Introduction

Although there have been few reports of anatomy learning outside the classroom, a shift has been reported from didactic methods to self-directed and independent study in medical education. Musculoskeletal anatomy has been taught previously through yoga and pilates [1] and the use of collaborative and self-directed learning approaches to teach surface anatomy and peer physical examination were shown to have a positive effect [2]. Self-directed learning helps students to develop their self-reflection and life-long learning skills and active learning of anatomy allows students to interact with the learning process. In particular, it has been reported that active learning and life-long learning are the result of social interaction and discussions in a clinical context [3,4,5]. Additionally, it has been suggested that an increased need for more diverse learning has led to an evolution of teaching practices outside the classroom [6]. In the area of biology, it was shown that the implementation of special peer-led team learning workshops outside the classroom was successful in assisting students to understand the subject and to learn to communicate appropriate solutions [7]. Education outside the classroom has been reported in school children in Scandinavia and involved innovative teaching methods that focused on interdependent relations between factors such as social relations, well-being, and motivation [8].

Surface anatomy, which is the identification of anatomical structures on living human beings, has been studied using anatomical body painting (BP) at several universities as a novel approach to teach human anatomy [4, 9–18]. When studying human anatomy, it is important that students also focus their efforts on surface anatomy [19–21] that deals with observation of living bodies to assess form, proportions, and surface landmarks that relate to underlying, deeper structures [22]. The study of surface anatomy is important as it allows students the opportunity to consolidate their learning using cadavers and relate it to living bodies. Surface anatomy has the advantage that it can be done on anyone: oneself, classmates, colleagues, friends, or family. BP is engaging as it involves both drawing and the study of surface anatomy [22–24]. BP is an important tool for learning surface anatomy and clinical skills, and is important for future health professionals and clinicians that will be working with patients or clients and as such need to identify anatomical structures on real bodies. It is a highly captivating and fun approach for students to learn human anatomy by observing, identifying surface anatomy features, palpating, drawing, and then painting [4, 9–14, 16–18]. BP has also been used successfully in veterinary anatomy on horses [25].

Medical and health science students necessarily need to master the skills of robust communication, and effective palpation and tactile skills for the safety of their future patients [26]. Many students report discomfort with intimate physical examinations, so recommendations have been made for teaching techniques to initially include the use of inanimate simulation models. Students then develop competency and progression to clinical situations depending on the individual student’s skills and experience [26]. Learning of surface anatomy is crucial for identification of thoracic landmarks for appropriate patient care by thoracic surgeons [27]. A clinical anatomy practicum was used to prepare students for inspection, palpation, percussion, and auscultation of the cardiovascular, respiratory, abdominal, and urogenital systems and self-assessment reported an improvement in understanding of the anatomical basis for clinical examination [28]. In chiropractic teaching, the high number of hours dedicated to anatomy has been reported to assist clinical skills and the retention of knowledge [29]. More recently, ultrasound skills [30–33], video-assistance [34], e-learning [35], and mobile applications [36] have been used to assist and enhance students’ physical examination skills. However, it has been suggested that the development and reliance on advanced imaging has led to a deterioration of physical examination skills among medical students [33]. Although ultrasound training can assist student palpation skills [30, 31, 33], it was reported that students needed pre-course anatomy learning before the training [30]. Devi et al. [34] reported that traditional demonstration of palpation skills scored much better than the video-assisted teaching program suggesting that blended learning techniques may be the way forward for enhancing learning. “Hands-on” approaches for learning physical examination and palpation have been reported to improve the clinical skills and professional attitudes of students assisting their transition into clinical practice [37].

