We hypothesized that the students’ motivation in terms of self-efficacy, achievement, and performance goal at the posttest stage increases while it slightly declines in the follow-up phase. Correspondingly, we assumed that higher anatomy scores and positive opinions on learning anatomy would be earned by the participants in the experimental group. Our results indicate that the students in the experimental group—who prepared handmade models—acquired significantly higher scores in terms of the performance goal of motivation. Students also show greater interest and joy when 3D visualization came to assist learning anatomy and consequently they obtained higher scores in some subjects where models were created and utilized.
Learning anatomy is dependent on 3D visualization and spatial ability of anatomical structures in different regions [24]. Spatial ability, as a cognitive skill, promotes structural visualization and orientation which can be applied in practical activities of student-centered programs and employed in the procedures of learning complex anatomical regions [25]. Cadaver dissection is a key component of teaching anatomy, however, there are ethical limitations and barriers that challenge the use of cadavers and prosection as gold standard tools [26]. Such limitations cause active practical student-centered programs to adopt passive observation. The current study encouraged medical students to create different part of Gi models on their own and they demonstrated their spatial ability as a cognitive practical skill required for learning anatomy. Participants showed better achievement of performance goal due to the acquired skills, with significant differences in the results of posttest phase. Additionally, self-efficacy and learning value in the posttest phase were reported relatively higher in comparison with the control group. However, in the follow-up stage after one year, students’ motivation declined in different aspects. According to the obtained results, the students who prepared models had better scores in the final exam on the created models (Table 2). In their study, Patil et al. made a comparison between animated video and playdough handmade models used by medical students. They found that the students who used playdough obtained better scores in posttest after one month, reflecting the higher effect of playdough on better memory retrieval of anatomical structures [27]. This indicates that the students who are involved in 3D dynamic structures learn more effectively than those who just passively watch 3D structures.
In view of the fact that practical activity and acquiring skills are a continuous process, whenever students are actively involved creating handmade models, their visual-tactical ability is enhanced. Likewise, if practical activities are paused for several months, students’ motivation and interest wane. In this study, the students in the control group had routine lectured courses based on observation in anatomy laboratories, hence it was predictable that in the posttest and follow-up stages, their motivation would slightly decrease as can be observed in the different graphs.
There is an unexpected finding in the learning environment stimulation at the follow-up stage for the control group. It appears that when students were preparing for their exam, the lecture-based students usually focused on memorizing and even though they thought they achieved learning, they did not accomplish deep learning of 3D structures or acquiring skills. Moreover, in our previous study, students did not like to learn anatomy by reciting. Rather, they preferred to understand anatomy in the clinical context [28]. On the other hand, the results indicated that the students in the experimental group were more eager and confident about their skills due to the practical learning, showing that creating models had an impact on the total score of motivation in the posttest. This was found to be in line with a study by Vaghela et al. on comparing the performance of students who prepared handmade models in contrast with those who did not try preparing the handmade models. They argued that spatial visualization of the models during model preparation causes better scores and understanding of anatomy [29]. So, in a laboratory suffering from the limitation of artificial models, the handmade models can serve as one of the most useful learning facilities instead of passive lecture classes. Lombardi (2014) notes that active learning and using models helps students to learn in a new situation, and incorporating model-assisted activity is beneficial to their learning [30].
There are some limitations in providing cadavers and it can be inaccessible for all students to dissect cadavers [31]. Similarly, Ghosh (2017) innovated learning methods that are necessary for learning 3D anatomy [32]. Moreover, prelab classes guide the students for better cadaver dissection [12]. In this study, the prepared handmade models were used as a multipurpose method to increase students’ skills, motivation, and interest as well as their satisfaction in order to improve learning anatomy. A similar study on the female genital tract anatomy showed that compared to the group who watched only videos, the medical students who prepared handmade models obtained better score and were more motivated in understanding anatomy [33]. So, it can be postulated that the handmade models enhance hand skills and abilities in students, known as an important feature for medical students in clinics. Haspel (2014) and Motoike (2009) state that clay models are effective for learning systemic anatomy and lead to a better identification of structures on human models. The virtual and 2D anatomical atlases fail to offer 3D concepts as they are untouchable, inactive, and lead to superficial and dull learning, unable to enhance 3D visualization [34, 35]. Lombardi (2014) holds that students who used plastic models for learning achieved higher scores compared to their peers in both the initial and follow-up tests. In this study, the students who prepared Gi regional models earned the highest anatomy scores in their related subjects as compared to the other Gi subjects [30]. Further, the evaluation of Gi subjects which were selected for 3D scanning by professors showed better scores (Table 1). This result was in compliance with the results reported by Sigma et al. who focused on model’s preparation under the judgment of anatomy professors. Based on their study, more than two third of the students believed that the model preparation process is enjoyable, useful, and interesting [36]. Hence, innovation in preparing anatomical models will facilitate learning anatomy. Oh (2009) notes that making abdominal organ models created a sense of satisfaction in students and promoted their understanding of 3D structures. Clay models are also useful for supplementary anatomy curriculums, especially for complex regions. Students who took part in creating models reported that it was easier for them to visualize the complex region and to develop clinical skills [37].
