gms | German Medical Science

Anatomy is one of the most important and intense courses offered during the first section of medical school. In the teaching of anatomy the dissection course is very important. In Germany it often begins during the first semester. Approximately 186 students, from a variety of different backgrounds, emerge each year to encounter, most likely for the first time, a dead human body. This experience, while doubtless emotionally taxing, provides essential knowledge required for the duration of their future studies. While the attainment of anatomical knowledge certainly plays an important role it is nearly as essential that the doctor learns to treat the sick, the dying, and the dead with the utmost of respect (learned-compassion; [6]).

The study seeks to identify what role emotional aspects played in the course. In addition, it will examine the student’s subjective perception with regard to the initial encounter, as well as subsequent encounters, in order to identify the precise difference within the group.

The literature on medical students and macroscopic anatomy is relatively large. In her dissertation, “Aspects of Socialization to the Doctor: An Empirical Study on the Effects of Practical Macro-Anatomy to Medical Students and their Attitudes toward Dying and Death”, Egbert [5] examined the formative influence of dissection courses on attitudes, and changes of attitude, toward dying, death, and fear of death. For their first hypothesis, “The participants at or near the beginning of dissection course, exhibit a different attitude toward death and dying as compared to the end of the course”, she utilized “fear of death” as a measure. It was confirmed that there was no significant difference between the measurement points. However, the study suggested that the second hypothesis, “Those persons with professional experience with dying and death exhibit fewer changes in attitude than those without such experiences”, was accurate. It is interesting to know whether differences exist with regard to anxiety and emotional distress among other groups, for example, age groups, gender, and emotional background. In another article from Voltmer et. al. [18], a “study investigating the required experience and behavior, self-care and social support available at the beginning of medical studies”, the authors demonstrated that in relation to the general population, physicians show greater risks of psychosocial stress and disease. The present study also investigates whether the foundations for these risks lie within the first semester of medical school. In 40% of the surveyed students “a constellation of psychosocial stress with health-threatening experiences and behavioral patterns” was reported. It will be interesting to determine both to what extent dissection plays a role and whether it, in fact, plays a role. This article, more than previous studies, shows not only whether there is an emotional burden on the students concerning the initial encounter with dissection, but, furthermore, precisely how much the emotional burden is associated with certain personality types as well as the nature of the students’ emotional developing during the course is investigated.

In conjunction with previous literature the following hypotheses were developed:

The subjects of the study were medical students at the Otto-von-Guericke University in Magdeburg, who had begun their medical education in October 2007. The subjects were asked to complete voluntarily the questionnaire under a pseudonym. Later in the course a pre-post investigation was administered at both the beginning and end of the first semester via a code number, which the students themselves devised. Each student had the right to refuse participation in the survey. Each student was informed verbally that, by completing and submitting the questionnaire, permission was thereby granted to analyze and publish received data. The ethics committee of the Magdeburg Medical Faculty found no fault with the submitted project.

It is desirable to have a drop-out analysis to identify those students who discontinued participation in the study sometime between the first and second survey. Owing to the use of a pseudonym, however, such identification was impossible. Hypothetically, if such a determination were possible, justified questions regarding the reasons for the discontinuation would emerge. For example: illness or, even disinterest. We had, therefore, no basis for a hypothesis regarding possible reasons for discontinuation.

Self-designed questionnaires were the primary method employed in this study. Because the questionnaire items possessed high logical validity a pre-review rating process was deemed unnecessary. Cronbach‘s Alpha was not particularly high for this study (0.55); however, given the nature of the study, it was deemed sufficient. At the beginning of the semester, the initial survey was introduced comprising 47 questions. The processing time was approximately 40 minutes. An additional survey was distributed shortly after the first semester, comprising 21 questions. The processing time for the second survey was approximately 20 minutes. It was assumed that administering the survey at two different measurement points would detect developments and changes. To identify personality characteristics 28 items, taken from the Freiburg Personality Inventory (FPI-R) were administered. Owing to restricted time, we used only questions about the personality traits “extraversion/introversion” as well as “emotional stability/instability”. The internal consistency of the FPI-R was determined by Cronbach‘s Alpha and, depending on the scale, from 0.73 to 0.83. [7]. The FPI is a proven method, supported by several respected studies, according to high external and internal scale validity.

