Yy

INVESTIGATIONS OF ANATOMICAL VARIATIONS OF THE THORAX
AND HEART, AND ANATOMICAL KNOWLEDGE FOR FIRST YEAR MEDICAL

DENTAL AND PODIATRY STUDENTS
A Dissertation
Submitted to
the Temple University Graduate Board
in Partial Fulfillment
of the Requirements for the Degree
DOCTOR OF PHILOSOPHY
by
Anne-Marie Verenna, M.S.
May 2013
Examining Committee Members:
James L. Heckman, PhD, Physiology
Mary F. Barbe, PhD, Anatomy and Cell Biology
Helen E. Pearson, PhD, Anatomy and Cell Biology
Steven Popoff, PhD, Anatomy and Cell Biology
Kim Noble, PhD, Widener University
Susan M. Miller, PhD, Kent State University

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by
Anne-Marie Verenna
2013
All Rights Reserved
ii

ABSTRACT
The universal presence of anatomy in healthcare professions is undeniable. It is a
cornerstone to each of the clinical and basic sciences. Therefore, further expansion of
current anatomical knowledge and effective methods to teach anatomy is essential. In this
work, the relationship of the dorsal scapular artery with the trunks of the brachial plexus
is explored with the hope that information on anatomical variation will assist
neurosurgeons in sparing these structures during clinical procedures. Additionally,
structures involved in biventricular pacing procedures, such as the coronary sinus and
Thebesian valve, are explored for their variations in both presence and presentation.
Simulations of cannulations with both 7F and 8F guiding catheters were used to collect
data regarding the length of travel of a catheter within the coronary sinus. This study
aimed to expand current knowledge of the coronary structures that are of importance to
electrophysiologists.
Furthering knowledge of how best to teach anatomy to healthcare professionals
was also an aim of this work. The first education study explored whether the method of
instruction affected student success in a basic science course. This study also investigated
the degree of knowledge mastery that healthcare professional students had achieved in
gross anatomy, microanatomy and physiology during their first year physiology course.
The students were assessed at the knowledge, comprehension, application and analysis
levels of Bloom’s taxonomy in each discipline. A pilot study explored the degree of prior
knowledge in human gross anatomy that the same healthcare professional populations
iii

(medical, dental and podiatry) possessed before beginning the first year general gross
anatomy course in their healthcare curriculum. The ability for these students to evaluate
when they had answered a gross anatomy question correctly and when they had answered
a question incorrectly (metacognition) was explored. All four studies in this work provide
further insight into anatomical education in both the clinical and basic science
environments.
iv

ACKNOWLEDGEMENTS
First and foremost, I would like to extend my deepest thanks to my advising
committee. Without their support, motivation and expertise, I never would have been able
to complete these projects and grow as both a student and an educator.
I would like to thank Dr. Heckman for his continuous support and hard work,
especially in creating the Assembler software and completing the IRB investigator forms.
I will always cherish the conversations we have had regarding our struggles and triumphs
at all tiers of higher education. I would like to thank Dr. Barbe for her guidance in all
aspects of my graduate career at Temple. Without your experience and expertise, I would
never would have been able to navigate the processes of publication, review and
graduation. I would like to thank Dr. Pearson for her willingness to pursue both education
and cadaveric research projects with me. I appreciate her not only for her thoughtful
reviews of our work but her partnership approach of collecting data together. Thank you
for making our time in the cadaver lab simulating cannulations exciting. I would like to
extend my thanks to Dr. Popoff for not only entertaining but encouraging an educational
project within the Anatomy and Cell Biology department. Additionally, I would like to
thank Dr. Noble for her encouragement throughout this entire process. Without her
original dissertation work, this project may not have been possible. I would also like to
thank Dr. Miller for her review and contribution to the educational aspects of this work.
Additionally, I would like to thank the Temple faculty who allowed me access to
the sample student populations, as well as the students who volunteered their time to
participate in my research projects. Lastly, I would like to thank my family, friends and
colleagues for their encouragement and support in this process.
v

TABLE OF CONTENTS
ABSTRACT ..................................................................................................................... III
ACKNOWLEDGEMENTS ............................................................................................ V
LIST OF TABLES .......................................................................................................... IX
LIST OF FIGURES .......................................................................................................XII
LIST OF ABBREVIATIONS ..................................................................................... XIII
CHAPTER 1 .......................................................................................................................1
LITERATURE REVIEW OF ANATOMICAL CURRICULA AND
CONTRIBUTORS TO RETENTION OF ANATOMICAL KNOWLEDGE
.............................................................................................1 Introduction
......................................................................................1 Curricular Change
............................................................................3 Bloom’s Taxonomy
.........................................................................5 Integrated Curriculum
....................................................................13 Knowledge
Retention.....................................................................18 Specific Aims
.................................................................................28 CHAPTER 2
.....................................................................................................................30
VARIATION IN THE ORIGIN OF THE DORSAL SCAPULAR
ARTERY AND ITS ANATOMICAL RELATIONSHIP WITH THE BRACHIAL PLEXUS
.......................................................................30 Overview
........................................................................................30 Introduction
....................................................................................31 Materials And
Methods..................................................................34 Results
............................................................................................35 Discussion
......................................................................................39 Conclusion
.....................................................................................40 CHAPTER 3
.....................................................................................................................41
CANNULATION OF THE CORONARY SINUS: VARIATION OF
ANATOMICAL STRUCTURES RELATED TO BIVENTRICULAR PACING
PROCEDURES .......................................41 Overview
........................................................................................41
vi

Introduction ....................................................................................42 Materials And
Methods..................................................................43 Results
............................................................................................45 Thebesian Valve
.................................................................46 Internal Diameter of the Coronary Sinus Ostium
..............47 Opening of the Coronary Sinus Ostium .............................47 Catheterization of the
Coronary Sinus ..............................47 7F Guiding Catheter
..........................................................47 8F Guiding Catheter
..........................................................48 Heart Weight
......................................................................51 Discussion
......................................................................................51 CHAPTER 4
.....................................................................................................................55
CORRELATION OF INTEGRATED INSTRUCTION AND SUCCESS
AT LOWER AND HIGHER TIERS OF BLOOM’S TAXONOMY IN ASSESSMENTS OF
BOTH IMMEDIATE AND DELAYED RECALL IN FIRST YEAR HEALTHCARE
PROFESSIONAL POPULATIONS .........................................................55 Overview
........................................................................................55 Introduction
....................................................................................55
Methods..........................................................................................58 Medical Students
................................................................58 Dental Students
..................................................................63 Podiatry Students
...............................................................68 Results
............................................................................................70 Medical Students
................................................................70 Dental Students
..................................................................78 Podiatry Students
...............................................................94 Discussion
....................................................................................102 Study Limitations
.........................................................................107 Medical Students
..............................................................107 Dental Students
................................................................107 Podiatry Students
.............................................................108 Future Investigations
....................................................................108 Conclusion
...................................................................................109 CHAPTER 5
...................................................................................................................110
DOES THE LEVEL OF ASSESSMENT ON A PRE-TEST
CORRELATE TO PERFORMANCE IN A HEALTHCARE PROFESSIONAL DEGREE
PROGRAM FIRST YEAR HUMAN GROSS ANATOMY COURSE?: A PILOT STUDY
...........110 Abstract ........................................................................................110 Introduction
..................................................................................111
Methods........................................................................................112 Results
..........................................................................................114 Discussion
....................................................................................120
vii

Conclusion ...................................................................................125 CONCLUSION
..............................................................................................................126
REFERENCES ...............................................................................................................132
APPENDICES ................................................................................................................159
INFORMED CONSENT FORM: MEDICAL STUDENT
POPULATION ..........................................................................................160
DISTRIBUTION OF QUIZ QUESTIONS BY LEVEL OF BLOOM’S
TAXONOMY: MEDICAL STUDENT POPULATION .......................161
THE ASSEMBLER PROGRAM ........................................................................162
ANNOUNCEMENT POSTED ON THE COURSE MANAGEMENT
SYSTEM TO RECRUIT DENTAL STUDENTS DURING THE SIXTH WEEK OF THE
DENTAL PHYSIOLOGY COURSE ...........163
DISTRIBUTION OF QUIZ QUESTIONS BY LEVEL OF BLOOM’S TAXONOMY:
DENTAL AND PODIATRY STUDENT POPULATION
..........................................................................................164 INFORMED CONSENT FORM:
MEDICAL STUDENT
POPULATION ..........................................................................................165
INSTRUCTIONS FOR ACCESSING RESEARCH PROJECT
MATERIALS – CONTROL GROUP: DENTAL AND PODIATRY POPULATIONS
.................................................................166
SEQUENCE FOR REVIEWING RESEARCH MATERIALS –
CONTROL GROUP: DENTAL AND PODIATRY POPULATIONS
........................................................................................167 INSTRUCTIONS FOR
INSTALLATION AND OPERATION OF THE
ASSEMBLER SOFTWARE ....................................................................168
INSTRUCTIONS FOR ACCESSING RESEARCH PROJECT
MATERIALS – EXPERIMENTAL GROUP: DENTAL AND PODIATRY
POPULATIONS .................................................................169 SEQUENCE FOR
REVIEWING RESEARCH MATERIALS –
EXPERIMENTAL GROUP: DENTAL AND PODIATRY POPULATIONS
........................................................................................170
INFORMED CONSENT FORM – PODIATRY STUDENT
POPULATION ..........................................................................................171
ANNOUNCEMENT POSTED ON THE COURSE MANAGEMENT
SYSTEM TO RECRUIT PODIATRY STUDENTS DURING THE SEVENTH WEEK OF
THE PODIATRY PHYSIOLOGY COURSE
....................................................................................................173
viii

LIST OF TABLES
Table 2-1: Comparison of origin of dosrsal scapular artery ............................................. 35
Table 2-2: Path of the dorsal scapular artery between the trunks of the brachial plexus . 36
Table 2-3: Summary of dorsal scapular origin and its path between the trunks of the
brachial plexus ............................................................................................................. 37
Table 3-1: Variations in coronary sinus measurement by gender (mean ± standard
deviation). .................................................................................................................... 46
Table 3-2: Average length of travel in the coronary sinus for a 7F and 8F cathether by
gender (mean ± standard deviation). ........................................................................... 49
Table 3-3: Raw data used for Figure 2 .............................................................................. 49
Table 4-1: Percent Correct on Gross Anatomy, Microanatomy, and Physiology Quizzes
for Medical Students .................................................................................................... 72
Table 4-2: Correlation of Total Score on Gross Anatomy, Microanatomy and Physiology
Quizzes for Medical Students ...................................................................................... 73
Table 4-3: Regression of Microanatomy Lower Order Cognitive Skills on Higher Order
Cognitive Skills in Medical Students ........................................................................... 74
Table 4-4: Regression of Physiology Lower Order Cognitive Skills on Higher Order
Cognitive Skills in Medical Students ........................................................................... 75
Table 4-5: Regression of Gross Anatomy Analysis Subscale on Physiology Quiz Total for
Medical Students .......................................................................................................... 76
Table 4-6: Correlation of Scores on Microanatomy and Physiology Quizzes with Final
Exam Score for Medical Students ................................................................................ 78
ix

Table 4-7: Percent Correct on Gross Anatomy, Microanatomy, and Physiology Quizzes
for Dental Students ...................................................................................................... 80
Table 4-8: Correlations of Total Scores on Gross Anatomy, Microanatomy and
Physiology Quizzes for Dental Students ...................................................................... 80
Table 4-9: Regression of Gross Anatomy Lower Order Cognitive Skills on Higher Order
Cognitive Skills for All Dental Students ..................................................................... 81
Table 4-10: Regression of Gross Anatomy Lower Order Cognitive Skills on Higher
Order Cognitive Skills for Dental Students Control Group ......................................... 82
Table 4-11: Regression of Gross Anatomy Lower Order Cognitive Skills on Higher Order
Cognitive Skills for Dental Students Experimental Group .......................................... 82
Cognitive Skills for Dental Students in the Control Group ......................................... 84
Cognitive Skills for Dental Students in the Control Group ......................................... 85
Table 4-16: Regression of Physiolology Lower Order Cognitive Skills on Higher Order
Cognitive Skills for Dental Students in the Experimental Group ................................ 86
Table 4-17: Regression of Gross Anatomy Subscales on Microanatomy Quiz Total for
All Dental Students ...................................................................................................... 88
Dental Students in the Experimental Group ................................................................ 88
All Dental Students ...................................................................................................... 89
x

Table 4-20: Regression of Gross Anatomy Subscales on Physiology Quiz Total for
Dental Students in the Control Group .......................................................................... 90
Table 4-21: Percent Correct on Quizzes by Bloom’s Levels for Experimental and Control
for Dental Students ...................................................................................................... 91
Table 4-22: Regression of Physiology Quiz Total on Final Examination Score for All
Dental Students ............................................................................................................ 94
Table 4-23: Podiatry Student scores by Percent Correct on Gross Anatomy,
Microanatomy, and Physiology Quizzes ..................................................................... 96
Table 4-24: Correlation of Total Score on Gross Anatomy, Microanatomy and
Physiology Quizzes for Podiatry Students ................................................................... 97
Table 4-25: Descriptive Statistics by Quiz for Podiatry Students .................................... 99
Table 4-26: Regression of Physiology Quiz Total on GI Examination Score for All
Podiatry Students ....................................................................................................... 102
Table 5-1: Ranking of confidence by anatomy topic for both pre-test groups ............... 118
xi

LIST OF FIGURES
Figure 2-1: The path of the dorsal scapular artery between the trunks of the brachial
plexus .......................................................................................................................... 38
Figure 3-1: Image of the coronary sinus ostium ............................................................... 50
Figure 3-2: Frequency of percent occlusion of the coronary sinus ostium by a Thebesian
Valve by group and gender. ........................................................................................ 51
Figure 4-1: Screen Shot of Assembler Software ............................................................... 61
Figure 4-2: Percent Correct by Level of Bloom’s Taxonomy from Medical students on
quizzes in Gross Anatomy, Microanatomy and Physiology ....................................... 73
Figure 4-3: Average scores by Topic, Level of Bloom’s Taxonomy and Method of
Instruction in Dental Students ..................................................................................... 92
Figure 4-4: Average Podiatry Student Score by Instructional Method, Quiz and Level of
Bloom’s Taxonomy. ................................................................................................. 100
Figure 5-1: Metacognitive average score by anatomy topic for students who completed a
pre-test with questions from the knowledge, comprehension, application and analysis
levels of Bloom’s taxonomy ..................................................................................... 116
Figure 5-2: Metacognitive average score by anatomy topic for students who completed a
pre-test with questions from the application and analysis levels of Bloom’s taxonomy
................................................................................................................................... 117
xii

LIST OF ABBREVIATIONS
Ana = Analysis Level of Bloom’s Taxonomy
App = Application Level of Bloom’s Taxonomy
BT = Bloom’s Taxonomy
BVP = Biventricular Pacing
C = Comprehension Level of Bloom’s Taxonomy
CRT = Cardiac Resynchronization Therapy
CS = Coronary Sinus
DSA = Dorsal Scapular Artery
HOCS = Higher Order Cognitive Skills
K = Knowledge Level of Bloom’s Taxonomy
LOCS = Lower Order Cognitive Skills
M/I = Middle and Inferior
MCQ = Multiple Choice Questions
NYHA = New York Heart Association
S/M = Superior and Middle
SA = Subclavian Artery
Subcl A = Subclavian Artery
TT = Thyrocervical Trunk
xiii

CHAPTER 1
LITERATURE REVIEW OF ANATOMICAL CURRICULA AND CONTRIBUTORS
TO RETENTION OF ANATOMICAL KNOWLEDGE
Introduction
Anatomy is a scientific discipline that identifies the various structures and
organization of the human body. Anatomy is a required course for all healthcare
professionals (physicians, dentists, podiatrists, etc.). It is often placed at the beginning of
a healthcare curriculum to introduce students to the blueprint of the human body. In
addition to learning structures, anatomy introduces the students to medical terminology.
Cited as “the basic language of medicine” (Miller et al, 2002), anatomy introduces
students to the use and construction of medical terminology. Students learn terms that
identify relationships (superior, inferior, lateral, medial), location (superficial, deep) and
number (bi, tri, quad). Anatomical terminology assists the student with his/her
understanding of course material and clinical language, allowing the student to bridge
his/her basic science knowledge with clinical science application (Mehta et al, 1996).
The human gross anatomy course is delivered during the basic science portion of
a healthcare professional curriculum. It is frequently a first semester course that is
divided into two components: lecture and laboratory. The lecture component of the
course uses medical terminology to disseminate information regarding the location and
relationships of structures. Traditional lectures are frequently presented in a classroom
1

setting where students gain knowledge by anatomical topic or body region. The lecture
environment permits communication of material to a large number of students at one
time, allowing for an efficient delivery of large amounts of material to a large number of
students. The laboratory component of gross anatomy provides the students with a unique
opportunity to visualize relationships of real body structures in three dimensions, unlike
the two dimensional representations of most other anatomical resources (atlases,
textbooks , etc.). Additionally, the laboratory component of gross anatomy requires
students to work in smaller groups than the lecture setting, which enhances teamwork and
cooperation. Also, students are introduced to the reality of death and biological variation.
(Older, 2004). Cadavers are one of the most common educational tools used in the
traditional healthcare professional gross anatomy laboratory. Variation occurs within
each institution and graduate program as to the extent in which medical students use
cadavers.
The relevance and importance of the gross anatomy course is identified with its
prominence in a clinical setting. Success in clinical disciplines, such as surgery, requires
a solid understanding of anatomical knowledge. At the end of residency, students have
ranked anatomy in the list of the top five subjects relevant to their success as physicians.
In a survey by Pabst and Rothkotter, German students identified gross anatomy as a
fundamental course and relevant for medicine (Pabst and Rothkotter, 1997). Similarly, in
a survey of American residency programs, anatomy was identified as the most important
basic science (Cottam, 1999).
Empirical evidence is needed to guide curricular planning for efficient gross
anatomy implementation for healthcare providers. Currently, there is a lack of original
2

research in anatomical education. Although the number of publications regarding
education in anatomy is increasing, there are consistent themes to the published
materials. Baernstein et al (2007) identified that the majority of publications report
studies that assess attitudes or perceptions instead of implementing and gathering data
regarding a curricular change. Additionally, publications are criticized for their research
methodology, including lack of hypotheses and improper use of statistical analysis
(Baernstein, 2007; Todres et al, 2007). Few publications discuss student achievement
after the study interventions have concluded.
Curricular Change
Historically, anatomy is the cornerstone of the medical school curriculum. In
recent years, curricular changes have transformed not only the structure and content of
the gross anatomy course but the method in which anatomical content is distributed.
Perhaps the most universal change in anatomy curricula is the drastic reduction in hours
that anatomy is allotted within the medical curriculum. During the last 10 years, there has
been a national trend toward reducing the number of instructional hours dedicated to
anatomy (Peterson and Tucker, 2005). According to Cottam, medical gross anatomy
was allotted an average of 182 hours within the curriculum in 1991. Just 6 years later, the
average hours allotted to gross anatomy was reduced to 165, a 13% decrease (Cottam,
1999). Similarly, Drake identified that the typical gross anatomy course averaged at 167
hours, with a range of 126-200 (Drake, 2002). It is projected that the curricular hours
dedicated to anatomy will continue to decrease to meet increasing demands to teach
students additional material, such as professionalism and ethics (Sugand et al, 2010).
3

Curriculum faculty are required to alter the delivery methods used in the gross
anatomy course due to the reduction in curricular hours. As a result, the majority of gross
anatomy hours are dedicated to the laboratory environment. A recent survey of medical
schools revealed that more than 80% of the respondents indicated that the laboratory
represented more than 50% of the total course hours (Drake, 2002). Therefore, content
that used to be presented in a traditional lecture is now more likely to be presented to the
students in an alternate format.
Usually, these alternative forms include independent learning on the part of the
student. Frequently, this requires the students to use computer-based technology to gain
anatomical knowledge. The content of the gross anatomy course has also been modified
due to curricular change. The application of anatomy to the clinical environment is
increasing its prevalence in the medical school curriculum. Therefore, many gross
anatomy courses now emphasize imaging techniques (CT, MRI, X-ray) and cross-
sectional anatomy (Ganske et al, 2006; Granger et al, 2006;).
Curricular change not only affects students while they are within the medical
school curriculum, but the change has repercussions that extend into postgraduate clinical
work. Sugand et al (2010) described concerns that recent medical graduates entering
residencies and clerkships were underprepared with regard to the required anatomy
knowledge to successfully perform clinical work (Sugand et al, 2010). Sugand et al
confirmed Cottam’s previous work. A survey revealed that residency directors believed a
majority (57%) of incoming residents needed a refresher in anatomy, with diagnostic
radiology and general surgical residents needing this refresher the most (Cottam, 1999).
Since anatomical knowledge is not normally a component of residency training and few
4

residency programs exist that provide a specialty-specific refresher, Cottam suggests
further evaluation of both the educational methods and curricular design for those
institutions that teach gross anatomy (Cottam, 1999). Although Cottam did not suggest
specific evaluation methods or curricular design improvements, he acknowledges that
further investigation into teaching and retention of the anatomical sciences be monitored
before additional curricular changes occur.
One indicator that a curriculum is successful is its ability to confirm that the
students are meeting the educational objectives of the curriculum and accrediting body.
The most common method to verify that the objectives are achieved is to assess students
by testing. Usually the students are assessed using multiple choice questions; however,
testing can take on multiple formats, such as short answer and essay. Since there are a
variety of formats that can be used to determine mastery, Benjamin Bloom and his
colleagues set a goal of creating a taxonomy that would provide a clearer way to evaluate
student learning.
Bloom’s Taxonomy
In 1956, Benjamin Bloom and his colleagues published the Taxonomy of
Educational Objectives: The Classification of Educational Goals, Handbook 1: Cognitive
Domain, often referred to as Bloom’s taxonomy, as a tool to provide a structural
framework for assessment. The hope for the taxonomy was to be able to provide a
common language to discuss learning goals and to facilitate the determination of an
alliance between educational goals and assessment (Krathwohl, 2002). Bloom and his
colleagues intended to provide instructors with clear statements that would link the
requirements of instruction with what the students were expected to learn. It was their
5

collective goal to provide a common language for assessment and facilitate the sharing of
testing material between faculty that have similar learning objectives (Bouchard, 2011).
Bloom’s taxonomy would allow instructors who have common educational goals to
discuss the level and degree students should be performing.
Bloom envisioned three general taxonomies: cognitive (what a student should
know), psychomotor (what skills a student should possess) and affective (associated with
emotions and values). Bloom’s publication focused his classification system on the
cognitive domain. Others later expanded upon Bloom’s framework, adding defined
taxonomies for the psychomotor and affective domains.
Bloom’s original taxonomy consisted of a six-tiered classification system. Each
tier was associated with a level of assessment and was given a name in noun form. It is
implied that progression from one tier to the next requires mastery of the prior tier.
Therefore, the taxonomy is cumulative. The levels are named knowledge,
comprehension, application, analysis, synthesis, and evaluation. Each of these levels has
a specific expectation of the student for assessment purposes. In the taxonomy, Bloom
provided subcategories for each of these levels, with the exception of application. It was
within these subcategories that a person was able to identify the exact requirements of
assessment at each level.
What a student produces in an assessment is a result of the level at which he/she is
assessed. For instance, the knowledge level is associated with being able to recall facts.
This level is often associated with rote memorization and requires the student to be able
to recognize information (Usova, 1997). The knowledge level is used to test a basic level
of understanding. Besides isolated facts, the knowledge level can be used to assess a
6

learner’s basic understanding of material. This understanding may include the ability to
define or identify critical terminology associated with a unit of instruction. The
knowledge level of Bloom’s taxonomy has also been referred to as the fundamental level
of assessment because success at this level of assessment identifies a superficial
understanding of material. The comprehension level requires slightly more familiarity
with the topic of the instruction. Learners who succeed at this level of assessment
demonstrate an ability to compare and contrast the content. The application level requires
a deeper understanding of the material than the knowledge and comprehension levels. It
is at this level that the learner is not only required to understand generalities of instruction
but is also required to predict how these parts of the instructional units would change in
different environments. A learner assessed at the application level should be able to
predict or hypothesize outcomes when presented with data. The process of successfully
achieving this assessment level requires a depth of knowledge, more so than the
knowledge and comprehension levels. The analysis level furthers the goal of a deep
approach to assessment by requiring the learner to take a complex process and dissociate
the process into simpler parts. As a result, the learner should be able to understand the
significance of each piece to the theoretical puzzle or the importance of each step in a
sequence. Synthesis requires that the pieces that a learner is able to rearrange the steps in
a sequence and predict how the change in steps will affect the sequence. Evaluation is the
highest level of assessment in Bloom’s taxonomy and requires the student to critique
material. The learner should be able to look at the whole picture and identify what the
problems are, as well as provide plausible resolutions to these problems. The last four
7

tiers (application, analysis, synthesis and evaluation) have been cited as active processes
that require a multiple step approach to resolving a question (Usova, 1997).
Bloom’s taxonomy is classified into levels that assess lower order cognitive skills
(LOCS) and higher order cognitive skills (HOCS) (Crowe, 2007). The LOCS require a
superficial understanding of the material being assessed and do not require critical
thinking skills. The HOCS require a deeper understanding of the material and requires the
learner to implement critical thinking skills and complex cognitive processes. The
knowledge and comprehension levels are categorized as lower order cognitive skills,
whereas application, analysis, synthesis and evaluation are categorized as higher order
cognitive skills. In this multi-tier approach, it is hypothesized that the ability to succeed at
one level of Bloom’s taxonomy was due partially to the success of achievement at a prior
level; therefore, the knowledge and comprehension levels can be identified as
foundational. If a student is unable to perform at the knowledge and comprehension
levels where only a superficial level of understanding is required, it is unlikely that the
student would be able to successfully perform at the application, analysis, synthesis or
evaluation levels which require a deeper level of understanding.
Bloom’s original taxonomy has been revised to provide additional clarification as
an assessment tool. One notable change from the original is the difference in
terminology. Although the content requirements remain similar to the original taxonomy,
the revised edition replaced the previous names of assessment levels identified as nouns
to verbs (Seaman, 2011). The revised taxonomy has the following levels: remember,
understand, apply, analyze, evaluate and create. The revision and new terminology
demonstrates a change in perspective. Whereas the original taxonomy focused on
8

assessment (producing responses), the revised taxonomy focuses on student learning
(cognitive processes) (Su and Osisek, 2011). The use of action verbs was implemented to
reflect the active processes of a student who successfully completed a tier instead of how
an instructor would write a question to test a tier of the taxonomy (Ven and Chuang,
2005).
Regardless of which version is used, Bloom’s taxonomy is a valuable tool for
assessment and has been used widely in curricular development. Bloom’s taxonomy has
been used in a variety of educational environments. It has been used to assess curricular
goals at the K-12 level (Azizan and Ibrahim, 2012; Roberts, 1976), the university level
(Dobson, 2001; Healey, Zinaida and Betts, 2011; Shaw, 2006) and the post-baccalaureate
levels (Harries and Botha, 2007; Knecht, 2001; Phillips et al, 2012; Plack, 2007; White
and Haftel, 2008). Its usage in licensure and matriculation examinations is also present in
the literature (Cizek, Lynn and Kalohn, 1995; Zheng, 2008). Additionally, it has also
been used to confirm the validity of new instructional techniques on curriculum, such as
distance learning as an effective educational modality (Collins, 2011).
Since the higher tiers of the taxonomy require multiple cognitive processes and a
deep understanding of the instructional material, it has been suggested that assessments
should maximize the number of questions at the higher levels, such as analysis and
synthesis, and minimize the use of knowledge questions that test lower order cognitive
skills (Krathwohl, 2002). Due to the taxonomy’s scaffolding structure, it has been
suggested that it is more efficient to test students at higher levels of the taxonomy
(Usova, 1997).
9

