DESCRIPTIVE ARTICLE

Body Painting as a Tool in Clinical Anatomy Teaching

Paul G. McMenamin* School of Anatomy and Human Biology, Faculty of Medicine, Dentistry and Health Sciences, The University of Western Australia, Crawley (Perth), Western Australia, Australia

The teaching of human anatomy has had to respond to signicant changes in medical curricula, and it behooves anatomists to devise alternative strategies to effectively facilitate learning of the discipline by medical students in an integrated, applied, relevant, and contextual framework. In many medical schools, the lack of cadaver dissection as the primary method of learning is driving changes to more varied and novel learning and teaching methodologies. The present article describes the introduction and evaluation of a range of body painting exercises in a medical curriculum. Body painting was introduced into integrated clinical skills teaching sessions which included clinically important aspects of respiratory system, musculoskeletal system, and topics in regional anatomy including head and neck. Nontoxic body paints, easels, a mixture of brush sizes, and anatomical images were supplied. Students were allowed between 20 and 40 min to complete body painting tasks, in which they were encouraged to alternate between painting and acting as a model. Students were encouraged to use life-like rendering and coloration where appropriate. Evaluation of these sessions was performed at the end of the semester as part of a larger evaluation process. The kinesthetic nature and active participation together with the powerful visual images of underlying anatomy appear to contribute to the value of body painting as a teaching exercise. In addition, it may have the added bonus of helping break down apprehension regarding peerpeer examination. Some practical advice on introducing this method of teaching in medical curricula based on the outcomes of the evaluation is given. On the basis of our experience and student feedback, we strongly advocate the use of body painting as an adjunct to surface anatomy and clinical skills teaching classes. Anat Sci Ed 1:139144, 2008. 2008 American Association of
Anatomists.

Key words: anatomy; body painting; musculoskeletal; live models; evaluation

INTRODUCTION
Dissection of human cadavers, essentially a regional-based approach to learning topographical anatomy, is no longer used as the principle method of delivery in a signicant number of UK, US, and Australian medical schools (Drake, 2002; Drake et al., 2002; Heylings, 2002; Hanna and Tang, 2005; Turney, 2007). Turney (2007) recently pointed out that one
*Correspondence to: Prof. Paul McMenamin, School of Anatomy and Human Biology, The University of Western Australia, Crawley (Perth) 6009, Western Australia, Australia. E-mail: mcmenamin@anhb.uwa. edu.au Received 25 February 2008; Revised 22 May 2008; Accepted 22 May 2008. Published online 14 July 2008 in Wiley InterScience (www.interscience. wiley.com). DOI 10.1002/ase.32 2008 American Association of Anatomists

of the fundamental reasons why anatomy may be in decline is that teachers of the profession have failed to evolve and adapt quickly enough, a point raised many years earlier by Allbrook (1958). Continued pleas, predominantly from surgeons, for a return to more traditional courses or get back to basics (Hanna and Tang, 2005) are unlikely to result in educational reform (Turney, 2007). Indeed, Turney (2007) recently stated that anatomy is often regarded as banausic, archaic, didactic, traditional, overly factual. However, there have been a number of developments including high-quality multimedia programs, such as An@tomedia (2002), and other learning aids such as The VH Dissector (2005), which allow students to explore anatomical features by digitally either removing layers or by electronically selecting cross-sectional levels have expanded the tools available to anatomy teachers to aid student learning. Novel uses of these technologies, including projection of anatomical images onto live models (McLachlan and de Bere, 2004), further extend the value of other teaching methods in the classroom.
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Surface or living anatomy, which is integral to an understanding of clinical anatomy, is likely taught in various forms in many medical anatomy programs (Aggarwal et al., 2006; see review, McLachlan and Patten, 2006); however, the extent of its use is difcult to ascertain, and indeed, it has been omitted in recent surveys of teaching methodologies (Drake et al., 2002; Heylings, 2002). Surface anatomy often involves students delineating anatomical landmarks and features on a volunteer or model using marker pens or wax crayons or cosmetic pencils. This approach results in a series of complex intersecting lines that quickly become difcult to interpret and for students to remember. Recently, body painting was described by Op den Akker et al. (2002) as a novel method of improving the effectiveness of learning surface anatomy in medical teaching, which complimented the teaching of palpation and auscultation. However, the concept of painting musculature on a live model as means of illustrating the dynamic nature of anatomy had been described some time earlier by Cody (1995), although its use as a teaching tool was not explored. In the present study, the author describes how the body painting method described by (Op den Akker et al., 2002) have been extended and introduced into new teaching sessions that combine medical anatomy and integrated clinical skills at The University of Western Australia. The purpose of this report is rst to illustrate, with some examples, the results of these sessions and second to present some early evaluation data.