It would have been desirable for the students to complete a survey before their first dissection lecture. However, for technical reasons, this simply was not possible. The first questionnaire was distributed to first year students just after their first day of the anatomy course. The survey asked the students to answer the questionnaire retrospectively with regard to possible fears. In addition, they were asked whether the fears accurately reflected their actual feelings during the first prep-course. The personality questionnaire was distributed at the same point of measurement. To identify changes and developments the students completed the second survey shortly after completing their first semester. In both cases, the student was given a sufficient amount of time to complete each survey.

Data were collected with SPSS version 18 and subsequently evaluated. Data have mostly the stage of nominal and ordinal scales. This type of scale allows only the calculation of medians, not the arithmetic mean. However, smaller value differences are removed when calculating only the median. Based on the advice of the Department of Biometrics at Otto-von-Guericke University in Magdeburg (Prof. Kropf) the arithmetic mean values of data with multi-level response options were also calculated. In what follows, therefore, comparison of pre- and post-data mean values ± standard deviations are given.

Significant tests were analyzed using the Wilcoxon-test for paired samples and the median test for unpaired samples. Multiple statistical analyses were corrected by using the Bonferroni-adjustment. Before data analysis we set the commonly employed threshold for the significance level of p<0.05. Calculation of correlations was performed via the Spearman rank correlation coefficient.

In the first survey, in October 2007, a total of 155 questionnaires were completed by medical students, shortly after the commencement of the practical portion of the anatomy course. After the second interview, we had complete records of 94 subjects, collected from both surveys. These subjects’ data is collected in the present study. Of these, 66 were female (70.2%) and 28 male (29.8%). The female age range was between 18-27 years (mean 20.03 years, standard deviation±1.66 years). The male age range was between 18-31 years (mean 21.36±2.97 years). 30% of respondents were from the former West Germany; 70% from former East Germany. 7.1% of the students came from foreign countries. Naturally, only students who were present in the relevant anatomy events participated: 83% of all matriculated students for this semester in the initial survey; however, only 50.5% of students for the second survey. Despite high participation the study could not exclude errors due to a selective sample of the latest testing.

Test quality criteria for the first examination were as follows

The items could be checked either „yes“ or „no“ or up to a seven-point scale from -3 to 3. With regard to the execution-objectivity of our self-developed questionnaire, it can be regarded as objective given that only response categories or scales were used on a standardized questionnaire. Objectivity of the evaluation was given by pure frequency counts. For an investigation of reliability, two questions were posed in similar form. The Spearman‘s correlations were R=0.77 and R=0.71. Therefore, high reliability was established. A validity check with a similar questionnaire (Egbert) was not possible due to time constraints. Questions regarding the validity can be posed with reference to the construct-validity of the content [9]; given the size of the sample it was also not possible to create an external criterion.

Results of the retrospective questionnaire prior to the first day of dissection course were as follows

Regarding our first hypothesis ("Students experience an inordinate degree of emotional stress in reponse to the dissection") it was studied whether the participants were already worried about possible reactions to the course before they had started their medical education. One can see in Figure 1 [Fig. 1] that 50.4% considered their possible reactions to the human cadavers (scale values: -1 to -3), 11% gave a lot of thought to their possible reactions (full scale -3). 36.2% gave little to no thoughts to their possible reactions (full scale +3). 13.5% checked Zero on the scale (median: -1.0±0.16).

In the next question, students should assess the importance of the dissection course. As shown in Figure 2 [Fig. 2], only 1.8% of the students reported the dissection as an unpleasant obstacle to completion of their medical education (scale values: -1 to -3); 0.6% judged the experience as a very unpleasant obstacle (scale values: +1 to +3). 54.8% with full scale looked curiously forward to the experience (+3), while 3.2% checked the scale value Zero (median: 3.0±0.08).

An important aspect of the study sought to determine the extent and nature of the students’ feelings subsequent to confronting the dissection of the cadaver. The results show that 38.8% of the participants felt anxiety in relation to the dissection (scale values: -1 to -3). 8.4% felt great anxiety (scale: -3). 46.4% expected the course relaxed (+1 to +3), while 14.2% reported no anxiety (+3). 14.8% checked Zero (media: 0.0±0.15).

A similar question examined whether the participants had previously thought about their possible reactions to the bodies. Results show that 50.4% of the students had previously worried about their reaction to the cadaver (scale values: -1 to -3); 12.3% were very concerned (full scale: -3). 36.2% reported no worries (scale values: +1 to +3). 11% reported absolutely no worries (full scale: +3). 13.5% checked scale value Zero (median -1.0±0.15).

