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DESCRIPTIVE ARTICLE
Design and Development of a New Facility for
Teaching and Research in Clinical Anatomy
John Richard T. Greene*
Department of Anatomy, University of Bristol, Bristol, United Kingdom
This article discusses factors in the design, commissioning, project management, and intellectual property protection of developments within a new clinical anatomy facility in
the United Kingdom. The project was aimed at creating cost-effective facilities that would
address widespread concerns over anatomy teaching, and support other activities central
to the university mission–namely research and community interaction. The new facilities
comprise an engaging learning environment and were designed to support a range of pedagogies appropriate to the needs of healthcare professionals at different stages of their
careers. Specific innovations include integrated workstations each comprising of a dissection table, with removable top sections, an overhead operating light, and ceiling-mounted
camera. The tables incorporate waterproof touch-screen monitors to display images from
the camera, an endoscope or a database of images, videos, and tutorials. The screens
work independently so that instructors can run different teaching sessions simultaneously
and students can progress at different speeds to suit themselves. Further, database access
is provided from within an integrated anatomy and pathology museum and display units
dedicated to the correlation of cross-sectional anatomy with medical imaging. A new
functional neuroanatomy modeling system, called the BrainTower1, has been developed
to aid integration of anatomy with physiology and clinical neurology. Many aspects of
the new facility are reproduced within a Mobile Teaching Unit, which can be driven to
hospitals, colleges, and schools to provide appropriate work-based education and community interaction. Anat Sci Ed 2:34–40, 2009. © 2009 American Association of Anatomists.
Key words: neuroanatomy; postgraduate; education; dissection; radiology
DESIGN MOTIVATORS AND
PRINCIPLES
This project was motivated by a desire to address specific
problems in the provision of anatomy teaching. These are
thought to include a shortage of skilled teachers, lack of
agreement concerning the level of anatomical knowledge
required at different stages of training, and a reduction in the
number of anatomical bequests (Older, 2004; Rainsbury
et al., 2007). Students themselves are clear that a detailed
knowledge of anatomy is important (Moxham and Plaisant,
*Correspondence to: Dr. Richard Greene, Department of Anatomy,
University College Cork, Cork, Ireland. E-mail: [email protected]
Grant sponsor: Higher Education Funding Council for England
Received 13 November 2008; Revised 12 January 2009; Accepted 13
January 2009.
Published online 18 February 2009 in Wiley InterScience (www.
interscience.wiley.com). DOI 10.1002/ase.70
© 2009 American Association of Anatomists
Anat Sci Ed 2:34-40 (2009)
2007) but the merits of different teaching methods (Winkelmann, 2007), and the contribution that activities such as
student-led dissection might make to the psychological and
sociological development of doctors (Dyer and Thorndike,
2000) are still debated. Although these are all important
considerations, the designs described here were influenced
more strongly by consideration of the uses for anatomical
knowledge, the context of its deployment and the identification of subjects to act as partners in the learning
process.
Anatomy continues to be a significant scientific discipline
in its own right (Fraher, 2007), but it also underpins the
study of physiology and pathology. William Harvey, the celebrated physiologist, dissected human bodies as he developed
his understanding of the circulation (Frank, 1980). This and
other journeys of discovery should be revisited by medical
students as they develop their own understanding of the relationships between structures and functioning. Intelligent use
of diagnostic algorithms such as ‘‘pre-renal,’’ ‘‘renal’’ and
‘‘post-renal’’ in the consideration of renal failure, adequate
clinical examinations, correct interpretation of radiological
images, safe and effective performance of procedures and
JANUARY/FEBRUARY 2009
Anatomical Sciences Education
accurate and informing explanations to patients of what has
happened to them, what can be done, and what might go
wrong all require an appropriate degree of anatomical knowledge. Credibility with patients, and colleagues, requires fluency in the language of the medical profession. Just as it is
impossible to remember a time when you could not speak
your mother tongue, doctors sometimes forget that much of
their professional vocabulary had to be learned, and to a
great extent this happened at the very beginning of their
careers through the study of anatomy.
The study of anatomy has often relied on the dissection of
human bodies (MacDonald, 2006) and virtually all academic
papers on the subject conclude that the use of cadavers in
some way or other is essential to medical training (McLachlan et al., 2004). However, fewer people are bequeathing
their bodies for this purpose. It is now more important than
ever to make the best possible use of all anatomical bequests–
so long as that use remains within the terms of informed consent (Greene, 2003a, 2003b). In the United Kingdom, greater
use has been made possible by the introduction of the Human
Tissue Act 2004 which allows the use of cadavers in surgical
training (Human Tissue Act, 2004) which in turn gives trainees an opportunity to develop their skills without endangering
patients. The usefulness of cadavers has also been enhanced
by the development of soft-fixation protocols which offer significantly more life-like colors and much greater flexibility
than is possible with traditional formaldehyde-based preservation techniques (Spackman et al., 2007).
