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The Place of Surface Anatomy in the Medical Literature and Undergraduate

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 RELEVANT REVIEW

The Place of Surface Anatomy in the Medical Literature

and Undergraduate Anatomy Textbooks
Samy A. Azer*
Curriculum Development Unit, College of Medicine, King Saud University, Riyadh, Saudi Arabia

The aims of this review were to examine the place of surface anatomy in the medical litera-
ture, particularly the methods and approaches used in teaching surface and living anatomy
and assess commonly used anatomy textbooks in regard to their surface anatomy contents.
PubMed and MEDLINE databases were searched using the following keywords “surface
anatomy,” “living anatomy,” “teaching surface anatomy,” “bony landmarks,” “peer exam-
ination” and “dermatomes”. The percentage of pages covering surface anatomy in each
textbook was calculated as well as the number of images covering surface anatomy. Clarity,
quality and adequacy of surface anatomy contents was also examined. The search identified
22 research papers addressing methods used in teaching surface anatomy, 31 papers that
can help in the improvement of surface anatomy curriculum, and 12 anatomy textbooks.
These teaching methods included: body painting, peer volunteer surface anatomy, use of a
living anatomy model, real time ultrasound, virtual (visible) human dissector (VHD), full
R R
body digital x-ray of cadavers (LodoxV StatscanV images) combined with palpating land-
marks on peers and the cadaver, as well as the use of collaborative, contextual and self-
directed learning. Nineteen of these studies were published in the period from 2006 to
2013. The 31 papers covered evidence-based and clinically-applied surface anatomy. The
percentage of surface anatomy in textbooks’ contents ranged from 0 to 6.2 with an average
of 3.4%. The number of medical illustrations on surface anatomy varied from 0 to 135. In
conclusion, although there has been a progressive increase in publications addressing meth-
ods used in teaching surface anatomy over the last six to seven years, most anatomy text-
books do not provide students with adequate information about surface anatomy. Only
three textbooks provided a solid explanation and foundation of understanding surface
anatomy. Anat Sci Educ 6: 415–432. V
C 2013 American Association of Anatomists.

Key words: gross anatomy education; surface anatomy; living anatomy; medical educa-
tion; anatomy textbooks; teaching methods; clinical procedures; evidence-based surface
anatomy; peer physical examination; review

INTRODUCTION structures are perceptible to touch in a living body, it is also

Surface anatomy is an essential component of studying the
human body (Leonard et al., 1999; Standring, 2012). It is not
just about knowing what lies under the skin and what
*Correspondence to: Prof. Samy A. Azer, Medical Education Depart-
ment, College of Medicine, King Saud University, PO Box 2925, Ri-
yadh 11461, Saudi Arabia. E-mail: azer2000@optusnet.com.au
Grant sponsor: College of Medicine Research Center, Deanship of
Scientific Research, King Saud University, Riyadh, Saudi Arabia.
Received 1 December 2012; Revised 21 February 2013; Accepted 18
March 2013.
Published online 6 May 2013 in Wiley Online Library
(wileyonlinelibrary.com). DOI 10.1002/ase.1368
C 2013 American Association of Anatomists
V example here is a patient presenting with upper abdominal
about enabling learners to improve their skills in clinical
examinations, interventional procedures (Leonard et al.,
1999), and interpretation of diagnosing images. Considering
the recommendations introduced to medical curriculum by ac-
creditation bodies such as the General Medical Council
“Tomorrow’s Doctors” (GMC, 2009), the Australian Medical
Council (AMC, 2010; Geffen, 2010; Field, 2011), and the
Association of American Medical Colleges (AAMC), (Bunton
et al., 2012; Hunt et al., 2012) and the fact that the aim of
these recommendations is to produce good doctors (Lockwood
and Roberts, 2007; Bunton et al., 2012), surface anatomy
should cover essential topics that general practitioners need
(McLachlan, 2004; McLachlan et al., 2004; Turney, 2007;
Kotze et al., 2012). In many instances, surface anatomy forms
the basis for generating hypotheses by the learner. A good