Table 1.
Anatomical Features and Concepts Reinforced by Body Painting in Teaching Sessions Upper limb Muscles acting on the shoulder joint Muscles of the arm Muscles of the forearm Muscles of the hand Cubital fossa Carpal tunnel Course of nerves of the upper limb and hand and their cutaneous distribution Vessels of the hand Dermatomes Bones and joints of the hand Head and neck Dermatomes (trigeminal) Distribution of the facial nerve and relation to parotid gland and duct

METHODS
Structure of Body Painting Sessions in the Medical Curriculum
At the University of Western Australia, a systems-based medical curriculum is taught in years one and two of the six-year undergraduate medical curriculum. In the second semester, year two, the musculoskeletal system, peripheral nervous system, and central nervous system are studied after all the other body systems have been completed. Anatomy is taught during this semester via a mixture of lectures, tutorials, and practical classes. Practical classes consist of a series of learning activities including surface anatomy, radiology, osteology, histology, and topographical anatomy, through which students rotate approximately every 20 min. In some classes, body painting was a learning activity. More recently body painting has been introduced into integrated clinical skills teaching sessions. To date, these sessions have included respiratory system, musculoskeletal system (including hand painting, foot painting), and topics in regional anatomy including head and neck. Participation was encouraged but not compulsory.

Muscles of the face Arteries and veins of the face and neck Anterior and posterior triangles of the neck Thorax Position of the heart and valves Position of the lungs and pleura Skeletal and muscular anatomy Lower limb Femoral triangle Popliteal fossa

Practical Organization
Students were allowed 3040 min to complete body painting tasks. Nontoxic body paints, easels, a mixture of brush sizes, and anatomical images were supplied. Students were asked to select, from a series of anatomical diagrams, a concept or structure of their choice and then paint this on their colleague. Mixtures of anatomical concepts were tackled by students. Students were encouraged to alternate between painting and acting as a model. In some integrated clinical skills sessions no diagrams were provided, and students were requested to use knowledge from previous anatomy sessions to paint key clinically important anatomical features. When anatomical features were being painted, as opposed to con140

cepts (e.g., dermatomes), students were encouraged to use life-like rendering and coloration. In these sessions, students are given the choice of working in single or mixed gender groups. In 2007, Integrated Clinical Skills Teaching Rooms were completed, and these had a curtained area that female students could work behind if they felt it necessary. All cultural groups were encouraged, but not forced, to participate. The author did not treat gender and culture as a signicant issue, and it never appeared to be an issue on the part of the students. The authors advice would be not to over emphasize this issue in the mind of the students.

Description of Anatomical Concepts, Topographical Anatomy, and Surface Projections that Can Be Taught with the Aid of Body Painting
The range of anatomical concepts where body painting was used as a teaching adjunct is included in Table 1. In addition,
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Figure 1.
Body painting on a model to illustrate the shape, size, lobular arrangement of the lungs, and their relation to the pleural recesses.

Figure 2.
Students using body painting to reinforce clinically relevant anatomy, in this case, the boundaries and contents of the cubital fossa.

Figure 3.
The use of body painting (performed by students) in classes dealing with the anatomy of the hand and face.

Figure 1.

Figure 2.

Figure 3.
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Table 2.
Evaluation of Body Painting Sessions by Medical Students (The 2005 Cohort) Question % Strongly disagree 3 3 3 3 % Disagree 3 13 8 12 % Neither 22 24 29 35 % Agree 51 46 42 38 % Strongly agree 22 13 18 10

I found the hand painting session enjoyable I found the hand painting to be a useful learning tool I found the face painting session enjoyable I found the face painting to be a useful learning tool

getting students to accurately paint on one another the specic size, positions, and relations of major nerves, vessels, bones, muscles, and tendons reinforces learning about these anatomical features, but also allows them to correlate this with surface anatomy and practice palpation.