Another item in the questionnaire asked about fears experienced during the direct sight of the corpse. 44.5% of the students report fears (scale values: -1 to -3); 10.3% were very afraid (full scale: -3). 45.2% reported anxiety of rather low scale values (+1 to +3); 22.6% checked “absolutely not” (scale value: +3). 10.3% chose Zero (median: 0.0±0.17). In response to the question whether students already had experience with the death of a person, 57.4% reported previous experience of encountering a corpse. 42.6% reported no experience (mean: 1.0±0.04).

Before the start of our study 17.3% of the participants had already completed training in one of the following areas: nursery, paramedic education, physical therapy, medical technician, and physician‘s assistant.

58.7% of students reported thoughts about death, or talked about death with family / friends (scale values: +1 to +3) (see Figure 3 [Fig. 3]). Before the start of the course 12.9% reported thoughts about death very often (full scale: +3). 23.9% either never thought about it or never talked about the topic with family / friends (scale values: -1 to -3). 3.9% reported that they absolutely never had thoughts about it (full scale: -3). 17.4% checked the scale value of Zero. (Median: 1.0±0.13).

At the beginning of the first semester, 95.8% of the students believed the course to be an interesting experience (mean: 2.34±0.97). After completion of the first semester of anatomy, all students (100%) now regarded the course as a very interesting experience (scale values: +1 to +3), 63.8% were absolutely convinced of it as an interesting experience (full scale: +3), (mean: 2.60±0.57). The pre-post-difference was 0.26±0.98; the Bonferroni-corrected Wilcoxon test for paired samples revealed no significant results.

Our second hypothesis indicated that emotional strain sensitivity would decrease during the first semester. At the beginning of the course 74.5% expected to feel increased relaxation during the preparation course (mean: 1.34±1.67). On average the second survey suggested that the students experienced increased relaxation during the dissection of corpses. Eventually 95.8% were more relaxed than expected (scale values: +1 to +3), 61.7% reached left extreme value (+3). Only 1.1% said they never completely relaxed (full scale: -2). 3.2% checked the scale value Zero, (mean: 2.47±0.86). The difference was -1.13±1.84; Bonferroni-corrected Wilcoxon test for paired samples revealed a high significance for the pre-post difference (p<0.005).

After the first day 33% reported increased discomfort or sickness after their first sight of the corpse (scale values: -1 to -3); the mean was 0.90±1.83. The number of those who felt sick in the anatomy course during the first semester decreased significantly and, at the beginning of the second semester, there were only 6.4% who felt ill during the course (scale values: -1 to -2), no one in extreme form (-3). 87.2% reported no such symptoms (scale values: +1 to +3); 50% absolutely not (full scale: +3). 6.4% checked the scale value of Zero (mean: 2.10±1.22). -1.19 ± 1.69 was the difference; the Bonferroni-corrected Wilcoxon test for paired samples revealed a high significance (p<0.005).

The results showed that after the first day of the course 26.6% of the students had dissected the corpses with a positive feeling (mean: 0.09±1.25) (see Figure 4 [Fig. 4]). In the second survey a significant change appeared. On average positive emotions increased during the dissection course. After the first semester, 33% reported positive feeling during the preparation (scale values: +1 to +3); 3.2% very high level (full scale: +3) and only 4.3% reported stressful negative emotions (scale values: -1 to -3); however none in a high degree. 62.8% reported neither negative nor positive feelings (0), (mean: 0.48±0.89). The difference was -0.39±1.44; the Bonferroni-corrected Wilcoxon test for related samples showed no significance.

Using the data of the first survey (total sample, n=155) we examined whether extroverted students reported fewer problems in the development of the course than introverted, and whether emotionally stable students reported fewer problems than emotionally unstable. Furthermore, we examined whether older students reported fewer problems than younger students. On the basis of the values of the aforementioned personality test, FPI-R, 10.97% of the students were classified as introverted (Stanine 1-3), 69.03% were average (Stanine 3-6) and 20% extroverted (Stanine 7-9). With regard to emotional stability, 30.32% of the first year students were classified as emotionally stable (Stanine 1-3), 57.42% were average (Stanine 4-6), and 12.26% as emotionally unstable (Stanine 7-9). We calculated the nonparametric Spearman's Rho rank correlation coefficient for one-sided issues, since our hypotheses goes in one direction. Table 1 [Tab. 1] shows the results.