Anatomical Sciences Education NOVEMBER/DECEMBER 2013 Anat Sci Educ 6:415–432 (2013)
pain in a problem-based learning (PBL) case. Students in the
early years may find it difficult to raise a substantial number
of possible hypotheses. The PBL tutor may facilitate this pro-
cess by asking open-ended questions such as: “What are the
anatomical structures in this area (placing his hand over the
upper abdomen) that can produce pain? Let us start from skin
and then proceed inward”. Students may create a list or draw
these structures on the whiteboard. The tutors then ask a sec-
ond open ended question- “what could possibly go wrong
with each of these anatomical structures and produce pain?”
(Azer, 2005). Such an exercise in PBL may enable students to
learn the significance of surface anatomy in generating hypoth-
eses. In clinical practice, surface anatomy helps practitioners to
locate structures under the skin by recognizing their normal
palpable surface characteristics (Chou et al., 2010). Despite
the availability of direct visualization techniques such as ultra-
sound guidance to help in interventional procedures, practi-
tioners have not suspended the need for relevant surface
anatomy knowledge to ensure successful and safe conduction
of procedures (Marhofer et al., 2010). Graney emphasized
even further the importance of surface anatomy in this area by
linking failure to achieve these objectives or the occurrence of
complications in invasive procedures to misunderstanding or a
lack of understanding of anatomy (Graney, 1996). Therefore,
practitioners always need a firm grounding in surface/living
anatomy (Ganguly and Chan, 2008). This necessitates the inte-
gration of radiology, including ultrasound in the teaching of
anatomy (Miles, 2005; Tshibwabwa and Groves, 2005; Grik-
saitis et al., 2012; Stringer et al., 2012a,b). Surface anatomy
and living anatomy is also essential for understanding the
foundation of physical examination, and the interpretation of
clinical findings (e.g., by examining the dermatomes and myo-
tomes in a patient with spinal injury, sensory/motor scores,
level of lesion and completeness of a spinal lesion can be deter-
mined). Too much focus on local surface anatomy and imme-
diate underlying structures can lead to incorrect diagnosis. For
example, the pain resulting from a herniated disc at the level
of L4/5 is usually perceived at the calf and foot. Over-empha-
sis on local surface anatomy may lead the physician to think
of popliteal (Baker’s) cyst or popliteal artery aneurysm, when
the patient’s problem is in their back. Therefore, it is impor-
tant to consider the role of surface/living anatomy in helping
practitioners to relate referred pain to the possible diseased
organ/anatomical structure responsible for pain perception and
its unique distribution. Such concepts are important in clinical
practice and are based on understanding surface anatomy and
dermatomes/myotomes (Lumley, 2008; Azer, 2012; Tunstall
and Shah, 2012; Field and Hutchinson, 2013). Surface anat-
omy is also important in understanding the techniques of ex-
amination (palpation of abdominal organs such as the liver and
spleen) (Lumley, 2008; Tunstall and Shah, 2012; Field and
Hutchinson, 2013). Therefore, there is a need for a solid foun-
dation in surface anatomy and medical curricula and learning
resources should devote learning material and time to this area.
It is imperative also, that surface anatomy should be incorpo-
rated in clinical practice and clinical training.
Recently three major reviews covered the place of anatomy
in medical education (Louw et al., 2009; Sugand et al., 2010;
Bergman et al., 2011), and although these extensive reviews
covered different aspects of anatomy teaching and learning in
current curricula and possible causes for challenges facing the
anatomy teaching, they neither adequately discussed the role of
surface and living anatomy in medical education nor explored
current research/studies in this area. In the meantime, there are
416
a number of recent publications addressing innovative ideas for
teaching surface anatomy in an integrated curriculum such as
learning surface anatomy through body painting (Op Den
Akker et al., 2002; McMenamin, 2008; Finn, 2010; Finn and
McLachlan, 2010). With the reduction of time allocated to
teaching anatomy in some schools, there is a need to use the
available time both efficiently and effectively and target best
teaching approaches to maximize learning outcomes (McHan-
well et al., 2007; Collins, 2008; Fitzgerald et al., 2008; Stringer
and Nicholson, 2008; Pabst, 2009; Standring, 2009). Although
medical students in a PBL or case-based learning curricula tend
to use a range of resources such as Web-based education
(Hallgren et al., 2002; Nieder and Nagy, 2002; Kim et al.,
2003; Glinkowski and Ciszek, 2007; Marker et al., 2012),
Google (Kingsley et al., 2011; Karamanlis et al., 2012), You-
Tube (Azer, 2012; Azer et al., 2012; Duncan et al., 2013;
Topps et al., 2013), computer-assisted learning (Stanford et al.,
1994; Garg et al., 1999a,b; Shaffer, 2004; Luursema
et al., 2006; Choi et al., 2008; Donnelly et al., 2009;
Tam et al., 2009), multimedia and web 3D (Rockford, 1985;
Brenton et al., 2007; Lufler et al., 2012; Preece et al., 2013),
journal articles as well as museums in their self-directed learn-
ing (Murad et al., 2010; Findlater et al., 2012), textbooks are
widely used by both students and teachers. Anatomy textbooks
provide learners with a solid foundation of understanding the
subject matter, including clinical applications, radiological
anatomy and in some textbooks have questions at the end of
each chapter to further consolidate learning. However, text-
books, tend to be behind in highlighting new knowledge con-
structed in the literature and do not necessarily address
students’ needs or are reflective of the changes introduced to
curricula (Waldum et al., 2001; Azer, 2004; Azer and Eizen-
berg, 2007; Drake et al., 2009; Wiegant et al., 2011).
Whether the effects of these changes on surface anatomy
research translate into significant effects on anatomy text-
books is still unknown. A number of studies have recently
highlighted inconsistencies in surface anatomy knowledge
and the need for evidence-based research in this area (Hale
et al., 2010; Mirjalili et al., 2010a). Other studies have intro-
duced new teaching approaches in surface anatomy sessions.
However, the impact of these studies on learning resources
such as anatomy textbooks is not known. Given the current
changes in anatomy curricula, it is important to identify the
teaching methods used in surface and living anatomy sessions
and whether there is a relationship between the changes in
the literature and the contents of anatomy textbooks.
Therefore, the present systemic review was designed with
the following aims in mind: (1) to examine methods used in
teaching surface/living anatomy in the literature, (2) to iden-
tify papers covering evidence-based surface anatomy and clin-
ical applications related to surface anatomy that can help in
the improvement of anatomy curricula and (3) to assess com-
monly used anatomy textbooks in regard to clarity and ade-
quacy of their contents in surface anatomy. In the context of
this paper, surface anatomy comprises dermatomes, Langer’s
lines (Langer, 1978), lines of Blashko (Bolognia et al., 1994),
simple visceral and bony landmark projections.
METHODS
Searching the Literature
A comprehensive search of PubMed and MEDLINE from the
earliest available online year of indexing up until January
Azer
2013 was conducted. The search strategy was based on the
research question, the aims of the review and using the fol-
lowing text words as search terms: “surface anatomy,”
“living anatomy,” “teaching surface anatomy,” “bony land-
marks,” “peer examination” and “dermatomes”. Using the
same search terms, the following journals’ websites were
searched: Anatomical Sciences Education, Clinical Anatomy,
The Anatomical Record, Surgical and Radiologic Anatomy,
Annals of Anatomy, Medical Education, Medical Teacher,
Academic Medicine, Advances in Health Sciences Education,
and BMC Medical Education. Other sources for eligible stud-
ies were the reference lists of related systemic reviews and
research papers identified in this search as well as the refer-
ence lists of studies included in the final analysis.
Eligibility and Exclusion Criteria
It was decided to include only articles in the English language
that met the following criteria: (1) They involved methods/
approaches used in teaching/learning surface anatomy to medi-
cal students, (2) They incorporated descriptive and research
studies on surface anatomy/living anatomy, and (3) They
examined inconsistencies in surface anatomy and the use of
evidence-based research as well as related clinical applications
such as common clinical procedures and physical examinations
that are based on understanding surface anatomy. Letters to
the Editors, conference abstracts, book reviews, invited lec-
tures, and papers covering specialized details were excluded.
Selection and Data Analysis
The selection process began by screening the title and abstracts
of all citations the research returned. Articles that on the basis
of the title and abstract that fulfilled the eligibility criteria
were examined. This was followed by a selection of articles
for full text-review. Data were extracted and a summary of
key findings were recorded on a template covering the follow-
ing items (1) study aim, (2) study design, (3) setting and popu-
lation, (4) any intervention, and (5) description of outcomes.
Searching Anatomy Textbooks
The aim of this search was to obtain a representative sample
of anatomy textbooks in order to describe the clarity, ade-
quacy and if any, deficiencies on surface anatomy in the con-
tents. The Google Book; previously known as Google Book
Search and Google Print (Google Inc., Mountain View, CA)
search engine was used to search for textbooks covering
human anatomy. The terms used in the search were
“anatomy” and human anatomy”. Only textbooks in English
published in 2007 through 2012 were included. Anatomy
atlases were excluded as it is difficult to assess clarity and ad-
equacy of contents on the bases of images or diagrams solely.
Also books covering surface anatomy only were not included
as it is not possible to compare contents related to surface
anatomy to other contents as per search protocol. Examples
of textbooks focusing only on surface anatomy are: Atlas of
