Introduction

Changes in medical education are on the agenda worldwide, and many medical schools have carried out reforms and experienced challenges [9, 14]. Human anatomy, the science of the structures and functions of the human body and the relations of its various parts, is one of the cornerstone courses of medicine [8, 13]. Moreover, human anatomy is one of the first basic medical courses medical students encounter and is a bridge between basic medical courses and clinical courses. Engels once said, "Without anatomy, there would be no medicine", which illustrates the importance of anatomy in medicine.

Studies have shown that anatomy is a necessary foundation for clinicians' development, and a thorough understanding of anatomy is a prerequisite for medical students to practice safely in a clinical setting [10, 16, 19]. Some clinical accidents are caused by poor knowledge of anatomy [6]. Surgery without solid anatomical knowledge can lead to increased mortality and morbidity [12]. These issues have forced medical schools to rethink the teaching and learning of anatomy. On the one hand, it is difficult for students to understand and apply human anatomy because of its complex content, abstract concepts, number of professional terms and lack of logical organization of systems descriptions. On the other hand, traditional anatomy teaching is mainly "teacher-centered" and based on lecture-based learning (LBL). This mode is systematic and complete, which is conducive to students building a complete knowledge framework. However, due to the lack of effective interaction between teachers and students as well as among students, students learn in a passive mode, and their learning enthusiasm is greatly affected. Moreover, students' mastery of the depth and breadth of knowledge is often limited by what is taught and what is not taught. At the same time, due to students' weak autonomous learning ability, the flexible application of knowledge is absent. Therefore, although students usually spend much time studying, the learning effect is still not ideal. The above factors have forced medical schools to introduce active learning activities and embrace the concept of "student-centered" education.

To this end, based on the establishment of a "safe" classroom climate, this study carried out a variety of learning activities, implemented a variety of teaching methods, and realized the transformation of classroom teaching in a gradual process from silence to question-and-answer exchanges, dialog, discussion, and debate. This approach allows every student to bring the spirit of "mastery" to the study of anatomy and to realize his or her own value. A "student-centered" multielement fusion teaching mode in human anatomy could also deepen students' internalization of learned knowledge, cultivate their professional spirit and practical operation ability, and expand the dimensions of their learning. Therefore, it was useful to practice the concept of "student-centered" learning, train future doctors in job competence and provide high-quality medical talent for society. These data provide practical demonstrations of teaching and learning reform in human anatomy instruction.

Materials and methods

Course participants

A total of 141 clinical medical students from grades 2016 and 2017 participated in this study. Sixty-two male and 79 female students were included, and their average age was 20 ± 2. The students were randomly divided into four classes: two experimental classes (class 14 from both grades) and two control classes (class 6 from both grades). The students had already completed the courses of basic chemistry, college English, medical higher mathematics, medical cell biology and so on, and in the second semester, they were going to learn human anatomy, histology and embryology, organic chemistry, medical physics and so on. Therefore, both classes in the same grade had the same major, similar basic knowledge and the same curriculum. Additionally, the human anatomy instruction in both classes was led by the same teacher, so the classes had homogeneity (Table 1). A "student-centered" multielement fusion teaching mode was used in the experimental group. First, LBL was taken as a guide to ensure the integrity and systematization of knowledge. Second, various teaching activities and teaching methods were carried out according to the contents, giving full play to students' subjective initiative and cultivating their comprehensive ability. Third, the combination of formative and summative assessments were used to test the learning effect. Generally, 1 h of LBL, 2 h of practical course, and 3 h of “student-centered” learning [such as jigsaw, peer instruction (PI), case-based learning (CBL), problem-based learning (PBL) and the role substitution approach (RSA)] were arranged per week. The control group adopted the LBL, that is, the theory class was explained by the teacher, the practical class was also explained by the teacher first and then the students observed by themselves, 3 h of LBL and 3 h of practical class were arranged per week. All the participants completed the whole trial and provided informed oral consent regarding the data acquisition for this study.

Table 1 Participant characteristics
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Methods

Building a "safe" classroom climate

All the students were told the following in the first class: everyone should attend and finish the class on time. They were equal in class and they should treat others as they wanted to be treated. The students could ask questions at any time after first raising their hand. They should be honest and have the courage to admit mistakes. When communicating with others, they should be humble and courteous. The students should answer questions positively in class, and even if the answers were wrong, they should not be laughed at. Moreover, they should help each other and share what they learned.

Developing various teaching activities

Integration of theoretical and practical courses

The models and specimens were brought into the theoretical course. Meanwhile, the "Chinese Digital Human Anatomy System" (CDHAS) was integrated into the teaching process, so that students could observe the anatomical structure intuitively, vividly and three-dimensionally.

