Exploring the use of a digital anatomy learning platform in a second-year medical student cohort

Abstract

Digital anatomy learning platforms hold potential academic benefits, yet there is currently no universally accepted pedagogical framework guiding their utilization. This study applied the lens of Laurillard's conversational framework to explore second-year medical students' experiences with a digital anatomy learning platform at a South African university. An explanatory sequential mixed methods design was employed. Phase 1 used whole population (N = 280) sampling to survey students' usage of, and access to, the digital anatomy learning platform. The survey response rate was 29%, with 47% of respondents reporting usage of the platform. Internet and device limitations were minimal, with 74% and 87% respectively reporting no hindrance. While 39% found Primal Pictures easy to use and helpful to their learning, a disconnect emerged between perceived value and actual usage, with only 5% of participants exhibiting high usage. Phase 2 used purposive sampling (n = 13) based on students' usage of digital anatomy learning platforms. Two focus groups and two individual interviews explored students' use of the learning platform. Qualitative data were both deductively and inductively analyzed. Two themes were identified: types of learning and influencers of learning. Findings from the deductive analysis indicated that students engaged mainly in acquisition-based learning. Inductive analysis showed students encountered various factors that influenced their learning behavior. Affective domain development emerged as a key factor in students' engagement with their anatomy studies and the digital learning platform, suggesting a potential gap in the conversational framework. Digital anatomy learning platforms may strengthen approaches to learning anatomy if implemented systematically, together with pre-training.

INTRODUCTION

Globally, anatomy is considered a foundational medical science that is taught to the majority of health professionals, generally within the early years of their undergraduate studies. Anatomical sciences are fundamental in assisting students in understanding the structure of the typical human body and are widely considered to be the cornerstone of medicine.¹

Although anatomy has been taught for many years, the methods for teaching have remained largely the same, consisting mainly of didactic lectures and dissection practicals in dissection laboratories.¹ However, this teaching strategy has become less feasible, with an increase in student numbers, decline in number of anatomy lecturers and high running costs in maintaining whole-body donor dissection laboratories impacting on these practices.^{2, 3} Moreover, a survey by McBride and Drake⁴ has demonstrated a significant downward trend in the amount of time allotted to anatomy teaching between the years of 1997 and 2017. The use of digital learning platforms is seen as a potential solution to the challenges facing anatomy departments and medical schools on a global scale, not only as a cost-saving measure but also to improve academic outcomes.⁵

Digital anatomy learning platforms have been available for many decades and are growing in use.^{6, 7} These platforms provide an additional learning tool and in some cases an alternative to traditional dissection-based teaching methods. This provides the potential to facilitate anatomy practical training without the excessive time and resource requirements of traditional methods.

Digital learning platforms are generally designed for specific educational purposes. However, it must be noted that fundamentally these platforms focus on making content easily accessible in high-yield format to optimize learning.^{7, 8} In digital anatomy learning platforms, the focus is on providing high-quality anatomical images and/or three-dimensional (3D) models presented with relevant theoretical information.⁷ These platforms are predominantly developed for online use only and require an active stable Internet connection.⁹

Developing countries face many socio-economic inequalities, which may influence the use of digital learning platforms in various ways. South Africa, for example, does not have ubiquitous stable Internet access or constant electricity provision for all communities.¹⁰ This poses significant challenges to the use of digital learning platforms that require constant and stable network connections.^10-12 Additionally, many South African youth encounter computers for the first time at university and thus have not developed appropriate levels of digital literacy.¹² These aspects, in combination with unfamiliar and challenging anatomy content matter, may prove to be a significant challenge to students' learning through digital platforms.

With multiple factors influencing students' learning with the use of digital anatomy learning platforms, it is important to understand how students use these platforms in their learning. While the challenges and opportunities of digital anatomy learning resources have been well described,^{13, 14} there is a paucity of literature on specific pedagogical frameworks that could inform the implementation of digital anatomy learning platforms in curricula and how they impact students' learning processes.¹⁴ However, Laurillard's conversational framework offers a universal approach to understanding complexities of learning from the student's perspective,^15-17 and may prove valuable in this instance. The conversational framework is particularly useful as its initial design was formulated to specifically look at the implementation of learning technologies in curricula.¹⁵ The Technological, Pedagogical, and Content Knowledge (TPACK) model is also commonly used in technology integration.¹⁸ The TPACK model seeks to describe teachers' understandings of technology, their pedagogical knowledge and content knowledge. The TPACK does not offer significant guidelines pertaining to the students' learning in relation to the teachers' understanding of technology use. Therefore, for this study the detailed nature of the conversational framework was selected to more effectively explore students' learning using digital anatomy learning platforms. This will be explained further in the section below.

The conversational framework explores students' learning by evaluating four key communication cycles in which teachers can develop learning opportunities that encourage students' learning in ways that modify the students' concepts and practice. These are the teacher communication cycle, peer communication cycle, teacher practice/modeling cycle and peer modeling cycle.¹⁵

Laurillard's conversational framework is further realized in six types of learning activities, namely acquisition, inquiry, production, discussion, practice and collaboration.¹⁷ The teacher communication cycle demonstrates the iterative generation and modulation of concepts between the teacher and student based on the teacher's desired outcomes. This cycle is characterized by acquisition, inquiry and production. Teacher-initiated concept interaction among peers forms the peer communication cycle and is characterized by discussion. The teacher practice/modeling cycle demonstrates how teacher-designed learning environments generate and modulate student practice; this is characterized by practice. The peer modeling cycle demonstrates how teacher-initiated peer interaction can generate and modulate student practice and is characterized by collaboration. The communication cycles in the conversational framework provide a structure by which student-centered learning can be explored using the six learning types. These can be seen in Table 1.

