In this study it was evidenced a haptic experience involving painting on 3D plaster models of skeletal elements, aided in the learning process of the shoulder’s anatomy by enhancing the student’s anatomical spatial awareness. It is known that there has been limited development of activities that support visuospatial and metacognitive skills in anatomy [17, 18]. Therefore, with this innovative approach, the limitations that traditional methods focused on a surface approach to learn, such as memorization, might be overcome [19].
To arrive at a deep learning approach, the student must understand the structure and manipulate the object to make sense of the relation between the elements. Hence, 3D plaster models of the shoulder skeleton were fabricated. Brumpt et al. carried out a systematic review describing the value of 3D printed anatomical models [11]. From their work, they selected 68 articles, of which 47 were designed form CT scans, and 51 articles mentioned bone printing. However, the shoulder was only mentioned in one study by Garas et al. [20]. Garas and colleagues, in their study with 23 undergraduate students of health sciences were exposed to plastinated, 3D-printed models and cadaverous specimens of the external heart, shoulder, and thigh, where the shoulder was plastinated. The students then had to take a test with nine questions on a pinned structure and were asked to identify it. Following, they were provided a post-test survey with five questions on a Likert scale. Collectively, from the Garas’ study it was concluded that 3D printing can be an asset in anatomy learning. Furthermore, the level of understanding was very basic and is not comparable with the present study.
Other researchers have used 3D printing and painting to learn anatomy. McMenamin and collaborators reported on high resolution 3D prints of accurate color reproductions of prosections based on CT scan images [15]. This article describes in depth the process of creating the models, yet no evaluation was carried out with students. Moreover, at Macquarie University and Western Sydney University in addition to anatomy models, medical images, prosected cadavers, and human bones; 3D prints of selected bones were fabricated from 3D surface scans [15]. In this letter to the editor, they described printed materials were used in anatomy laboratories in both universities; however, it is centered on bone elaboration and its usefulness, rather than evaluating the student’s perception of their learning process.
In the present study the overall experience of the participants of shoulder anatomy was rated as very good or excellent by almost 90% of the 3D models group members. In contrast, the students in the group 2D rated the activity primarily as fair or good by 65%, and none of them rated it as excellent. Likewise, a study carried out by Pandya, Mistry and Owens [16], described the use of videoconferencing and use of tactile learning with 3D models to assess the differences in undergraduate students’ attitudes toward tactile and non-tactile learning. In their results students believed tactile learning was statistically superior (p = 0.017).
Furthermore, Reid et al. described a study where five students participated in a special studies module entitles "Drawing and Anatomy" at the University of Cape Town [21]. Reid’s study coupled exploring the skeletal element, such as a skull, with a haptic experience with one hand and drawing with the other hand. The students were then interviewed mid-way thorough their intervention. Collectively, the experience resulted in an increased comprehension of the 3D form and detail of anatomical parts and cavities. Similar to the answers obtained from the 3D focus group. Other experiences using painting to learn anatomy were evaluated by Shapiro et al. [17]. In their study, they employed haptic surface painting to support learner engagement and spatial awareness. They described haptico-visual observation can support spatial, holistic anatomy learning.
Haptic sensing involves perceiving a variety of object features, such as object shape, size, weight, surface texture, compliance, and thermal characteristics [22]. In this manner, somatosensory haptic acquired information is also subjected to detailed analysis [23]. In our study, the students surveyed in the group that used 3D models perceived that the haptic activity favored their overall learning process, rating it primarily between the very good and excellent, representing 71.5% of their answers; while in the group that used only 2D images, more than 60% perceived the contribution that the activity provided to their learning process as poor or fair.
The haptic experiences in this study support the argument that their implementation favors meaningful, autonomous and collaborative learning, characteristics that are sought in all academic activities in current medical education. The opportunity to work with the 3D plaster models and actively participate in painting on them, demonstrated a significant impact on the learning of the medical students who scored 90% in the very good and excellent categories. It is evident that the bone plaster model material provided 3D metacognition of the structures, consolidating knowledge, making learning more motivating and satisfactory.
In regard to bone accidents, bone element laterality, muscle insertion and joint movement it demands from the student to orient the element in a spatial manner. The group that worked with the 3D plaster bone models graded it in the survey, as very good and excellent (between 85 and 90%). However, joint movement was not properly developed in this workshop. These same categories were rated between fair and poor (50 – 70%) for the 2D group. Collectively, haptic experiences in this study was shown to favor a significant learning, characterized by an autonomous and collaborative approach.
Although results in this study were satisfactory, the limitations observed were the workshop only lasted 90 minutes. Most likely, another 90-minute laboratory might allow students to recognize bone articulation and movements. Additionally, radiological images should also be included in the workshop to verify if learned concepts can be applied in a clinical setting. Last, evaluations of this nature should not be implemented after midterm examination, as they might affect students’ performance.