by Julie H. Youm, Ph.D.
On August 6, 2010, the medical students in the incoming class at the University of California, Irvine, School of Medicine were awarded their white coats. More interestingly, was the non-traditional gift these students were bestowed during this ceremony: an iPad, Apple’s new tablet device that had only debuted a few short months before. These iPads represent a major step forward in the new iMedEd Initiative at UCIrvine to develop a fully digital curriculum, a goal set forth by Dr. Ralph V. Clayman, Dean of the UCIrvine School of Medicine. The iMedEd Initiative, led by faculty director, Dr. Warren Wiechmann, was conceived out of efforts to blend technology into an innovative and interactive learning environment to facilitate a move away from the passive lecture model of conventional medical education approaches.
One of the first courses into which the iPads were integrated at UCIrvine is Anatomy. Anatomy has long been a critical part of medical education. Most of the learning in this course happens through active, hands-on exploration in a lab that commonly consists of donated cadavers draped in sheets and lying on rows of dissection tables. The introduction of 10 new iPads and enabling Internet connectivity within the lab was a groundbreaking addition for the UCIrvine lab this year. However, prior to making the iPads available for the students, there were several logistical issues that needed to be addressed to support them: (1) protecting them from the cadaver tissue and biohazardous materials in the lab; (2) loading relevant and effective software to facilitate the learning of anatomy; (3) determining the most efficient way for students to share documents with themselves, other students and faculty from inside the lab; and (4) establishing Internet connectivity to allow document sharing, access to external resources and handling updates of installed apps.
Video 1. This is a brief video demonstrating iPad usage in UCIrvine's Anatomy lab. The iPad is being protected by a simple Ziploc bag and still maintains functionality with both a gloved hand and a stylus. The content being viewed on the iPad is the Modality Body App with the Thieme Atlas of Anatomy as well as the PocketBodyHD app by PocketAnatomy.
Cadaver tissue and biohazardous materials are unavoidable in an anatomy lab. Unfortunately, these materials do not mix well with iPads and a need to protect them in a sanitary and waterproof manner is necessary. A comprehensive test and review of the market for suitable cases by the iMedEd team was cut short in favor of an admittedly unfashionable solution using Ziplock bags in an effort to get the iPads into the anatomy lab as quickly as possible (Figure 1).
Figure 1. iPad in Ziplock bag (Credit: UCIrvine)
So far, this solution has proven effective in the lab. The Ziplock-encased iPad screens respond well to touch by latex-gloved fingers (though requiring slightly longer contact). The Ziplock bags can be easily wiped down after each use, and they can be replaced often since they are a fraction of what other cases may cost. When not in use, the encased-iPads are stored in stacked letter trays that are connected to power adaptors so they can be recharged in between lab sessions (Figure 2).
Figure 2. iPads stored in stacked letter trays (Credit: UCIrvine)
The iPad serves as a preeminent platform to deliver rich, interactive multimedia presentations of information and gross anatomy is an ideal subject matter to complement the iPad’s features with its largely media-based approach to teaching, for example, utilizing images of body structures, radiographic films, MRI’s and videos of dissections. Accordingly, there are quite a few apps that effectively marry anatomy content and the iPad technology such as the Pocket Body HD app by Pocket Anatomy. Pocket Body allows its user to explore an anatomically correct human character with nine layers of musculoskeletal content that can be peeled away to study structures at the muscle, joints/ligaments and skeletal levels. A copy of this app was purchased for each anatomy iPad along with Epocrates Essentials, a mobile drug and disease reference. Though it is not a media intensive app, Epocrates provides quick and easily searchable access to a wealth of clinical information in a format that is also well-suited for the iPad interface.
The most interesting use of the iPad in the anatomy lab has been with OsiriX HD, an app that displays and supports interactive analysis of medical images. Full CT scans of two cadavers were captured allowing students to explore structures in OsiriX, for example, by zooming, panning and measuring them, to complement their learning experience before and after dissections. A few students tested the functionality of the OsiriX app and it will be planned for rollout in the Anatomy lab next year.
Another area that shows great potential for the iPad and anatomy and which the iMedEd team has spent a lot of time researching is eTextbooks. Because physical textbooks have always been available for reference in the lab, the iPads need to demonstrate value above and beyond what was currently offered to the students for them to sustain a significant role in the lab. Inkling and modality, Inc. are two eTextbook providers that are offering anatomy titles through their respective iPad apps, Inkling and modalityBODY. These apps were selected for use in the anatomy lab based on their more fully developed highlighting and annotating features as well as the greater level of interactivity and productivity offered through features such as zooming in/out, robust search capabilities, quizzes for self-assessment and embedded video. With such features, the textbooks offered through these apps achieve the goal of being more than passive translation of hardcopy text to a digital format.
