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Introduction of Vertical Integration and Case-Based Learning
in Anatomy for Undergraduate Physical Therapy and
Occupational Therapy Students
Suresh K. Parmar, Bertha A.D. Rathinam*
Department of Anatomy, Christian Medical College, Vellore, Tamil Nadu, India
The purpose of the present pilot study was to evaluate the benefits of innovative teaching methodologies introduced to final year occupational and physical therapy students in
Christian Medical College in India. Students’ satisfactions along the long-term retention
of knowledge and clinical application of the respiratory anatomy have been assessed.
The final year undergraduate physical therapy and occupational therapy students had respiratory anatomy teaching over two sessions. The teaching involved case-based learning
and integrated anatomy lectures (vertical integration) with the Anatomy department. Pretest and immediate and follow-up post-tests were conducted to assess the effectiveness
of the innovative methods. A feedback questionnaire was marked to grade case-based
learning. The method of integrated and case-based teaching was appreciated and found
to be useful in imparting knowledge to the students. Students retained the gained
knowledge adequately and the same was inferred by statistically significant improvement
in both post-test scores. Vertical integration of anatomy in the final year reinforces their
existing knowledge of anatomy. Case-based learning may facilitate the development of
effective and clinically sound therapists. Anat Sci Educ 4:170–173. © 2011 American Association
of Anatomists.
Key words: anatomy teaching; vertical integration; gross anatomy education; case-based
learning; physical therapy education; occupational therapy education; India
Learning and retention of basic science information has long
been a central concern in undergraduate medical education.
During the 1980s and early 1990s, basic science instruction
was commonly criticized for an emphasis on rote learning of
an unrealistically large volume of factual material, a lack of
clinical relevance for portions of the material covered, inattention to the practical application of basic science knowledge to clinical situations, and use of passive, lecture-based
teaching methods (Barrows and Peters, 1984; Neame, 1984;
*Correspondence to: Dr. Bertha A.D. Rathinam, Department of
Anatomy, Christian Medical College, Bagayam, Vellore 632002, Tamil
Nadu, India. E-mail: [email protected]
Received 7 February 2011; Revised 5 March 2011; Accepted 9 April
Published online 9 May 2011 in Wiley
( DOI 10.1002/ase.225
© 2011 American Association of Anatomists
Anat Sci Educ 4:170–173 (2011)
Tosteson, 1990). Therefore, medical education has been
transformed in the recent decade to meet the challenges of
future professionals in various ways including horizontal and
vertical integration, student-centered, community-oriented,
and problem-based learning (Dornan and Bundy, 2004;
Kamalski et al., 2007). Many institutions universally have
ongoing research to improvize their curricula, not only to develop attitudes and affective behaviors of the future professionals but also to build professional competence and confidence
(Lie, 1995; Ten Cate, 2007).
Several studies indicate that the majority of clinicians feel
current anatomical education of medical students is inadequate, and below the minimum necessary for safe medical
practice (Fitzgerald et al., 2008; Ahmed et al., 2010; Smith
and Mathias, 2011). There is widespread support among
clinicians for more vertical integration of anatomy teaching
throughout the undergraduate curriculum (Waterston and
Stewart, 2005; Sugand et al., 2010). Case-based learning has
been demonstrated to be successful in fostering independent
reasoning and problem-solving skills that are vital for future
practitioners (Banda, 2009; Bowe et al., 2009; DiLullo et al.,
2009; Layne et al., 2010). Although widely adapted in many
Anatomical Sciences Education
nations, innovations in teaching for occupational therapy
(OT) and physical therapy (PT) students have not risen in
India to address this need. (Solomon 2005; Foord-May, 2006;
Youdas et al., 2008; Van Peppen et al., 2009; Wait et al.,
2009). The purpose of this study was to introduce vertically
integrated and case-based learning (CBL) of respiratory anatomy for final year OT and PT students to nurture their ability
to assimilate knowledge and transfer such information to
solve problems analytically.
students, because one was absent in the post-test. The mean
pretest score was 10.50 (50.3%), the immediate post-test
score was 15.88 (79.4%), and the follow-up post-test score
was 14.82 (74.1%). The increase was found to be statistically
significant in both immediate and follow-up post-test scores
(P < 0.001). All the students felt that the integration with
anatomy was effective and useful; the topics were relevant
and clinically applicable.