TABLE 1. Conversational framework: communication cycles, learning types and learning strategies and tools.¹⁵

Communication cycles	Types of learning	Learning strategies and tools
Teacher communication cycle	Acquisition	Learning through acquisition is achieved through reading, watching and listening to learning materials. This can be in the form of documents, videos and audio podcasts. The teacher controls the narrative in this learning type
	Inquiry	Learning through inquiry is a guided learning process, in which students engage with various resources (these include printed and online resources such as websites and/or interactive learning platforms) that relate to concepts being taught. Students are in control of their own learning in this learning type
	Production	Learning through production is achieved by students performing activities that lead to the demonstration of understanding or ability. This can be achieved with the use of assessments and tasks (e.g., essays and reports) hosted on a learning management system. Teachers control the learning narrative in this learning type
Peer communication cycle	Discussion	Learning through discussion is achieved when students engage peers' concepts through reciprocal critique of ideas, in relation to concepts being taught. In the online space, this is achieved using online discussion boards, for example. Teachers direct the learning narrative, but it is ultimately controlled by the students
Teacher practice/modeling cycle	Practice	Learning through practice is done through performing tasks that relate to the required task goals. Learning is supported through feedback and is focused on modifying learner actions in subsequent attempts. Teachers construct the learning environment, but the learning narrative is ultimately controlled by the students
Peer modeling cycle	Collaboration	Learning through collaboration similarly requires students to engage with peer concepts. The fundamental factor in collaboration is students' need to develop a combined understanding and produce a desired product to demonstrate the learning. This can be done using discussion boards, online meetings and shared documents. Teachers direct the learning narrative, but it is ultimately controlled by the students

This study sought to address the gap in the literature by applying Laurillard's conversational framework¹⁵ as a lens to explore second-year medical students' experiences of the use of a digital anatomy learning platform in their anatomy studies at a South African university.

METHODS

Academic context

Stellenbosch University in South Africa offers a 6-year Bachelor of Surgery and Medicine (MBChB) program. Anatomy is taught within the first two years of the program and is focused on providing students with a foundation to understand the structure and function of the human body. This is achieved by using a systems-based approach in which students engage with the anatomy of a system while simultaneously being exposed to the physiology of the same system. This is followed by clinical content relating to the specific system. The combination of these two aspects is referred to as a teaching block.

The teaching strategy for anatomy consists of didactic lectures and team-based learning through whole-body dissection. To facilitate dissection, students are divided into small groups of 6–9 students per dissection table. In this group, students are expected to self-assign roles of dissector (1 student), readers (2 students) and runners (remainder of students) on a session-by-session basis. Students are guided by Gray's Clinical Photographic Dissector of the Human Body, 2nd edition.¹⁹ Throughout these two years of study, students are also given access to the Primal Pictures digital anatomy learning platform and urged to use it as an additional learning resource. This access is extended past the two years of study for revision purposes in years 3 to 6. Primal Pictures is a licensed commercial product that is paid for by the university and provided to students free of charge. This platform is designed to provide a student with 3D visual resources combined with high-yield theoretical information of anatomy.

Students are assessed on their anatomy knowledge by means of multiple-choice question (MCQ) examinations, spot tests and oral examinations. MCQ examinations are conducted at the end of each teaching block, with questions pertaining to the pre-clinical and clinical aspects of the given system. Approximately 15% of the MCQ examination is on anatomy content, with the remainder focused on the physiology and relevant clinical information pertaining to the system. Oral examinations are performed at team-based level with the various dissection groups at the end of each teaching block. Spot tests are performed under examination conditions and consist of up to 50 questions labeled on whole-body donor specimens. When this is not feasible, an image-based spot examination is performed instead.

Study design

This study was framed within the interpretivist paradigm, which focuses on subjective meaning that is constructed by individuals.²⁰ This meaning is informed by the social context, conventions and standards of the individual and the experience.²¹

The study employed an explanatory sequential mixed methods design.²² In phase 1 quantitative data was obtained using a survey to evaluate access to, and usage of, a selected digital anatomy learning platform. In phase 2 qualitative data was obtained by focus group discussions and individual interviews to explore students' use of the platform for learning. This approach enabled the researchers to evaluate overall usage of the platform as well as gain a deeper understanding of how students employ digital anatomy learning platforms in their learning.

This study received ethical approval from the Stellenbosch University Health Research Ethics Committee (S22/03/041). Additionally, institutional and program approval were obtained prior to the commencement of this research. All study participants provided a completed informed consent form prior to participating in this study.