It is evident in the literature that faculty at all educational levels have dedicated
time to review their assessments as they apply to the levels of Bloom’s taxonomy. These
analyses have driven curricular revision. A common result of these analyses is the
identification of a discrepancy between the level at which faculty aim to assess their
students with the level that the faculty currently assess their students. Investigators have
found that their assessments contain mostly lower order cognitive skill questions. Saqib
et al.’s (2011) research revealed that over 86% of the biology questions on a standardized
exam for intermediate and secondary education students, equivalent to middle school in
the United States, were at the knowledge and comprehension levels of Bloom’s
taxonomy, with 53% at the knowledge level. There were no questions at the application,
synthesis or evaluation level (Saqib et al, 2011). Rupani and Bhutto identified similar
results in their study of secondary school students and concluded that both teaching and
learning in their present curriculum occurred at the lower tiers of the taxonomy (Rhupani
and Bhutto, 2011). Both Saquib et al and Rupani and Bhutto acknowledge that their
assessments were mostly in the form of multiple choice questions. Multiple choice
questions are a common testing method and some of the most prevalent question types
found in test banks. Test banks have provided students and instructors with a resource for
lower order cognitive skill questions. Duan found that nursing school tests banks usually
tested knowledge level questions, approximately 50%, and few (6.5%) were written at the
analysis level (Duan, 2006). The preference for testing lower order cognitive skills is not
exclusive to multiple choice exams. In instances where students are required to write for
their assessments instead of selecting from answer choices, similar findings were
observed with respect to the levels of Bloom’s taxonomy. For instance, Plack et al
10

studied journal entries from medical students in a pediatric clerkship and found that over
90% of the journal entries were written at the knowledge level (Plack et al, 2007). Since
the taxonomy has proven to accurately assess a student’s mastery of knowledge, it is
important that the discrepancies between the level at which students are assessed and the
level at which the students should be assessed are corrected.
Azizan and Ibrahim identified that young students trying to learn fractions who
were unable to master lower order cognitive skill questions found difficulty in answering
high order cognitive skill questions (Azizan and Ibrahim, 2012). Dobson (2011)
confirmed that students studying anatomy and physiology were more successful at lower
levels of Bloom’s taxonomy than at higher levels of Bloom’s taxonomy (Dobson, 2011).
His analysis confirmed that the taxonomy was a mechanism to distinguish among
students who can and cannot perform at levels requiring a deep understanding of the
tested material. Knecht (2001) also confirmed these findings in a population of pharmacy
students. Knecht identified that students in the lower portion of the class performed well
on knowledge questions, but failed to perform on higher order questions; students in the
top portion of the class were able to perform well on the higher order questions (Knecht,
2001). Harries and Botha also confirmed these findings in a medical school population
(Harries and Botha, 2007).
The support for Bloom’s taxonomy is also validated in licensing and entrance
examinations. Zheng evaluated the MCAT (Medical College Admissions Test) and found
that the instrument tested learning at all levels of the taxonomy, requiring students to not
only know facts but to be able to apply concepts (Zheng, 2008). Entrance and licensing
examinations are used to identify prospective students who are able to perform
11

successfully at high levels of Bloom’s taxonomy, indicating that they have a
predetermined depth of knowledge and an implied ability to succeed in a rigorous
curriculum. Cizek, Webb and Kalohn confirmed that higher levels of performance on
higher order items in licensing exams were associated with success on the total test
(Cizek, Webb and Kalohn, 1995).
It is not to say, however, that the taxonomy is without criticism. Roberts studied
5th and 6th grade students and found that students’ scores at the application level of
Bloom’s taxonomy were significantly higher than their scores at both the knowledge and
comprehension levels (Roberts, 1976). Stedman also questioned the validity of Bloom’s
taxonomy. His study with high school biology students resulted in no statistically
significant differences between student scores at the knowledge and comprehension
levels or at the application and analysis levels. However, he did notice a significant
difference between the scores at the comprehension and application levels of Bloom’s
taxonomy (Stedman, 1973). Paul faults Bloom’s taxonomy because it implies a
unidirectional movement and contends that the taxonomy should reflect a bidirectional
movement (Paul, 1985). Paul affirms that one level of the taxonomy cannot be mastered
without another level but the mastery does not have to occur in a strictly ascending
manner, as was originally presented by Bloom and his colleagues.
Overall, in spite of these concerns, Bloom’s taxonomy is important as an
evaluative tool for assessing what a student knows, as well as to what extent the student
has mastered the material. Many of these skills which are required for mastery of a level
at Bloom’s taxonomy, specifically at the higher tiers, are expected in a workplace
environment. Ven and Chuang compared occupational competencies for computer
12

programmers and identified that the job descriptions in three countries focused on skills
that would be required at the higher levels of Bloom’s taxonomy. Almost half of the
competencies required for success in this occupation occur at the synthesis level. Very
few of the competencies (5%) were at the knowledge and comprehension level (Ven and
Chuang, 2005), indicating that testing at the higher levels of Bloom’s Taxonomy is a
valid preparation for real-world application.
Integrated Curriculum
One of the frequent challenges facing healthcare professional educators is to
cover all required content in an allotted timeframe. Nationally, the amount of time given
to presenting curricular content is decreasing, which places an extra stress on faculty.
Faculty have responded in different ways to this challenge. Some require students to
complete a substantial amount of reading outside of the classroom. Others have
implemented new curricula, such as problem or team-based learning. Another solution is
to implement an integrated curriculum that combines similar and/or relevant topics into
coordinated modules.
Although no universal definition exists for an integrated curriculum, Muller
provides the following definition: “interdisciplinary block courses in pre-clerkship years
that bring together basic, clinical and social sciences into one course or weave
longitudinal curricular themes across the curriculum” (Muller, 2008). Besides the need to
conform to decreasing curricular hours, integrated curricula have been used in medical
schools to replace teaching of isolated disciplines. It allows for relevant material to be
taught simultaneously and requires students to not only learn material, but to develop and
analyze skills that evaluate the patient as a whole (Madhuri, 2008). An integrated
13

curriculum has also made it possible to prevent repetition within the curriculum, allowing
for more time to discuss new content. It is the goal of an integrated curriculum to
promote problem solving skills and avoid gaps in knowledge (Shimura, 2004).
Integration has a strong foundation in learning theory, suggesting that it may decrease the
attention on learning facts, aid in retention, promote problem solving skills and develop
effective clinical reasoning skills (Dienstag, 2011; Muller, 2008; Shimura, 2004).
Implementation of an integrated curriculum has presented in the literature primarily in
two ways: 1. between disciplines of the basic sciences (such as anatomy and physiology)
and 2. between disciplines of the clinical sciences (such as medicine and radiology).
Within the basic sciences, there is evidence that an integrated curriculum which
links the basic science disciplines of anatomy and physiology will provide students the
opportunity to achieve the desired curricular objectives. Wilhelmsson notes that their
integration of these disciplines in a second year medical student population resulted in
positive student feedback (Wilhelmsson, 2010). Specifically, students felt that they were
successfully able to make connections between structure and function. These connections
promoted relevance to the course content and the ability to construct a cognitive model
that synthesizes and evaluates information, much like the skills needed in clinical
practice. Khalil, Nelson and Kibble’s experience with implementing basic science self
learning modules provided additional support for implementing an integrated curriculum
(Khalil, Nelson and Kibble, 2010). The self learning modules were computer based and
introduced knowledge in basic sciences, such as anatomy, physiology, neuroscience,
microanatomy and embryology. The modules allowed the students to pace themselves as
they proceeded through the learning of the material. This allowed the students to control
14

the time they dedicated to mastering the material. Upon analysis, the students performed
at least as well on examinations as students that were in the traditional (non-integrated)
lecture based curriculum. Klement, Paulsen and Wineski also experienced success with
an integrated basic science curriculum. Similar to Khalil, Nelson and Kibble, Klement,
Paulsen and Wineski integrated the disciplines of histology, gross anatomy and
embryology and structured their curriculum around regional cadaveric dissections. Their
integrated curriculum increased the students’ independent study time by 2-3 hours per
day, thus reducing the time in a traditional classroom environment. The students
demonstrated an increase in course averages for all of the basic sciences involved in the
integration (7% in histology and physiology, 9% in gross anatomy and embryology)
(Klement, Paulsen and Wineski, 2011). Muller also found that integrating the basic
sciences of anatomy, physiology, and pharmacology enhanced student knowledge of the
cardiovascular system (Muller, 2008).
The use of an integrated curriculum is not restricted to the basic sciences.
Researchers have successfully implemented integrated curricula in the clinical sciences.
For instance, Madhuri used an undergraduate medical student population to integrate the
departments of pathology and medicine to teach students about diabetes mellitus (Maduri,
2008). After reviewing the integrated material, the students demonstrated improvement in
both the cognitive and psychomotor domains (Maduri, 2008). Students were also asked to
provide their feedback on this new teaching method by completing a questionnaire.
Eighty percent (80%) of the students who completed the questionnaire expressed
enthusiasm for the new teaching method; 87% of the students felt that this method
helped with their retention of the material (Maduri, 2008). Radwany et al. (2011) also
15

used an integrative approach to the clinical science portion of their medical curriculum.
Instead of using examination scores as a gauge of success, Radwany et al. (2011) focused
on expanding knowledge and interest in palliative care. They were implementing an
integrated curriculum between third and fourth year medical students in internal and
family medicine clerskhips. While in the integrated curriculum, students were exposed to
the field of palliative care. This introduction acted as a catalyst for the students to further
develop an interest and understanding of palliative care. As a result of their exposure and
interest, the creation of student groups that discussed concerns/interests of palliative care
increased (Radwany et al, 2011). This integration assisted in the curricular objectives of
exposing the student population to palliative care and allowing the students to research
and develop their interests. Although the educational objectives were met, it is important
to note that the process of integration required substantial development and collaboration
among the faculty.
Implementing an integrated curriculum is challenging for both administration and
faculty. An investment of institutional finances and faculty time are two major challenges
to implementing an integrated curriculum. Also included in these challenges are the
planning (what material will be integrated) and restructuring processes (where the
integrated material will be placed in the curriculum) required to construct the integrated
curriculum (Khalil, Nelson and Kibble, 2010; Klement, Paulsen and Wineski, 2011;
Muller, 2008; Radwany et al., 2011).
Usually, the implementation of an integrative curriculum requires the use of
technology. Technology allows faculty to determine the content presented and the
students to have an organized structure in which to process course material. Technology
16

also allows the students freedom both in the location in which they access material (on
campus or off campus), as well as the manner in which they access material. The use of
computer-based technology in a curriculum has many advantages: it provides easy and
repeat access to materials, it provides an interactive learning environment (Foreman et al,
2005) helps foster self-guided learning (Ketelsen et al, 2007), and permits the student to
access multiple learning modalities (text, sound, static images, animations, video clips,
interactive simulations) (Granger et al, 2006; Grunewald et al, 2006; Inwood and Ahmad,
2005; Jastrow and Hollinderbaumer, 2004). Technology has been used to present students
with textual information related to the basic sciences and allowed instructors to
incorporate clinical science materials, such as images (CT, MRI, angiograms), slides,
videos, photographs and simulations to further enhance the student’s understanding and
application of the material (DiLullo et al, 2006; Granger et al, 2006; Inwood, 2005;
McNulty, 2004; Patham, 2009). Technology permits a student to individualize his/her
learning experience and adapt learning to his/her personal preferences (i.e. selecting the
pace at which they proceed through the content, volume and speed of audio playback,
etc.). It also benefits faculty by providing evaluative assessments (quizzes, examinations)
outside of a traditional classroom setting. It allows faculty to track student progress
through a program (linearly or non-linearly), identify the time that the student spent using
the technology, acquire feedback from polling the students and identify correlational data
regarding the use of technology and success in the course (McNulty et al, 2000; McNulty
et al, 2004; Nieder and Nagy, 2002; Rizzolo et al, 2006).
17

Knowledge Retention
Another concern of educators is to ensure that the material taught is retained.
Educators have used delayed recall to measure retention in students and found a
significant decline in retention as students progress through the curriculum. Researchers
have tracked retention in healthcare professional programs and found that a decrease in
basic science knowledge as a student progresses in the curriculum (specifically anatomy)
has been of interest to many. Hall and Durward cited previous studies where anatomy
scores had decreased from 90% to 37.25% in a medical school population after a period
of at least two years (Hall and Durward, 2009). Feigin et al demonstrated the decline in
retention of thoracic anatomy knowledge by one half from the first year of medical
school to the fourth year of medical school (Feigin et al, 2007). Feigin noticed a decrease
in anatomical knowledge in fourth year medical students on material they had mastered
in both oral and multiple choice question exams in their second year of medical school.
The mean of the fourth year students scores on an anatomical exam was 37% (4.47
points earned out of 12 possible points) two years after the students were originally
introduced to the material (Feigin, Smirniotpoulos and Neher, 2002). These results are
not unique to Feigin’s study. Similar observations are seen at other institutions,
prompting faculty to ask how do these students lose knowledge after taking an intense
anatomy course at the beginning of the medical curriculum (Kerfoot et al, 2007)?
To answer this question, investigators have focused their research into three areas:
1) altering the student’s approach to the material, 2) altering the forms of assessment
completed by the students, and 3) implementing the material at specific time intervals
within the curriculum. Investigators use information from both neurological and
psychological studies to further their understanding of memory and knowledge retention.
18

Scientists have categorized memory into two main types: declarative and
procedural. Declarative memory is responsible for remembering facts and is often
associated with conscious behavior; procedural is responsible for remembering how to
perform a skill (such as driving a car). Learning anatomy is more frequently the result of
declarative memory formation; therefore, this work will focus on declarative memory. It
is generally accepted that the medial temporal lobe of the brain, as well as the
hippocampus, are active during declarative memory formation. Injury to this portion of
the brain has resulted in impaired memory formation and retrieval. The radial arm maze
experiment helped solidify the relationship between declarative memory formation and
the hippocampus.
David Olton and his colleagues used rats to study learning and memory behavior.
In their experiment, the rats were required to find food at the terminal ends of a radial (8
armed) maze. Some of these terminal ends contained food. Olton and his colleagues
wanted to observe how rats learned which arms the rats had visited, as well as if food was
present in that arm. When the rat reached the terminal end of the maze, it was returned to
the center of the maze. Normal rats were able to learn which arms they had previously
visited and which arms they had not visited. Rats with hippocampal lesions were unable
to distinguish between the arms that they had visited and those that they had not visited.
(Bear et al, 2007).
A few years later, the Morris water maze experiment was performed to study
memory (Bear et al, 2007; Purves et al, 2008). In this experiment, rats were placed in a
pool of milky water and were observed as they tried to find a hidden platform. Rats were
placed in the pool of water multiple times so they could learn where the platform was
19

located. Once the rats learned where the platform was, they would proceed to the
platform as soon as they entered the water. This movement towards the platform was
observed in rats that did not have brain injuries. However, rats that had hippocampal
lesions were unable to find the platform as quickly as the rats that did not have the
lesions, indicating that the memory of where to find the platform was stored in one of
these lesioned areas. Besides identifying the location of memory, psychologists also
studied memory retention.
Psychologists have defined memory on a chronological timeline: short term or
immediate memory (occurs within fractions of a second to seconds after initial learning),
working memory (occurs seconds to minutes after initial learning) and long term memory
(occurs days to years after initial learning) (Purves et al, 2008). Long term memory is
most frequently associated with knowledge retention. Ebbinghaus, a psychologist, has
contributed to the understanding of knowledge retention by testing long term memory
(Custers and Cate, 2011).
Ebbinghaus’s research focused on the differences in retention between
meaningful and meaningless data and observed that meaningful data had a slightly longer
retention rate than meaningless data, indicating that relevance is critical to retention.
Ebbinghaus quantified his conclusions in graphical form, termed the Ebbinghaus curves.
These curves identify the relationship between the quantity of knowledge retained and
time. Ebbinghaus’s research confirmed the decline of knowledge retention over time,
with a significant decline in knowledge retention immediately after initial learning.
Custers and Cate (2011) expanded upon Ebbinghaus’s research and investigated
retention of basic science knowledge in both medical student and physician populations.
20

They were able to specify three ranges where the amount of retention changed over time.
Immediately after learning, up until six years after the initial learning, a large amount of
knowledge is not retained. During this time, there is an inverse relationship between
knowledge retained and time elapsed (Custers and Cate, 2011). Custers and Cate’s
colleagues, Bahrick and Hall, explored the relationship between time of initial learning
and knowledge retention. They identified two additional stages of decreased retention
after the sixth year post initial learning period. From the sixth year after initial learning,
up to and including approximately the 25th year post initial learning, a slow, if any,
decline in retention is noticed. This is identified as a plateau on the curve. The final
retention period is identified graphically by another decrease in retention. This phase
begins after the 25th post initial learning year (Custers, 2010).
Educators for healthcare professionals often observe a drastic decrease in
retention as students complete their curriculum. This decrease in retention occurs within
the first segment of Ebbinghaus’s curve where knowledge loss is greatest. Therefore, it is
important that research into knowledge retention and memory be expanded. Research into
retention rates in healthcare professional student populations have focued on three topics:
1) identifying the students’ approach to learning, 2) evaluating the methods used to assess
students, and 3) by observing retention rates specific to the basic science disciplines.
The first area of investigation to determine how to increase retention of basic
science knowledge was to review the student’s approach to learning. Usually, students
approach material with either a surface or deep strategy. The surface strategy is focused
on short term learning, such as achieving the type of mastery needed to pass an
examination of a course. The deeper approach to learning has a focus to truly understand
21

the content in a variety of contexts and applications. This deeper approach to learning is
often catalyzed by a student’s motivation, but could also be influenced by the learning
environment (Hall and Durward, 2009). It has been suggested that the traditional lecture
format can promote surface learning. A moderate negative relationship was found
between the surface approach to learning and retention in student radiographers (Hall and
Durward, 2009). It has been hypothesized that different methods of instruction, such as
using multimedia tutorials, may guide students toward a deeper approach to learning and,
consequently, a higher retention rate. In a study that observed students who used
animations with embryology, the students’ retention of material four months after initial
learning was significantly higher than their peers who did not use the tutorials (Feigin,
Smirniotopoulos and Neher, 2002). The animations are able to assist both students and
educators to achieve the educational objectives. Students are able to gain science
knowledge by altering their approach strategy and educators are able to assign the
animations outside of a regularly scheduled course time, allowing for the educators to
adapt to the trend of decreasing curricular hours.
Another area of investigation for increasing student knowledge retention was to
examine the methods used for student assessment. Frequently, students are assessed using
multiple choice questions (MCQs). This method of assessment is often easiest for
educators because it allows educators to create detailed distractors that allow educators to
test specific student knowledge. MCQs facilitate the ease of grading and are used as an
objective assessment tool. Since MCQs are the most frequently used method of
assessment, many studies have researched how this type of assessment relates to both
learning and retention (Custers, 2010; Hall and Durward, 2009; Subramanian et al, 2012).
22

The validity of using MCQs as a means of assessment has been researched for a “cueing”
effect for students (Hall and Durward, 2009) and the ability to test very specific facts of
knowledge (Last et al, 2000) instead of a more global understanding of a concept, leading
to a criticism for promoting a superficial approach to student assessment of material
knowledge. Since superficial learning is often successful in only short term memory and
has been documented to be negatively related to retention, it is hypothesized that multiple
choice examinations may prevent long term retention. With the hope to find a better
method of assessment for knowledge retention, researchers have investigated how the use
of a short answer/fill-in-the-blank assessment affected students’ knowledge and retention.
One of the most cited short answer/fill-in-the-blank assessments in the medical
education literature is the carpal bone exam (Strkalj et al, 2011; Valenza et al, 2012). It is
used to determine retention of carpal bone anatomy. In this exam, students are given a
picture of the hand and wrist, with all 8 carpal bones labeled with a letter. Students are
required to provide answers in a fill-in-the-blank format within a predetermined time
frame. Since there are no distractors (as is the case with MCQs) or cues, the onus is on
the student to identify and provide the correct name for each carpal bone. In a study
comparing medical and physical therapy students that have taken the carpal bone test two
years after initial learning, the researchers revealed that retention was decreased in both
populations, with only 29% of all students able to identify all 8 bones properly (Valenza
et al, 2012). Differences in the number of bones that were identified by the students
varied. The physical therapy students had an overall better retention of carpal bones than
the medical students. Since the students are exposed to the same carpal bone material, the
23

difference may be attributed to curricular design (i.e. format of exposure to material) and
also perceived clinical relevance (Valenza et al, 2012).
The same carpal bone test was used to assess chiropractic students’ knowledge
when compared to medical student knowledge. The chiropractic students exhibited longer
retention rates and statistically significant differences from the medical students. In
Strkalj’s study, only 16% of fourth year medical students were able to identify all 8 bones
but 38% of fifth year chiropractic students were able to complete the same task. The
chiropractic students outperformed the medical students at accurately naming 5 of the
bones (60% chiropractic, 32% medical). The student populations identified specific
carpal bones that related to their scope of practice more frequently than those that did not.
For instance, the pisiform was most frequently identified by chiropractic students (5th for
medical students) because it is commonly used in manipulation techniques (Strkalj et al,
2011). This same carpal bone test was used for a between-subjects assessment of 3rd and
4th year medical students who also showed a decreased knowledge of the carpal bones
prompting an increased concern regarding students level of anatomy knowledge retention
(Valenza et al, 2012). Similar to multiple choice question exams, short answer exams,
such as the carpal bone test, revealed a decrease in retention. It is suspected that, due to
the lack of distractors, short answer exams more accurately identify the knowledge of
each student. It is also speculated that the short answer exam promotes a deeper approach
to learning, which should help increase retention. It is important to note that multiple
types of assessment should be required of students to help increase retention (Hall and
Durward, 2009). The implementation of various assessment types can assist in the decline
24

of basic science knowledge since different learning strategies are required for each
assessment type.
One last area of research regarding retention rates focuses on the specific
disciplines that are being tested for retention. Studies have shown that there are varying
degrees of retention in the basic sciences over time. The disciplines of anatomy,
physiology and biochemistry are often investigated most frequently for retention. These
disciplines are often taught at the beginning of a graduate healthcare professional
curriculum; therefore, they are more susceptible to retention loss by the time the students
are immersed in a clinical setting. Also, since these disciplines are the foundational basic
sciences, the students inability to retain information in these disciplines will adversely
affect their learning of more complex content. Researchers have observed differences in
basic science retention among various healthcare professional populations. For instance,
Last et al identified that dental students showed the largest decline in biochemistry
retention, followed by the disciplines of anatomy and physiology (Last et al, 2000)
whereas Custers identified gross anatomy as the basic science with the least amount of
retention, followed by physiology in a medical student population (Custers, 2000). This
retention of basic science is not only reserved for current students. In a survey of
physicians, Custers observed that physicians’ knowledge of basic science that was taught
to them during medical school decreased significantly after graduation. For example,
physicians who recently graduated from medical school answered approximately 40% of
questions correctly on a questionnaire that tested the disciplines of anatomy, physiology,
biochemistry and pathophysiology. In comparison, physicians who had graduated 50
years earlier, answered 25% of the questions correctly (Custers, 2000).
25

Several strategies have been identified to improve basic science retention and the
implementation of the strategies have offered some important findings. Spaced education
uses the principles of the spacing and testing effects (Shaw et al, 2011) and is often
implemented using technology. It allows for material to be repeated and tested on
multiple occasions (Shaw et al, 2011; Verkoeijen and Delaney, 2007). Investigation into
how to prevent this decline in knowledge have identified some important findings. First,
how the information is presented aids in retention. When material is compartmentalized
into systems (cardiovascular, gastrointestinal), it has been shown to produce higher
retention rates in students than material that is not centralized around a specific system
(Custers, 2000). The ability to increase the number of times that the material is presented
also increases retention. This theory, often termed spaced education, permits the learner
to be introduced to material and then become reintroduced and reacquainted with the
material. Kerfoot et al describes the implementation of spaced education in the form of
clinical cases that were e-mailed to medical students weekly to reinforce their
understanding of anatomy and physiology. The educators in this study found this use of
spaced education to be an efficient learning tool for the students and observed increase
retention with respect to the basic science information presented in these clinical cases
(Kerfoot et al, 2007). Kerfoot et al’s (2012) success in identifying improved retention
stimulated additional studies of implementing spaced eduction practices in a medical
student population. Students expressed enthusiasm for the use of spaced education as part
of their curriculum. Additionally, clinicians completing continuing medical education
also enjoyed participating in a spaced education program. Participant responses from this
study reported an increase in both their confidence of the knowledge that was presented
26

and their ability to apply the presented material in a clinical setting (Shaw et al, 2011).
Although much is known about basic science retention as time past initial learning
increases, there is still additional information regarding these processes to investigate.
Guided by a review of the educational literature regarding the anatomical and
physiological sciences, current instructional trends and curricular changes, this body of
work will examine the integration and retention of anatomy and physiology subject
material in graduate healthcare professional programs. Additionally, this work aims to
expand current knowledge of the relationship between the dorsal scapular artery and the
brachial plexus, as well as the anatomical structures related to biventricular pacing
procedures. The aim of these studies is to further clinicians’ knowledge of anatomical
variations and aid in their preparation for clinical procedures involving these anatomical
structures. Lastly, results from a pilot study regarding prior anatomy knowledge and its
correlation with anatomy course grades in a first year healthcare professional population
will be presented.
We also investigated anatomical variations present in the thoracic outlet region and
coronary sinus of the heart. The location and path of the dorsal scapular artery has been
studied intensely because it is responsible for supplying the levator scapulae, trapezius
and rhomboid muscles which are involved in elevation, depression and retraction of the
scapula, as well as arm adduction. However, literature regarding the origin of the dorsal
scapular artery is inconsistent. Our aim was to provide further empirical data on the
origin and association of the dorsal scapular artery with the brachial plexus. Next, we
sought to provide additional insight into coronary sinus anatomy and the frequency of
anatomic variations among the structures related to Biventricular Pacing (BVP)
27

procedures, since the success of these procedures is partially related to the ability to
implant leads into the heart, and since it is accepted that the coronary venous anatomy is
inconsistent and lead placement can be challenging because of this anatomical variation.
Our aims were to investigate the anatomical structures encountered in the coronary sinus
during biventricular pacing, including the various presentations of the Thebesian valve
and the diameters of the coronary sinus ostium, and to provide new data regarding the
length and diameter of the coronary sinus, as determined by cannulation of the sinus by
different sized catheters.
The specific aims of this dissertation are listed below.
Specific Aims
1. To determine if a relationship exists between the dorsal scapular artery and the
trunks of the brachial plexus.
a. Does the relationship between the dorsal scapular artery and the trunks of
the brachial plexus differ between genders?
b. Does the relationship between the dorsal scapular artery and the trunks of
the brachial plexus differ by side (left vs. right)?
2. To investigate the anatomical structures encountered in the coronary sinus during
biventricular pacing.
a. To determine the amount of travel of a catheter within the coronary sinus
from a 7F and an 8F guiding catheter, and if it differs by gender.
b. How does the Thebesian valve vary in its percent of occlusion at the
ostium of the coronary sinus?
28

3. Does prior knowledge of anatomy, and the level of that knowledge (assessed
using Bloom’s taxonomy) influence success in physiology?
a. Does prior knowledge of gross anatomy and microanatomy (histology)
have an influence on learning physiology?
b. Does performance at a moderate level of Bloom’s taxonomy predict
success at another level?
c. Does the professional curriculum in which the student is enrolled affect
their success in physiology?
d. Does the method of instruction have an influence on learning physiology,
or affect recall (immediate versus delayed)?
4. Does the level of assessment on a pre-test relate to performance in a healthcare
professional degree program first year human gross anatomy course?
29

CHAPTER 2
VARIATION IN THE ORIGIN OF THE DORSAL SCAPULAR ARTERY AND
ITS ANATOMICAL RELATIONSHIP WITH THE BRACHIAL PLEXUS
Overview
The most common origin of the dorsal scapular artery is the subclavian artery,
though less frequently, it arises from the thyrocervical trunk. There are also known
variations in its path through the brachial plexus. Our goals were to review prior
investigations into the origin and anatomical relationship of the dorsal scapular artery
with the brachial plexus, and to provide further empirical data. Forty-one sides of 34
cadaveric specimens were examined using anatomical dissection: 17 females and 17
males. Our findings match prior reports of a common origin of the dorsal scapular artery
from the subclavian artery (62.5%), with branching from the thyrocervical trunk observed
less frequently (37.5%). We also observed that the dorsal scapular artery passed with
equal frequency between the superior and middle brachial plexus trunks (45%) as the
middle and inferior trunks (45%). The dorsal scapular artery originated from the
subclavian artery and passed between the superior and middle trunks most frequently
(33%; 40% in males and 27% in females), and less frequently from the thyrocervical
trunk before passing either between the superior and middle brachial plexus trunks or
above the plexus (9.5% each in both genders). Females had a higher frequency for an
origin of this artery from the thyrocervical trunk before it passed between the middle and
30

inferior brachial plexus trunks (27%) than males (10%). We found gender-based
variations in the combined anatomical relationship of the origin of the dorsal scapular
artery and its path through the brachial plexus.
Introduction
The dorsal scapular artery is also known as: a. dorsalis scapulae, scapularis
descendens, a. scapularis dorsalis, ramus profundus of transverse cervical artery and the
descending scapular artery (Weiglein et al, 2005). The location and path of the dorsal
scapular artery has been studied intensely because it is responsible for supplying the
levator scapulae, trapezius and rhomboid muscles which are involved in elevation,
depression and retraction of the scapula, as well as arm adduction. However, literature
regarding the origin of the dorsal scapular artery is inconsistent.
Arterial compression of nerves resulting in pain or dysfunction is a known
phenomenon intracranially (Kandan et al, 2010; Sarsam et al, 2010); there are numerous
extracranial examples, as well (Kaufman et al, 2012; Trimble et al, 2011; Tubbs et al,
2003). Neurogenic thoracic outlet syndrome is frequently a result of anatomical
variations in the region of the brachial plexus. While cervical ribs, hypertrophied scalene
muscles and anomalous bands are most commonly implicated in the etiology of thoracic
outlet compression syndrome, a contribution from traversing arteries has also been
suggested, with the dorsal scapular artery being the most frequently implicated artery
(Chloros et al, 2009; Tubbs et al, 2006; Roos, 1976). In these cases, a location between
the middle and lower trunks of the brachial plexus is most often the problematic
anatomical variant.
31

