Do images influence assessment in anatomy? Exploring the effect of images on item difficulty and item discrimination

Strategies to Effectively Utilize Images in Anatomical Teaching and Assessment

Anatomical images are commonly used in the teaching process to help students understand the spatial orientation of anatomical structures. Previous research has shown that images effectively visualize the relationship between anatomical structures that are difficult to comprehend through verbal or written explanations alone. However, there is a lack of guidelines that specifically address the various methods of utilizing anatomical images and delivering them through multimedia and cognitive load principles. This article aims to provide a concise overview of the proper utilization and delivery of anatomical images and how these images can facilitate student interaction.

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

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.

Show them what they can't see! An evaluation of the use of customized 3D printed models in head and neck anatomy

Difficulty in visualizing anatomical structures has been identified as a challenge in anatomy learning and the emergence of three-dimensional printed models (3DPMs) offers a potential solution. This study evaluated the effectiveness of 3DPMs for learning the arterial supply of the head and neck region. One hundred eighty-four undergraduate medical students were randomly assigned to one of four learning modalities including wet specimen, digital model, 3DPM, and textbook image. Posttest scores indicated that all four modalities supported participants' knowledge acquisition, most significantly in the wet specimen group. While the participants rated 3DPMs lower for helping correct identification of structures than wet specimens, they praised 3DPMs for their ability to demonstrate topographical relationships between the arterial supply and adjacent structures. The data further suggested that the biggest limitation of the 3DPMs was their simplicity, thus making it more difficult for users to recognize the equivalent structures on the wet specimens. It was concluded that future designs of 3DPMs will need to consider the balance between the ease of visualization of anatomical structures and the degree of complexity required for successful transfer of learning. Overall, this study presented some conflicting evidence of the favorable outcomes of 3DPMs reported in other similar studies. While effective for anatomy learning as a standalone modality, educators must identify the position 3DPM models hold relative to other modalities in the continuum of undergraduate anatomy education in order to maximize their advantages for students.

Impact of gross anatomy laboratory on student written examination performance: A 3-year study of a large-enrollment undergraduate anatomy course

The efficacy of the various pedagogies that are used in human anatomy laboratories has been extensively debated. Nevertheless, an important question remains relatively unexamined-how the learning experience in the anatomy laboratory impacts students' mastery and application of anatomical knowledge beyond the laboratory setting. In this study, the effect of a prosection-based anatomy laboratory on overall comprehension and mastery of anatomical knowledge was evaluated in an upper division undergraduate anatomy curriculum that consists of a mandatory lecture course and an optional laboratory course. This flexible curricular structure permitted assessing the merit of laboratory learning on the written examination performance of the lecture course. In 2019 and 2022, the anatomy laboratory was taught in-person using prosections, while in 2021 due to the Covid-19 pandemic related regulations, it was taught remotely with live-streaming of prosections using document cameras. In both in-person and remote instructive formats, written examination scores of the lecture course were compared between two cohorts of students: Those enrolled in lecture only and those enrolled in both lecture and laboratory. Results showed that the cohort enrolled in both lecture and laboratory courses consistently outperformed the lecture-only cohort by one full letter grade. Furthermore, when the degrees of improvement on written examination scores were compared between the two instructive formats, in-person laboratory had a greater increase compared to remote laboratory. Altogether this study demonstrates that the prosection-based anatomy laboratory enhances students' mastery of anatomical knowledge beyond the laboratory setting by promoting comprehension of spatial relationships of anatomical structures.

Testing anatomy: Dissecting spatial and non-spatial knowledge in multiple-choice question assessment

Limited research has been conducted on the spatial ability of veterinary students and how this is evaluated within anatomy assessments. This study describes the creation and evaluation of a split design multiple-choice question (MCQ) assessment (totaling 30 questions divided into 15 non-spatial MCQs and 15 spatial MCQs). Two cohorts were tested, one cohort received a 2D teaching method in the academic year 2014/15 (male = 15/108, female 93/108), and the second a 3D teaching method in the academic year 2015/16 (male 14/98, female 84/98). The evaluation of the MCQ demonstrated strong reliability (KR-20 = 0.71 2D and 0.63 3D) meaning the MCQ consistently tests the same construct. Factor analysis of the MCQ provides evidence of validity of the split design of the assessment (RR = 1.11, p = 0.013). Neither cohort outperformed on the non-spatial questions (p > 0.05), however, the 3D cohort performed statistically significantly higher on the spatial questions (p = 0.013). The results of this research support the design of a new anatomy assessment aimed at testing both anatomy knowledge and the problem-solving aspects of anatomical spatial ability. Furthermore, a 3D teaching method was shown to increase students' performance on anatomy questions testing spatial ability.