Target population and sampling

The participants of this study were sampled from the 2022 second year MBChB program cohort of students (N = 280) at Stellenbosch University. Sampling for phase 1 was conducted using total population sampling.²³

Participants for phase 2 of this study were purposively selected from those who completed phase 1, based on their self-reported usage of the selected digital anatomy learning platform. Sampling for the second phase was influenced by the prerequisite that students had to provide consent that their personal and identifiable contact information could be used by the researchers to invite them to participate in this phase. This adhered to recommendations made by the Stellenbosch University Human Research Ethics Committee to ensure compliance with the Protection of Personal Information Act (2013). A total of 14 students consented to be contacted for phase 2 of the study. All students had indicated some level of interaction with Primal Pictures and thus were included in phase 2 of the study. Of these 14 respondents, 11 were self-reported low users and 2 were self-reported high users. One participant withdrew from the study. The low users were divided into two focus group discussions.²⁴ The high users were interviewed as there were insufficient numbers²⁴ to constitute a focus group.

Data generation and analysis

Phase 1

A non-validated researcher-generated survey was used to explore participants' self-reported usage of Primal Pictures, as well as characterize their access to and use of online digital learning materials. The survey consisted of multiple-choice questions and Likert scale questions. Full survey can be found in supporting material. Descriptive statistics were used to report on the survey data.

Phase 2

Focus groups and interviews were conducted in a semi-structured manner with the use of the same five probing questions (see Table 2). Questions were developed to holistically explore the ways students learn in accordance with the nature of the conversational framework.¹⁵

TABLE 2. Focus group discussion and interview questions.

Question 1	How do you approach your anatomy studies?
Question 2	Do you have any specific strategies that you use to study anatomy? Please elaborate
Question 3	How would you describe your usage of Primal Pictures?
Question 4	How does the use of Primal Pictures impact the way that you learn?
Question 5	Do you feel there are any factors supporting or hindering you from using Primal Pictures as a learning tool? Please elaborate

All focus groups and interviews were recorded with the permission of the participants, transcribed and thematically analyzed using computer-assisted qualitative data analysis software (CAQDAS), ATLAS.ti 22 Windows (Version 3.15.0-2022-03-09). One focus group was transcribed by the primary researcher and the remaining audio recordings by an independent transcriber.

Deductive and inductive thematic analyses were employed in this study according to Braun and Clarke's six-step process.²⁵

• Step 1: The primary researcher became familiar with the data by reading and re-reading the transcripts multiple times.
• Step 2: Data was organized in a meaningful way by means of coding. This occurred in two phases. Initially, deductive coding was conducted using a priori codes²⁶ that were developed according to the six learning types described in Laurillard's conversational framework¹⁵ (acquisition, inquiry, production, practice, discussion and collaboration). Subsequently, an inductive approach was followed to code data that did not fit within the a priori codes.
• Step 3: The primary researcher then reviewed codes to identify patterns and meaningfully grouped them into categories and themes.²⁶
• Step 4: During this phase, both researchers reviewed and modified the categories and themes that were identified in step 3.
• Step 5: The primary researcher then defined and named each theme according to the meaning of its content.
• Step 6: Finally, the findings of the study are reported in this article.

FINDINGS

The findings of this study provided insight into how medical students use digital learning platforms when studying anatomy. The findings will be presented in the two phases in which the study was conducted.

Phase 1

Twenty-nine percent (81/280) of students in the second-year MBChB cohort agreed to participate in completing a survey. The findings from phase 1 of this study provided insight into students' usage of and access to Primal Pictures, as well as any access limitations experienced while using Primal Pictures.

Usage

Participants were initially asked if they used the platform in their studies. 47% of participants indicated that they did make use of the platform, 42% did not and the remaining 11% had not heard of the program before (Figure 1A).

FIGURE 1

Self-reported usage of Primal Pictures.

Participants were then asked to rate their self-reported usage of the platform. The majority of participants (51%) had low usage and only 5% had high usage. A large proportion (27%) of the participants had no usage of the platform and 17% had average usage (Figure 1B). Some participants that had indicated they did not make use of the platform in the first question indicated that they had low usage in the second question.

Participants were asked to indicate their agreement with the statement ‘I find Primal Pictures helpful to study anatomy’. The majority (48%) of the participants found the platform helpful to study anatomy, and 9% of these strongly agreed. 43% responded as neutral to the helpfulness of the platform to their learning. 9% of participants disagreed with the statement and 3% of these strongly disagreed (Figure 1C).

In summary, of the 47% of participants that use Primal Pictures only 5% report using the platform at a self-reported high level. However, 39% of the cohort indicate that Primal Pictures is helpful to their learning.

Access

In exploring aspects related to access to Primal Pictures, the participants were asked whether they felt that their access to the Internet or a digital device limited their access to using the platform. Most (74%) participants felt that their Internet access did not limit their access to the platform, but 7% indicated that Internet access was a limitation. 19% indicated that Internet access sometimes limited their usage of the platform (Figure 2A). Similarly, the majority (87%) of participants felt that their devices did not limit their access to the platform. 12% indicated that their device sometimes limited their usage of the platform and 1% indicated that their device was a limitation (Figure 2B).

FIGURE 2

Access to Primal Pictures.

Usability was also explored by asking the students if they agreed with the statement ‘I find Primal Pictures easy to use’. Many (39%) of the participants agreed that they found the platform easy to use, with 7% agreeing strongly with the statement. 40% were neutral with regard to the statement and 21% disagreed with the statement, 7% of whom strongly disagreed (Figure 2C).

