AAMC Reporter, November 2000:Like Nothing on Earth: A Doctor Records His Experiences Aboard Mir

VOLUME 10, NUMBER 4

JORDAN J. COHEN, M.D., PRESIDENT

JANUARY 2001

When the Dead Teach the Living: Easing the Emotional Impact of Human Dissection

By Barbara A. Gabriel

Hilary, a Cornell University medical student whose journal entries about her dissection experience appear in "Anatomy of Anatomy," uses her own arm as a reference during a lab exam. Photo credit: © Meryl Levin, from "Anatomy of Anatomy"

Carrie, a contributor to "Anatomy of Anatomy," learns about the skeletal structure of the human body during her freshman anatomy lab. Photo credit: © Meryl Levin, from "Anatomy of Anatomy"

"When I went to school, you had to play it cool; humor and denial were the only tools we had," recalls Sandy Marks Jr., Ph.D., D.D.S., of his freshman anatomy lab dissection experience. Now a professor of cell biology, radiology, and surgery at the University of Massachusetts Medical School, Dr. Marks has created a program within the school's anatomy course that allows students to explore the emotional impact of dissecting a human body, recognizing that this encounter with their first "patient" may well set the tone for how they will interact with future patients.

"It's a course about scientific discovery and self-discovery," explains Dr. Marks, who has been teaching gross anatomy at the University of Massachusetts Medical School since its founding in 1970. "There's a long history of denying human mortality both in our culture and in the medical profession. Some students become very good deniers - they adopt an emotional armor in which the humanistic motives of caring for another person are lost."

Dr. Marks himself did not see the need to address emotional issues in his anatomy course until a student brought them to his attention. "In the early 1970s, a medical school student unexpectedly dropped out," recalls Dr. Marks. "When he returned the following year, he explained to me that a close relative had died while he was in the midst of his anatomy lab. The emotional impact of the dissection process immobilized him, and he had to leave to grieve for his loss. He felt there was a need to address issues of death and mortality with students, whose encounter with their cadaver may bring those issues to the surface for the first time."

Dr. Marks began to experiment with different methods of introducing discussions about death and dying into his anatomy lab. When Sandra Bertman, Ph.D., a professor of humanities in medicine, arrived at U-Mass in the late-1970s, he had found a colleague to help him lay the foundation for a program that is part of the anatomy course taken by today's University of Massachusetts medical students.

The program starts before the students arrive on campus: Drs. Marks and Bertman ask the incoming freshman class to send in pictures or drawings that illustrate how they feel about the human dissection they will soon participate in. On the first day of class, Dr. Marks talks to students about the history of dissection, emphasizing the relatively recent concept of individuals making the choice to donate their bodies to science.

"I stress the parallel between people making the decision to donate their bodies and patients who will come to them for healing - both are trusting the students with their physical selves," Dr. Marks says. Students then tour the dissection lab in small groups. A cadaver is unwrapped and Dr. Marks explains how the bodies are prepared and how to take proper care of them. A few days later dissection begins.

"The most difficult periods of dissection are the first view, the first cut, and the dissection of the head and neck," Dr. Marks explains. "If they haven't before, students come face to face with the individuality of their cadavers during this time." Thus the second session Drs. Marks and Bertman provide takes place prior to the head and neck dissection. In this session, students are shown the drawings they submitted before the class began and are encouraged to talk about the effect the course is having on them.

At the conclusion of their anatomy lab, Dr. Marks' students organize a memorial service for the donated bodies - a tradition that has taken place at U-Mass for the past 20 years. They invite the family members of those who have donated their bodies and conduct what Dr. Marks calls "an incredibly moving and articulate celebration of life and a closure of this whole process."

Pairing Dissection and the Humanities At the MCP Hahnemann University School of Medicine, first-year students are gathered together to discuss "Cadaver Stories," a published set of narratives in which medical students at the State University of New York at Stony Brook imagine the life of the person whose body they are dissecting or examine their own relationship to that body. The stories are meant to generate discussion during a two-hour group session in which students are encouraged to explore their thoughts and feelings about beginning anatomy lab.

Another nine-session elective course called "Cutting Cold Flesh: Perspectives From the Humanities" invites students to examine the process of dissection through the lenses of non-scientific fields of study. Steven Peitzman, M.D., professor of medicine at MCP Hahnemann and creator of the course, explains that the course's goal is to "expand the students' understanding of why they are undertaking this very difficult activity."