Jigsaw

Jigsaw teaching is a method of applying jigsaw ideas to teaching activities that is essentially a cooperative learning model based on contemporary cognitive science and constructivist theory. Jigsaw teaching was initially introduced in osteology and arthrology. The process is shown in Fig. 1. First, the students were divided into groups according to the learning tasks. Second, students in the same group were regrouped and given different tasks. Third, the students in charge of the same task formed an "expert group", and they reached a consensus after discussion. Fourth, the "expert group" returned to the original group to share the knowledge gained. Fifth, the original group reported to the class. Sixth, the teacher summarized the overall content and answered students’ questions.

Fig. 1
figure 1

Flowchart of the Jigsaw teaching activities in anatomy learning

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Peer instruction

The PI method refers to guiding every student to participate in the learning process, transforming traditional teaching into autonomous learning and cooperative inquiry based on analyzing a specific problem to construct an innovative teaching mode of independent and cooperative learning. The operational mode is shown in Fig. 2. The teacher handed out the pre-reading materials, gave a small lecture, and then threw out well-designed conceptual questions. The students were allowed to make independent choices first. A correct rate less than 30% indicated that the students were unclear about the concept, and the teacher needed to explain again. A correct rate of more than 70% suggested that most students had mastered the concept, and the teacher only needed to point out the mistakes and provide the answers. Interestingly, when the correct rate was between 30 and 70%, the teacher should allow the students to communicate with their peers for a few minutes instead of explaining. Then, the second choice was made; surprisingly, the correct rate was often over 90%, sometimes even reaching 100%. At this time, the teacher listened to the students' explanation in each group and encouraged them to discuss.

Fig. 2
figure 2

Flowchart of peer instruction in anatomy learning

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Implementing multiple teaching methods

In the overall process of teaching and learning, we implemented CBL, PBL and RSA on the basis of LBL.

Case-based learning

CBL was used in the content closely related to clinical cases. The operational mode is as follows. First, the teacher sent out the case, and then the students searched the materials and discussed them in groups. Next, each group reported to the class. Finally, the teacher summarized the case and commented. For example, a uterine transplantation case was presented in a section on the female reproductive system. This case skillfully combined anatomical knowledge of the uterus with clinical knowledge of organ transplantation. In the case analysis, the students not only mastered anatomical knowledge of the position, shape, function and support of the uterus but also preliminarily discussed medical ethics and doctor-patient communication from the perspective of medical humanities. CBL can change boring anatomy teaching into specific case discussions, which arouse students' enthusiasm and initiative and improve the learning effect.

Problem-based learning

For the classic cases, we used PBL. The case of "Mr. Yu's back and leg pain" is given as an example. It began with Mr. Yu's pain in his back and leg, followed by a medical history, observation of signs, clinical examination, the diagnosis and treatment. First, the students were divided into four groups, a chairman and a recorder were selected for each group. Driven by progress on the case, the knowledge was presented step by step. Usually, it took four classes for one case. The cases were handed out 3–5d in advance. The students could use their spare time to collect information, find and analyze the problems, then try to solve them. They brought difficulties to class for intragroup and intergroup discussions. Throughout the process, the teacher did more about listening than explaining. More importantly, they should pull students back in time when they are too far away from the topic. Questionnaires were distributed to evaluate the effect of PBL to improve teaching and learning in the future.

Role substitution approach

RSA is a teaching method that substitutes students for "teachers". This approach was applied mainly in practical courses. The specific implementation was as follows (Fig. 3). Take the practical course in "the connection of the upper limb bone" in class 14 from grade 2017 as an example. First, the students were divided into five groups (different colors represent different content, n = 7). Each group was assigned different content (the sternoclavicular joint and acromioclavicular joint, shoulder joint, elbow joint; the connection between the radius and ulna; the radiocarpal joint along with the connections between the hand bones). Second, one "teacher" was selected from each group to explain their content. Third, two students from different groups were randomly paired to communicate with each other (i.e., each student was paired with another student from the other four groups). This pairing ensured that each student had mastered all five aspects of the content. Finally, to determine the learning effect for the students, the teacher performed a random check.

Fig. 3
figure 3

Pattern diagram of the role substitution approach in anatomy learning

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Analysis and assessments

Formative assessments

The formative assessments consist of mutual evaluations between teachers and students, mutual evaluations among students, assignments in and outside class and questionnaires. The questionnaires were designed according to the requirements of medical talent training and administered to the students in the experimental group. Then, the results were analyzed, and timely feedback was provided.

Summative assessments

At the end of the semester, theoretical and experimental tests were carried out. The test requirements and assessment standards were the same for both groups, and the scoring was performed together. The theoretical test was randomly selected from the test question bank. For the experimental test, 20 specimens from the same batch and of similar difficulty were prepared for the students to identify, and 1 min was allowed for each specimen. The total score was 60% theoretical score, 20% experimental score and 20% usual performance.

