Creative project completers
In the first year, approximately half of the class participated in the creative project option by completing at least one project; in subsequent years, approximately a third of the class participated. Female students tended to be somewhat overrepresented among those who completed creative projects (Table ), but the difference was not statistically significant (Z = 1.58, p = .11). Of students who consented to participate in this research, the largest number came from year 2 (Table ). Female students were significantly overrepresented (Z = 3.14, p = .003). Compared to both the study body as a whole and project completers, female students were also overrepresented in the subset of interviewed students (Z = 2.69, p = .01). The large majority of study participants who chose the creative project option completed written projects (n = 36/46; 78.3%), primarily poems (n = 19/36;57.6%) and essays (n = 13/36;39.4%) Of these, 19 were Time 1 and 17 were Time 2 projects. The art projects tended to explore the human body, relationship with the cadaver, and emotional responses to dissection in ways that mirrored the written projects.
We identified three major themes in our analysis of all projects, each of which was in some way related to professionalism issues. We labeled the first theme Reflections on Doctoring. Overall, two-thirds of students' projects addressed in some form how dissection taught them not only anatomy, but also the importance of teamwork, good role-modeling, and a deepening understanding that medicine is a humane calling rather than a technical career.
"I feel that I have undergone tremendous personal growth, becoming a more sensitive, socially conscious individual. Whereas before I use to jump at the opportunity to view surgeries, procedures, and conditions, in a sense not thinking about the person as a whole, but viewing the human body as a marvelous machine; now I get a bit uneasy, I began to reflect on the individual who is undergoing the procedure, their loved ones and how they all must feel. Now I usually say a little prayer for them, take a deep breath and do my best to serve them in any way possible." (#29, female, year 2)
A little over one-quarter of students specifically explored what it meant to become a doctor, emphasizing that knowledge acquisition was insufficient, and the importance of qualities of respect, humility, caring and appreciation.
The second theme we identified was Relationship with the Cadaver. Almost half the students reflected on some aspect of the student-cadaver relationship. Slightly more than half of the students considered the cadaver as a tool for learning or imagined the former life of the cadaver. A smaller number portrayed the cadaver as their teacher, often from the perspective of the cadaver.
"But don't you cringe or feel
Any sorrow for my death or life.
Just focus and dissemble this shell
With your quaking, gleaming knife.
And be not afraid, for the most grotesque
Offense you would commit
Is to drop the line and jump the deck
Before you knew all of it." (#41, male, year 1)
Only a handful thought of the cadaver as their first patient.
The final theme we found was the student's Emotional Response to Dissection. The most frequently expressed emotion (by about half the students) was gratitude and thankfulness toward the cadavers for the donation of their bodies. Over a third of the students expressed awe at the wonders of the human body. However, about a third of students also expressed or portrayed concern regarding their actions toward the cadavers, especially a sense of becoming emotionally detached and desensitized.
"Old man, I know not your name
And nor who you are
But don't you explain!
I need nothing but these
Damned utensils, so
Do not try to move me
To thoughts of your life,
Who you might be
Or rather, wherefore
I just can't care" (#41, male, year 1)
Almost one-quarter of students referenced negative emotions of shame/guilt, fear/anxiety, and sense of sacrilege.
Shifts in professionalism: reflections on doctoring
Student projects were more likely to reflect on what anatomy had to teach them, and what the practice of medicine entailed, at Time 1 vs. Time 2, although large numbers at both periods acknowledged an alteration in their views (75% of students at Time 1, almost 60% at Time 2). Approximately equal percentages of students at Times 1 and 2 explored what becoming a doctor involved. Students at Time 2 were almost three times as likely to engage in specific personal reflection about how they were changing as a result of their medical training.
Shifts in professionalism: relationship with cadaver
This was a topic of significance to respondents at both time periods, but students tended to address this issue in their projects somewhat more frequently in the final project. Students at Time 1 were much more likely to speculate about the person of the cadaver:
"There were times during lab when I would find myself, unconsciously, rubbing our 'patient's' arm, wondering how she died and whether or not she knows what is happening to her body right now." (#99, female, year 2)
Students at Time 1 were the only ones to talk about the cadaver as their first patient. Conversely, students at Time 2 were much more likely to mention the cadaver as a means of advancing their own learning. Approximately equal percentages of students at Times 1 and 2 regarded their cadaver as a teacher, although Time 2 students were slightly more likely to do so.
Shifts in professionalism: Emotional responses to dissection
While gratitude was by far the most common emotions shared by students, negative emotions were prevalent at both Times 1 and 2, with between a fifth and a quarter of students expressing guilt, shame, fear, or anxiety.
"I must admit that the thought of taking human anatomy was a scary one. Despite taking a Human Anatomy Lab course as an undergraduate five years ago, I felt nervous ..." (#29, female, year 2)
However, a sense of sacrilege was in evidence much more frequently at Time 1:
"And when my lab partner cut into her breast, it made me angry. How dare he? The act felt violent and violating." (#22, female, year 3)
Overall concern about dissection was also judged to appear more often in initial projects. By contrast, students' joy at the revelations resulting from dissection almost doubled from Time 1 to Time 2, as did students' sense of awe at the mysteries of the human body. Students' early worries about emotional distancing were largely replaced by an attempt to achieve emotional balance:
" [I am] attempting to distance myself in a professional manner while maintaining some empathy" (#52, female, year 2)
Although the emotion of gratitude was widespread at both time points, it did increase noticeably in the final projects.