Overall, it was found that device and Internet limitations were not significant limiting factors to students using Primal Pictures. Ease of use was indicated to be slightly more relevant but not to the same proportion to which students do not use the platform.

The data shows a disconnect between the value students attributed to the use of Primal Pictures and their actual usage thereof. While 39% agreed and 9% agreed strongly that the platform is helpful to their learning, only 5% of students indicated a high usage. This is not accounted for in data pertaining to participant access to Primal Pictures. Therefore phase 2 of this study provided further exploration.

Phase 2

Phase 2 findings elucidated participants' approaches to learning anatomy and how using Primal Pictures impacted their learning. Two themes, namely types of learning and influencers of learning, were identified during qualitative data analysis. The two themes and their related categories and subcategories are summarized in Figure 3.

FIGURE 3

Themes, categories and subcategories of qualitative data analysis.

Theme 1: Types of learning

This theme was constructed using Laurillard's conversational framework and the six types of learning¹⁵ to explore how students' use of Primal Pictures impacted how they learned anatomy. This theme was developed using a deductive coding approach. The theme is organized according to the four communication cycles described by Laurillard¹⁵: the teacher communication cycle, the teacher practice/modeling cycle, the peer communication cycle and the peer modeling cycle.

Category 1: Teacher communication cycle

This category reflects the learning interactions between the student and the teacher at conceptual level, as influenced by the teacher's desired outcomes (Teacher led engagements). This category consists of three types of learning organized into the subcategories of acquisition, inquiry and production.

Subcategory 1.1 Acquisition

All except one of the participants explained that their primary way of learning was to use their lecture materials. Some participants indicated that they may progress to using additional learning materials to ensure their understanding of the content:

For me, studying anatomy, I generally just go from the lectures, and then write it down and then just imagine it 3D. (FGD 1)

How I study anatomy is I do the lecture slides, and then I watch a video, and then go to Primal Pictures maybe when I'm looking for a specific structure. (FGD 1)

Participants' responses revealed that the additional resources they used in their learning were varied and guided by the region of anatomy they were studying. These additional materials included videos, textbooks and Primal Pictures:

I usually use the Moore's textbook to look at the pictures, and also the notes, the PDFs. Sometimes I do use YouTube to like listen to some videos… I did also use Primal Pictures. I think the last time I used them was in the GIT module, ja, for spot tests. (FGD2)

Subcategory 1.2 Inquiry

Student responses indicated that they mostly used textbooks, Internet-based sources and videos when inquiring about content.

Like you know, using the internet and searching for images, because sometimes the notes don't give, like the lecturers don't provide like images that show the certain structures. So it really helps to like Google stuff. (FGD 2)

I also use McMinn's (textbook) and also Google. I Google images of the structures. (FGD 2)

Additionally, some participants explained that the Primal Pictures mouse-over and integrated notes functions specifically assisted them in inquiry-based learning. This was primarily seen when students were engaging with 3D models.

But with Primal Pictures, you slide your mouse across and you can see all of the labels, and there is also the write-ups on the side. Like for Primal Pictures, I download the PDFs. So, there's that setting, and I find that it's easier to learn. (Interview 2)

Subcategory 1.3 Production

Production in this anatomy course is through written assessment and spot tests. Assessments were not generally understood by participants as a part of their learning, but rather were seen to be the event to learn for. Participants expressed how assessment drove the way they engaged with all learning resources, including Primal Pictures.

I think like my focus when I wanted to use Primal Pictures, although it's like you will definitely need to know the 3D anatomy, it was more just focussed for the spot test. (FGD 1)

One participant who reported using Primal Pictures at a high usage level identified production as a means to learn and not just as a means of being assessed.

I was using a little bit more of the textbook, and a lot of the slides, and of course now you have spot tests, so that's also a new way to study. (Interview 2)

The data of this category ‘the teacher communication cycle’ has indicated that students predominantly use resources provided by lecturers with additional resources of various modalities being sought by some participants. Students' active engagement through production appears to be focused on assessments with some formative opportunities outside of the dissection laboratory.

Category 2: Teacher practice/modeling cycle

This category describes the interactions between learners and their environment (teacher constructed learning environments). This can be characterized by the learning activity ‘practicing’.

Subcategory 2.1 Practice

The majority of students, regardless of their use of Primal Pictures, spoke to the efficacy of hands-on practice during dissections to learn anatomy. Dissection was favored above other methods, including Primal Pictures.

I think dissections actually for me are the best. I would much rather be going to the dissection lab, than onto Primal Pictures. (FGD 1)

Participants also highlighted the importance of preparing for dissections to be an effective learning opportunity. Moreover, a focus group of participants with a self-reported low-level usage of Primal Pictures felt that the platform could be used as a means to prepare for whole-body dissection.

If you come prepared to the dissection lab [laughter]. If you actually study the work beforehand, then I think nothing can replace dissections. (FGD 1)

I think it would be great if you can use that [Primal Pictures] before dissections, so that you already have like a 3D idea. (FGD 1)

Some participants felt that whole-body dissection did not always allow them to learn the structure and function of anatomy simultaneously. Consequently, participants consulted multiple resources as they attempted to gain the full understanding required by the outcomes of the module.