Finally, universities are rightly concerned by the costs of
teaching and often charge activities for the space they occupy
and support services they require. However, it has to be recognized that the secure, hygienic and respectful accommodation for human body parts is expensive. These apparently
competing interests must be balanced. One approach is to
ensure that facilities are not profligate with space. A second
is to ensure that the facilities support university objectives
other than teaching. Chief amongst these should be research,
but there are also opportunities to help widening participation initiatives and promote cooperation between institutions
and interaction with the community.
The overall aim of this project was to address the foregoing issues by developing a series of novel resources and
locating them in an engaging and intuitive learning environment capable of supporting a range of pedagogies appropriate
to the needs of healthcare professionals at different stages of
their careers. What follows is an account of the design, development and implementation process which it is hoped will be
of interest to all those who work in facilities with a similar
purpose.
THE DESIGN AND COMMISSIONING
PROCESS
Many aspects of the new facility are highly innovative. The
development process required many concept drawings and
prototypes with which to test ideas and communicate them
to potential manufacturers (Fig. 1). At the simplest level, concept drawings comprised sketches and diagrams augmented
with photographs from catalogues. This process produced the
drawing of the integrated anatomy and pathology museum
(Fig. 1C). This pastiche is indeed crude but it captures the
spirit of the design and helped the manufacturer to move rapidly to a production drawing (Fig. 1D) that was an excellent
Anatomical Sciences Education
JANUARY/FEBRUARY 2009
representation of the final museum (Fig. 2F). Prototypes (Fig.
1A and 1G), were particularly helpful in communicating the
tactile and aesthetic aspects of particular items—these subjective qualities are important means to engage and inspire
users.
Finding people to make prototypes can be very difficult.
This process can be helped by the use of relatively simple
computer-aided design software. This approach enabled the
author to create the drawings for a novel neuroanatomical
modeling system called the BrainTower1. These drawings
were used directly by a computer-controled abrasive water-jet
cutting system to produce 2D parts from plastic (Fig. 1H).
The creation of graphic representations of items in 3D is
more complicated. The example shown in Figure 1J was created by the manufacturer following consideration of simple
2D drawings (Fig. 1I) and prototypes (Fig. 1G). These drawings were then used to produce injection molds that made the
finished parts.
WORKSTATION DESIGN
Initially, commercially-available operating tables were considered, but these are large and expensive not least because they
cater for living patients up to 2-m tall and have to account
for their comfort and safety. In contrast, cadaveric surgery,
and the study of clinical anatomy, can be performed effectively using body parts. It was therefore decided to develop a
smaller table (1.6-m in length). This reduced costs, increased
the number of tables that could be accommodated and provided an opportunity to incorporate into the tables specific
bespoke features (Figs. 1A, 1B and 2A, 2B). In particular, the
tops are flat and comprise two removable sections each with
multiple specimen anchor points. The table-tops, with partcompleted dissections attached, can be transferred to trolleys
for storage in the cold room. They can be returned to the
tables at the start of the next dissection session. Tabletops are cleaned in a modified industrial dishwasher with a
10-minute cycle. These features decrease set-up and cleardown times to increase the working time within sessions and
thereby the number of students who can use the facilities. A
further advantage of the removable top-pieces is that a radiolucent over-hang can be created to enable the use of C-arm
radiological imaging equipment (Fig. 2B). Imaging and dissection can then be performed on the same specimens thereby
integrating two approaches to the study of anatomy (Fig.
2C). The tables have a compressed air supply for small tools.
Irrigation, suction and drainage facilities are present but are
not of high capacity because fluid loss from cadavers is not
great (Fig. 2A). The tables rise, fall and tilt electronically
making them easy to adjust and encouraging students to consider the effect that correct positioning might have on themselves and the outcome of a procedure.
TOUCH-SCREEN MONITORS
Each workstation features a rugged and waterproof touchscreen monitor. They have unusually wide viewing angles and
very high levels of contrast and brightness so that the images
are easy to see in the brightly-lit environment (Fig. 2A). A
unique positioning system enables the monitors to be placed
anywhere along the table and in virtually any orientation.
Images can then be viewed adjacent to the anatomical specimen being studied. This offers a distinct advantage over the
35
Figure 1.
