Aims: To evaluate the beliefs, feelings and knowledge of undergraduate medical students towards dissection in this part of the world as an exercise in joining other researchers to solve the attendant challenges.

Methods: An anonymous self-administered 17-item structured questionnaire was generated from available indexed journals admitted to preclinical medical students using a 5-point Likert scale options. Collated data were entered into Statistical Package for Social Scientists (SPSS version 21) software for analysis with utilization of simple means, frequency and Kendall's Coefficient of Concordance. Statistical significance was taken as p < 0.05. Results: Out of 135 students qualified to partake in this study, only 114 returned the completed questionnaire representing a response rate of 84.4%. Kendall's Coefficient of Concordance revealed no significant values by comparing items 1, 2, 3, 4, and 15; items 5, 6 and 7 but significant in items 8 and 13; items 9 and 10; and items 11 and 14.

Conclusion: This study affirmed emotional distress as constant issue towards human cadaveric dissection and kind-heartedness to cadavers as psycho-social appraisal to the livings. Dissection was preferred to prosection in acquisition of skill and knowledge. Human dissection was applauded against plastic models and computer gadgets. Issues on integration of underground music were positive towards treatment of emotional stress in dissection. Majority of students endorsed future specialization in anatomy.

Keywords: Cadaver, Career, Emotion, Underground music

Historically, Anatomy is the oldest of all medical sciences beginning from the use of sacrificial victims to the modern-day use of computer and sophisticated tools. Initiation of the study of human anatomy was credited to the ancient Egypt at about 1600 BCE at the instance of Edwin Smith Surgical Papyrus [1]. The acknowledgement of Anatomy as a discipline came into limelight with the Greek advancement at about the 5th decades BCE according to literature [2]. Equally at 480 BCE Aristotle and some other Greeks popularized comparative Anatomy by dissection. About 300 to 200 BCE, Alexandria's first educational institution of Anatomy was established in which dissections were performed on legally executed criminals [3]. As sequence of advances in Anatomy proceeded from ancient time, Galen, in second century AD compiled chronicle of Anatomy and made further enquiry by dissection of animals [2],[3]. Mondino de Luzzi contributed his own quota as the first anatomist who performed the first dissection on humans in Western Europe [4]. Leonardo da Vinci coupled his own human dissection with artistic drawing [5], [6]. Andreas Vesalius was said to have contributed most innovation to Anatomy by human dissection within and outside his territory rectifying the contraventions in the works of earlier anatomists including Galen [7], [8]. Vesalius's high skill in dissection and drawing earned him the professorial title in surgery and Anatomy. Grave-robbing otherwise described as body snatching and the so-called anatomic murder were vices practiced in order to increase human body for dissection as man continued inquiry to Anatomy in the 17th and 18th centuries AD [9].

The act of dissection (from Latin dissecare 'to cut to pieces'; also called anatomization) continued to survive all odds and proceeded from theatrical domain to classroom in an attempt to balance the equation between the number of multitude who could benefit from cadaver dissection and individuals who might not [3],[10]. By 19th century BCE, as histology, embryology and other branches of Anatomy were coming up, specimens were being produced for medical museums to advance comparative Anatomy [11]. Hitherto, embalmers were used as formaldehyde, alcohol, saline, phenol, glycerin and others. Nevertheless, it is fundamental to take account of the works of Gunther von Hagens on plastination which had revolutionized tissue preservation and embalmment, thereby, making dissection easier and prosection abundant across the globe [12], [13]. Scientific and technological advancement in this computer age have channeled so many substitutes in terms of plastic and computer models, MRI, CAT and PET scans to support anatomic sciences. The polemicists may be in support of substitutes but what about the practical palpation in autopsy/vivisection of the real specimen for further exploration of 'the body structure as an extension of the soul'?

Getting in contact to cadaver (which is seen as the first teacher and the first patient in medical institution) is an integral part of studying gross Anatomy which is posing variance of psychological challenges. Unpleasantness of formaldehyde, fear of cadaveric specimen, unwillingness to touch cadaver among others are the commonest emotional stressful experience by the students [14], [15], [16].