Art-based assignment in head and neck anatomical course, a dynamic experience

In recent years, alternative uses of art within medical education have been explored and extended. We report here a method of art-based assignments in anatomy and histology, which we have incorporated into the head and neck course as a means of enlivening didactic lectures. One hundred and two first-year medical students at the Alborz University of Medical Sciences participated in a 15-week educational intervention, in which an art-based assignment method was employed. The learning module focuses on the human anatomy and histology of head and neck. In each session, after the teacher's lecture and practical work, students were given an assignment based on the topics of that session and based on the drawing. The learning outcome was evaluated twice, 1 week and 4 weeks after the course. Student's feedbacks were collected via an anonymous questionnaire at the end of the module. The data were analyzed by using the SPSS 20 software by paired and independent t-tests and the normality of data was evaluated by the Kolmogorov-Smirnov test. Most of students (90%) had rated the new format as very informative. Exam scores were significantly higher at 4 weeks tests (P ≤ 0.05) and data showed significant difference in long-term retention of knowledge. The use of this module by medical students during their head and neck course improves their confidence through drawing. Teacher's feedback provides a step-wise approach that simplifies the learning of anatomy and histology. The strategy has appeal for visual, auditory, read/write, and kinesthetic learners.

Past and Current Learning and Teaching Resources and Platforms

For over two centuries, the educational landscape both nationally and globally has changed tremendously. The more traditional teaching and learning resources and platforms, such as traditional textbooks, chalkboards and whiteboards, overhead transparency and carousel projectors, and traditional classroom settings, have been either replaced or supplemented in the anatomical sciences by integrated and virtual eBooks, online learning management (OLM) platforms, and virtual learning and meeting apps. Virtual teaching and learning, especially proliferated with the advent and aftermath of the COVID-19 pandemic, and institutions worldwide that had already been utilizing virtual class and lab sessions in their anatomy curricula expanded virtual course offerings. Many institutions have retained virtual course offerings even after the pandemic, given the distance learning benefits. The future of anatomy education holds many promising possibilities given the voracious speed with which technology is advancing. One such promising advancement is the full, seamless incorporation of virtual three-dimensional (3D) immersive and semi-immersive learning into anatomy laboratories and classroom settings globally as well as into students' laptops and handheld devices for easy use at home or anywhere.

Implications of introducing case based radiological images in anatomy on teaching, learning and assessment of medical students: a mixed-methods study

BACKGROUND

Introducing radiological anatomy in the preclinical curriculum can increase the understanding of Anatomy. Regardless of the integration when teaching anatomy, it is essential to maintain oversight as to what and how much is being taught. In addition, the knowledge requirements for preclinical students should be considered. The purpose of this kind of integration is that the student should be able to apply the knowledge which can help them better understand anatomy and not to make the course more challenging. This study aimed to understand whether adding radiological images would increase the difficulty level of the questions.

METHODS

We introduced radiological images, including X Rays, CT scans and MRIs, when teaching anatomy in the preclinical curriculum. A class of 99 students were tested using A-type MCQs (n = 84). All 84 questions were categorized on whether they were case-based with or without a radiological image. The item analysis of both groups of test questions was then compared based on their difficulty and discrimination index. A qualitative student perception regarding the inclusion of radiological images in anatomy was also measured using a questionnaire with a 5-point Likert scale.

RESULTS

The results showed that the performance level of the students was similar when comparing the test questions in both groups. The item analysis of the MCQs in the two groups revealed that by integrating radiological images when teaching anatomy, the various parameters in both groups of test questions were in the same range. More than 80% of the students felt that radiological images facilitate the achievement of learning outcomes and help to apply their knowledge in clinical contexts. The study's findings reported that the rate of satisfaction by including radiological images when teaching anatomy is high.

CONCLUSION

Recognition and interpretation of images are essential in an undergraduate medical program. Students found it helpful when radiological images were introduced to them when teaching anatomy. Since the students' performance in summative exams in both groups of questions was in the same range, the findings also point out that adding radiological images when teaching anatomy does not increase the difficulty of the subject.

Drawing in Veterinary Anatomy Education: What Do Students Use It For?

In contrast to medical education, information on the use of arts as a learning approach is scarce in veterinary anatomy. The aim of this prospective, questionnaire-based study was to survey students' use of drawing in various aspects of veterinary anatomy learning (self-study, examinations, preparation for, and reflection on cadaver dissection). The quantitative data showed that first-year students with artistic preferences used drawing significantly more often in most aspects of anatomy learning than students with no such preferences, apart from the reported use of drawing in examinations and for reflection after cadaver dissection. The lack of significant correlations of the reported use of drawing in examinations with any other study variable provided support for the author's observation that student-generated drawings are not as commonly used in examinations as previously. In contrast to the study hypothesis, previous university studies did not correlate significantly with any aspect of the use of drawing in anatomy learning. None of the reported uses of drawing addressed the benefits of drawing in learning the comparative anatomy of animal species, a characteristic distinguishing veterinary anatomy from human anatomy. Qualitative student feedback indicated that encouragement and teacher-produced images would increase the use of drawing as a learning approach even if the implementation of drawing into the curriculum is not feasible. Conclusions from this study were implemented through self-directed learning in anatomy courses that replaced the canceled cadaveric dissections during the COVID-19 outbreak and also through the ongoing drawing workshops to further advance the use of drawing in veterinary anatomy learning.

