Anatomy: Spotlight on Africa

. RESEARCH REPORT Anatomy: Spotlight on Africa Beverley Kramer,* Nalini Pather, Amadi O. Ihunwo School of Anatomical Sciences, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa Anatomy departments across Africa were surveyed regarding the type of curriculum and method of delivery of their medical courses. While the response rate was low, African anatomy departments appear to be in line with the rest of the world in that many have introduced problem based learning, have hours that are within the range of western medical schools and appear to be well resourced. Human body dissection is a constant and strong aspect of the majority of the courses surveyed. The staff to student ratio appears to be relatively high in Africa, but in many of the responding African institutions, there appears to be little difficulty in attracting suitable faculty (including those who are medically qualified) to teach anatomy. Retaining this faculty, in some cases, may be difficult because of a global demand for anatomy educators. Anat Sci Ed 1:111–118, 2008. © 2008 American Association of Anatomists. Key words: anatomy curricula; anatomy teaching; medical schools; medical education; Africa Concern for anatomy and its reduction in the undergraduate and postgraduate curricula have been voiced repeatedly over the last few decades. Disquiet has been expressed regarding the preparedness of recent medical graduates who have to face professional examinations ‘‘with a much greater knowledge deficit’’ (Hanna and Tang, 2005). As a result of the reduction in anatomy, grave consequences are being experienced with regard to patient care (Fraher, 2007). Between 1995 and 2000, a sevenfold increase in claims associated with anatomical errors was submitted to the Medical Defense Union (UK) (Older, 2004). In 2000, Cahill et al., expressed concern that, of the 80,000 avoidable deaths per year in the United States of America, some could be attributed to anatomical error. A solid foundation in anatomy is still perceived by many students and anatomists with different geopolitical and cultural backgrounds (in Cardiff and Paris) to be the best preparation for safe basic clinical procedures (Moxham and Plaisant, 2007). In recent years, the anatomy curricula in many institutions have undergone change concomitant with a significant reduc*Correspondence to: Prof. Beverley Kramer, School of Anatomical Science, Faculty of Health Sciences, University of the Witwatersrand, 7 York Road, Parktown 2193, Johannesburg, South Africa. E-mail: [email protected] Received 30 November 2007; Revised 5 March 2008; Accepted 28 March 2008. Published online 19 May 2008 in Wiley InterScience (www.interscience. wiley.com). DOI 10.1002/ase.28 © 2008 American Association of Anatomists Anatomical Sciences Education MAY 2008 tion in the time allocated to anatomy teaching (Collins et al., 1994; Dangerfield et al., 2000; Verhoeven et al., 2002). Few institutions, even within a country, have the same curriculum (Cottam, 1999; Gartner, 2003). Anatomists have been forced to curtail their curricula because of additional subjects being added to the medical course, different teaching modes being introduced and in some cases, the belief that the subject is content driven and not skills based (Patel and Moxham, 2006). In general, anatomists seem to be troubled by what is happening to their discipline and appear to be hamstrung as to what can be done to alleviate the problems they face. Africa is a vast landmass composed of 54 countries with more than 933 million people and more than 150 medical schools. While there is a substantial amount of information in the literature on different aspects of the teaching of anatomy in other parts of the world (Drake et al., 2002; Heylings, 2002; Kagan, 2002; Plaisant et al., 2004; Azer and Eizenberg, 2007), there is very little in the literature regarding the teaching of anatomy in Africa. Some articles in the literature originating from southern Africa have focused on the threat to anatomy in the medical curriculum (Satyapal and Henneberg, 1997), the clinical relevance of problem-oriented teaching (Boon et al., 2000), clinical anatomy as the basis for clinical examination (Boon et al., 2002), the challenges facing medical education in South Africa (Ncayiyana, 1999), and the improvement of academic performance of medical students by the introduction of problem based learning (PBL) (Iputo and Kwizera, 2005). However, no other information could be found in the literature regarding the nature of anatomy courses in Africa. To investigate the nature (i.e., type of curriculum and method of delivAnat Sci Ed 1:111–118 (2008) Table 1. Medical Program in African Countries Number of medical schools surveyed Number of medical schools in country Age of medical school (range) Curriculum years of medical program Years of Internship (range) Student numbers (range) Ratio traditional to problem