The main point of this study was to get students create their models accurately, using 3D concepts suitable for education. Guidelines for designing the models were adopted from the 2D pictures of atlases. Models created of complex regions which were difficult for the students to visualize, including anatomical regions such as pharynx, earned the lowest scores. Whereas the maximum total scores were earned for the liver, since liver, as a separate organ, is easier to visualize from different angels in comparison with other complex Gi structures. Achieving 3D visualization is dependent on the visual perception of real objects and there is a significant relationship between spatial and practical abilities [25]. Liver is easier to achieve visual perception of than is pharynx, for it is possible to see liver from different aspects, while for pharynx it is impossible to visualize from lateral or posterior angels. Fernandez (2011) argues that spatial cognitive abilities are important in clinical anatomy education and experience contributes to the development of these abilities [15]. Creating anatomical models is an attractive experiment for undergraduate students and encourages them by granting them a sense of satisfaction, when cadavers and other expensive modern facilities are lacking in some anatomy departments.
Another aspect of this study is to prepare 3D printing of the created models. 3D anatomical printers were developed several years ago. They offer 3D samples for teaching anatomy [38]. There are many commercial plastic models for anatomy; however, apart from their high costs, some of them lack the anatomical details required for learning clinical points [9]. On the other hand, handmade models designed and created by students contain many details, as they are designed through different views of several anatomical atlases as valid references. They can be scanned three-dimensionally and printed in different sizes and in large numbers at a low cost. Thus, medical schools can prepare their own repository [39]. In addition, the results showed that preparing the gastrointestinal 3D printing from handmade models by second year students has made the anatomy course more interesting. This was found to be similar to a study by Chen et al. which focused on learning gastrocolic anatomy by 3D printer technology, among a number of intern medical students. They showed more satisfaction for deep learning anatomy and better scores too [40]. Another study by Smith et al. confirmed that, compared to the traditional method based on using only cadaver, learning anatomy in small groups by additionally using 3D printing models could improve and increase the knowledge of anatomy and bring in certain advantages [41]. Likewise, the results of the present study provided evidence on the promoted motivation of students in terms of different subscales of motivation in the posttest (after six months). Fleming (2020) maintains that 3D printer models assist medical students with limited knowledge of anatomy, but they are not useful for medical residents [42]. It has also been proved that 3D printed models are an effective tool in learning anatomy for they are easily used and accurate, and enhance experiment and personal performance [43]. In our study, the 3D printers of students’ handmade models displayed the abovementioned characteristic. The accuracy was verified by expert lecturers and it was proved helpful in gaining experience for beginner anatomists and medical students. Needless to say, these models are ineffective for expert residents or surgeons [44]. 3D printer prototypes are very enjoyable and effective for acquiring an actual perception of anatomy. It was also found that students achieve a higher visualization in learning anatomy, as they make efforts to create their own handmade models which lead to educations products particularly for complex anatomical regions, which students often found boring for learning. More than %75 of the second year students who created the 3D printer models believed that this experience has made learning anatomy more interesting and enjoyable for them. This finding confirmed the result obtained in a study by Cai et al. based on which %70 of first year medical students reported improved learning of the spatial anatomical structures when using dynamic 3D printer [45]. Also more than %80 of students in the presented study asserted that models are necessary to be used in clinics for learning anatomy, which is consistent with Wu et al.’s research, providing evidence on higher perceived satisfaction among medical students learning spatial anatomy of fracture bones, when used 3D print bone instead of pictures [46]. Chen (2017) maintains that 3D printer models are also relatively cheaper, more accessible, and suitable for different situations including in clinics. It goes without saying that the different tools used for learning anatomy such as plastic models, handmade models, and 3D printers cannot replace studying cadavers; however, they can promote anatomy education [19]. Along these lines, there is no superiority for 3D printers over cadaver alternatives and traditional teachings [41, 47].
It should also be mentioned that in the year 2020, the covid-19 pandemic posed a major challenge for education, which calls for efforts to be made in order to resolve the problem of distance and virtual learning of anatomy, as the subject significantly depends on spatial ability. Franchi (2020) states that anatomy without access to practical based learning materials is seldom favorable and brings about difficulties. The accessible handmade and 3D printer models can serve as suitable tools in distance learning, while they are also the right alternatives for expensive commercial models. Learning anatomy through 3D models generates different experiments in comparison with 2D atlases. Learners are more eager and encouraged as they acquire better understanding even in remote or virtual learning environments [48].
Limitations of the study
The research included a one-year follow-up of different students. Also during the follow-up, some of the students who initially contributed to the study left the project, for various reasons such as changing their university, or dropping the gastrointestinal course. We predicted such problems, hence we presented one subject of anatomical region at least for several students; however, in one-year follow-up, some of the students withdrew from contributing. Consequently, for some subjects, we had only a few models; and in the final anatomy scores, there were limitations in evaluating and analyzing the different scores. Moreover, some corrected models were impossible to submit for 3D scanning and printing. Hence, we suggested small groups of students to prepare a few defined models.