Living and Surface Anatomy for Sport Medicine (Harris and
Ranson, 2008), Surface Anatomy: The Anatomical Basis of
Clinical Examination (Lumley, 2008), A Brief Atlas of the
Human Skeleton, Surface Anatomy and Selected Medical
Images (Tortora, 2008), Surface Anatomy: Pocket Tutor
Anatomical Sciences Education NOVEMBER/DECEMBER 2013
(Tunstall and Shah, 2012), and Field’s Anatomy, Palpation
and Surface Markings (Field and Hutchinson, 2013). Only
textbooks intended for undergraduate medical students were
included; anatomy textbooks written for surgeons, gynecolo-
gists, postgraduate students or other health professionals
were excluded. Study guides or companion books were also
excluded. Additionally, the same terms of search were used
to search websites of multinational electronic book commerce
companies (Amazon, 2013; Barnes & Noble, 2013).
Assessing the Surface Anatomy Contents
A copy of each textbook identified was obtained from King
Saud Medical Library and inter library loans. Quantity was
calculated from the actual page content and percentage of con-
tent devoted to surface anatomy; reflecting the commitment of
the authors to provide learners with an adequate understand-
ing of the topic. Percentages were calculated by dividing the
actual page count by the total number of pages and multiply-
ing by 100. Pages in the book committed to glossaries, appen-
dices, and bibliographies were excluded from the total number
of pages. Clarity, quality and adequacy of surface anatomy
contents were ranked using a scale of 1 to 3 (where 1 means
poor, 2 average, and 3 adequate/optimum level). Ranking was
completed independently by the author and two research assis-
tants. Consistency among the three assessors was measured
using Fleiss’ kappa inter-rater correlation. Also the number of
medical illustrations used in these textbooks to explain surface
anatomy was recorded. Thus, contents of surface anatomy
were examined for content congruent with current needs in
integrated undergraduate medical curricula.
RESULTS
Literature Search
The search of PubMed and MEDLINE databases revealed
3,444 papers covering surface and living anatomy and 1,198
papers were identified from searching anatomy and medical
journals. The results were as follows: Anatomical Sciences
Education 186 papers, Clinical Anatomy 213, The Anatomi-
cal Record 149, Surgical and Radiologic Anatomy 128,
Annals of Anatomy 24, Medical Education 152, Medical
Teacher 45, Academic Medicine 56, Advances in Health Sci-
ences Education 6, and BMC Medical Education 105. Other
searches from the lists of references of studies and reviews
revealed 134 papers- making a total of 4,642 citations. After
excluding 4,392 (duplicates and not directly related to the
research topic), a total of 250 articles were identified. A sec-
ond assessment resulted in the exclusion of 185 articles
(book reviews, invited lectures, conference abstracts, and let-
ters) and only 65 were researched as full text articles. A final
evaluation of the full text resulted in the exclusion of 12
articles (covering specialized details) and thus only 53 were
used in this study (22 on approaches used in teaching and 31
covering evidence-based surface anatomy and clinical applica-
tions). The final two steps were checked by two other inde-
pendent research assistants.
Approaches to Teaching Surface Anatomy
Table 1 summarizes studies conducted on approaches for
teaching surface anatomy. The study by Stillman et al. (1978)
417
from the University of Arizona, College of Medicine repre-
sents the oldest study among the 22 studies identified. Nine-
teen of these studies were published in the years from 2006
to 2013 and the remaining two papers were published in
2002 reflecting the recent changes and advancements in
teaching surface anatomy. Among the methods used in teach-
ing surface/living anatomy are body painting (Op Den Akker
et al., 2002; McMenamin, 2008; Finn, 2010; Finn et al.,
2011; Finn and McLachlan, 2010; Nanjundalah and Chow-
dapurkar, 2012), peer volunteer surface anatomy (Aggarwal
et al., 2006; Rees et al., 2009), use of a living anatomy model
(Stillman et al., 1978; Collett et al., 2009; Chinnah et al.,
2011;), yoga and Pilates (McCulloh et al., 2010), drawing
(Azer, 2011), integration of surface anatomy with clinical
skills training (Boon et al., 2002; Chou et al., 2010); real
time and portable ultrasound (Ivanusic et al., 2010; Stringer
et al., 2012a,b; Swamy and Searle, 2012), virtual human dis-
sector (VHD) based on Visible Human Project (Patten, 2007,
Donnelly et al., 2009), full body digital x-ray of cadavers
(Lodox statscan images) combined with palpating landmarks,
organs on their colleagues and the cadaver, as well as the use
of collaborative (Kotze et al., 2012), contextual and self-
directed learning (Bergman et al., 2013), and use of appropri-
ate learning resources such as YouTube videos (Azer, 2012).
These studies were from the following countries: eight
from the United Kingdom, three from each of Australia and
USA, two from each of Netherlands and South Africa,
and one study each from India, Malaysia, New Zealand and
Saudi Arabia.
Evidence-Based and Clinically Applied Surface
Anatomy
These studies can be categorized into three main groups: (1)
studies examining the accuracy of current knowledge in sur-
face anatomy and providing evidence-based research (12
papers), (2) studies examining the use of surface anatomy as
the bases for conducting common clinical procedures and
physical examination (11 papers), (3) studies about univer-
sities sharing their experiences that can enhance surface anat-
omy curriculum (8 papers) (Table 2).
Evidence-Based Surface Anatomy Research
Twelve studies evaluated the surface anatomy of anatomical
organs and bony landmarks in living adults (Table 2). These
studies aimed at assessing inconsistencies in clinically impor-
tant surface markings and, whether the use of living adults
and modern radiological techniques could help in providing
evidence-based answers. Five of these studies were conducted
recently by Mijalili et al. from the University of Otago, New
Zealand. They investigated key thoracic surface anatomical
landmarks in vivo (Mirjalili et al., 2012a), the surface anat-
omy of major abdominal vessels, kidneys, spleen, gastro-
esophageal flexure (Mirjalili et al., 2012b), accuracy of
common anatomical planes (Mirjalili et al., 2012c), vertebral
levels of the hard palate, hyoid bone, thyroid cartilage, cri-
coid cartilage, and bifurcation of the common carotid artery
(Mirjalili et al., 2012d), and mapping of the surface anatomy
of the spinal accessory nerve in the posterior triangle of the
neck (Mirjalili et al., 2012e). This important work identified
several differences from contemporary descriptions of surface
anatomy. For example, the renal arteries were most
418
commonly at L1 vertebral level (left 55%, right 43%); the
11th rib was a posterior relation of the left kidney in only
28% of scans, and the spleen was most frequently located
between the 10th and 12th ribs (48%) with its long axis in
line with the 11th rib (55%) of normal adults included in the
studies (Mirjalili et al., 2012c). The authors also found that
only the vertebral level of the hard palate (C1) was consistent
with contemporary discretions. Other landmarks were
located most frequently at the following vertebral levels: the
center of the body of hyoid bone at C4 (54% of cases), the
superior limit of the lamina of the thyroid cartilage at C4 in
women (60%) and C5 in men (52%; the difference was sig-
nificant), the inferior border of the cricoid cartilage in the
midline anteriorly at C6 in women (37%) and C7 in men
(47%; the difference was significant) and the bifurcation of
the left and right common carotid arteries at C3 (left 56%,
right 62%) (Mirjalili et al., 2012d). Therefore, the surface
anatomy of the body needs revising in light of these results
from living subjects by using modern imaging techniques.
The other seven studies focused on the same goal but, by
using different imaging techniques. For example, Burykh
(2004) reported a new system of topographic studies that
coordinate on the principles of global projection cartography
in which lines of latitude and longitude are assigned to the
surface of the human body. The system used 3D reconstruc-
tion of anatomical structures in creating drawing maps and
defining the topography of the human body, while Ohl et al.
R
(2010) used EOSV low-dose stereoradiography system in
order to validate the accuracy of contemporary knowledge
about the scapular and humeral bony landmarks and the
reproducibility of their specific locations. Stringer et al.
(2012a, b) used ultrasound in mapping the surface anatomy
of the parotid duct. The other studies highlighted the need
for mapping the surface anatomy of the spinal accessory
nerve in the region of the posterior triangle of the neck
(Symes and Ellis, 2005), examining the surface anatomy of
the neck (Williams, 1997), and the importance of understand-
ing thoracic surgical landmarks in successful by placing a
thoracic incision (Sayeed and Darling, 2007). Recently, Smith
and Darling (2011) reviewed the surface markings of the
lungs and other thoracic structures including the heart, great
vessels and the mediastinum with the aim of enhancing clini-
cal skills and appropriate patient care.
The common conclusion made by these authors highlights
the need for researching the surface anatomy of the human
body in living adults using modern imaging techniques. Such
a move is essential for safe clinical practice and will ensure
consistency in the teaching of this area and related clinical
applications.
Clinical Procedures and Physical Examinations
Two papers from the Education Affairs Committee of the
American Association of Clinical Anatomists (Leonard et al.,
1999, 2001) discussed the anatomical bases and use of sur-
face anatomy in a number of invasive clinical procedures
taught in undergraduate medical curricula, such as catheteri-
zation, subclavian vein catheterization, lumbar puncture, and
tracheostomy whereas the second paper (Leonard et al.,
2001) discussed the use of surface anatomy and gross anat-
omy as the fundamental basis for physical diagnosis (Table
2). Research in this area also highlighted the importance of
the surface anatomy of the inferior epigastric artery in
Azer
 Table 1.
Description of Approaches Used in Teaching/Learning Surface/Living Anatomy and Included in This Review