The following is a list of the digital textbooks and atlases that were purchased for the anatomy iPads:
- Moore's Essential Clinical Anatomy (4th Edition) by Moore, Agur and Dalley.
- Atlas of Anatomy
- Imaging Atlas of Human Anatomy
- Netter's Anatomy Flash Cards
- Rohen's Photographic Anatomy Flash Cards
- Sylvius MR: Atlas of the Human Brain
Productivity apps such as Noterize and iAnnotate were installed for note-taking needs and Dropbox was installed for sharing documents via a secured server. Overall, Martin Roman Hofmann, a first-year medical student in the program, finds that “the advantages [of the iPad] are mostly the same in the lab as they are outside of it: it's excellent design and ability to contain the resources needed for an assignment, all in one place. Before we were carrying around 15-20 pounds of textbooks in addition to book stands so they could be positioned around the table. While some students still prefer doing that now, I see people increasingly grabbing an iPad and having that right near the site of the cadaver they're working on."
Unlike the dedicated iPads that were given to each student at the white coat ceremony, the anatomy iPads are shared devices for use only in the lab. This precluded students from being able to set up email accounts in the Mail app or personalize them in any way for security reasons. Yet, the students still required a way to share documents created outside the lab, for example, notes from lecture, to the iPads in the lab and vice versa.
Dr. Mary Frances Ypma-Wong, an educational facilitator with the iMedEd Initiative, handled this issue by coordinating a central Dropbox account for use only in the lab. Students were instructed to do the following:
Once the folders were shared and the invitations accepted by Dr. Ypma-Wong, Dropbox became a workable means to transfer documents from these shared iPads in and out of the lab. The main drawback with the use of a central anatomy Dropbox is that student folders are accessible to all users of the iPads, i.e., privacy cannot be maintained. However, the level of professionalism that is maintained by medical students for the privilege of being in the anatomy lab was deemed enough to expect a respect of privacy amongst the students and has not surfaced as a concern from the many students who share their folders.
Internet connectivity became available in the anatomy lab for the first time with the arrival of the iPads. Without the Internet, the iPads are standalone devices that proceed to serve as an interactive resource with note-taking capabilities, but are limited in their ability to transfer the isolated learning experiences in the labs back home with the students. An Internet connection is necessary to share documents, handle regular updates to apps and fully take advantage of the iPad.
As a bonus, the Internet connection in the lab has opened up an unprecedented access to a myriad of free resources beyond the physical ones available in the lab. Hofmann states that he “…use[s] the iPad in the anatomy lab primarily as a one-stop shop type resource.” “It's awfully nice to be able to flip between the guide to the dissection, an anatomy atlas, and Internet resources from Google and Wikipedia to anatomy dictionaries that provide the etymology for various terms…” says Hofmann.
Further, because the iPads did not get into the labs until about a month after the lab sessions began, students were able to compare their experiences in the lab pre- and post-iPad. Raja Narayan, another first-year medical student, found that “there is no other effective way to take notes in the anatomy lab that can be taken out and studied later. With the iPads, we are now able to take notes on dissections in the lab and use them later. It's almost ridiculous to consider what happened in the past - that we had to memorize everything we saw in the lab or leave notes in the lab that could only be studied there. Now, having the ability to jot down notes and send them from the lab to our home computer…iPads have revolutionized how I study for anatomy.”
The UCIrvine School of Medicine is pleased with their first implementation of the iPads into the anatomy lab and is already looking ahead to the fall, when the incoming students will receive iPad 2’s. While the iPad 2’s faster graphics and built-in cameras will certainly create more opportunities for anatomy app development, UCIrvine is also aware that this could open up other issues to address in the lab, such as a continued observation of respect, e.g., with regards to photo-taking. As exciting new applications and eTextbooks become available, the iMedEd Initiative will continue to work with the Anatomy course director, to discover different ways in which the technology can be fully leveraged and improve learning.
Finally, the best testament for the potential of the iPad for anatomy education has come from the students themselves. When asked in a recent survey about their “dream” iPad app, a majority of the student respondents cited an improved anatomy app with more interactive features. This suggests a recognition and desire by the students to improve the value an iPad can bring to their study of anatomy. Fortunately, it seems that the iPads have already had a great start in this respect, as summarized by Narayan, “The iPads enable us to have a single set of notes that we can work on in the lab or at home but be able to access from both locations at any time; they are cheaper in the long run as compared to replacing books that become too soggy from cadaveric tissue over the years; having all textbooks we refer to or study from in a single device that can be used right there with the cadaver adds much more utility to the anatomy lab that didn't exist in years prior; having the Find function through apps or in Spotlight greatly reduces time spent flipping through pages or looking through an index…it leaves more time for learning…”
