Strength, Weakness, Opportunity, Threat (SWOT) Analysis of the Adaptations to Anatomical Education in the United Kingdom and Republic of Ireland in Response to the Covid‐19 Pandemic

Lectures

Universities opted to replace lectures with recorded presentations and accompanying audio that was uploaded to the Virtual Learning Environment. The most common lecture recording platform used was “Panopto” (Panopto Inc., Seattle, WA), with 50% of universities citing its use. Thirty‐six percent of universities also provided live sessions and tutorials via platforms such as “Zoom” (Zoom Voice Communications Inc., San Jose, CA), “Collaborate Ultra” (Blackboard Inc., New York, NY), and “Big Blue Button” (Big Blue Button Inc., Ottawa, Canada).

Practical sessions

All bar two universities in the sample group used cadaveric material to teach anatomy prior to the pandemic. Universities replaced practical sessions by supplementing Virtual Learning Environments with additional resources. Twenty‐nine percent of universities used digitized cadaveric resources only, seven percent used 3D virtual resources only, and 43% used a combination of cadaveric and 3D virtual resources (Table 1). Digitized cadaveric resources included “Acland's Video Atlas of Human Anatomy” (Acland, 2013), high‐quality cadaveric images, bespoke videos of prosected/plastinated specimens, YouTube^(TM) videos (YouTube, San Bruno, CA), and the Visible Human Project (U.S National Library of Medicine, Bethesda, MD) (Table 2). Three‐dimensional virtual resources included “Visible Body” (Argosy Publishing, Inc., Newton, MA), “Complete Anatomy” (3D4Medical/Elsevier, Dublin, Republic of Ireland), 3D models using “Sketchfab” (Sketchfab, New York, NY), “Anatomy TV” (Primal Pictures Ltd., Colchester, UK), and “Sectra” (a virtual dissection table; Sectra AB, Linköping, Sweden) (Table 2). Forty‐three percent of universities provided further support for practical sessions by hosting live tutorials and sessions using platforms such as “Zoom” (Zoom Voice Communications Inc., San Jose, CA) and “Microsoft Teams” (Microsoft Corp., Redmond, WA).

Assessment

Fourteen percent of universities did not have a summative practical assessment in their curriculum, a further 36% of universities canceled their assessment and 21% completed online digital spotter examinations (Table 3). Written examinations were canceled in seven percent of universities (Table 3). Thirty‐six percent opted for online multiple‐choice questions (MCQs)/Extending matching questions (EMQs)/Single‐answer questions (SAQs)/Single‐best‐answer (SBAs) examinations and 21% opted for open‐book examinations (Table 3). There were no regional differences noted with regard to assessment.

Opportunities and challenges

Despite chronic disruption to curricula, the Covid‐19 pandemic has presented many opportunities to universities. The opportunity to develop new online resources was highlighted by 71% of universities. Fifty percent of universities cited academic collaboration as an important opportunity, and 29% highlighted the importance of working from home. Universities identified other opportunities such as upskilling in new technologies (21%), incorporation of blended learning (14%), development of alternative examination methods (7%), and free access to online resources (7%) (Table 4). The most commonly expressed concern was the time investment associated with the development of new resources to replace lectures and practical classes. This challenge was highlighted by 57% of universities. Fifty percent of universities were concerned about lack of practical sessions/cadaveric exposure, and 36% of universities identified reductions in student engagement. Universities also highlighted concerns regarding the teacher–student relationship (21%), assessment (14%), working from home (14%), suspension of Body Donor Programs (7%), and lack of technical support (7%) (Table 4).

Development of new online resources

In response to the Covid‐19 lockdown, both digitized cadaveric resources and 3D virtual anatomy platforms were used by 43% of universities, in an attempt to emulate canceled practical sessions. Twenty one percent of universities created unique videos. Bespoke resources have been shown to lead to a significant increase in student satisfaction (Mandernach, 2009). New resources created and developed by academics include videos, virtual dissections, formative quizzes, and updating practical dissection notes that will be available to students through Virtual Learning Environments. Previous studies have elucidated that students appreciate anatomical videos and they have the potential to improve test scores (Pereira et al., 2004; DiLullo et al., 2006; Topping, 2014). To date, there are limited data on the effectiveness of virtual dissections; however, the results have been positive, when used in conjunction with cadaveric material (Yammine and Violato, 2015; Darras et al., 2019). A significant number of medical students have reported that they find online resources helpful (Smith et al., 2014) This echoes a statement by one academic who stated gaining “free access to high quality resources from publishers” was a positive aspect of the pandemic. Interestingly, the usefulness of online resources for individual students has been linked to personality preference, and thus the switch to distant learning may prove harder for certain groups of students (McNulty et al., 2006).