Stage of education/
Study (author/year) Research question Intervention Study design Settings/Country population Summary of findings

Aggarwal et al. (2006) Assessment of medical Peer volunteers in sur- Students completed an Guy’s, King’s and St First year, UG/Medical Students appreciated
students’ attitudes face anatomy classes. anonymous question- Thomas’s School of Bio- students. the importance of sur-
towards surface anat- naire at the end of their medical Sciences, UK. face anatomy. How-
omy classes. last session of the year. ever, female students

Anatomical Sciences Education

from ethnic minority
groups were espe-
cially reluctant to vol-
unteer to be subjects.

Azer (2011) Which learning approach Use of two learning Randomized study. Universiti Teknologi First year, UG/Medical Both techniques
is useful in learning sur- methods (reading text MARA, Faculty of Medi- students. improved students’
face anatomy. and drawing abdominal cine, Malaysia. post-test scores.
organs versus reading However, learning by

NOVEMBER/DECEMBER 2013
the same text and drawing showed
answering short-answer higher scores.
questions).

Azer (2012) Are there educationally YouTube website was Mixed qualitative and King Saud University, Videos suitable for UG/ At the time of the
useful videos on You- researched from Novem- quantitative study. College of Medicine, Medical students. study, YouTube was
Tube that can be used ber 8 to 30, 2010 using Saudi Arabia. an inadequate source
in teaching/learning sur- research terms. of information for
face anatomy? learning surface
anatomy.

Bergman et al. (2013) Best ways to teach sur- Use of collaborative, Descriptive study. Maastricht University UG/Medical students. The use of these
face anatomy. contextual & self- and Radboud Universi- approaches leads to
directed learning. ty,The Netherlands. higher student
satisfaction.

Boon et al. (2002) Impact of integrated Introducing integrated A Likert-type question- University of Pretoria, Second year UG/Medi- More than two-thirds
anatomy practicum on practicum conducted on naire was used for stu- Faculty of Medicine, cal students. of students thought
students’ learning. a station basis to pre- dent evaluation of the South Africa. that the practicum
pare students in clinical practicum. improved their under-
examination. standing of the ana-
tomical basis for
clinical examination.

Chinnah et al. (2011) Explore students’ per- Peer physical examina- Exploratory focus Universities of Exeter Years’ 3–5 students. Peer physical exami-
ceived impacts of using tion and palpation in liv- groups and a question- and Plymouth, UK. UG/Medical students. nation and palpation
hands-on approaches ing anatomy classes. naire survey. is a useful pedagogi-
involving peer/life model cal tool in learning liv-
physical examination in ing anatomy.
learning living anatomy.

419
 Table 1. Continued

420
Stage of education/
Study (author/year) Research question Intervention Study design Settings/Country population Summary of findings

Collett et al. (2009) Role of living anatomy Introducing classes in Ethnographic study of Peninsula Medical Year one and year two Living anatomy mod-
model in teaching living which living anatomy living anatomy classes. School, Peninsula Col- UG/Medical students. els can foster an
anatomy. models take a leading Field notes and conver- leges of Medicine and additional dimension
role. sations with models, Dentistry, UK. to the anatomy class.
students and tutors
were used.

Chou et al. (2010) To explore whether the Integrating basic anat- Students worked in University of California, Year one, UG/Medical Students appreciated
integration of surface omy learning, clinical pairs: one student por- San Francisco, USA. students. the integration of sur-
anatomy with clinical interviewing and giving trayed a patient (stu- face anatomy with the
skills could help in the and receiving feedback. dent-patient); while the professional skills
development of commu- other portrayed a doctor involved in medical
nication skills and (student-doctor). history taking, physi-
professionalism. cal examination and
giving feedback.

Finn (2010) How can I run a body Use of experience and Descriptive study. School of Medicine and UG/Medical and health The tips offer advice
painting session? the literature in creating Health, Durham Univer- professional students. on practicalities of
12 tips that help in de- sity, UK. running a successful
velopment and running a body painting session
body painting session. in a supportive
environment.

Finn and McLachlan To assess whether or Body painting sessions Qualitative study, 24 School of Medicine and UG/Preclinical medical Body painting is a
(2010) not medical students in which students paint focus groups. Data were Health, Durham Univer- students. useful adjunct to tra-
found body painting an- a peer or being pained. analyzed using sity, UK. ditional anatomy and
atomical structures to grounded theory. clinical skills learning.
be an educationally ben-
efit learning activity.

Finn et al. (2011) Can bright colours play Body painting sessions Students completed a School of Medicine and UG/Medical students. The use of colour had
a role in retention of in which students were pre-test before a body Health, Durham Univer- no impact on short-
knowledge in body allocated to block colour painting teaching ses- sity, UK. term or long-term
painting sessions? group or black outline sion. Students sat a retention of anatomy
group. mid-test, and a post- knowledge.
test.

Ivanusic et al. (2010) To explore student per- Relevant cardiac anat- Students completed a Faculty of Medicine, UG/Medical students. Ultrasound could be a
ceptions of the use of omy was explored on a questionnaire about the Dentistry and Health useful tool, in con-
ultrasound to teach student volunteer and learning experience and Sciences, University of junction with tradi-
“living anatomy”. images were projected invited to provide open Melbourne, Australia. tional teaching
in real-time to all stu- feedback. methods, to reinforce
dents via an audio-visual the learning of living
projection system. anatomy.

Azer
 Table 1. Continued
Study (author/year) Research question
Kotze
 et al. (2012) Can full body X-ray
images images be used
in surface anatomy
education?
Anatomical Sciences Education
McCulloch et al. Assess the impact of the
(2010) Living AnatoME pro-
gram, used in teaching
musculoskeletal anat-
omy through yoga and
NOVEMBER/DECEMBER 2013
Pilates.
McMenamin (2008) Explore alternative strat-
egies to effectively facili-
tate learning surface
anatomy.
Nanjundaiah and Assess the use of body-
Chowdapurkar (2012) painting in learning/
teaching surface
anatomy.
Op Den Akker et al. Assess the use of body
(2002) painting in enhancing
the course on living
anatomy.
Patten (2007) Impact of using the Visi-
ble Human
Dissector (VHD)
program in lively
anatomy sessions.
421
Stage of education/
Intervention Study design Settings/Country population Summary of findings
Full body digital x-ray Descriptive study. Faculty of Health Scien- UG/Second year medi- Digital x-ray images
R
images (LodoxV ces, University of Stel- cal students. are beneficial for
R
StatscanV) of each lenbosch, Tygerberg, viewing most sys-
cadaver were provided South Africa. tems’’ organs except
to students to visualize for pelvic organs.
landmarks, organs and
structures on the digital
x-ray and the cadaver.
Medical students partici- The impact of the pro- Mount Sinai School of UG/Medical students. Significant improve-
pated in a 1.5 hour Liv- gram on students’ com- Medicine, USA. ment in total Living
ing AnatoME session on prehension of AnatoME scores; indi-
the upper and lower musculoskeletal anat- cating the possible ef-
limbs. omy was analyzed ficacy of Living
through the administra- AnatoME in teaching
tion of pre- and post- anatomy.
tests.
Introducing body paint- Descriptive study. University of Western UG/Medical students. Body painting is an
ing exercises into inte- Australia, Australia. adjunct to surface
grated clinical skills anatomy and clinical
teaching sessions. skills teaching classes
A few surface anatomy Descriptive study. MS Ramaiah Medical UG/Physiotherapy and The educational
classes were conducted College, Bangalore, dental students. objectives of the pro-
by using body painting India. ject were achieved.
exercise.
Introduction of body Descriptive study. University Medical Cen- UG/Medical students. The course objectives
painting as a new ter, Utrecht, The were achieved.
method in teaching living Netherlands.
anatomy.
Projection onto the Descriptive study Durham University, Dur- UG/Medical students While not replacing
living body using VHD ham, UK. other teaching meth-
program. The exercise is ods entirely, this
conducted on peer stu- approach does pro-
dents and is interactive. vide some
advantages.
422
Table 1. Continued