The Effectiveness of Collaborative Augmented Reality in Gross Anatomy Teaching: A Quantitative and Qualitative Pilot Study

In the context of gross anatomy education, novel augmented reality (AR) systems have the potential to serve as complementary pedagogical tools and facilitate interactive, student-centered learning. However, there is a lack of AR systems that enable multiple students to engage in collaborative, team-based learning environments. This article presents the results of a pilot study in which first-year medical students (n = 16) had the opportunity to work with such a collaborative AR system during a full-day gross anatomy seminar. Student performance in an anatomy knowledge test, conducted after an extensive group learning session, increased significantly compared to a pre-test in both the experimental group working with the collaborative AR system (P < 0.01) and in the control group working with traditional anatomy atlases and three-dimensional (3D) models (P < 0.01). However, no significant differences were found between the test results of both groups. While the experienced mental effort during the collaborative learning session was considered rather high (5.13 ± 2.45 on a seven-point Likert scale), both qualitative and quantitative feedback during a survey as well as the results of a System Usability Scale (SUS) questionnaire (80.00 ± 13.90) outlined the potential of the collaborative AR system for increasing students' 3D understanding of topographic anatomy and its advantages over comparable AR systems for single-user experiences. Overall, these outcomes show that collaborative AR systems such as the one evaluated within this work stimulate interactive, student-centered learning in teams and have the potential to become an integral part of a modern, multi-modal anatomy curriculum.

Virtual Reality Bell-Ringer: The Development and Testing of a Stereoscopic Application for Human Gross Anatomy

As post-secondary education migrates online, developing and evaluating new avenues for assessment in anatomy is paramount. Three-dimensional (3D) visualization technology is one area with the potential to augment or even replace resource-intensive cadaver use in anatomical education. This manuscript details the development of a smartphone application, entitled "Virtual Reality Bell-Ringer (VRBR)," capable of displaying monoscopic two-dimensional (2D) or stereoscopic 3D images with the use of an inexpensive cardboard headset for use in spot examinations. Cadaveric image use, creation, and pinning processes are explained, and the source code is provided. To validate this tool, this paper compares traditional laboratory-based spot examination assessment stations against those administered using the VRBR application to test anatomical knowledge. Participants (undergraduate, n = 38; graduate, n = 13) completed three spot examinations specific to their level of study, one in each of the modalities (2D, 3D, laboratory) as well as a mental rotation test (MRT), Stereo Fly stereotest, and cybersickness survey. Repeated measures ANCOVA suggested participants performed significantly better on laboratory and 3D stations compared to 2D stations. Moderate to severe cybersickness symptoms were reported by 63% of participants in at least one category while using the VRBR application. Highest reported symptoms included: eye strain, general discomfort, difficulty focusing, and difficulty concentrating. Overall, the VRBR application is a promising tool for its portability, affordability, and accessibility. Due to reported cybersickness and other technical limitations, the use of VRBR as an alternative to cadaveric specimens presents several challenges when testing anatomy knowledge that must be addressed before widespread adoption.

Online Assessment of Applied Anatomy Knowledge: The Effect of Images on Medical Students' Performance

Anatomical examinations have been designed to assess topographical and/or applied knowledge of anatomy with or without the inclusion of visual resources such as cadaveric specimens or images, radiological images, and/or clinical photographs. Multimedia learning theories have advanced the understanding of how words and images are processed during learning. However, the evidence of the impact of including anatomical and radiological images within written assessments is sparse. This study investigates the impact of including images within clinically oriented single-best-answer questions on students' scores in a tailored online tool. Second-year medical students (n = 174) from six schools in the United Kingdom participated voluntarily in the examination, and 55 students provided free-text comments which were thematically analyzed. All questions were categorized as to whether their stimulus format was purely textual or included an associated image. The type (anatomical and radiological image) and deep structure of images (question referring to a bone or soft tissue on the image) were taken into consideration. Students scored significantly better on questions with images compared to questions without images (P < 0.001), and on questions referring to bones than to soft tissue (P < 0.001), but no difference was found in their performance on anatomical and radiological image questions. The coding highlighted areas of "test applicability" and "challenges faced by the students." In conclusion, images are critical in medical practice for investigating a patient's anatomy, and this study sets out a way to understand the effects of images on students' performance and their views in commonly employed written assessments.

Changes in the learning styles and approaches of students following incorporation of drawing during cadaveric dissection

The teaching of anatomy is challenging due to the constraints of material and personnel resources. Research has established that the learning preferences of students are malleable and determined by the requirements of the course. Further, drawing has been reported to aid learning in anatomy by facilitating problem solving and reducing the cognitive overload in students. Considering these issues, the aims of the study were to investigate (a) if positive changes occur in the learning styles and approaches following the incorporation of drawing during cadaveric dissection, and (b) whether they are associated with improved learning outcomes. One cohort of students in an anatomy course received training in creating scientific drawings from dissected human cadavers, while two cohorts of students did not receive such training. The learning preferences of students and their final examination grades were assessed at the commencement and conclusion of the course. Majority of student who had training in drawing transitioned from being bimodal, to trimodal or quadrimodal learners. This was associated with efficient learning approaches and a significant (p < .05) improvement in learning outcomes in these students. There were no changes in any parameters in students who had not received training in drawing. Therefore, the modulation of learning preferences of students through drawing is a pragmatic approach in anatomy teaching.