Because at the moment, when you do dissections, we're spending time because someone has got the study guide, the list of things [structures] we need, someone has got like the McMinns [textbook] and someone has got the other textbook, then what we were trying to see, okay, this is what it looks like, and this is what the other text says it does. (FGD 1)

One participant with a high self-reported usage of Primal Pictures indicated that they used Primal Pictures while in whole-body dissection as a primary resource to understand the structures of the anatomy.

Like when I'm in the dissection, or when I'm trying to, I would have the laptop open at Primal Pictures, and then I'd look at the body in front of me and try to kind of match it up. (Interview 2)

Overall participants indicated that dissection is an effective method for their learning with some emphasizing the need to be prepared. Additionally, participants identified that traditional resources limit the holistic learning experience and recognize the use of Primal Pictures as a potential tool to address this.

Category 3: Peer communication cycle

This category demonstrates the interactions between the concepts of students and their peers and can be characterized by discussion (teacher-initiated concept interaction).

Subcategory 3.1 Discussion

Discussion was seen among students only as it related to whole-body dissection. Specifically, this referred to how individuals all had to communicate clearly as part of the dissection group, as each one had either a resource which was guiding the dissection or was performing the dissection on the whole-body donor.

Because at the moment, when you do dissections we're spending time because someone has got the study guide, the list of things we need, someone has got like the McMinns [textbook] and someone has got the textbook, then what we were trying to see, okay, this is what it looks like, and this is what the dissector guide says, and this is… (FGD 1)

Category 4: Peer modeling cycle

In this category interactions between the student and their peers that generate and module their practice are explored by collaboration (teacher-initiated peer interaction).

Subcategory 4.1 Collaboration

The only indication of collaboration by participants in this study was when students had to work together in a group to perform the whole-body dissection as stated in subcategory 3.1.

Regardless of their level of usage of Primal Pictures, participants in this study did not favor working collaboratively in their anatomy studies. Participants reported that personal preference and time were the major reasons why they preferred not to work collaboratively outside of whole-body dissection.

No, I haven't, but that's purely because I don't really like studying with other people. I am a lone wolf in that aspect. (Interview 1)

We don't really have study groups, because there's not enough time [laughs]. (FGD 2)

These four categories demonstrate the student's engagement with their teachers, peers and resources to facilitate learning. These are explored in the discussion.

Theme 2: Influencers of learning

This theme elucidates the factors that influenced students' learning behavior. This theme was identified using an inductive coding approach and has been organized into the categories of barriers, enablers, perceived time shortage, anxiety and curriculum awareness. A total of 78 quotations were identified to develop this theme. Please see Table 3 for breakdown of number of quotations per category.

TABLE 3. Number of quotations per category in theme 2.

Theme 2 categories	Count of quotes
Category 1—Barriers	27
Category 2—Enablers	18
Category 3—Perceived time shortage	15
Category 4—Anxiety	17
Category 5—Curriculum awareness	1

Category 1: Barriers

This category provides insight into the perceived barriers to learning and the use of Primal Pictures. Participants with a low self-reported usage of Primal Pictures identified the main barriers to their usage of Primal Pictures as a lack of understanding of how to access and use the platform and technical challenges.

Many students felt that if they had received adequate guidance on how to use the platform, they would most likely have used it as part of their anatomy learning.

I think for me, if we had proper training to use Primal Pictures and know how to use it… (FGD 1)

The perceived lack of guidance, coupled with technical glitches in the use of the platform due to poor Internet connectivity and device limitations, led to students becoming frustrated and this hindered their continued use of Primal Pictures.

I only figured out how to do it on my laptop, and then it was also a little bit like slow-moving, and just timewise, it also just didn't really make sense for me now to try and figure out a whole new platform… (FGD1)

One participant indicated that they also felt that the graphic depiction and specifically the coloring of images on Primal Pictures did not align with whole-body donor dissection or living anatomy and therefore presented a barrier to transferring knowledge to applicable scenarios.

I was like maybe it will help me to identify structures, but also, because it looks – it just – it doesn't do what actual dissections and the pictures of cadavers do, because when you get to that spot test, you're like, It's still colour-coded. The veins are still blue. The arteries are still red, and then nerves are still yellow, and then the cadaver, everything is pink [laughs]. I think it's a good platform to learn from theoretically, but as we apply it to our assessment, I don't think it satisfies kind of our assessment needs. (FGD 1)

Category 2: Enablers

Category 2 highlights the enabling factors that participants indicated helped them in their learning. Key aspects that students identified as benefiting them in their learning were the usage of 3D models and imagery, and teacher-curated learning materials.

All participants, regardless of the usage level of Primal Pictures, indicated that a 3D understanding of anatomy was valuable in their learning.

For me, studying anatomy, I generally just go from the lectures, and then write it down and then just imagine it 3D. Because I think I'm quite lucky, because I can see in 3D. (FGD 2)

Participants across usage levels indicated that they used Primal Pictures to develop a 3D understanding of the anatomy they were learning.

It [Primal Pictures] really does help me to have a 3D image in my brain. I can do it from pictures, but sometimes I just want to see like what's at the back. (FGD 1)

One of the key and repeated enablers was when teachers provided curated information, either in the form of lecture materials or by adding direct links on the learning management system to content on Primal Pictures.

