Surg Radiol Anat (2006) 28: 189–194

DOI 10.1007/s00276-005-0062-z

TEACHING

René Yiou Æ Daniel Goodenough

Applying problem-based learning to the teaching of anatomy: the example

of Harvard Medical School

Received: 4 October 2004 / Accepted: 21 October 2005 / Published online: 7 March 2006
Ó Springer-Verlag 2006

Abstract The introduction of problem-based learning

techniques into the teaching of anatomy has been subject
Introduction
to great controversies. This paper debates the rationale
The teaching of medicine has been the subject of pro-
behind this concept using the example of the curriculum
found changes during the past decades at several uni-
of Harvard Medical School in which problem-based
versities in the United States. In many of these, the
learning techniques have been used during the past
lectures have become progressively more conceptual and
20 years. The anatomy curriculum is covered during the
less dense, and a more interactive approach of learning,
eight first weeks of the medical studies, and is an original
based on the resolution of clinical problems in small
combination of discussions of clinical cases in small
groups, has been introduced. This method of teaching,
groups, and work in gross anatomy, histology and
named the new pathway at Harvard Medical School
radiology laboratories. The lectures are reduced to
which incorporates components of problem-based
the minimum and emphasize general concepts. In this
learning, was initially developed with the aim of
setting, the learning of anatomy is mostly led by students
encouraging students’ motivation and responsibility to-
who have prepared for the different laboratory sessions
ward learning [14]. The rationale was based on the idea
and tutorials. The implementation of problem-based
that it is not realistic to assign students to assimilate the
learning to the teaching of anatomy requires a close
increasing mass of essential details generated by the
follow-up of each student with regular feedbacks on his
evolution of medicine, and that the development of
work. Tutorials must be considered as a cornerstone
appropriate skills and attitudes of learning is preferable
between lectures and work in laboratories. Traditional
to rote memorization. While most of the Universities in
aspects of the teaching of anatomy, such as work in
North America have integrated problem-based learning
dissection laboratories, are given an important role
in the clinical disciplines, it remains controversial
as they are aimed to clear-up misunderstood points.
whether such a concept of teaching can be applied to
Further studies are required to compare at the long term
basic sciences, and in particular to anatomy.
the level of medical students who learned anatomy in a
The teaching of anatomy occupies a unique place in
problem based versus traditional learning setting.
the medical curriculum. Like no other discipline, it
constantly gives rise to great debates and surveys con-
Keywords Problem-based learning Æ Anatomy Æ
cerning what exactly should be taught and how [2, 3, 6,
Medical education
10]. This may be explained partly by the fact that it is, by
essence, interdisciplinary, and, henceforth, highly influ-
enced by concepts introduced in other areas of medicine.
In that sense, anatomy is a very living and modern
R. Yiou (&) subject. An important task assigned to the teaching
Service d’Urologie et département d’Anatomie, C.H.U. Henri anatomy department consists of balancing modern and
MONDOR, 56 Avenue du Maréchal de Lattre de Tassigny,
94010, Créteil, France traditional basic anatomy while still providing the
E-mail: rene.yiou@hmn.ap-hop-paris.fr foundations of a medical education.
Tel.: +33-1-49812559 The methods of teaching of anatomy are also bound
Fax: +33-1-49812552 to be modified dramatically with the arrival of the
D. Goodenough Æ R. Yiou
computer and the internet. The use of interactive soft-
Department of Cell Biology, Harvard Medical School, ware has been suggested to help in the understanding of
240 Longwood Avenue, Boston, MA 02115, USA anatomical concepts in several venues such as during
190
lectures [4], in gross anatomy laboratories [8] and for
students’ self-preparation. However, the exact role that
these new technologies should play in the learning pro-
cess and their place with regard to classical blackboard
drawings remain vague and vary considerably from one
university to another. As mentioned by Reidenberg and
Laitman [11], newer generations of students may advo-
cate a greater interactivity, and this should be taken into
