The need for ethical and pedagogical frameworks for developing online media in anatomy education

We read with interest Miller and Lewis’ Letter to the Editor (Miller and Lewis, 2016) in which they discuss aspects of our original article “Anatomy education for the YouTube generation” published in your journal (Barry et al., 2016). We agree fully with Miller and Lewis that the ethical issues associated with online videos of human cadaveric material is of grave significance as the general neglect of ethical oversight of online resources is likely to have a corrosive effect on standards of professionalism within the healthcare sector. Nonetheless, the pressure on academics to increase research output coupled to increasing student-staff ratios (Drake et al., 2009) is ensuring anatomy staff will seldom be in a position to facilitate and guide the process of user-generated online content, or to check the validity of information and clarity of delivery once uploaded. However, educators do have a critical role to play in reinforcing codes of professional conduct by selecting images or video clips of appropriate validity, clarity, and sensitivity for teaching purposes. Furthermore, of analogous concern is the proliferation of online video clips of surgical procedures and patients displaying pathological signs. An unpublished survey of YouTube sites for teaching purposes by the present authors found that of 2,000 anatomy-related video clips, 22.5% were of live subjects and just 1.3% cited consent to broadcast. While consent to use video for teaching purposes including broadcast may have been provided by the subject, this is not easy to establish. Many YouTube video clips make a declaration of the “Standard YouTube License” or “Creative Commons License,” which cover the copyright entitlements of those who upload the videos, yet do not make any mention of the subjects consent. In many cases, this may be implicit as the subjects are video recording themselves, or may be healthcare students mimicking pathological signs, yet many are also of patients which generally offer the greatest impact, garnering more views. Therefore, despite the perceived benefit to the student (Topping, 2014) the use of human tissue-based video, alive or dead is fraught with a number of legal, moral, and ethical considerations. An overlay narration by academics when using these as teaching resources would help fulfil the ethical obligations of educators (Miller and Lewis, 2016). The need for this is highlighted in a recent study of human heart anatomy videos on YouTube, where it was reported that 21% of available videos featured cadaveric material that achieved over 500,000 views, while, in contrast to this, plastinated specimens achieved 433 views (Raikos and Waidyasekara, 2014). Corroborating Miller and Lewis’ view, this study found that the majority of videos (86.7%) were uploaded by individuals, while only 13.3% were endorsed by institutions and the numbers of uploaded videos tripled between 2009 and 2012 (Raikos and Waidyasekara, 2014). Given these statistics, can much be done to highlight the ethical issues associated with the unregulated distribution and use of human material particularly in a healthcare education context? This will be challenging, although tools such as Google Trends R may allow assessment of search patterns in anatomical syllabi (Smith et al., 2016), which may be useful to institutions to identify particular aspects of anatomy in which to develop targeted online supports for student learning. Miller and Lewis (2016) also flag the need for consideration of the educational benefits of using online videos in anatomy education. Blended learning is recognized as a more effective approach in optimizing student insight into functional and clinical anatomy (Pereira et al., 2007; Green and Whitburn, 2016). From a scholarship of teaching and learning perspective, the four dimensions of disciplinary understanding—knowledge, method, purpose, and form may also be addressed more effectively by incorporating diverse online resources (Mansilla and Gardner, 1998). Historically, there has been a tendency to teach anatomy with a focus on the knowledge domain or rather what we treat as knowledge (Sch€ on, 1995), particularly if we define knowledge as not merely what a student knows, but what they can do with this information. There is now a greater integration of clinical skills with anatomy and this change is being driven by course compression and reduced contact hours requiring greater efficiency of integration. Confounding this shift are changes in assessment as highlighted by Rowland and colleagues who found that medical students who graduated before 2005 were assessed more frequently by practical (94.2 vs. 33.3%) and oral (84.5 vs. 13.1%) methods than those whose graduated after (Rowland et al., 2011). This would seem to be a regressive emphasis on the “knowledge” dimension of anatomy rather than its application, possibly due to the increasingly litigious environment of third level education. In this context, the three specific benefits we feel online resources can offer are firstly, animations or live videos showing the *Correspondence to: Dr. Denis Barry, Department of Anatomy, Trinity Biomedical Sciences Institute, Trinity College Dublin, Dublin 2, Ireland. E-mail: debarry@tcd.ie (or) Dr. Gerard O’Keeffe, Department of Anatomy and Neuroscience, School of Medicine, University College Cork, Cork, Ireland. E-mail: g.okeeffe@ucc.ie