based curriculum Egypt 3 19 26–60 6 0–2 130–550 2:1 Nigeria 5 27 27–42 5-6 1 150-400 1:4 Uganda 2 4 3–4 5 1 60–80 1:1 Zambia 1 1 39 7 1.5 65 1:0 Malawi 1 1 15 5 1.5 60 1:0 Mozambique 1 4 44 6 1 120 1:0 RSA 6 8 22–95 6-4 2 110–220 2:5a Country a One school in the Republic of South Africa (RSA) has both traditional and PBL tracts. ery) of anatomy teaching in Africa and what, if any, changes to the curricula have occurred in the last few years, we set out to survey as many medical anatomy courses on the continent as possible. teaching, the number of staff that are medically qualified, and whether the staff were also involved in research. RESULTS OF SURVEY MATERIALS AND METHODS Ethical clearance to undertake this study was provided by the Human Ethics Committee of the University of the Witwatersrand (HEC nos: M050510 1 M070601). A questionnaire was developed in English by the authors, and was later also translated into French. It was electronically distributed during the years 2006 and 2007, either directly to anatomy departments where known, or to the Deans of medical schools with a request to forward the questionnaire to their anatomy department. In some cases, the questionnaire was delivered by hand. Numerous e-mail reminders were sent to achieve a substantial response. The survey was restricted to anatomy courses delivered to medical students only. The questionnaire requested a wide spectrum of information such as the year in which the anatomy course is taught and the total course hours, including the distribution of the hours between and within the anatomy subdisciplines (e.g., gross [topographical] anatomy, histology and embryology). The type of curriculum (e.g., traditional or problem based) was requested. In the context of deliveries in publications and at congresses, ‘‘traditional’’ was given to mean didactic teaching and systematic dissection of the human body. ‘‘PBL’’ was given to mean the teaching and learning of anatomy with the integration of the clinical sciences using clinical cases. The nature and number of assessments were also surveyed. Furthermore, we enquired about the availability of learning tools (e.g., cadavers for dissection, articulated skeletons, prosected specimens, and computer-assisted learning [CAL]). The respondents were also asked to state what they considered was the best way to teach anatomy. From a faculty perspective, the respondents were asked to include information on their staff to student ratio, numbers of staff involved in 112 Information was obtained from 19 anatomy departments representing seven countries only. As very few responses were obtained, detailed statistical analysis was not possible. The information is provided here according to country of origin of the department covering the north, west, east, and southern African regions in accordance with the WHO grouping of regions in Africa. North Africa Egypt. Three medical departments out of 19 responded from Egypt. These departments are between 26 and 60 years of age (Table 1). Two of the departments use a traditional method for teaching anatomy, while one department has a PBL course. The medical program is six years and anatomy is taught in the first and second years of the curriculum. In the department utilizing PBL, the numbers of students was much lower than at one of the departments teaching in the traditional manner (Table 1). The anatomy course varies between 315 hr (with four assessments) and 480 hr (with six assessments) at the two ‘‘traditional’’ departments (Fig. 1) and does not include histology as part of these courses. The breakdown of hours in the different subspecialties of the anatomy course is shown in Figure 2. Two of the three departments do not use dissection. Individual bones, articulated skeletons and CAL are additional resources. All three departments use multiple choice questions (MCQs), short questions (SQs), and spot (practical) tests, while the traditional departments use long questions (LQs) as well. All three departments had strong views on the best way to teach anatomy such as: the use of practical/laboratory sessions before lectures; well prepared prosected specimens, well established museum and fully equipped computer laboratory, dedicated staff and computer monitors in dissection halls; correlating anatomy to clinical Kramer et al. Figure 1. Distribution of total anatomy curriculum hours (gross anatomy 1 histology 1 embryology 1 self study where provided) for the respective departments of anatomy in Africa. RSA, Institutions in the Republic of South Africa. Figure 2. Breakdown of curriculum hours in anatomy. The figure illustrates the breakdown of hours between gross (morphological) anatomy, histology, embryology, and self study where provided. 