Stage of education/
Study (author/year) Research question Intervention Study design Settings/Country population Summary of findings

Rees et al. (2009) The researchers explore The Examining Fellow Mixed study. Office of Postgraduate First year UG/Medical First-year students
first-year Students (FES) question- Medical Education, students. are anxious about
medical students’ naire was used and col- University of Sydney, examining intimate
anxiety about peer lected data from the six Australia. body regions. A
physical examination of schools were analyzed staged approach
intimate body regions in starting with manikins
six schools in UK, is recommended in
Australia, New Zealand, peer examination.
Japan, and Hong Kong.

Stillman et al. (1978) Role of introducing After each major An evaluation University of Arizona First-year students Living models were
living anatomy models in segment of cadaver questionnaire was College of Medicine, UG/Medical students. rated superior to
enabling students to dissection, a clinical used at the end Arizona, USA. using cadavers in
apply knowledge learnt correlation session was of the course. learning surface
from cadaver dissection. introduced by clinicians anatomy.
using live models.

Stringer et al. (2012a) Can real-time ultrasound A single one hour ultra- Descriptive study. A Otago School of UG/Medical students. The method enables
be used in teaching liv- sound demonstration of questionnaire was Medical Sciences, linking ultrasound to
ing anatomy to large living anatomy. completed by the University of Otago, learning surface
classes with limited students at the New Zealand. anatomy.
resources? end of the session.

Swamy and Searle To assess the use of The students were Descriptive study. A School of Medicine and UG/Medical students. Ultrasound acts as a
(2012) portable ultrasound in divided into groups of questionnaire was Health, University useful adjunct to
living anatomy and 15–20. Ultrasound dem- completed by the Boulevard, Stockton on teach anatomy in a
evaluate its impact as onstration was carried students at the end of Tees, UK. clinical context to
an adjunct to out on volunteers. the session. medical students.
cadaveric anatomy
teaching.

UG 5 undergraduate.

Azer
Table 2.
Summary of Papers, and Studies on Surface/Living Anatomy That Can Help in Improving the Surface Anatomy Curriculum

Study (author/year) University/Institute (country) Objectives Examples/outcomes

Bugbee and Botte, University of California, USA. Relationship of the hand-palmar skin creases to bones. Quantification of these relationships should help in
(1993) hand examination and placement of surgical
incisions.

Buykh, (2004) Kharkiv State Medical University, Ukraine. Report a new system of topographic examination of the The study highlights the importance of the system
body. and the use of 3D reconstruction of anatomical struc-
tures in creating topography of the human body.

Epstein et al. (2004) King’s College London, UK. Examining the surface anatomy of the inferior epigastric The findings were used in proposing guidelines for
artery (IEA). safer trocar placement for laparoscopic surgery.

Ganguly et al. (2003) Arabian Gulf University, Kingdom of Sharing experience in anatomy curriculum design. Structured living anatomy sessions integrated with
Bahrain. the clinical professional skill program were
successful.

Gangata, (2009) University of Cap Town City, South Africa. Black Zimbabwean subjects were examined for clinical The author proposed a new technique to test the ten-
surface anatomy anomalies of the tendon of palmaris don of PLM.
longus muscle (PLM).

Greyling et al. (2007) University of Pretoria, South Africa. Examining bony landmarks in relation to the course of Bony landmarks can be applied to clinical setting in
facial nerve. identifying the course of facial nerve.

Hendry, (2013) University of Western Sydney, Australia. A literature review examining the perceptions and atti- Several ethical, cultural and religious beliefs could
tudes of peer-physical examination of the lower limb interfere with peer-physical examination.
amongst medical and health science students.

Jayasekera et al., King’s College Hospital, UK. Assessing carpal bone surface anatomy knowledge The majority of participants did not perform an accu-
(2005) among surgeons. rate physical examination of the carpal bones and
lacked information about surface anatomy of the car-
pal bones.

Lammy, (2009) ULC School of Medicine, UK. Studying surface anatomy of the buttock area. The author concluded that the standard safe area is
too generous and should be half the size immediately
adjacent to the tip of the greater trochanter.

Lee et al., (2008) University of Otago, New Zealand. A systematic literature review covering the available evi- Current dermatome maps are inaccurate. A novel evi-
dence for the distribution of human dermatomes. dence-based dermatome map was discussed.

Leonard et al. (1999) American Association of Clinical Anato- Use of surface anatomy in a number of invasive clinical Central venous catheterization, subclavian vein cathe-
mists (AACA), USA. procedures. terisation, lumbar puncture, aspiration of the knee
joint, tracheostomy.
Table 2. Continued

Study (author/year) University/Institute (country) Objectives Examples/outcomes

Leonard et al. (2001) American Association of Clinical Anato- Use of surface and gross anatomy as the basis for The paper discusses: physical examination of the
mists (AACA), USA. physical diagnosis. thorax, abdomen, perineum, and pelvis.

Louw et al. (2009) University of Cape Town, South Africa. The authors summarised the educational bases for clini- Examples discussed are: Joint and body cavity taps,
Monash University, Australia. cal examination, and clinical procedures in medical vascular access, nerve blocks, and injections.
Mayo Clinic, USA. curricula.

McKeown et al. (2003) Queen’s University of Belfast, Belfast, UK. The impact of introducing curricular changes, on the The new system-based curriculum did not help stu-
students’ knowledge in surface anatomy. dents in learning surface anatomy.

McLachlan, (2004) Peninsula Medical School, UK The study presented the new experience of teaching The authors debated that the use of living anatomy
anatomy at Peninsula Medical School. and imaging versus dissection in teaching anatomy.

Mirjalili et al. (2012a) University of Otago, New Zealand Identifying key thoracic surface anatomical landmarks in Common surface markings were markedly inaccurate.
vivo using high-resolution thoracic CT scans.

Mirjalili et al. (2012b) University of Otago, New Zealand Identifying surface anatomy of major abdominal vessels The majority of vascular surface landmarks are con-
and abdominal organs using CT scans. sistent with standard descriptions. However, the sur-
face anatomy of the kidneys, renal arteries, and
spleen needs to be revised.

Mirjalili et al. (2012c) University of Otago, New Zealand. Accuracy of common anatomical planes in vivo using The surface anatomy of anatomical planes needs
computed tomographic imaging. revising in light of the results obtained from living
subjects.

Mirjalili et al. (2012d) University of Otago, New Zealand. Identifying surface anatomy of the head and neck. There is a need for evidence-based studies on living
subjects.

Mirjalili et al. (2012e) University of Otago, New Zealand. Using ultrasound in mapping the surface anatomy of the Surface anatomical landmarks of the spinal accessory
spinal accessory nerve in the posterior triangle of the nerve are not a reliable guide to the position and
neck. course of the nerve.

Ohl et al. (2010) Ecole Nationale Supe rieure d’Arts et Examining the reproducibility of shoulder bony land- The reliability and reproducibility of the procedure is
Metiers, Laboratoire de Biomecanique, marks location using the EOS low-dose stereoradiogra- clinically useful.
France. phy system.