Statistical analysis

A statistical analysis of the test scores was performed using 19.0 SPSS. The measurement data are expressed as the mean ± standard deviation (\(\overline{x}\) ± s). The two groups were compared with t test analysis.

Results

Results of the questionnaires

As shown in Table 2, 100% of the students highly approved this teaching mode. More than 90% of the students believed that the teaching mode stimulated students' interest, promoted learning, improved students’ language skills, consolidated knowledge, contributed to the application of knowledge and prepared them for early clinical practice. More than 80% of the students agreed that the teaching mode could improve their ability to identify, analyze and solve problems; increase their breadth and depth of knowledge; strengthen the teamwork and the relationship between students. Moreover, 71.42% of the students said that the teaching mode could strengthen their ability to consult the literature and prepare for future research.

Table 2 Results of questionnaires in the experimental group
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The theoretical and experimental test scores

As shown in Fig. 4, the average score of the experimental test in the experimental group was 16.50 ± 0.3203, which was significantly higher than that in the control group, 12.65 ± 0.4731 (P < 0.01). The average score of the theoretical test in the experimental group was 45.86 ± 0.6273, compared with the average score of 46.59 ± 0.6636 in the control group; there was no significant difference between the two groups (P > 0.05).

Fig. 4
figure 4

Average scores of the experimental and theoretical courses. A The average scores of the experimental courses, *P < 0.01, vs. the control group; B The average scores of the theoretical courses

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Discussion

Human anatomy is an important main medical course that is the basis of all medical disciplines. There are many problems with traditional teaching methods, such as a single teaching mode, less interaction between teachers and students and among students, and students' weak passive learning and autonomous learning ability [25, 28]. The concept of "student-centered" learning originates from the concept of "child-centered" learning by Dewey, an American child psychologist and educator, which centers students in the process and enables them to participate in learning happily and actively. Students are the main body of learning, and teachers should help them invest in the spirit of ownership and realize their own value in the process [5]. Therefore, the Department of Human Anatomy of Chengde Medical University reformed the teaching of human anatomy in 2013.

The classroom climate is the "soil" of classroom teaching and the "vital energy" of the existence, operation and development of subject teaching. Only in a "safe" classroom climate can students boldly express their views and truly participate. Therefore, the "safe" classroom climate is the guarantor of "student-centered" learning. Manzano-Sanchez D’s study showed that a classroom climate could satisfy students' basic psychological needs and improve their learning motivation, prosocial behavior and classroom atmosphere [17]. Therefore, we first established a "safe" classroom climate at the beginning of the course. After several rounds of observation, we found that it was a very effective method.

Socrates, a medical educator, once said, "Education is not a matter of indoctrination; it is a lighting of fire". Classroom teaching should be the fire, as teachers ignite students' pursuit of truth. Therefore, our teachers carefully designed a variety of learning activities to ignite the flame of students seeking knowledge.

First, practical and theoretical courses were integrated organically, and the CDHAS was added. The phenomenon of "disconnection" between the theoretical and practical courses was thus avoided. One study showed that the practical classes could not be well understood without face-to-face classroom [20]. Justin F Shaffer et al. revealed that anatomical models were the most helpful materials for student learning [23]. Chytas et al. demonstrated that augmented reality is a highly acceptable and enjoyable anatomy teaching tool that showed remarkable efficacy in terms of helping students understand the three-dimensional organization of structures and achieve satisfactory examination results [7]. Therefore, anatomical models and/or specimens were added into theoretical classes. It not only avoids the boring of theory alone but also provides a visual impact for students, such "visible and tangible" objects were easy to understand and improved the learning. With the investment in teaching reform, the university introduced the CDHAS in 2014. To date, more than 600 students have used this system. CDHAS largely solved the problems of lack of cadaver specimens, unpleasant smell of soaked specimens and easy damage to the models. In the CDHAS, students can conduct structural separation and superposition and rotate an image 360°, so it brought a new experience [11].

Jigsaw is the literal translation of the "jigsaw puzzle", with a complete pattern being broken up into small pieces that can be reassembled by different people in a specific way. One of the important features of jigsaw teaching activities was the formation of the "expert group" by students who were allocated for the same question. Another feature is the "experts" returned to the original group sharing what they had gained. Through jigsaw teaching activities, students' language expression ability, problem analysis, problem solving, and team cooperation consciousness were improved. Thus, jigsaw teaching activities fully practice the "student-centered" concept. One study suggested that jigsaw teaching activities promoted students' independent learning and provided opportunities for communication among group members [26]. According to the report of Oakes DJ, jigsaw teaching activities improved students' performance by engaging students in group work and peer-led learning [18]. Our questionnaire also confirmed this point.