Thus, our goals here were to review prior investigations into the origin and
association of the dorsal scapular artery with the brachial plexus, and to provide further
empirical data from 34 predissected cadaveric specimens. We will begin with a review of
the literature.
The origin of the dorsal scapular artery is most frequently associated with the
following structures: the thyrocervical trunk, the transverse cervical artery and the
subclavian artery. Previous research identifies the dorsal scapular artery as a branch of
the subclavian in 70-75% of cadaveric observations (Huelke, 1962; Lischka et al, 1982;
Reiner and Kasser, 1996). However, more recent studies have identified the prevalence of
the dorsal scapular artery originating from the subclavian at 37% (Weiglein et al, 2005),
with lower incidence from other arteries, as discussed further below. The disparity in
frequency of origin from the subclavian artery may be the result of differences between
the left and right subclavian arteries during embryological development and formation
because the left and right subclavian arteries have different arterial origins. The right
subclavian artery arises from three different structures during embryological
development: the right fourth aortic arch (proximal portion), the right dorsal aorta
(middle portion) and the right seventh segmental artery (distal portion). The left
subclavian artery develops entirely from the left seventh segmental artery (Kau et al,
2007). These differences from embryological development may affect the gross
anatomical location of the left and right subclavian arteries.
The subclavian artery is usually divided anatomically into three regions based on its
relationship to the anterior scalene muscle. Since the location of the dorsal scapular artery
is one key concern during surgeries in the brachial plexus region, an understanding of the
32

anatomical location of the dorsal scapular artery to these three regions of the subclavian
artery is needed. The second portion of the subclavian artery (which is posterior to the
anterior scalene muscle) and the third portion of the subclavian artery (which is lateral to
the anterior scalene muscle) of the subclavian artery are cited as the most frequent sites of
origin for the dorsal scapular artery. The dorsal scapular artery appears to arise from the
second and third parts of the subclavian artery with equal frequency. The dorsal scapular
artery has been shown to originate from the second part of the subclavian artery in
approximately 33% of observed cadavers (34% in Huelke, 1962; 35% in Reiner and
Kasser, 1996), and from the third portion of the subclavian artery in another one third
(33% in Huelke, 1962; 38.9% in Reiner and Kasser, 1996; and 35% in Tubbs et al, 2006).
In the remaining cadavers, the dorsal scapular artery arises from either the transverse
cervical artery with a frequency of 25-37% (25% in Reiner and Kasser, 1996; 31% in
Huelke, 1962; 33% in Huelke, 1958; and 37% in Weiglein et al, 2005). Additional
origins, though very rare, include the thyrocervical trunk (1%; Weiglein et al, 2005),
internal thoracic artery with a prevalence of 1% (Weiglein et al, 2005) to 10% (Lischka et
al, 1982), and the costocervical trunk (3%; Weiglein et al, 2005).
Cardiovascular and nervous structures of the brachial plexus have often been studied
simultaneously, due to their proximity to each other, and thus combined neurovascular
compression or complications in pathological states. With regard to the dorsal scapular
artery, a large variation of relationships with the brachial plexus have been reported. It
appears to pass most frequently between the superior and middle trunk, with prevalence
as high as 89% in a study by Reiner and Kasser (1996). However, other studies report
that when the dorsal scapular artery originates from the second portion of the subclavian,
33

it passes between the superior and middle trunks of the brachial plexus in 40-47% of
observed cadavers (Huelke, 1958; Reiner and Kasser, 1996). When the dorsal scapular
artery originates from the third part of the subclavian, the path is much more variable,
passing between the middle and inferior trunks with a range of 11% (Reiner and Kasser,
1996) to 40% (Huelke, 1958) of observed cadavers. In these instances, the dorsal scapular
artery has been documented to pass anterior to or through the medial scalene muscle
(Lischka et al, 1982). It may also be located posterior or lateral to the anterior scalene
muscle (Huelke, 1962). In cases where the dorsal scapular artery originates from the
transverse cervical artery, the dorsal scapular artery does not appear to pass through the
brachial plexus and is located medial to the anterior scalene muscle (Huelke, 1962).
In light of these inconsistencies, our next aim was to provide further empirical data
from 34 predissected cadaveric specimens.
Materials And Methods
Forty-one sides of 34 predissected cadavers were used to observe the origin of the
dorsal scapular artery, as well as its anatomical relationships to the brachial plexus. 17
females and 17 males were used. Cadavers ranged in age from 45 to 100 years old. Most
of the cadavers were pre-dissected by students (medical, physical therapy and
occupational therapy) enrolled in gross anatomy courses, although most of the cadavers
required additional dissection for this purpose. However, not all sides of each cadaver
could be used for this study as a result of these pre-dissections. As a consequence, 41
sides were used for data analysis. Cadavers were excluded from the study if a visible
cervical pathology or a surgical intervention in the cervical area was observed. Cadavers
34

were also excluded if the origin of the dorsal scapular artery or the components of the
brachial plexus could not be identified.
Results
In the 34 cadavers and 41 cadaveric sides used for this study, 24 sides were used to
determine the origin of the dorsal scapular artery. We found that it originated more
frequently from the subclavian artery (62.5% of the observed cadavers) than from the
thyrocervical trunk (37.5% of the observed cadavers). There was no significant difference
between the genders (Table 2-1).
Table 2-1: Comparison of origin of dosrsal scapular artery
Thyrocervical Trunk Subclavian Artery Males 4 8 Females 5 7 Total # 9 (37.5%) 15

(62.5%)
Twenty-five sides were used to observe the anatomical relationship of the dorsal
scapular artery with the trunks of the brachial plexus: 10 males and 12 females. The
dorsal scapular artery passed between the trunks of the brachial plexus in both genders:
82% in males, 78.5% in females (Table 2-2). The dorsal scapular artery passed superior
to the plexus in two remaining cadavers and inferior to the plexus in three cadavers
(Table 2-2). With approximately equal incidence, the dorsal scapular artery passed
between the superior and middle trunks of the plexus (Fig. 2-1A,B), as between the
middle and inferior trunks (Fig. 2-1C,D). Males were observed to have a slightly higher
incidence of the dorsal scapular artery passing between the superior and middle trunks
(45% compared to 36%); females had a slightly higher incidence of the artery passing
between the middle and inferior trunks (43% compared to 36%) (Table 2-2).
35

Table 2-2: Path of the dorsal scapular artery between the trunks of the brachial plexus
Above the plexus

Between S/M
Between M/I
Under the Plexus
Totals
Males 1 5 4 1 11 Males Females 1 5 6 2 14 Females Total # 2(8%) 10 (40%) 10 (40%) 3(12%)
25 Total
Examined Key: M/I =
middle and inferior trunks, S/M = superior and middle trunks
Twenty-four sides were used to observe both the origin of the dorsal scapular artery
and its anatomical relationship with the trunks of the brachial plexus: 10 males and 11
females. The most prevalent combination of dorsal scapular artery origin and brachial
plexus relationship observed was an origin from the subclavian artery before passing
between the superior and middle trunks of the plexus (29%; Table 2-3), with an origin
from the subclavian artery before passing between the middle and inferior trunks of the
plexus next most prevalent (25%). An origin from the subclavian artery before passing
under the trunks of the plexus was observed (13%) in both males and females. An origin
from the thyrocervical trunk and passing either between the superior and middle trunks of
the plexus (8%) or above the plexus (8%) were less common (Table 2-3). Of these,
females showed a higher occurrence of a thyrocervical trunk origin and a path between
the middle and inferior brachial plexus trunks, than males (15% compared to 9%).
36

Table 2-3: Summary of dorsal scapular origin and its path between the trunks of the brachial plexus
L. SA L. S/M
R. SA R. S/M
L. SA L. M/I
R. SA R. M/I
R. SA R. U
L. SA L. U
L. TT L. S/M
R. TT R. S/M
R. TT R. M/I
L. TT L. M/I
R. TT R. A Male 1 3 2 1 1 0 0 1 1 0 1 Female 2 1 3 0 1 1 1 0 2 1 1 Total # 3 4 5 1 2 1 1 1 3 1 2
SA SA SA TT TT TT S/M M/I U S/M M/I A Male 4 3 1 1 1 1 Female 3 3 2 1 3 1 Total # 7
(29%)
6 (25%)
3 (13%)
2 (8%)
4 (17%)
2 (8%) Key: A = Above, U = Under, L = Left, R = Right, M/I = Middle and Inferior Trunks, S/M
= Superior and Middle Trunks, SA = Subclavian Artery, TT = Thyrocervical Trunk
37

Figure 2-1: The path of the dorsal scapular artery between the trunks of the brachial plexus (A) The DSA
(indicated with an arrow) traversing between the superior and middle trunks of the brachial plexus. (B)
Higher power image of DSA from panel A, shown traversing between the superior (S) and middle (M)
trunks of the brachial plexus. (C) The DSA (arrow) traversing between the middle and inferior trunks of
the brachial plexus traversing between the middle and inferior trunks of the brachial plexus.(D) Higher
power image of DSA from panel A, shown traversing between the middle (M) and inferior (I) trunks of
the brachial plexus. Abbreviation: Subcl A = subclavian artery.
38

Discussion
Variability occurs with the origin of the dorsal scapular artery and its anatomical
relationship to the brachial plexus. This anatomical relationship is of interest to
anatomists and clinicians. Multiple studies have used cadaveric dissections to identify the
origin of the dorsal scapular artery. Older studies have cited that 70% of cadavers have
the dorsal scapular artery originate from the subclavian artery (Huelke, 1962), while more
recent studies report that slightly more than a third (37%) of cadaveric specimens have
the subclavian artery as the origin (Weiglein et al, 2005). The results from this study
identified that 62.5% of the specimens had the subclavian artery as the origin for the
dorsal scapular artery. Our findings indicate that gender is insignificant when discussing
the origin of the dorsal scapular artery.
The anatomical relationships of the dorsal scapular artery with the trunks of the
brachial plexus were also studied. It is widely accepted that the dorsal scapular artery has
an anatomical relationship with the trunks of the brachial plexus; however, the prevalence
and location of this relationship is highly variable. The dorsal scapular artery has been
documented to pass between the superior and middle trunks in 89% of cadavers (Reiner
and Kasser, 1996). This study identified a slightly lower prevalence rate of 40%. The
same prevalence rate (40%) occurred between the middle and inferior trunks. Previous
literature has documented this observation in as few as 11% (Reiner and Kasser, 1996)
and as many as 40% (Huelke, 1958) of cadavers. We found several gender differences in
this study, when the origin of the dorsal scapular artery was combined with its path
through brachial plexus were combined. These included an origin of the dorsal scapular
39

artery from the subclavian artery before it passed between the superior and middle trunks
(36% in males and 23% in females), and an origin of the dorsal scapular artery from the
thyrocervical trunk before it passed between the middle and inferior brachial plexus
trunks (23% in females and 9% in males).
We have a number of limitations to our study, including the small number of
cadavers. Additionally, the anterior scalene muscle was often unattached from its
insertion and could not be used as a structural reference. Previous experiments used the
anterior scalene muscle as a landmark to divide the subclavian artery into three
anatomical regions. The second part of the subclavian artery has been cited as the origin
of the dorsal scapular artery in approximately 33% of cadaveric specimens (34% in
Huelke, 1962, 35% in Reiner and Kasser, 1996). The third part of the subclavian artery
had a similar rate of origin (33% in Huelke, 1962, 38.9% in Reiner and Kasser, 1996 and
35% in Tubbs et al, 2006). Since the cadavers in this study were predissected, we were
not able to identify the relationship of the dorsal scapular artery to the subclavian artery.
Conclusion
Gender-based variations in the combined anatomical relationship of the origin of the
dorsal scapular artery and it path through the brachial plexus should be considered before
surgery to the brachial plexus region.
40

CHAPTER 3
CANNULATION OF THE CORONARY SINUS: VARIATION OF
ANATOMICAL STRUCTURES RELATED TO BIVENTRICULAR PACING
PROCEDURES
Overview
Biventricular Pacing (BVP) or Cardiac Resynchronization Therapy (CRT)
procedures are commonly performed on patients classified as NYHA class III or IV. The
success of BVP is partially related to the ability to implant leads into the heart. Three
leads are usually implanted: one into the right atrium, one into the right ventricle, and one
into the coronary sinus. It is accepted that the coronary venous anatomy is inconsistent
and lead placement can be challenging because of this anatomical variation. Therefore,
we aimed to provide additional insight into coronary sinus anatomy and the frequency of
anatomic variations among the structures related to BVP procedures. A total of 50 (26
male, 24 female) predissected cadavers were used to gather information regarding the
internal diameter of the coronary sinus ostium (7.47±2.69mm), the presence of a
Thebesian valve and the percent occlusion of the coronary sinus ostium by the Thebesian
valve. A Thebesian valve was present in 64% of the cadavers. The percent occlusion of
the coronary sinus ostium varied, with one cadaver having a complete occlusion.
Average measurements were compared by gender and analysis confirmed slight
differences between genders with respect to anatomical structures and variation. Two
41

different gauge catheters (7F and 8F) were used to simulate coronary sinus cannulation
and determine the length of catheter that could be extended into the coronary sinus from
the ostium towards the posterior surface of the heart.
Introduction
Biventricular pacing is a therapeutic modality for patients classified with NYHA
(New York Heart Association) class III or IV heart failure, i.e. those defined with either
marked or severe limitation in activity due to symptoms. Patients with a left ventricular
ejection fraction of 35% or less and a QRS interval of at least 120 ms are candidates for
biventricular pacing procedures (Jarcho, 2006). Biventricular pacing requires the
insertion of leads to help resynchronize ventricular contraction. Usually, three leads are
inserted into the heart via the subclavian or cephalic vein (Mair et al, 2005): one in the
right atrium, one in the right ventricle to pace the right ventricle and one via the coronary
sinus in order to pace the left ventricle. The third lead in biventricular pacing procedures
is threaded into the coronary sinus in order to reach a position close to the surface of the
left ventricle. Proximity of the tip of the lead to the left ventricle epicardium is necessary
to achieve pacing of the left ventricle.
It is recognized that the diameter of the coronary sinus and its formation by
cardiac vein tributaries show individual variation, as does the presence of a Thebesian
(coronary) valve at the coronary sinus ostium (Anh et al, 2008; Habib, Lachman,
Christensen, & Asirvatham, 2009; Hellerstein and Orbison, 1951; Karaca, Bilge, Dinckal,
& Ucerler, 2005). The Thebesian valve is a semicircular fold of the atrial membrane that
protects the entrance of the coronary sinus and prevents regurgitation of blood into the
sinus during right atrial contraction (Gray, 1995). The potential for anatomic occlusion
42

of the coronary sinus ostium by the Thebesian valve in any given patient is important
procedurally because even partial occlusion of the coronary sinus may prevent the
passage of a catheter and hence prevent successful placement of the lead that would
enable the left ventricle to be successfully paced. It is recognized that a knowledge of
coronary venous anatomy is important in cardiac resynchronization therapy (Duckett, et
al., 2011) and that the anatomy of the coronary venous system is highly variable (Loukas,
Bilinsky, Bilinsky, El-Sedfy, & Anderson, 2009). The inability to cannulate the coronary
sinus is often cited as a reason for biventricular pacing procedure failure (Karaca, Bilge,
Dinckal, & Ucerler, 2005; Loukas, Bilinsky, Bilinsky, El-Sedfy, & Anderson, 2009).
One purpose of this study was to investigate the anatomical structures
encountered in biventricular pacing, including the various presentations of the Thebesian
valve and the diameters of the coronary sinus ostium. Another aim of this study was to
provide new data regarding the length and diameter of the coronary sinus, as determined
by cannulation of the sinus by different sized catheters. In placing the left ventricular
pacing lead, it is often difficult for the clinician to identify which size catheter to use, as
well as how far into the coronary sinus the catheter can be extended. Therefore, we used a
7F and an 8F guiding catheter to simulate coronary sinus cannulation. By providing data
that will be helpful in selecting catheters for coronary sinus cannulation, it is our aim to
aid the electrophysiologist in increasing the success of biventricular pacing procedures.
Materials And Methods
This study used a total of 50 (26 male, 24 female) cadavers ranging in age from
47 to 100 (average age of both genders 81.9; male 79.0, female 85.1) years old. All
bodies were donated to the Humanity Gifts Registry of the Commonwealth of
43

Pennsylvania and were assigned to Temple University for the purposes of medical and
dental student education and research. A copy of the death certificate for each cadaver
was available and provided information on the age and cause of death of the donor.
However, the cause of death is not always an indicator of heart disease. We were unable
to review the medical history of the cadavers and the state of heart disease in each
cadaver is unknown. The cadavers were used initially in the gross anatomy course for
dental students, who completed a dissection of the thorax to expose the heart, lungs and
mediastinum.
Once the anatomy course was complete, the cadavers were used to gather data
regarding heart weight, presence or absence of the Thebesian valve, the diameter of the
coronary sinus ostium, the percent occlusion of the ostium of the coronary sinus by the
Thebesian valve and the length of the coronary sinus that could be cannulated by two
different sized catheters. Linear measurements were made using calipers (Mitutoyo
Absolute Digimatic Calipers Model Number CD-6”CX, Code number 500-171-20).
Figure 1 shows a schematic of the coronary sinus and Thebesian valve dimensions
measured. The catheters were both products of the Guidant Corporation and are
commonly used in biventricular pacing procedures.
In situ hearts were extracted from the cadaver by incising the great vessels at the
level of the sternal angle, which corresponds to the T4-T5 vertebral level, and is used as
an anatomical landmark for the inferior border of the aortic arch and the bifurcation of
the trachea. Any remaining pericardium was removed and any inferior attachments to the
diaphragm were severed. Blood clots were removed from the great vessels and the
chambers of the heart, as well as from the coronary sinus, using forceps. The presence of
44

bypass grafts, staples or leads was noted, and all leads were removed from the heart. Each
heart was flushed with water and towel dried prior to making any measurements.
The heart was weighed. The coronary sinus was inspected, noting the presence of
a Thebesian valve and whether the valve was membranous or trabeculated. Calipers were
used to determine the internal diameter of the coronary sinus ostium and the diameter of
the Thebesian valve. When measuring the internal diameter of the coronary sinus ostium,
we made sure to mimic the true presentation of the ostium by not compressing or
stretching the sinus. If a Thebesian valve was present, in addition to measuring the
diameter of the ostium, we also measured the opening between the free edge of the
Thebesian valve and the opposite wall of the coronary sinus ostium. This measurement
was termed the opening of the coronary sinus ostium (Figure 3-1). We also measured the
distance of catheter travel possible within the coronary sinus. We inserted a catheter into
the coronary sinus from the right atrium and continued to cannulate the coronary sinus as
far as possible without piercing or tearing the vessel. We used this approach with
catheters of 2 different sizes: a 7 French catheter (Outer diameter: 2.34mm, Inner
diameter, 1.87mm) and an 8 French catheter (Outer diameter: 2.67mm, Inner diameter:
2.2mm). Due to the varying degree and proficiency of the student dissection, not all
cadavers could be used for all of the desired measurements.
Results
In this study, we took various measurements pertaining to the coronary sinus that
will increase electrophysiologists’ knowledge of possible anatomical variations that may
hinder biventricular pacing procedures. A summary of the coronary sinus measurements
is listed in Table 3-1.
45

Table 3-1: Variations in coronary sinus measurement by gender (mean ± standard deviation).
Males Females Both Genders
Presence of Membranous Thebesian Valve
16 11 27
Presence of Trabeculated Thebesian Valve
0 3
3
Percent Occlusion of Coronary Sinus by Thebesian Valve
40.82±22.05% 41.57±26.22%
41.17±23.70%
Internal Diameter of the Coronary Sinus Ostium
12.18±3.63mm 10.66±2.56mm 11.44±3.21mm
Opening of the Coronary Sinus Ostium
7.82±3.30mm 7.08±1.82mm 7.47±2.69mm
Thebesian Valve
Sixty-two percent of the cadavers (31 out of 50) in our study had a Thebesian
valve. The majority of the valves (n=28) were membranous; however, three cadavers, all
female, presented with trabeculated (fenestrated) valves. The valve occluded a varying
percentage of the coronary sinus (minimally at 8.26% and maximally at 100%). Percent
occlusion was calculated as the difference between the internal diameter of the coronary
sinus ostium and the opening of the coronary sinus ostium divided by the internal
diameter of the coronary sinus ostium. Figure 3-2 shows the frequency of occlusion as a
group and also by gender. The average percent of occlusion in both genders was 41.17 ±
23.70 percent. The average female percent of occlusion was 41.57 ± 26.22 and males
yielded an average percent occlusion of 40.82 ± 22.05.
46

Internal Diameter of the Coronary Sinus Ostium
The ostia of most coronary sinuses had a circular presentation. When an ovoid
coronary sinus was present, the maximum diameter was recorded as the internal diameter
measurement. The internal diameter of the coronary sinus ostium as it opened into the
right atrium among both sexes averaged 11.44 ± 3.21mm. The ostia in females averaged
10.66 ± 2.56mm and 12.18 ± 3.63mm in males.
Opening of the Coronary Sinus Ostium
The measurement of the opening of the coronary sinus ostium identifies the
distance from the free edge of the Thebesian valve to the opposite edge of the coronary
sinus ostium. This measurement corresponds to the amount of space available for a
catheter to pass from the right atrium through the ostium and into the coronary sinus. The
average measurement for the opening of the ostium in both genders was 7.47 ± 2.69mm.
The ostium opening in females was an average of 7.08 ± 1.82mm and in males was an
average of 7.82 ± 3.30mm.
Catheterization of the Coronary Sinus
A summary of the data from coronary sinus cannulation is available in Table 3-2.
7F Guiding Catheter
For both genders, the average length of travel possible along the coronary sinus
for the 7F guiding catheter was 66.26 ± 5.94mm. In females, the cannulation distance was
slightly shorter (58.63±12.05mm) when compared to males (72.62 ± 15.94mm). In one
female cadaver with a Thebesian valve, the coronary sinus could not be fully cannulated
47

due to the presence of a blood clot. In that cadaver, the catheter was advanced 52.13mm
before being impeded by the blood clot.
Among both genders, a strong positive linear correlation (r=0.53, p<0.05) was
observed between the distance that the coronary sinus could be cannulated by the 7F
catheter and the internal diameter of the coronary sinus ostium. This correlation indicates
that the 7F catheter could be advanced farther in a coronary sinus with a larger internal
diameter of the coronary sinus ostium. The Pearson correlation between the distance
cannulated and the internal diameter of the coronary sinus ostium showed that males have
a stronger linear correlation between these two structures (r=0.50) than females (r=0.35).
8F Guiding Catheter
The average length of travel possible along the coronary sinus for the 8F guiding
catheter averaged 62.39 ± 16.03mm in females. Males averaged a slightly longer length
of travel (75.57 ± 18.06mm). Measurements using the 8F catheter yielded an average
length of travel among all cadavers of 69.39 ± 18.12mm.
Measurements from the 8F catheter showed a less statistically significant
correlation between cannulation distance and the internal diameter of the coronary sinus
ostium among both genders (r=0.39) than for the 7F catheter. For the 8F cannulation,
males yielded a stronger positive correlation (r=0.35) between cannulation distance and
the internal diameter of the coronary sinus ostium when compared to females (r=0.20).
48

Table 3-2: Average length of travel in the coronary sinus for a 7F and 8F cathether by gender
(mean ± standard deviation).
Males Females Both Genders Catheter size
7F Catheter 72.62±16.27mm 58.63±12.05mm 66.26±15.94mm
8F Catheter 75.57±18.06mm 62.39±16.03mm 69.39±18.12mm
Table 3-3: Raw data used for Figure 2
% Occlusion
Males Females Both
Genders 1-10 1 2 3 11-20 3 2 5 21-30 2 2 4 31-40 4 1 5
41-50 3 2 5 51-60 2 2 4 61-70 1 3 4 71-80 0 0 0 81-90 0 0 0 91-100 0 1 1
49

Figure 3-1: Image of the coronary sinus ostium (A) Lower power image of the coronary sinus ostium
(indicated by the asterisk) (B and C) Higher power image of the coronary sinus ostium and the free edge
of the Thebesian valve (indicated by the arrows) (D) Method of measurement of the coronary sinus. The
dotted circle indicates the ostium of the coronary sinus. A indicates the measurement site of the internal
diameter of the coronary sinus ostium. B indicates the measurement site of the height of the Thebesian
valve. C indicates the combined height of the ostium of the coronary sinus and the Thebesian valve,
which is the potential full size of the coronary sinus.
50

6
5
4
3
Females
2
Males
1
0
Figure 3-2: Frequency of percent occlusion of the coronary sinus ostium by a Thebesian Valve by group
and gender.
Heart Weight
The average heart weight in both genders was 293.04 ± 84.28 grams. Average
female heart weight was 267.57 ± 72.19 grams; average male heart weight was 316.55 ±
89.04 grams.
Discussion
Biventricular pacing or cardiac resynchronization therapy procedures are often
performed in patients that are classified as NYHA class III (Vlay, 2004). When
implanting pacing leads into the patient, the left ventricular lead placed into the coronary
sinus is often the most difficult lead to implant. Success rates with the cardiac
resynchronization procedure range between 53 and 98% (Ogul, Canbay, Diker, &
Aydogdu, 2010). The most common reason for failure is the inability to properly place
the left ventricular lead, which has been shown to occur in up to 12% in clinical trials
51

(Duckett, et al., 2011). As mentioned previously, the variable coronary venous anatomy
contributes to the difficulty of this procedure. Another complication is a stenotic
Thebesian valve (Loukas, Bilinsky, Bilinsky, El-Sedfy, & Anderson, 2009). The
Thebesian valve is a remnant of the inferior portion of the embryological right venous
valve (Sadler, 2004). Prior cadaveric research projects have identified a variable presence
of a Thebesian valve, ranging from an occurrence of 41% (Karaca, Bilge, Dinckal, &
Ucerler, 2005) to 67% (Loukas, Bilinsky, Bilinsky, El-Sedfy, & Anderson, 2009). Our
data supports this range with 64% of our cadavers presenting with a Thebesian valve.
In addition to variable presence of the valve, the composition of the Thebesian
valve also varies, with the valve presenting as either a membranous or a trabeculated
(fenestrated) structure. Loukas et al have documented variations in the number of tissue
strands that form the Thebesian valve (Loukas, Bilinsky, Bilinsky, El-Sedfy, &
Anderson, 2009). Our study supports that trabeculated Thebesian valves exist; however,
they are much less prevalent (3 out of 27) than membranous Thebesian valves.
The degree of occlusion of the coronary sinus ostium by the Thebeisan valve also
varies. Occasionally, the valve may completely occlude the coronary sinus, impeding
both the venous flow from the coronary sinus into the right atrium and the entrance of the
catheter from the right atrium into the coronary sinus (Habib, Lachman, Christensen, &
Asirvatham, 2009; Loukas, Bilinsky, Bilinsky, El-Sedfy, & Anderson, 2009). Our study
supports this variation in the degree of coronary sinus ostium occlusion (Figure 3-2). In
the cadavers that we observed, the average percent of occlusion was 41% in both genders.
Thebesian valves were noted to minimally occlude (8.25%), as well as completely
occlude the coronary sinus ostium (100%).
52

The success of implanting a catheter into the coronary sinus is not restricted to the
absence of a Thebesian valve or one that minimally occludes the sinus ostium. The size
of the opening of the coronary sinus ostium also affects the success of lead implantation.
We observed an average internal diameter of the coronary sinus ostium of 11.4mm
among both genders. These values are consistent with previous research studies that have
identified the diameter to range from 5 to 20mm, (Loukas, Bilinsky, Bilinsky, El-Sedfy,
& Anderson, 2009) 9±2.1mm with cited ranges of 5.2-14.0mm, (Tsao, et al., 2006) and 4-
14mm (Habib, Lachman, Christensen, & Asirvatham, 2009).
This information is valuable to electrophysiologists because it provides insight
into the differences that occur between genders with respect to lead advancement during
BVP or CRT procedures. Although additional studies will need to be performed, this
study provides empirical data identifying the different lengths that 7F and 8F catheters
are able to can be advanced into the coronary sinus from the right atrium.
It is important to note that these measurements were taken from hearts that had
been preserved. It is essential that these measurements be repeated in living subjects
because there are different challenges associated with live and preserved tissues. For
instance, we did our best to clear out all of the blood clots that resulted from the
preservation process. In a few occasions, the catheter was unable to advance due to a
blood clot in the vessel. In addition to the blood clots, the degree of dissection also
hindered our ability to gain the most accurate representation of the structures we were
researching. Often, the coronary sinus was cut and the full extent of cannulation could not
be determined. The flexibility of this vessel also varies between live and preserved tissue.
It is also important to note that we used the same 7F and 8F catheters for all of the hearts
53

that we measured. We used the same catheters in the hopes to gather data from a
consistent and reliable instrument. Since the catheters are flexible, it is possible that the
shape of the catheter changed (due to bends or kinks being introduced during
cannulation) and may have affected measurements in subsequent heart measurements.
Due to these complications, it is essential that further research investigate the
variations of anatomical structures associated with this procedure since the coronary
sinus, as supported by the literature, is highly variable in its presentation. This study
focused on the coronary sinus and its variations by looking at both genders, as well as
differences that occur between genders and furthered our knowledge of the coronary
sinus and Thebesian valve.
Despite these limitations, this knowledge will hopefully allow clinicians to have a
clearer understanding of the structural dimensions of the heart and vessels involved in
biventricular pacing procedures. Additionally, this information will help clinicians make
a more informed decision when selecting catheters for biventricular or cardiac
resynchronization therapy procedures.
54