0–100 50 25 50 0 0–100 0-25 3–75 13–100 10–75 50 50 100 8 30 92 67 33 67 62 0–16 67–100 16–100 44-60 10–67 50–90 0–11 0-16 50 21 23–37 42–75 100 Percent medically qualified staff (range) Ph.D. Percent of highest qualifications (range) Nigeria. There are 27 medical schools in this large country, of which we have obtained information from five. The schools are well-established with their age ranging from 30 to 45 years (Table 1). Of the five departments, only one uses a traditional method of teaching. Student numbers range from 150 to 400 per year. Anatomy is taught in the second and third year of study. The total number of hours in these courses varies between the departments (Fig. 1). In all these departments, neuroscience is taught separately. Dissection is the preferred method of teaching morphological anatomy in all the departments. Bones, articulated skeletons, museum, libraries, histology slides, and CAL are additional resources for the students in all the departments. The frequency of assessment ranges from three to ten per year. Of all the different modes of assessment, three departments include a viva voce (oral examination). One department does not use SQs. Vast variation occurs in the staff to student ratio at these departments (1:15 to >1:35) (Table 2). The majority of the staff is medically qualified. Only one department mentioned difficulty in obtaining staff and as a result, initiated a B.Sc. course to increase the number of students who could be trained as future staff. Masters West Africa Honors Bachelor Percent medically qualified with Ph.D. aspects, using the computer to teach cross-sectional, radiological and endoscopic anatomy. The staff to student ratios in the ‘‘traditional’’ departments was 1:35 and 1:25, respectively, while in the ‘‘PBL’’ department the ratio was 1:15 (Table 2). All staff in these departments are medically qualified, with a very high number of staff also having postgraduate degrees. In 2003, the PBL department revised its curriculum to adopt more clinically oriented practicals to fit PBL. One of the ‘‘traditional’’ departments introduced CAL for pretutorials in 2006. 114 8–32 5–15 4 2 2 3–6 1:25 to >1:35 RSA Mozambique 1:30 1:25 Malawi Zambia 13 9 1:25 Uganda 4 3 2 1:30 to >1:35 Nigeria 1 2–6 1–3 1:15 to >1:35 Egypt 1–3 6–10 1:15 to 1:35 Country 1–9 4–9 19–24 19–24 Gross Histo Number of teaching staff (range) Staff to student ratio (range) Staff Profile in African Countries Table 2. Uganda. Of the four medical schools in Uganda, information was obtained from two schools. The responding departments are three and four years old, respectively. The anatomy course is taught in the first and second year in both departments as part of a five year curriculum (Table 1). In the one case, a traditional course is followed, while in the second department, PBL is used. There are 60 students per year in the traditional course and 80 students per year in the PBL course. More hours are spent in anatomy in the PBL course (360), than in the traditional course (278) (Table 1, Fig. 1). In both courses, most of the teaching hours are spent in gross anatomy (Fig. 2). An additional 98 hr are spent in a neuroscience course in the ‘‘traditional’’ department. In both departments, dissection is utilized and supplemented with prosected specimens. Other supplementary resources utilized are bones, articulated skeletons, histology slides, and CAL. The staff to student ratio is 1:30 in the traditional department and more than 1:35 in the PBL department (Table 2). While four assessments per year are used in the PBL department, assessment is carried out six times per year in the traditional department. Assessments are in the form of MCQs, SQs, and spot tests. The two teaching staff in the traditional department are both medically qualified and in addition, have higher degrees, while only one staff member in the PBL department is medically qualified (Table 2). Both departments express difficulty in obtaining staff. The traditional department is initiating a B.Sc. course to develop potential staff and the PBL department recommends staff development for overcoming staff shortages. Total East Africa Kramer et al. Southern Africa Zambia. There is only one medical school in the country. The school is 39 years old. Anatomy is taught in the third and fourth year of a seven year, 300 hr traditional curriculum (Table 1). There are 65 students in the course. Most of the hours in anatomy are spent in gross anatomy (Fig. 2) and most of the teaching is carried out in practical format. Continuous assessment is carried out during the year (six assessments) with an additional two examinations. MCQs, SQs, and spot tests form the basis of this assessment. Dissection is used in gross anatomy and microscopes are used in the teaching of histology. The practical teaching is supplemented with bones, articulated skeletons, and histology slides. There is correlation with clinical and applied anatomy. The staff to student ratio is 1:30 and all four staff are medically qualified (Table 2). All staff have a higher postgraduate qualification. In the year 2000, a semester course