consideration in the design of the curriculum.
Thus, the anatomy curriculum requires regular
updates in terms of presentation and content. However,
there has been a lack of consensus regarding the way
these modifications should be performed. In addition,
adaptation of the curriculum has become problematic
because the time, importance and academic credit allo-
cated to anatomy has been progressively restricted to the
benefit of other emerging disciplines, such as neurobi-
ology or ethics. As a result, most of the departments
constantly struggle to preserve essential—yet costly and
time-consuming—aspects of the curriculum such as
dissections.
A pragmatic way of addressing these issues has been
adopted at several universities in the United States by
applying the concepts of the new pathway to the teaching
of anatomy. In this setting, the lectures and tutorials are
limited to provide only general and clinically relevant
anatomical concepts. From this material, the students
have to define their own set of objectives with the
underlying principle that they acquire the anatomical
knowledge important in solving clinical problems. By
bridging the gap existing between anatomy and clinical
disciplines, the students are given a greater responsibility
for their learning of anatomy and can be sensitized to
newer technologies and imaging techniques with the help
of computers. The limitation of the number of lectures
permits a relative increase in the proportion of time spent
in the gross anatomy laboratory, during which most of
the teaching of descriptive anatomy is provided.
The principles of this method of teaching have often
been perceived with skepticism, because of the lack of
detailed lectures and the role of facilitator played by the
teacher. In addition, the implementation of problem-
based learning to anatomy requires a radical reorgani-
zation of the curriculum and a precise definition of the
role played by the tutorials, the lecture and the work in
the laboratory, each aspect being strongly complemen-
tary from the others. The aim of this paper was to
provide a detailed description of the organization of the
curriculum of anatomy of Harvard Medical School, a
university of reference in the United States and a pioneer
in the new pathway, in order to illustrate the principles
of problem-based learning applied to the teaching of
anatomy.
Description of the curriculum of anatomy
The global organization of the curriculum of anatomy
and the characteristics of the faculty panel in Harvard
Medical School are displayed in Tables 1 and 2. This
course takes place during the eight first weeks of the first
year of the medical curriculum. During this period, the
students are given a global vision of gross anatomy,
radiology and histology. Each day is arranged as
follows: 1 h of tutorial (discussion of clinical cases), 1 h
of lecture and 2 h of histology laboratory exposure or
3 h of gross anatomy laboratory exposure (with dissec-
tion). Afternoons are dedicated to the preparation of the
next tutorials, and practical experience in either the
histology or gross anatomy laboratories.
Organization of the tutorials
Nine clinical cases are discussed during the eight weeks
that deal successively with the anatomy of (1) the fore-
arm (case of a prematurely sutured soiled wound com-
plicated by compartment syndrome of the forearm); (2)
the rachis and spinal cord (case of sciatic nerve com-
pression); (3) the thoracic outlet (case of thoracic outlet
syndrome with vascular compression of the subclavian
artery); (4) the thorax (case of spontaneous pneumo-
thorax); (5) the neck (case of a retropharyngeal abscess
secondary to trauma); (6) the sinus of the face and their
relationship with the meninges (case of frontal sinusitis
with meningitis); (7) the abdominal wall and the peri-
toneum (inguinal hernia); (8) the abdomen (case of acute
pancreatitis); (9) the pelvis (case of ectopic pregnancy).
Groups of eight students meet for 1 h every day
under the supervision of a faculty member (tutor), and
discuss the clinical cases with the help of books (medical
dictionary, Grant’s Atlas, Histology, Cell Biology and
the Harrison’s Internal Medicine) and of a computer
connected to internet. Sessions usually start by the
reading of the text describing the initial symptoms and
are followed by the definition of the new vocabulary.
Several hypotheses concerning the organs and structures
involved in the clinical symptoms are generated. Since
the students have not yet seen the clinical disciplines, the