The context of the anatomical learning environment has undergone a paradigm shift since the lockdown, and this may result in students adopting different strategic approaches to their learning (Smith et al., 2014). Thus, it is imperative to ensure that these new resources are based upon sound pedagogical theory in order to foster deep learning strategies (Kreber, 2002). In addition, the number of new resources has the potential to overwhelm the learner, having negative implications for their extraneous cognitive load. Extraneous cognitive load is affected by how information is presented by the instructor (Leppink and van den Heuvel, 2015).

Upskilling in new technologies and resources

Three institutions (21%) noted that this is an opportunity to develop technological skills. One academic stated this was a “chance to upskill and incorporate alternative software and novel resources into our teaching.” This sudden leap in upskilling and innovation by a large proportion of academics has the potential to transform medical education by incorporating online learning to all aspects of the curricula (Skochelak and Stack, 2017; Rose, 2020). One academic stated that that this was an “opportunity to improve staff awareness of online teaching methods and their confidence in using them.” For anatomists, this is a unique opportunity to assess the educational benefits of this software, encouraged by free licenses offered by many companies during this time, such as “Visible Body” (Argosy Publishing, Inc., Newton, MA) and “Human Biodigital” (Biodigital Inc., Seoul, South Korea).

Furthermore, it has triggered the development of new skills in assessment modalities. As all universities have adopted an online approach to written examinations, new skills in utilizing the full capabilities of Virtual Learning Environments are being explored. Virtual Learning Environments allow academics to easily build question banks and design assessments that can be marked automatically or manually. Virtual Learning Environments also facilitate randomized presentation of questions, time constraints, and prohibit backtracking in order to prevent collaborative answering. For example, “Brightspace” (D2L Corp., Kitchener, Canada) facilitates precise keystroke recording—an important feature to prevent cheating during online spotters. The move to online assessment has identified an opportunity to improve examination conditions (Dennick et al., 2009). Specifically, this is true for summative continuous assessments that often involve image‐based spotter examinations as there is a high workload associated with designing and implementing station‐based spotter exams. Schubert et al., (2009) reported that designing, implementing, and invigilating a station‐based gross anatomy examination encompassed 3.5 days' work (Shubert et al., 2009). Dennick et al., (2009) showed that student performance on gross anatomical examination is no different between traditional spotter examinations compared to digital online modes. The development of skills in online assessment modalities may be of benefit for future academic practice without endangering academic integrity or student performance (Meyer et al., 2016).

Time constraints

Time is ultimately of the essence when it comes to creating additional anatomical resources in response to Covid‐19, with universities identifying it as the top challenge in the delivery of anatomical education. One academic noted that the “time needed to learn how to use technologies” was an issue. Creating new resources can take at least three times as much work compared to a traditional format (Gewin, 2020). This may be attributed to the steep learning curve required to learn how to use technologies effectively. The added pressure of producing “high‐quality resources,” in addition to fulfilling other academic duties in a limited time period may put undue pressure on academics. Therefore, it is imperative to weigh‐up the cost–benefit implications of the time needed to create new resources against the educational benefit for the students. Indeed, it was observed that instructor‐made videos lead to no measurable improvements in student achievement (Mandernach, 2009); however, it may have an impact in student engagement as discussed in the section outlining potential threats. Furthermore, well‐renowned anatomical educational resources already exist, so one must decide if it is worth ‘re‐inventing the wheel’, so to speak. For example, “Acland's Video Atlas of Human Anatomy” (Acland, 2013), created in 1993, is still used by medical schools today along with other useful online resources as outlined by participating universities (Table 2).

Lack of practical sessions and cadaveric exposure

The results show that a major concern for academics is the loss of cadaveric‐based teaching, as expressed by 50% of participating universities. Cadavers are utilized as the pillar pedagogical tool in many medical schools across the globe (Habicht et al., 2018). Indeed, one academic stated that “not physically attending practical sessions will limit haptic understanding and reduce discussions concerning variations and pathology.” The benefits of cadaveric‐based teaching have been eluded in a number of studies (Aziz et al., 2002; Estai and Bunt, 2016). Cadaveric‐based teaching has been shown to lead to a deep understanding of the three‐dimensional relationships of the human body and allows students to appreciate anatomical variations and pathologies (Azer and Eizenberg, 2007; Smith and Mathaias, 2010; Fruhstorfer et al., 2011; Hafferty and O’Donnell, 2013). Cadaveric dissection can be a sensory explosion, arguably one that cannot be stimulated by technology (Korf et al., 2008). In addition, it allows students to develop competencies of medical profession and gain attributes through the hidden anatomical curriculum, for example, encountering death, empathy, and professionalism, in addition to communication and teamwork skills (Estai and Bunt, 2016; Kumar Ghosh and Kumar, 2019). Additionally, students themselves believe that working with cadaveric material helps them learn anatomy and is an important component of becoming a healthcare professional (Smith et al., 2014; Flack and Nicholson, 2018).