CHAPTER 4
CORRELATION OF INTEGRATED INSTRUCTION AND SUCCESS AT LOWER
AND HIGHER TIERS OF BLOOM’S TAXONOMY IN ASSESSMENTS OF BOTH
IMMEDIATE AND DELAYED RECALL IN FIRST YEAR HEALTHCARE
PROFESSIONAL POPULATIONS
Overview
This study investigates student performance by level of Bloom’s taxonomy in the
disciplines of gross anatomy, microanatomy and physiology. Student volunteers in the
Schools of Medicine, Dentistry and Podiatric Medicine at Temple University participated
via a computer-based course management system (Blackboard 8) to learn elective
computer based tutorials and complete multiple choice quizzes in the disciplines of gross
anatomy, microanatomy and physiology. These quizzes served as immediate learning
assessments. Delayed learning was measured by performance on select items on the
physiology final examination. Podiatry student performance was also measured by a
section examination during the course.
Introduction
Anatomy (gross and microscopic) and physiology are requirements for students in
all healthcare professional programs (e.g., medical, dental, podiatry). However,
placement of these topics within the overall curriculum, as well as how the materials are
disseminated varies among individual programs and schools.
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Anatomy and physiology courses are part of the basic science portion of
healthcare professional curricula and are vulnerable to current curricular trends, including
a decrease in the hours dedicated to each course (Cottam, 1999; Drake, 2002; Peterson
and Tucker, 2005;). In order to cover all required materials, many institutions have
replaced traditional lectures with technology based instruction. With this model, students
are required to use technology to facilitate their learning and understanding of course
material outside of a traditional classroom environment. Unresolved are two issues: (a)
the most effective method to implement technology within a basic science curriculum,
and (b) the most effective way to organize content. Current literature describes the
advantages of implementing the use of technology for self guided learning (Foreman et
al, 2005; Granger et al, 2006; Grunewald et al, 2006; Inwood and Ahmad, 2005; Jastrow
and Hollinderbaumer, 2004; Ketelsen et al, 2007) and includes empirical research on
using technology in the basic science curriculum (DiLullo et al, 2006; Granger et al,
2006; Inwood, 2005; McNulty, 2004; Patham, 2009).
One way to evaluate the success of a curriculum is to assess student achievement
on specific learning objectives. Bloom’s taxonomy is a frequently used curriculum
development and assessment framework to organize and evaluate cognitive learning
goals at particular levels of cognitive complexity. The taxonomy is a multi-tiered
hierarchy that describes cognitive learning goals along a continuum of cognitive
complexity (i.e., from knowledge to evaluation). Mastery of a tier on the taxonomy is
determined by the ability of a student to perform a cognitive action at that level. For
instance, the foundational levels of the taxonomy test a basic understanding of
information. In these levels, students are expected to recall, as well as compare and
56

contrast, facts. Higher levels of the taxonomy require students to manipulate and apply
the material being assessed. For instance, students may be required to predict an outcome
or propose a resolution to a problem. Student success at individual levels of the taxonomy
has been studied across a variety of subject populations. Dobson (2001) confirmed the
taxonomy’s hierarchical structure when his research revealed that students studying
anatomy and physiology were more successful at lower levels of Bloom’s taxonomy than
at higher levels of the taxonomy. Additionally, success at the higher tiers of the taxonomy
has been correlated with greater success in an overall course (Cizek, Webb and Kalohn,
1995; Harries and Botha, 2007; Knecht, 2001), as well as with a deeper level of content
mastery (Azizan and Ibrahim, 2012).
Basic sciences are essential components of any healthcare curriculum and provide
prerequisite knowledge for the clinical sciences. The question of how to provide effective
and efficient science coverage within the demands of increased clinical focus is of
importance to healthcare educators and administrators. Traditionally, basic sciences are
presented as individual courses by discipline: one course dedicated entirely to gross
anatomy and another course dedicated entirely to physiology. There is a small but
growing movement to integrate multiple basic science courses in a single integrated
course. For instance, one course may cover both the gross anatomy and physiology of a
certain organ system. The idea of instruction of multiple science disciplines by topic
within one course is the foundation for an integrated curriculum. It is hypothesized that
students who participate in an integrated curriculum achieve higher scores on course
assessments and retain knowledge longer than students who are enrolled in a traditional
curriculum (Dienstag, 2011; Muller, 2008; Shimura, 2004)
57

The major focus of this study is to investigate the most effective means for the
teaching and learning of anatomical and physiological knowledge for first year healthcare
professional students. Students from medical, dental, and podiatry schools volunteered to
participate in this study. Methods and results are reported separately for each academic
sample. Four questions drive this investigation:
1. Do data support the theoretical assumption of Bloom’s taxonomy as a
hierarchical arrangement in which the success on higher order skills is related
to or predicted by success on lower order skills?
2. Does recall of prior knowledge in gross anatomy correlate with and predict
new learning of microanatomy and physiology?
3. Does the use of an integrated curriculum compared to a traditional separate
curriculum increase learning of microanatomy and physiology topics?
4. Does success on immediate achievement of microanatomy and physiology
topics predict success on later testing?
Methods
Medical Students
Sample
A group of 213 first year medical students were asked to participate in an IRB
approved (protocol 13926) educational research project. All IRB forms are located in the
appendix. This project took place during the first year, ten week medical physiology
course. Students were introduced to the study by the course director during regularly
58

scheduled class time. Students who chose to participate were required to complete three
multiple choice quizzes: 65 students initially enrolled in the research project and
completed the first quiz, 54 students completed the second quiz, and 45 students, who are
considered to be the final sample, completed the third quiz. A comparison of student
scores on the first and second quizzes revealed that there were no differences in
achievement between those who chose to continue their participation and those who
withdrew during the course of the study. Students who participated in this research
project did not receive any academic (extra credit) or monetary compensation.
Research Design
This is a single shot experiment design (Campbell and Stanley, 1963). The
dependent variables were the scores from four multiple-choice examinations: a quiz on
gross anatomy, a quiz on microanatomy, a quiz on physiology and select items embedded
in the final examination for the first year medical physiology course.
Materials
The adjunct course content was presented using software titled the Assembler
developed by Dr. James Heckman (2011). The Assembler program presents on the screen
as one page with four different sections: a table of contents, an audio section, a transcript
area and a PowerPoint slide area. A table of contents appears in the middle of the screen.
The table of contents identifies a page number and a title for each page and describes the
content presented on that page. There is a scroll bar on the right side of the table of
contents to allow a student to view all of the page titles in the tutorial. By clicking on the
59

table of contents, a student is able to immediately load a specific page of information.
The second section, located beneath the table of contents, is a block titled audio
transcript. This box displays the text associated with a specific page and has controls for
the student to be able to increase or decrease the font size. The third section, located
above the table of contents, contains four navigation buttons. These buttons allow the
student to change their position in the tutorial, much like a fast forward or rewind button.
Beneath the navigation buttons is a linear marker of the students location within the
tutorial. The final section of the tutorial is a box titled Bullet Points. This box presents a
PowerPoint slide containing important points from a specific page of the tutorial. The
PowerPoint slide in this box acts as a brief summary of the material being presented at
that time in the tutorial. Each page of the tutorial is linked with one PowerPoint slide.
With each click forward, the audio transcript, the audio file and the Bullet Points box
changes content. Students are unable to proceed to the next page until the audio file has
run from start to finish. After a student completes the entire tutorial, by viewing every
page, he/she is then able to return to any part of the tutorial. At this time, the student is
able to freely navigate the tutorial and does not need to wait for the audio file to finish to
advance to another page. This is accomplished by clicking on either the table of contents
or the audio section of the tutorial. Students were able to exit and reenter the program as
often as they desired. A screen shot of the Assembler software is shown in Figure 4-1.
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Figure 4-1: Screen Shot of Assembler Software
Instrumentation
Gross Anatomy Quiz
The Gross Anatomy Quiz is a 10-item, multiple-choice quiz designed to assess
learning of gross anatomy relating to the stomach, pancreas, and duodenum. Each
question of the quiz was linked to a level of Bloom’s taxonomy. Two questions were
designed to test learning at the knowledge level, 3 questions at the comprehension level,
2 questions at the application level and 3 questions at the analysis level. Questions were
presented in random order and students could only view each question once.
Microanatomy Quiz
The Microanatomy Quiz is a 10-question multiple choice quiz and tested
microanatomy (histology) knowledge of the stomach, pancreas, and duodenum. Similar
to the Gross Anatomy Quiz, the distribution of items across for the four lower levels of
Bloom’s taxonomy were the same: two questions at the knowledge level, 3 questions at
61

the comprehension level, 2 questions at the application level and 3 questions at the
analysis level. Questions were presented in random order and students could only view
each question once.
Physiology Quiz
The Physiology Quiz is a 10-question multiple choice quiz and tested physiology
knowledge of gastric and pancreatic secretion.The Physiology Quiz had the same
distribution of questions by Bloom’s taxonomy as the Gross Anatomy Quiz and the
Microanatomy Quiz: two questions at the knowledge level, 3 questions at the
comprehension level, 2 questions at the application level and 3 questions at the analysis
level.Questions were presented in random order and students could only view each
question once.
Course Final Examination
The final assessment consisted of 14 questions embedded as part of the final
examination for first year medical physiology. Seven questions tested microanatomy
content of the stomach, pancreas, and duodenum and seven questions tested physiology
knowledge of physiology content.
Procedures
Students were required to log into the course management system (Blackboard,
version SP8) and complete the Gross Anatomy Quiz prior to the instructional modules.
Students were given one hour to complete the quiz and were permitted access to the quiz
only once. Questions were randomized and students were allowed to view only one
question at a time. After completion of this first review quiz, students could then view the
didactic, computer-based tutorial covering microanatomy of the stomach, duodenum
62

and pancreas, as well as the layers of the alimentary canal. Upon completion of the
tutorial, the students were instructed to complete the Microanatomy Quiz. Similar to the
Gross Anatomy Quiz, the Microanatomy Quiz questions were randomized and viewed
only one question at a time. After completing the Microanatomy Quiz, students were
instructed to view another didactic computer based tutorial using the same software as the
microanatomy tutorial. The second tutorial introduced the physiological concepts of
gastric and pancreatic secretion. Upon completion of the physiology tutorial, the students
were instructed to complete the Physiology Quiz.
Students were encouraged to complete the entire research project within a one
week period. Project materials were presented to the students prior to their formal
didactic lectures titled gastrointestinal (GI) microstructure, gastric function and exocrine
pancreatic secretion in the physiology course. The first three quizzes became unavailable
at the time of the first in class didactic lecture although the tutorials were available until
the conclusion of the course (from the eighth week until the course was completed).
Dental Students
Sample
A group of 127 first-year dental students were asked to participate in an IRB
approved educational research project (protocol number 13926) during their first year, ten
week dental physiology course. All IRB forms are available for review in the appendix.
At the end of the third week of the course, students were introduced to the project by the
faculty instructor as well as by the student investigator. Participation in the research
project was voluntary and students who participated in the research project and
63

completed all of the research materials received extra credit on the physiology final
examination. Eighty seven students volunteered to participate: 43 students were randomly
assigned to the control (traditional curriculum) group and 44 students were randomly
assigned to the experimental (integrated curriculum) group.
Research Design
This study is a post-test only control group design (Campbell and Stanley, 1963).
The dependent variables were scores from four multiple-choice examinations: a quiz on
in the final physiology examination. The independent variable was the order of the
instruction that the students received (traditional vs. integrated). Students in the
traditional group viewed microanatomy information and physiology information
separately; students in the integrated group viewed microanatomy information and
physiology.
Materials
Similar to the medical students, the dental students used the Assembler software
to view research materials. The Assembler program used in the dental student
investigation was similar to the program that was used for the medical student study.
When the Assembler program was launched, the screen presented four different tables: a
table of contents, a transcript area, a PowerPoint area titled Bullet Points and a
PowerPoint slide area titled images. The dental student investigation used an upgraded
Assembler software program that permitted students to change the size and location of
each box by clicking and dragging the mouse.
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Instrumentation
Similar to the medical students, the dental students were required to complete
three multiple choice quizzes: one that tested gross anatomy of the stomach, duodenum
and pancreas (Gross Anatomy Quiz), one that tested the microanatomy of the stomach,
duodenum and pancreas (Microanatomy Quiz) and one that tested the physiology of
gastric and pancreatic secretion (Physiology Quiz). The score on microanatomy and
physiology items that were embedded in the physiology course final examination was
also used in data analysis.
Gross Anatomy Quiz
Similar to the Gross Anatomy Quiz in the medical student investigation, each
question on the Gross Anatomy Quiz in the dental student experiment reflected one of the
following levels of Bloom’s taxonomy: knowledge, comprehension, application or
analysis. The dental student Gross Anatomy Quiz contained 15 questions (in comparison
to the 10 questions on the medical Gross Anatomy Quiz): 3 at the knowledge level, 4 at
the comprehension level, 3 at the application level and 5 at the analysis level. Five
additional questions were added to the Gross Anatomy Quiz used for medical students.
Students had thirty minutes to complete each quiz; each question was presented only
once.
Microanatomy Quiz
Each question on the 15 question multiple choice Microanatomy Quiz was linked
to one of the following levels of Bloom’s taxonomy: knowledge, comprehension,
application or analysis. The dental student Microanatomy Quiz had an identical
distribution of items as the Gross Anatomy Quiz in the dental student experiment: 3 at the
65

knowledge level, 4 at the comprehension level, 3 at the application level and 5 at the
analysis level. Five additional questions were added to the Microanatomy Quiz used for
medical students. Students had thirty minutes to complete each quiz; each question was
presented only once.
Physiology Quiz
The Physiology Quiz is a 15 question multiple-choice quiz that has an identical
distribution of questions by Bloom’s taxonomy level as the Gross Anatomy Quiz and the
Microanatomy Quiz: 3 at the knowledge level, 4 at the comprehension level, 3 at the
application level and 5 at the analysis level. Five additional questions were added to the
Physiology Quiz used for medical students. Students had only thirty minutes to complete
each quiz; each question was only presented once.
Final Course Examination
The final examination for the dental physiology course was administered 18 days
after the completion of the final topic of the study (i.e., physiology). The final
examination covered material that was presented during the 10-week course. Thirteen
items covering the tutorial topics were embedded in the final examination. These served
as a measure of delayed recall.
Procedures
All of the research project materials were made accessible to the dental students
via Blackboard at the end of the sixth week of the course. The order of topic presentation
varied by condition. Students in the control group received the same presentation of
topics as in the traditional physiology course where microanatomy is presented first and
independent of physiology. Participants in the experimental group were presented
66

microanatomy and physiology simultaneously in an integrated format. Students from
both groups were required to complete the three previously mentioned multiple choice
quizzes. Students were able to access each quiz only once.
After first completing the Gross Anatomy Quiz, students in the control group were
presented two tutorials: one covering the microanatomy of the alimentary canal, stomach,
duodenum, and pancreas and one covering the physiology of gastric and pancreatic
secretion. Students were required to complete the microanatomy tutorial prior to the
physiology tutorial. The quizzes were presented separately after the corresponding
tutorial was completed. For students in the experimental group, after completing the
Gross Anatomy Quiz, they had access to the integrated learning tutorial. After completing
the tutorial, they had access to the Microanatomy Quiz, followed by the Physiology Quiz.
Students were not required to complete all research materials in one sitting. They
had the flexibility to log into and out of the tutorials, as well as between a tutorial and its
corresponding quiz. However, once a quiz was started, the student was required to
complete the quiz since he/she was not permitted to reenter the quiz. The dental students
were given six days to study the tutorial(s) and complete the three quizzes prior to
classroom lectures that addressed the topics in the tutorial(s). At that time, the quizzes
became unavailable to the students but students were still able to access the tutorial(s) for
their group. The scores from the Gross Anatomy Quiz, Microanatomy Quiz and
Physiology Quiz were not factored into a student’s final course grade.
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Podiatry Students
Sample
A group of 97 first-year podiatry students were asked to participate in an IRB
approved (protocol 20923) educational research project that occurred during their
nineteen week first year physiology course. All IRB forms are available for review in the
appendix. The project was introduced by the faculty instructor during the seventh week
of the course. Participation in the educational research project was voluntary. Students
who participated in the research project and completed all of the research materials
received extra credit on the final examination of the first year, podiatry physiology
course. Seventy eight students volunteered to participate: 38 students were randomly
assigned to the control (traditional) group and 40 students were randomly assigned to the
integrated (experimental) group.
Research Design
This investigation is a replication of the post-test only control group design
implemented with dental students. The dependent variables were scores from the same
four multiple-choice examinations that occurred in the prior investigations: a quiz on
in the final physiology examination. Scores on an in-class examination were also
included as a delayed test. The independent variable was the order of the instruction that
the students received (traditional vs. integrated).
Materials
Identical materials were used with the podiatry student sample as were used with
the dental student sample. These materials were previously described.
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Instrumentation
Identical instruments were used in the podiatry student experiment as were used
in the dental student sample. A description of these instruments is not repeated here. In
addition to the class final examination, data were also available from an in-class
examination that only covered topics related to gastrointestinal (GI) physiology. This
assessment is termed GI Exam and the student scores from this assessment were used in
the analysis of delayed recall.
Procedures
Procedures for podiatry students were identical to those followed in the dental
student inventigation. After first completing the Gross Anatomy Quiz, students in the
control group completed a tutorial and the Microanatomy Quiz (on microanatomy of the
alimentary canal, stomach, duodenum and pancreas) followed by a tutorial and the
Physiology Quiz (on physiology of gastric and pancreatic secretion). Students were
required to complete the microanatomy tutorial prior to the physiology tutorial. For
students in the experimental group they first completed the Gross Anatomy Quiz,
followed by an integrated microanatomy/physiology tutorial and then the Microanatomy
Quiz, followed by the Physiology Quiz.
Students were not required to complete all research materials in one sitting. They
had the flexibility to log into and out of the tutorials, as well as between a tutorial and its
corresponding quiz. However, once a quiz was started, the student was required to
complete it. Podiatry students had five days to complete the tutorials and quizzes prior to
when these topics were presented by the faculty in the classroom. At that time, the
quizzes were made inaccessible; however, students in both groups were still able to view
69

the tutorial(s) for their group. The in-class GI examination occurred 11 days after the
completion of the last tutorial and quiz; the final examination occurred 11weeks after the
last tutorial and quiz were completed. The scores from the Gross Anatomy Quiz,
Microanatomy Quiz and Physiology Quiz were not factored into a student’s final course
grade.
Results
Medical Students
Data from the medical student sample was used to answer: Research Questions 1, 2 and
4. This was a single group design so Research Question 3 was not addressed.
Research Question 1: Do data support the theoretical assumption of Bloom’s taxonomy
as a hierarchical arrangement in which the success on higher order skills is related to or
predicted by success on lower order skills?
Descriptive Findings
Gross Anatomy Quiz.
For medical students, the Gross Anatomy Quiz was a review of prior knowledge
from a previous course. If they had engaged in deep learning of this topic, they were
expected to perform well at all levels of learning. However, a visual inspection of the
correct percent of responses (Table 4-1) revealed that medical students did not perform
in the predicted manner. They performed well on the knowledge level questions;
however, medical students were most successful on the application level questions. The
percent correct scores ranged from 39.3% on the analysis level to 74.5% on the
70

application level. Pearson correlations were conducted between scores on the four levels
of Bloom’s taxonomy. No statistically significant relationships exist between levels of
Bloom’s taxonomy on the gross anatomy quiz.
Microanatomy Quiz.
A visual inspection of the data (Table 4-1) reveals that students performed more
successfully on lower order cognitive skills (i.e., knowledge and comprehension) than
higher order cognitive skills (i.e., application and analysis). The medical students were
most successful at the comprehension level (83%) and least successful at the analysis
level (34%). Pearson correlation analysis revealed a statistically significant correlation (r
= .41, p = 0.006) on the Microanatomy Quiz between scores on the comprehension and
analysis levels (Table 4-2).
Physiology Quiz.
A visual inspection of the data (Table 4-1) indicates the predicted hierarchical
arrangement of Bloom’s taxonomy. Medical students were most successful at the
knowledge level (94.5% correct) and were least successful at the analysis level (38.7%
correct). As the questions increased in cognitive complexity, students found it more
difficult to be successful. Results of Pearson’s correlation between levels revealed a
statistically significant correlation between the comprehension and application levels of
Bloom’s taxonomy, r = .42, p = 0.004, (See Table 4-2), indicating that students who were
successful at the comprehension level of Bloom’s taxonomy tended to be successful at
the application level of Bloom’s taxonomy.
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Table 4-1: Percent Correct on Gross Anatomy, Microanatomy, and Physiology Quizzes for Medical Students
No. items Gross Anatomy
Percent
Microanatomy Percent
Physiology Percent Knowledge 2 73.5% 72.0% 94.5% Comprehension 3 54.0% 83.0% 69.7%
Application 2 74.5% 73.5% 40.0% Analysis 3 39.3% 34.0% 38.7% Total 10 57.6% 64.2% 59.3% Note:
Scale scores are expressed in terms of percent correct due to variability in the number of items for each
level of Bloom’s taxonomy.
For each of the medical topics, the decreasing success on items as the level of
cognitive complexity increases is illustrated in Figure 4-2. In summary, medical students
did not perform as well as predicted on the Gross Anatomy Quiz. Since the medical
students completed an entire course in gross anatomy prior to the experiment, it was
expected that the students would score well on all levels of Bloom’s taxonomy. The
students were predicted to be more successful on lower order cognitive skills (i.e.,
knowledge and comprehension) and less successful on the higher order cognitive skills
(i.e., application and analysis) as they were in the process of building their mental
representations of the new topics of microanatomy and physiology (See Figure 4-2).
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100
90
80
70
60
Knowledge Comprehension Application Analysis
Gross Anatomy
Microanatomy
Physiology
50
40
30
20
10
0
Figure 4-2: Percent Correct by Level of Bloom’s Taxonomy from Medical students on quizzes in Gross
Anatomy, Microanatomy and Physiology
Table 4-2: Correlation of Total Score on Gross Anatomy, Microanatomy and Physiology Quizzes for Medical
Students
GK GC G1 G2 GT MK MC M1 M2 MT PK PC P1 P2 PT
GK -.051 -.283 -.039 .225 -.094 -.018 .085 -.175 -.086 .174 -.140 .013 .116 .032
GC .224 -.169 .639* -.020 -.156 -.093 -.119 -.168 .092 .078 .068 -.091 .027
G1 -.043 .479* -.048 .072 -.140 -.030 -.060 -.178 -.041 .139 -.016 -.011
G2 .443* .072 .098 .262 -.009 .181 -.010 .217 .309* .202 .317*
GT -.033 -.017 .063 -.170 -.067 .042 .101 .298* .101 .213
MK -.110 .044 .236 .490* -.095 .147 .124 .274 .244
MC .045 .405* .593* -.178 -.084 -.093 -.350* -.293
M1 .102 .505* -.203 .052 .012 -.011 -.013
M2 .745* -.232 -.096 -.112 -.046 -.150
MT .303 .006 -.031 -.066 -.097
PK .037 .000 .130 .265
PC .420* .148 .703*
P1 .238 .674*
P2 .717*
PT
Note: GK = Gross Anatomy Knowledge, GC= Gross Anatomy Comprehension, G1 = Gross Anatomy Application,
G2 = Gross Anatomy Analysis, GT = Gross Anatomy Total, MK = Microanatomy Knowledge, MC =
Microanatomy Comprehension, M1 = Microanatomy Application, M2 = Microanatomy Analysis, MT =
Microanatomy Total, PK = Physiology Knowledge, PC = Physiology Comprehension, P1 = Physiology Application,
P2 = Physiology Analysis, PT = Physiology Total. N = 45.* p < .05.
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Regression Analyses
For each quiz, knowledge and comprehension items were combined to form lower
cognitive skills and application and analysis scores were summed to form higher order
cognitive skills. Simple regression analysis of microanatomy lower order cognitive skills
on higher order cognitive skills was statistically significant, F(1,43) = .6.845, p = .012,
accounting for 13.7% of the variance of higher order cognitive skills (Table 4-3),
indicating that success on lower order cognitive skills can predict success on higher order
cognitive skills in microanatomy.
Table 4-3: Regression of Microanatomy Lower Order Cognitive Skills on Higher Order Cognitive Skills in
Medical Students Model Sum of
Squares
Df Mean Square F Sig.
Regression 4.565 1 4.565 6.845 0.012 Residual 28.679 43 0.667 Total 33.244 44
Summary
Model R R Square Adj. R Square Std. Error of Est. 1 0.371 0.137 0.117 0.81667
Coefficient Model Unstandardized B
Coefficient Std. Error
Standardized Coefficient Beta
T Sig.
Constant 0.923 0.611 1.511 0.138 Higher Ord 0.398 0.152 0.371 2.616 0.012 N = 45.
For the Physiology Quiz, simple regression analysis of lower order cognitive skills
on higher order cognitive skills was statistically significant, F (1,43) = 5.213, p = .027,
accounting for 10.8% of the variance of performance on higher order cognitive skills (see
Table 4-4).
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Table 4-4: Regression of Physiology Lower Order Cognitive Skills on Higher Order Cognitive Skills in
Medical Students Model Sum of
Squares
Summary Model R R Square Adj.R Square Std. Error of Est. 1 0.329 0.108 0.087 1.22129
Coefficient Model Unstandardized
B
Standardized Coeff. Beta
t Sig.
Constant 0.132 0.819 0.161 0.873 Higher Ord. 0.459 0.201 0.329 2.283 0.027 N = 45.
Research Question 2: Does recall of prior knowledge of gross anatomy influence new
learning of microanatomy and physiology?
Descriptive Analyses
Pearson correlations were calculated to determine relationships among scores on
gross anatomy, microanatomy, and physiology quizzes (see Table 4-2). Statistically
significant positive correlations were identified between the Gross Anatomy Quiz score
and the physiology application subscale (r = .298, p = .047). Additionally, statistically
significant positive correlations were found between the gross anatomy analysis subscale
and the physiology application subscale (r =.309, p = .039) and the gross anatomy
analysis subscale and the Physiology Quiz score (r = .317, p = .034). A statistically
significant correlation was found between microanatomy comprehension and physiology
application (r = -.350, p = .018, Table 4-4), indicating that students who scored well on
the microanatomy quiz at the comprehension level of Bloom’s taxonomy tended not to
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score well on the physiology quiz at the application level of Bloom’s taxonomy.
Additional analyses were conducted to see if scores on the gross anatomy subscales
related to scores on the microanatomy quiz. No other statistically significant correlations
were found.
Regression Analyses
A multiple regression using the Gross Anatomy subscales as predictors of the
Physiology Quiz score was not statistically significant. Based on the occurance of
statistically significant correlations (see Table 4-2), simple regressions were conducted.
The Gross Anatomy Analysis subscale was found to be a statistically significant
predictor of the final score on the Physiology Quiz for medical students, F(1,43) = 4.806,
p = .034 and it accounted for 10.1% of the variance (see Table 4-5). Further exploration
revealed that the gross anatomy analysis subscale accounted for 8.9% of the variance for
the physiology application subscale.
Table 4-5: Regression of Gross Anatomy Analysis Subscale on Physiology Quiz Total for Medical Students
Model Sum of
Squares
Df Mean
Square
F Sig.
Summary
.
Model R R Square Adj.RSquare Std. Error of the est. 1 0.317 0.101 0.080 1.728
Standardized Coeff. Beta
t Sig.
Constant 0.366 0.387 0.947 0.349 Physiology 0.137 0.062 0.317 2.192 0.034 N = 45.
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Research Question 4: Were students who were successful on the Microanatomy Quiz and
the Physiology Quiz (immediate learning) successful on microanatomy and physiology
items on the final examination (delayed learning)?
Pearson correlations did not reveal any statistically significant relationships
between (a) the total score of the microanatomy quiz and the sum of the 7 microanatomy
items on the final examination and (b) the total score on the physiology quiz and the sum
of the 7 physiology items on the final examination. However, there was a statistically
significant relationship between the sum of the microanatomy questions on the final exam
with the sum of the physiology questions on the final exam (Table 4-6), indicating that
students who scored well on the microanatomy final exam questions tended to score well
on the physiology final exam questions.
Regression Analysis
A multiple regression using the four subscales of the microanatomy quiz (i.e.,
knowledge, comprehension, application and analysis) was conducted on the sum of the
microanatomy items on the final examination. No statistically significant predictors were
obtained. A multiple regression using the four subscales of the physiology quiz on the
sum of the physiology items on the final exam did not reveal any statistically significant
predictors.
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Table 4-6: Correlation of Scores on Microanatomy and Physiology Quizzes with Final Exam Score for
Medical Students Correlation of Discipline Quiz Scores with Final Examination Scores
MA Quiz P Quiz MA Final P Final MA Quiz -0.097 0.146 0.027 P Quiz 0.202
0.168 MA Final 0.334* P Final Note: MA = Microanatomy, P = Physiology.* p < 0.01.
Dental Students
Eighty-seven dental students participated in the educational research project: 43
students were assigned into the control group (group A) and 44 students were assigned to
the experimental/integrated (group B) group. These data allowed all four research
questions to be addressed.
as a hierarchical arrangement in which success on higher order skills is related to or
Gross Anatomy Quiz
Dental students had previously completed a course in gross anatomy, thus the
Gross Anatomy Quiz was a review of prior knowledge. Similar to hypotheses about the
performance of medical students, it was predicted that the dental students would perform
well on the four levels of the Gross Anatomy Quiz. However, the pattern of correct
percent responses revealed that dental students did not perform in the predicted manner.
They tended to answer about half of the questions correctly with the lowest performance
on comprehension (45.1%) and the highest on the application (61.3%). (See Table 4-7).
Analysis of Pearson correlations for all dental students (N = 87) revealed statistically
78