To that end, the interdisciplinary course features guest lecturers who focus on aspects of the history or experience of dissection as interpreted through art, religion, literature, anthropology, and other disciplines. Starting with a lecture on the history of human dissection, students go on to learn about the role of dissection in the evolution of art, how different religions view the sanctity of the body, and what sort of powers and taboos are associated with the dead body in different cultures. An artist also leads the students in drawing a face that evokes a sense of their cadaver as a person.

"Students say that the sessions help them to better understand dissection's potential benefits, as well as to situate themselves as a privileged group in a lineage of previous dissectors," says Dr. Peitzman.

Exploring Dissection Through the Arts "I've been personally frustrated for many years by the lack of an emotional and artistic means for stimulating discussion, thought, and reflection on the issues of death and mortality that inevitably arise in the anatomy lab," says Tom Cole, Ph.D., professor and graduate program director of the Institute for Medical Humanities at the University of Texas Medical Branch at Galveston (UTMB). Dr. Cole, who previously produced a critically acclaimed documentary about desegregation, decided to use film to examine what he felt was the unexplored emotional terrain that accompanies human dissection.

Dr. Cole explains that he was inspired to produce the film "Anatomy and Humanity: Conversations With Donors and Dissectors" more than two years ago when he witnessed a memorial service held by anatomy students at UTMB at the end of their lab, in which the cremated remains of the cadavers are scattered from a boat into the Gulf of Mexico. "I wanted to explore the emotional journey that had led up to this very moving event," Dr. Cole explains.

And so he began interviewing first-year medical students about the emotional impact the dissection process was having on them, asking questions such as, "Was there a moment when you felt in your heart that this body had once been a living person?" and "If you could speak to the person who donated their body, what would you say?" Dr. Cole then began interviewing people who intend to donate their bodies to medicine, asking them about their motives for donation and what messages they have for the students who will ultimately learn from them. The result, Dr. Cole says, is "a conversation between the living and the dead."

"There is a profound, largely unexplored relationship between the donor and the dissector," Dr. Cole says. "In the 18 years I have been teaching freshman medical students, the more clear it becomes to me that there are inadequate means for incorporating the moral, psychological, and spiritual aspects of this experience. My sense is that it is a collaboration between the living and the dead. The more we can understand that and the more students can open themselves up to the humanistic side of anatomical learning, the more compassionate they will become."

Upon the film's completion next spring, Dr. Cole hopes to distribute it to all of the nation's academic medical centers as a resource for anatomy professors to initiate discussion with their first-year medical students. "By encouraging medical students and faculty members to reflect on what they're thinking and feeling in relation to the cadaver, the film makes dissection a more human experience," explains Dr. Cole.

The Anatomy of Anatomy Meryl Levin, a documentary photographer whose interest in health and social welfare often brings her into contact with health care providers, was intrigued by the emotional distance many of the physicians she worked with were able to maintain in potentially overwhelming situations. Curious, she began questioning them about it. "They pointed to anatomy as one of the earliest moments in their training when they began to hone the skill of scientific objectivity that many of them feel serves them well in making rational decisions about their patients' care," Levin says. She began to think about documenting an anatomy course to explore the complex emotions that arise when a young medical student is first confronted with death in its most raw form.

Levin found an ear for her idea at the Cornell University Joan and Sanford I. Weill Medical College. She was given permission to photograph the freshman class of 1998 as they proceeded through their gross anatomy course. In addition, out of a class of 101, Levin worked closely with 11 students who agreed to keep journals of their dissection experience. Many of their journal entries accompany Levin's photographs in "Anatomy of Anatomy: In Images and Words," a publication that Levin calls "an alternative textbook for medical students."

"My hope is that the book is used as a springboard to discuss death and dying, what it means to take apart someone who used to be alive, and how students can respect themselves and their own emotions as well as those of the patients they will come to treat," explains Levin. "Ultimately, the book can be a private reflective device, allowing students to interact with 11 sensitive people who have been through what they are experiencing."

Through a grant from the Open Society Institute's Project on Death in America, Levin is taking her photographs on the road where they will be displayed with excerpts from the participating students' journals at several medical schools.

"It's extremely important for our future physicians to have thought through issues of death and dying and be comfortable with their own mortality so they can better approach these subjects with patients and their families," she says. "For many medical students, this is one of the first experiences they will have with death. Learning how to deal with it is a skill that doesn't always accompany their scientific training."