hypotheses are initially based on student’s prior
knowledge and experience. The questions that cannot
be answered are written on the blackboard, and the
students define tasks for the next sessions in order to
solve these problems. The students then study on their
own, using the library, computers and may return in the
histology or gross anatomy laboratories. During the
next session, each student brings his or her contribution
to the understanding of the case, and progressively, the
patient’s symptoms are related to anatomical concepts.
A new part of the case is then disclosed by the tutors.
The clinical evolution raises new questions and
hypotheses that are progressively focused on a specific
part of the body. Radiological images are shown to
illustrate the case and the principle of treatment, usually
based on surgery, is discussed. Discussion around
radiological material and therapeutic options serve as
support to review anatomy. The role of the tutors is to
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Table 1 Global organization of the curriculum of anatomy in
Harvard Medical School
Gross anatomy laboratory 41 h (31.3%)
Histology laboratory 26 h (19.8%)
Radiology laboratory 7 h 30 min (5.7%)
Lectures 28 h 30 min (21.5%)
Tutorials 28 h (21.3%)
Total number of hours 131 h
Numbers of teachers/students 36/172
clarify the group’s objectives, rather than to provide
detailed information.
At the end of each case, the important points are
summarized by answering to three questions: (1) what
spaces or compartment boundaries have been violated in
this case? (2) what homeostatic mechanisms were com-
promised in this case? (3) how does a local event have a
global consequence?
Lectures
The topics of the lectures are displayed in Table 3. Most
of the lectures provide general concepts such as the
global organization of one part of the body and
emphasize the notion of compartments and boundaries.
The lectures are presented with the aid of a computer
using PowerPoint and animations, videos and drawings
on the blackboard. All of them are filmed and retrans-
mitted on the web site.
Problem-based learning may be used as a support to
introduce anatomical basis of a region. For instance, a
case of traumatic hemopneumothorax is presented to
cover the anatomy of the thoracic wall and pleura.
During this lecture (1 h), the students learn how to
recognize a broken rib radiolographically, while the
anatomy of the lung and pleura is described on CT scans
with the aid of projected cross-sectional drawings. The
function of respiratory muscles is explained and the
pathophysiology of respiratory failure relevant to
the case is detailed. A clinician then introduces the
anatomical basis of pleural drainage.
Table 3 Description of the topics of the lectures. These were
arbitrarily divided in conventional and nonconventional lectures
with regard to a traditional curriculum
Nonconventional lectures
Cellular biological systems (1 h)
Organization of the human body I: building tissue
from molecules (1 h)
Organization of the human body II: compartments
and planes (1 h)
Sections and projections (1 h)
Anatomy of circulation of body fluid (2 h)
Mechanism of respiration (1 h)
Examination of the head and neck
(clinical exercise with clinician) (3 h)
Clinical issues in the pelvis and their anatomy (1 h)
Putting it together (1 h)
Anatomical basis of diagnosis
(case of esophageal cancer with a patient) (2 h)
Conventional lectures
Organization of the nervous system (2 h)
Organization of the limbs (1 h)
Organization of thoracic cavity (1 h)
Organization of the immune system (1 h)
Organization and compartment of head and neck (3 h)
Endocrine organ (1 h)
Organizations of abdomen: peritoneum (1 h)
Gastrointestinal system and liver (1 h)
Kidney: nature’s dialysis bag (1 h)
Peritoneum and referred pain (1 h)
Organization of the pelvis (1 h 30 min)
Gross anatomy, histology and radiology sessions
The topics of the gross anatomy, histology and radiology
sessions are displayed in Table 4. In the different labo-
ratories, an average of 32 students works under the
supervision of four tutors. A handout that defines the
goals of each session is distributed at the beginning of the
course. It may, for instance, describe the different steps of
dissection in gross anatomy laboratories, emphasize
important points of structural and functional anatomy
and raise several clinically relevant questions that the
students will have to answer in group. The students
use this material to orientate their preparation for the
sessions.

