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The symptoms and stress experienced by medical students in anatomy dissection halls

Objective Exposure to the dissection of human cadavers is a stressful experience that causes a wide range of symptoms among medical students. This study examined the symptoms experienced by newly enrolled medical students of a Nigerian university following their first exposure to cadavers. Methods During the academic years 2018–2019 and 2019–2020, we conducted a survey among 87 second-year medical students who belonged to the Nile University of Nigeria. A self-administered questionnaire that assessed different symptoms and the Appraisal of Life Events (ALE) Scale were used to collect data. Results The participants obtained mean scores of 6 out of 30 (20.33%), 16 out of 30 (55.50%), and 5 out of 20 (26.15%) on the threat, challenge, and loss dimensions of the ALE Scale, respectively. When they were exposed to the cadaver, a majority of the students reportedly felt not only curious and excited but also anxious. Additionally, they reported experiencing symptoms such as palpitations, difficulty breathing, nausea, and feeling faint and dizzy. In order to alleviate such feelings, most of the students focused on the task at hand (i.e. dissection), engaged in religious activities, tried to relax, or sought the help of their lecturers. Conclusions Our findings revealed that, even though their first exposure to a cadaver was stressful, the students were resilient. The students appraised this experience positively and had taken efforts to cope with their symptoms. This is unlikely that stressful feelings pose negative influence on the medical students during their study in anatomy dissection hall.


Abstract
Objective: Exposure to the dissection of human cadavers is a stressful experience that causes a wide range of symptoms among medical students. This study examined the symptoms experienced by newly enrolled medical students of a Nigerian university following their first exposure to cadavers.
Methods: During the academic years 2018e2019 and 2019e2020, we conducted a survey among 87 secondyear medical students who belonged to the Nile University of Nigeria. A self-administered questionnaire that assessed different symptoms and the Appraisal of Life Events (ALE) Scale were used to collect data.
Results: The participants obtained mean scores of 6 out of 30 (20.33%), 16 out of 30 (55.50%), and 5 out of 20 (26.15%) on the threat, challenge, and loss dimensions of the ALE Scale, respectively. When they were exposed to the cadaver, a majority of the students reportedly felt not only curious and excited but also anxious. Additionally, they reported experiencing symptoms such as palpitations, difficulty breathing, nausea, and feeling faint and dizzy. In order to alleviate such feelings, most of the students focused on the task at hand (i.e. dissection), engaged in religious activities, tried to relax, or sought the help of their lecturers.
Conclusions: Our findings revealed that, even though their first exposure to a cadaver was stressful, the students were resilient. The students appraised this experience positively and had taken efforts to cope with their symptoms. This is unlikely that stressful feelings pose Introduction Any significant change that has the potential to alter the subsequent behaviours or functioning of an individual is a significant life event. 1 One's first close-up exposure to a dead body is widely regarded as a significant life event. 2 Exposure to a dead body can be regarded as an acute stressor because it is transient in nature. 3 Students experience stress when they are confronted with a stressor. 4 Students are exposed to several stressors, one of which is cadaveric dissection. 5,6 Such experiences tend to have a negative impact on student learning. 7,8 Depending on their stress response, the impact can be either positive or negative. Many medical students are exposed to dead bodies for the first time during cadaveric dissection in anatomy dissection halls. 9e11 The stress that they experience during such events determines their dispositions towards cadaveric dissection. A recent study 12 found that significant life events are related to sleep disturbances, which are known to have a negative effect on academic performance and promote antisocial behaviours.
According to the transactional theory of stress and coping (TTSC), 13 stress is a by-product of interactions between individuals and their immediate surroundings or environments. Their responses to a stressor are determined by their perceptions of the respective event. 14 Within the framework of the TTSC, there are three levels of stress appraisal: primary, secondary, and re-appraisals. Primary appraisals are appraisals of whether a stressor is threatening. Secondary appraisals entail an assessment of the resources that are available to cope with a stressor. Re-appraisal involves continuous appraisals of a specific stressor and available resources. When faced with a stressful event, an individual will adopt either problem-or emotion-focused coping strategies, depending on their secondary appraisals of a stressor. 13 Individuals use problem-and emotion-focused coping strategies when the resources that they require to cope with a stressor are perceived to be sufficient and insufficient, respectively. 13 In Nigeria, the first-year medical curriculum covers primarily the general sciences (e.g. biology, chemistry, and physics), whereas the second-and third-year curricula cover the basic medical sciences (e.g. anatomy, physiology, and biochemistry). The two notable methods that are used in the study of anatomy are didactic lectures and cadaveric dissection. 15,16 There is evidence to suggest that the symptoms of post-traumatic stress disorder (PTSD) are exacerbated by exposure to human cadavers in anatomy dissection halls. 17 Long-term participation in an anatomy dissection course has been found to increase the prevalence of the symptoms that are indicative of PTSD among medical students. 17 The prevalence of stress, and possibly, PTSD, that is attributable to cadaveric dissection ranges from 8% to 9%. 18 Students who dissect human cadavers experience negative emotional reactions (e.g. depression, fear), palpitation, insomnia, a loss of appetite, and visual images of cadavers. 19,20 More importantly, stress and anxiety are related to general memory and learning deficits. 21,22 Therefore, further exposure to stressful events may increase their risk of academic failure and dropping out of medical school.
The Nile University of Nigeria in Abuja recently established a medical school. Accordingly, we conducted this study to examine (1) the symptoms experienced by young medical students following their first exposure to cadavers in an anatomy dissection hall and (2)