I think if they would put the links [to Primal Pictures] again on each module, like on SUNLearn [learning management system] because that's much easier to use. (FGD 2)

Category 3: Perceived time shortage

This category shows the diverse ways in which a perceived lack of time influenced student learning behavior. Students' perception of time constraints affected their interactions with the classroom materials, peers as well as additional learning resources such as Primal Pictures.

As identified in theme 1, most students used their classroom study materials as their primary or initial point of departure for their learning. Participants with a self-reported low usage of Primal Pictures indicated that they had insufficient time to engage with other learning materials or platforms.

There is no time to use another platform, except your lecture slides…. And time is something we don't have. (FGD1)

This perceived lack of time also limited students' engagement in peer-to-peer learning as evidenced in categories 3 and 4 of theme 1.

Conversely, when a self-reported high-level user of Primal Pictures was asked whether they felt that the use of Primal Pictures sped up or slowed down their learning, they explained that it had sped up their learning by a factor of 2.

No, I definitely think it's [sped] up. I think probably almost by double. Yes, you see, when you're just sitting with slides, it's really, really difficult to learn, I think the way the slides are set up as well. And the textbook, I mean, you're just sitting and like covering and trying to figure things out. But with Primal Pictures, it really is, it's a lot quicker. (Interview 2)

Category 4: Anxiety

This category highlights how anxiety experienced by students influenced their learning behaviors, both in relation to using additional learning resources and engaging with their peers. This theme also identifies sources of anxiety as indicated by participants.

Anxiety and stress for participants appeared to be linked to the assessments that students needed to complete. This anxiety regarding assessment limited participants' engagement with additional learning materials.

It [Primal pictures] just made me frustrated, more frustrated than I was before using that, and I was writing in like two days. (FGD 1)

Additionally, anxiety around time usage was seen to limit how students engaged one another in their learning.

I like explaining to people. Like if somebody came up to me and the asked, can we spend 15 minutes going over a certain topic, I'd be happy. But like I can't spend more time than that. (FGD 1)

Category 5: Curriculum awareness

This category expressed the participants' awareness of the curriculum and how it influenced their learning behavior.

Participants showed little awareness of the greater curriculum structure, with a focus on content recall over understanding as driven by assessment, as can be evidenced in categories 2 and 3 of theme 2.

One participant displayed an understanding of the curriculum and its requirements, noting that this influenced them to seek out additional learning materials and platforms to meet the outcomes of the course.

… how our curriculum is set up right now, a lot of it is not just looking at something and be able to label it, which is how I think a lot of medical students think we should be studying anatomy. We just need to be able to label everything. But a lot of it, the questions even in the tests, in the spot tests or in the theory tests, it's a lot of ‘in relation to’. So everything is in relation to each other. It's not just straightforward. So that's very difficult to learn when you are just looking at a textbook, and you're just looking at a picture, because that's basically just labelling. (Interview 2)

This participant displayed an awareness of their own learning needs in the context of the curriculum. This involved identifying methods that did not suit their learning needs and finding alternative learning methods.

There wasn't much interaction. It was all podcasts, so no live lectures or anything. So we literally just studied straight from the PowerPoint. That's what I did in first year. It wasn't very effective for me.

At the beginning of second year, again, I was using a little bit more of the textbook, and a lot of the slides, and of course now you have spot tests, so that's also a new way to study. I think only this year around June maybe, ya, it'd say May/June, I started using Primal Pictures, and that helped a lot. Right now, I use slides, I use the textbook, but mostly Primal Pictures. (Interview 2)

DISCUSSION

Anatomy education is the cornerstone of modern medical training and forms a large component of the foundational sciences taught to medical students. This study applied Laurillard's conversational framework¹⁵ to explore how second-year medical students use a digital anatomy learning platform in their learning process. This framework was chosen because there is currently, to our knowledge, no existing pedagogical framework to guide the implementation of digital anatomy learning resources.¹⁴ Laurillard's conversational framework¹⁵ is used in this discussion to consider how the digital learning platform, Primal Pictures, is used by second-year medical students studying anatomy.

Quantitative findings from this study are that although students see the value in using Primal Pictures, the majority did not report high usage of the platform. The initial consideration was that this was as a result of access or usage challenges due to device or Internet access limitations. This is typical for developing countries and has been identified in a previous study.¹² In this study, survey results indicated that there were no significant Internet or device limitations when accessing and using the platform. However, when this was explored further in focus group discussions, technical difficulties related to Internet and device limitations were expressed. Therefore, although participants indicated that they had adequate access and means to use the digital anatomy learning platform, the quality of this access still impacted their use of the platform, potentially leading to decreased usage or hampered educational impact.

Theme 1

Laurillard's conversational framework aims to explore the roles of teachers, students and peers in the learning process and has been proven to be effective in analyzing the implementation of learning technologies.^{15, 16} This study shows the value of this universal framework in understanding how students engage with Primal Pictures in their anatomy education, specifically, being able to evaluate students' behavior according to the six types of learning highlighted by Laurillard.¹⁵

The primary type of learning that was identified was through acquisition by means of lectures, lecture materials and textbooks as guided by teachers. Acquisition is considered a passive way of learning. Acquisition leads students to engage with teacher concepts presented through materials. However, this does not require the student to interrogate, critique or compare information, nor apply it to their own concepts in a meaningful way.¹⁷ El Sadik and Al Abdulmonem²⁷ describe how a blended learning approach using digital anatomy platforms can promote active learning. The authors believe that a structured integration of a digital anatomy learning platform could promote active learning among students.