In the UK and ROI, fortunately the lockdown occurred nearer the end of the academic term, thus students will have been exposed to cadaveric material for approximately six or seventh months. Conversely, this is not the case for other countries, e.g., in Australia and New Zealand, where the academic term begins in February/March. All medical students may be disproportionately affected by the lack of cadaveric‐based classes. Although further studies will elucidate how the current Covid‐19 crisis will affect students' understanding of anatomy, a previous report revealed that students participating in gross anatomy laboratories received significantly higher grades, compared to those taking an online course (Mathiowetz et al., 2016).

With many institutions looking to produce new online content to replace cadaveric dissection the HTA have released a new statement regarding the use of cadaveric images, reiterating the importance of protecting the dignity of the deceased (HTA, 2020a). Where cadaveric images are to be used to supplement online teaching, it is imperative to check if the donor provided consent for their remains to be used in images and videos. (HTA, 2016; Hennessy et al., 2020). Some institutions have also put in measures to limit sharing of cadaveric material now available on Virtual Learning Environments by ensuring students are able to view but not download this content.

Issues with assessment

Twenty‐nine percent of the institutions surveyed did not have pre‐existing summative assessments based on practical content. Of those that did, 36% canceled the summative element, and 21% switched to online assessments to maintain normal student progression (Table 3). However, online assessments pose their own unique challenges. One key principle that needs to be considered is the preservation of constructive alignment of the assessment task to the intended learning outcomes and teaching/learning activities (Biggs and Tang, 2011). Many higher education institutions teach through cadaveric dissection and assess the practical element of learnings through a traditional spotter style format. This will encourage students to construct their knowledge of anatomy through learning activities with a focus on cadaveric material. However, online assessments cannot replicate the wealth of information available in a cadaveric specimen that can act as a retrieval cue for learning that took place during practical classes (Ali et al., 2015).

A switch to online assessment could cause a breakdown of constructive alignment between the teaching learning activity and assessment task. The results highlighted that 14% of universities identified compromised assessment standards as a significant concern, with “questions around validity and practicality of delivering exams online.” One way of mitigating this would be to ensure that images used in online assessments reflect those used during teaching and learning activities. Research has suggested that assessment modality does not significantly influence student achievement (Attardi and Rogers, 2015) and highlights the need for carefully chosen images with clear orientation (Meyer et al., 2016). In order to maintain constructive alignment, it is important that new assessment modalities are chosen that best assess the skills students are expected to achieve through their learning.

Academic collaboration and working remotely

The Covid‐19 pandemic presented opportunities for online collaboration between academic peers, both within and between institutions to gain “insight and inspiration” from others that “are facing similar challenges.” These were ranked as the main opportunities by 50% of the universities in this study. Additionally, four institutes commented on the opportunity to create new and effective online working environments which particularly highlights the opportunity for remote working in the future. While there were two responses regarding the negative aspects of working from home, they both reflected the impact of the current Covid‐19 crisis (i.e., lack of textbooks and childcare responsibilities). Already, there has been a wealth of support and resources offered by numerous academics on Twitter^(TM) (Twitter Inc., San Francisco, CA), Facebook^(TM) (Facebook Inc., Menlo Park, CA), and other social media platforms. In addition, the Anatomical Society has a collaborative database containing online resources (AS, 2020). An online network, particularly in circumstances such as these can have an impact on academic success (Maican et al., 2019). External collaborations can act as a source of support and are particularly important in institutions with small teams of anatomists. Nurturing these collaborations and developing an online community of practice in the future is a huge opportunity for the anatomical community. This is especially important for the next academic year as the impact of Covid‐19 on the body donor program and anatomical education is yet to be fully appreciated. Additionally, as many anatomy departments are developing new technological skills in teleconferencing, there is a potential to pool expertise among institutions. It gives departments the opportunity to have “online connections made between peers,” to share expertise in anatomical sub‐specialties and to showcase cutting‐edge anatomical research across satellite campuses, and indeed across institutions worldwide.

Incorporation of blended learning in future curriculum development

Academics reported being excited at the chance to develop new resources as it was the most frequently cited opportunity among the cohort (71% of responders). The decline in the priority of cadavers, and indeed anatomy as a subject, within medical curricula is well documented (Drake et al., 2002; Drake et al., 2009 ). With diminished resources including curricula time, budgets, and staffing, in conjunction with increased student numbers, innovative and novel approaches are needed to solve these pressing issues. Perhaps Covid‐19 could act as a catalyst to do so. Fourteen percent of academics suggested that this crisis presented them with an opportunity to develop resources that can be used in the upcoming academic year, allowing them to incorporate more blended learning techniques and review the curriculum. Therefore, it is imperative that enough time can be dedicated in order to create high‐quality references.