Concept drawings and prototypes. Original concept drawings and early prototypes are shown. A, Drawing of the workstations. Inset are details of the removable
tops and the author’s prototype monitor positioning system; B, Production drawing of the table and (inset) monitor support arm; C, Original pastiche depicting the
museum and incorporating catalogue images of the Hunterian Museum at the Royal College of Surgeons of England; D, Production drawing of the museum; E,
Concept drawing of cross-sectional anatomy and radiology station and F, Production drawing of cross-sectional display; G, Author’s prototype BrainTower models;
H, Drawing of horizontal brain section ready for use in a computer-controled cutting system; I, Diagram of plastic element to represent brain nuclei; J, 3D representation of the nucleus element shown in I, created as part of the process of producing injection molding tools. (Note: labels in small font are those that were attached
to the original drawings and are not intended to be read in this figure.)
36
Greene
Figure 2.
Overview and details of specific resources. Specific aspects of the new facility are shown. A, Overview depicting six of twelve workstations. The monitor in the foreground shows the touch–screen interface that gives access to the image database. One of three cross-sectional anatomy and radiology display units can be seen as
can the integrated anatomy and pathology museum. The monitor mounted on the table in front of the museum is displaying a live, magnified image of the skull
obtained via the overhead camera; B, Table extended to create a radiolucent overhang and accommodate a C-arm radiological imaging device; C, Image of the spine
of a cadaveric specimen obtained using the set-up shown in figure B; D, BrainTower functional neuroanatomy model; E, Alternative view, looking out from within
the museum towards the tables and, in the far distance, further cross-sectional displays; F, Detail of the museum showing the two externally-controled turn-tables
and the two study alcoves complete with touch-screen monitors; G, Reception area with the Mobile Teaching Unit (MTU) ‘‘docked;’’ H, Enclosed stairway from
reception to MTU; I, internal view of MTU.
more usual system of ceiling-mounted monitors displaying
pre-selected material in that students do not need to look
away from their work when consulting additional material
and they can select it themselves via the monitor’s touchscreen interface (Fig. 2A). Future iterations of the database
software will log the use of specific resources. This information will be related to the outcome of learning tasks and
thereby provide evidence of the value of particular resources
in the learning process.
OVERHEAD CAMERAS
Each station has a waterproof overhead camera with oversized controls for easy operation even when wearing surgical
gloves. The overhead cameras can be positioned precisely and
the images displayed on the table monitor and/or recorded
for later analysis as part of an objective assessment of technical competence. The camera, in conjunction with the tablemounted monitor, provides a useful magnification device and
as such functions as a very economical partial replacement
for an operating microscope.
The camera and monitor combination renders specimens
as two-dimensional images. These can be displayed alongside
reference images. Students can triangulate between the real
specimen, a two dimensional rendition and a labeled reference image (which could be radiological in origin), which it
is hoped will help them as they develop their 3D understanding of body structure.
INTERACTIVE MUSEUM OF
ANATOMY AND PATHOLOGY
In many undergraduate courses the study of normal anatomy
is separated in time and space from the study of pathology
and the synergies between the subjects are lost. Separate
facilities can also increase the costs of licensing under the
new Human Tissues Act (Human Tissue Act, 2004). The new
facilities overcome these problems with an extensive museum
of both anatomical and pathological specimens (Fig. 2A, 2E,
and 2F). The specimens have been chosen to show the basic
anatomy that relates to the signs and symptoms of common
diseases; to show how normal structure is perturbed by common pathological conditions and to illustrate aspects of anatomy relevant to operative techniques.
Some specimens show the relationships between different
body systems. They were created to readdress an inherent
weakness in systems-based courses—namely that students do
not appreciate the relationships between anatomically adjacent structures that belong to different systems and are therefore studied at different times. There are also examples of dissections prepared during research projects (Wiles et al., 2007)
to emphasize that anatomical knowledge continues to develop
and that anatomy has the same requirements of life-long
learning as those of more obviously dynamic disciplines.
Large specimens that show particular regions or link different body systems are often awkward to handle and thereby
susceptible to under-use. To address this problem, the museum features two externally controlled turntable stacks (Fig.
2F). Students can easily rotate the specimens and view them
from different angles as they form a 3D understanding. Each
specimen is cross-referenced to the database of medical
images accessed via monitors within study alcoves.
38
The museum color scheme follows that of the new Hunterian Museum at the Royal College of Surgeons in London,
and was chosen to offset the yellow tinge that sometimes
develops in the preserving solution that surrounds mounted
specimens.
