Anatomy education at central Europe medical schools: a qualitative analysis of educators’ pedagogical knowledge, methods, practices, and challenges | BMC Medical Education

One overarching theme “Transforming Anatomy Teaching and Learning in the Glocal Classroom: Navigating the Intersections of Pedagogical Practice, Constructive Alignment, and Student-Centred Approaches” was identified from the data. Through thematic analysis, we identified one umbrella theme, two main themes, and five subthemes (three under theme 1 and two under theme 2), as illustrated in Fig. 2.

Theme 1 enhancing pedagogical practice in the glocal classroom: balancing constructive alignment and student-centred approaches in the face of outdated curriculum content and traditions

Subtheme 1 navigating outdated curriculum content and traditions

Almost all respondents acknowledged a defined curriculum provided by their HEIs to outline the content to be covered in each class. However, several respondents identified certain aspects of the anatomy curriculum as outdated, irrelevant, or overly focused on lexical knowledge rather than practical application: “It would be nice if we could filter out the information and the curricula that are completely outdated and have no use for medical students. So, the problem is that a lot of people still have in their minds that quantity is more important than quality, and that quantity is more important because they will forget about it anyway […] The fact that we can’t get rid of traditions, traditions that are really quite outdated, that’s probably the biggest negative, and for me the lack of accountability” (ED 3).

Respondents raised important concerns about the current state of medical education, particularly regarding an over-reliance on tradition. There appears to be a tendency to adhere to long-established practices and the legacy of historically influential faculty, even when these may no longer align with current international standards. Additionally, the curriculum is viewed as overly broad, potentially incorporating non-essential content that can overwhelm students. Consequently, there is a growing call among respondents to modernize the curriculum, emphasizing knowledge that is more relevant and essential for today’s medical students. These concerns reflect themes in recent academic literature, which discusses the challenges of information overload in medical education [21] and the need to address gaps in knowledge through reforms to traditional teaching methods [22].

Subtheme 2: balancing constructive alignment and student-centred frameworks

Nearly 70% of the educators were unfamiliar with CA and its underlying framework and expressed doubts about the specifics of this method. However, after being introduced to the definition of CA, most respondents concurred that this approach would be applicable to their teaching methods. One educator believed that CA assists in maintaining student engagement and motivation by clearly conveying the objectives and benefits of the learning activities. Nevertheless, the educator recognised the need for improvement in the systematic application of CA, especially in terms of providing effective feedback to students. Within CA, educators have some flexibility to adapt their lesson delivery and to improvise to a certain extent, depending on circumstances. While the structured curriculum and partial focus on student-centred learning align somewhat with the principles of CA, the lack of continuous assessment and feedback mechanisms represents a significant area where current practices diverge from the CA framework.

In relation to teaching objectives, CA supports the formulation of performance criteria that clearly define what students should be able to accomplish. For students, CA guides the design of exams to ensure they accurately assess the intended learning outcomes, thereby ensuring validity [17].

While most respondents were familiar with the term ILOs, they reported that no clear, standardised set of ILOs or minimum requirements were defined for their anatomy curricula. Instead, the expected knowledge and skills are shaped more by tradition and individual educator preferences than by a centralised, objective framework. The absence of continuous, weighted assessments contributing to the final grade is seen as a major gap, as it reduces student accountability and motivation [23]. One educator explained: “It’s very important because we have a high failure rate in this subject, which can indicate various issues. One key issue is that students aren’t receiving quality feedback about their progress. This means a lot of time passes while they are off track, and it’s often not until exam time that we realize they’ve been struggling. By then, they have little time to catch up, which affects their chances of passing, let al.one achieving a good score. Implementing constructive alignment could help improve failure rates. It would be beneficial if it were applied systemically” (ED 4).

Most respondents reported that the ILOs are often not documented nor are they formally written. Some respondents noted that ILOs are typically determined by senior professors during collaborative group discussions, where these senior faculty members decide what should be included in the ILOs, and the final approval is always required from the head of the department.: “The intended learning outcomes are often written by the head of the unit or department but mainly kept for administrative purposes only, we revise them every three years” (ED 9). Another respondent mentioned: “In teams (teams: the working group that includes several anatomy teachers) at department, each team will be responsible to write ILOs” (ED 1). When respondents were asked: do you revise ILOs and if so, who revises them? One respondent answered: “If it will be revised it will be the leader” (ED 12), while another said: “It’s not written to be revised”. A respondent added: “Very rarely, it’s a tried and tested method, the anatomy doesn’t change much, so very rarely there are 1–2 changes at most, but not typical” (ED 7). This indicates that different universities have different routines and traditions.

Subtheme 3 pedagogical knowledge in the glocal classroom

To explore the pedagogical knowledge of educators, a series of introductory questions were presented asking them about their familiarity with such pedagogical principles as CA, ILOs, and student-centred learning. They were presented with the following definition:

“Pedagogical knowledge means the knowledge of teachers and includes all the required cognitive knowledge for creating effective teaching and learning environments. Most research studies use the distinction between declarative (‘knowing that’) and procedural knowledge (‘knowing how’) from cognitive psychology as a theoretical basis. This approach is relevant as it focuses on understanding how knowledge is related to behaviour, or in other words, the quality of teaching performance” [24].