Albeit there is really no perfect alternative to human cadaver, the limitation in supplying human cadaver coupled with the difficulty in getting enough is making some institutions to use the synthetic cadavers as an alternative. In Nigeria, body donation is virtually not practiced due to numerous socio-cultural heritages and religious beliefs. Besides, only a very few medical schools have artificial cadavers for simulation and dissection purposes. In the US medical institutions, a survey in 2013 revealed the continued use of real human cadavers as against total dependency on synthetic and digital models [17].

Music, usually instrumental in composition, brings about common ideas for sincerity, intimacy and freedom of creative expression as against noise which is an unwanted sound [18]. Nevertheless, at the University of Michigan Medical School, playing music in Anatomy laboratories is outlawed while the use of headphones is accepted without any substantive reasons given for the same [19].

In view of the various declarations on dissection across the globe, this study was designed to abridge any communication gaps among different researchers by evaluating the beliefs, feelings and knowledge of undergraduate medical students towards Anatomy dissection in this part of the world. The specific objectives are: include clarification of emotional disturbances in human cadaveric dissection; evaluation of feelings towards cadaveric specimen; evaluating matters arising on dissection and prosection; investigating issues on human dissection and plastic models; ratification of decision on underground music in dissection laboratory and evaluation of career-development in anatomic sciences.

The study was conducted in the Department of Anatomy of Ekiti State University (EKSU), Ado-Ekiti, Nigeria. A self-administered 17-item structured questionnaire generated from available indexed journals admitted to preclinical medical students preparing for the first MBBS examination based on their experience so far in training [20]. The options were graded on a 5-point Likert scale: 5 = strongly agree, 4 = agree, 3 = neutral, 2 = disagree and 1 = strongly disagree. Questions were made simple for maximal compliance. Besides, the anonymous questions were structured in a chronological manner to address the specific objectives. An approval was obtained from the institution's ethics and clearance committee after conduction of a pilot study involving 10 preclinical medical students. The students were encouraged to participate voluntarily without any incentive and completed the filling of the questionnaire forms within one week. Collated data were entered into Statistical Package for Social Scientists (SPSS version 21) software for analysis with utilization of simple means, frequency and Kendall's Coefficient of Concordance (KCC). Statistical significance was taken as p < 0.05. Results were represented in words and tables using Microsoft office software.

Out of 135 students qualified to partake in this study, only 114 returned the completed questionnaire representing a response rate of 84.4% (Table 1).

Kendall's Coefficient of Concordance (KCC) revealed a p-value of 0.118; hence, the null hypothesis was accepted. Therefore, there were no significant differences among the items in 1, 2, 3, 4 and 15 at 95% Confidence Interval (CI) question (Table 2).

The p-value was 0.354. There was no need to reject null hypothesis. At 95% CI, there were no differences among items in Q5, 6 and 7 (Table 3) .

The p-value was 0.049. Null hypothesis was then rejected. The items in Q8 and 13 were therefore of independent views at 95% CI: working with a tutor was not synonymous to working as a group (Table 4).

The p-value was 0.010. There was no need to accept null hypothesis. At 95% CI, dissection potentiating thinking skills in an orderly manner was not synonymous to dissection as the best learning method of understanding human Anatomy (Table 5).

The p-value was 0.049. Null hypothesis was rejected. Therefore, at 95% CI, issues surrounding ethics and total body donation were not in accordance (Table 6).

Undergraduate medical education in Nigeria is fundamentally categorized into two phases: pre-clinical and clinical. Dissection as part of gross Anatomy is crucial; therefore, contact with cadavers is inevitable and understanding the historical perspective of Anatomy goes a long way to address the issues with medical students and dissection of human cadavers. This study is the first of its kind in the newly emerging medical institution in Ekiti, Nigeria. Majority of the students 84.4% out of pre-clinical medical students returned the dispatched questionnaires for the study as against 75.7% of similar study about the perceptions and opinions of medical students on the subject of physiology in the United Arab Emirates [20].

