Jo Matthan (Director of Academic Studies, School of Dental Sciences) talks about the teaching of Head and Neck Anatomy (DEN1101) within the School of Dental Sciences (SDS) at the Faculty of Medical Sciences (FMS), and how the move to online teaching necessitated the development of a specialised Digital Code around the use of cadaveric imagery.
In Present-in-Person (PiP) teaching, students attending this foundational head and neck anatomy course would typically have access to the Dissecting Room for their learning. This would be delivered over a six-month period in their first year on either the Dental Surgery (BDS) or the BSc Oral and Dental Health Sciences degrees. This face-to-face time has been reduced to 12 hours from the approximately 50 hours of hands-on anatomy teaching delivered, which left a considerable amount of content to be covered in the digital format. In normal times, a code of conduct is signed by every student the first time they enter the restricted Anatomy and Clinical Skills Centre teaching facility. This was utilised in a digital format during the pandemic but, due to the major overhaul in teaching delivery, there was no way of reinforcing the messages contained within the code of conduct on a regular basis. It felt like a tall order to expect students to remember and understand a list of statements that is seemingly far-removed from them at the start of their anatomy learning journey, and to retain this volume of information in the digital era.
Due to the highly sensitive nature of working with donated cadaveric material and the associated professional standards and ethical considerations linked to this usage, it was necessary to develop a set of guidance to protect the dignity of donors, whilst simultaneously guiding educators, students and institutions on the manifold issues to consider when transitioning to online cadaveric teaching. The sensitive material (i.e., cadaveric images) would not normally be available to students on an ad hoc basis on their own devices. As this content still needed to be covered to ensure the healthcare professionals received all of the necessary training they needed to practice their profession safely and keep patients safe, questions arose around the potential for covert screen-capture, unauthorised viewing and wider sharing of cadaveric content. Such breaches of professionalism have widespread implications, not merely for the course and programme but potentially for the institution. It became clear that it was necessary to collate clear guidance for staff and students to steer through the digital landscape.
Developing an In-house Digital Code
An in-house digital code was developed as part of the SDS Digital Delivery Working Group – a student-staff collaboration that convened over summer 2020 to specifically mitigate for any anticipated issues that could arise from the shift to online delivery for both students and educators within the School. Three different digital codes were created, each in the form of a holding slide that could be utilised in (1) Cadaveric Anatomy Teaching, (2) Clinical Teaching and (3) Seminar or Lecture-based teaching situations. These slides were circulated to the FMS TEL Group and then circulated for feedback from the other Schools that grapple with similar concerns around donor dignity and patient confidentiality. A basic confidentiality agreement was later put in place institutionally, but this was not specific to anatomy or teaching involving potential breaches of patient information. It was felt that, in the new era of digital delivery, it would be more beneficial to reinforce the message of a common digital code at every learning encounter to clearly communicate to students the expectations and behaviours appropriate for this form of teaching. For this purpose, the Digital Code for anatomy was developed, with the aim of utilising it as a holding slide for every synchronous encounter, and as a recorded slide at the start of each non-synchronous session that included cadaveric content.
Digital Code in Practice
The Digital Code slide is displayed at the beginning of every teaching session, whether synchronous or non-synchronous. In synchronous sessions, it is used as the ‘holding slide’ displayed as students enter the video call. When teaching begins, the slide is also reinforced verbally to signal the start of the learning and shared professionalism code of conduct. In practice, it may feel that the points around ethical standards and professionalism are somewhat overemphasised but, given how important they are, the Digital Code does bear repeating. In non-synchronous sessions, a pre-recorded initial slide is added to every lecture recording to reinforce the message not to view the recording in public and to adhere to the digital code. This is added to all recordings from all contributors.
The Digital Code slide gives a simple overview of both the required professional behaviours for healthcare professionals and unacceptable behaviours, bringing the more abstract guidance document into clear actionable focus. As a result, students are very clearly aware of the professional expectations expected of them in their chosen field of study, and these regular reminders serve to reinforce this. This is much more effective than simply citing a document which may have only been seen once at the beginning of the course. The existence of this Code is beneficial not only for students who, it is hoped, develop a sense of responsibility with the access to sensitive content, but also for donors, teachers and institutions who can rely on clear guidance but also appreciate that institutions have pre-defined consequences for any breaches – of which none have been reported thus far. Students have displayed high levels of professional conduct throughout the anatomy teaching in SDS and have adopted the digital code without any apparent reluctance or challenges. It is highly likely that, once students return to physical classrooms, this practice will be continued and developed.
Taking it a step further: Developing National Guidance for Online Cadaveric Imaging
Due to manifold misunderstandings on the legislation and guidance around the use of cadaveric images, it became clear at an informal National Designated Individual (DI) / Head of Anatomy Forum (convened to improve communication during the pandemic and consisting of heads of anatomy units and DIs from across the UK, as well as representatives of the regulatory bodies from each country) that educators could benefit from a unified front with regards to digital cadaveric education. A small group from within this informal forum (consisting of representatives from Brighton Sussex Medical School, Newcastle University and University of Nottingham) collated anecdotal and professional experiences with patient confidentiality and social media guidance documentation and developed a three-pronged approach to using cadaveric content online. The first step was to search for guidance from the relevant professional bodies. The Human Tissue Authority (HTA), the national body who regulate teaching related to cadaveric specimens in England, is virtually silent on the use of images of a cadaveric nature, and decisions relating to how images can be used are made by the local HTA DI within institutions. There is also a paucity of guidance on image usage in this context from the devolved nations’ regulatory bodies/inspectors. Some institutions do have some guidance around social media and images, but there is no unified and unambiguous guidance on cadaveric teaching in the online era.
The draft guidance document was circulated to the DI Forum and to the HTA for comments and the final document amended with suggested changes. The current version, along with a suggested PowerPoint slide, is already utilised at SDS for teaching purposes. It has recently been presented at the March 2021 meeting of the Trans-European Pedagogic Anatomical Research Group (TEPARG), at which it proved very popular across the European countries represented, and has been widely lauded for its clarity and utility during this period of intense change. The guidance document, with the digital code appended to it, is now in use across many institutions nationally and internationally and is being reviewed for formal dissemination.
TEPARG – Trans-European Pedagogic Anatomical Research Group
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