Educators in this study predominantly lacked comprehensive pedagogical knowledge, failing to recognize the critical distinction between ‘what to teach’ and ‘how to teach’. This latter aspect is essential for cultivating effective teaching and learning environments, particularly in enhancing the quality of anatomy education. Effective teaching transcends simple information transfer; it entails nurturing a profound understanding and enthusiasm for the subject matter. By doing so, educators can guide students to become active learners capable of applying their knowledge to real-world scenarios [24]. While this endeavour is undoubtedly challenging, implementing appropriate strategies and maintaining a dedication to continuous learning and improvement can yield immensely rewarding results [25].

This is particularly relevant in today’s multiculturally and linguistically diverse learning environments. All respondents confirmed that their student population is diverse, and that their anatomy education programme includes both local/national and international students, especially on the English-taught programmes. Some educators expressed concern over the lack of focus on inclusion and diversity in their institutions, stating: “The teaching here is about quantity, not quality, no consideration for diversity or inclusion” (ED 13). This quote underscores the reality that these HEIs are not in alignment with global initiatives such as SDG4.7, which emphasises the importance of being culturally and linguistically responsive in teaching. Such responsiveness is crucial for ensuring equitable and inclusive education that caters to the diverse needs of students from various backgrounds, ultimately enhancing the overall learning experience and outcomes in anatomy education. The concerns raised by these educators mirror the findings of the LEANbody needs analysis survey, which revealed that over 70% of anatomists (49/69) from a number of Central European universities have limited knowledge of international quality standards in medical education [11]. This observation aligns with research highlighting the deeply ingrained cultures within academic disciplines, which can lead to various challenges, including demographic underrepresentation, difficulties in addressing differences, and the presence of an implicit curriculum in anatomy education [26]. To address these issues, it is crucial for educators to develop glocal competences. This concept combines global awareness with local understanding, referring to an educator’s ability to interact effectively with students from diverse backgrounds while considering both global and local contexts. Glocal competences involve the ability to bridge global perspectives with local realities, ensuring that educational practices are both internationally relevant and locally appropriate. Educators with glocal competence can create inclusive learning environments that value diversity, promote cross-cultural understanding, and prepare students for success in an interconnected world [12].

Theme 2 Navigating the challenges of anatomy teaching without formal pedagogical training: Impact on students’ learning

Subtheme 1 Challenges posed by the lack of pedagogical direction that impact students’ learning

Several respondents mentioned the lack of a clear, professionally grounded pedagogical direction or a set of guidelines as a significant challenge. They stated that many colleagues were perceived to be going in different directions, which makes it difficult for educators to implement evidence-based pedagogical approaches. The educators expressed a desire for more tools and training in effective pedagogical techniques: “It would be nice if I had more tools, like a pedagogical direction that is professionally grounded. The question now is not whether the direction is well-established, but how well-known these professional guidelines are, and my experience is that they are not known among colleagues. Many colleagues are going in a different direction, which is perceived by the students, and so they take the attitude that why am I hanging out, why am I doing it differently from other colleagues. It would help a lot if there was a unified professional direction to go towards the best quality” (ED 4). This subtheme shows clearly the essential need for pedagogical tools and comprehensive educator training develop educators who can positively impact student learning, foster a love of learning, and contribute to the overall success of the education system [27].

Subtheme 2 The lack of formal pedagogical training is offset by the tradition of juniors following the teaching methods of their senior colleagues

When educators shared their experience of when they first started teaching, they stated that they had to learn teaching skills and techniques through trial-and-error, without the benefit of a pedagogical foundation. Most of them had to rely on learning from senior colleagues and their own intuition. As the characteristics, qualities and attitudes of today’s students have changed, our respondents believe that more formal pedagogical training is needed to effectively engage and teach students. Many respondents reported being assigned teaching responsibilities without sufficient preparation. Instead of formal training, they relied on observing and learning from their more experienced colleagues’ teaching methods. One participant explained: “Never any formal training. How to teach anatomy specifically or how to teach anatomy to medical students and how to teach anatomy to dental students and how to teach to anatomy to some other group of students. So this is something that we learn on the fly as basically you get thrown in and do your best regarding that. Of course, the Department of the Anatomy has a lot of people who are well versed in these things. So and we are like a tight knit group, so everyone basically is willing to help in these aspects. But there is like not formal training where someone takes. Yeah, you like, when you come at the department and then you are like studying a year under someone to how to teach.” (ED 1). This subtheme highlights that the educators recognise the need for formal pedagogical training and guidance to improve their teaching practices and effectively address the diverse learning needs of students [27] in anatomy education, which is currently lacking in the discipline’s established tradition [28].