significant relationships between the knowledge and application levels (r = .296, p =
.005), comprehension and application levels (r = .261, p = .015), comprehension and
analysis levels (r = .313, p = .003) and application and analysis levels (r = .348, p = .001)
(Table 4-8).
Microanatomy Quiz
The Microanatomy Quiz was a partial review of prior knowledge for the dental
students. The dental students completed a full semester course titled general and oral
histology which contained general principles that could aid them in their performance in
microanatomy. The dental students were most successful on the comprehension questions
(57.5%) and least successful on the analysis questions (26.0%) (Table 4-7). Statistically
significant relationships between lower and higher levels were found for knowledge and
comprehension levels (r = .328, p = .002) and the comprehension and application levels (r
= .222, p = .039) (Table 4-8).
Physiology Quiz
The percent correct on the physiology quiz ranged from a low of 22.6% at the
application level to 64.8% on the knowledge level. Student performed better on lower
order cognitive skills than higher order cognitive skills, as predicted by Bloom’s
taxonomy (Table 4-7). Similar to the microanatomy quiz, a statistically significant
correlation was found between knowledge and comprehension levels (r = .404. p = .000)
on the physiology quiz and between the comprehension and analysis levels (r = .435, p =
.000) (Table 4-8).
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Table 4-7: Percent Correct on Gross Anatomy, Microanatomy, and Physiology Quizzes for Dental Students
Percent
Microanatomy Percent
Physiology Percent Knowledge 3 45.2% 48.9% 64.8% Comprehension 4 45.1% 57.5% 46.6%
Application 3 61.3% 55.6% 22.6% Analysis 5 46.7% 26.0% 30.3% Total 15 48.9% 44.8% 40.0% Note:
Scale scores are expressed in terms of percent correct due to variability in the number of items for each
level of Bloom’s taxonomy. N = 87.
Table 4-8: Correlations of Total Scores on Gross Anatomy, Microanatomy and Physiology Quizzes for Dental
Students
GK .203 .296* .208 .531* .153 .179 .066 .014 .175 .138 .180 .098 .208 .256*
GC .261* .313* .685* .280* .305* -.070 -059 .205 .292* .236* .084 .030 .256*
G1 .348* .703* .336* .309* .282* .079 .414* .290* .223* .156 .212* .354*
G2 .751* .370* .318* .073 .110 .365* .224* .166 .046 .174 .251*
GT .439* .422* .126 .059 .442* .358* .295* .136 .220* .409*
MK .328* .190 .065 .634* .305* .287* .327* .062 .375*
MC .222* .092 .730* .397* .223* .043 .167 .338*
M1 .060 .580* .210 .223* -.137 .291* .266*
M2 .480* .113 .029 .165 -.039 .091
MT .431* .312* .157 .199 .442*
PK .404* .075 .127 .641*
PC .017 .435* .798*
P1 -.065 .323*
P2 .669*
PT
P2 = Physiology Analysis, PT = Physiology Total. * p < .05.
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Regression Analyses
Simple regression analyses of lower order cogntive skills on higher order
cognitive skills for each discipline quiz (i.e., gross anatomy, microanatomy and
physiology) were statistically significant. Gross anatomy lower order cognitive skills on
gross anatomy higher order cognitive skills was statistically significant, F(1, 85) =
18.328, p = .000, accounting for 17.7% of the variance (Table 4-9). Similar regressions
were conducted for the control group and the experimental group separately. For the
control group, The predictor variable accounted for 15.0% of the variance (F(1, 41) =
7.220, p = .010) (See Table 4-10) and for the experimental group it accounted for 21.2%
of the variance (F (1,42) = 11.295, p = .002) (See Table 4-11).
Table 4-9: Regression of Gross Anatomy Lower Order Cognitive Skills on Higher Order Cognitive Skills for
All Dental Students Model Sum of
Squares
Regression 44.063 1 44.063 18.328 .000 Residual 204.351 85 2.404 Total 248.414 86
Summary
Model R R Square Adjusted R Square Std. Error of the est. 1 .421 .177 .168 1.55052 Coefficient
Model Unstandardized B
t Sig.
Constant 2.422 .441 5.489 0.000 Higher Ord .554 .129 .421 4.281 0.000 N = 87.
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Dental Students Control Group Model Sum of
Squares
Summary
Model R R Square Adjusted R Square Std. Error of the est. 1 0.387 .150 .129 1.55380
Coefficient
t Sig.
Constant 2.544 .631 4.029 0.000 Higher Ord 0.486 .181 0.387 2.687 0.010 n = 43.
Dental Students Experimental Group Model Sum of
Squares
Summary
Model R R Square Adjusted R Square Std. Error of the est. 1 0.460 .212 .193 1.57216
t Sig.
Constant 2.270 .629 3.611 0.001 Higher Ord .633 .188 0.460 3.361 0.002 n = 43.
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Simple regression analysis of microanatomy lower order skills on higher order
microanatomy skills was statistically significant, F(1, 85) = 5.199, p = .025, accounting
for 5.8% of the variance (Table 4-12). The same analysis was conducted by group. The
regression analysis for the control group was statistically significant with the lower order
skills predicting higher order skills in microanatomy, F(1, 41) = 5.206, p = .028 and
accounting for 11.3% of the variance (Table 4-13). For the experimental group, the
regression was not statistically significant.
Table 4-12: Regression of Microanatomy Lower Order Cognitive Skills on Higher Order Cognitive Skills for
All Dental Students Model Sum of
Squares
Summary
t Sig.
Constant 2.255 .344 6.561 0.000 Higher Ord .189 .083 .240 2.280 .025 Note: N = 87.
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Table 4-13: Regression of Microanatomy Lower Order Cognitive Skills on Higher Order Cognitive Skills for
Dental Students in the Control Group Model Sum of
Squares
Summary
Model R R Square Adjusted R Square Std. Error of the
estimate 1 0.336 .113 .091
1.36132
t Sig.
Constant 2.012 .517 3.892 0.000 Higher Ord .304 .133 0.336 2.282 .028
Note: n = 43.
Finally, a simple regression using physiology lower order skills on higher order
skills was statistically significant, F(1, 85) = 10.049, p = .002, accounting for 10.6% of
the variance (Table 4-14). Further regressions were conducted separately for tthe control
and experimental groupse For the control group, lower order skills accounted for 9.4% of
the variance in the higher order skills, F(1, 41) = 4.237, p = .046, (Table 4-15). For the
experimental group, lower order skills accounted for 12.9% of the variance in the higher
order skills, F(1, 42) = 6.207, p = .017 (Table 4-16).
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Table 4-14: Regression of Physiology Lower Order Cognitive Skills on Higher Order Cognitive Skills for All
Dental Students Model Sum of
Squares
Summary
Model R R Square Adjusted R Square Std. Error of the est. 1 .325 .106 .095 1.20353
t Sig.
Constant 1.246 .326 3.820 0.000 Higher Ord .250 .079 .325 3.170 0.002 Note: N= 87.
Table 4-15: Regression of Physiology Lower Order Cognitive Skills on Higher Order Cognitive Skills for
Dental Students in the Control Group Model Sum of
Squares
Summary
t Sig.
Constant 1.191 .539 2.211 .033 Higher Ord .257 .125 .306 2.058 .046 n = 43.
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Table 4-16: Regression of Physiolology Lower Order Cognitive Skills on Higher Order Cognitive Skills for
Dental Students in the Experimental Group Model Sum of
Squares
Summary
t Sig.
Constant 1.293 .388 3.335 .002 Higher Ord .243 .098 .359 2.491 .017 Note: n = 44.
Research Question 2: Does recall of prior knowledge in gross anatomy correlate with
Pearson correlations were calculated to determine the relationship among scores
on gross anatomy, microanatomy, and physiology quizzes. A number of positive
statistically significant correlations exist between the gross anatomy subscales and the
microanatomy subscales and the physiology subscales (Table 4-8). Statistically
significant correlations were found between the Gross Anatomy Quiz and the
Microanatomy Quiz (r = .442, p = .000) as well as between the Gross Anatomy Quiz and
the Physiology Quiz (r = .354, p = .001). The higher order skills in the gross anatomy
quiz (i.e., application and analysis) were positively correlated and were also statistically
significant correlated with the Microanatomy Quiz. Each subscale on the gross anatomy
quiz was statistically significantly related to the Physiology Quiz total. Pearson
86

correlations revealed statistically significant positive relationships between the disciplines
of gross anatomy and physiology. The gross anatomy comprehension subscale had a
statistically significant relationship with the physiology knowledge subscale (r = .292, p
= .006), the physiology comprehension subscale (r = .236, p = .028) and the physiology
total score (r = .256, p = .017).
Regression Analysis
Microanatomy Quiz final score was statistically significant, F(4, 82) = 6.114, p = .000,
accounting for 23.0% of the variance (Table 4-17). Gross Anatomy application and
analysis subscales were the significant predictors. Similar multiple regressions were
calculated for both the control and experimental groups. No statistically significant
relationships were observed in the control group. However, a statistically significant
relationship between the Gross Anatomy subscales and Microanatomy Quiz was
observed for the experimental group (F (4, 39) = 3.905, p = .0096) and accounted for
28.6% of the variance (Table 4-18). The significant predictor was the analysis subscale.
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Table 4-17: Regression of Gross Anatomy Subscales on Microanatomy Quiz Total for All Dental Students
Model Sum of

Squares
Summary
t Sig.
Constant 3.651 .759 4.810 0.000 Knowledge .097 .407 .025 .239 .812 Comp .109 .257 .044 .425
.672 Application .829 .285 .313 2.908 0.005 Analysis .523 .236 .237 2.215 0.030 Note: Comp =
Comprehension. N = 87.
Table 4-18: Regression of Gross Anatomy Subscales on Microanatomy Quiz Total for Dental Students in the
Experimental Group Model Sum of
Squares
Summary
estimate 1 .535 .286 .213
2.25259
t Sig.
Constant 3.277 1.098 2.984 0.005 Analysis .826 .368 .360 2.246 0.030 n = 44.
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Physiology Quiz score was statistically significant F(4, 82) = 4.505, p = .002, which
accounted for 18.0% of the variance (Table 4-19). Gross Anatomy application and
analysis subscales were significant predictors. Similar regressions were calculated for
both the experimental and control groups. The regression for the control group revealed
statistically significant results, F (4, 42) = 3.951, p = .009, accounting for 29.4% of the
variance (Table 4-20). The Gross Anatomy application subscale was a significant
predictor for the Physiology Quiz score for the control group. The multiple regression for
the experimental group was not statistically significant.
Table 4-19: Regression of Gross Anatomy Subscales on Microanatomy Quiz Total for All Dental Students
Model Sum of
Squares
Summary
t Sig.
Constant 3.110 .750 4.145 0.000 Application .622 .282 .245 2.205 0.030 Analysis .201 .233 .095
.862 0.391 Note: N = 87.
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Table 4-20: Regression of Gross Anatomy Subscales on Physiology Quiz Total for Dental Students in the
Control Group Model Sum of
Squares
Summary
t Sig.
Constant 2.587 1.106 2.339 0.025 Knowledge -.014 .555 -.004 -.026 .979 Comprehens ion
.501 .391 .187 1.283 .207
Application 1.183 .490 .392 2.416 0.021 Analysis .277 .326 .124 .849 .401 n = 43.
Research Question 3: Does the method of presentation of topics in microanatomy and
physiology influence learning physiology?
The percent correct scores from the control and experimental groups were similar.
The application level had the highest percent correct on the Gross Anatomy Quiz for both
groups. The experimental group had the highest percent correct at the comprehension
level on the Microanatomy Quiz; the control group had the highest percent correct at the
application level. Both groups had the highest percent correct at the knowledge level for
the Physiology Quiz.
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Table 4-21: Percent Correct on Quizzes by Bloom’s Levels for Experimental and Control for Dental Students
Gross Anatomy Microanatomy Physiology
Bloom Levels No.
Items
Exp Control Exp Control Exp Control
Knowledge 3 42.4% 48.1% 50.0% 47.3% 59.8% 70.0%
Comprehension 4 45.5% 44.8% 61.4% 53.5% 46.7% 62.0%
Application 3 65.2% 57.4% 53.8% 57.3% 22.0% 23.2%
Analysis 5 45.5% 47.9% 24.5% 27.4% 30.5% 30.2%
Total 15 73.2% 73.5% 68.0% 67.0% 58.4% 61.6%
Note: Scale scores are expressed in terms of percent correct due to variability in the number of items for
each level of Bloom’s taxonomy.
Average scores by discipline quiz and level of Bloom’s taxonomy for both groups are
summarized in Figure 4-3.
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80
70
60
50
40
30
20
10
0
Gross Anatomy Control Group
Gross Anatomy Experimental Group
Physiology Control Group
Physiology Microanatomy
Microanatomy
Experimental Control Group
Experimental
Group Group Knowledge Comprehension Application Analysis
Figure 4-3: Average scores by Topic, Level of Bloom’s Taxonomy and Method of Instruction in Dental
Students
Analysis of Variance Findings.
Univariate analyses of variance were conducted on the Microanatomy Quiz as the
dependent variable and group condition (curriculum order) as the independent variable.
Both the Gross Anatomy Quiz and the gross anatomy analysis score were used as co-
variants. No statistically significant results were obtained. Multivariate analyses of
variance were also conducted on the the four microanatomy subscales as the dependent
variables with the group condition as the independent variable and Gross Anatomy Quiz
of gross anatomy analysis subscale as co-variates. No statistically significant results were
obtained. Similar univariate analyses of variance and multivariate analyses of variance
were conducted on Physiology Quiz. No statistically significant differences were found in
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performance between dental students in the experimental condition and dental students in
the control condition.
Descriptive Statistics
Thirteen questions from the cumulative physiology final examination were used
as a measure of delayed recall. Students in both the control and experimental groups
scored a total of 75% correct on these 13 questions.
Regression Analyses
A simple regression using the microanatomy total quiz score and final
examination score did not reveal statistically significant results when the dental students
were identified as a whole and by group, indicating that the microanatomy quiz total
score was not a significant predictor of final examination score. A simple regression
using the physiology total quiz score and the final examination score revealed statistically
significant results, F(1, 86) = 4.328, p = .040, accounting for 4.8% of the variance (Table
4-22). No statistically significant relationships were observed for the control or
experimental groups.
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Table 4-22: Regression of Physiology Quiz Total on Final Examination Score for All Dental Students
Model Sum of

Squares
Summary
t Sig.
Constant 87.873 5.019 17.507 .000 Physiology 1.619 .778 .220 2.080 .040 Note: N = 87.
Podiatry Students
Seventy eight first year podiatry students completed all of the required research
materials: 38 students were randomly assigned to the control group and 40 students were
randomly assigned the experimental group. These data allowed for all four research
questions to be addressed.
as a hierarchical arrangement in which success on higher order skills is related to or
Gross Anatomy Quiz
Podiatry students were currently enrolled in a gross anatomy course at the time
that they were enrolled in the physiology course. Due to the podiatry curriculum, the
podiatry students had completed the majority of the gross anatomy course when they
began the physiology course. Therefore, it would be expected that the students would
94

perform well on both the lower order and higher order cognitive skills. The podiatry
students did not perform as well as expected. Their scores ranged from 8.4% on the
analysis level to 51.3% on the knowledge level (Table 4-23). A Pearson correlation
revealed a statistically significant relationship between the gross anatomy application and
gross anatomy analysis subscales (r = .238, p = .010). A statistically significant
relationship was observed in the experimental group between the gross anatomy
application and gross anatomy analysis subscales (r = .455, p = .003). (See Table 4-24).
Microanatomy Quiz
The physiology course in which the podiatry students were enrolled had several
lectures dedicated to the discipline of microanatomy. At the time of the experiment, the
students had already recived introductory lectures on microanatomy topics. Therefore, the
students may have learned general concepts that could aid them in their performance on
the microanatomy quiz. Student scores ranged from 26.4% at the analysis level to 49.1%
at the knowledge level (Table 4-24). A Pearson correlation revealed a statistically
significant relationship between the knowledge and comprehension scores (r = .338, p =
.002). (See Table 4-26). A statistically significant relationship was observed in the
control group between the microanatomy comprehension and microanatomy application
subscales (r = .336, p = .039); a statistically significant relationship was observed in the
experimental group between the microanatomy knowledge and microanatomy
comprehension subscales (r = .415, p = .008).
Physiology Quiz
The podiatry students had no prior coursework in physiology at the time of the
study. Therefore, it would be predicted that the students would be most successful at the
95

lower order cognitive skill levels (i.e., knowledge and comprehension) and would be less
successful on the higher order cognitive skill levels (i.e., application and analysis). The
students performed in the predicted manner with the lowest percent correct at the analysis
level (8.4%) and the highest percent correct at the knowledge level (51.3%). There was a
statistically significant correlation between the knowledge and comprehension levels (r =
.305, p = .007) and between the comprehension and application levels (r = .229, p =
.044). (See Table 4-24). When correlations were conducted at the group level, a
statistically significant relationship was observed between the physiology knowledge and
physiology comprehension subscales in the control group (r = .402, p = .012) and
between the physiology comprehension and application subscales in the experimental
group (r = .392, p = .012).
Table 4-23: Podiatry Student scores by Percent Correct on Gross Anatomy, Microanatomy, and Physiology
Quizzes
Percent
Microanatomy
Percent
Physiology
Percent
Knowledge 3 38.5% 49.1% 51.3%
Comprehension 4 32.4% 35.9% 38.1%
Application 3 39.7% 47.9% 23.9%
Analysis 5 29.0% 26.4% 8.4%
Total 15 33.9% 37.8% 33.6%
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Table 4-24: Correlation of Total Score on Gross Anatomy, Microanatomy and Physiology Quizzes for
Podiatry Students
GK .170 .029 -.058 .405* .086 .141 .068 .035 .152 .009 .214 .113 -.053 .103
GC -.052 .148 .593* -.040 .022 -.013 .051 .015 -.135 .149 .044 .048 .034
G1 .288* .581* -.002 .204 .176 .080 .139 .162 -.027 -.126 .064 .056
G2 .653* -.124 .148 .126 -.026 .067 .077 .081 .016 .000 .075
GT -.049 .222 .157 -.012 .154 .048 .170 .008 .036 .112
MK .338* -.017 -.080 .520* .103 .043 .183 .022 .136
MC .186 -.087 .670* .349* .273* .010 .131 .345*
M1 .038 .548* .088 .245* .285* .095 .279*
M2 .437* -.182 .066 -.069 .007 -.078
MT .163 .294* .171 .119 .310*
PK .305* .147 .040 .667*
PC .229* -.051 .605*
P1 .161 .561*
P2 .530*
PT
P2 = Physiology Analysis, PT = Physiology Total. * p < 0.05.
Simple regression analyses for lower order cognitive skills on higher order
cognitive skills for each discipline (i.e. gross anatomy, microanatomy and physiology)
were calculated. Regression analysis were calculated using the total podiatry sample.
None of the regression analyses were statistically significant. Similarly, when these
analyses were conducted for each experimental condition, none of the regressions were
statistically significant.
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Research Question 2: Does recall of prior knowledge in gross anatomy correlate with
Pearson correlations were calculated to determine relationships among scores on
gross anatomy, microanatomy, and physiology quizzes. No statistically significant
relationships were observed between the gross anatomy subscales and the microanatomy
subscales nor were statistically significant relationships observed between the gross
anatomy subscales and the physiology subscales when viewed as a single group (Table 4-
26). A statistically significant relationship was observed in the control group between the
knowledge level of gross anatomy and the comprehension level of physiology (r = .363, p
= .025). The gross anatomy application subscale had a statistically significant relationship
with the comprehension level of microanatomy (r = .395, p = .014), the microanatomy
application level (r = .386, p = .017) and the total microanatomy score (r = .400, p = .013)
in the control group.
Regression Analysis
A multiple regression was conducted for all podiaty students, as well as by
assigned group, using the Gross Anatomy subscales as predictors of the total
Microanatomy Quiz score. Muliple regressions were also conducted on the Physiology
Quiz score by total sample and by experimental conditions. No statistically signficant
results were obtained.
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The percent correct values were similar between the experimental and control
groups. The experimental group was most successful on the knowledge level on the
Gross Anatomy Quiz and the control group was most successful on the application level
of the Gross Anatomy Quiz. For the Microanatomy Quiz, the experimental group was
most successful on the application level questions; the control group was most successful
on the knowledge level questions. Both groups were most successful on the knowledge
level questions on the Physiology Quiz (Table 4-25).
Table 4-25: Descriptive Statistics by Quiz for Podiatry Students
Quizzes by Discipline and Level of Bloom's Taxonomy
Gross Anatomy Microanatomy Physiology
Experimental Control Experimental Control Experimental Control
Knowledge 35.8% 41.2% 45.8% 52.6% 52.5% 50.0%
Comprehension 32.5% 32.3% 33.8% 38.2% 36.9% 39.5%
Application 34.2% 45.6% 52.5% 43.0% 23.0% 24.6%
Analysis 27.0% 31.1% 25.0% 27.9% 25.0% 25.3%
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60
50
40
30
20
Knowledge
Comprehension 10
Application
0
Analysis
Figure 4-4: Average Podiatry Student Score by Instructional Method, Quiz and Level of Bloom’s
Taxonomy.
Analysis of Variance Findings.
Univariate analyses of variance were conducted on the Microanatomy Quiz as
dependent variable using group condition (curriculum order) as the independent variable.
Both the Gross Anatomy Quiz and the gross anatomy analysis score were used as co-
variates. No statistically significant results were obtained. Multivariate analyses of
variance were also conducted on the the four microanatomy subscales as the dependent
variables with group condition as the independent variable and Gross Anatomy Quiz or
gross anatomy analysis subscale as co-variates. No statistically significant results were
obtained.
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Similar univariate analyses of variance and multivariate analyses of variance were
conducted on Physiology Quiz. No statistically significant differences were found in
performance between podiatry students in the experimental condition and in the control
condition.
physiology have an influence on recall of microanatomy and physiology?
Descriptive Statistics
A multiple choice GI examination was administered 11 days after the gross
anatomy, microanatomy and physiology quizzes were completed. The control group had
an average score of 86.02% on this exam; the experimental group had an average score of
84.9%. A Pearson correlation revealed a statistically significant relationship between the
physiology total score and the GI examination (r = .227, p = .046) for all podiatry
students.
A final examination was administered 11 weeks after the research materials were
completed. The control group had an average score of 81.94% on the final exam; the
experimental group had an average score of 77.65%. A Pearson correlation did not reveal
a statistically significant relationship between the final exam score and the discipline quiz
total scores when calculated by group or as a whole.
Regression Analyses
A simple regression was calculated between total Microanatomy Quiz score and
the GI examination and final examination scores. No statistically significant results were
obtained. A significant result F(1, 76) = 4.119, p = .046 was observed between the total
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physiology quiz score and the GI examination, accounting for 5.1% of the variance
(Table 4-26). No significant result was observed between the total Physiology Quiz score
and the final examination.
Table 4-26: Regression of Physiology Quiz Total on GI Examination Score for All Podiatry Students
Model Sum of