Pabst et al. (1986) Medical School of Hannover, Germany The author described four supplements to stimulate The integration of basic and applied anatomy gener-
first-year medical students to learn anatomy including ates a high level of student interest in gross anatomy.
living anatomy, X-ray anatomy, patient presentations,
and films on clinical problems.

Pascual et al. (2011) Vienna International Centre, Austria. Assessing integration of radiology education in under- The practical use of different aspects of radiology is
graduate medical education across the curriculum. essential to learning surface anatomy and physical
examination.
Table 2. Continued

Study (author/year) University/Institute (country) Objectives Examples/outcomes

Roche et al. (2009) The Royal Liverpool and Broadgreen Uni- Testing the knowledge of clinicians of the surface ana- The knowledge of surface anatomy overall by junior
versity Hospitals Trust, UK. tomical landmarks of foot and ankle injuries. clinicians was found to be very poor.

Sayeed and Darling, University of Toronto, Canada Assessing the importance of understanding thoracic sur- Knowledge of the chest wall musculature and surface
(2007) gical landmarks in successful placing a thoracic anatomy is essential in muscle flaps reconstruction
incision. and thoracostomy.

Schabort et al. (2005) University of Pretoria, South Africa. Assessing the value of bony and prominent soft tissue A greater degree of certainty may be attained when
landmarks around the ankle in the identification of the palpable landmarks are used to determine the posi-
nerves around the ankle. tion of the nerves in the ankle region.

Smith and Darling, University of Toronto, Canada The authors reviewed the surface markings of the lungs Surface landmarks of the lungs, heart, great vessels,
(2011) and other thoracic structures. and mediastinum were discussed.

Sugand et al. (2010) South Kensington, UK The use of surface anatomy in preparing students in Examination of different body systems (inspection,
Warwick Medical School, UK. early clinical examination. palpation, & percussion).
University Hospital of Wales, UK.

Stringer et al. (2012a) University of Otago, New Zealand. Mapping the surface anatomy of the adult parotid duct Mapping of the parotid duct should assist with early
using ultrasound. diagnosis of parotid duct lesions and avoidance of
iatrogenic injuries.

Symes and Ellis, (2005) Royal Free and University College Medical Degree of accuracy achievable in mapping the surface Defining an accurate surface anatomy was not possi-
School, UK. anatomy of the spinal accessory nerve in the neck. ble. Because of the wide variation of the spinal
accessory nerve in the posterior triangle of the neck.

Williams, (1997) Wake Forest University, USA. Studying the anatomy and surface anatomy of the neck. The author discussed the anatomy and surface anat-
omy of the neck.
proposing guidelines for safe trocar placement for laparo-
scopic surgery (Epstein et al., 2004), the identification of the
bony and prominent soft tissue landmarks around the ankle
to aid in the identification of the nerves around the ankle
(Schabort et al., 2005), the examination of the hand-palmar
skin creases in relation to the bones (Bugbee and Botte,
1993), and the examination of the tendon of palmaris longus
muscle for any anomalies (Gangata, 2009). Ideas raised in
these papers can be used in enhancement of the teaching/
learning of surface anatomy. The extensive guide written by
Louw et al., (2009) and published in Medical Teacher sum-
marizes the anatomical bases behind clinical examination and
procedures from the teaching perspective. The guide is useful
for medical educators and those interested in anatomy
teaching.
Studies of Universities Sharing Their
Experiences in Surface Anatomy
The study by Roche et al. (2009) aimed at testing the knowl-
edge of clinicians of the surface anatomical landmarks that
should be examined routinely in the assessment of foot and
ankle injuries. The study found that the knowledge of surface
anatomy overall by junior clinicians was very poor. The
authors recommended that the teaching of surface anatomy
should begin in undergraduate medicine. The research study
by Sugand et al. (2010) confirms this notion and the impor-
tance of teaching surface anatomy early in the curriculum.
The authors showed that such initiative has helped students
in examining different body systems through inspection, pal-
pation, percussion, and auscultation. It would be of interest
to assess the impact of such experience on the students’ per-
formance in the clinical years.
In other studies, the authors shared their experiences and
the design of their surface/living anatomy curricula and cited
such evidence of how surface/living anatomy curricula has
developed, including the use of living anatomy delivered to
the students through peer examination and life models
(McLachlan, 2004; Hendry, 2013); integration of basic and
applied anatomy through living anatomy, X-ray anatomy,
patient presentations and films on clinical problems (Pabst
et al., 1986). These studies together with the 22 studies on
teaching methods provide an understanding of the current
research and directions on surface anatomy research.
Anatomy Textbooks
The search ended with the identification of 12 anatomy text-
books commonly used in teaching anatomy in medical
schools in undergraduate medical courses. All these books
met the search criteria and were obtained for further assess-
ment (Table 3). The inter-rater reliability between assessors
as measured by Cronbach alpha varied between 0.70 and
0.86 which are within the acceptable range (Nunnaly and
Bernstein, 1994).
The percentage of surface anatomy content ranged from
6.2% in Clinically Oriented Anatomy by Moore et al. (2008)
to 0% in Gross Anatomy by Chung and Chung (2008) with
an average of 3.4%. The number of medical illustrations
committed to explaining surface anatomy ranged from 0
image in Clinical Anatomy: Applied Anatomy for Students
and Junior Doctors by Ellis and Mahadevan (2010) to 135 in
Clinically Oriented Anatomy by Moore et al. (2008). Living
426
anatomy illustrations (with arrows indicating the identified
structures) comprised over 90% of the illustrations commit-
ted to surface anatomy in textbooks by McKinley and
O’Loughlin (2008), Moore et al. (2008), Standring (2008),
Tortora and Nielsen (2009), Drake et al. (2010), and Saladin
(2010). However, only 24% of these medical illustrations
were found in Clinical Anatomy by Regions (Snell, 2012)
and 0% in Clinical Anatomy: Applied Anatomy for Students
and Junior Doctors (Ellis and Mahadevan, 2010). The text-
books: Clinically Oriented Anatomy by Moore et al. (2008),
Gray’s Anatomy for Students by Drake et al. (2010), and
Gray’s Anatomy: The Anatomical Basis of Clinical Practice
by Standring (2008) provided the most clear, high quality
and adequate information pertinent to surface anatomy. Snell
(2012), in his textbook entitled, Clinical Anatomy by Regions
has discussed surface anatomy in a clearer and adequate way
when compared to his second book, entitled Clinical Anat-
omy by Systems (Snell, 2007). In both, he committed the end
of each chapter to radiologic anatomy, surface anatomy and
clinical application. However, in his second book Clinical
Anatomy by Systems (Snell, 2007), radiological anatomy
dominated that part with less emphasis on surface anatomy.
Although Ellis and Mahadevan (2010) in Clinical Anatomy:
Applied Anatomy for Students and Junior Doctors committed
23 pages for surface anatomy and the percentage of pages
surrounding surface anatomy was 5.3%, the authors included
only seven medical illustrations to explain surface anatomy.
There are no living anatomy images in the book and the
parts covering surface anatomy are deficient and not clearly
written. The book Last’s Anatomy: Regional and Applied by
Sinnatamby (2011) did not give adequate information about
surface anatomy. For example, it did not address the surface
landmarks of the abdominal organs, and the head and neck.
Considering the large size of Gray’s Anatomy: The Ana-
tomical Basis of Clinical Practice by Standring (2008) and its
authority in the field, only 29 pages out of 1,464 were com-
mitted to surface anatomy. The content provided and the
illustrations on surface anatomy were helpful but, there is a
need to add more clinical applications related to surface anat-
omy in the new editions. Several textbooks, such as Human
Anatomy by McKinley and O’Loughlin (2008) or Principles
of Human Anatomy by Tortora and Nielsen (2009), con-
tained no information about surface anatomy of the lungs,
heart, major blood vessels, liver, pancreas, spleen, stomach,
and kidneys. None of the books has an associated video link
or CD ROM to outline living anatomy/surface anatomy,
methods for teaching surface anatomy or how to integrate
surface anatomy with clinical examination and learning inva-
sive procedures. However, with the reduction of anatomy
time within the curriculum, and the fact that anatomy mate-
rial has been moved into other courses such as early clinical
exposure, clinical procedures, and clinical simulation, one
may understand this shift in integrating surface anatomy
teaching with other clinical practices.
DISCUSSION
As far as the author is aware, this is the first systemic review
to specifically evaluate the place of surface anatomy in the
literature and examine whether the current changes in the
research translate into effects on anatomy textbooks. The
review has identified 22 studies addressing approaches and
methods used in teaching surface and living anatomy, 31
papers addressing clinical applications and evidence-based
Azer
 Table 3.
Summary of Surface Anatomy in Anatomy Textbooks