In 1984, Professor Eric Mazur of Harvard University founded the PI in physics teaching practice. PI emphasizes initiatives and team cooperatives in learning, guides students to self-inquiry and stimulates their inner desire for knowledge [22, 27]. PI has been popular with teachers and students in many colleges and universities in China and abroad [1, 3]. The research suggested that PI could improve learning efficiency [4]. An example of the locomotor system is "Where is the most common place for lumbar disc herniation?" The choices were as follows: anterior, posterior and posterolateral sides. The correct rate of the first time was approximately 50%, and then they were asked to discuss with peers for 2 min and chose again. Surprisingly, the correct was 96% of the second time. Moreover, we were surprised to find that group discussion enabled learners to form a correct understanding soon. In fact, during the whole process, the important thing was how the students deduced the answer logically not the answer itself, which was the charm and the greatest gain of PI.

Tolstoy said, "Successful teaching need is not mandatory, but rather to stimulate interest". In addition to the active classroom activities mentioned above, we implemented a variety of teaching methods, mainly CBL, PBL and RSA. These methods increased the students' interest and participation.

CBL originated in the 1920s at Harvard Business School in the United States. It takes clinical cases as the entry point and presents knowledge gradually, so that students can learn the knowledge hidden from the cases [24]. Since human anatomy is opened in the first year of university, students have a strong desire for learning, but inadequate knowledge limits their access to medical information. Therefore, it is necessary to set up CBL courses to help students acquire clinical medical knowledge and establish clinical thinking. So the cases were carefully designed, in the locomotor system, cases with a history of obvious trauma and sensory and motor disorders were selected; in the visceral system, cases of common and frequently occurring diseases were selected; in the nervous system, typical cases related to key points such as the spinal cord and internal capsule were selected. Moreover, CBL pays attention to "student-centered" learning, mobilization of students' learning enthusiasm, and communication between teachers and students and among students.

PBL pedagogy is problem-based, student-centered and teacher-guided [29]. PBL maximizes students' autonomous learning, acquiring knowledge through a process of discussion, self-study, rediscussion and relearning [15]. Bains M demonstrated that a combination of anatomy teaching and PBL could promote learning efficiency and students' comprehensive ability [2]. The Human Anatomy Department of Chengde Medical University began to implement PBL pedagogy in March 2013. So we accumulated some experience. In the experimental group, the following cases were applied: "Mr. Yu's back and leg pain", "Wandering abdominal pain", "Kidney stones", "What is wrong with my eyes?" and "Sudden hemiplegia". The instructional design hid the basic knowledge in the carefully designed case. At the end of each case, the students not only gradually mastered the anatomical knowledge but also understood the clinical knowledge. Moreover, humanistic literacy was involved in the whole case. In the whole process, students were the main body of learning, and their ability to express and solve problems could be well exercised. Teachers were the guides, information consultants and commentators. They guided the students to use various resources, collect relevant materials, discuss and analyze the problems, and determine the most suitable solutions.

RSA originated from role-play activities (RPAs) in the United States, but it differs from RPAs. It is a teaching method based on learning motivation theory, and humanist and constructivist learning theory. RSA was mainly carried out in practical courses of this study. On the one hand, practical classes consolidate and expand theoretical knowledge and provide a platform for students to display through interactions among themselves [21]. On the other hand, RSA puts forward higher requirements for students' learning by substituting students for teachers. Teaching is the sublimation and leap of knowledge. Only when knowledge is understood thoroughly can it be passed on to others. Therefore, when students played the role of "teacher", they would inevitably fully prepare what they had learned before explaining it to others. In summary, the introduction of RSA undoubtedly deepened the students' understanding and application of the knowledge and helped them achieve higher learning goals. Meanwhile, students' ability to provide information and respond to emergencies was enhanced. The real teachers provided supervision, confirmation, encouragement and guidance and prevented the emergence of the "forgotten corner" and "escaped fish" phenomena after assigning the tasks.

This study has some limitations. Due to the impact of COVID-19, some activities could not be well implemented online, resulting in a slightly small sample size for this study. In addition, the current evaluation system is not good enough to achieve a comprehensive evaluation; therefore, a long-term evaluation mechanism should be established for follow-up in the future. Moreover, as the "student-centered" multielement fusion teaching mode benefit the students in the experimental group, we made up for the control students through variety of teaching activities and methods on the next semester.

Conclusion

Medical teaching should focus not only on imparting basic theoretical knowledge to students but also on cultivating and developing students' abilities. In view of pain points in traditional teaching, this study carried out a variety of teaching activities, implemented a variety of teaching methods, and fully practiced the "student-centered" learning concept on the basis of establishing a "safe" classroom climate. This mode not only helps students learn basic medical knowledge but also develops their independent learning, communication, teamwork, problem finding, analysis and solving abilities and helps students establish critical thinking and clinical thinking abilities. We hope that the reform represented by the "student-centered" multielement fusion teaching mode implemented in this study can be popularized and applied in other majors or colleges to benefit more students.