Squares
Summary
estimate 1 .227 .051 .039
9.04588 Coefficient
T Sig.
Constant 80.532 2.640 30.505 .000 Physiology .098 .048 .227 2.030 .046 N = 78.
Discussion
as a hierarchical arrangement in which the success on higher order skills is related to or
Data from each student sample (medical, dental and podiatry) supported the
hierarchical arrangement of Bloom’s taxonomy. Overall, the students were successful at
levels of Bloom’s taxonomy that tested lower order cognitive skills (i.e., knowledge and
comprehension) and were less successful at levels of Bloom’s taxonomy that tested
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higher order cognitive skills (i.e., application and analysis). These results are consistent
with previous research where students were more successful on questions that tested the
lower levels of Bloom’s taxonomy than the higher levels of Bloom’s taxonomy (Azizan
and Ibrahim, 2012; Crowe, 2007; Dobson, 2001). The predicted pattern, where
knowledge level questions would yield the highest scores, followed by comprehension,
application and analysis scores was consistently observed in the Physiology Quiz. This
quiz contained content that was the most unfamiliar to all of the students and may
provide the most support for the hierarchical nature of Bloom’s taxonomy in this study.
As mentioned in the results section, both the medical and dental student samples had
significant prior coursework in gross anatomy. The podiatry students were also
introduced to gross anatomy, but did not have the same degree of prior coursework, as
they were still currently enrolled in the first year gross anatomy course at the time of this
investigation. The three samples had been introduced to the discipline of microanatomy
prior to the investigation. Even though students did not complete coursework specifically
in Gastrointestinal microanatomy, the ability to generalize and transfer information from
prior exposure to the discipline may have allowed the students to succeed at higher levels
of the taxonomy.
Results from Pearson correlations confirm statistically significant relationships
between lower levels of the taxonomy with higher levels of the taxonomy. In each first
year student sample, the comprehension level (a lower order cognitive skill) had a
positive statistically significant relationship (p < .01) with either the application or
analysis level (higher order cognitive skills). This can be important for instructors
creating course assessments. Since many examinations test lower order cognitive skills
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(Duan, 2006; Rhupani and Bhutto, 2011; Saqib et al, 2011), it may be more efficient to
test students at the comprehension level of Bloom’s taxonomy to represent the lower
order cognitive skills than to test the knowledge level.
Results from regression analyses further support the hierarchical nature of
Bloom’s taxonomy. In both the medical and dental samples, scores on lower order skills
in microanatomy were significant predictors of performance on higher order skills in
microanatomy. Identical results were observed with lower order skills in physiology and
higher order skills in physiology.
Research Question 2: Does recall of prior knowledge of gross anatomy influence with
Since each sample (medical, dental and podiatry) had previous exposure to gross
anatomy, scores on the Gross Anatomy Quiz were used as an indicator of prior
knowledge. Pearson correlations revealed statistically significant relationships in each
sample population between gross anatomy and physiology, which reaffirms Custer’s
prior research that anatomy and physiology scores are related (Custers, 2010).
Regression analysis using the dental students’ scores revealed that scores from the
Gross Anatomy Quiz, specifically the higher levels of Bloom’s taxonomy, were
significant predictors of the Microanatomy Quiz score. Additionally, regression analysis
identified that the Gross Anatomy Quiz score was a significant predictor of the
Physiology Quiz score. These results were not reproduced in the medical and podiatry
samples. This may be partially attributed to the gross anatomy curriculum of each
sample. Although the content of each gross anatomy course is similar, differences exist
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between the courses (e.g., degree of GI content presented, amount of time spent on GI
material, placement of GI content within the gross anatomy course).
The control and experimental groups yielded similar results in average percent
correct scores in both the dental and podiatry student samples. Univariate and
multivariate analyses of variance confirmed that there were no statistically significant
differences between the groups with respect to their performance on the Microanatomy
Quiz and the Physiology Quiz. These results are similar to those of Khalil, Nelson and
Kibble who discovered that students who reviewed their self learning modules as part of
an integrated instruction performed just as well, and sometimes better, as the students that
were part of the traditional (control) instructional method (Khalil, Nelson and Kibble,
2010).
It is possible that no statistically significant differences were observed between
the control and experimental group because only a small amount of anatomy/physiology
material was integrated. This investigation also occurred at the end of each first year
physiology course. It is possible that placement at a different part of the curriculum may
yield different results. Also, the students may not have valued the content of the
integration as as relevant to clinical practice. This may have decreased the amount of
time that they spent learning the material.
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The dental and podiatry students demonstrated a relationship between success on
immediate learning with success on delayed learning. Regression analyses from both
dental student groups identified the Physiology Quiz score as a significant predictor of the
final exam score; the Microanatomy Quiz score was not a significant predictor of the final
exam score. The dental students were informed that the final examination would contain
more physiology questions than microanatomy questions. Therefore, it is possible that the
dental students dedicated more time to learning physiology than learning microanatomy.
Results from regression analyses in the podiatry sample did not identify the
Physiology Quiz score as a significant predictor of the score on the final examination.
However, the regression did identify the Physiology Quiz score as a significant predictor
of the score on the GI Exam. This difference may be due to the composition of the
assessments. The GI Exam tested only material from the GI unit; the final examination
tested material from the GI unit, as well as other units that were covered during the
physiology course. Therefore, there would be fewer items that tested GI information on
the physiology final examination in comparision to the GI Exam. The larger number of
GI physiology questions on the GI Exam, in comparison to the physiology final
examination, may have influenced these results.
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Study Limitations
Medical Students
It is important to acknowledge that limitations are present in the study with the
medical students. First, no control group was present, preventing the ability to determine
if method of presentation would affect performance in physiology. Second, the
participants were volunteers, creating a volunteer bias. Third, due to the presentation of
this material at the end of the course, there was a high drop out rate (students who did not
complete all three quizzes) and very little time between the quizzes and the final exam,
which hindered the ability to determine the effect of this instruction on delayed recall. It
is also important to note that no material was removed from the curriculum. The
traditional lectures in both microanatomy and physiology were given, making it unclear if
the success on the final examination was due to the interventions of this research project.
Additionally, students were only taking one basic science class during this time;
therefore, this data may differ if replicated in a curriculum where more than one basic
science course is administered at a time.
Dental Students
Similar to the medical students, there is a volunteer bias. An additional bias was
introduced into this portion of the study than with the medical students because the dental
students were offered extra credit to participate in the research project. The dental
students also had prior knowledge of both gross anatomy and microanatomy due to prior
coursework, which may have altered their success in these gross anatomy and
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microanatomy quizzes, as well as the microanatomy questions that were presented on the
physiology final examination.
Podiatry Students
Similar to the dental students, a volunteer bias is present. Students who completed
the required research materials by the project deadline received extra credit towards the
calculation of their final grade. Unlike the medical and dental student populations, the
podiatry students were completing coursework in both gross anatomy and microanatomy
during the physiology course.
Future Investigations
In future investigations, it will be important to increase the time interval between
viewing the research project material and the final examination to gain more data
regarding long term retention and delayed recall. Most studies have used 1 week as a
measure of delayed recall; however, a few studies have used up to 6 weeks to measure
delayed recall (Larsen et al, 2008). The podiatry population had the longest measure of
delayed recall of the three sample studied in this experiment (11 weeks).
Each sample group received the traditional lectures in addition to the research
project materials, making it difficult to determine what effect the research materials had
on overall learning. In addition to removing the traditional lectures for the research
project materials, it will also be important to collect data about the students. In the future,
demographic information, such as prior course work or experience with the material
being assessed should be gathered. There was also no information collected to identify
how frequently or how long the students used the tutorials. Additionally, there was a very
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short time frame (approximately one week) to complete the tutorials. This research
project had to be completed either over a holiday or at the very end of the semeseter,
which may have decreased the time the students spent on learning the material from the
tutorials. Each quiz had a small number of questions, more specifically in the medical
student experiment, which makes it difficult to get an accurate understanding of what the
students knew. A mandate to complete the project, eliminating volunteer bias, with
completion directly related to the course grade, could also add validity to the study.
Conclusion
This project provides further support for the hierarchical nature of Bloom’s
taxonomy; students tended to perform well on the lower levels of Bloom’s taxonomy
than the higher levels of the taxonomy. Pearson correlation tests demonstrated statistical
significance between the comprehension level of Bloom’s taxonomy and higher levels of
Bloom’s taxonomy, indicating that the comprehension level may be a level of Bloom’s
taxonomy that should be tested in all assessments. Prior gross anatomy knowledge was
also proved to positively correlate with success in physiology. Therefore, curricula that
require students to complete an anatomy class prior to enrollment in a physiology course
may aid the students in learning physiology.
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CHAPTER 5
DOES THE LEVEL OF ASSESSMENT ON A PRE-TEST CORRELATE TO
PERFORMANCE IN A HEALTHCARE PROFESSIONAL DEGREE PROGRAM
FIRST YEAR HUMAN GROSS ANATOMY COURSE?: A PILOT STUDY
Abstract
Bloom’s taxonomy is used as a structural framework for educational assessment,
with a multi-tiered approach that allows evaluators to determine the depth of knowledge a
learner possesses. The cumulative approach to the taxonomy implies that success at
higher tiers is the result of mastery at lower tiers. In this pilot study, students in the first
year of three professional healthcare programs (MD, DPM and DMD) were asked to
complete a pre-test that evaluated their knowledge of human gross anatomy. Participating
students from each program were randomly assigned into two groups: one group
completed a pre-test that assessed human gross anatomy knowledge at the knowledge,
comprehension, application and analysis levels of Bloom’s taxonomy and the other group
completed a pre-test that assessed knowledge at the application and analysis levels of
Bloom’s taxonomy. Overall pre-test scores, as well as scores from each of the tested
levels of Bloom’s taxonomy, were analyzed. The goals of this study were to determine
the type of experiences that first year healthcare professional students possess prior to
beginning a first year human gross anatomy course, identify the topics that are most and
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least familiar to these students and to determine if the students were able to accurately
determine when they had answered a gross anatomy question correctly.
Introduction
Benjamin Bloom and his colleagues developed the Taxonomy of Educational
Objectives: The Classification of Educational Goals, Handbook 1: Cognitive Domain as a
tool to provide a structural framework for assessment. The framework identifies abilities
that a learner should possess in order to achieve a desired level of learning. Bloom and
his colleagues constructed a tiered system which implied that mastery at a lower level
was required before mastery at a higher level could occur. Bloom’s taxonomy was
revised and the revisions were accepted in 2001 (Seaman, 2011). The fundamentals of the
taxonomy remain unchanged, but the tier names were changed to verb forms instead of
the previously used noun forms. The revision changed the perspective of the taxonomy,
from one of assessment to one of cognitive processes (Su and Osisek, 2011; Ven and
Chuang, 2005). Both versions lend themselves to two categories of skills: lower order
cognitive skills and higher order cognitive skills (Crowe, 2008). The lower order
cognitive skills focus on factual information and frequently require the learner to recall
an isolated fact or to compare and contrast isolated facts. The higher order cognitive
skills require the learner to apply and manipulate information, often requiring students to
predict outcomes.
Studies have shown that students who are unable to perform well at the lower tiers
of the taxonomy are often unsuccessful at the higher tiers of the taxonomy (Azizan and
Abraham, 2012; Dobson, 2001; Harries and Botha, 2007; Knecht, 2001). Additionally,
researchers have discovered that assessments focus on the lower tiers of the taxonomy
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instead of the higher tiers (Rhupani and Bhutto, 2011; Saqib et al, 2011). In this project,
we constructed two pre-tests: one that tested only higher order cognitive skills and one
that tests both lower order cognitive skills and higher order cognitive skills to determine
the degree of difference of student scores by level of assessment. This study was
designed to answer the following research questions:
1. What previous experience(s) do first year healthcare professional students
have with gross anatomy?
2. What prior anatomical knowledge do first year healthcare professional
students possess?
3. Are first year healthcare professional students able to accurately identify when
they know an answer to a gross anatomy question?
Methods
First year medical, podiatry and dental students who were enrolled in a first year
human gross anatomy course were asked to participate in an IRB approved research
project. Students were required to complete a 10 question demographic questionnaire and
a 100 multiple choice question examination. 50 questions of the multiple choice exam
tested human gross anatomy knowledge and 50 questions asked the students to rate their
confidence level that they had answered the gross anatomy question correctly. Odd
numbered questions on the exam tested gross anatomy knowledge; even numbered
questions on the exam were metacognitive (rate your confidence) questions. All
participating students were required to complete the demographic questionnaire in one
sitting and were allotted 30 minutes to complete this task. The students were also
required to take the multiple choice pre-test examination in one sitting, but not
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necessarily at the same time as the demographic questionnaire. The students were given a
90 minute time limit to complete the pre-test. All research materials (questionnaire and
pre-test) could be viewed only once and were available to the participating students until
the first day of the human gross anatomy course. The participating students had to
complete all research materials prior to the first human gross anatomy class.
Students participating in the research project were required to complete an
informed consent form. Upon submission of the consent form, the investigator randomly
placed the student into one of two groups. The groups differed by the taxonomy level of
human gross anatomy knowledge to be tested. Students in group A were required to
answer gross anatomy questions that corresponded with the knowledge, comprehension,
application and analysis levels of Bloom’s taxonomy. Students placed into group B were
required to answer gross anatomy questions that corresponded with the application and
analysis levels of Bloom’s taxonomy. All of the application and analysis level questions
used on group A’s exam were also used on group B’s exam. Each exam tested the
following concepts and/or regions: general gross anatomy concepts, back, upper
extremity, lower extremity, thorax, abdomen, pelvis and perineum, and head and neck.
All participating students had to answer metacognitive questions. Metacognition is the
self-reflective process of understanding what material one has learned and mastered, as
well as what material one has not yet mastered. The metacognitive questions in this
study used a four point Likert scale to determine how confident the student was in
answering each gross anatomy question correctly. Students used a Blackboard (version 9)
site that was solely dedicated to this research project to gain access to the research
materials.
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Results
Demographic Questionnaire
A total of 24 students (7 medical, 13 podiatry, 4 dental) completed a demographic
questionnaire. The demographic questionnaire collected data regarding gender (14 males,
10 females), age (20 between 21-25 years old, 3 26-30 years old and 1 31-35 years old),
primary undergraduate major (17 biology, 3 science (not chemistry, biology or physics),
1 chemistry, 1 business, 1 humanities and 1 other (not science, business or humanities)),
completion of an advanced degree (5 students have Master’s degrees) and time since they
were enrolled in an undergraduate curriculum (4, 0-3 months; 2, 4-6 months; 5, 7-12
months; 4, 12-18 months; 3, 19-24 months and 6, more than 24 months). The
demographic questionnaire also gathered data regarding any prior educational setting in
which the students had taken an anatomy course (1 had no prior coursework; 13 had a
lecture component in high school; 6 had a laboratory component in high school; 19 had a
lecture component at the bachelor’s level; 13 had a laboratory component at the
bachelor’s level; 3 had a lecture component at the graduate level; 2 had a laboratory
component at the graduate level). 1 student participated in the Temple post-baccalaureate
program, which includes both lecture and laboratory components of gross anatomy within
the first year dental gross anatomy course.
Group A Pre-test
14 students (4 medical, 8 podiatry, 2 dental) completed a 100 question pretest that
tested gross anatomy knowledge at the knowledge, comprehension, application and
analysis levels of Bloom’s taxonomy. The highest average scores were seen at the
knowledge level (77%), followed by comprehension (53%), analysis (41%) and
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application (36%). When all four levels of the taxonomy were included in the analysis,
questions testing thoracic anatomy showed the highest average score (68%), followed by
head and neck (57%), general concepts (54%) and back (54%). Metacognitive questions
were administered after every gross anatomy question and required the student to rate
his/her confidence level in selecting the correct answer. Overall, students felt most
confident in answering questions regarding the thorax and head and neck. They felt least
confident in the areas of upper extremity and abdomen. The student confidence scores by
anatomical region are displayed in Figure 5-1.
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Figure 5-1: Metacognitive average score by anatomy topic for students who completed a pre-test with
questions from the knowledge, comprehension, application and analysis levels of Bloom’s taxonomy.
Metacognitive legend: 1 = Very confident 2 = Somewhat Confident 3 = Completely unfamiliar with the
topic 4 = Didn’t feel confident
Group B Pre-test
10 students (2 medical, 6 podiatry, 2 dental) completed a 100 question pre-test
that assessed gross anatomy knowledge at the application and analysis levels of Bloom’s
taxonomy. Both the application and analysis levels had the highest average score in the
topic of general anatomy concepts (65%). The lower extremity was the second highest
average score at the application level (35%) and the back was the second highest average
score at the analysis level (60%). Similar to group A, metacognitive questions were
administered after each gross anatomy question. Students felt most confident in general
anatomy concepts at both the application and analysis levels. Figure 5-2 displays the
student confidence scores by anatomical topic/region for this group of students.
Head/Neck
Pelvis
Abdomen
y m o t a n A
Thorax
Lower Extremity
Upper Extremity
Back
General
0 0.5 1 1.5 2 2.5 3 3.5 Metacognitive Average Score
Analysis
Application
Comprehension
Knowledge
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Head/Neck
Pelvis
Abdomen
y m o t a n A
Upper Lower Extremity Extremity Thorax
Analysis
Application
Back
General
0 1 2 3 4 Metacognitive Average Score
Figure 5-2: Metacognitive average score by anatomy topic for students who completed a pre-test with
questions from the application and analysis levels of Bloom’s taxonomy. Metacognitive legend: 1 = Very
confident, 2 = Somewhat Confident, 3 = Completely unfamiliar with the topic, 4 = Didn’t feel confident
Metacognitive Score Comparison
The confidence by topic differed between the two groups. The students in group
A rated their confidence the highest with questions regarding the thorax. The students in
group B rated their confidence the highest with the general anatomy questions. Both
groups rated the upper extremity and abdominal questions as questions that they
answered with the lowest amount of confidence. Table 5-1 shows the ranking of student
confidence from both groups.
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Table 5-1: Ranking of confidence by anatomy topic for both pre-test groups
Group A Group B Most Confident Thorax General Anatomy
Head/Neck Back General Concepts Thorax
Back Pelvis Pelvis Lower Extremity Lower Extremity Head/Neck
Abdomen Abdomen Least Confident Upper Extremity Upper
Extremity
Group A: Correlation of Pre-test scores with Gross Anatomy Course Examinations and
Final Grade – Podiatry student population
Pearson correlation tests were used to determine if there was any statistical
significance between the score on the pre-test and the examinations in the human gross
anatomy course. 6 statistically significant relationships resulted. Four of the statistically
significant correlations were found between a component of the pre-test and the third
(final) examination in the gross anatomy course. Each tested level of Bloom’s taxonomy,
with the exception of the application level, had a positive correlation with the score on
the final examination (knowledge, r = 0.407; comprehension, r = 0.342; analysis, r =
0.552). The overall pre-test score and the score on the final examination was also
statistically significant (r = 0.411). Two statistically significant relationships were found
between levels of Bloom’s taxonomy and the final average in the gross anatomy course:
knowledge, r = 0.365, and analysis, r = 0.333.
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Group B: Correlation of Pre-test scores with Gross Anatomy Course Examinations and
Final Grade – Podiatry student population
Pearson correlation tests were performed to determine if there was any statistical
significance between the score on the pre-test and the examinations in the human gross
anatomy course. 5 statistically significant relationships were discovered. Three of these
relationships showed a negative correlation between the score on the pre-test and the
score on the first gross anatomy examination. The average score on the application
questions and the average score on the analysis questions with the first gross anatomy
examination both yielded a significant correlation (r = -0.570). The average pre-test score
and exam one score yielded a moderate significant correlation (r = -0.333). A similar
moderate significant correlation resulted from the average application score and the third
(final) examination (r = -0.374). This same correlation value was found between average
analysis score and the final gross anatomy course average.
Group A: Correlation of Pre-test scores with Gross Anatomy Course Examinations and
Final Grade – Medical student population
Similar to the podiatry population, medical student scores on the pre-test were
compared with the examinations of the required human gross anatomy course for their
program. Pearson correlations were used to investigate the relationship between each
level of Bloom’s taxonomy with the written exam grades. Only two written examinations
were administered to the medical students: a mid-term examination and a cumulative
final examination. Three significant relationships resulted from Pearson correlation tests.
The scores from the comprehension level of Bloom’s taxonomy and the mid-term
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examination yielded a Pearson correlation of r = -0.371. Additionally, the scores from the
application level of Bloom’s taxonomy and the mid-term examination yielded a strong
statistically significant relationship (r = -0.936). The score on the pre-test and the mid-
term examination score also had a statistically significant relationship (r = -0.431). The
scores on the knowledge level of Bloom’s taxonomy and the application level of the
taxonomy showed statistically significant relationships with the final examination
(knowledge, r = 0.290; application, r = -0.883). The score on the pre-test and the final
examination was also statistically significant (r = -0.395).
Group B: Correlation of Pre-test scores with Gross Anatomy Course Examinations and
Final Grade – Medical student population
Each Pearson correlation test yielded a statistically significant relationship. All
relationships yielded a r value of -1.00 for the following comparisons: score on the
application level of Bloom’s taxonomy and the mid-term examination, score on the
analysis level of Bloom’s taxonomy and the mid-term examination, score on the
application level of Bloom’s taxonomy and the final examination, score on the analysis
level of Bloom’s taxonomy and the final examination, overall score on the pre-test and
the mid-term examination and overall score on the pre-test and the final examination.
Discussion
There were four aims to this pilot study: determine the demographics of the
student populations tested with respect to their undergraduate coursework and also any
prior coursework in anatomy, determine the depth of anatomical knowledge the students
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possess by evaluating the students at different levels of Bloom’s taxonomy, determine if
pre-test scores resulting from assessment at different levels of Bloom’s taxonomy were
statistically significant with respect to performance in the first year human gross anatomy
course and determine if first year healthcare professional students are able to accurately
predict their knowledge of human gross anatomy by rating their confidence in answering
a human gross anatomy question.
The demographic survey results revealed that most students had previously taken
anatomy coursework. The majority of that coursework occurred at the undergraduate
level. Craig et al showed that there are initial performance differences between those
students that are science and non-science graduates; their research also showed that these
differences decreased over time (Craig et al, 2004). Since only one student did not have
any prior anatomy coursework and three students (12.5%) identified as a non-science
major in an undergraduate program, it is plausible that graduate anatomy faculty may be
able to assume some prior knowledge for most students in their student populations. The
manner in which prior knowledge affects performance is not well understood. Tsai and
Tsai assert that prior knowledge influences acquiring new knowledge; however, the
specific methods and variables that influence this learning are still not completely
understood (Tsai and Tsai, 2005). 8 out of the 10 students (80%) who had taken a high
school anatomy course had passing final averages (above 70%) in the graduate human
gross anatomy course. 13 out of 15 (87%) students who had completed anatomy
coursework at the baccalaureate level passed the graduate gross anatomy course (above
70%), reaffirming that prior coursework may influence grades in future anatomy courses.
However, it is also important to note that students who had prior anatomy coursework at
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the baccalaureate level did not always pass the graduate human gross anatomy course.
One student, who had taken gross anatomy at the graduate level, did not pass the human
gross anatomy course. Therefore, prior coursework, even at the same educational level,
does not automatically result in a passing grade. Additionally, one student received a
passing grade (above 80%) without any prior gross anatomy coursework.
To the best of our knowledge, there has been no prior research evaluating prior
knowledge in a pre-test format by levels of Bloom’s taxonomy in the first year medical,
dental and podiatry populations with respect to the field of human gross anatomy. In this
pilot study, we created two pre-tests. The pre-test that tested knowledge, comprehension,
application and analysis levels of Bloom’s taxonomy showed that the students scored
highest on the lower order cognitive skills. As expected, students scored highest on the
knowledge (rote memorization or recall of an isolated fact) questions (77%). This was
followed by the comprehension questions which were still based in factual recall. The
higher order cognitive skills (application and analysis) resulted in a lower overall score.
However, the application score was lower (36%) than the analysis score (41%). Although
this does not coincide with the expected outcomes, it is also not unusual to see that there
are differences between average scores at the various tiers of Bloom’s taxonomy. Prior
research studies have even shown higher order cognitive skill averages to be higher than
lower order cognitive skill averages (Roberts, 1976). Students who took the pre-test that
only tested the higher order cognitive skills (application and analysis) also showed higher
scores in the analysis level (33.2%) when compared to the application level (27.7%).
This study also investigated the existence of statistically significant correlations
between pre-test scores and performance in the human gross anatomy course. Other
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studies have used correlational statistics to confirm statistically significant relationships
between prior science coursework and student success in undergraduate anatomy and
physiology (Harris et al, 2004), scores in introductory anatomy and physiology and
success on licensing examinations (Wong and Wong, 1999) and scores in anatomy and
physiology predicting success in clinical courses (Wong and Wong, 1999). It was
hypothesized that statistically significant correlations between pre-test and human gross
anatomy course scores existed. In group A, the most significant correlation in the
podiatry population occurred between the analysis level score and the final examination
score (r = 0.552). The scores at the application level of the taxonomy showed statistically
significant relationships with the final examination (r = -0.883) in the medical student
population. Additionally, scores from the application level of Bloom’s taxonomy and the
mid-term examination yielded a strong statistically significant relationship (r = -0.936)
with the medical student population. Since the examinations in both human gross
anatomy courses are targeted at the application and analysis levels, it is understandable
that students who initially were successful at answering questions at the higher levels on
a pre-test would be successful on these types of questions on the human gross anatomy
examination. However, it is also important to note that an inability to succeed at
answering higher order cognitive skills prior to the human gross anatomy course does not
result in an inability to be successful at higher order questions during or after the human
gross anatomy course. In group B, a significant negative correlation was discovered
between the analysis level of Bloom’s taxonomy and the score on the first gross anatomy
exam (r = -0.570) for the podiatry students. The correlation between the application score
and the first human gross anatomy examination score was identical to the analysis score
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(r = -0.570) implying that taking a pre-test may provide the students with test taking
strategies to be successful on the first gross anatomy examination. A stronger negative
correlation (r = -1.00) was observed in the medical student population.
The final aim of this pilot was to determine if students were able to identify when
they answered a gross anatomy question correctly or incorrectly. Therefore, we attempted
to gather data regarding metacognition in our sample populations. Hsu cited
metacognition as knowing what one knows (Hsu, 2010). Studies in non-professional
student populations have yielded results that there is a weak association between actual
performance and perceived performance (Jaccard and Dodge, 2005). As cited in Jaccard
and Dodge, Kruger and Dunning’s study showed that those with little knowledge
overestimated their ability than those with higher levels of knowledge (Jaccard and
Dodge, 2005). Therefore, we aimed to investigate how well the students were able to
accurately identify their level of knowledge. Both groups reported the highest levels of
confidence in the areas that had the highest scores. In group A, students had the highest
ratings for questions asking information about the thorax and head and neck (the two
highest ranking areas on the pre-test). Similarly, the students in group B reported the
highest confidence level in the area of general anatomy concepts, which was also their
highest scoring section on the pre-test.
It is important to identify two significant limitations to this study: sample size and
volunteer bias. The sample size of this study (n=24) is quite small. Therefore, when the
study is repeated, it is important that the sample size be increased. Additionally, all
participants in this study were volunteers. Participants did not receive monetary
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compensation nor were they awarded academic credit in their anatomy coursework for
their participation.
Conclusion
Since this was a pilot study, it is important to replicate this study with a larger
sample size to correctly identify any statistically significant relationships with assessing
prior knowledge at various levels of Bloom’s taxonomy, grades from multiple first year
professional human gross anatomy courses, and the students ability to report when they
accurately answered human gross anatomy questions.
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CHAPTER 6
CONCLUSION
The universal presence of anatomy in healthcare professions is undeniable. It is a
cornerstone to each of the clinical sciences. Clinical educators use anatomy to advance
their students understanding of the clinical disciplines (pathology, medicine). A solid
understanding of anatomy is required to develop and perfom clinical skills correctly.
Basic science eductors use anatomy as a foundation to increase knowledge in other basic
science disciplines (physiology, microbiology). This body of work is dedicated to the
advancement of anatomical knowledge and educational methods for both practicing
clinicians and healthcare professional students.
The first study explores the gross anatomy and structural relationships of the
lower cervical and upper extremity region. Thoracic outlet syndrome has become a
prevalent condition for clinicians to treat. Neurogenic thoracic outlet syndrome is
frequently a result of anatomical variation in the brachial plexus. Therefore, in this study,
data was collected from predissected cadavers to investigate the relationship between the
trunks of the brachial plexus and the dorsal scapular artery. Since this artery is easily
damaged during neurological surgery, this study focused on the dorsal scapular artery’s
relationship with the brachial plexus. Additionally, the study investigated the origin of the
dorsal scapular artery and the presence of a statistically significant difference with respect
to the relationship of the dorsal scapular artery with the trunks of the brachial plexus by
gender. Since the dorsal scapular artery and brachial plexus are bilateral structures, data
regarding their relationship by side was gathered. A specific aim of this study was to
determine if there was a consistent difference in presentation on the left side of the body
from the right side of the body.
A total of 34 cadaveric specimens were examined in this study. The origin of the
dorsal scapular artery was most frequently a direct branch of the subclavian artery
126

(62.5%) but was also observed to be a direct branch of the thyrocervical trunk (37.5%).
Passage of the dorsal scapular artery between the superior and middle trunks of the
brachial plexus was observed as frequently as passage of the dorsal scapular artery
between the middle and inferior trunks of the brachial plexus (40% each). Gender based
variations were observed. Males had a higher frequency of the dorsal scapular artery
arising from from subclavian artery and passing between the superior and middle trunks
(36%) than females (23%). Females had a higher frequency of the dorsal scapular artery
arising from the thyrocervical trunk and passing between the middle and inferior trunks
of the brachial plexus (23%) than males (9%). The results of this study are expected to be
helpful to the practicing clinician who may need to perform procedures in this area.
Future plans for this research project include using additional cadaveric specimens to
gather more data regarding gender differences in both origin of the dorsal scapular artery
and its relationship with the trunks of the brachial plexus.
Similar to the first study, the second study is intended to enhance the practicing
clinician’s knowledge. This study focused on venous cardiac anatomy. Specifically, the
second study aims to further the current understanding of the anatomy of the coronary
sinus. The coronary sinus is used in biventricular pacing procedures to properly place a
lead that would be used to pace the left ventricle. Frequently, biventricular pacing
procedures fail because clinicians are unable to navigate the coronary sinus to properly
implant a lead. This failure is partially due to the variable anatomy of the coronary sinus.
Therefore, it was an aim of this study to gather information regarding the diameter of the
coronary sinus ostium, as well as identify the frequency in which a Thebesian valve was
present. The goal of this study was to advance electrophysiolgists’ knowledge of the
coronary sinus and provide these clinicians with a better understanding of anatomical
structures that are encountered during biventricular pacing procedures. Using a 7F and a
8F guiding catheter, this study simulated a coronary sinus cannulation to determine the
distance that a catheter would travel into the coronary sinus from the coronary sinus
127

ostium. Additionally, the study aimed to identify the presence of gender differences in
anatomical structures related to biventricular pacing procedures.
A total of 50 predissected cadaveric specimens were examined in this study. The
average diameter of the opening of the coronary sinus ostrium was 7.47±2.69mm but
differences were observed between the genders. Males had a slightly larger coronary
sinus ostium opening (7.82±3.30mm) when compared to females (7.47±2.69mm).
Thebesian valves were observed in 31 cadavers (62%) at the coronary sinus ostium and
their percent occlusion of the coronary sinus by the Thebesian valve was variable (8.26%
- 100%). Differences were also observed in the distance that a catheter was able to travel
into the coronary sinus. The 7F catheter traveled 66.26±15.94mm in both genders; the 8F
catheter traveled 69.39±18.12mm. Data regarding the annulus of the tricuspid valve, the
diameter of the left phrenic nerve and heart weight were also recorded to add to the
current knowledge of cardiac anatomy. Similar to the first cadaveric study, future plans
for this research project includes examining additional specimens to confirm the results
of this study. Additionally, data regarding the position of the Thebesian valve at the
coronary sinus ostium will be recorded.
The third study focuses on teaching future clinicians in the medical, dental and
podiatry populations. This study asked students enrolled in a first year physiology course
to participate in an IRB approved educational research project to determine if
instructional method (integrated or non-integrated) resulted in higher test scores. The
students were required to complete multiple choice assessments as they learned both the
microanatomy of the alimentary canal and pancreas and the physiology of gastric and
pancreatic secretion. These assessments were used to test both immediate and delayed
recall. The immediate recall assessments were three multiple choice quizzes that were
administered using an online course management system (Blackboard, Version SP8) and
tested the students at the knowledge, comprehension, application and analysis levels of
Bloom’s taxonomy. Scores from the immediate recall assessments were used to
128

determine if correct answers at a certain level of Bloom’s taxonomy were correlated with
instructional method. The delayed recall assessments were the first year physiology
course final examinations.
The first student population in this study was first year medical students. The
medical students had higher scores at the knowledge and comprehension level questions
when they were unfamiliar with a topic (gastric and pancreatic secretion), but scored
higher on higher level questions (analysis) when they were more familiar with a topic
(microanatomy). The second and third student populations (dental and podiatry) were
randomly distributed into either an integrated or non-integrated group. The students that
viewed the integrated material had their highest scores at the higher levels of Bloom’s
taxonomy (application) and the students that viewed the non-integrated material had their
highest scores at the lower levels of Bloom’s taxonomy (knowledge). Analysis revealed
that success in anatomy is positively correlated with success in physiology. Therefore,
curricula that require students to complete an anatomy class prior to enrollment in a
physiology course may aid the students in learning physiology. In the future, participation
in the study will be mandatory. This will increase sample size, as well as eliminate the
volunteer bias that was present in this study.
The fourth study was a pilot study that explored first year medical, dental and
podiatry students’ prior knowledge of gross anatomy and their ability to correctly identify
when they had answered gross anatomy questions correctly (metacognition). The study
hoped to provide anatomical educators with an understanding of the students’ prior
experience with gross anatomy. A demographic questionnaire was used to determine the
level at which students had previously completed coursework in anatomy. The study also
investigated the type of anatomical knowledge the students possessed prior to
matriculation in a first year healthcare professional gross anatomy course by testing their
knowledge of gross anatomy at various levels of Bloom’s taxonomy. Two pre-tests were
used to assess the students’ knowledge. One pre-test assessed knowledge at the
129

knowledge, comprehension, application and analysis levels. The other pre-test assessed
knowledge only at the application and analysis levels. The intention was to determine the
depth of knowledge the students had by body region. The study also evaluated the
students’ metacognitive abilities by ranking their confidence that they correctly or
incorrectly answered gross anatomy questions.
A total of 24 students enrolled in the IRB approved educational research project.
Only 1 student did not have any prior coursework in gross anatomy. The remaining
participants had varying degrees of experience with gross anatomy that ranged from
coursework at the high school level to course work at the graduate level. The highest
scores were seen at the knowledge level of Bloom’s taxonomy (77%) when students were
tested at the knowledge, comprehension, application and analysis levels. From their
answers to the metacognitive questions, students in this group felt most confident
answering questions about the thorax. Students who completed the pre-test that assessed
the application and analysis levels of Bloom’s taxonomy felt most confident in answering
questions about general anatomy concepts. The highest gross anatomy scores in this
group were seen at the application level (33.2%). Both groups of students felt the least
comfortable with answering questions about the upper extremity and the abdomen.
Similar to the previous educational study, future plans for this experiment includes
mandating the students to complete the pre-test. Additionally, the number of questions on
the pre-test will be increased.
In conclusion, each of the described studies focus on expanding current
knowledge in the anatomical sciences. The first two studies demonstrate the need to
continue anatomical research based on structural variations. The application of this
research in a clinical environment is seen both with pathological states (thoracic outlet
syndrome) and with clinical interventions (biventricular pacing procedures).
Additionally, it is important to further current understanding of how to effectively
educate healthcare professional students in anatomy. The third study uses two
130

instructional methods to present microanatomy and physiology of the gastrointestinal
system to first year healthcare professional students. The scores on multiple choice
assessments were used to determine if one method was more prone to retention. Also, the
assessment scores linked to different levels of Bloom’s taxonomy presented valuable data
that furthered our understanding of the depth of knowledge the students’ possessed
immediately after learning the material. The fourth study clarified the presence and type
of prior knowledge that healthcare professionals possess in gross anatomy, as well as
their ability to discriminate material that they know and material that they do not know.
These four studies provide further instight into anatomical education in both the clinical
and academic environments.
131