Materials and Methods
This descriptive cross-sectional study was conducted among the medical students of the Nile University of Nigeria in Abuja. The study population was 100 second-year (Year II) medical students (2018e2019 academic session: n ¼ 50, 2019e2020 academic session: n ¼ 50). Convenience sampling was used, and second-year students who were willing to participate in the study were included in the sample. Data were collected from the two samples in November 2018 and 2019, respectively. Getachew 23 has developed a reliable and valid measure of dissection hall experiences, and this assessment was used in this study. It was pre-tested and validated as a part of this study.
On the day on which they were first present in the anatomy dissection hall, the students were provided with the measurement instruments. The questionnaire consisted of three parts: demographic data, symptomology (i.e. a modified version of Getachew's 23 assessment), and the Appraisal of Life Events (ALE) Scale, which assesses the dimensions of threat, challenge, and loss. 24 The 16 items of the ALE scale assess threat (items: 1, 2, 4, 5, 14, and 15; maximum possible score: 30), challenge (items: 3, 6, 7, 8, 12, and 13; maximum possible score: 30), and loss (items: 9, 10,11, and 16; maximum possible score: 20). Threat and loss are considered to be negative appraisals, whereas challenge is considered to be a positive appraisal. Responses are recorded on a six-point Likert scale that ranges from 0 to 5. Students provided informed consent after they were informed about the study and its purpose. Subsequently, they completed and returned the measurement instruments. To analyse the data, ranges, means, and percentages were computed using Microsoft Excel 2010 for Windows. The results are presented in tables and illustrated using bar charts.

Results
During the 2018e2019 academic session, 40 (80.00%) out of the 50 second-year medical students consented and participated in this study. During the 2019e2020 academic session, 47 (94.00%) out of the 50 second-year medical students consented and participated in the study. Therefore, the overall response rate was 87.00% (n ¼ 87). The sample consisted of 14 (16.09%) men and 73 (83.91%) women. The mean age of the participants was 18.10 years (range: 15e26 years).
Descriptive statistics for the scores that the participants obtained on the ALE scale are presented in Table 1. They obtained a mean score of 6.1 (20.33%) out of 30, 16.65 (55.50%) out of 30, and 5.23 (26.15%) out of 20 on the threat, challenge, and loss dimensions, respectively. Their scores on the threat, challenge, and loss dimensions ranged from 0 to 24, 3 to 25, and 0 to 19, respectively.
Specifically, 59 and 45 of them reported feeling curious and excited, respectively. However, 18 and 14 of them reported feeling shocked and frightened, respectively. Additionally, 5 participants reported that they cried (Figure 1). Figure 2 presents the symptoms that the participants had experienced when they were present in the anatomy dissection hall. Out of the 87 participants, 30 of them reported experiencing palpitations, 16 of them had difficulty breathing, and 16 of them felt nauseated. Further, 12 students reported experiencing dizziness, a headache, and eye irritation. Seventeen students experienced 'other' symptoms, and 21 of them did not experience any symptoms when they were present in the dissection hall. With regard to the other symptoms, 8, 6, and 5 participants reported feeling faint, experiencing  Figure 1: Students' emotional responses following their first exposure to cadavers.  tremors, and coughing, respectively. Restlessness and a loss of appetite were reported by 4 participants each.
With regard to the possible causes of the symptoms that were experienced by the participants, it can be inferred from Figure 3 that a majority of them (n ¼ 52) reported that their symptoms were caused by the smell of the environment. The sight of the cadaver was the second most commonly reported trigger (n ¼ 32). Twelve students reported that looking at certain parts of the cadaver triggered their symptoms. Only a few students reported that their symptoms were triggered by their exposure to a cadaver (n ¼ 9) and a fear of infection (n ¼ 4).
In response to the question that assessed the strategies that they had used to cope with the symptoms triggered by their exposure to a cadaver (Figure 4), most of the participants reported that they had tried to relax (n ¼ 34), focus on the task at hand (n ¼ 31), or pray (n ¼ 30). Others socialised with their friends by means of joking (n ¼ 22), whereas others sought the advice or counsel of their lecturers (n ¼ 12). A few students (n ¼ 8) read the scriptures of their respective faiths. Moreover, 13 (n ¼ 13) students engaged in 'other' activities.