The Benefits of an Augmented Reality Magic Mirror System for Integrated Radiology Teaching in Gross Anatomy

Early exposure to radiological cross-section images during introductory anatomy and dissection courses increases students' understanding of both anatomy and radiology. Novel technologies such as augmented reality (AR) offer unique advantages for an interactive and hands-on integration with the student at the center of the learning experience. In this article, the benefits of a previously proposed AR Magic Mirror system are compared to the Anatomage, a virtual dissection table as a system for combined anatomy and radiology teaching during a two-semester gross anatomy course with 749 first-year medical students, as well as a follow-up elective course with 72 students. During the former, students worked with both systems in dedicated tutorial sessions which accompanied the anatomy lectures and provided survey-based feedback. In the elective course, participants were assigned to three groups and underwent a self-directed learning session using either Anatomage, Magic Mirror, or traditional radiology atlases. A pre- and posttest design with multiple choice questions revealed significant improvements in test scores between the two tests for both the Magic Mirror and the group using radiology atlases, while no significant differences in test scores were recorded for the Anatomage group. Furthermore, especially students with low mental rotation test (MRT) scores benefited from the Magic Mirror and Anatomage and achieved significantly higher posttest scores compared to students with a low MRT score in the theory group. Overall, the results provide supporting evidence that the Magic Mirror system achieves comparable results in terms of learning outcome to established anatomy learning tools such as Anatomage and radiology atlases.

Illustrated versus non-illustrated anatomical test items in anatomy course tests and German Medical Licensing examinations (M1)

Illustrated Multiple-choice questions (iMCQs) form an integral part of written tests in anatomy. In iMCQs, the written question refers to various types of figures, e. g. X-ray images, micrographs of histological sections, or drawings of anatomical structures. Since the inclusion of images in MCQs might affect item performance we compared characteristics of anatomical items tested with iMCQs and non-iMCQs in seven tests of anatomy courses and in two written parts of the first section of the German Medical Licensing Examination (M1). In summary, we compared 25 iMCQs and 163 non-iMCQs from anatomy courses, and 27 iMCQs and 130 non-iMCQs from the written part of the M1 using a nonparametric test for unpaired samples. As a result, there were no significant differences in difficulty and discrimination levels between iMCQs and non-iMCQs, the same applied to an analysis stratified for MCQ formats. We conclude that the illustrated item format by itself does not seem to affect item difficulty. The present results are consistent with previous retrospective studies which showed no significant differences of test or item characteristics between iMCQs and non-iMCQs.

Determinants of Difficulty and Discriminating Power of Image-based Test Items in Postgraduate Radiological Examinations

RATIONALE AND OBJECTIVES

The psychometric characteristics of image-based test items in radiological written examinations are not well known. In this study, we explored difficulty and discriminating power of these test items in postgraduate radiological digital examinations.

MATERIALS AND METHODS

We reviewed test items of seven Dutch Radiology Progress Tests (DRPTs) that were taken from October 2013 to April 2017. The DRPT is a semiannual formative examination, required for all Dutch radiology residents. We assessed several stimulus and response characteristics of test items. The response format of test items included true or false, single right multiple choice with 2, 3, 4, or ≥5 answer options, pick-N multiple-choice, drag-and-drop, and long-list-menu formats. We calculated item P values and item-rest-correlation (Rir) values to assess difficulty and discriminating power. We performed linear regression analysis in image-based test items to investigate whether P and Rir values were significantly related to stimulus and response characteristics. Also, we compared psychometric indices between image-based test items and text-alone items.

RESULTS

P and Rir values of image-based items (n = 369) were significantly related to the type of response format (P < .001), and not to which of the seven DRPTs the item was obtained from, radiological subspecialty domain, nonvolumetric or volumetric character of images, or context-rich or context-free character of the stimulus. When accounted for type of response format, difficulty and discriminating power of image-based items did not differ significantly from text-alone items (n = 881). Test items with a relatively large number of answer options were generally more difficult, and discriminated better among high- and low-performing candidates.

CONCLUSION

In postgraduate radiological written examinations, difficulty and discriminating power of image-based test items are related to the type of response format and are comparable to those of text-alone items. We recommend a response format with a relatively large number of answer options to optimize psychometric indices of radiological image-based test items.

Effects of image-based and text-based active learning exercises on student examination performance in a musculoskeletal anatomy course

Research on the benefits of visual learning has relied primarily on lecture-based pedagogy, but the potential benefits of combining active learning strategies with visual and verbal materials on learning anatomy has not yet been explored. In this study, the differential effects of text-based and image-based active learning exercises on examination performance were investigated in a functional anatomy course. Each class session was punctuated with an average of 12 text-based and image-based active learning exercises. Participation data from 231 students were compared with their examination performance on 262 questions associated with the in-class exercises. Students also rated the helpfulness and difficulty of the in-class exercises on a survey. Participation in the active learning exercises was positively correlated with examination performance (r = 0.63, P < 0.001). When controlling for other key demographics (gender, underrepresented minority status) and prior grade point average, participation in the image-based exercises was significantly correlated with performance on examination questions associated with image-based exercises (P < 0.001) and text-based exercises (P < 0.01), while participation in text-based exercises was not. Additionally, students reported that the active learning exercises were helpful for seeing images of key ideas (94%) and clarifying key course concepts (80%), and that the image-based exercises were significantly less demanding, less hard and required less effort than text-based exercises (P < 0.05). The findings confirm the positive effect of using images and active learning strategies on student learning, and suggest that integrating them may be especially beneficial for learning anatomy. Anat Sci Educ 10: 444-455. © 2017 American Association of Anatomists.