REFERENCES
50 modern thinkers on education (2001). In Palmer J. A. (Ed.), . New York: Rotledge
Taylor & Francis Group.
Adler, M. D., & Johnson, K. B. (2000). Quantifying the literature of computer-aided
instruction in medical education. Academic Medicine, 75(10), 1025-1028.
Angrigiani, C., Grilli, D., Karanas, Y., Longaker, M., & Sharma, S. (2003). The dorsal
scapular island flap: An alternative for head, neck and chest reconstruction. Plast.
Reconstr. Surg., 111, 67.
Anh, D. J., Eversull, C. S., Chen, H. A., Mofrad, P., Mourlas, N. J., Hardwin Mead, R., et
al. (2008). Characterization of human coronary sinus valves by direct visualization
during biventricular pacemaker implantation. Pacing and Clinical
Electrophysiology, 31(1), 78-82. doi:10.1111/j.1540-8159.2007.00928.x
Arroyo-Jimenez Mdel, M., Marcos, P., Martinez-Marcos, A., Artacho-Perula, E., Blaizot,
X., Munoz, M., et al. (2005). Gross anatomy dissections and self-directed learning in
medicine. Clinical Anatomy, 18(5), 385-391.
Aziz, M. A., McKenzie, J. C., Wilson, J. S., Cowie, R. J., Ayeni, S. A., & Dunn, B. K.
(2002). The human cadaver in the age of biomedical informatics. Anatomical
Record, 269(1), 20-32.
Azizan, U. H., & Ibrahim, F. (2012). Identifying pupil's cognitive level in fractions using
bloom's taxonomy. International Journal of Business and Social Science, 3(9), n/a.
Retrieved from http://search.proquest.com/docview/1010396343?accountid=14270
132

Balslev, T., de Grave, W. S., Muijtjens, A. M., & Scherpbier, A. J. (2005). Comparison
of text and video cases in a postgraduate problem-based learning format. Medical
Education, 39(11), 1086-1092.
Barling, P. M., & Ramasamy, P. (2011). Model construction by students within an
integrated medical curriculum. The Clinical Teacher, 8(1), 37-42.
doi:10.1111/j.1743-498X.2010.00419.x
Bear, M. F., Connors, B. W., & Paradiso, M. A. (2007). Neuroscience Exploring the
Brain (Third ed.). Philadelphia: Lippincott Williams and Wilkins.
Bouchard, G. (2011). In full bloom: Helping students grow using the taxonomy of
educational objectives. The Journal of Physician Assistant Education, 22(4), 44.
Burns, E. R. (2006). Learning syndromes afflicting beginning medical students:
Identification and treatment--reflections after forty years of teaching. Medical
Teacher, 28(3), 230-233.
Butler, J. A. (1992). Use of teaching methods within the lecture format. Medical Teacher,
14(1; 1), 11.
Campbell, D.T., & Stanley, J. C. (1963). Experimental and Quasi-Experimental Designs
for Research. Boston: Houghton Mifflin Company.
Carlson, B. M. (2002). Embryology in the medical curriculum. Anatomical Record,
269(2), 89-98.
Carmichael, S. W., & Pawlina, W. (2000). Animated PowerPoint as a tool to teach
anatomy. Anatomical Record, 261(2), 83-88.
133

Chou, C. (2003). Interactivity and interactive functions in web-based learning systems: A
technical framework for designers. British Journal of Educational Technology,
34(3), 265-279.
Chumley-Jones, H. S., Dobbie, A., & Alford, C. L. (2002). Web-based learning: Sound
educational method or hype? A review of the evaluation literature. Academic
Medicine, 77(10 Suppl), S86-93.
Chloros GD, Crosby N, Apel P, Li Z.(2009) Anomalous vasculature as direct cause of
upper brachial plexus thoracic outlet syndrome. Joint Bone Spine. 76(1):92-4.
Cizek, G. J., Webb, L. C., & Kalohn, J. C. (1995). The use of cognitive taxonomies in
licensure and certification test development. Evaluation & the Health Professions,
18(1), 77-91. doi:10.1177/016327879501800106
Clark, D. J. (1998). Course redesign. incorporating an internet web site into an existing
nursing class. Computers in Nursing, 16(4), 219-222.
Cohen-Schotanus, J. (1999). Student assessment and examination rules. Medical Teacher,
21(3; 3), 318-321.
Collins, K. S. (2011). Evaluating differences in test achievement of medical dosimetry
students participating in instruction with synchronous versus asynchronous video
considering personal learning style and bloom's taxonomy level. (Ph.D., Southern
Illinois University at Carbondale). ProQuest Dissertations and Theses, Retrieved
from http://search.proquest.com/docview/902013042?accountid=14270
Cottam, W. W. (1999). Adequacy of medical school gross anatomy education as
perceived by certain postgraduate residency programs and anatomy course directors.
Clinical Anatomy, 12(1), 55-65.
134

Craig, P., Gordon, J., Clark, R., and Langendyk, V. (2004). Prior academic background
and student performance in assessment in a graduate entry programme. Medical
Education, 38, 1164-1168
Crowe, A., Dirks, C., & Wenderoth, M. P. (2008). Biology in bloom: Implementing
bloom's taxonomy to enhance student learning in biology. CBE - Life Sciences
Education, 7(4), 368-381.
Custers, E. (2010). Long-term retention of basic science knowledge: A review study.
Advances in Health Sciences Education, 15(1), 109.
Custers, E. J. F. M., & ten Cate, O. T. J. (2011). Very long-term retention of basic science
knowledge in doctors after graduation. Medical Education, 45(4), 422-430.
doi:10.1111/j.1365-2923.2010.03889.x
Dienstag, J. (2011). Evolution of the new pathway curriculum at harvard medical school:
The new integrated curriculum. Perspectives in Biology and Medicine, 54(1), 36.
Dillon, A., & Gabbard, R. (1998). Hypermedia as an educational technology: A review of
the quantitative research literature on learner comprehension, control, and style.
Review of Educational Research, 68(3), 322-349.
DiLullo, C. (2006). A novel way to engage medical students in learning gross anatomy at
the philadelphia college of osteopathic medicine. Medical Teacher, 28(7), 665-666.
DiLullo, C., Coughlin, P., D'Angelo, M., McGuinness, M., Bandle, J., Slotkin, E. M., et
al. (2006). Anatomy in a new curriculum: Facilitating the learning of gross anatomy
using web access streaming dissection videos. Journal of Visual Communication in
Medicine, 29(3), 99-108.
135

Dobson, C. (2001). Measuring higher cognitive development in anatomy and physiology
students. (D.A., Idaho State University). ProQuest Dissertations and Theses,
Dolan, S., Mallott, D. B., & Emery, J. A. (2002). Passive learning: A marker for the
academically at risk. Medical Teacher, 24(6), 648-649.
Donal, E., Thibault, H., Bergerot, C., Leroux, P., Cannesson, M., Thivolet, S., et al.
(2008). Right ventricular pump function after cardiac resynchronization therapy: A
strain imaging study. Archives of Cardiovascular Diseases, 101(7–8), 475-484.
doi:10.1016/j.acvd.2008.06.004
Drake, R. L. (1998). Anatomy education in a changing medical curriculum. Anatomical
Record, 253(1), 28-31.
Drake, R. L. (2007). A unique, innovative, and clinically oriented approach to anatomy
education. Academic Medicine, 82(5), 475-478.
Drake, R. L., Lowrie, D. J.,Jr, & Prewitt, C. M. (2002). Survey of gross anatomy,
microscopic anatomy, neuroscience, and embryology courses in medical school
curricula in the united states. Anatomical Record, 269(2), 118-122.
Drury, N. E., Powell-Smith, E., & McKeever, J. A. (2002). Medical practitioners'
knowledge of latin. Medical Education, 36(12), 1175.
Duan, Y. (2006). Selecting and applying taxonomies for learning outcomes: A nursing
example. International Journal of Nursing Education Scholarship, 3(1)
136

Duckett, S. G., Ginks, M. R., Knowles, B. R., Ma, Y., Shetty, A., Bostock, J., et al.
(2011). Advanced Image Fusion to Overlay Coronary Sinus Anatomy with Real-
Time Fluoroscopy to Facilitate Left Ventricular Lead Implantation in CRT.
Pacing and Clinical Electrophysiology, 226-234.
Elizondo-Omana, R. E., Garcia-Rodriguez Mde, L., Morales-Gomez, J. A., & Guzman-
Lopez, S. (2006). Study pace as a factor that influences achievement in a human
anatomy course. Anatomical Record.New Anatomist, 289(4), 134-138.
Elizondo-Omana, R. E., Morales-Gomez, J. A., Guzman, S. L., Hernandez, I. L., Ibarra,
R. P., & Vilchez, F. C. (2004). Traditional teaching supported by computer-assisted
learning for macroscopic anatomy. Anatomical Record.New Anatomist, 278(1), 18-
22.
Eva, K. W., Cunnington, J. P., Reiter, H. I., Keane, D. R., & Norman, G. R. (2004). How
can I know what I don't know? poor self assessment in a well-defined domain.
Advances in Health Sciences Education, 9(3), 211-224.
Feigin, D. S., Magid, D., Smirniotopoulos, J. G., & Carbognin, S. J. (2007). Learning and
retaining normal radiographic chest anatomy: Does preclinical exposure improve
student performance? Academic Radiology, 14(9), 1137-1142.
doi:10.1016/j.acra.2007.06.023
Feigin, D. S., Smirniotopoulos, J. G., & Neher, T. J. (2002). Retention of radiographic
anatomy of the chest by 4th-year medical students. Academic Radiology, 9(1), 82-
88. doi:10.1016/S1076-6332(03)80299-4
137

Finucane, P. M., Johnson, S. M., & Prideaux, D. J. (1998). Problem-based learning: Its
rationale and efficacy.[see comment]. Medical Journal of Australia, 168(9), 445-
448.
Fitzharris, T. P. (1998). Survey of gross anatomy courses in the united states and canada.
Anatomical Record, 253(6), 162-166.
Foreman, K. B., Morton, D. A., Musolino, G. M., & Albertine, K. H. (2005). Design and
utility of a web-based computer-assisted instructional tool for neuroanatomy self-
study and review for physical and occupational therapy graduate students.
Anatomical Record.New Anatomist, 285(1), 26-31.
Ganske, I., Su, T., Loukas, M., & Shaffer, K. (2006). Teaching methods in anatomy
courses in north american medical schools the role of radiology. Academic
Radiology, 13(8), 1038-1046.
Garg, A. X., Norman, G., & Sperotable, L. (2001). How medical students learn spatial
anatomy. Lancet, 357(9253), 363-364.
Garg, A., Norman, G., Spero, L., & Taylor, I. (1999). Learning anatomy: Do new
computer models improve spatial understanding? Medical Teacher, 21(5; 5), 519-
522.
George M Usova. (1997). Effective test item discrimination using bloom's taxonomy.
Education, 118(1), 100-110. Retrieved from
http://search.proquest.com/docview/196422439?accountid=14270
Geuna, S., & Giacobini-Robecchi, M. G. (2002). The use of brainstorming for teaching
human anatomy. Anatomical Record, 269(5), 214-216.
138

Giffin, B. F., & Drake, R. L. (2000). Gross anatomy of the head and neck and
neuroscience in an integrated first-year medical school curriculum. Anatomical
Record, 261(2), 89-93.
Granello, D. H. (2001). Promoting cognitive complexity in graduate written work: Using
bloom's taxonomy as a pedagogical tool to improve literature reviews. Counselor
Education & Supervision, 40, 292-307.
Granger, N. A., & Calleson, D. (2005). Finding support for educational projects in
anatomy: Tips, tools, and lessons learned. Anatomical Record.New Anatomist,
282(1), 13-17.
Granger, N. A., Calleson, D. C., Henson, O. W., Juliano, E., Wineski, L., McDaniel, M.
D., et al. (2006). Use of web-based materials to enhance anatomy instruction in the
health sciences. Anatomical Record.New Anatomist, 289(4), 121-127.
Gray, H. (1995). In Pick T. P., Howden R. (Eds.), Gray's anatomy (15th ed.) n.p.
Grunewald, M., Ketelsen, D., Heckemann, R. A., Zenk, J., Schick, C., Bison, B., et al.
(2006). Www.tnt-radiology.de: Teach and be taught radiology: Implementation of a
web-based training program based on user preferences as determined by survery.
Academic Radiology, 13(4), 461-468.
Guttmann, G. D. (2000). Animating functional anatomy for the web. Anatomical Record,
261(2), 57-63.
Habib, A., Lachman, N., Christensen, K. N., & Asirvatham, S. J. (2009). The anatomy of
the coronary sinus venous system for the cardiac electrophysiologist. Europace,
v15-v21.
139

Hahne, A. K., Benndorf, R., Frey, P., & Herzig, S. (2005). Attitude towards computer-
based learning: Determinants as revealed by a controlled interventional study.
Medical Education, 39(9), 935-943.
Halawi, L. A., McCarthy, R. V., & Pires, S. (2009). An evaluation of E-learning on the
basis of bloom's taxonomy: An exploratory study. Journal of Education for
Business, 84(6), 374-380.
Hall, A. S., & Durward, B. R. (2009). Retention of anatomy knowledge by student
radiographers. Radiography, 15(3), e22-e28. doi:10.1016/j.radi.2009.03.002
Hallgren, R. C., Parkhurst, P. E., Monson, C. L., & Crewe, N. M. (2002). An interactive,
web-based tool for learning anatomic landmarks. Academic Medicine, 77(3), 263-
265.
Handfield-Jones, R., & Nasmith, L. (1993). Creativity in medical education: The use of
innovative.. Medical Teacher, 15(1; 1), 3.
Harries, C. S., & Botha, J. (2007). Undergraduate medical students' reasoning with regard
to the prescribing process. South African Journal of Higher Education, 21(5), 455-
467. Retrieved from
http://search.ebscohost.com/login.aspx?direct=true&db=ehh&AN=32080468&site=e
host-live&scope=site
Harris, D., Hannum, L. and Gupta, S. (2004). Contributing factors to student success in
anatomy and physiology: lower outside workload and better preparation. The
American Biology Teacher, 66(3), 168-172.
140

Healy, W. J., Taran, Z., & Betts, S. C. (2011). Sales course design using experiential
learning principles and bloom's taxonomy. Journal of Instructional Pedagogies, 6, 1-
10. Retrieved from
Heidger, P. M.,Jr, Dee, F., Consoer, D., Leaven, T., Duncan, J., & Kreiter, C. (2002).
Integrated approach to teaching and testing in histology with real and virtual
imaging. Anatomical Record, 269(2), 107-112.
Hellerstein, H. K. & Orbison, J.L. (1951). Anatomic Variations of the Orifice of the
Human Coronary Sinus. Circulation, 514-523.
Hsu, L. (2010). Metacognitive inventory for nursing students in Taiwan: instrument
development and testing. Journal of Advanced Nursing, 66(11), 2573-2581.
Huelke, DF (1958) A study of the transverse cervical and dorsal scapular arteries. Anat
Rec., 132; 233-245.
Huelke, DF (1962) The dorsal scapular artery – a proposed term for the artery to the
rhomboid muscles. Anat Rec 142:57-61.
Inwood, M. J., & Ahmad, J. (2005). Development of instructional, interactive,
multimedia anatomy dissection software: A student-led initiative. Clinical Anatomy,
18(8), 613-617.
Jaccard, J and Dodge, T. (2005). Metacognition, risk behavior and risk outcomes: the role
of perceived intelligence and perceived knowledge. Health Psychology, 24(2),
161-170.
141

Jacobs, J., Caudell, T., Wilks, D., Keep, M. F., Mitchell, S., Buchanan, H., et al. (2003).
Integration of advanced technologies to enhance problem-based learning over
distance: Project TOUCH. Anatomical Record.New Anatomist, 270(1), 16-22.
Jaffe, C. C., & Lynch, P. J. (1995). Computer-aided instruction in radiology:
Opportunities for more effective learning. AJR.American Journal of Roentgenology,
164(2), 463-467.
Jarcho, J. A. (2006). Biventricular Pacing. The New England Journal of Medicine, 288-
94.
Jastrow, H., & Hollinderbaumer, A. (2004). On the use and value of new media and how
medical students assess their effectiveness in learning anatomy. Anatomical
Record.New Anatomist, 280(1), 20-29.
Jui-Hung Ven, & Chien-Pen Chuang. (2005). The comparative study of information
competencies-using bloom's taxonomy. Journal of American Academy of Business,
Cambridge, 7(1), 136-143. Retrieved from
Kalyuga, S., Chandler, P., & Sweller, J. (2000). Incorporating learner experience into the
design of multimedia instruction. Journal of Educational Psychology, 92(1), 126-
136.
Kandan SR, Khan S, Jeyaretna DS, Lhatoo S, Patel NK, Coakham HB. (2010) Neuralgia
of the glossopharyngeal and vagal nerves: long-term outcome following surgical
treatment and literature review. Br J Neurosurg. 24(4):441-6.
142

Karaca, M., Bilge, O., Dinckal, M. H., & Ucerler, H. (2005). The Anatomic Barriers in
the Coronary Sinus: Implications for Clinical Procedures. Journal of
Interventional Cardiac Electrophysiology, 89-94.
Kathryn T Knecht. (2001). Assessing cognitive skills of pharmacy students in a
biomedical sciences module using a classification of multiple-choice item categories
according to bloom's taxonomy. American Journal of Pharmaceutical Education,
65(4), 324. Retrieved from
Kau, T., Sinzig, M., Gasser, J, Lesnik, G., Rabitsch, E., Celedin, S., Eicher, W., Illiasch,
H., Hausegger, K. (2007). Aortic Development and Anomalies. Seminars in
Interventional Radiology, 24(2): 141-152.
Kaufman MR, Willekes LJ, Elkwood AI, Rose MI, Patel TR, Ashinoff RL, Colicchio
AR. (2010) Diaphragm paralysis caused by transverse cervical artery compression of
the phrenic nerve: the Red Cross syndrome. Clin Neurol Neurosurg. 114(5):502-5.
Kerfoot, B. P., DeWolf, W. C., Masser, B. A., Church, P. A., & Federman, D. D. (2007).
Spaced education improves the retention of clinical knowledge by medical students:
A randomised controlled trial. Medical Education, 41(1), 23-31. doi:10.1111/j.1365-
2929.2006.02644.x
Ketelsen, D., Schrodl, F., Knickenberg, I., Heckermann, R. A., Hothorn, T., Neuhuber,
W., et al. (2007). Modes of information delivery in radiologic anatomy education:
Impact on student performance. Academic Radiology, 14(1), 93-99.
143

Khalil, M. K., Nelson, L. D., & Kibble, J. D. (2010). The use of self-learning modules to
facilitate learning of basic science concepts in an integrated medical curriculum.
Anatomical Sciences Education, 3(5), 219-226. doi:10.1002/ase.177
Kibble, J. D., & Johnson, T. (2011). Are faculty predictions or item taxonomies useful for
estimating the outcome of multiple-choice examinations? Advances in Physiology
Education, 35(4), 396-401. doi:10.1152/advan.00062.2011
Klement, B., Paulsen, D., & Wineski, L. (2011). Anatomy as the backbone of an
integrated first year medical curriculum: Design and implementation. Anatomical
Sciences Education, 4(3), 157.
Krathwohl, D. R. (2002). A revision of bloom's taxonomy: An overview. Theory into
Practice, 41(4, Revising Bloom's Taxonomy), pp. 212-218. Retrieved from
http://www.jstor.org/stable/1477405
Kruidering-Hall, M., O'Sullivan, P. S., & Chou, C. L. (2009). Teaching feedback to first-
year medical students: Long-term skill retention and accuracy of student self-
assessment. JGIM: Journal of General Internal Medicine, 24(6), 721-726.
doi:10.1007/s11606-009-0983-z
Lammers, R. L. (2008). Learning and retention rates after training in posterior epistaxis
management. Academic Emergency Medicine, 15(11), 1181-1189.
doi:10.1111/j.1553-2712.2008.00220.x
Lang, W. P. (1995). Trends in students' knowledge, opinions, and experience regarding
dental informatics and computer applications. Journal of the American Medical
Informatics Association, 2(6), 374-382.
144

Last, K. S., Appleton, J., Ferguson, D. B., & Stevenson, H. (2000). The value of a
questionnaire in assessing the acquisition and retention of basic science knowledge
by dental students. European Journal of Dental Education, 4(1), 3-9.
doi:10.1034/j.1600-0579.2000.040102.x
Lei, L. W., Winn, W., Scott, C., & Farr, A. (2005). Evaluation of computer-assisted
instruction in histology: Effect of interaction on learning outcome. Anatomical
Record.New Anatomist, 284(1), 28-34.
Leonard, D. C. (2002). Learning theories A to Z. Westport, CT: Greenwood Press.
Leung, K. K., Lu, K. S., Huang, T. S., & Hsieh, B. S. (2006). Anatomy instruction in
medical schools: Connecting the past and the future. Advances in Health Sciences
Education, 11(2), 209-215.
Levine, M. G., Stempak, J., Conyers, G., & Walters, J. A. (1999). Implementing and
integrating computer-based activities into a problem-based gross anatomy
curriculum. Clinical Anatomy, 12(3), 191-198.
Levinson, A. J., Weaver, B., Garside, S., McGinn, H., & Norman, G. R. (2007). Virtual
reality and brain anatomy: A randomised trial of e-learning instructional designs.
Levy, S., Taylor, G., Baudet, J., & Gue ́rin, J. (2003). Angiosomes of the brachial plexus:
An anatomical study. Plast. Reconstr. Surg., , 1799.
Lischka MF, Krammer EB, Rath T, Riedl M, Ellbock E. (1982) The human thyrocervical
trunk: configuration and variability reinvestigated. Anat Embryol 163:389-401.
145

Lewis, K. N. (2004). The language of modern medicine: It's all greek to me. American
Surgeon, 70(1), 91-93.
Lord, T., & Baviskar, S. (2007). Moving students from information recitation to
information understanding: Exploiting bloom's taxonomy in creating science
questions. Journal of College Science Teaching, 36(5), 40-44. Retrieved from
http://search.ebscohost.com/login.aspx?direct=true&db=ehh&AN=24359802&site=e
host-live&scope=site
Loukas, M., Bilinsky, S., Bilinsky, E., El-Sedfy, A., & Anderson, R. H. (2009). Cardiac
Veins: A Review of the Literature. Clinical Anatomy, 129-145.
Luki, I. K., Glunci, V., Katavi, V., Petanjek, Z., Jalsovec, D., & Marusi, A. (2001).
Weekly quizzes in extended-matching format as a means of monitoring students'
progress in gross anatomy. Annals of Anatomy, 183(6), 575-579.
Madhuri, K., Kulkarni, U., Supe, A., & Deshmukh, Y. (2010). Introducing integrated
teaching in undergraduate medical curriculum. International Journal of
Pharmaceutical Sciences and Research, 1(1), 18.
Mair, H., Sachweh, J., Meuris, B., Nollert, G., Schmoeckel, M., Schuetz, A., et al. (2005).
Surgical epicardial left ventricular lead versus coronary sinus lead placement in
biventricular pacing. European Journal of Cardio-Thoracic Surgery, 27(2), 235-242.
doi:10.1016/j.ejcts.2004.09.029
Marsh, K. R., Giffin, B. F., & Lowrie, D. J. (2008). Medical student retention of
embryonic development: Impact of the dimensions added by multimedia tutorials.
Anatomical Sciences Education, 1(6), 252-257. doi:10.1002/ase.56
146

Mattick, K., Dennis, I., & Bligh, J. (2004). Approaches to learning and studying in
medical students: Validation of a revised inventory and its relation to student
characteristics and performance. Medical Education, 38(5), 535-543.
Mayer, R. E., & Massa, L. J. (2003). Three facets of visual and verbal learners: Cognitive
ability, cognitive style, and learning preference. Journal of Educational Psychology,
95(4), 833-846.
Mayer, R. E., & Sims, V. K. (1994). For whom is a picture worth a thousand words?:
Extensions of a dual-coding theory of multimedia learning. Journal of Educational
Psychology, 86(3), 389-401.
McKeown, P. P., Heylings, D. J., Stevenson, M., McKelvey, K. J., Nixon, J. R., &
McCluskey, D. R. (2003). The impact of curricular change on medical students'
knowledge of anatomy. Medical Education, 37(11), 954-961.
McLachlan, J. C., & Patten, D. (2006). Anatomy teaching: Ghosts of the past, present and
future. Medical Education, 40(3), 243-253.
McLeod, P. J., Meagher, T., Steinert, Y., Schuwirth, L., & McLeod, A. H. (2004).
Clinical teachers' tacit knowledge of basic pedagogic principles. Medical Teacher,
26(1), 23-27.
McNulty, J. A., Halama, J., Dauzvardis, M. F., & Espiritu, B. (2000). Evaluation of web-
based computer-aided instruction in a basic science course. Academic Medicine,
75(1), 59-65.
McNulty, J. A., Halama, J., & Espiritu, B. (2004). Evaluation of computer-aided
instruction in the medical gross anatomy curriculum. Clinical Anatomy, 17(1), 73-
78.
147

Mehta, L. A., Natrajan, M., & Kothari, M. L. (1996). Understanding anatomical terms.
Miller, S. A., Perrotti, W., Silverthorn, D. U., Dalley, A. F., & Rarey, K. E. (2002). From
college to clinic: Reasoning over memorization is key for understanding anatomy.
Anatomical Record, 269(2), 69-80.
Mitchell, B. S., McCrorie, P., & Sedgwick, P. (2004). Student attitudes towards anatomy
teaching and learning in a multiprofessional context. Medical Education, 38(7), 737-
748.
Mitchell, B. S., & Stephens, C. R. (2004). Teaching anatomy as a multimedia experience.
Morgan, J. and Delgado, V. (2009), Lead Positioning for Cardiac Resynchronization
Therapy: Techniques and Priorities. Europace, 11:v22-28
Mueller, D., Georges, A., & Vaslow, D. (2007). Cooperative learning as applied to
resident instruction in radiology reporting. Academic Radiology, 14(12), 1577-1583.
Muller, J. H., Jain, S., Loeser, H., & Irby, D. M. (2008). Lessons learned about
integrating a medical school curriculum: Perceptions of students, faculty and
curriculum leaders. Medical Education, 42(8), 778-785. doi:10.1111/j.1365-
2923.2008.03110.x
Murata, H., Sakai, A., Hadzic, A., & Sumikawa, K. (2012). The presence of transverse
cervical and dorsal scapular arteries at three ultrasound probe positions commonly
used in supraclavicular brachail plexus blockade. Anesthesia and Analgesia,
148

Nieder, G. L., & Nagy, F. (2002). Analysis of medical students' use of web-based
resources for a gross anatomy and embryology course. Clinical Anatomy, 15(6), 409-
418.
Norman, G. (2002). What does two disciplines of scientific psychology have to say to
medical education?. Advances in Health Sciences Education, 7(1), 57-62.
Norman, G. (2000). The essential role of basic science in medical education: The
perspective from psychology. Clinical & Investigative Medicine, 23(1), 47.
Ogul, U., Canbay, A., Diker, E., & Aydogdu, S. (2010). Long Eustachian valve
interfering with the access to coronary sinus during biventricular pacemaker
implantation. Anadolu Kardiyoloji Dergisi , 185-186.
Older, J. (2004). Anatomy: A must for teaching the next generation.[see comment].
Surgeon Journal of the Royal Colleges of Surgeons of Edinburgh & Ireland, 2(2),
79-90.
Pabst, R., & Rothkotter, H. J. (1997). Retrospective evaluation of undergraduate medical
education by doctors at the end of their residency time in hospitals: Consequences
for the anatomical curriculum. Anatomical Record, 249(4), 431-434.
Pabst, R. (2009). Anatomy curriculum for medical students: What can be learned for
future curricula from evaluations and questionnaires completed by students,
anatomists and clinicians in different countries? Annals of Anatomy - Anatomischer
Anzeiger, 191(6), 541-546. doi:10.1016/j.aanat.2009.08.007
Pandey, P., & Zimitat, C. (2007). Medical students' learning of anatomy: Memorisation,
understanding and visualisation. Medical Education, 41(1), 7-14.
149

Parker, J. A., Wallis, J. W., Halama, J. R., Brown, C. V., Cradduck, T. D., Graham, M.
M., et al. (1996). Collaboration using internet for the development of case-based
teaching files: Report of the computer and instrumentation council internet focus
group. Journal of Nuclear Medicine, 37(1), 178-184.
Paul, R. W. (1985). Bloom's taxonomy and critical thinking instruction. Educational
Leadership, 42(8), 36. Retrieved from
http://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=8875068&site=eh
ost-live&scope=site
Peterson, C. A., & Tucker, R. P. (2005). Undergraduate coursework in anatomy as a
predictor of performance: Comparison between students taking a medical gross
anatomy course of average length and a course shortened by curriculum reform.
Phillips, A. W., Smith, S. G., Ross, C. F., & Straus, C. M. (2012). Improved
understanding of human anatomy through self-guided radiological anatomy
modules. Academic Radiology, 19(7), 902-907. doi:10.1016/j.acra.2012.03.011
Plack, M. M., Driscoll, M., Marquez, M., Cuppernull, L., Maring, J., & Greenberg, L.
(2007). Assessing reflective writing on a pediatric clerkship by using a modified
Bloom’s taxonomy. Ambulatory Pediatrics, 7(4), 285-291.
doi:10.1016/j.ambp.2007.04.006
Porter, K. B. (2008). Current trends in student retention: A literature review. Teaching
and Learning in Nursing, 3(1), 3-5. doi:10.1016/j.teln.2007.09.001
150