in clinical and applied anatomy was introduced. In Zambia too, difficulty is experienced in acquiring suitably qualified staff. Malawi. A response was received from the only medical school in the country. This school is 15 years old. Anatomy is currently taught in the first and second year of the curriculum. There are 60 students in the course (Table 1). In general, the 480 hr course is traditional. The breakdown of hours in the different divisions of the course is shown in Figure 2. Delivery of the course is approximately equally divided between practicals and lectures. Dissection is the method of teaching morphological anatomy and is supplemented with prosections and self-study. Four assessments are utilized during the course and are composed of MCQs, SQs, LQs, spot tests, and viva voces. Additional resources used are bones, articulated skeletons, histology slides, and CAL. The staff to student ratio is 1:25 (Table 2). The majority of staff (two of three) are medically qualified and one medically qualified staff member also has a Ph.D. There is difficulty in obtaining suitably qualified staff. The basic sciences courses will be moved to first year in 2008. Mozambique. There are four medical schools in Mozambique of which we were able to contact one. The responding school was established 44 years ago. The length of the medical course is six years, with a traditional anatomy course of 432 hr (Fig. 1). The course is taught over the first and second year. Gross anatomy is taught over two years (120 hr/year) while histology is taught in one year and comprises 192 hr of the course. Neuroscience is taught as a separate 80 hr course. The students are actively engaged in dissection of the cadaver. Learning resources include articulated skeletons, computer facilities, histology slides, and a museum. Of the six assessments given each year, two are written and an additional four are practical in nature. There are 120 students enrolled per year. The department believes that horizontal and vertical integration in the curriculum allows for a stronger clinical correlation. A total of 13 staff members are involved in the teaching of the course, with 12 of these being medically qualified and almost half of the staff having a M.Sc. and Ph.D. (Table 2). No difficulty is experienced with obtaining suitably qualified staff. In 2000, human cadaveric dissection was reintroduced into the course, as well as spot tests. In addition, more objective assessments were utilized, such as MCQs. Republic of South Africa. Of the eight medical schools in the Republic of South Africa, six responded to our questionnaire. The age of the responding medical schools ranged from Anatomical Sciences Education MAY 2008 22 to 95 years. All the medical schools in South Africa have had major curricular changes in the last few years due to a directive from the Health Professionals Council of South Africa (HPCSA, 2008). The major emphasis of curricular revisions included the introduction of PBL with vertical and horizontal integration, as well as providing students with an opportunity for early patient contact. As the HPCSA did not define a national core, each University has implemented its own curriculum. While these curricula have some similarities, they also differ markedly from each other (Figs. 1 and 2; Table 1). The academic years in which anatomy is taught varies between institutions: two departments teach anatomy from the second to fourth year, another two departments teach anatomy in all the years of the medical program, one department teaches anatomy in only the second year, while the final department teaches anatomy in the first two years of the program. The department teaching anatomy in only the second year has not implemented a PBL approach due to staff shortages and concerns about student performance. This is currently being reviewed. At one institution, a dual entry curriculum is in place. This program accepts one cohort of students who have matriculated from secondary schooling into a six year program which comprises two years of a traditional curriculum in basic sciences. This is followed by a four year integrated PBL curriculum. The second cohort of students (with a prior degree) is accepted directly into the four year integrated problem based curriculum (also known as the Graduate Entry Medical Program). The first cohort of students therefore completes a ‘‘traditional’’ second year anatomy course. In all of the six departments that responded, the number of students enrolled for the medical program ranged from 110 to 220 (Table 1). In all of these cases, gross anatomy utilizes a larger proportion of the time allocated to anatomy, largely because these departments still use dissection as an important tool in teaching. Neuroanatomy is taught as part of all of the anatomy courses surveyed. All of the departments have additional resources ranging from each student having a complete set of