Longitudinal retention of anatomical knowledge in second-year medical students

The Radboud University Medical Center has a problem-based, learner-oriented, horizontally, and vertically integrated medical curriculum. Anatomists and clinicians have noticed students' decreasing anatomical knowledge and the disability to apply knowledge in diagnostic reasoning and problem solving. In a longitudinal cohort, the retention of anatomical knowledge gained during the first year of medical school among second-year medical students was assessed. In May 2011, 346 medical students applied for the second-year gastro-intestinal (GI) tract course. The students were asked to participate in a reexamination of a selection of anatomical questions of an examination from October 2009. The examination consisted of a clinical anatomy case scenario and two computed tomography (CT) images of thorax and abdomen in an extended matching format. A total of 165 students were included for analysis. In 2011, students scored significantly lower for the anatomy examination compared to 2009 with a decline in overall examination score of 14.7% (±11.7%). Decrease in knowledge was higher in the radiological questions, compared to the clinical anatomy cases 17.5% (±13.6%) vs. 7.9% (±10.0%), respectively, d = 5.17. In both years, male students scored slightly better compared to female students, and decline of knowledge seems somewhat lower in male students (13.1% (±11.1%) vs. 15.5% (±12.0%), respectively), d = -0.21. Anatomical knowledge in the problem-oriented horizontal and vertical integrated medical curriculum, declined by approximately 15% 1.5 year after the initial anatomy course. The loss of knowledge in the present study is relative small compared to previous studies. Anat Sci Educ 10: 242-248. © 2016 American Association of Anatomists.

Stereopsis, Visuospatial Ability, and Virtual Reality in Anatomy Learning

A new wave of virtual reality headsets has become available. A potential benefit for the study of human anatomy is the reintroduction of stereopsis and absolute size. We report a randomized controlled trial to assess the contribution of stereopsis to anatomy learning, for students of different visuospatial ability. Sixty-three participants engaged in a one-hour session including a study phase and posttest. One group studied 3D models of the anatomy of the deep neck in full stereoptic virtual reality; one group studied those structures in virtual reality without stereoptic depth. The control group experienced an unrelated virtual reality environment. A post hoc questionnaire explored cognitive load and problem solving strategies of the participants. We found no effect of condition on learning. Visuospatial ability however did impact correct answers at F(1) = 5.63 and p = .02. No evidence was found for an impact of cognitive load on performance. Possibly, participants were able to solve the posttest items based on visuospatial information contained in the test items themselves. Additionally, the virtual anatomy may have been complex enough to discourage memory based strategies. It is important to control the amount of visuospatial information present in test items.

Evaluation of the effectiveness of 3D vascular stereoscopic models in anatomy instruction for first year medical students

The head and neck region is one of the most complex areas featured in the medical gross anatomy curriculum. The effectiveness of using three-dimensional (3D) models to teach anatomy is a topic of much discussion in medical education research. However, the use of 3D stereoscopic models of the head and neck circulation in anatomy education has not been previously studied in detail. This study investigated whether 3D stereoscopic models created from computed tomographic angiography (CTA) data were efficacious teaching tools for the head and neck vascular anatomy. The test subjects were first year medical students at the University of Mississippi Medical Center. The assessment tools included: anatomy knowledge tests (prelearning session knowledge test and postlearning session knowledge test), mental rotation tests (spatial ability; presession MRT and postsession MRT), and a satisfaction survey. Results were analyzed using a Wilcoxon rank-sum test and linear regression analysis. A total of 39 first year medical students participated in the study. The results indicated that all students who were exposed to the stereoscopic 3D vascular models in 3D learning sessions increased their ability to correctly identify the head and neck vascular anatomy. Most importantly, for students with low-spatial ability, 3D learning sessions improved postsession knowledge scores to a level comparable to that demonstrated by students with high-spatial ability indicating that the use of 3D stereoscopic models may be particularly valuable to these students with low-spatial ability. Anat Sci Educ 10: 34-45. © 2016 American Association of Anatomists.

The effect of images on item statistics in multiple choice anatomy examinations

Although multiple choice examinations are often used to test anatomical knowledge, these often forgo the use of images in favor of text-based questions and answers. Because anatomy is reliant on visual resources, examinations using images should be used when appropriate. This study was a retrospective analysis of examination items that were text based compared to the same questions when a reference image was included with the question stem. Item difficulty and discrimination were analyzed for 15 multiple choice items given across two different examinations in two sections of an undergraduate anatomy course. Results showed that there were some differences item difficulty but these were not consistent to either text items or items with reference images. Differences in difficulty were mainly attributable to one group of students performing better overall on the examinations. There were no significant differences for item discrimination for any of the analyzed items. This implies that reference images do not significantly alter the item statistics, however this does not indicate if these images were helpful to the students when answering the questions. Care should be taken by question writers to analyze item statistics when making changes to multiple choice questions, including ones that are included for the perceived benefit of the students. Anat Sci Educ 10: 68-78. © 2016 American Association of Anatomists.

The eye of the beholder: Can patterns in eye movement reveal aptitudes for spatial reasoning?