A substantive number 61(53.5%) of the students agreed to being excited having visited dissection room for the first time which might be suggestive of either failure of prior exposure to human remains at home or denial of opportunity to pre-dissection counseling that was initially not practiced in this medical institution. Besides, this majority might have not gotten opportunity to participate in medical tourism to other parts of the country having medical schools during their post primary education. The very few 5(4.4%) who strongly disagreed might represent the candidates who were admitted from another states with opportunity to prior exposure and guidance either at home or in other medical institutions across the country. The neutral group 8(7.0%) hypothetically represented the students who saw the exercise as a conventional procedural step in medical training and were not moved.

A study carried out in Pakistan to investigate motivations of students in choosing medical profession and their attitudes toward their future profession reported a disappointment among some students and the need for assistance from career counselor was advised [21]. In the UK, similar study towards general surgery was concluded by suggesting provision of potential incentives in order to attract robust recruitment [22]. In India, positive attitude of medical student towards Anatomy was recorded but only few of them were ready to pursue postgraduate training in Anatomy [23]. In Saudi Arabia, re-designation of gross Anatomy curriculum to more of practices in clinical Anatomy was favoured as a way forwards in choosing Anatomy as future career [24]. A cohort study in Kenya indicated the arousing attitude of medical students towards Anatomy. However, only very few of the students were willing to take it up in postgraduate and suggestion was then made on the need to place more emphasis on pre-dissection training and counseling to make experience better for future specialization in Anatomy [25]. Career choosing in physiology was conducted in the United Arab Emirates in 2014. Only few medical students were observed to be interested in basic medical sciences and the need to address apathy towards these subjects in the medical curriculum was suggested as a critical matter for policy makers [20].

Stress can be cognitive, emotional, physical or behavioural. Anxiety, restless, worrisomeness, irritability, depression, sadness, anger, feeling insecure, lack of focus, burnout and forgetfulness are inter-related common emotional phenomena associated with dissection [26]. Psychogenic shock may also be added at the extreme of emotional stress. A similar study was conducted on paramedics evaluating the impact of event scale (IES) on the first cadaver exposure reported a significant number 69.7% agreed and strongly agreed to have been distressed and apprehended [27]. These effects were said to be alleviated over time with introduction of 'prior sensitization', the culture which was thereby suggested to be energized in the Department of Anatomy of EKSU. The idea of raising educative programs and team work should also be strengthened as registered earlier in order to reduce emotional needs [14]. The reasoning for the afore-mentioned 'emotional needs' could also go for 'fear of touching cadaver for the first time'.

A reasonable aggregate of pre-clinical medical students (63.2%) who strongly agreed and those who agreed that cadaver appeared like a living human-being similar to themselves [14]. Unfortunately, having much respect to cadavers might have not influenced the decision of medical students in accepting themselves for body donation after death as demonstrated by a study in Nairobi [28]. Accordingly, the numerous socio-cultural heritages and various religious beliefs in Africa might have rationalized this dicey affirmation towards donation of body as anatomic gift. Inadequacies in embalming techniques and cost of modern embalming in this locality might also be factors militating against students appreciating human cadavers as being similar to them. However, the majority of students that cared for cadavers might understand the psycho-social mood of relatives left behind in body donation for anatomic education knowing very well or not knowing at all the destination of their loved ones ending as cadavers. Consequently, one would have expected a total of 71.0% who strongly agreed to have kind-heartedness for cadavers while dissecting for the first time to give full respect to human cadavers with resultant meticulous practical advancement in discerning of tissues as reported in earlier researches [24]. In another manner at present (now), an assessment shows that the initial spirit of kind-heartedness might have been due to fear associated with seeing dead bodies at the first time with almost equal number 69.3% disagreed and strongly disagreed in this study [15], [16].

Plastination first came to the mind of Gunther von Hagens as an Anatomy assistant having been encountered with a kidney embedded in a clear plastic [29]. In this study the context of carrying out dissection with the tutor had a total support from 75.4% of the students, thereby, suggesting the fact that their tutors as the assistants (likened to Hagen's phenomenon) can equally bring out something reputable in scientific world. In a similar study conducted amongst female medical students in Saudi Arabia, majority (86%) agreed to perform dissection with their teachers which could be likened to the majority in this study who strongly agreed and agreed to this assertion. The candidates who disagreed and strongly disagreed are fewer and might have preferred performing dissection solely with instruction from available dissecting manuals which off-course were not all self-explanatory. The students who preferred to be neutral might just wanted to get through and pass the examination in Anatomy as a prerequisite to the next stage rather than having postgraduate degree in anatomic sciences in future. Nevertheless, 'conflict', if developed during the exercise of dissection with varying attitudes would be better contained by the tutor if present. In Table 4, working with tutor as assistant and working as a group as enshrined in most medical training was statistically-significant: the views of the majority of students in this study were attuned with reality.