BP is a popular approach that is suitable for the development of physical examination skills in all health professional students and students of different cultures. This approach has been shown to be successful when implemented as part of the anatomy curriculum, and included in weekly anatomy practical classes. It has also been suggested that this approach may result in improved results for medical and health science students [3, 4]. Student performance is improved significantly by an active learning environment that encourages and teaches successful self-directed study strategies [4, 38]. This research differed from previous studies by investigating the value of teaching anatomy, through BP of the entire human body, “outside the classroom”. We attempted to inspire and drive learning by running extra-curricular BP projects to encourage self-directed, group-based learning, to facilitate the development of physical examination and palpation skills and to engage anatomy students further to learn surface anatomy outside the classroom. This work also aimed to produce learning resources and promotional materials for the department and the university.

Methods

Anatomical BP projects by the chief investigator were carried out at James Cook University (JCU) (2008–2012) and Royal Melbourne Institute of Technology University (RMIT) (2012–2018). The BP projects were developed from 2010 onwards to assist with the introduction of BP during the first week of musculoskeletal anatomy as a motivational tool to encourage and inspire student engagement and learning “outside the classroom”. The projects were organised by the chief investigator and were carried out entirely by a student team consisting of a model, artists (4–5), and a photographer. The projects were not run during the regular teaching schedule, but rather were programmed as extra-curricular events, outside the classroom. In these projects, student artists painted the entire body of a student model to further their own anatomical knowledge and as a way of shocking, inspiring, and motivating their classmates. This was done within or near the teaching laboratory so that students could observe and participate if desired (Fig. 1). At least one to two projects were carried out each year. This research was approved by the RMIT Human Ethics Committee (ASEHAPP 16–13) for the student surveys. Students were asked to sign a media release form in week 1 and as part of the BP projects to allow the researcher to use all photographs.

Fig. 1
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The first Anatomical Man at JCU project depicted muscles of the entire body and was carried out near the anatomy teaching laboratory. The completed Anatomical Man (a) was brought into the class to motivate and inspire both tutors (b) and students (c)

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Participants

Participants in these projects were students who were doing, or had done, anatomy courses with the chief investigator. It was an important decision to use current anatomy students, rather than students from the art department as their knowledge of anatomy was crucial in producing accurate representations of the human body. All cohorts of students had talented student artists who were capable of this standard of work. Student participants volunteered or were recruited through word of mouth. Student models and photographers usually volunteered; student artists volunteered or were invited by the chief investigator after observing the quality of their work in anatomy classes. Students who participated in these projects were from the medical, pharmacy, engineering, and dentistry programs at JCU or from the chiropractic, osteopathy, and biomedical science programs at RMIT.

Procedure

The “Anatomical Man” projects included the study of both man and woman subjects. These anatomical BP projects were typically run overnight and often took 18 to 24 h to complete. The process of BP was followed precisely to obtain accurate results (Figs. 1, 2, 3, 4, and 5). First, the models were landmarked accurately using pictures and anatomy atlases (Figs. 4 and 5). The land marking was done using black whiteboard markers to accurately delineate all muscles, bones, bony landmarks, organs, blood vessels, and nerves. This phase was important as it created the stencil that was used for the second phase. In some projects, this initial phase of land marking took up to 8 to 10 h to complete. The second phase of each project consisted of painting and shading. Professional face and body paints (Face Paints Australia) were used for all the BP projects as the finished product was long-lasting and did not crack; a range of professional paintbrushes and makeup brushes were also used for these projects. Anatomical pictures from anatomical atlases such as Atlas of Human Anatomy by Netter were used as guides for the student artists. At the completion of the painting stage, a student photographer took professional photographs for use as resources, publication, and promotion.