Mental rotation ability (MRA) is linked to academic success in the spatially complex Science, Technology, Engineering, Medicine, and Mathematics (STEMM) disciplines, and anatomical sciences. Mental rotation literature suggests that MRA may manifest in the movement of the eyes. Quantification of eye movement data may serve to distinguish MRA across individuals, and serve as a consideration when designing visualizations for instruction. It is hypothesized that high-MRA individuals will demonstrate fewer eye fixations, conduct shorter average fixation durations (AFD), and demonstrate shorter response times, than low-MRA individuals. Additionally, individuals with different levels of MRA will attend to different features of the block-figures presented in the electronic mental rotations test (EMRT). All participants (n = 23) completed the EMRT while metrics of eye movement were collected. The test required participants view pairs of three-dimensional (3D) shapes, and identify if the pair is rotated but identical, or two different structures. Temporal analysis revealed no significant correlations between response time, average fixation durations, or number of fixations and mental rotation ability. Further analysis of within-participant variability yielded a significant correlation for response time variability, but no correlation between AFD variability and variability in the number of fixations. Additional analysis of salience revealed that during problem solving, individuals of differing MRA attended to different features of the block images; suggesting that eye movements directed at salient features may contribute to differences in mental rotations ability, and may ultimately serve to predict success in anatomy. Anat Sci Educ 9: 357-366. © 2015 American Association of Anatomists.

Remote histology learning from static versus dynamic microscopic images

Histology is the study of microscopic structures in normal tissue sections. Curriculum redesign in medicine has led to a decrease in the use of optical microscopes during practical classes. Other imaging solutions have been implemented to facilitate remote learning. With advancements in imaging technologies, learning material can now be digitized. Digitized microscopy images can be presented in either a static or dynamic format. This study of remote histology education identifies whether dynamic pictures are superior to static images for the acquisition of histological knowledge. Test results of two cohorts of second-year Bachelor in Medicine students at Ghent University were analyzed in two consecutive academic years: Cohort 1 (n = 190) and Cohort 2 (n = 174). Students in Cohort 1 worked with static images whereas students in Cohort 2 were presented with dynamic images. ANCOVA was applied to study differences in microscopy performance scores between the two cohorts, taking into account any possible initial differences in prior knowledge. The results show that practical histology scores are significantly higher with dynamic images as compared to static images (F (1,361) = 15.14, P < 0.01), regardless of student's gender and performance level. Several reasons for this finding can be explained in accordance with cognitivist learning theory. Since the findings suggest that knowledge construction with dynamic pictures is stronger as compared to static images, dynamic images should be introduced in a remote setting for microscopy education. Further implementation within a larger electronic learning management system needs to be explored in future research. Anat Sci Educ 9: 222-230. © 2015 American Association of Anatomists.

Student performance on practical gross anatomy examinations is not affected by assessment modality

Anatomical education is becoming modernized, not only in its teaching and learning, but also in its assessment formats. Traditional "steeplechase" examinations are being replaced with online gross anatomy examinations. The aims of this study were to: (1) determine if online anatomy practical examinations are equivalent to traditional anatomy practical examinations; and (2) to examine if students' perceptions of the online or laboratory testing environments influenced their performance on the examinations. In phase one, 10 third-year students were interviewed to generate perception items to which five anatomy lecturers assigned content validity. In phase two, students' gross anatomical knowledge was assessed by examinations in two modes and their perceptions were examined using the devised survey instrument. Forty-five second-year chiropractic students voluntarily participated in Phase Two. The two randomly allocated groups completed the examinations in a sequential cross-over manner. Student performance on the gross anatomy examination was not different between traditional "steeplechase" (mean ± standard deviation (SD): 69 ± 11%) and online (68 ± 15%) modes. The majority of students (87%) agreed that they felt comfortable using computers for gross anatomy examinations. However, fewer students found it easy to orientate images of cadaver specimens online. The majority of students (85%) agreed that they felt comfortable working with cadavers but there was less agreement on the effect of moving around the laboratory during practical examinations. This data will allow anatomists to confidently implement online assessments without fear of jeopardizing academic rigor or student performance.

Actual drawing of histological images improves knowledge retention

Medical students have to process a large amount of information during the first years of their study, which has to be retained over long periods of nonuse. Therefore, it would be beneficial when knowledge is gained in a way that promotes long-term retention. Paper-and-pencil drawings for the uptake of form-function relationships of basic tissues has been a teaching tool for a long time, but now seems to be redundant with virtual microscopy on computer-screens and printers everywhere. Several studies claimed that, apart from learning from pictures, actual drawing of images significantly improved knowledge retention. However, these studies applied only immediate post-tests. We investigated the effects of actual drawing of histological images, using randomized cross-over design and different retention periods. The first part of the study concerned esophageal and tracheal epithelium, with 384 medical and biomedical sciences students randomly assigned to either the drawing or the nondrawing group. For the second part of the study, concerning heart muscle cells, students from the previous drawing group were now assigned to the nondrawing group and vice versa. One, four, and six weeks after the experimental intervention, the students were given a free recall test and a questionnaire or drawing exercise, to determine the amount of knowledge retention. The data from this study showed that knowledge retention was significantly improved in the drawing groups compared with the nondrawing groups, even after four or six weeks. This suggests that actual drawing of histological images can be used as a tool to improve long-term knowledge retention.