Table 2 Global organization of

the curriculum of anatomy in Lectures Tutorials Histology Gross anatomy Radiology
Harvard Medical School laboratory laboratory laboratory

Surgeons 1 4 3 4 b
(n=7)
Clinical 1 3 3 5 b
a physicians
Some tutors (category miscel- (n=8)
laneous) may not have a med- Radiologists 6 3 2 2 6
ical or biological background (n=6)
b
At the exception of the radi- Biologists 2 9 8 6 b
ologists, the participation to the (n=10)
teaching in radiology labora- Miscellaneousa 2 2 2 5 b
tories of other categories may (n=5)
vary
192
Table 4 Topics of histology lab and radiology and gross anatomy
sessions
Gross anatomy lab (41 h)
Superficial structures (2 h)
Limbs (9 h)
Thoracic walls, lungs and pleurae (3 h)
Mediastinum and root of the neck (3 h)
Head and neck (9 h)
Abdomen (9 h)
Pelvis (6 h)
Histology lab (26 h)
Cells and tissues (2 h)
Epithelium and connective tissues (2 h)
Cartilage and bone (2 h)
Nerve and muscle (2 h)
Heart lung and trachea (2 h)
Immune system (2 h)
Esophagus tongue and exocrine glands (2 h)
Blood and blood vessels (2 h)
Stomach and small intestine (2 h)
Liver colon and RA junction (2 h)
Kidney, ureters and bladder (2 h)
Female reproductive system (2 h)
Male reproductive system (2 h)
Radiology lab (7 h 30 min)
Extremities and breast (1 h 15 min)
Cardiovascular (1 h 15 min)
Chest (1 h 15 min)
Head and neck (1 h 15 min)
Abdomen (1 h 15 min)
Pelvis (1 h 15 min)
Active cadaver dissections in the gross anatomy lab-
oratory form the core of the curriculum where concepts
described in lectures and tutorials are reviewed in detail
and deepened. Four students dissect one cadaver. The
faculty members watch over each table and clear-up the
misunderstood points using, if necessary, drawings on a
blackboard and a skeleton present in the laboratory.
Prosections prepared by the teachers are available to the
students at the end of the sessions.
The students have an introduction to each histology
sessions using slide projection images in an amphitheater
setting. In the laboratory, each student has his or her
own microscope and slide box. Multihead microscopes
and microscopes connected to a video camera can be
used to review the slides of the day, allow interactive
teaching to occur between faculty members and
students, to answer student questions and to clarify
important teaching points.
During radiology sessions, CT scan, MRI and
radiographs are analyzed by the students in groups under
the supervision of faculty members.
An illustrative example of the interdisciplinary
nature of each case
During the tutorial of the third week, a case is presented
of finger ischemia due to a thoracic outlet syndrome,
with formation of a microthrombus in the subclavian
artery and emboli to the finger. This presentation comes
after a lecture about the global organization of the limbs
(1 h), and is accompanied by three sessions of 3 h of
dissection of the limbs in the gross anatomy laborato-
ries. The observation begins with the description of the
initial symptom, a sudden blue coloration of a finger in a
woman while she carries her heavy baby. The students
have to associate the cyanosis of the finger to a patho-
logical process of vascular or neurological origin. The
study of the innervation of the hand has been seen in the
first tutorial (case of compression of the median nerve at
the forearm) and the arm and forearm have been dis-
sected in the gross anatomy laboratories. Based on this
prior knowledge, the students orientate their hypotheses
toward a vascular disease because of the localization of
the cyanosis. They determine next what should be done
in the clinical exam. One of the tasks defined by the
group consists of reviewing the location of the palpable
pulses of the upper limb and their anatomical land-
marks. The disclosure of a supraclavicular murmur and
a positive Adson’s test orientates toward pathology of
the subclavian artery. The relationship between possible
disease in the subclavian artery and the ischemia of the
finger is discussed. The question of the vascular supply
of the fingers is then approached paying attention to
the deep and superficial palmar arch of the hand. The
students try to figure out how a disease of the subclavian
artery can result in the cyanosis of an isolated finger.
The pathophysiology of thrombus and of emboli for-
mation is discussed under the guidance of the faculty
member, while the notion of variations of the palmar
arches and their functional significance is covered in the
gross anatomy sessions. A radiograph and an angiogram
are then displayed showing a cervical rib and a stenosis
of the subclavian artery with a slight dilatation down-
stream. The students analyze these exams in detail
paying attention to the anatomy of the subclavian
artery, and to the radiological anatomy of the ribs and
clavicle. The mechanism of vascular compression is
related to the functional anatomy of the thoracic outlet
and the respiratory muscles. The therapeutic options
and the possibility to remove the cervical rib are then
discussed. It is revealed that the resection of the cervical
rib and of a Scalenus Minimus muscle was performed.
The surgical approach of this procedure is finally
detailed by the students.
This case is intercalated between the lectures on the
organization of the limbs and before the lectures
involving the neck and thorax. During the period of this
tutorial (4 days), two lectures (2 h) entitled ‘‘Anatomy
of Circulation of Body Fluid’’ are given and 3 h in the
histology laboratories are spent in a small group tutorial
covering the histology of blood vessels, muscles and
nerves. At the end of the tutorial in the gross anatomy
laboratories, the thorax is opened and the clavicle
is divided allowing the entire subclavian artery to be
displayed from its origin to its end.