Surface
anatomy Total Surface Number of
(number number anatomy surface anatomy Content
Author(s) Title of pages) of pages (% of pages) illustrations clarity Quality Adequacy Comments

Moore et al. Clinically Oriented 67 1,082 6.2 135 3 3 3 A range of pedagogy techniques are
(2006) Anatomy. used to explain surface anatomy.

Drake et al. Gray’s Anatomy for 62 1,079 5.7 134 3 3 3 Living anatomy is clearly

Anatomical Sciences Education

(2010) Students. demonstrated.

Snell (2012) Clinical Anatomy by 42 719 5.8 79 2 2 2 55 images out of 79 (70%) are radiol-
Regions. ogy images and diagrams.

Jacob (2007) Human Anatomy: A 14 244 5.7 29 1 1 2 Surface anatomy is covered in text
Clinically-Oriented and in images.
Approach.

NOVEMBER/DECEMBER 2013
Snell (2007) Clinical Anatomy by 35 918 3.8 27 1 1 2 A good resource for learning anat-
Systems. omy but deficient in surface
anatomy.

Saladin (2008) Human Anatomy. 9 739 1.2 30 2 2 1 Information represented in images of

living body with no explanation in
text.

Tortora and Principles of 19 815 2.3 30 1 2 1 Well illustrated text, integrating anat-
Nielsen Human Anatomy. omy. However limited in explaining
(2009) surface anatomy.

McKinley and Human Anatomy. 15 873 1.7 25 1 2 1 No mention of surface anatomy of

O’Loughlin heart, lungs, aorta, other major blood
(2008) vessels, and abdominal organs.

Ellis and Clinical Anatomy: 23 431 5.3 7 1 1 1 Surface anatomy is not adequately
Mahadevan Applied Anatomy addressed.
(2010) for Students and
Junior Doctors.

Chung and- Gross Anatomy. 0 423 0 0 0 0 0 There is no surface anatomy

Chung (2008) mentioned.

Sinnatamby Last’s Anatomy: 6 512 1.1 4 1 1 1 Limited information on surface

(2011) Regional and anatomy.
Applied.

Standring Gray’s Anatomy: 29 1,464 1.9 42 3 3 3 Surface anatomy is well covered and
(2008) The Anatomical Ba- discussed. Considering the size of