Fig. 2
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The finished Anatomical Man project in Melbourne, Australia; front (a) and back (b). The completed Anatomical Man was taken out onto a major Melbourne street adjacent to the university (c)

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Fig. 3
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The completed Skeletal Man project at JCU displayed all the bones of the body on a background of black skin. Front (a), rear (b), and head view (c) of the body are illustrated

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Fig. 4
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Anatomical Woman displayed muscles of the entire body (a) and a Pregnant Woman at 4 months (b) and 9 months (c) of gestation displayed development of the breasts and abdomen (foetus). Systems Man was completed to display the organs of the thoracic and abdominal cavities through land marking (d) and painting (e)

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Fig. 5
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The Multi-coloured Man project took 24 h to complete at JCU. Land marking took 10 h (a) and the painting 14 h (b). The completed project can be seen: front (c) and back (d). The superficial muscles were displayed on the right-hand side of the body and the deep muscles on the left-hand side

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The “Anatomical Man” BP projects complimented the BP carried out by students from week 1 of each course. In anatomy classes, students were encouraged to place importance on the “process” of BP, not on the finished product. In this way, it became a real learning exercise and the artistic abilities of the students were not essential [3, 4, 15]. The process of BP consisted of observation of bony landmarks, form and proportions, palpation of important landmarks, the use of whiteboard markers to outline the important landmarks, drawing in of origins and insertions, the outlining of important organs, and finally the painting. For the “Anatomical Man” BP projects, however, it was important that students had advanced artistic abilities to ensure the precision and accuracy of the finished works.

Analyses

A SurveyMonkey survey was used to assess the value of these anatomical BP projects for the student participants for several projects. The online survey on student perceptions of the extra-curricular BP projects was offered to participants 1 week after the project. Students were asked ten questions to assess the variables known to predict student engagement regarding BP [39–42], such as enjoyment, use as a learning tool, participation in BP activities, class bonding, assistance in learning anatomy, and overall level of interaction with classmates. Students were also asked to rate (self-assess) how much the BP projects helped them with their long-term, deeper understanding of anatomy. Students rated each variable across a 4-category Likert scale with 1 being the lowest and 4 being the highest-none (1), a little (2), some (3), or substantial (4)-and were asked for comments regarding the activity. Data were coded numerically and entered into SPSS release 19 for Windows. Table 1 describes numerical variables as mean values and standard deviations (https://docs.google.com/document/d/1V48_WY-7NTzdErwz9q-y00duEjHmsKvE/edit?usp=sharing&ouid=109877924874709001981&rtpof=true&sd=true).

Table 1 Frequency analyses of students’ views on involvement in body painting projects outside of the classroom (n = 31)
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Results

The sixteen extra-curricular BP projects carried out were as follows: Anatomical Man (muscles; 4 projects) (Figs. 1 and 2), Skeletal Man (bones; 2 projects) (Fig. 3), Anatomical Woman (muscles; 2 projects), Pregnant Woman (pregnant woman painted once per month until birth) and Systems Man (visceral anatomy, organs; 2 projects) (Fig. 4), Multi-coloured Man (muscles in multiple colours; 3 projects) (Fig. 5), Process Man (4 quadrants to show the process of BP), and Neurovascular Man (half nervous system, half cardiovascular system). Most projects were completed within 24 h; about 8 to 10 h for land marking and 12 to 14 h for painting. An invitation was made to the university community to watch the process, and we had many visits from staff and current students across many programs, not only the ones doing anatomy, also from the Head of School, Dean of Medicine, and Deputy Vice-Chancellor. These visits were important in providing the team with moral support through the long hours of the projects.

Surveys were returned by 31/41 (75.6%) participants comprising medical, dental, osteopathy, biomedical science, and chiropractic students at both institutions. Numerical variables in Table 1 (https://docs.google.com/document/d/1V48_WY-7NTzdErwz9q-y00duEjHmsKvE/edit?usp=sharing&ouid=109877924874709001981&rtpof=true&sd=true) are described as mean values out of 4 and standard deviations, while categorical variables are described as percentages (for the highest categories of some/substantial).