Despite the extensive teaching experience of the educators in this study, most of them lacked formal pedagogical training. Only 2 educators had received pedagogical training, one abroad and the other through a one-week online teaching course during the COVID pandemic. The absence of pedagogical preparation likely contributed to the challenging experiences faced by these educators. “We have an educational tradition that doesn’t require pedagogical knowledge basically. It is a rather strict tradition, which means that as young teachers we have done things based on the experience of older teachers. At several points there were checks, we sat a lot of exams when we were young, where we saw the main pedagogical skills, the pedagogical skills used in exams, which were not specifically formulated, but still very different people at the institute level worked on similar principles and so you actually inherit this kind of abstraction of what are the principles that we teach on. That’s what we call a tradition.” (ED 5). Consistent with findings from a recent study in Hungary [29], educators reported that there are no formal requirements for pedagogical training or knowledge at these institutions. Instead, new educators are expected to learn and adopt teaching methods and principles from senior faculty members. These institutions maintain a strong, established educational tradition that heavily influences their teaching approaches, placing little emphasis on external or standardized pedagogical frameworks [30]. As a result, teaching styles and strategies vary widely. One educator described their approach: “I help them, but I’m also strict. I don’t lecture; I engage them in the lesson. Some students dislike that I call them by name in class. My lessons are interactive, with constant questioning. I try to demonstrate and come up with new ways to improve myself” (ED 2).

In this way, quality medical education faces significant challenges due to misalignments between formal curricula, teaching methods, assessment practices, and the hidden curriculum that shape professional culture. These systemic issue impacts the quality and effectiveness of medical training, potentially compromising the development of well-rounded, competent healthcare professionals, as shown in Fig. 3 below.

Perceived challenges and current problems of anatomy medical education-Figure created in Napkin

The disconnect between curriculum content and teaching methods is a primary concern in medical education. Traditional lecture-based approaches remain prevalent, despite evidence supporting more interactive and engaging pedagogical techniques [31]. Many medical educators lack formal training in teaching methodologies, often relying on methods passed down from senior faculty without critical evaluation of their effectiveness. Furthermore, there’s a noticeable gap between basic science instruction and clinical application. This disconnect can leave students struggling to apply theoretical knowledge in practical settings, hindering their ability to develop crucial clinical reasoning skills.

The hidden curriculum, comprising unwritten rules and cultural norms, significantly influences students’ professional development. This informal learning environment often reinforces traditional hierarchies and institutional cultures that may contradict the formal teachings on professionalism. For instance, students might observe behaviours from senior clinicians that conflict with the ethical standards taught in classrooms, leading to confusion and potential erosion of professional values [32].

By addressing these systemic misalignments, medical education can evolve to better prepare future healthcare professionals for the complex, dynamic healthcare environment they will navigate. This holistic approach ensures that formal curricula, teaching methods, assessment practices, and professional culture work in harmony to produce competent, ethical, and adaptable medical practitioners.

Recommendations for central european medical schools

The LEANbody project investigated strategies to enhance the quality of anatomy teaching in Central European medical schools. To address this challenge, we propose an integrated approach that combines four key educational principles: student-centred learning, internationalisation of education, Sustainable Development Goal 4.7 (SDG4.7), and constructive alignment (CA).

Conclusions and future directions

Student-centred learning places learners at the heart of the educational process, encouraging active participation and critical thinking. This approach aligns well with SDG4.7, which focuses on promoting inclusive, equitable, and quality education for all, while emphasizing global citizenship and sustainable development. Internationalisation of education broadens students’ perspectives and prepares them for a globalised healthcare environment. Constructive alignment ensures that learning outcomes, teaching methods, and assessments are coherently linked to enhance educational quality. The intersection of these concepts is expected to create a framework for improving anatomy education as shown in Fig. 4 below.

This is a fishbone graph representing a framework for enhancing anatomy teaching in central European medical schools-Figure created in Napkin

By integrating these elements into the curriculum, we can create a learning environment that not only enhances the quality of anatomy education but also empowers students to become knowledgeable, skilled, and engaged global citizens. This approach requires regular pedagogical training for teachers to ensure effective implementation and adaptation to evolving educational needs.

To implement this integrated approach, medical schools should:

1. 1.

   Provide comprehensive training for educators on student-centred active learning techniques, internationalisation strategies, and the principles of SDG4.7.

2. 2.

   Develop clear guidelines for incorporating these principles into anatomy course design and delivery.

3. 3.

   Establish mechanisms for ongoing evaluation and improvement of teaching practices.

4. 4.

   Foster collaboration between anatomy departments and international partners to enhance global perspectives in the curriculum.

This integrated approach could potentially generate a more responsive, inclusive, and effective educational experience that prepares students for the complex challenges of modern healthcare and sustainable development in a globalised world. A near-future follow-up project incorporating regular formal educators training and subsequent evaluation shall be considered. This shall be aligned with implementing the suggested frameworks for improving anatomy teaching in medical schools across Central Europe.

Limitations of the study

This study had a limited number of educators due to the inclusion criteria, which restricted participation to members of the LEANbody project. This limited number of participants may not fully capture diversity of perspectives teaching practices, and institutional contexts present within and across central European universities. As a result, the findings may have limited generalizability and may not reflect the broader experiences or challenges faced by anatomy educators outside the project or at other institutions. For future research, it would be advantageous to involve more institutions and anatomy educators to broaden the participant pool. These results may not be generalizable. Researchers with different reflexivity than those conducting this study might uncover aspects not identified in this research.