human bones and histology slides to access to CAL to supplement teaching. Curriculum hours (in those institutions which have adopted a PBL curriculum) dedicated solely to anatomy ranged from 180 to 250 (Fig. 2). In addition to these hours that are dedicated exclusively to anatomy, all of the institutions except one also teach anatomy in a vertically integrated problem based platform in subsequent years—the hours for anatomy in this part of the program are difficult to distinguish due to the integrated nature of the course. In two of the departments, the staff to student ratio is 1:25, while the remaining four departments have a staff to student ratio of more than is 1:35. Only three of the institutions acknowledged difficulty in obtaining suitably qualified staff to teach anatomy. The percentage of medically qualified staff teaching anatomy ranged from 10 to 100% (mean: 45%). In one department, all the teaching staff were medically qualified and had Ph.D. degrees. All of the departments have taken on the task of training future faculty in their science programs. DISCUSSION Given the paucity of literature on anatomy teaching in Africa, this article attempts to provide some insight into African practice and experiences. Despite the limited number of 115 responses obtained, some important facts did emerge. One of these is that Africa does not appear to be isolated from global trends in medical education. Eleven of the 19 responding African departments utilize PBL as the mode of instruction and appear to have converted to this mode of teaching prior to 2000. Most of the respondents indicated that they are continuously reviewing their curricula. It is gratifying to note that anatomy curricula in Africa have not and will not remain static. One department in South Africa utilizes both a traditional (second year level) and a PBL (third and fourth year) approach. The latter curriculum is similar in format (vertical integration and systems based learning) to the graduate medical curricula at Queensland, Sydney and Flinders Universities in Australia (Jones and Harris, 1998). Perhaps the last mentioned South African curriculum, if more extensive than others in Africa, is closest to what Drake (1998) had proposed as the best of each of a traditional, PBL and systems-oriented learning model which could be fused into a truly integrated curricular model. On an hourly basis, the course in Malawi appears to have the longest curriculum (by virtue of the number of hours dedicated) in anatomy (480 hr), and Mozambique being a close second with 432 hr. Both these courses are traditional. In general, the PBL courses have shorter contact hours dedicated solely to anatomy. These hours do not appear to take into consideration vertical integration of anatomy that may be taking place in later years of the curricula. The total hours for teaching anatomy in Africa are generally more substantial than that found for nine French departments of anatomy and for five other European medical schools surveyed by Plaisant et al. (2004). Where schools outside Africa appear to have experienced significant decreases in time allotted to the teaching of anatomy (Moxham and Plaisant, 2007) most African departments have been able to retain the hours and also introduce ‘‘newer’’ modes of teaching such as PBL. In contrast, South African anatomy departments have been pressurized to decrease their total anatomy teaching hours. The range of hours in gross anatomy varies from one African department to another. In some cases, the stated hours are far in excess of that reported for medical schools in the United States by Drake et al. (2002). In addition, the majority of the responding African departments (traditional) showed an emphasis on the teaching of gross anatomy over that of histology, which compares to the study of Drake et al. (2002). Microscopes are still used in the majority of the courses teaching histology in the African anatomy departments surveyed, as is reported in the United States. In some of the African courses, embryology was heavily weighted and was often taught in conjunction with gross anatomy to which we believe it relates best. In the USA, embryology hours range between three and 65 (Drake et al., 2002). Neuroscience is taught as a separate course in eight (42%) of the departments surveyed, with the number of hours ranging from 48 to 98. The range of hours for neuroscience in USA medical school curricula was 9–180 (Drake et al., 2002) compared with neuroanatomy course hours in the United Kingdom and Ireland of 6–81 (Heylings, 2002). While debate on the importance of inclusion of full body dissection in the teaching of anatomy has occurred in the mainly Western (USA, UK, and European) literature (Callahan and Gavan, 1968; Ferm and Lyons, 1971; Mottershead, 1980; Beahrs, 1991; von Lüdinghausen, 1992; Newell, 1995; Skidmore, 1995), dissection appears to have continued una116 bated in Africa with