"Learning, admiring/Just feeling honored and privileged to learn/
From selfless and pale phantom teachers" (#59, female, year 3)
Overall, dissection was generally viewed as less sacrilegious and more acceptable by the end of the year. Students expressed self-pride and enthusiasm for having completed a great adventure, and imagined a satisfied cadaver:
" [I have] no regrets or reservations...
My purpose fulfilled/
The ability to teach and heal/...
Lives granted strength and happiness." (#24, male, year 2)
Evolving professionalism based on student interviews
Ten of 12 completers felt completing a creative project improved their self-awareness and ability to reflect on experience.
"I think it has taught me like, um, [to] think [about] what you feel at the moment because usually with the whole rush of med school, you're just going through the motions, and doing something like this, such as the project, gives you a chance to, um, to kind of reflect on [feelings] that you wouldn't have before." (#21, female, MS2)
The majority of students felt completing the projects also changed or reinforced their attitude toward medicine in a positive way:
"I think if the project wasn't there, I would be more inclined to think that the profession was more brutal and not very humanistic at all." (#18, female, MS1)
A smaller number felt the project gave them additional insight into the doctor-patient relationship. Students who reported this response tended to detect a continuum from care of the cadaver to patient care. These students mentioned the importance of having respect for the patient, developing emotional connection with the patient, having empathy for the patient's subjective experience, and being able to interpret both the medical and emotional meaning of a patient's symptoms.
"The project helped [me] connect the whole anatomy class to real people. These are things that you see on real people and they will be on your patients, on yourself, and so that's a tie to real life..." (#2, female, MS1)
Several students reported that doing the project improved their attitude toward anatomy in particular. One person who expressed a positive valuation noted that the project helped instill an attitude of wonder and respect for the cadavers. Another student commented that doing the project gave her a boost during dissection by making her more interested in body parts that she could incorporate into her creative project. Still others commented that they learned to think about the perspective of the cadaver. Even non-completing students seemed to appreciate the ability of the projects to stimulate self-reflection:
"I loved seeing my classmates' artworks displayed, and I liked the fact that it made me [think], well, how do I express my anatomy experiences? And I have thought about it, how is anatomy affecting me? How [could] I express it?" (#22, female, MS1)
Relation of stress to project completion
Most project completers (9/12) thought anatomy was either stressful or very stressful. Fewer non-completing students rated anatomy as stressful or very stressful (5/12). (The remaining students in both groups described anatomy as producing little or no stress). The primary sources of stress for both groups appeared to be information overload.
"I felt I was always studying for anatomy. I enjoyed the material, but it was a constant stressor b/c of the amount of work it took to excel in the course"; "There's so much material and you can't learn it all." (#e1, female, MS2)
Several completers also noted lab-related stress, describing it as gross, disgusting, and generally uncomfortable. Female students reported higher levels of stress than males, but these were non-significant except for the stress of practical exams (p = .04).
Most completers (9) felt that participating in the creative project option reduced either anatomy-related stress, or medical school stress in general. They saw the project as a relaxing break, a way to avoid burn-out, a calming, tension-releasing experience, and a means of attaining a different, and healthier, perspective on anatomy.
"I think it was more a way for me to take the class and not go crazy ... I think it [the project] kept my interest, so like I said, not getting burned-out..." (#2, female, MS1)
Completing creative projects provided an outlet for difficult emotions, offered a way to acknowledge the "feeling" aspect of medicine, to explore multiple perspectives, and through reflection, to resolve contradictory response to the anatomy experience. About half of the non-completing students spontaneously made positive comments about the value of the creative projects to reduce their own stress.
" [Seeing] the anatomy projects like helped me get through some of the things I was dealing with." (#8, male, MS2)
Project completers performed significantly less well than noncompleters on the first written exam; and the superior performance of noncompleters approached but did not achieve significance on the first practical exam (both of these exams occurred pre-project completion). After completion of the first creative project, there were no significant differences on the subsequent individual exams; and this pattern continued to hold after the second creative project was completed. However, project non-completers performed better than completers on all exams. When all exam scores were combined and analyzed as a single score, the mean difference between non-completers and completers achieved statistical significance (Table ).
Exam Scores/Final Grades by Project Completers/Non-Completers
Relation of project completion to test performance
Most project completers did not believe that doing creative projects enhanced their knowledge acquisition:
"I don't think that I learned anything about anatomy specifically... learning this nerve goes here, here, and here, the project, I don't think it aided in that at all."(#15, male, MS2)
However, one or two students each mentioned that, as a result of the project, they felt they were more attentive, could pay better attention to details, were more curious about anatomy, were more comfortable with dissection, and had greater "ownership" of the course in the sense that they were more actively engaged with the material, and from a greater range of perspectives (i.e., anatomical, biomedical, aesthetic, and emotional).
"...The project really gave me something else to be looking at while I was dissecting... so just having that little 'ump' I'm on the search for cool things in the body... helped my anatomy experiences a lot... I'm hoping that I'm gonna keep this curiosity and just...um... and looking for the spectacular...um...special things in medicine other than just focusing uh... here's what you do." (#2, female, MS1)