Medical student perceptions of radiology use in anatomy teaching

The use of radiology in the teaching of anatomy to medical students is gaining in popularity; however, there is wide variation in how and when radiology is introduced into the curriculum. The authors sought to investigate students' perceptions regarding methods used to depict and teach anatomy and effects of integrated radiology instruction on students' abilities to correctly identify imaging modalities and anatomical structures on radiological images. First-year medical students completed questionnaires at the beginning and end of the first academic year that incorporated ten hours of radiologic anatomy teaching in the anatomy curriculum. Questions used a combination of Likert scales, rankings, and binary options. Students were tested on their ability to identify radiology modalities and anatomical structures on radiology images. Preresponse and postresponse rates were 93% (157/168) and 85% (136/160), respectively. Postmodule, 96.3% of students wanted the same or more radiology integration. Furthermore, 92.4% premodule and 96.2% postmodule agreed that "Radiology is important in medical undergraduate teaching." Modality and structure identification scores significantly increased from 59.8% to 64.3% (P < 0.001) and from 47.4% to 71.2% (P < 0.001), respectively. The top three preferred teaching formats premodule and postmodule were (1) anatomy laboratory instruction, (2) interactive sessions combining radiology with anatomy, and (3) anatomy lectures. Postmodule, 38.3% of students were comfortable reviewing radiology images. Students were positive about integrating radiology into anatomy teaching and most students wanted at least the same level of assimilation but that it is used as an adjunct rather than primary method of teaching anatomy.

A meta-analysis of the educational effectiveness of three-dimensional visualization technologies in teaching anatomy

Many medical graduates are deficient in anatomy knowledge and perhaps below the standards for safe medical practice. Three-dimensional visualization technology (3DVT) has been advanced as a promising tool to enhance anatomy knowledge. The purpose of this review is to conduct a meta-analysis of the effectiveness of 3DVT in teaching and learning anatomy compared to all teaching methods. The primary outcomes were scores of anatomy knowledge tests expressed as factual or spatial knowledge percentage means. Secondary outcomes were perception scores of the learners. Thirty-six studies met the inclusion criteria including 28 (78%) randomized studies. Based on 2,226 participants including 2,128 from studies with comparison groups, 3DVTs (1) resulted in higher (d = 0.30, 95%CI: 0.02-0.62) factual knowledge, (2) yielded significant better results (d = 0.50, 95%CI: 0.20-0.80) in spatial knowledge acquisition, and (3) produced significant increase in user satisfaction (d = 0.28, 95%CI = 0.12-0.44) and in learners' perception of the effectiveness of the learning tool (d = 0.28, 95%CI = 0.14-0.43). The total mean scores (out of five) and ±SDs for QUESTS's Quality and Strength dimensions were 4.38 (±SD 1.3) and 3.3 (±SD 1.7), respectively. The results have high internal validity, for the improved outcomes of 3DVTs compared to other methods of anatomy teaching. Given that anatomy teaching and learning in the modern medical school appears to be approaching a crisis, 3DVT can be a potential solution to the problem of inadequate anatomy pedagogy.

Is a picture worth a thousand words: an analysis of the difficulty and discrimination parameters of illustrated vs. text-alone vignettes in histology multiple choice questions

BACKGROUND

Advances in cognitive load theory have led to greater understanding of how we process verbal and visual material during learning, but the evidence base with regard to the use of images within written assessments is still sparse. This study examines whether the inclusion of images within the stimulus format of multiple choice questions (MCQs) has a predictable or consistent influence on psychometric item properties, such as difficulty or discrimination.

METHODS

Item analysis data from three consecutive years of histology multiple choice examinations were included in this study. All items were reviewed and categorised according to whether their stem, or stimulus format, was purely textual or included an associated image.

RESULTS

A total of 195 MCQs were identified for inclusion and analysed using classical test theory; 95 used text alone and 100 included an image within the question stem. The number of students per examination ranged from 277 to 347, with a total of 60,850 student-question interactions. We initially examined whether the inclusion of an image within the item stem altered the item difficulty using Mann-Whitney U. The median item difficulty for images with purely textual stems was 0.77, while that for items incorporating an appropriate image was 0.80; this difference was not significant (0.77 vs. 0.80; p = 0.862, Mann-Whitney-U = 4818.5). Mean values showed that the Item Discrimination Index appeared unaffected by the inclusion of an image within the stem, and Item point biserial correlation also showed no difference in means between these two groups (Independent samples t-test; 2-tailed).

CONCLUSION

We demonstrate that the addition of illustrations within undergraduate histology Multiple Choice Question stems has no overall influence on item difficulty, or measures of item discrimination. We conclude that the use of images in this context is statistically uncritical, and suggest that their inclusion within item stems should be based upon the principles of constructive alignment. However, further research with respect to the effect of images within item stems on cognitive processing, particularly with regard to image complexity or type, would enable the development of more informed guidelines for their use.