The skill of that great Professor of Anatomy, Andreas Vesalius, was said to have been potentiated by the numbers of human dissections performed within and outside his dominion [7], [8]. Taking this into consideration, the majority (91.3%) of our students who strongly agreed and agreed that dissection potentiated thinking skills in an orderly manner was in order for skill acquisition. Besides, this affirmation could be supported by an earlier study on 'Cadaver dissection: A positive experience among Saudi female medical students' [30]. Interestingly, none of the students in this study strongly disagreed and the very few 3(2.6%) who disagreed should be considered qualitatively impertinent.

Right from inception, dissection was seen as the best means of learning Anatomy in which the Greeks did a lot by performing dissection to understand human body function [2], [3], [4], [7], [8]. Meanwhile in the past, grave-robbing and some other so-called unlawful acts were practiced in order to provide more cadavers for dissection rather than prosection [7]. In the process of evaluating the issue between dissection and prosection, a study on the role of cadaver dissection in modern medical curricula statistically-significantly had the majority of the students in support of dissection as the best effective approach to studying Anatomy [31]. This current study had a total of 81.6% of the students in support of this assertion. The remaining very few students might have voted for prosection as a quick way of learning Anatomy which would not guarantee the best-of-the-best in gross Anatomy, after all, the prosected specimens were once dissected by some individuals: prosection is the product of dissection. From the views of the students, dissection potentiating thinking skills in an orderly manner and dissection as the best learning method of understanding human Anatomy seemed to be two different entities as the p-value was statistically-significant making each item an independent opinion. Even though majority of the students were in support of these assertions with p < 0.05 (Table 5), more time is needed, perhaps, at the clinical phase of undergraduate training where clinical Anatomy is better applauded to bring out the virtue in dissection. Medical ethics entails the principles of right or wrong as far as the time of Hippocrates and being accepted by an individual physician or a group of physicians in an organization. Presently, ethics is becoming controversial in the light of recent medical advances and the varying possible advancements that technology has brought up. Of note is the criticism surrounding the breakthrough by Gunther von Hagens and his Bodyworlds in the dissection and exhibition of human cadavers [32]. Emphasis on ethics fundamentally is on what an individual orders: shall or shall not be done with his or her body at death, despite social need or public interest [33]. Broadly, irrespective of the controversies being generated on ethics, this study recorded a total of 80.7% of students who strongly agreed and agreed that human dissection was ethically accepted, thereby depicting the unflinching interest in gross Anatomy.

A lot has been discovered in dissection in the past [2],[5] and so many more are still going to be discovered from our 'first teacher' and 'first patient' called cadaver in future rather than embracing substitutes than can be fraught with tricks. A total of 64.0% who strongly disagreed and disagreed to substitutes in feature might have expressed the mind of the majority towards this assertion in this locality. Limitation of cadaver can be sort out by strengthening the ethics, laws and acts surrounding the sourcing of human cadaver for dissection in different sovereign nations viz developed and developing. The issue against the support for substitute as demonstrated in this study should not be seen as affordability or availability of substitutes rather as an institutional or national determination as obtained in some countries including the USA [15]. According to William Hunter: Anatomy is the basis of surgery and consequently, dissection which is an integral part of gross Anatomy might be better embraced by the majority of our students declining substitutes, thereby, wishing to feel the touch of cadaver and desiring specialization in surgery in future [34].

Group projects can help students develop a host of skills that are increasingly important in the professional world [35],[36]. In addition, incontrovertible group experiences have been shown to contribute to student learning, retention and overall success in an institution [37]. A total of 92.1% of the students who were in support of group dissection might have appreciated the advantages as a means of discussing difficult aspects of the program and to alleviate the fear of an individual getting in contact with dead human body.