Evaluation Process
A short questionnaire on this and other aspects of their learning process was circulated at the end of the teaching semester. The responses were on a ve-point Likert scale. All the students featured in the illustrations have given permission for their images to be published. In some classes, formally consented paid models were used as subjects and were generally prepainted prior to commencement of the class. The professional models signed a Model Release Form.

specially designed Integrated Clinical Skills Teaching Rooms, which provide a more professional clinical teaching environment. For example, a curtained area for the use of female students is available if they wish more privacy in these teaching sessions. This occurs only occasionally. In general, males and females intermingle readily during the learning sessions and are generally very enthusiastic about these teaching sessions. The involvement of clinical skills teachers, predominantly general practitioners, in these programs and the teaching of the material in a clinical context alongside anatomy teachers is considered critical to the success of the program.

Qualitative and Quantitative Evaluation

In 2004, the practical anatomy session on the hand was the sole session in which body paint was introduced to students. Whilst no formal evaluation was performed, the encouraging results and positive verbal feedback from the students prompted the author to introduce this method more formally in 2005.

RESULTS
Body painting is a very powerful means of illustrating the surface projections of viscera (Fig. 1), which has been traditionally taught using pens or crayons. Prepainted models or peerpainted students can then be used to reinforce clinical skills such as auscultation and taking of pulses and measurement of blood pressure. Body painting can also be used to teach clinically important topics in topographical or regional anatomy (see Table 1), such as the cubital fossa (Fig. 2) and innervation of the hand and face (Fig. 3), femoral triangle, posterior triangle of neck, etc. In the three years since the introduction of this method of teaching into the medical curriculum at the University of Western Australia, there has been a diminution in apprehension about upper torso painting and peerpeer interactions that are critical to the success of these sessions. This change has probably been aided by the completion of

The 2005 Cohort

The 2005 cohort of second-year medical students participated in hand and face painting during anatomy practical classes, and these sessions were evaluated. Of the 176 medical students, 97 returned completed questionnaires. The results of the evaluation of hand painting and face painting are shown in Table 2. As can be seen, 73% agreed or strongly agreed that the hand painting was enjoyable and 60% found the face painting enjoyable. Only 6% or 11%, respectively, disagreed or strongly disagreed with the statement on enjoyment. A sizeable proportion was equivocal about the experience. Qualita-

Table 3.
Evaluation of Body Painting Sessions by Medical Students (Upper Limb, Face, Torso Painting) (The 2007 Cohort) Question % Strongly disagree 5 3 % Disagree 11 11 % Neither 19 23 % Agree 50 53 % Strongly agree 15 11

I found the body painting in the integrated clinical skills sessions enjoyable I found body painting to be a useful learning tool

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tive observations during the class and the free comments in the evaluation forms suggested that the fun and enjoyment of the exercise was a strong factor in the success of these classes. Around 5060% agreed that the sessions were a useful learning tool. Around 2435% seemed undecided on this question, and face painting was thought to be less useful than hand painting. One possible explanation for the large number of undecided is that the questionnaire may have been delivered too soon after the classes for sufcient reection to have occurred.

The 2007 Cohort

The 2007 cohort, besides participating in hand and face painting, also used body painting to reinforce other topics (e.g. cubital fossa, lower limb, torso) during integrated clinical skills sessions that took place in the new facilities. Of the 146 in the class, 120 responded. Around 65% found the sessions both enjoyable and a valuable learning tool (Table 3), which is slightly higher than the 2005 cohort who had less extensive use of the method of teaching and who did not use the method in potentially sensitive body areas such as femoral triangle and upper torso. The proportion that disagreed or were undecided in this cohort was slightly less (35%) than the 2005 cohort. ~

Use of Professional Artists and Models

Prepainted models can be used not only to demonstrate a variety of anatomical features (Fig. 1) but, for example when illustrating muscles, the teacher can by instructing the model to perform particular movements and actions create the illusion of muscle shortening and lengthening.