Typically, participants would require multiple sources in the acquisition of their knowledge. This finding is supported by Abdullah et al.,¹³ who found that medical students used six resources (whole-body donor dissection, dissection videos, plastinated specimens, plastic models, printed resources and electronic resources) in their anatomy studies. In the current study, fewer resources (text resources, online videos and Primal Pictures) were used by participants. This was often attributed to anxiety around perceived time shortages or what was deemed appropriate for the upcoming assessment. This reluctance to use additional resources may limit the depth of students' learning.

Primal Pictures was not clearly identified as a primary learning resource; rather it was seen as a visual resource aiding in developing a 3D understanding of the specific area of anatomy. Berney et al.⁶ show evidence that the use of 3D models in learning leads to improved spatial relational and spatial visualization abilities, which have been shown to be advantageous and lead to higher academic achievements in anatomy assessments.⁶ Although academic achievement was not considered in this study, it is fair to say that the impact Primal Pictures had on students' spatial relational and spatial visualization skills could lead to improved academic outcomes.

When exploring participants' learning through inquiry, it was found that students were most likely to use Internet-based resources to find information in the form of images and/or videos. However, the majority of students seemed to be content to simply use the learning material provided. Anstey²⁸ found that inquiry-based learning activities allowed students to explore, critique and compare various sources of information and develop their understanding of the anatomical structures. Additionally, this may lead to the development of affective skills in reasoning and evaluative judgment.²⁸ In this study, it was clear that the majority of students had not consciously and actively engaged with the affective learning domain. Participants who demonstrated a greater metacognitive awareness appeared to be more in command of their learning. The affective domain plays a crucial role in the development of self-directed learning and clinical reasoning skills. Therefore, this finding highlights the need to develop strategies that engage all domains of learning. Additionally, this points to a potential limitation in the conversational framework, as this finding was not identified through the a priori coding that focused on the six types of learning, but rather was identified through further iterative engagement with the data.

Participant production was limited to assessment in the anatomy module, but was seen to drive the majority of learning actions taken by the participants. ‘Assessment drives learning or learning behaviour’ is a commonly understood educational concept and holds true in anatomy education as well.²⁹ This concept is specifically important when students consider the relatively small component anatomy represents in the theory examination. Moreover, the spot test drives learning for identification rather than understanding. This could be a contributing factor to the perceived lack of time expressed by participants, who reported that they felt they could only dedicate a small amount of time to their anatomy studies, and this could potentially be driving self-limiting learning behaviors.

Participants also indicated a limited level of practice in their learning, which was confined to the whole-body donor dissections. Participant responses clearly indicated a preference for dissection and an awareness that preparing for these activities led to improved outcomes. This demonstrates a level of intrinsic feedback derived from participating in the learning activity, which was also identified by Laurillard.¹⁵ However, what is not clearly demonstrated in the conversational framework is how the participants develop the evaluative judgment to understand that preparation beforehand could lead to improved outcomes. This elucidates a need to review how evaluative judgment development is incorporated into the conversational framework.

Whole-body donor dissection is consistently reported by students as one of the most effective ways to learn anatomy.¹³ However, in an editorial, Lachman and Pawlina³⁰ point out that there is no empirical evidence to prove that whole-body donor dissection leads to better academic outcomes in early undergraduate training; rather, continuous and effective engagement with the subject matter leads to better academic outcomes. Considering the above statement, this study identified that participants use a combination of Primal Pictures and whole-body donor dissection to extend exposure to the subject matter which potentially leads to beneficial academic outcomes.

Collaboration and discussion among students appeared to be limited to the dissection practicals in which students are required to work together to dissect and consult multiple resources to understand the content. The minor expression of these two types of learning could significantly limit how students develop, challenge and defend their understanding among their peers. Laurillard¹⁷ shows that learning technologies can be used to extend discussions into the online space, creating rich learning interactions where students incorporate activities of inquiry while engaging with peer concepts and developing and refining their own understanding. It was interesting to note that participants in this study did not display this collaborative behavior. Instead, they indicated that collaboration was limited by their perceived time constraints as well as their personal preferences for non-collaborative learning. A richer leaning experience may be developed by the teacher if a stronger emphasis is placed on collaborative types of learning. Moreover, collaboration would require students to actively articulate their own understanding modulated by peer concepts to collaboratively produce a task.¹⁵

Theme 2

Students' experiences indicated that they encountered barriers to the use of digital anatomy platforms in their learning. Chief among these were technical difficulties experienced by participants. These difficulties may not be inherent to the learning platform but rather caused by Internet limitations and device limitations, as students reported the platform as being slow and/or glitchy. These issues influenced students' use of digital platforms negatively and need to be mitigated for successful implementation of digital anatomy learning platforms into the curriculum.