Analyses showed that 93.5–100% of participants enjoyed the projects and considered them a valuable learning experience (Table 1; https://docs.google.com/document/d/1V48_WY-7NTzdErwz9q-y00duEjHmsKvE/edit?usp=sharing&ouid=109877924874709001981&rtpof=true&sd=true). Furthermore, participants rated the relevance of BP to their profession at 80.7–87.1%, level of accomplishment at 93.6%, and interactions with classmates at 87.1%. Student participants reported that participation in the BP projects assisted their deeper understanding of human anatomy (93.5%) and their long-term memory of anatomy (93.3%). Students were very complimentary of the experience and their comments are summarised in Table 2.

Table 2 Student comments in SurveyMonkey surveys regarding participation in body painting projects outside of the classroom
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The average marks for each year for the entire cohort and the marks obtained by participants of the BP projects at both institutions are shown in Fig. 6 for comparison. Assessment items were similar at both institutions. Class averages ranged from 51 to 68% (average 63%, SD 5.6); while the marks obtained by participants ranged from 67 to 95%, with an average of 84% (SD 4.8).

Fig. 6
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Distribution of average marks for the entire student cohort (blue) and the participants in the BP projects (purple)

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All finished work was photographed professionally at the end of each project to provide valuable learning resources for teaching and results for publication and promotion. Many projects were also photographed by the press at the finished stage and were reported in major Australian newspapers (The Townsville Bulletin, The Age, The Australian), television and radio, and on websites in over sixty countries all around the world. Furthermore, the work was reported widely on social channels.

Discussion

This work demonstrated that medical and health science students can be inspired and engaged to learn surface anatomy “outside the classroom” using a self-directed approach. Although many previous BP studies reported regional learning, dedicated to one or two regions per session and under supervision of an academic, the current study is novel as it includes BP the entire body, as a living, and dynamic model, with the student team being able to improve their physical examination skills, anatomy knowledge, and engagement as observed by the chief investigator during the projects and self-assessed by participants. These projects presented previously unpublished reports of body painting of the entire human body by students with advanced artistic abilities, thus producing learning resources and unintended benefits for the department and the university. The teacher in this study had a reputation for innovative approaches to teach anatomy [3, 4, 15] that encourage students to use innovative approaches to learn anatomy at home (“outside the classroom”), whether BP on relatives or friends or using Play-Doh and whiteboards to learn anatomy. Indeed, in 2020, during online teaching during the COVID-19 lockdown, many students uploaded photographs of their work at home, including BP their children, creating anatomical structures such as the larynx using origami or Play-Doh, or drawing on their cupboards or mirrors [43]. In this study, student participants reported that they found learning outside the classroom, via the extra-curricular BP projects, valuable for improving their palpation and tactile skills, as well as assisting them with deep and life-long learning of human anatomy, consistent with previous reports for BP in class [3, 4, 44]. During these projects, other students (non-participants) were able to observe the participants at work, learn from them, and participating if they desired. The “Anatomical Man” BP projects shocked, inspired, and amazed participating students and other student observers, achieving a very high level of engagement as quantified in Table 1 (https://docs.google.com/document/d/1V48_WY-7NTzdErwz9q-y00duEjHmsKvE/edit?usp=sharing&ouid=109877924874709001981&rtpof=true&sd=true). In the weeks following the projects, we observed an increased number of non-participating students participating in BP in anatomy practical classes, markedly more than in previous years where there were no projects. For example, before the project about five students would BP in a practical class, while after the project, we observed an increase of up to twenty students BP per class. Also, the fact that the projects were carried out by a student team was an effective way of showing these students that everybody is capable of this work, as students were able to see their classmates participating and achieving inspiring results. Students subsequently become very confident and motivated to carry out this learning approach as either models or artists in class. This became evident when we saw several students who were not keen on the BP at the start of the course change their views significantly as the semester progressed and many of these students became active, capable, and enthusiastic participants in BP by the end of the course [15].