approximately 90% of responding departments retaining dissection. Dissection appears to be the preferred mode of tuition of anatomy in 17 of the 19 departments that responded to the questionnaire. In the case of the two departments that reported no cadaveric dissection, one was involved in PBL and the other has replaced dissection with CAL. This may be related to a difficulty with obtaining cadavers in these areas. The stated preference by African anatomists for the use of human cadaveric dissection in teaching morphological anatomy to medical students echoes the findings of Patel and Moxham (2006). The latter authors surveyed anatomists in the United Kingdom and Europe and found that the majority (69%) favored human cadaveric dissection. Decreased time for human cadaveric dissection outside of Africa appears to have occurred in order to ‘‘make’’ time for the explosion of knowledge in other biomedical science disciplines and to reduce the ‘‘burden’’ of factual information (Patel and Moxham, 2006). The importance of human dissection in the medical curriculum resonates through the literature (Utting and Willan, 1995; Amadio, 1996; Bouchet, 1996; Moore, 1998; Marks, 2000; Ellis 2001; Aziz et al., 2002; Older, 2004). Evidence has shown that dissectors score better than nondissectors in assessments, and that there is thus, an advantage gained from dissection (Yeager, 1996). For others, the reasons for retaining dissection go further than assessment. The reality of the cadaver in the emotional sense (Amadio, 1996), the importance of anatomy from the perspective of three-dimensionality and the interrelationships of structures (Hanna and Tang, 2005; Rizzolo and Stewart, 2006), manual dexterity and anatomical variability (Older, 2004) are only some of the factors in the quest of anatomists to retain dissection. Most African departments responding to this questionnaire did not express any problems with the retention of human dissection or of obtaining cadavers. One department (Mozambique) had reintroduced dissection in 2000 following an investigation into its merits in the teaching of medical students. While dissection is not practiced in one African country (nonrespondent) because of current Human Rights issues (personal communication), most African countries appear to have good access to cadavers. This may be an additional important reason for the continuation of full body dissection in Africa. This access to cadavers may be envied by some countries (e.g., Australia) which have experienced difficulty in acquisition (Parker, 2002; Nayak, 2004). There are other countries such as the USA which have successful body donor programs (UAGA, 1968; Dalley et al., 1993) and no problems in acquiring cadavers (e.g., Thailand); (Winkelman and Güldner, 2004). Recent concerns about the health hazard posed by formalin and the shortage of staff have also made many institutions reconsider the use of dissection (Nayak, 2004; Parker, 2002), as has the problem of HIV/AIDS (Asala et al., 1997; Ihunwo, 1998). Staff to student ratios are comparatively high at African medical schools when compared to western countries such as the United Kingdom (Heylings, 2002). Those departments utilizing PBL generally have higher staff to student ratios as this type of delivery is resource intensive. Although staff to student ratios are high in Africa, only eight of the 19 African departments commented that they had difficulty with recruiting/attracting suitably qualified staff. It is not always clear whether the response to this type of question relates to difficulty in obtaining staff or difficulty in retaining staff. In Africa, the latter may play an enormous role. Kramer et al. Difficulty with recruiting staff in Africa (while not numerically similar) correlates with a survey conducted by the American Association of Anatomists to which 83% of heads of departments reported great or moderate difficulty in recruiting qualified gross anatomy teachers (AAA, 2008). We would like to suggest that the difference in these two cases relates to research activity. In the United States, more emphasis is placed on research productivity for promotion and tenure, and thus many graduate students have turned away from becoming anatomy teachers where the average commitment to teaching is in the region of 160 contact hours per year (McCuskey et al., 2005). While contact hours in Africa are as high in most departments, research has only recently become emphasized. The high numbers of qualified medical graduates among staff in anatomy departments in Africa will we feel, be envied in the rest of the world. Glover and McCloskey as early as 1976 warned about the low proportions of medically qualified staff in preclinical departments and related this to both poor salary and career prospects. In the UK, the number of medically qualified staff teaching gross anatomy may be related to the reduction in demonstrator posts (Older, 