The operation of getting human cadavers for dissection had passed through series of awful consequences amongst this was grave-robbing in the 17th and 18th centuries AD [7]. Individuals and anatomists had paid sacrifices of bequeathing or pledging relations for anatomic dissection as a parting gift to the developing of medical education. Amongst the latest is the personal courageous public proclamation by Gunther von Hagens donating his body for dissection and exhibition after death [32]. In this study, majority (80.7%) of the students clinched to the socio-cultural heritage and religious beliefs in which body donation for dissection remained a taboo. This should be regarded as a dicey act, perhaps, because the act on human donation by self or relations after death to gear up people is not popular and seems not existing in Nigeria to the best of our knowledge where cadavers are obtained from either unclaimed victims or legally executed criminals [38]. The fact that majority of the students (64.0%) were also not in support of cadaver substitutes then calls for further investigation and ratification of heritable and religious issues militating against medical education in this geographical entity. The views of the students in this locality definitely might have not represented the global orientation in medical training where cadavers are respected as the 'first teacher and first patient'. Our numerous socio-cultural heritages and religious beliefs needed further evaluation to strike a balance.

The premeditated idea of counseling, seeing dead bodies in audio-visual and in physical; and prior interaction with cadavers before gaining admission to study medicine and anatomic sciences related courses could be considered blessing in disguise. Having opportunity to some or all of these notions might be of help in desensitization against emotional stress as supported by majority (74.5%) of the students in this study. The fewer (17.5%) of the students who were against the assertion of seeing dead body before gaining admission to medical school might have gotten the mindset of Medicine as a course being a dignified one amongst others and had to carrying on at all cost irrespective of all odds. The fewest (7.9%) of the student who stayed neutral might be dwelling in the concept of having enough opportunity for each stage of medical training and counted prior sensitization superfluous.

Playing underground music (as a wanted sound) has a way of boosting ones spirit while at work. Even though one man's food/music is another man's poisoning/noise, a total of 64.1% of our students who voted in support of underground music during dissection had expressed psychogenic or behavioural comportment in audio gadgets as a means of reducing emotional stress in diversionary solution. On the other hand, the students (23.7%) who were against the gesture of underground music might perceive this as a noise that could not be regulated to an agreeable level. The conflict, underground music will generate in the dissection room may be difficult to contain, perhaps, if the tutor in-charge is not a lover of the selected music at that particular point in time. Ambiguously, the habitual use of head-phones in case of underground music may disrupt the group conversation while dissection is on-going. There are very few accounts of underground music in dissection room, having search the web and literature. The University of Michigan Medical School outlawed underground music and accepted the use of headphones with no concrete reasons [19]. In a similar local study strong positive relationship was established between love for underground music and its perception as a tool for learning and alleviation of stress associated with dissection [39]. The way forwards to matters on underground music and manner of selection may have to be channeled by various medical institutions across the globe by reviewing the existing laws and ethics.

With the majority of our students (67.6%) willing to have further studies in Anatomy in future upon all the ups and downs experienced in dissection, there is hope to improvement and resolution of the various challenges influencing anatomic sciences in this geographical location. A crucial lack of interest in future specialization in basic medical sciences including Anatomy earlier noted among undergraduate medical students across the globe was contrary to the finding in this present study as majority of our student valued postgraduate degrees in Anatomy [19] [24]. Thereby giving some incentives, advancing career counseling plus or minus regular modification of medical curricula will yield more interest amongst undergraduate students towards future appraisal of anatomic sciences as earlier documented [21],[22],[23].

Undergraduate medical students showed kind-heartedness towards cadavers once lived like them and dissection was preferred to prosection in acquisition of skill and knowledge. Human cadaveric dissection was applauded while plastic models and computer gadgets were to remain adjuncts rather than substitutes. Integration of underground music was suggested by majority as a drive towards the treatment of emotional stress and majority of students voted in favour of future specialization in anatomic sciences.

Human cadaveric dissection (anatomization) had passed through series of worrisome time right from inception but remains the head-corner stone the builder refuses which shall continue to be reckoned with as integral part of gross Anatomy. This study further affirmed emotional distress as ever-present psycho-social phenomenon in dissection which fades away with time.

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