Participation in BP projects was popular among students in all the courses. Running extra-curricular anatomical BP projects was inspirational and pivotal in enthusing students and giving them the confidence to participate in BP during anatomy classes and was also a valuable and engaging extra-curricular exercise for those students seeking extra anatomy learning and engagement through the projects. Spending a period of 18–24 h drawing and painting anatomical structures was both educational and inspiring to student participants as it allowed them the opportunity to improve their palpation and tactile skills and their deep learning of anatomy and to establish valuable peer interactions. As can be seen from student comments in Table 2, participants appreciated the interactions with their peers and teacher and they enjoyed working as part of a team in the learning process. Learning outside the classroom in teams allowed students to further develop the self-directed learning skills that were fostered in the classroom by the teacher. Positive peer interactions are known to assist in the development of collaborative learning and motivation for students to learn [41]. Consistent with “engagement theory”, peer learning was an important part of the extra-curricular BP experience for students in this study, as students were engaged in meaningful learning activities involving peer interaction to achieve deep learning [40, 41].

Students who participated in the “Anatomical Man” BP projects reported that this experience was the highlight of their programs: They reported it to be very beneficial for their own learning outcomes in anatomy, particularly in relation to improvement of their palpation and tactile skills, and an engaging and memorable experience. This student-centred approach moved the focus from teaching to learning [45] and encouraged energised and active learning by student participants. The results from this study are consistent with previous reports that students prefer group-based and experiential (“hands-on”) practical learning of anatomy [4, 46, 47]. Experiential learning approaches, like BP, that are stimulating, engaging, and fun have been reported to produce confident and self-directed learners that achieve both deep learning and life-long learning [2,3,4, 15, 24, 48], while also developing the palpation and tactile skills needed for their professions. Students who participated in the BP projects were the high achievers in the cohort tending to obtain distinctions (75–84%) and high distinctions (85–100%) in the subjects, and although we cannot attribute these final marks unequivocally to participation in the BP projects, we propose that their participation played a significant role in their success. Projects were open for inspection by all students and staff at these universities and in fact we had students from other programs visit during the night-long projects, so we were able to reach a much larger audience than anticipated initially. This work is ongoing and will be offered to health science students at CSU, Albury, Australia, in the coming years.

Running anatomical BP projects outside of the lecture theatre or anatomy laboratory was foundational work that will provide economic development in educational opportunities for learning anatomy and will be a vital approach moving forward for anatomical education. The “Anatomical Man” BP projects carried out by medical, health science, and biomedical science students in their first years at university received considerable media coverage since 2010: newspapers, radio, television, over 441,060 views on YouTube, and university publications. This work was not only used to teach anatomy at university, but was also presented to external groups such as medical specialists such as radiologists from the local hospital and at the British Institute of Embalmers and the Australian Institute of Embalmers conferences in Australia [15].

Conclusions

Anatomy can successfully be taught outside of the classroom. The extra-curricular BP projects were important foundational work for anatomy education that resulted in a rich experience of self-directed anatomy learning for student participants, encouraging improvement of physical examination and palpation skills, peer learning, high engagement, and assisted deep and long-term learning of anatomy. The self-assessment of improved “long-term memory” by student participants refers to the recall of anatomy over the semester and not into future years or careers. The limitations of this study are that this is self-reported data; students self-assessed the effects of BP on their recall and learning of anatomy. Future work will use longitudinal studies to assess “long-term memory” over longer periods of time (6–12 months), and 12 months plus. These projects using entire human bodies were novel and brought anatomy to life, and not only benefited the participants, but also assisted the (non-participating) students studying anatomy courses to observe the process, and to be enthused and inspired to try BP themselves in the practical classes. This study merged human anatomy with art and may inspire other anatomy departments to experiment with student-led extra-curricular body painting to improve student engagement and outcomes. The unintended benefits of this work were that the marketing and media departments of two universities received large amounts of positive feedback.

The extra-curricular BP projects provided an economical means to develop new opportunities for student learning “outside of the classroom”. Considering the increasing significance of online education and the situation encountered by many during COVID-19, this perspective on education will now become more relevant than ever. This work will lead the way with anatomy education post-COVID.