Case-Based Learning
The entire cohort of undergraduate OT and PT students was
introduced to CBL and integrated anatomy lectures in their
final year. This pilot intervention focused on the respiratory
anatomy module. The OT and PT curriculum of the Tamilnadu Dr. M.G.R. Medical University in Tamilnadu, India
spans over four years followed by six months compulsory
revolving internship. In the first year, 200 hours of gross
anatomy is taught. The rest of the three years include clinical
and paraclinical specialties and relevant OT and PT subjects.
The present curriculum does not include any integrated or
problem-based teaching learning methods. The OT and PT
students do not have any revisits to the Department of Anatomy after the first year, according to the existing regulations.
The entire cohort of students’ mean score was found to be
unsatisfactory (56.7%) after traditional teaching of clinical
respiratory module, in formative assessment. This formative
assessment included essay, short answers, and brief questions.
Therefore, a pilot intervention was designed to assess if CBL
and integrated anatomy lectures would facilitate the students
in assimilating knowledge and transfer the information
learned to solve problems analytically.
Ten students from OT and ten students from PT programs
(n 5 20) were included for the pilot study after obtaining ethical clearance from the Institutional Review Board. They were
assessed for existing knowledge of anatomy by a pretest which
included multiple choice and reason–assertion questions (Appendix A). Of the topics in respiratory anatomy, some like respiratory movements, biomechanics of thoracic cage were
taught as didactic lectures and demonstration with prosected
specimens. For CBL, the students were divided into two mixed
groups of ten students each and given a clinically oriented case
at the end of the first session (Appendix B). The relevant anatomy learning was facilitated through discussion of the case and
its clinical application by faculty. Post-tests of similar format
and difficulty, covering similar content as pretest were conducted at the end of the second session and four weeks later. A
standardized questionnaire was provided to the students at the
end of the sessions, and they were asked to rate the effectiveness of integration and CBL using a five-point psychometric
Likert scale with open ended questions for their comments and
suggestions. Content analysis of open ended questions was
done. Statistical analysis of the results of tests and the rating of
the questionnaire was done using SPSS statistical package, version 16.0 (SPSS Inc., Chicago, IL).
Integrated Anatomy Lectures
Of the twenty students, 18 took the pretest and only 17
answered both the post-tests. Paired t test was done for 17
Anatomical Sciences Education
All the students felt that the topics chosen for case-based
learning were relevant, and 87.5% thought that it is clinically
applicable. 68.8% opined that the time allotted for CBL was
not sufficient. 93.8% felt that the entire program enhanced
their learning of anatomy. 68.8% strongly suggested similar
integrated and CBL to be introduced in the first year of college. None of them had been exposed to integrated or casebased learning before. There was no difference in the performance between the two student groups (OT and PT) and
both student groups benefitted equally from the intervention
(P 5 0.1068).
Content analysis of the open ended questions revealed the
following themes: ‘‘CBL makes learning very interesting
(100%),’’ ‘‘effective (60%),’’ and ‘‘very much appreciated
(72%),’’ and they also suggested similar methods to be followed for other subjects (10%).
Vertical integration by definition incorporates preclinical sciences with paraclinical and clinical subjects. It is the mantra
of contemporary medical education. Integrated education is
proven to be effective in enabling the students to comprehend
basic sciences and promote lifelong learning (Dahle et al.,
2002). A study inferred that a rationale for early experience
would be to strengthen and deepen cognitively, broaden affectively, contextualize, and integrate medical education (Dornan
and Bundy, 2004). Another study concluded that vertical integration of anatomy teaching throughout the full medical
course may be useful (Bhangu et al., 2010). Knowledge of
anatomy is perceived to be important for safe clinical practice. Anatomy should be taught with other relevant system or
clinical modules (Ahmed et al., 2010). Our study showed
improved performance of the students by an increase of 5.38
points in mean post-test scores at the end of the session (P <
0.001) and an increase of 4.32 (P < 0.001) in the four weeks
follow-up post-test scores. It is unlikely that the significant
increase in the immediate post-test performance can be attributed to mere memory recall, because the students’ demonstrated sustained, similar improvement in the follow-up posttest. This shows that there is better assimilation of knowledge
and comprehension leading to long-term retention of facts
necessary for clinical practice.