CROSS-SECTIONAL ANATOMY
AND RADIOLOGY DISPLAYS
There is no doubt that advances in medical imaging are
changing the way in which clinicians view and think about
the body. It has been suggested that the best models for anatomy teaching will incorporate cadaveric and imaging-based
approaches (Gunderman and Wilson, 2005). Techniques such
as Magnetic Resonance Imaging (MRI) often present the
body as a series of cross-sections. It is important for students
to understand the relationship between these images and the
appearance of a real body so unique display units have been
developed (Greene, 2007). Each unit has a compact footprint
of approximately 0.7 m2 and comprises a touch screen and
four banks of cases (19 cases in total). Each case holds nine
anatomical sections in square pots or six larger pots in portrait or landscape orientation. To relate a particular anatomical section to an MRI image the student slides the relevant
case to a position adjacent to the monitor and then accesses
the appropriate image from the database (Fig. 2A).
BRAINTOWER1 FUNCTIONAL
NEUROANATOMY MODELS
The purpose of this part of the project was to create a tool
for teaching functional neuroanatomy along-side brain specimens, normal and diseased, in the dissection room. The aim
was to help students progress from recognizing particular
morphological features of the brain to understanding the
functions of particular nerves, nuclei and cortical regions and
appreciating the nature of information flows between them.
Students build their own models by repeating a few simple
processes. This form of active involvement in the learning
process is seen as being educationally advantageous (Chickering and Gamson, 1987). The BrainTower1 comprises plates
representing sections through the nervous system at different
levels (relating to axial MRI images). These plates are perforated to show the particular pathways and can be used as
stencils to create diagrams in student workbooks. The plates
were created directly from the author’s 2D computer drawings using an abrasive water-jet cutting system. This approach
was particularly helpful because it enabled multiple iterations
of the design to be processed quickly and without the cost
associated with alternative approaches such as injection
molding. Wires run between the plates in the positions of
functional columns and subdivisions of the reticular formation. Shaped components representing nuclei or cortical
regions are connected to the plates and wires. These components presented a particular problem in that very large numbers needed—typically 150 or more—for each model. These
could be produced by turning them individually on a lathe,
but this would be both slow and expensive. Furthermore,
some of the aesthetic aspects of these parts would have been
difficult to produce by turning. It was therefore decided to
produce these parts by injection molding. To allow some
scope for future modifications the molds were not fully-hardGreene
ened. The cost of this added flexibility is a reduction in the
durability of the mold and ultimately the number of components that it can produce. The molded parts are interconnected with color-coded monofilaments depicting different information flows. Again, the realities of industrial manufacture
caused some problems with the production of working prototypes. These monofilaments would have been produced most
efficiently by extrusion of colored plastic but companies specializing in this process require very large minimum orders—
often multiple kilometers of material. This was not a practical proposition so the filaments were created by dying small
batches of heavy-weight fishing line. Once the design has
been finalized, after large-scale testing in various teaching
situations, it will be possible to adopt a more industrial
approach to manufacture, at which point the unit cost will
fall significantly.
MOBILE TEACHING UNIT
To integrate applied sciences more effectively in to the clinical
parts of the undergraduate course and to support on-site
postgraduate surgical training, a Mobile Teaching Unit
(MTU) has been developed (Fig. 2G). It contains a modified
workstation, additional monitors, a collection of anatomical
models and surgical simulations, projection facilities and a
high definition LCD monitor (Fig. 2I). The unit has heating,
air conditioning, running water and a fridge. It draws power
from an external source or its own generator. To maximize
usage, the MTU ‘‘docks’’ with the reception area of the Bristol Clinical Anatomy Suite to become a contiguous tutorial/
demonstration room for 20 students (Fig. 2H).
REFLECTIONS ON THE DESIGN
AND COMMISSIONING PROCESS
Despite the difficulty of finding manufacturers to make complex equipment in small volumes it is important to select
carefully by looking at their work, gauging their professionalism and determining their understanding of the wider aims of
the project. The concept drawings and prototypes are particularly important in this regard. The ability to create our own
prototypes, and modify them as the design developed, was
very helpful.