Prince, K. J., Scherpbier, A. J., van Mameren, H., Drukker, J., & van der Vleuten, C. P.
(2005). Do students have sufficient knowledge of clinical anatomy?. Medical
Education, 39(3), 326-332.
Prince, K. J., van Mameren, H., Hylkema, N., Drukker, J., Scherpbier, A. J., & van der
Vleuten, C. P. (2003). Does problem-based learning lead to deficiencies in basic
science knowledge? an empirical case on anatomy. Medical Education, 37(1), 15-21.
Purves, D., Augustine, G. J., Fitzpatrick, D., Hall, W. C.-S., McNamara, J. O., & White,
L. E. (2008). Neuroscience (Fourth ed.). Sunderland: Sinauer Associates, Inc.
Radwany, S. M., Stovsky, E. J., Frate, D. M., Dieter, K., Friebert, S., Palmisano, B., et al.
(2011). A 4-year integrated curriculum in palliative care for medical undergraduates.
American Journal of Hospice and Palliative Medicine, 28(8), 528-535.
doi:10.1177/1049909111406526
Reidenberg, J. S., & Laitman, J. T. (2002). The new face of gross anatomy. Anatomical
Record, 269(2), 81-88.
Reiner A, Kasser, R. (1996) Relative frequency of a subclavian vs a transverse cervical
origin for the dorsal scapular artery in humans. Anat Rec 244:265-268.
Rizzolo, L. J., Aden, M., & Stewart, W. B. (2002). Correlation of web usage and exam
performance in a human anatomy and development course. Clinical Anatomy, 15(5),
351-355.
Rizzolo, L. J., Stewart, W. B., O'Brien, M., Haims, A., Rando, W., Abrahams, J., et al.
(2006). Design principles for developing an efficient clinical anatomy course.
Medical Teacher, 28(2), 142-151.
151

Roberts, N. (1976). Further verification of bloom's taxonomy. Journal of Experimental
Education, 45(1), 16.
Roos, DB. (1976) Congenital anomalies associated with thoracic outlet syndrome.
Anatomy, symptoms, diagnosis, and treatment. Am J Surg. 132(6):771-8.
Rupani, C., & Bhutto, M. (2011). Evaluation of existing teaching learning process on
bloom's taxonomy. International Journal of Academic Research in Business and
Social Sciences, 1, 119.
Sadler, T. W. (2004). Langman's medical embryology (9th ed.). Philadelphia, PA:
Lippincott Williams & Wilkins.
Sánchez-Quintana, D., Cabrera, J. A., Climent, V., Farr, J., Weiglein, A., & Siew Yen, H.
O. (2005). How close are the phrenic nerves to cardiac structures? implications for
cardiac interventionalists. Journal of Cardiovascular Electrophysiology, 16(3), 309-
313. doi:10.1046/j.1540-8167.2005.40759.x
Saqib Shahzad, Abdul Qadoos, Syed Naeem Badshah, Hussain Muhammad, & S M
Ramzan. (2011). Analytical study of question papers on bloom taxonomy.
Interdisciplinary Journal of Contemporary Research in Business, 3(8), 336-345.
Sarsam Z, Garcia-Fiñana M, Nurmikko TJ, Varma TR, Eldridge P. (2010) The long-term
outcome of microvascular decompression for trigeminal neuralgia. Br J Neurosurg.
24(1):18-25.
152

Schuwirth, L. W. T., Blackmore, D. E., Mom, E., Wildenberg, F. V. D., Stoffers, H. E. J.
H., & Vleuten, C. P. M. V. D. (1999). How to write short cases for assessing
problem-solving skills. Medical Teacher, 21(2; 2), 144-150.
Scott, T. M. (1993). How we teach anatomy efficiently and effectively. Medical Teacher,
15(1; 1), 67.
Seaman, M. (2011). Bloom's taxonomy: Its evolution, revision, and use in the field of
education. Curriculum and Teaching Dialogue, 13, 29+. Retrieved from
http://go.galegroup.com/ps/i.do?id=GALE%7CA284325094&v=2.1&u=temple_mai
n&it=r&p=AONE&sw=w
Shaw, J. (2006). The assessment of critical thinking skills in anatomy and physiology
students who practice writing higher order multiple choice questions. (D.A., Idaho
State University). ProQuest Dissertations and Theses, Retrieved from
Shimura, T., Aramaki, T., Shimizu, K., Miyashita, T., Adachi, K., & Teramoto, A.
(2004). Implementation of integrated medical curriculum in japanese medical
schools. Journal of Nippon Medical School, 71(1), 11.
Siefert, M et al. (2010) Influence of pacing configurations, body mass index, and
position of coronary sinus lead on frequency of phrenic nerve stimulation and
pacing thresholds under cardiac resynchronization therapy Europace 12(7): 961-
967
153

Sites, B., Macfarlane, A., Sites, V., Naraghi, A., Chan, V., Antonakakis, J., et al. (2010).
Clinical sonopathology for the regional anesthesiologist part 1: Vascular and neural.
Reg Anesth Pain Med, 35, 272.
Smith, C. F., & Mathias, H. (2007). An investigation into medical students' approaches to
anatomy learning in a systems-based prosection course. Clinical Anatomy, 20(7),
843-848.
Smith, S. B., Carmichael, S. W., Pawlina, W., & Spinner, R. J. (2007). Latin and greek in
gross anatomy. Clinical Anatomy, 20(3), 332-337.
Stalmeijer, R. E., Gijselaers, W. H., Wolfhagen, I. H., Harendza, S., & Scherpbier, A. J.
(2007). How interdisciplinary teams can create multi-disciplinary education: The
interplay between team processes and educational quality. Medical Education,
41(11), 1059-1066.
Stedman, C. (1973). An analysis of the assumptions underlying the taxonomy of
educational objectives: cognitive domain. Journal of Research in Science Teaching,
10(3), 235-241.
Steele, D. J., Johnson Palensky, J. E., Lynch, T. G., Lacy, N. L., & Duffy, S. W. (2002).
Learning preferences, computer attitudes, and student evaluation of computerised
instruction. Medical Education, 36(3), 225-232.
Strkalj, G., Schroder, T., Pather, N., & Solyali, V. (2011). A preliminary assessment of
the fifth-year chiropractic students' knowledge of anatomy. Journal of Alternative &
Complementary Medicine, 17(1), 63-66. doi:10.1089/acm.2010.0157
154

Su, W. M., & Osisek, P. J. (2011). The revised bloom's taxonomy: Implications for
educating nurses. The Journal of Continuing Education in Nursing, 42(7), 321-7.
doi:10.3928/00220124-20110621-05
Subramanian, A., Timberlake, M., Mittakanti, H., Lara, M., & Brandt, M. L. (2012).
Novel educational approach for medical students: Improved retention rates using
interactive medical software compared with traditional lecture-based format. Journal
of Surgical Education, 69(2), 253-256. doi:10.1016/j.jsurg.2011.12.007
Tan, K., & Tan, B. (200). Extended lower trapezius island myocutaneous flap: A
fasciomyocutaneous flap based on the dorsal scapular artery. Plastic and
Reconstructive Surgery, 105(5), 1758.
Tedman, R. A., Alexander, H., Massa, H., & Moses, D. (2011). Student perception of a
new integrated anatomy practical program: Does students' prior learning make a
difference? Clinical Anatomy, 24(5), 664-670. doi:10.1002/ca.21180
Trimble C, Reeves A, Pare L, Tsai F (2011).Vertebral Artery Anomaly Causing C2
Suboccipital Neuralgia, Relieved by Neurovascular Decompression. J
Neuroimaging. 2011 Jun 17. doi: 10.1111/j.1552-6569.2011.00602.x
Tsai, M. and Tsai, L. (2005). The critical success factors and impact of prior knowledge
to nursing students when transferring nursing knowledge during nursing clinical
practice. Journal of Nursing Management, 13, 459-466
Tubbs, R. Shane, Tyler-Kahara, Elizabeth C., Salter, E. George, Sheetz, J, Zehren, Steven
J., Oakes, Jerry W. (2006) Additional vascular compression of the brachial plexus in
a cadaver with a cervical rib: case illustration. Surg Radiol Anat 28:112-113.
155

Tubbs RS, Smyth MD, Salter G et al (2003) Anomalous traversement of the
suprascapular artery through the suprascapular notch—an anatomical study. Med Sci
Monit 9:BR2–BR5
Tutarel, O., Luedemann, W., Nautrup, C. P., Jahn, K., Wilke, M., & Berens von
Rautenfeld, D. (2000). Introduction and evaluation of a modular seminar system in
gross anatomy teaching at the hannover medical school. Annals of Anatomy, 182(4),
393-396.
Valenza, M. C., Castro-Martín, E., Valenza, G., Guirao-Piñeiro, M., De-la-Llave-Rincón,
A. I., & Fernández-de-las-Peñas, C. (2012). Comparison of third-year medical and
physical therapy students' knowledge of anatomy using the carpal bone test. Journal
of Manipulative and Physiological Therapeutics, 35(2), 121-126.
doi:10.1016/j.jmpt.2011.12.005
Van Sint Jan, S., Crudele, M., Gashegu, J., Feipel, V., Poulet, P., Salvia, P., et al. (2003).
Development of multimedia learning modules for teaching human anatomy:
Application to osteology and functional anatomy. Anatomical Record.New
Anatomist, 272(1), 98-106.
Verhoeven, B. H., Verwijnen, G. M., Scherpbier, A. J. J. A., Holdrinet, R. S. G.,
Oeseburg, B., Bulte, J. A., et al. (1998). An analysis of progress test results of PBL
and non-PBL.. Medical Teacher, 20(4; 4), 310.
Vrchota, D. (2004). Touchstone award: Challenging students' thinking with bloom's
taxonomy. Communication Teacher, 18(1), 2-5. doi:10.1080/1740462032000142086
156

Walker, D. S., Lee, W. Y., Skov, N. M., Berger, C. F., & Athley, B. D. (2002).
Investigating users' requirements: Computer-based anatomy learning modules for
multiple user test beds. Journal of the American Medical Informatics Association,
9(4), 311-319.
Weiglein, Andreas H., Moriggl, B., Schalk, C. Kunzel, K.H., Muller, U. (2005) Arteries
in the posterior cervical triangle in man Clin Anat 18:553-557.
White, C., Ross, P., & Haftel, H. (2008). Assessing the assessment: Are senior
summative OSCEs measureing advanced knowledge, skills, and attitudes? Academic
Medicine, 83(12), 1191.
Wilhelmsson, N., Dahlgren, L., Hult, H., Scheja, M., Lonka, K., & Josephson, A. (2010).
The anatomy of learning anatomy. Advances in Health Sciences Education, 15, 153.
Wise, G. (2000). The new anatomy: A forecast of hope. Clinical Anatomy, 13, 148-149.
Wong, J. and Wong, S. (1999). Contribution of basic sciences to academic success in
nursing education. International Journal of Nursing Studies, 36, 345-354
Yiou, R., & Goodenough, D. (2006). Applying problem-based learning to the teaching of
anatomy: The example of harvard medical school. Surgical & Radiologic Anatomy,
28(2), 189-194.
Zeegers, P. (2001). Approaches to learning in science: A longitudinal study. British
Journal of Educational Psychology, 71(Pt 1), 115-132.
157

Zheng, A. Y., Lawhorn, J. K., Lumley, T., & Freeman, S. (2008). Application of bloom's
taxonomy debunks the "MCAT myth". Science, 319(5862), 414-415.
doi:10.1126/science.1147852
158

APPENDICES
159

APPENDIX A
INFORMED CONSENT FORM: MEDICAL STUDENT POPULATION
Title: Effects of Integration of Cardiac Anatomy with Physiological Concepts on Immediate and Delayed
Recall of Anatomical Knowledge. IRB Protocol #: 13926
Student Investigator Anne-Marie Verenna, Department of Anatomy and Cell Biology; Principal Advisor
James Heckman, PhD. Department of Physiology, 215-707-3286
We are currently engaged in a study that identifies the retention of anatomical knowledge with success in
mastering physiology knowledge. To help us gain further insight into this area, we ask that you participate
in our study.
As a participant in the study, you will be asked to answer questions regarding your prior knowledge of
anatomy. These questions will be answered in the form of online quizzes throughout Block 3. The quizzes
will be available online and will be accessible both on and off campus. Each quiz will take less than 10
minutes to complete.
Your AccessNet ID, provided to you by Temple University, and a login password, which you will create,
will be used to secure the information gathered during the study. Only the investigators will have access
to the collected information.
Although the study team has placed safeguards to maintain the confidentiality of my personal
information, there is always a potential risk of an unpermitted disclosure. To that degree, all documents
and information pertaining to this research study will be kept confidential, unless required by applicable
federal, state, and local laws and regulations to be disclosed. I understand the records and data generated
by the study may be reviewed by Temple University and its agents, the study sponsor or the sponsor’s
agent (if applicable), and/or governmental agencies to assure proper conduct of the study and compliance
with regulations. I understand that the results of this study may be published. If any data is published, I
will not be identified by name.
Participation in this research project is voluntary. You will not be penalized if you do not participate in
this research study.
Information that is collected from this project will be used for dissertation research.
If I have any questions about my rights as a research subject, I may contact the Institutional
Review Board Coordinator at (215) 707-3390. The IRB Coordinator may also be reached by
email: IRB@temple.edu or regular mail: Institutional Review Board Coordinator Temple
University Research Administration Student Faculty Conference Center 3340 North Board Street
– Suite 304 Philadelphia, PA 19140. Signing your name below indicates that you have read and
understand the contents of this form.
Participant’s Signature/Printed Name Date
160

APPENDIX B
MEDICAL STUDENT POPULATION
Gross Anatomy Quiz Knowledge – 2 Comprehension – 3 Application – 2 Analysis – 3
Microanatomy Quiz Knowledge – 2 Comprehension – 3 Application – 2 Analysis – 3
Gastric and Pancreatic Secretion Quiz Knowledge – 2 Comprehension – 3 Application – 2
Analysis – 3
161

APPENDIX C
THE ASSEMBLER PROGRAM
The Assembler program used in the dental and podiatry student population was
similar to the program that was used for the medical student population. When the
Assembler program is launched, the screen presents four different tables: a table of
contents, a transcript area, a PowerPoint area titled Bullet Points and a PowerPoint slide
area titled images. In this version of the Assembler, these four tables are initially
identically sized. The student is able to change the size and location of each box by
clicking and dragging the mouse (features that were not available to the medical
students). The audio section of the Assembler is located at the bottom of the screen.
.
162

APPENDIX D
ANNOUNCEMENT POSTED ON THE COURSE MANAGEMENT SYSTEM TO
RECRUIT DENTAL STUDENTS DURING THE SIXTH WEEK OF THE DENTAL
PHYSIOLOGY COURSE
As you may remember, a few weeks ago my graduate student and I described an educational
research project in which we would like you to participate. Dr. Martin has agreed to add three
points to the final examination grade of each student who participates in this project by
completing the required tutorials and quizzes. The estimated time for you to complete the project
is two hours. Since the material presented in these tutorials is similar to what will be presented
during the upcoming GI lectures it is expected that by participating in the project you will reduce
the time required to learn the material presented during the lectures.
Participation in this project will require you to view computer tutorials and complete several
multiple choice quizzes. The tutorials and the multiple choice quizzes will be administered in
Blackboard, and therefore can be accessed either on or off campus. You do not need to complete
the entire project in one sitting. However, you will only have one opportunity to take each quiz.
The quizzes will not count towards the calculation of your final grade. You must complete the
tutorials and quizzes by 9 AM Friday, June 1, 2012.
If you are interested in participating, you must complete the following steps in the order they are
listed:
1. Review the informed consent form that is attached to this e-mail. 2. Send an e-mail to
tua75765@temple.edu with Research Project in the subject line. In the body of the e-mail, please
type the following: I have reviewed the informed consent form posted on Blackboard and would
like to participate in protocol # 13926. 3. Upon receipt of your e-mail, Anne-Marie Verenna (my
graduate student) will
send you an e-mail confirming your participation in the project. You should then log into
Blackboard using FireFox not Internet Explorer, and look under the Groups tab. An assignment
will be posted for you to review. Please make sure to open the assignment because it will tell you
the order in which to complete the tutorials and quizzes. It is important that you follow the
instructions in the assignment. Only students that fully complete the instructions will receive the
additional points on their final examination grade. If you have any questions regarding this
project, please do not hesitate to contact Anne- Marie at tua75765@temple.edu.
I ask you to seriously consider participating in this project. It will not only give you extra credit
but will help us create better ways to teach future Dental students. Thank you!
163

APPENDIX E
DENTAL AND PODIATRY STUDENT POPULATION
Gross Anatomy Quiz Knowledge – 3 Comprehension – 4 Application – 3 Analysis – 5
Microanatomy Quiz Knowledge – 3 Comprehension – 4 Application – 3 Analysis – 5
Gastric and Pancreatic Secretion Quiz Knowledge – 3 Comprehension – 4 Application – 3
Analysis – 5
164

APPENDIX F
INFORMED CONSENT FORM: MEDICAL STUDENT POPULATION
Title: Effects of Integration of Anatomy with Physiological Concepts on Immediate and Delayed Recall
of Anatomical Knowledge. IRB Protocol #: 13926
Student Investigator Anne-Marie Verenna, Department of Anatomy and Cell Biology; Principal Advisor
James Heckman, PhD. Department of Physiology, 215-707-3286
We are currently engaged in a study that identifies the retention of anatomical knowledge with success in
mastering physiology knowledge. To help us gain further insight into this area, we ask that you participate
in our study.
As a participant in the study, you will be asked to answer questions regarding your prior knowledge of
anatomy. These questions will be answered in the form of online quizzes during the dental physiology
course. The quizzes will be available online and will be accessible both on and off campus. Each quiz will
take less than 10 minutes to complete.
You will access the quizzes through BlackBoard. You will need your AccessNet ID, provided to you by
Temple University, and a login password, which you have created, to access the experimental materials.
Only the investigators will have access to the collected information.
Although the study team has placed safeguards to maintain the confidentiality of my personal
information, there is always a potential risk of an unpermitted disclosure. To that degree, all documents
and information pertaining to this research study will be kept confidential, unless required by applicable
federal, state, and local laws and regulations to be disclosed. I understand the records and data generated
by the study may be reviewed by Temple University and its agents, the study sponsor or the sponsor’s
agent (if applicable), and/or governmental agencies to assure proper conduct of the study and compliance
with regulations. I understand that the results of this study may be published. If any data is published, I
will not be identified by name.
Participation in this research project is voluntary. You will not be penalized if you do not participate in
this research study.
Information that is collected from this project will be used for dissertation research.
If I have any questions about my rights as a research subject, I may contact the Institutional
Review Board Coordinator at (215) 707-3390. The IRB Coordinator may also be reached by
email: IRB@temple.edu or regular mail: Institutional Review Board Coordinator Temple
University Research Administration Student Faculty Conference Center 3340 North Board Street
– Suite 304Philadelphia, PA 19140.
165

APPENDIX G
INSTRUCTIONS FOR ACCESSING RESEARCH PROJECT MATERIALS –
CONTROL GROUP: DENTAL AND PODIATRY POPULATIONS
Hi Student Name,
Thank you for choosing to participate in the educational research project. You now have access
to the research project materials on Blackboard. To complete the project and receive your extra
credit points, please complete the following actions in the following order:
1. Log into Blackboard using Firefox. 2. On the left side of your screen, find the groups tab.
Click on Group 1. 3. A drop down menu will appear. Please click on group homepage. 4. Under
group assignment, you should see an assignment titled Research Project.
Please click on the assignment. 5. The assignment will have .air files attached, as well as
instructions. Please
carefully read the instructions. They will tell you how to complete the required tutorials and
quizzes. The instructions refer you to two places: tutorials and quizzes. The .air files are the
tutorials and are located in the assignment. The quizzes are located under the content tab in
Blackboard. You will be required to download both Adobe Flash Player and Adobe Air. I have
attached a word document that tells you how to download both Adobe Flash Player and Adobe
Air for free. The attachment also provides you with instructions on how to navigate the tutorials.
Please let me know if you have any questions or problems with the research project. Thank you
again for participating in this project.
Best, Anne-Marie
166

APPENDIX H
SEQUENCE FOR REVIEWING RESEARCH MATERIALS – CONTROL GROUP:
DENTAL AND PODIATRY POPULATIONS
Thank you for agreeing to participate in this education research project. To participate in the
project and receive your three points on the final examination grade, please perform the
following steps. It is crucial that you complete the steps in the following sequence:
1. Click on the Gross Anatomy Quiz. You will only be able to access this quiz once, so please
make sure you allot sufficient time to complete the quiz. The quiz has a 30 minute time limit. 2.
Click on the file GIMicroanatomy.air. This file will permit you access to the
microanatomy tutorial. If you do not have the latest version of Air, you will be prompted to
install it. The installation is free. Please complete the installation and then open the
GIMicroanatomy.air file. You will be able to access this material many times so it is not critical
that you complete the tutorial in one sitting. 3. Click on the Microanatomy Quiz. Without using
the microanatomy tutorial or
additional resources, complete the quiz. You will only be able to access the quiz once. The quiz
has a 30 minute time limit. 4. Click on the file GIPhysiology.air. This file will permit you access
to the
physiology tutorial. You will be able to access this material many times so it is not critical that
you complete the tutorial in one setting. 5. Click on the Gastric and Pancreatic Secretion Quiz.
Without using the physiology tutorial or additional resources, complete the quiz. You will only
be able to access the quiz once. The quiz has a 30 minute time limit.
167

APPENDIX I
INSTRUCTIONS FOR INSTALLATION AND OPERATION OF THE ASSEMBLER
SOFTWARE
Installation and Operating Instruction for “The Assembler” Program
If you have any problems installing or using this software do not hesitate to contact
Anne-Marie (tua75765@temple.edu)
“The Assembler”
Installation: Use the FireFox browser and no other for all of the following. Do not use
Internet Explorer. To get the latest version of FireFox click here.
You should install the latest version of Adobe Flash Player and Adobe Air. Go to
Adobe.com to download them.
Operating Instructions for The Assembler Program
1. Turn on your sound system and set the volume appropriately 2. Navigation options
a. Click the green buttons to go forward or backward. b. Click in the Table of Contents
window. c. Select the slider on the top of the screen and drag it right or left. d. Click the
Auto Advance button and activate its check mark. When the sound clip finishes, the
program will automatically take you to the next page, Unchecking the button will allow
you to manually navigate forward or back. 3. Audio Transcript
a. A complete transcript of each audio clip will be available in the
transcript window. b. It may be necessary to scroll down to be able to see all of the
text
Thanks for your help with this project! Dr. Heckman Anne-Marie
168

APPENDIX J
INSTRUCTIONS FOR ACCESSING RESEARCH PROJECT MATERIALS –
EXPERIMENTAL GROUP: DENTAL AND PODIATRY POPULATIONS
Thank you for choosing to participate in the educational research project. You now have access
to the research project materials on Blackboard. To complete the project and receive your extra
credit points, please complete the following actions in the following order:
1. Log into Blackboard using Firefox. 2. On the left side of your screen, find the groups tab.
Click on Group 2. 3. A drop down menu will appear. Please click on group homepage. 4. Under
group assignment, you should see an assignment titled Research Project.
Please click on the assignment. 5. The assignment will have .air files attached, as well as
instructions. Please
carefully read the instructions. They will tell you how to complete the required tutorials and
quizzes.
The instructions refer you to two places: tutorials and quizzes. The .air file is the tutorial and is
located in the assignment. The quizzes are located under the content tab in Blackboard. You will
be required to download both Adobe Flash Player and Adobe Air. I have attached a word
document that tells you how to download both Adobe Flash Player and Adobe Air for free. The
attachment also provides you with instructions on how to navigate the tutorials.
Please let me know if you have any questions or problems with the research project. Thank you
again for participating in this project.
Best, Anne-Marie
169

APPENDIX K
SEQUENCE FOR REVIEWING RESEARCH MATERIALS – EXPERIMENTAL
GROUP: DENTAL AND PODIATRY POPULATIONS
Thank you for agreeing to participate in this education research project. To participate in the
project and receive your three points on the final examination grade, please perform the
following steps. It is crucial that you complete the steps in the following sequence:
1. Click on the Gross Anatomy Quiz. You will only be able to access this quiz once, so please
make sure you allot sufficient time to complete the quiz. The quiz has a 30 minute time limit. 2.
Click on the file GIIntegratedTutorial.air. This file will permit you access to the
microanatomy and physiology tutorial. If you do not have the latest version of Air, you will be
prompted to install it. The installation is free. Please complete the installation and then open the
GIIntegratedTutorial.air file. You will be able to access this material many times so it is not
critical that you complete the tutorial in one sitting. 3. Click on the Microanatomy Quiz. Without
using the microanatomy tutorial or
additional resources, complete the quiz. You will only be able to access the quiz once. The quiz
has a 30 minute time limit. 4. Click on the Gastric and Pancreatic Secretion Quiz. Without using
the physiology tutorial or additional resources, complete the quiz. You will only be able to
access the quiz once. The quiz has a 30 minute time limit.
170

APPENDIX L
INFORMED CONSENT FORM – PODIATRY STUDENT POPULATION
Title Of The Research Study: Effects Of Integration Of Anatomy With Physiological Concepts
On Immediate And Delayed Recall Of Anatomical Knowledge
Name and Department Of Investigator: James Heckman, PhD TUSM Physiology
This study involves research. The purpose of the research is to investigate how prior anatomy
knowledge influences academic achievement in physiology.
What You Should Know About A Research Study:
• Someone will explain this research study to you.
• You volunteer to be in a research study.
• Whether you take part is up to you.
• You can choose not to take part in the research study.
• You can agree to take part now and later change your mind.
• Whatever you decide, it will not be held against you.
• Feel free to ask all the questions you want before and after you decide.
The estimated duration of your study participation is approximately two hours.
The study procedures consist of viewing online software that contains microanatomy and
physiology content as well as completing three multiple choice quizzes. Your scores on the
multiple choice quizzes, as well as the score from the final exam of the physiology course., will
be used for data analysis.
There are no reasonably foreseeable risks or discomforts.
The benefit you will obtain from the research is knowing that you have contributed to the
understanding of this topic.
The alternative to participating is not to participate.
Please contact the research team with questions, concerns, or complaints about the research and
any research-related injuries by calling 215-707-3286 or e-mailing tua75765@temple.edu.
This research has been reviewed and approved by the Temple University Institutional Review
Board. Please contact them at (215) 707-3390 or e-mail them at: irb@temple.edu for any of the
following: questions, concerns, or complaints about the research; questions about your rights; to
obtain information; or to offer input.
171

Confidentiality: Efforts will be made to limit the disclosure of your personal information,
including research study records, to people who have a need to review this information.
However, the study team cannot promise complete secrecy. For example, although the study
team has put in safeguards to protect your information, there is always a potential risk of loss of
confidentiality. There are several organizations that may inspect and copy your information to
make sure that the study team is following the rules and regulations regarding research and the
protection of human subjects. These organizations include the IRB, Temple University, its
affiliates and agents, Temple University Health System, Inc., its affiliates and agents, and the
Office for Human Research Protections.
Signature Block for Capable Adult
Your signature documents your permission to take part in this research.
Signature of subject Date
Printed name of subject
172

APPENDIX M
ANNOUNCEMENT POSTED ON THE COURSE MANAGEMENT SYSTEM TO
RECRUIT PODIATRY STUDENTS DURING THE SEVENTH WEEK OF THE
PODIATRY PHYSIOLOGY COURSE
Dear TUSPM Class of 2016,
I am writing to inform you of an educational research project that Dr. Heckman and his graduate
student (Anne-Marie Verenna) are conducting in the next week. They are asking for your
participation.
Participation in this project will require you to view computer tutorials and complete three
multiple choice quizzes. The tutorials and the multiple choice quizzes will be administered in
Blackboard and can be accessed either on or off campus. The estimated time to complete the
research project is two hours. Participants will not be required to complete the project in one
sitting. However, you will only have one opportunity to take each quiz. The quizzes will not
count towards the calculation of your final grade.
The material presented in these tutorials is similar to what will be presented during the upcoming
GI lectures; it is expected that by participating in the project you will reduce the time required to
learn the material presented during the lectures. I have agreed to add two points to the final
course grade of each student who participates in this project by completing the required tutorials
and quizzes. To receive these additional points, all required quizzes and tutorials must be
completed by 10AM on October 18, 2012.
Anne-Marie will begin enrolling students in the research project on October 13, 2012. If you are
interested in participating, you must complete the following steps in the order they are listed:
1. Review the informed consent form that is attached to this announcement. 2. Send an e-mail to
tua75765@temple.edu with Research Project in the subject line. In the body of the e-mail, please
type the following: I have reviewed the informed consent form posted on Blackboard and would
like to participate in protocol # 20923. 3. Upon receipt of your e-mail, Anne-Marie Verenna will
send you an e-mail
confirming your participation in the project. You should then log into Blackboard using FireFox,
not Internet Explorer, and look under the Groups tab. An assignment will be posted for you to
review. Please make sure to open the assignment because it will tell you the order in which to
complete the tutorials and quizzes. It is important that you follow the instructions in the
assignment. Only students that fully complete the instructions will receive the additional points
on their final course grade.
173

If you have any questions regarding this project, please do not hesitate to contact Anne- Marie at
tua75765@temple.edu. I ask you to seriously consider participating in this project. It will not
only give you extra credit but will help us create better ways to teach future Podiatry students.
174

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