Reduced student engagement

A frequently expressed concern was diminished student engagement as a function of the rapid implementation of distance learning (36% of responders). On consideration, this may be compounded by the fact that many universities are no longer pursuing typical mandatory attendance policies for teaching sessions. Moreover, the current Covid‐19 crisis may cause an increased risk of isolation, anxiety, and boredom among the population (Rubin and Wessely, 2020). This was also highlighted by one institution as a major concern among the student population where they were worried about the levels of “anxiety” that students face on “the future of their education.” Previous studies have shown a decrease in quality of life and stress negatively impacts student motivation and academic results (Artino et al., 2010; Lyndon et al., 2017). Specifically, the responses from this study included comments that highlighted their concerns with “creating resources that students will actively engage with” as well as how to “encourage and maintain student engagement.” Thus, academics adapting their approach to anatomical education should consider the need for support, interactivity, and social engagement with and between the students. A reduction in these elements may ultimately impede academic progress and student satisfaction. Ultimately, one academic expressed they wanted to ensure that students “were getting value for money” from their course. Additionally, technical issues, for example, unstable internet connections or lack of suitable electronic devices, will also impact student engagement (Wimpenny and Savin‐Baden, 2013; Ilgaz and Gülbahar, 2015). The unexpected shift to distance learning means that some students may not be technically prepared for distant learning and assessment. Therefore, due consideration to accessibility must also be considered as a potential threat to delivery of distance learning and assessment. In conjunction with potential issues in relation to the student population, staff may not have proficient knowledge of pedagogical techniques specific to the delivery of online teaching. Some staff members may not have been able to fully evaluate the theoretical and practical implications of distance learning prior to the cessation of face‐to‐face teaching. This may also impact on their ability to boost student engagement (Wimpenny and Savin‐Baden, 2013).

Teacher–student relationship

Maintaining the teacher–student relationship was considered a threat (21% of responders) as online resources lead to a perceived improvement in the online instructor social presence (Draus et al., 2014). The online instructor presence effectively reduces the transactional distance between student and instructor (Attardi et al., 2018; Stone and Barry, 2019) by increasing the likelihood of interaction. One way to address this issue is to host synchronous (live) classes (McBrien et al., 2009; O’Flaherty and Laws, 2014). This approach was taken by 36% of universities that hosted live lectures and 43% hosted live tutorials to support practical sessions. Many synchronous software packages contain interactive polls that can be used to assess knowledge, encourage engagement, and provide instant feedback to students. Studies have shown that timely feedback from instructors is hugely important in maintaining engagement (Martin and Bolliger, 2018; Ragusa and Crampton, 2018). Interactive polling can therefore be utilized in a flipped‐classroom approach, shown to increase student interactivity as all levels of Bloom’s taxonomy can be assessed if correctly designed (Gilroy et al., 2015). Providing clear guided instructions for problem solving and linking content to clinical practice and prior knowledge are other methods that are proven to improve engagement (Wimpenny and Savin‐Baden, 2013; Boton and Gregory, 2015; Ilgaz and Gülbahar, 2015; Buelow et al., 2018; Martin and Bolliger, 2018). Thus, within the synchronous classes, staff can potentially utilize anatomical education software programs to incorporate applied anatomy and clinical scenarios into their sessions. In this regard, there is evidence that virtual synchronous conferencing methods may increase peer–peer and peer–teacher interactions (McBrien et al., 2009; O’Flaherty and Laws, 2014).

However, in the Covid‐19 crisis, synchronous teaching may be deemed unsuitable for a proportion of the student population. Students living in different time zones or those with parental and caregiving responsibilities may be unable to attend scheduled synchronous sessions. As synchronous sessions offer potential for interactivity, students unable to attend may feel particularly isolated if departments solely relied on synchronous teaching methods. To address this, interactive asynchronous teaching methods have been employed, for example, Twitter^(TM) and discussion boards or Padlet^(TM) (Padlet, Inc., San Francisco, CA) (Table 1). A strong teacher–student relationship results in students feeling more comfortable engaging with online communication platforms such as discussion boards (Griffiths and Graham, 2009; Rose, 2009). The use of social media has been shown to diminish anxiety and foster a sense of community (Hennessy et al., 2016). However, if these options are unavailable, adapting resources that are already used across ten institutions in our study can include interactive elements within asynchronous teaching. This includes creating a short video content of problem‐solving tasks with recorded audiovisual input from the tutor. Such an approach permits students to consistently see and hear their tutor, with the potential to aid in student engagement (Wimpenny and Savin‐Baden, 2013; Boton and Gregory, 2015; Ilgaz and Gülbahar, 2015; Buelow et al., 2018; Martin and Bolliger, 2018).