Table 5 Roles attributed to computers
Planning of the laboratory work. Distribution of the handouts for tutorials and laboratory sessions
Source of preparation for the tutorials. Online access to most of the international reviews and some medical books
Disclosure and illustrations of the clinical cases (pictures, X-ray, CT scan, MRI, relevant to the ongoing case)
Retransmission of the lectures or slides displayed during the lectures
Demonstrations of the dissections
Bank of images. Interactive software for recognition of anatomical structure on CT scans or describing anatomic layers of dissections
Examination
Feed back tutor/student and student/tutor
Role of computers
Students are required to enter individualized code
numbers to access the web site of Harvard Medical
School. The tutor can control the resources that the
students of his tutorials have access to and can com-
municate with them individually or in groups on the
network. The roles played by computer are shown in
Table 5.
Examination and evaluation
Each tutor individually meets with the students of his
tutorial four or five times during the course. The aim of
these meetings is to give the student a feedback on his or
her progression and preparation during the tutorials.
The students give their global impression on the different
aspects of the courses and fulfill a self-evaluation form in
which they have to define their goals of learning and
assess their strengths and goals for improvement.
A take-home exam with clinical question is given at
midterm. The aim of this exam is to test the ability of the
student to solve clinical problems using anatomy. A final
examination is given at the end of the 8 weeks by the
students resulting in an appreciation pass or marginal
pass. All questions are problem based and are corrected
by the tutors in group. Usually 2–3 students/year get a
‘‘marginal pass’’. If they get a marginal in another
course, they go on academic probation, meaning that
they must give up all extracurricular activities and work
with a designated faculty member to get them on track.
Examples:
1. Explain the neuroanatomical bases of peritoneal
pain.
2. Identify the muscles of the shoulder on a CT scan of a
patient with poliomyelitis and severe atrophy of the
left arm and determination of the nerves involved.
Discussion
The anatomy curriculum described in this paper differs
dramatically from the traditional methods of teaching.
One of its most striking aspects is the use of clinical
material to introduce anatomy. In the tutorial example
provided, the students have to understand the patho-
193
physiology of ischemia of the upper limb and relate the
symptoms to the angioanatomy of this area. This
learning process goes in an opposite direction of a tra-
ditional way of teaching anatomy that would describe
first a normal pattern of vascularization of the upper
limb, region by region, and would then briefly mention
how ischemia can occur. In the curriculum described,
the basic anatomy relevant to the case is taught, prior
to the tutorials, by short lectures. For instance, the
organization of the upper and lower limbs is covered in a
1-h lecture that mainly focuses on the notion of com-
partment and muscle function. The learning of detailed
anatomy is left to the students themselves, and reviewed
during the dissection sessions that occur concurrently
with the tutorial cases.
This lack of detailed lectures has given rise to
passionate debates among North American teachers.
Cahill and Leonard wrote very provocative papers
accusing the new pathway of considerably lowering the
level of medical student knowledge in anatomy [2, 3]. In
particular, the function of the tutors was very criticized
because they mainly act as discussion facilitators during
the tutorials, resulting in a risk of missing important
points. Mc Lean [9] found that if most of the tutors
believe in the philosophy of problem-based learning,
61% were doing so for promotional purposes. In the
curriculum described here, the tutorials must be con-
sidered as an intermediate step between the lectures and
the cadaveric dissections and not as an isolated entity.
An essential goal of the tutorials is to have the student