427
sis of Clinical the book, there is an opportunity to
Practice. add more to surface anatomy.
research in surface anatomy, and 12 anatomy textbooks. The
studies raised a number of innovative teaching ideas such as
learning from peer/life group model (Aggarwal et al., 2006,
Rees et al., 2009), enabling artists’ model/living anatomy
model to actively participate in teaching (Stillman et al.,
1978; Collett et al., 2009; Chinnah et al., 2011), drawing
and outlining the surface anatomy of organs on living body
images (Azer, 2011), learning surface anatomy through col-
laboration, self-directed learning and contextual tasks (Berg-
man, 2013), linking learning surface anatomy with early
clinical examination (Chou et al., 2010; Boon et al., 2002),
exploring the learning of surface anatomy through body
painting (Op Den Akker et al., 2002; McMenamin, 2008;
Finn, 2010; Finn and McLachlan, 2010; Finn et al., 2011;
Nanjundalah and Chowdapurkar, 2012) as well as using the
virtual human dissector (VHD) program in lively anatomy
sessions (Patten, 2007). The studies indicate that there is a
shift to make more of an emphasis on surface anatomy in
medical curricula and link surface anatomy with early clinical
examination. The learning environment dominating these
studies reflects encouragement of student’s interaction
through class volunteers or the use of living anatomy models,
together with the use of simple technology, to foster living
anatomy learning. Considering the creativity of researchers
and educators in this area over the last 10 years as shown
from these studies, one would think a parallel change in med-
ical resources such as anatomy textbooks would only be inev-
itable. However, none of the textbooks studied reflected these
changes in teaching surface/living anatomy. While Snell
(2012) and Drake et al. (2010) placed surface anatomy at the
end of each chapter of their books, other authors committed
a whole chapter to cover surface anatomy of the human
body (Tortora and Nielsen, 2009; McKinley and O’Loughlin,
2008; Saladin, 2010). On the other hand, Moore et al.
(2008) distributed issues related to surface/living anatomy
throughout the discussion of each chapter and linked surface
anatomy and bony landmarks to dissection and clinical appli-
cations. Moore et al. (2008), and to some extent Drake et al.
(2010) used a number of pedagogical approaches to enhance
the teaching/learning of surface anatomy. For example: (1)
images highlighting surface anatomy are reproduced with
numbered overlays, indicating structures that can be seen or
felt (palpable organs), (2) the surface markings of deeper
structures such as muscles, tendons or bony structures have
been accompanied by images showing corresponding dissec-
tion findings, (3) Bony landmarks have been highlighted on
living body images and corresponding x-ray images have
been shown to help the learner correlate findings, (4) the text
describes the anatomical features of the illustrated structures
and key anatomical markings to define them on a living
body, and (5) clinical applications linked to surface anatomy
such as the injection of local anesthetics, accessing blood ves-
sels, making incisions etc. have been discussed.
Peer physical examination whether aimed at learning sur-
face anatomy or practicing of clinical examination and palpa-
tion, offers a number of advantages including: (1) enabling
students with the opportunity to practice clinical skills prior
to approaching patients, (2) providing students with the
opportunity to manage their own anxiety in performing an
examination and feel more confident through repeated prac-
tice, (3) enabling the schools of medicine to conduct less ex-
pensive teaching as compared to including simulated patients
or a model, and (4) giving students the opportunity to peruse
and understand a range of body morphologies. However,
428
peer surface anatomy/physical examination may not be possi-
ble in some cultures and, alternative approaches should be
encouraged in classrooms (O’Neill et al., 1998; Chang and
Power, 2000; Braunack-Mayer, 2001; Rees et al., 2005).
McLachlan et al. (2004) proposed that the teaching and
learning of anatomy should focus on medical imaging and
living anatomy. This should be the priority, irrespective of
controversial views about the necessity of dissection. In fact,
the use of the living body is not a recent trend; it has been
promoted for decades (e.g., Stillman et al., 1978; Halperin,
2009). As early as 1931, a British anatomist from University
of St Andrews, David Waterston (1871–1942) published a
book entitled Anatomy in the Living Model in which he indi-
cated that the study of the living models was introduced into
anatomy in medical schools as a means of supplementing
knowledge obtained from the dissection of cadavers (Water-
ston, 1931). This suggests that the practice of living anatomy
in UK medical schools was present for years (McLachlan and
Patten, 2006). About eight years later, Professor Hartwig
Kuhlenbeck (1897–1984) from Woman’s Medical College of
Pennsylvania in the United States published a paper entitled,
Teaching of Living Anatomy in which he discussed concerns
about a decline in using living anatomy in the teaching of
gross anatomy and, provided a justification for the uses of
surface anatomy (Kuhlenbeck 1939). Interestingly, Professor
Kuhlenbeck in his paper quoted statements made by the
Dean of Marquette University School of Medicine in Milwau-
kee, Wisconsin, Professor Eben J. Carey about the dynamics
of living anatomy in understanding the human body (Kuhlen-
beck 1939). This comment originated from Professor Carey’s
presentation on results of his world-wide survey concerning
teaching of living anatomy entitled The place of living anat-
omy in medical schools given at the 38th Annual Meeting of
Association of American Medical Colleges in Montreal, Can-
ada on October 24–26, 1927 (Carey, 1928). Taking this in-
formation together with the findings of this study, there is
evidence that researching methods used in teaching surface
anatomy has disappeared for over 75 years and only recently
become the focus of medical schools in the last 6 to 10 years.
Although the studies listed in Table 1 provided innovative
ideas about methods for teaching surface anatomy; these
methods are not carefully examined in regard to their impact
on student’s learning and grasp of knowledge/skills long-
term. Further studies are needed to examine each of these
methods and provide evidence about which of these methods
is/are able to provide optimum learning and hands-on skills.
Similarly, some studies evaluated resources that could be
used in teaching and learning surface anatomy (e.g., Azer,
2012), but there are no further studies available in the litera-
ture assessing the impact of using YouTube videos in stu-
dent’s learning of surface anatomy. Such studies may be
needed and, the results of such studies will help in introduc-
ing these resources in the medical curriculum and self-
directed resources in the preclinical years. There is also a
need for research assessing best evidence in teaching/learning
surface anatomy. A few studies compared methods in learn-
ing surface anatomy such as reading text followed by short-
answer questions versus reading the same text followed by
drawing the outlines of organs on an image of the abdomen
(Azer, 2011). The study examined the impact of learning on
student’s performance in MCQs and concluded that both
methods resulted in the improvement of student’s perform-
ance in MCQs but the difference was significantly higher in
the group that used drawing, emphasizing the importance of
Azer
spatial learning (Rochford, 1985; Garg et al., 1999a, 2001,
Guillot et al., 2007; Fernandez et al., 2011; Lufler et al.,
2012). Such an impact was measured at the end of the ses-
sion (on short-term basis). However, there remains a need for
assessing the impact of the two methods on surface anatomy
learning on a long-term basis. Such research will be of great
value not only to anatomists, clinical teachers, course design-
ers, or medical educators, but also to authors and editors of
books covering anatomy and surface/living anatomy. Under-
graduate textbooks usually address surface anatomy at the
end of each chapter covering a particular body system. While
there are differences between anatomy textbooks in regard to
contents, percentage of pages (coverage) of surface anatomy
as well as clarity, quality and adequacy of these contents, it
would be of great value if the new editions considered adding
videos demonstrating living anatomy/surface anatomy on
artists (simulated patients) and the use of techniques
described in the literature such as body painting (Op Den
Akker et al., 2002; McMenamin, 2008; Finn, 2010; Finn and
McLachlan, 2010; Finn et al., 2011; Nanjundalah and Chow-
dapurkar, 2012), drawings on mannequins, and the use of
peer volunteers. Such videos could be available online
through a web link or be provided on a CD-ROM with anat-
omy textbooks. A small chapter at the beginning of text-
books covering best evidence in teaching surface anatomy
and how to link the teaching of surface anatomy with early
clinical examination will be of great value in bringing such
changes to the students and teachers. Recently, Mirjalili and
others (Table 2) raised the need to investigate the surface
anatomy anatomical planes, major abdominal vessels, ab-
dominal organs, and thoracic surface anatomy landmarks
using computed tomography (CT) and modern imaging tech-
niques with the aim of establishing evidence-based surface/liv-
ing anatomy (Mirjalili, et al., 2012a, b, c, d, e). Such
research is needed and will be imperative as a useful addition
to the teaching/learning resources available as well as in
regards to updating the contents of textbooks and ensuring
consistency in anatomical resources across the board. This
means editors and authors of anatomy textbooks should use
such research as foundation to update the information in
their textbooks regarding surface anatomy content.
FUTURE DIRECTIONS
This review presents an overview of the current state of sur-
face anatomy in medical literature. While this review has
identified the progressive increase in surface anatomy
research and teaching methods used over the last 6–10 years,
the review has identified a number of deficiencies in anatomy
textbooks in this area and in the literature. Therefore, the
research in surface and living anatomy should consider
achieving the following objectives.
First, surface anatomy of the human body must be contex-
tually reliable (Standring, 2012). Researching inconsistencies
in surface anatomy landmarks and re-examining clinically rel-
evant surface markings in the context of variables such as
age, sex, ethnicity, BMI should be prioritized. Such research
should be carried out on living healthy individuals using the
modern imaging techniques. Joint work from several univer-
sities in different countries with the aim of comparing the
effects of ethnicities should be encouraged.
Second, further studies are required to assess the real evi-
dence of the efficacy of the different teaching methods
described in the literature and outlined in this review. The
Anatomical Sciences Education NOVEMBER/DECEMBER 2013
aim should be to assess their impact on student’s learning sur-
face anatomy and related clinical competencies, such as phys-
ical examination and clinical procedures. Comparing these
methods and understanding factors that can reinforce learn-
ing need to be understood.
Third, it is imperative that research is carried out regard-
ing the effectiveness and impact of integrating surface anat-
omy with clinical examination and clinical procedures early
in the curriculum and whether such teaching has a positive
impact on clinical skills and patient’s care.
CONCLUSIONS
Although there has been a progressive increase in publica-
tions addressing methods used in teaching surface living anat-
omy and evidence-based surface anatomy research and
clinical applications over the last years, most anatomy text-
books do not provide students with adequate information
about surface anatomy. Only three textbooks provided a
solid explanation and foundation of understanding surface
anatomy.
ACKNOWLEDGMENT
The author alone is responsible for the content and writing of
the paper. The author would like to thank Dr. Wojciech Paw-
lina, the Co-Editor-in-Chief and the three reviewers for their
valuable comments and constructive feedback that helped in the
improvement of this manuscript. Also would like to thank
Mary Hadlocon and Laniefel Mendoza from the Curriculum
Development and Research Unit for their help and Drs. Sarah
Azer and Diana Azer for their comments on the manuscript.
NOTES ON CONTRIBUTOR
SAMY A. AZER, M.D., Ph.D. (U.Syd), M.Ed (U.N.S.W.),
F.A.C.G., M.P.H. (U.N.S.W.), is a professor of medical educa-
tion and the Head of Curriculum Development Unit in the
College of Medicine, King Saud University, Riyadh, Saudi
Arabia. Formerly he was a professor of medical education
and Chair of Medical Education Research and Development
Unit in the Faculty of Medicine at Universiti Teknologi
MARA, Selangor Darul Ehsan, Malaysia. Over the last few
years, he has a special interest in problem-based learning,
curriculum design, staff development, assessment, simulation,
and learning anatomy. He is one of the Associate Editors of
BMC Medical Education and on the Editorial Board of
MedEdWorld, UK.
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