The data reveal that the correlations have no statistical significance. Extroverted students did not report fewer difficulties with fears and anxieties during the dissection course than introverted students. Emotionally stable first year students did not report a less intense reaction to the corpse than emotionally unstable students. Age was found to play an insignificant role in the student‘s experience: older students showed no differences from the young with respect to their concerns. Therefore, hypotheses 3a to 3c were rejected. Data from the first survey (total sample, n=155) were also examined as to whether previous experience with death and dying affected the mental attitudes toward the anatomy course. Data were again calculated via Spearman's Rho correlation coefficient for one-sided questions. Table 2 [Tab. 2] shows the results.

The results reveal that those students who reported no experience with a corpse significantly correlated with the group who reported fears when confronted with the sight of a corpse. A highly significant correlation was also found between those freshmen who reported increased fears with the fact of human mortality, with those students who reported increased fear at the sight of corpses during the course. Also we discovered a high degree of significance for the group of first year students who had increased fears of death with negative and stressful feelings to the dissection course. Hypothesis 3f is thus applicable.

A further examination of the first survey (total sample, n=155) sought to determine whether there existed differences in psychological distress among students of different gender (f=112, m=43) or between those with and without medical pre-training (with=27, no=128). We calculated the statistical significance using the median test for unpaired samples; after Bonferroni correction the significance level was p<0.01. Table 3 [Tab. 3] shows the results.

The data revealed no significant differences in terms of worries and thoughts about death and dissection between students with and without a previous training in the medical field. Hypothesis 3d was thus rejected. With regard to gender, the results showed significant differences. On average women reported increased worries about possible reactions to the human specimens; they reported increased fear at the sight of corpses, and in relation to men, on average, increased negative emotions and stressful feelings emerged at the first dissection. Hypothesis 3e was, thus, confirmed.

Our data reveal that a significant proportion of the students reported serious concerns before the first contact with the dead; that is, whether and how this experience could be tolerated. The comparative data also reveals that most students quickly returned to their default emotional setting, and subsequently described the dissection course as one of the most significant aspects of their studies. This conclusion was even reached from Schneller [15]: "Before the course 42 percent of students stated they experience significantly, strong or very strong fears, inhibitions and fears. (…) Yet most students managed the rate adjustment much faster and less problematic than expected." Note that the first survey was made after the first day of the dissecting course and the retrospective collected data may therefore be flawed. The questions regarding worries and fears of the course may have been answered exaggeratedly owing to present emotional states and reactions to the first contact with the deceased. It is quite possible that the number of those reporting increased worries had increased in contrast to a survey before the first day of the course. Even if a considerable proportion of students initially reported an emotional burden, it should not be ignored that, overall, the majority of first year students reported no difficulties in the processing of these new impressions of the course. Furthermore, one should note the data reporting that most students, who felt mental stress in the beginning, did not report a decreased emotional state after course completion. These results parallel various other publications on this topic. Boeckers et al. [2] found that half of the tested students, who previously saw the dissection as burden, increasingly reported normal emotional states. McGarvey et al. [11] reported that “most students (95%) found the prospect of their first visit to the anatomy room exciting. A small number initially experienced physical symptoms, but these had improved significantly 10 weeks later.” Dinsmore, Daugherty and Zeitz [3] found that a majority of students reported positive feelings toward their first anatomy class; but, of course, for a small percentage of freshmen it represented a traumatic experience. These results were also seen in an earlier study by Nnodim [12] in which it emerged that at the beginning of the course many negative reactions occur, which were progressively replaced through neutral to positive reactions. One reason for the demise of emotional stress throughout the course may be that students become acclimated to a situation with which they never had contact. During the first semester each participant individually dealt with feelings and processed them. With each day of the course, the focus was increasingly placed more on the practical than on the emotional part of the work with cadavers. Through this, the feelings regressed into the background. This was reported by Arraez-Aybar, Castaño-Collado and Cascado-Morales [1]. The study claims that emotional reactions decreased and the attitudes and opinions of students changed once they had gained more experience during dissection. Other processing mechanisms, e.g. repression, rationalization, or distancing, may have also played a role. One must, however, keep in mind that only those students who participated in both the first and second survey were included in the total sample. Thus, on average, some participants who faced dissection of a dead body with skepticism and trepidation, and who many have cancelled their medical education because they regarded such work as an insurmountable obstacle, were not represented in final data.