define objectives for their own learning. This method of
teaching certainly imposes a greater investment from the
faculty as a close follow-up of each student is necessary
to orientate his way of working. The gross anatomy
sessions usually clear-up misunderstood points and may
actually be considered as a substitute to traditional
lectures.
As noted by several authors [1–3], the time allotted to
cadaver dissection has decreased progressively in most
universities. This may result in a dramatic impairment of
the understanding of anatomy required to start prac-
ticing medicine safely and competently. It is noteworthy
that, in the curriculum described, the number of hours
allocated to work in gross anatomy laboratories, both in
absolute and in relative (41 h, and 31.3% of the global
time allocated to anatomy and histology), is higher than
in most of the traditional forms of curriculum [6].
Hence, we believe that the progressive diminution of the
194
work in gross anatomy laboratories is not an effect of
the new pathway approach, but instead can be explained
by the fact that new disciplines have emerged which
influence the overall make-up of the medical curriculum.
Interestingly, the entire curriculum of anatomy, with the
exception of neuroanatomy and additional course of
clinical anatomy, is covered during the eight first weeks
of the medical studies, and the global number of hours is
lower than with a traditional curriculum which is usually
spread over a period of 2–3 years. This compaction of
the curriculum of anatomy may facilitate the perception
of the body as a whole and the understanding of sub-
sequent disciplines. The integration of histology to the
curriculum gives the students a broader vision of struc-
tural anatomy, and may result in an additional gain of
time due to a better coordination of the disciplines.
Neuroanatomy is taught as part of the 8 weeks block
called ‘‘Human Nervous System and Behavior’’ during
the second year. It comprises two 3-h laboratory ses-
sions/week that include dissection of human brain,
radiological anatomy and some neuropathology.
An optional summer course of clinical anatomy is
offered to the third year medical students interested in
surgery or radiology. During these sessions, an average
of 30 students will review basic anatomy in a clinical
context, complete guided dissections based on surgical
approaches in the gross anatomy laboratory and attend
clinical anatomy lectures by leading surgeons and radi-
ologists in a variety of clinical specialties.
The profile of the faculty panel in Harvard Medical
School also contrasts with most of the universities
over Europe, in which anatomy is essentially taught by
surgeons or radiologists. Although this aspect is
also often criticized [13], the diversification of area of
expertise, including biologists and nonphysicians, per-
mits to increase the number of teachers available. It
remains to be determined whether the additional costs
required to pay the faculty salaries ($200,000 per year at
Harvard Medical School for the curriculum of anatomy)
would be acceptable in other universities. However, it is
noteworthy that the student’s fees (approximately
$25,000 a year) do not significantly differ from other
universities in United States.
Evaluation of the level of medical students who
learned anatomy in a traditional versus problem-based
learning setting would be extremely interesting, as well
as an evaluation of the global cost of each curriculum.
To our knowledge, such an evaluation has never been
reported. One could assume that the basic knowledge of
anatomy may be higher right after following a tradi-
tional way of teaching, but it remained unclear how it
would persist at the long term, since problem solving has
been shown to be a more efficient process of memori-
zation [5, 12]. Hence, an evaluation would have to be
done latter in the medical curriculum and should take
into consideration the ability to find an anatomical
interpretation to a clinical problem.
Acknowledgements We would like to thank Geoffrey Liu for shar-
ing his experience of teaching and for his critical reading of the
manuscript, and Amel Ounnoughene for her technical support.
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