2004). The positive value of temporary lecturer’s posts in anatomy for medically qualified staff was discussed by Willan et al. (1998). Peck and Skandalakis (2004) commented that ideally gross anatomy teachers should be health care professionals. The authors do not agree with the latter statement and believe that a balance between clinical and basic science staff is important. While in Australia and New Zealand the majority of staff in all but one of the 12 anatomy departments do not hold medical qualifications (Jones and Harris, 1998), in Africa it appears that some medical graduates still aspire to teach anatomy! While it is important that clinical anatomists participate in the teaching of anatomy to medical students, it is our belief that due to financial (salary) constraints, science graduates should be trained in clinical and applied anatomy to assist where clinicians are not present. CONCLUSION/SUMMATION In summary, it is our belief that the information received in this initial survey is extremely valuable in assessing the nature of anatomy being taught on the African continent. No statistical data could be generated from this study, but anatomy appears to be forging ahead despite the challenges. While there is considerable variation between courses, human cadaveric dissection is a constant feature of most departments and is well supplemented by a variety of resources. Contact hours in gross anatomy, histology, and embryology compare favorably with departments outside of Africa. African departments appear to be well resourced and in most cases, adequately staffed. We believe that the retention of dissection and a ‘‘best of both’’ approach will remain features of African anatomy for medical students in the future. It is hoped that this report will inspire some interactions between the Anatomy departments in Africa and also stimulate African departments to send us, or publish their own, information. ACKNOWLEDGMENTS We gratefully acknowledge those respondents who enabled this paper by being willing to share information. We are most Anatomical Sciences Education MAY 2008 grateful to Professor Pierre Sprumont of Fribourg, Switzerland for the French translation of the questionnaire and the accompanying documents (Merci beaucoup!). We would like to thank Dr. M.S. Ajao for aiding with personal delivery of questionnaires to members of the anatomy community in Nigeria and Mr. R. Maheter for assisting in obtaining some of the information from South Africa. NOTES ON CONTRIBUTORS BEVERLEY KRAMER, B.Sc. (Hons), Ph.D., is a professor of anatomy and Assistant Dean for Research and Postgraduate Support, University of the Witwatersrand, Johannesburg, South Africa. She currently teaches histology, oral biology, and embryology to undergraduate and postgraduate students. NALINI PATHER, B.Med.Sc. (Hons), M.Med.Sc., is a lecturer and Head of the Division of Morphological Anatomy at the University of the Witwatersrand, Johannesburg, South Africa. She teaches morphological anatomy to medical and allied health sciences students at both the undergraduate and postgraduate level. AMADI O. IHUNWO, B.Med.Sc. (Hons), M.Sc., PH.D., is a senior lecturer at the University of the Witwatersrand, Johannesburg, South Africa. He teaches morphological anatomy to undergraduate and postgraduate medical and allied health sciences students. LITERATURE CITED AAA, American Association of Anatomists. 2008. Survey of academic departments related to anatomy. Bethesda, MD. Available at: http://www.anatomy.org/files/public/quest_results.htm. Accessed Feb. 20, 2008. Amadio PC. 1996. Reaffirming the importance of dissection. Clin Anat 9:136– 137. Asala SA, Mawera G, Zivanovic S. 1997. HIV/AIDS and the teaching and learning of anatomy. Cent Afr J Med 43:58–61. Azer SA, Eizenberg N. 2007. Do we need dissection in an integrated problembased learning medical course? Perceptions of first- and second-year students. Surg Radiol Anat 29:173–180. Aziz MA, McKenzie JC, Wilson JS, Cowie RJ, Ayeni SA, Dunn BK. 2002. The human cadaver in the age of biomedical informatics. Anat Rec 269:20–32. Beahrs OH. 1991. Gross anatomy in medicine. Clin Anat 4:310–312. Boon JM, Meiring JH, Richards PA, Jacobs CJ. 2000. Evaluation of clinical relevance of problem-oriented teaching in undergraduate anatomy at the University of Pretoria. Surg Radiol Anat 23:57–60. Boon JM, Meiring JH, Richards PA. 2002 Clinical anatomy as the basis for clinical examination: Development and evaluation of an introduction to clinical examination in a problem-oriented medical curriculum. Clin Anat 15:45–50. Bouchet A. 1996. In defense of human anatomy—A commentary. Surg Radiol Anat 18:159–165. Cahill DR, Leonard RJ, Marks SC Jr. 2000. Standards in healthcare and medical education. Clin Anat 13:150. Callahan WP, Gavan JA. 1968. A course in gross anatomy. J Med Educ 43:1105–1114. Collins TJ, Given RL, Hulsebosch CE, Miller BT. 1994. Status of gross anatomy in the