
group-process. (Notably, teamwork is becoming the
norm in medical practice.) To be effective, team
members have to communicate frankly, yet respect-
fully. Often, personal desires need to be subjugated
to group needs. These attitudes are enabled if the
group establishes a safe environment, where mistakes
are viewed as learning opportunities. By sharing
insights and information, or confusion and probing
questions, each student can contribute to the group’s
progress. By making group problem-solving our core
pedagogical tool, we are able to directly observe and
assess each student’s daily progress. We are finding
that students are more prepared for class, as nearly
every student actively participates in the discussion.
In survey and focus group data of the past 2 years, stu-
dents cited group-process as a strength of the course
(Rizzolo, unpublished data). Furthermore, group-
process enables students and faculty to support one
another in the affective aspects of human dissection.
Because the class includes various social and religious
backgrounds, open discussion helped developing the
professional ethic of compassion and respect for diver-
sity. This diversity became evident following the first
lab and a lecture on the history of dissection when
students met to discuss their own reactions to, and
debate the need for, dissection. In this environment,
we found that students felt encouraged to share the
angst, frustration, and joys of their experience (Riz-
To promote group-process, our first lecture dis-
cusses professionalism and the attitudes that enable
learning. We divide the class into learning societies of
20 students and a mentor who work together in lab
and in small-group conferences. The society structure
gives students the opportunity to share library and
laboratory research techniques, to practice scientific
reasoning and peer teaching, and to develop the
familiarity that enables them to share reflections on
the experience of dissection. To foster a sense of
community, each society is named for a prominent fig-
ure in Yale’s history and a biographical sketch of that
individual is posted in the society’s lab area. Each
society develops its understanding of professionalism
by negotiating a community agreement about how to
meet their responsibilities to each other, and by
throughout the year. Instead of a reprimand, ‘‘viola-
tions’’ are viewed as learning opportunities for the
group to review the practicality of their agreement
and to reaffirm their professional commitment to one
another (Kegan and Lahey, 2001). For example, one
student stopped coming to conference because he felt
he knew more than that of his colleagues and was not
benefiting. When he learned how sharing his insights
would exercise the professional ethic of altruism,
while deepening his own understanding through
teaching, he became an enthusiastic member of the
Anatomy instruction and professionalism are inter-
twined. Attention to the social structure of the anat-
omy course simultaneously promotes the learning of
anatomy and the development of group-process skills.
Group-process in and of itself embodies many aspects
of professionalism. Group-process develops professio-
nal attitudes of scientific reasoning, research, and
analysis, while it provides a forum to discuss the affec-
tive aspects of dissection. However instructors choose
to do it, professionalism is an integral part of the anat-
omy course that cannot be relegated to someone
The authors would like to thank Susan Lawrence,
Michael O’Brien, Naomi Rogers, and William Stewart
for reviewing drafts of this manuscript. This work was
supported in part by Grant P116B03017 from the US
Department of Education (LJR).
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