CBL is an educational method in which small groups of
students are given case scenarios (Bowe et al., 2009). A study,
among second year medical students, confirms that students
have recognized that the case-based projects were about
obtaining a deeper understanding of the anatomy (Peplow,
1990). In another CBL study introduced to second year medical students, they were able to identify their own deficiencies,
develop strategies for thinking and learning, resulting in the
acquisition of expertise in problem solving, and extend their
communication skills by working with colleagues (Scott,
1994). The goals of working out the clinical case are to provide a clinical context for learning, activate prior knowledge,
motivate students, and stimulate discussion (Aziz et al., 2002;
Banda, 2009). Self-directed learning which is student-centered
is the major strength of this program (Peplow, 1990; Saarinen-Rahiika and Binkley, 1998). This study suggests that
introduction of CBL improves comprehension of the students,
enabling them to be better health care providers.
Although this pilot study was of short duration and with a
small sample size, it is evident that vertical integration of basic sciences and CBL during students’ clinical postings are
very much welcomed and appreciated by students. It not only
improves their academic performance, as shown by their
post-test scores, but also prepares them for better clinical
practice. We recommend that CBL become an integral part of
curriculum of the paramedical courses as this would ensure
better health care delivery and professional competence in the
students when they become practitioners.
SURESH K. PARMAR, M.Sc. (Anatomy), B.P.T., is a senior
demonstrator in the Department of Anatomy at the Christian
Medical College, Vellore, Tamil Nadu, India. He teaches
gross anatomy to medical, nursing, and paramedical undergraduate students.
BERTHA A. D. RATHINAM, M.S. (Anatomy), M.B.B.S.,
is an assistant professor of anatomy at the Christian Medical
College, Bagayam, Vellore, Tamil Nadu, India. She teaches
gross anatomy to postgraduate and undergraduate medical,
nursing, and paramedical students.
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Authors acknowledge Dr. Vyas Rashmi, core educator in the
Medical Education Cell and professor of physiology at Christian Medical College, Vellore, for her valuable input toward
the planning of the educational intervention and help in revision of the manuscript and Mrs. Rebekah Grace, a statistician at Christian Medical College, Vellore, for her statistical
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Parmar and Rathinam
Appendix A
Appendix B
Example of a multiple choice question and reason-assertion
Example of a clinical case for group discussion. The integrated
respiratory anatomy module for OT/PT final year examination:
1. A 60 year-old female who has copious amounts of fluid
in the left pleural cavity due to acute pleurisy, was
admitted under your care. When you examine her as
she sits up in the bed (trunk upright), where would the
fluid tend to accumulate?
(a) Left costodiaphragmatic recess
(b) Left costomediastinal recess
(c) Cupola pleurae
(d) Hilar region
1. A 28 year-old female was brought to the hospital with
high fever, difficulty in breathing and severe pain in
the right side of the chest. The pain radiated to the
right anterior abdominal wall. Auscultation of the
chest showed absent breath sounds over the inferior
lobe of the right lung and chest X-ray confirmed the
presence of fluid in the pleural cavity in the right side.
(1) Name the condition in which there is accumulation
of fluid in the pleural cavity.
(2) Name the different regions of the parietal pleura
and give its innervation.
(3) Give explanation for radiation of pain to anterior
abdominal wall in this case.
(4) Describe the pleural recesses.
2. Reason: The right main bronchus is shorter, wider and
more vertical compared to the left side. (True / False)
Assertion: Aspiration of foreign bodies is more common
to the left lung. (True / False)
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