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Anatomy Is Overrated

Anatomy Is Overrated Blog

“Richard Feynman’s father, Melville, taught his son, the difference between knowing the name of something and knowing what goes on:

See that bird?  It’s a brown-throated thrush, but in Germany it’s called a halzenfugel, and in Chinese they call it a chung ling and even if you know all those names for it, you still know nothing about the bird.  You only know something about the people; what they call the bird.

Now the thrush sings, and teaches its young to fly, and flies so many miles away during the summer across the country, and nobody knows how it finds its way.

Doesn’t this tell us something in the sense of learning?  Words or names don’t constitute knowledge. Knowing the name of something doesn’t help us understand it.”

-Bevlin’s Seeking Wisdom, the “secret f’ing weapon” according to Mladen Jovanovic

Anatomy is overrated for physical therapists and movement professionals.  To preempt the strawman responses, anatomy is not unimportant. Anatomy is just not typically taught in a manner that contextualizes its real utility.  Traditionally, the study of anatomy is akin to memorizing the instruction manual (including all the parts and unique nomenclature- effectively learning a new language) for a car in hopes of becoming a better driver.  During my first semester of physical therapy school I was responsible for identifying every muscle, bony landmark, blood vessel and nerve in the body. Almost eight years later, I would most certainly fail any of the written or practical exams from that course.  I can no longer draw the brachial plexus from memory. My current inability to do so does not diminish my appreciation for how the brachial plexus is important conceptually. If clinical practice alone does not reinforce the information tested in an entry level course, however, then said course is a means of initiation or selection, not a precondition for clinical competence.

We “study” for exams.  True learning is generally a much more joyful process.  The anatomy course is the ultimate rite of passage in most medical programs owing to the sheer volume of information that must be regurgitated and later mainly forgotten.  Holding aspiring medical providers accountable for memorizing anatomical details that can be instantly looked up on a smartphone doesn’t reflect modern clinical priorities.  Drawing the brachial plexus from memory is the academic equivalent of “grinding” 16x200m to develop speed or training football players like Dale Hawkins to develop “mental toughness”.  Sometimes, hard work and subsequent virtue signaling about said effort interferes with actual readiness.  Anatomy courses almost always miss the forest for the trees.  Anatomy is a lot like “energy systems”, a useful albeit often overcomplicated construct for informing clinical reality.  

Dale Hawkins…

While medical providers need to speak a common language, including an anatomical one, to effectively communicate, their linguistic abilities are most effectively developed and retained by practicing, not by learning esoteric terms devoid of clinical context as generally occurs in a gross anatomy course.  “Structure dictates function” is the primary justification for the manner in which most anatomy courses are taught. This statement seems at odds with the possibility that structure and function evolve concurrently to solve environmental problems and maximize the chance of survival. Perhaps a more accurate statement is “evolutionary pressure to survive drives adaptations that manifest themselves structurally”.  Anatomy is a dynamic, not a static concept. Anatomical details would be better retained if courses took a more multi-disciplinary approach.  

Furthermore, immersive learning develops linguistic acumen better than the reverse engineering of language that occurs mainly in academic settings.  For physical therapists and sport coaches in particular, the application of anatomy is much different than identifying landmarks on a cadaver or software program.  Additionally, the logistics of cadaver dissection necessitate that gross anatomy is seldom taught in conjunction with corresponding physiological and clinical blocks of instruction.  Observing anatomical structures in a cadaver is a unique and amazing experience. I’m just not sure that my current inability to recall much of what I memorized during my anatomy course is influencing my clinical outcomes. 

 If I’m being honest, my clinical decision making process and pattern recognition ability wouldn’t change at all if I forget the names of most of the anatomical landmarks I can currently recall from memory.  A physical therapist need not necessarily recite “long thoracic nerve” to refer a patient with pronounced scapular winging following a traumatic injury to a neurologist. For movement professionals, the ability to identify a pathological joint or gross anatomical anomaly is more important than recalling the name of a structure that seldom manifests clinically.  Besides, one can always confirm a nerve innervation or muscular attachment site on a smartphone in a few seconds. 

Learning what a pathological joint looks and feels like is cultivated through experience (e.g. assessing many joints), not in a cadaver class.  I’m not suggesting that physical therapists, as an example, not know what an ACL is. I do, however, think physical therapists and other medical professionals should be a little more reflective about the relationship between the degree of theoretical precision that enhances clinical competence and self aggrandizing minutiae.  Unnecessary complication pervades much of physical medicine and sports performance. Medicine, like many professions, often looks inward at the expense of the end user. Internal constructs like anatomy should inform, not confound, the bigger picture.  

So what if much of what people learn in courses like anatomy is forgotten?  Time and resources are finite. Unnecessary complication increases curriculum length and tuition costs are already a deterrent to entering medicine.  Why is it a given that physical therapy school must be three years and medical school four years (not including residency/fellowship), as examples. Universities are naturally incentivized to make entry level medical programs as long as possible but not so long that people won’t sign up.  Moreover, attention and focus are finite. Overly emphasizing certain models/constructs, like anatomy and energy systems, necessarily comes at the expense of something else. Overemphasis on anatomy may lead to overvaluing micro level measurables like EMG. Remember when the vastus medialis was the magic muscle for knee pain?  Now it’s the gluteus medius. Soon it will be something else. For now, clam shell variations are “good” and I can’t justify why beyond the fact that they elicit high EMG readings in a muscle we like; they provide us with data points that are easy to measure. Worshipping anatomy for its own sake is scientism. 

In depth anatomy reviews frequent manual therapy courses and specialty certifications for physical therapy.  The idea with manual therapy is that one needs to know what tissue (s)he is palpating to elicit a therapeutic effect.  This narrative supposes that practitioners are skilled enough to definitively differentiate among the deep hip rotators, as an example, and that the ability to differentiate them actually matters clinically.  With any intervention, one certainly needs to know what not to do to avoid harm (via negativa- e.g. don’t dry needle the sciatic nerve) but I doubt that manual therapists are as therapeutically precise as many of them think they are.  Thankfully, it probably doesn’t matter. It’s easier to create multiple weekend-long manual therapy courses and fellowships if there’s a “specific” technique for every muscle in the body though. Complexity sells better than “desensitize the painful area through whatever combination of touch and non threatening movement reduces symptoms”.  Additionally, manual therapy is something to be physically done, not “studied” via relearning the first semester of graduate school.       

All models are wrong but some are useful- I agree.  I’m not advocating epistemological nihilism here. Some models are better than others, however, and these models allow people to ask more informed questions to presumably find more satisfying answers.  There are reasons to study anatomy in great depth no matter the carryover to clinical practice. Those reasons don’t necessarily apply to entry level medical programs or clinical professional development programs though.  The methods need to match the intent. The “best” physical medicine providers are often the ones with the greatest anatomical recall. These providers also tend to be the most driven and motivated to excel via whatever means they are selected and judged.  Much like the content on standardized tests, anatomical recall is probably a proxy for other qualities that correlate with clinical success.  The question academia should always be asking, however, is would the return on investment be better spent emphasizing something else.  Selection bias masks antiquated educational practices.