Furthermore, it was investigated to what extent the students had prior experience in dealing with death and dying and how many already had completed another training in the medical field. Judging by the results one can see that many of the first year students, at baseline, reported contact with the topic of death and dying, either by direct experience or by discussion of the issue. However, in addition, there was an approximately equally large group who reported no contact with this subject and for whom the dissection was the first confrontation with death. It seems evident that some students reacted with emotional stress in relation to the course. If a medical student is confronted, for the first time, with a corpse on which dissections will be performed during the semester, the student will not only be introduced into the knowledge about the anatomy of the human body, but in addition with a flush of emotions and questions, e.g. thoughts about human mortality and what motivates people to donate their body to an anatomical research institute. This was described by Wagoner and Romero-O'Connell [19] as follows: “For many, facing a dissection for the first time elicits a wide range of emotions. These may include their own thoughts of mortality to the sheer admiration of knowing that someone cared enough to help others learn about the body, even in death.”

That there is a correlation between students without previous contact to the deceased and reported fears before the first day of class described was described as follows by Schneller [15]: “The 30% of students who had never seen a dead body, had on the first day particular difficulties and showed numerous physical and psychological symptoms.” However, note that students in the further development of their studies are confronted with the death of patients. It is fair to infer that the students, owing to their work on cadavers, will be prepared, to the extent that is possible to deal with the subsequent death of patients. Skandalakis [17] described it thus: “Cadavers offer surgical skill-building opportunities and confrontation with death.”

We also examined gender differences with respect to concerns and fears before and during the course. Our results suggest that women are subject to a stronger emotional burden than men; this result corresponds to other studies. For example, Shindel et al. report: “Depressive symptoms are common in female medical students.” [16]. There is, however, the possibility that female students were more willing to admit their worries and fears with respect to the questionnaire. Schneller [15] wrote: "Younger, female students confess more frequently their fears than older, male students."

Finally, it is important to ask: How one can offer support to students who react with anxiety and report increased emotional difficulties in processing new and intense experiences? Future discussion on this topic should address to what extent such a support service is within the capacities and capabilities of a university.

A relatively simple procedure which allows students to process and understand the new experiences is to articulate these experiences in writing. This was described in Doll et. al. [4]: "Previous research suggests that students may be more willing to discuss issues associated with death through written correspondence rather than through oral communication." Even Wagoner and Romero-O'Connell [19] found that "students often attain memorable experiences from cadaver dissections through reflective writing." Besides the fact that it helps the student to write from inside her or his subjective experience, other students could benefit from these experiences. Each university could create a kind of report collection. New freshman students could then get access to it and it would perhaps help them to learn that they are not alone with their fears. Because the experience relates to the individual manner and sequence of teaching in this university, it would be important to offer this collection of reports only to this specific university. Pabst [13] wrote: "Due to the great variability in the number of teaching hours, type of teaching methods, previous qualifications of medical students, number and qualification of demonstrators and several other parameters it is impossible to assume one experiences in institutions and / or country to be valid for another." One approach to a better processing of the worries and fears surrounding the issue of death and dying was the participation in peer groups. That such a concept promises success is a result of a recent study examining the benefits of a peer-group-mentoring for students of dentistry. Lopez, Johnson and Black [10] concluded that the students could be supported in this way to deal with stress. Another approach to prevention of mental overload of first year students due to the dissection course is the support by older students from the clinical faculty of medical education (tutoring). These older students act as mentors and provide an outlet for first year students to better express their feelings. Furthermore, students find it easier to speak with older students than with teachers. A study by Houwink et al. [8] has shown that the first year students who were accompanied on the first dissection course by older students suffered less anxiety and stress than a comparison group without accompaniment. Often, students lack a possible outlet to discuss and communicate problems outside the medical community and there is uncertainty to whom these questions can be given. A paper of Petersen-Ewert et al. [14] describes: "In addition, many of the students do not know what counseling services at its medical school are present and now to get advice from their peers." The fresh individual experiences of students in the clinical section of the medical education can offer support for the freshmen. A seminar-group-based student advisor, with whom the freshmen can talk at regular meetings about their fears and experiences is recommended. The most important part would be opening the students' minds to the difficult topic of death and dying. It is imprtant that the students' realize that fear and uncertainty are normal reactions and thus nothing to be ashamed of. This requires a well-functioning seminar group where everyone is accepted and taken seriously.

To conclude: This study showed that many students have and face considerable concerns about their own emotions before the first contact with human corpses. Even when these emotions returned to a default setting it is absolutely necessary to consider ways and methods to better prepare students for this kind of confrontation with death.

We thank all students for participating in this study. We thank the stuff of the Institute of Anatomy in Magdeburg for their offer to make this study. We thank Ryan Mullins for his help in translating the German version of this article into English.

The authors declare that they have no competing interests.