DISCUSSION
A reduction in didactic teaching, factual overload, and assessment coupled with increased horizontal and vertical integration of the scientic basis of clinical medicine and preparation for lifelong learning are just some of the curricular changes having an impact on traditional discipline-based teaching such as anatomy (Turney, 2007). Inclusion of topics in medical curricula that are unquestionably important in health care delivery such as clinical skills, procedural skills, population health, chronic disease management, indigenous studies, and personal and professional development (IIME, 2002) together with the growing knowledge in the elds of molecular biology, immunology, and genetics highlight the difculties of maintaining dedicated teaching time for many of the traditional subjects including anatomy, physiology, and pathology. Several medical schools have sought alternative methods of teaching topographical anatomy besides conventional cadaver dissection. The present, largely descriptive, article aimed to illustrate the value of body painting as a teaching tool in anatomy. Examples have been chosen to convey the value of this learning aid in transmitting important anatomical concepts to medical undergraduates as a supplement to existing structured prosection-based anatomy sessions or combined anatomyclinical skills sessions. The positive evaluation, both qualitative and quantitative, by the students of body painting as a teaching aid, can likely be attributed to a combination of use of visual and kinesthetic senses and active student participation. This contrasts with teaching practices that rely on rote memorization or passive learning. Structured
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learning activities that involve reasoning are known to positively effect assessment outcomes (Miller et al., 2002; Vason, 2003; Van Sint Jan et al., 2003; McMenamin, 2005). Slight differences in student evaluations between the two cohorts of students (2005 and 2007) may be due to the use of new specially designed Integrated Clinical Skills Teaching Rooms that became available for teaching to the 2007 cohort. It may also be due to a greater level of acceptance as the 2007 cohort of second-year medical students had been introduced to prepainted models as part of their rst year clinical skills classes when studying the cardiovascular and respiratory systems. Whilst previously the author had used traditional marker pens and wax crayons for teaching surface anatomy on volunteers or models, the introduction of student participation in body painting not only provides a more memorable visual image than traditional methods but also has been popular as it a practical, participatory, and active learning experience. (Op den Akker et al., 2002), who rst described a method of painting detailed realistic images of abdominal and thoracic viscera on the skin of the models or peers, emphasized that body painting, in addition to allowing students to gain an insight into spatial relations or surface projections of the internal viscera, also assisted students to overcome natural reticence about professional physical contact in the early years of their curriculum. Whilst not formally evaluated in the present study, the author noted a general willingness of most students to participate in these sessions; however, further studies would be required to support this qualitative impression and further examine issues of gender, age, and race inuences on peerpeer body painting. The present study extended the use of body painting in medical teaching beyond that described by Op den Akker et al. (2002) to include nonvisceral body systems (such as vascular and musculoskeletal systems) as well as important anatomical concepts, such as dermatomes. The use of body painting to assist student learning of clinically relevant anatomy has proved to be a positive educational experience for medical students. Its usefulness as an adjunct to other methods of learning human topographical and clinically relevant anatomy is not restricted to medical students and could easily be translated to the teaching of anatomical sciences to other allied health professionals and science students. Following the introduction of body painting in medical teaching, it has proven to be a very powerful visual method of teaching anatomy to life drawing artists interested in human form and has also proven useful in illustrating human anatomy to members of the public at faculty or university open days.

ACKNOWLEDGMENTS
The author thanks Ms. Joanna Robertson, Director of Kidogo Arthouse, Fremantle, Western Australia, for her valuable contribution during the teaching of life drawing artists. The author also thanks Prof. John McLachlan for valuable discussions in the early phases of the trials of body painting. Finally, the author acknowledges the willingness of all the medical students at The University of Western Australia to participate in the classes. The author also thanks the paid models for their enthusiastic participation.

NOTES ON CONTRIBUTOR
PAUL G. McMENAMIN, B.Sc., Ph.D., M.Sc. (Med. Sci.) is a professor of anatomy and an Associate Dean for Teaching
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and Learning (2004-2007) in the School of Anatomy and Human Biology, Faculty of Medicine, Dentistry and Health Sciences of the University of Western Australia, Crawley (Perth), Western Australia, Australia.

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