Mobile technology: Creation and use of an iBook to teach the anatomy of the brachial plexus

In an era of digitally connected students, there is a demand for academic material to be delivered through electronic mobile devices and not just through traditional methods such as lectures and tutorials. A digital interactive book-iBook (for use on the Apple iPad)-was created to teach undergraduate anatomical science students (n = 26) four key areas of the brachial plexus: definitions, gross anatomy, relative anatomy, and functions of terminal branches. Students were asked to complete preresource and postresource questionnaires, which were used to calculate the mean improvement score and ultimately the efficacy of the resource. Free text comments were gathered to evaluate student opinions on this mode of learning. The mean score on the preresource and postresource questionnaires was 4.07 of 8 and 5.69 of 8, respectively. The overall mean improvement score was 1.62, determined statistically significant by a dependent t-test (P = 0.0004). Findings demonstrate that digital books on the iPad provide a uniquely interactive way of delivering information and engaging students. Furthermore, digital books can be used alongside traditional methods of teaching anatomy to enhance and promote deep learning in students.

Anatomical knowledge gain through a clay-modeling exercise compared to live and video observations

Clay modeling is increasingly used as a teaching method other than dissection. The haptic experience during clay modeling is supposed to correspond to the learning effect of manipulations during exercises in the dissection room involving tissues and organs. We questioned this assumption in two pretest-post-test experiments. In these experiments, the learning effects of clay modeling were compared to either live observations (Experiment I) or video observations (Experiment II) of the clay-modeling exercise. The effects of learning were measured with multiple choice questions, extended matching questions, and recognition of structures on illustrations of cross-sections. Analysis of covariance with pretest scores as the covariate was used to elaborate the results. Experiment I showed a significantly higher post-test score for the observers, whereas Experiment II showed a significantly higher post-test score for the clay modelers. This study shows that (1) students who perform clay-modeling exercises show less gain in anatomical knowledge than students who attentively observe the same exercise being carried out and (2) performing a clay-modeling exercise is better in anatomical knowledge gain compared to the study of a video of the recorded exercise. The most important learning effect seems to be the engagement in the exercise, focusing attention and stimulating time on task.

Modified team-based learning strategy to improve human anatomy learning: A pilot study at the Universidad del Norte in Barranquilla, Colombia

As part of an institutional program sponsored by the Centre for Teaching Excellence at the Universidad del Norte, Barranquilla, Colombia, we developed an educational research study on two sessions of human anatomy in which we combined team-based learning (TBL) and the use of iPads. Study data included the TBL, assessments applied during the course, student's grades on mid-term examinations and students' perceptions of their experiences. Students reported a positive attitude toward the use of the TBL sessions, and the results showed a significant improvement in their learning between the first and second sessions. Significantly positive correlations (P < 0.05) were obtained between (a) the individual students' readiness test performance 1 and mid-term examination 1, (b) the individual readiness test performances from Session 1 to Session 2, and (c) the group readiness test performances from the first and second sessions. These results point to positive learning experiences for these students. Analyses of the students' reflections on their activities also pointed toward future challenges.

Exploring the validity of assessment in anatomy: do images influence cognitive processes used in answering extended matching questions?

Assessment is an important aspect of medical education because it tests students' competence and motivates them to study. Various assessment methods, with and without images, are used in the study of anatomy. In this study, we investigated the use of extended matching questions (EMQs). To gain insight into the influence of images on the validity of test items, we focused on students' cognitive processes while they answered questions with and without images. Seventeen first-year medical students answered EMQs about gross anatomy, combined with either labeled images or answer lists, while thinking aloud. The participants' verbal reports were transcribed verbatim and then coded. Initial codes were based on a task analysis and were adapted into final codes during the coding process. Results showed that students used more cues from EMQs with images and visualized more often in EMQs with answer lists. Ready knowledge and verbal reasoning were used equally often in both conditions. In conclusion, EMQs with and without images elicit different results in this think aloud experiment, indicating different cognitive processes. They seem to measure different skills, making them valid for different testing purposes. The take-home message for anatomy teachers is that questions without images seem to test the quality of students' mental images while questions with images test their ability to interpret visual information. It makes sense to use both response formats in tests. Using images from clinical practice instead of anatomical drawings will help to improve test validity.

Learning anatomy enhances spatial ability

Spatial ability is an important factor in learning anatomy. Students with high scores on a mental rotation test (MRT) systematically score higher on anatomy examinations. This study aims to investigate if learning anatomy also oppositely improves the MRT-score. Five hundred first year students of medicine (n = 242, intervention) and educational sciences (n = 258, control) participated in a pretest and posttest MRT, 1 month apart. During this month, the intervention group studied anatomy and the control group studied research methods for the social sciences. In the pretest, the intervention group scored 14.40 (SD: ± 3.37) and the control group 13.17 (SD: ± 3.36) on a scale of 20, which is a significant difference (t-test, t = 4.07, df = 498, P < 0.001). Both groups show an improvement on the posttest compared to the pretest (paired samples t-test, t = 12.21/14.71, df = 257/241, P < 0.001). The improvement in the intervention group is significantly higher (ANCOVA, F = 16.59, df = 1;497, P < 0.001). It is concluded that (1) medical students studying anatomy show greater improvement between two consecutive MRTs than educational science students; (2) medical students have a higher spatial ability than educational sciences students; and (3) if a MRT is repeated there seems to be a test effect. It is concluded that spatial ability may be trained by studying anatomy. The overarching message for anatomy teachers is that a good spatial ability is beneficial for learning anatomy and learning anatomy may be beneficial for students' spatial ability. This reciprocal advantage implies that challenging students on spatial aspects of anatomical knowledge could have a twofold effect on their learning.