Once manufacturers were in place, the major difficulty
was ensuring that all aspects of the project would work
together. One approach would have been to draw up rigid
specifications and use it as a contract. This takes time and
although it might have provide financial redress had something gone wrong it would not have guaranteed delivery of
what was wanted—partly because that changed as the project
progressed and new ideas emerged. In this project we adopted
a slightly more fluid approach which enabled developments
to be incorporated into the final design even at a late stage of
the process. The attraction of this ‘‘organic’’ approach was
balanced against the risk that individual components would
not work together. Functional alternatives were identified as
substitutes for failed development projects—for example, a
commercial monitor arm was identified as a substitute for the
functionally superior one developed specifically for the new
facility. Coordination was achieved by email circulations, regular meetings, and site meetings. Occasionally, views need to
be reinforced by visits to factories and workshops. In a proAnatomical Sciences Education
JANUARY/FEBRUARY 2009
ject like this, a significant factor is the time taken to Conceive, Build, Test and Modify designs. It is recognized that
when this ‘‘cycle,’’ which may need several iterations, can be
completed quickly the resulting products are more closely
aligned with ‘‘customer’’ needs (Ulrich and Eppinger, 2003).
A short cycle time was achieved in this project because many
of the prototypes were built by the author or within University workshops. A detailed description of the process, relating
specifically to the BrainTower1 can be found elsewhere
(Greene, 2006).
On reflection, too much of project overview was held in
the mind of the author acting as ‘‘project champion"—this is
not an uncommon finding in such projects but brings with it
obvious dangers. As an example, the final version of the operating table (Fig. 2A) differs from the production drawing
(Fig. 1B) but these changes arose at a very late stage during a
factory-floor meeting and were not drawn in advance. Had
there been greater design documentation the process would
have been slower but final commissioning might have been
easier and there would have been greater scope for delegation. A significant influence on the emotional response to a
project is proximity to the budgetary ceiling. In this case,
equanimity, morale and momentum were retained with the
support of a substantial (if undeclared) contingency fund—
which meant that improvements in design, even if more expensive than planned, were greeted with enthusiasm and were
adopted.
INTELLECTUAL PROPERTY ISSUES
Universities are keen to exploit their intellectual property but
focus on high growth/high yield areas and sometimes overvalue their intellectual property in relation to the costs of
turning ideas into products. To encourage companies to be
involved in the project the author effectively traded intellectual property inherent in the designs in return for development and production at an affordable price. A different
approach was taken with the BrainTower, which is now registered design in European and other territories.
CONCLUSIONS
The project took under two years from receipt of funding to
teaching the first students in 2007. The building work cost
approximately £800,000 and comprised substantial refurbishment of existing laboratory space, a major upgrade to the air
handling facilities and a new reception area and MTU docking station. The equipment and MTU cost a further
£495,000. A series of evaluations are underway that will
address the effectiveness of individual components of the
facility. In the longer term these will provide an objective
account of the success of the project and guide its further
development.
ACKNOWLEDGMENTS
We most gratefully acknowledge the generosity of those persons who bequeath their bodies to the department and the
relatives who facilitate the process. Many of the exhibits
within the museum were supplied via The Institute of Anatomical Science as part of its important scheme to re-home
specimens from disbanded museums.
39
The facilities form part of a ‘‘Center for Excellence in
Teaching and Learning’’ funded by the Higher Education
Funding Council for England.
Many people have contributed to the project, but in particular I thank Professor Gareth Williams, Derek Telling,
Steve Gaze, and Bernie Wrigley for their support and encouragement. Similarly, I thank Mr Dick Rainsbury, Director of
the Raven Department of Education at the Royal College of
Surgeons of England.
Our design objectives were achieved through close collaboration with specialist manufacturers whose contributions are
gratefully acknowledged. The clinical anatomy tables and
cross-sectional anatomy displays were built by Technik Technology (Broseley, UK), who also supplied the operating lights.
The monitors and monitor arms were built by Bluestone
Technology (Plymouth, UK). Modified cameras were supplied
by Image Solutions (Preston, UK). Precision Molded Products
(Essex, Great Dunmow, UK) molded the 3D parts of the
BrainTower1 (Sciss, Kent, UK) cut the perforated sheets and
Precision Technology Supplies (East Grinsted, UK) made the
metal parts. The forgoing suppliers also equipped the Mobile
Teaching Unit which itself was built by W.H. Bence (Yate,
South Gloucestershire, UK). The Museum was built by ClickNetherfield (Livingston, Scotland). The building work was
completed by Bray and Slaughter (Bristol, UK). The architect
was John Page and the building project managed by Provelio
(Bristol, UK) with the help of a team of specialists both internal and external to the University of Bristol.
NOTE ON CONTRIBUTOR
JOHN RICHARD T. GREENE, B.Sc., Ph.D., M.B.B.S.,
M.B.A., is the professor of anatomy and Head of the Department of Anatomy at the University College Cork, Cork, Ireland. He teaches anatomy, specializing in neuroanatomy, and
is engaged in neuroscience research.
40
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