US and Canada: Dilemma of the 21st century. Clin Anat 7:275– 296. Cottam WW. 1999. Adequacy of medical school gross anatomy education as perceived by certain postgraduate residency programs and anatomy course directors. Clin Anat 12:55–65. Dangerfield P, Bradley P, Gibbs T. 2000. Learning gross anatomy in a clinical skills course. Clin Anat 13:444–447. Dalley AF II, Driscoll RE, Settles HE. 1993. The uniform anatomical gift act: What every clinical anatomist should know. Clin Anat 6:247–254. Drake RL. 1998. Anatomy education in a changing medical curriculum. Anat Rec 253:28–31. Drake RL, Lowrie DJ Jr, Prewitt CM. 2002. Survey of gross anatomy, microscopic anatomy, neuroscience, and embryology courses in medical school curricula in the United States. Anat Rec 269:118–122. Ellis H. 2001. Teaching in the dissecting room. Clin Anat 14:149–151. 117 Ferm VH, Lyons JH. 1971. Experience with a shortened curriculum in gross anatomy. J Med Educ 46:673–676. Fraher J. 2007. Anatomy 2020: The view from across the pond. Newsletter of American Association of Anatomists 16:1,10. Gartner LP. 2003. Anatomical sciences in the allopathic medical school curriculum in the United States between 1967-2001. Clin Anat 16:434– 439. Glover WE, McCloskey DI. 1976. Staffing crisis in preclinical medicine. Med J Aust 1:531–535. Hanna SJ, Tang T. 2005. Reduced undergraduate medical science teaching is detrimental for basic surgical training. Clin Anat 8:465–466. Heylings DJ. 2002. Anatomy 1999-2000: The curriculum, who teaches it and how? Med Educ 36:702–710. HPCSA, Health Professionals Council of South Africa. 2008. Pretoria, South Africa. Available at: www.hpcsa.co.za/. Accessed Feb. 20, 2008. Ihunwo AO. 1998. Keeping dissection alive using HIV/AIDS cadavers. Cent Afr J Med 44:82–83. Iputo JE, Kwizera E. 2005. Problem-based learning improves the academic performance of medical students in South Africa. Med Educ 39:388–393. Jones DG, Harris RJ. 1998. Curriculum developments in Australasian anatomy departments. Clin Anat 11:401–409. Kagan II. 2002. Traditions and peculiarities of clinical anatomy education in Russia. Clin Anat 15:152–156. Marks SC Jr. 2000. The role of three-dimensional information in health care and medical education: The implications for anatomy and dissection. Clin Anat 13:448–452. McCuskey RS, Carmichael SW, Kirch DG. 2005. The importance of anatomy in health professions education and the shortage of qualified instructors. Acad Med 80:349–351. Moore NA. 1998. To dissect or not dissect? Anat Rec 253:8–9. Mottershead S. 1980. The teaching of anatomy and its influence on the art and practice of surgery. BMJ 280:1306–1309. Moxham BJ, Plaisant O. 2007. Perception of medical students towards the clinical relevance of anatomy. Clin Anat 20:560–564. Nayak S. 2004. Good method to get cadavers for dissection. BMJ Rapid response. Available at: http://bmj.com/cgi/content/full/329/7480/1455#responses. Accessed Feb. 20, 2008. 118 Ncayiyana D. 1999. Medical education challenges in South Africa. Med Educ 33:713–715. Newell RLM. 1995. Follow the royal road: The case for dissection. Clin Anat 8:124–127. Older J. 2004. Anatomy: A must for teaching the next generation. Surgeon 2:79–90. Patel KM, Moxham BJ. 2006. Attitudes of professional anatomists to curricular change. Clin Anat 19:132–141. Parker L. 2002. Anatomical dissection: Why are we cutting it out? Dissection in undergraduate teaching. ANZ J Surg 72:910–912. Peck D, Skandalakis JE. 2004. The anatomy of teaching and the teaching of anatomy. Am Surg 70:366–368. Plaisant O, Cabanis EA, Delmas V. 2004. Going back to dissection in a medical curriculum: The paradigm of Necker-Enfants Malades. Surg Radiol Anat 26:504–511. Rizzolo LJ, Stewart WB. 2006. Should we continue teaching anatomy by dissection when? Anat Rec 289B:215–218. Satyapal KS, Henneberg M. 1997. Anatomy into the next millennium: Quo vadis, or simply where to? Clin Anat 10:41–43. Skidmore JR. 1995. The case for prosection: Comment on R.L.M. Newell’s paper. Clin Anat 8:128–130. UAGA, Uniform Anatomical Gift Act. 1987. National Conference of Commissioners on Uniform State Laws, Newport Beach, CA. Available at: http://www. law.upenn.edu/bl1/archives/ulc/fnact99/uaga87.htm [accessed 20 Feb 2008]. Utting M, Willan P. 1995. What future for dissection in courses of human topographical anatomy in universities in the UK? Clin Anat 8:414–417. Verhoeven BH, Vervijnen GM, Scherpbier AJ, van der Vleuten CP. 2002. Growth of medical knowledge. Med Educ 36:711–717. von Lüdinghausen M. 1992. The goal of dissection in clinically oriented teaching. Clin Anat 5:488–489. Wilkelmann A, Güldner FH. 2004. Cadavers as teachers: The dissecting room experience in Thailand. BMJ 329:1455–1457. Willan PLT, Whitmore I, Humpherson JR. 1998. Career progress of temporary lecturers in anatomy. Clin Anat 11:50–54. Yeager VL. 1996. Learning gross anatomy: Dissection and prosection. Clin Anat 9:57–59. Kramer et al.