June C. Penney F.S.R., T.E.

Professor, Faculty of Medicine

Dalhousie University
Halifax, Nova Scotia CANADA B3H 4H7

(+) 1-902-494-3400
(+) 1-902-494-7119

Medical students arrive every September full of enthusiasm and idealism; lots of energy and anticipation. In general, they really care — they want to help and to heal. They want to be the right kind of people.

They arrive very enthused, they also arrive very anxious. For the past few years they have been anxious about applying for medical school; how many applications? Will I get in? Then the question becomes will I make it? Can I cope? Suddenly they realize that 50% of them will be in the bottom half of the class and they have never been there before,either in high school or university! They are often obsessive compulsive and about 50% are women (mostly first-born females). They will find the work difficult and demanding; there will be an enormous amount of material to absorb, tremendous competition, and a fear of failure. It is important to recognize that in a class where the average age is between 24 and 25 most of them are entering a phase of major life changes and major decisions. Many will marry and become parents during their 4 years in medical school.

Let us look at the process of becoming a physician. Medical students experience a loss of many of the things that we would consider constitute a ā€œnormal lifeā€.
?They lose time for family and friends.
?They lose time for socializing.
?They have financial worries.
?They suffer fatigue from loss of sleep.
?They tend to lose confidence in their own abilities -because for the first time they may not be at the top.

All students in professional schools work very hard but in addition there are some specific stresses that have been identified for medical students. Two of them are their first visit to the anatomy lab, and the fear of death.

Educational processes are dependent upon good relationships, and we learn best from those we care about and who care about us. It may be accurate to say that if an anatomy teacher is more preoccupied with bones, muscles and tendons then with relating to his students, then students will not learn much anatomy; or if the teacher is keen to have his students achieve in order to enhance his own image he will see his students only as objects to be manipulated. The student is there to serve his ends. Our concern for our studentsā€™ own needs may shape their future outlook and behavior. These needs are physical, emotional, psychosocial and spiritual. I suggest that the actual planning of a medical school curriculum should not be devised merely to cover the necessary material but also to meet the needs of our students.

But we do a very strange thing to new medical students. Usually during the first few weeks, we send them to the anatomy lab and expect them to begin dissecting a human body! For many this is their first experience with death, and in fact, most have never seen an actual cadaver before. This was one important finding which became apparent as the result of a study1 using an anonymous questionnaire designed primarily to determine medical studentsā€™ reactions to human dissection. In addition, it provided us with some insights into many other needs. Questionnaire response rate was 96% and our results are summarized in Table 1. From this study it appeared there were many concerns that could be addressed. This sampling indicated that our medical students expressed strong reactions to human dissection, that the experience had a profound effect upon their thinking about life and death; they were concerned about the need to balance objectivity and compassion; and importantly, they expressed a need to be better prepared for the experience. The strongest reaction appeared to be the anticipation of dissection!

As a direct result, an ā€œOrientation to Dissectionā€ program was created and introduced into our anatomy curriculum. This program consists of three parts. At their first anatomy lecture, students are given information on donors and receive copies of the printed material sent to prospective donors. Three questions are asked during this session: 1) Do you know of someone who has donated their body to this medical school recently? 2) Have you experienced a recent death? 3) Have you had any experience where you thought you were near death? If the answer to any of these questions is yes, the student is requested to contact the lecturer. In the case of a known donor, that cadaver is removed from the anatomy laboratory until the following year. If a recent death has been experienced it is arranged that the students work on a cadaver of the opposite sex to the deceased and preferably one of a different age. Students who have experienced any type of personal assault may need professional counseling.

In the second part of the program, the students are given an opportunity to see a cadaver prior to their first dissecting laboratory. Discussion groups of 12 students visit the dissecting room accompanied by an anatomy faculty member. They are seated around a wrapped cadaver which is rapidly unwrapped at the beginning of the session. During the session, students are encouraged to express their reactions and the anatomy faculty candidly share their own feelings. There is discussion about the factors which may influence their emotions, such as previous and recent experiences of death, previous dissecting experience and ethnic and religious backgrounds. Students are usually very aware both of the need to allow themselves to have emotions in order to relate to their dying patients, and the necessity to balance objectivity and compassion.

The third part of the program consists of viewing a videotape, made by two members of the Anatomy Department, which describes the techniques of dissection. This is shown at the first laboratory session just before students begin dissecting. All students are then encouraged to begin dissection and to encourage each other to do so.

This three-step program has been used at Dalhousie now for several years, and student feedback continues to be extremely positive. Death is a natural and important part of life, yet for most of us it still holds many fears and mysteries. Regardless of profession or station in life, each of us sooner or later must come to acceptable terms with a perception of death. It is important we recognize that for most medical students this time first comes in our dissecting rooms, and thus just prior to that experience is the most appropriate time to help them prepare. We have developed a rational and structured means for students to confront these fears and establish workable perceptions which will serve them in both personal and professional life. Becoming more comfortable with their own views of death, dying, and compassion for patients and family, many of our students are able to contribute meaningfully to an annual memorial service for donors and interact with relatives at the brief reception which follows.

1.Penney, June C. Reactions of Medical Students to Dissection. Journal of Medical Education 60:58-60, 1985.