Additionally, students found that their usage of Primal Pictures for learning was limited by their understanding of the platform. Salmon et al.³¹ support these views that students need to have easy access and support when digital applications are first introduced. A structured and supportive approach to students needs to be taken when implementing digital learning tools. This is especially true in the context of developing countries,¹⁰ as was clearly demonstrated in this study.

Furthermore, a number of positive influences were identified, with chief among them being the active curation of learning materials by lecturers. This was evident in the students focusing on the classroom learning materials provided as their main source of learning. Participants also indicated that they found Primal Pictures most usable and helpful when lecturers gave them direct links to specific content. However, the passive nature of this type of learning and the potential effects on student performance need to be considered.²⁷ An active approach to learning in blended learning is deemed more favorable and can lead to better outcomes. Therefore, although students may find curated content beneficial, activities must be included in which students engage with their learning content in an active way.

In this study, a small proportion of participants showed an increased awareness of the curriculum and their interaction with it. This potentially speaks to the metacognitive abilities of students and the awareness of what and how they are studying and the implications of this. While the majority of students were concerned with studying to pass the examinations (as seen in subcategory 1.3), it was found that the students with a higher-level usage of Primal Pictures also considered the anatomical content they were learning and their approach to learning the content. They took these factors into consideration and applied a systematic approach to their anatomy studies. This is consistent with literature¹⁴ indicating that participants using digital learning platforms focus on concept integration and understanding anatomy for application rather than for recall only. A greater awareness of the curriculum design and expected outcomes may assist students in prioritizing authentic learning behaviors.²⁸ This study supports the need to develop students' awareness of the curriculum outcomes in relation to their own learning needs in their professional development as a clinician.

Limitations and recommendations for further research

This study had several limitations. The qualitative nature and context of this study limit the generalizability of these findings. Additionally, this study was conducted with students who had one year of study through emergency remote teaching due to the COVID-19 pandemic and one year of study on campus. It is not clear from the literature how students were affected by this transition, and how it impacted on student learning, specifically in developing countries.

A key factor that still needs to be explored is the perceptions of lecturers in using digital anatomy learning platforms, as this could be a key enabler of or barrier to the successful implementation of these tools. There are also certain areas of this study that could be explored further, such as the affective development and metacognitive skills of students who use digital anatomy learning platforms. This may elucidate the need to include affective components into the conversational framework, as this study clearly indicates that the ways of learning are affected by students' affective development. Characterizing the affective domain in relation to the conversational framework may strengthen the application of this framework in various learning contexts.

CONCLUSION

This study explored the experiences of students using a selected digital anatomy learning platform in their anatomy studies. Findings from this study demonstrate the complex nature of the learning process and emphasize the need for a pedagogical framework to better understand how students learn when using a digital anatomy platform. Laurillard's conversational framework¹⁵ provides a suitable and holistic approach to understanding how students use digital anatomy learning platforms.

Through the use of the conversational framework, it was clearly demonstrated that students use digital anatomy learning tools as a means to acquire visual information, inquire about theoretical information and practice in the form of whole-body donor dissections. The conversational framework also assisted in identifying where digital anatomy learning platforms were not being used effectively, specifically in the peer practice cycle and peer communication cycle in the form of discussion and collaboration.

Although the conversational framework provided a way to understand student learning in this study, an additional theme of influencers was required to understand the factors that may alter students' learning behaviors. Some of the key influencers of learning that were identified related to students' perceptions of their anatomy studies in general. However, it was found that with greater awareness of the curriculum and of their personal learning needs, students engaged with anatomy content and digital learning platforms more effectively.

This study demonstrates that digital anatomy learning platforms offer several opportunities to students while studying anatomy. However, these platforms need to be considered in the light of the context in which they are implemented and what support measures may be required. Participants in this study clearly indicated that additional student training is needed to use the digital platform effectively. Additionally, it was shown that engagement with a digital anatomy learning platform is best suited when it is incorporated with their classroom material. Therefore, it is recommended that structured student and teacher training be offered to support the use of digital anatomy learning platforms.

Digital anatomy platforms show the potential to offer a system that provides effective high-yield information valuable to students' development as medical professionals. However, this is only truly grasped when students see the importance of understanding anatomy in light of their professional development as clinicians.

ACKNOWLEDGMENTS

The authors of this study would like to express their appreciation to the participants of this study for their valuable contributions.

FUNDING INFORMATION

Research was funded by author.

CONFLICT OF INTEREST STATEMENT

Both authors of this manuscript declare that they have no potential competing financial interests.

ETHICS STATEMENT

All human subjects in this study participated only after written consent was obtained. Ethics approval was received from the Stellenbosch University Human research Ethics Committee before research was commenced. Consent form can be found in supporting information.

Biographies

• Jaudon Ron Foiret, MSc Anatomy, is a blended learning advisor in the Centre for Health Professions Education at Stellenbosch University, South Africa. His current focus is on implementing blended learning curricula into undergraduate health professions programs including Medicine, Physiotherapy, Nursing and Occupational Therapy.

• Mariette Volschenk, PhD, is a senior lecturer in the Centre for Health Professions Education at Stellenbosch University, South Africa. She is the program leader of the MPhil in Health Professions Education Programme and manager of Learning Technologies. Her research interests include professional identity construction, postgraduate supervision and digital education.

Open Research

DATA AVAILABILITY STATEMENT

All data can be delivered upon request.