Discussion
Everyone faces stressful events as a part of their daily lives, but medical students experience higher levels of stress, which are attributable to specific aspects of their training that the general population is not exposed to. 25e27 Similar to the findings of past studies that have been conducted using different student samples, first-time exposure to a cadaver was found to be a stressor. 28,29 In a past study, 23 many students had reported that they had experienced a loss of appetite and fear and could smell the odours in the dissection hall. In one study, which was conducted among the students of the University of Jos in Nigeria, the most commonly reported concerns were a fear of infection and dizziness. 30 In another study that was conducted in Australia, the smell of the dissection hall was identified as a factor that caused students to avoid attending dissection sessions. 31 Similar to past findings, the smell of the dissection hall was the most commonly reported trigger of the symptoms that were experienced by students. Therefore, it is necessary to ensure that dissection halls are adequately ventilated to mitigate the negative effects of such odours. Similar to past findings, several participants reported feeling faint and experiencing palpitations, dizziness, eye irritation, and difficulty breathing. This is attributable to the fact that the chemical that is most commonly used to preserve cadavers, namely, formaldehyde, is known to cause adverse symptoms, especially in those with allergies. 32,33 Most of the participants perceived this experience to be a challenge, which is a positive appraisal. This finding concurs with those of past studies. 4,29,34,35 Since their overall perception of this experience was positive, it is unlikely that students will avoid attending dissection sessions. Their positive appraisals of these experiences may be accounted for by an explanation that has been offered by Schwarzer and Schulz 36 : anticipated events cause more stress than unanticipated ones do. Though exposure to cadavers is stressful, past studies have shown that students adapt to such experiences rather quickly (i.e. within a few weeks). 4,34 However, due attention should be paid to the few students who appraise this experience negatively. To ensure that such experiences do not adversely affect their academic progress, strategies that can effectively address their concerns should be adopted. This is particularly important in countries (e.g. Nigeria) where cadaveric dissection is a strategy that is commonly employed in the study of anatomy. As past studies have shown, failure to address the concerns of such students will render them very vulnerable to psychological morbidities. 26 Consistent with past findings, most of our participants adopted problem-focused coping strategies to deal with their stressful experiences. 36,37 Most students perceived the event as a challenge; accordingly, instead of avoiding dissection, they focused on the task at hand, as evidenced by their reports that they were curious and felt excited. They were able to cope with their challenging experiences by socialising with their classmates, talking to their lecturers, and engaging in religious rituals (e.g. reading the scriptures of their respective faiths). A study that was conducted in 1995 38 found that spirituality is an important factor that helps individuals cope with stressful events, and this finding is consistent with our own results.
In general, students consider cadaveric dissection to be exciting and integral to their learning. However, it is important for them to be adequately prepared for the emotional ramifications of such an exercise before they commence dissection. 39,40 A recent study 41 found that playing background music in the dissection hall is effective in ameliorating some of the symptoms that are experienced by students. Adopting such strategies will not only make the dissection hall less repulsive but also enhance the extent to which students benefit from dissection sessions.

Conclusion
Going by our finding, even though their first exposure to a cadaver was stressful, our participants appraised this experience positively and tried to cope with the resultant symptoms. Thus, the stress that is caused by exposure to cadaveric dissection is unlikely to have a negative effect on student learning in anatomy dissection halls. Due attention should be paid to the few students who appraise this experience negatively. Their concerns about the environment of the dissection hall should be addressed to make the laboratory more student-friendly and conducive to learning. In addition, teachers should adequately prepare their students for cadaveric dissection by informing them about what they should anticipate, and equipping them with strategies that they can use to cope with any resultant negative experiences. Such strategies may enhance the extent to which cadaveric dissection is meaningful and beneficial to their learning process.

Source of funding
This study did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Conflict of interest
There is no conflict of interest.

Ethical approval
Ethical approval to conduct this study was obtained from the Ethical Review Board of the Nile University of Nigeria in Abuja. This study was conducted in accordance with the Declaration of Helsinki.

Consent
The participants were informed about the aim of the study, and they provided informed consent prior to participation.

Authors contributions
TC and OIO conceived and designed the study. AOA and OO conducted the study and identified suitable research instruments. MIO collected and organised the data. All the authors analysed the data and interpreted the results. All the authors wrote the initial and final drafts of the article and provided logistic support (where necessary). All authors have critically reviewed and approved the final draft and are responsible for the content and similarity index of the manuscript.