Background

Medical education provides information in the medical sciences and clinical practice (1). Various methods are used for medical education, including traditional face-to-face instruction, e-learning, and blended learning. Teaching medical students in the clinical setting with real patients is a time-honored tradition. This technique is a crucial component of clinical training. The traditional method allows medical students to engage in clinical activities and practice and become acquainted with the cultural and social aspects of the clinical environment. Direct observation and receiving feedback are two important factors in the successful education of medical students (2).

E-learning aims to provide distance health education using Information and Communication Technologies (ICT) (3). With the outbreak of the Coronavirus Disease in 2019 (COVID-19), using this method of education has become more popular, particularly in medical education. However, practical issues, including unstable internet connectivity, a lack of computer laboratories, and the shortage of PCs and laptops, make it difficult to employ e-learning effectively (4).

The combined use of electronic and traditional education is called blended learning (5). Using this method creates flexible learning environments and more interaction in learning (6). Blended learning has different forms, which have a high potential to transfer content (7). Nowadays, various types of combined learning models, such as hybrid and flipped models, are among the most widely used educational methods in education and provide continuous and effective learning (8).

A study demonstrated that mobile applications could improve the performance of medical student learners (9). Another study showed that 3-dimensional (3-D) anatomical models could improve medical students’ knowledge of ear anatomy more than traditional teaching methods (10). Although numerous studies have reported the benefits of e-learning in medical education, others have indicated that it cannot replace the traditional method. For instance, a study conducted in Greece revealed that traditional anatomy teaching is a more preferred and effective teaching method than e-learning. Remote learning cannot replace the conventional method of anatomy instruction, but it can be used as part of a blended learning approach (11).

According to the literature, blended learning can replace two other methods in medical education because it enhances the learning experience and the satisfaction of both students and teachers (12). It also enhances students’ commitment by involving them in learning (13).

Anatomy is a major in medical education. Numerous studies have been conducted on the effectiveness of blended learning in anatomy courses (14-16). Based on our knowledge and investigations, despite various studies in this field, no study has examined the effect of blended learning on anatomy education.

Objectives

The present study was conducted to investigate the effect of blended learning on teaching anatomy to medical students.

Methods

This comprehensive literature review was conducted on December 3, 2022. Our research was conducted by adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

Sources of Data: Online databases PubMed, Eric, and Web of Science were systematically searched for relevant articles using predefined keywords. Using EndNote, all relevant literature published within the past five years was retrieved and further analyzed. Table 1 summarizes the search strategy.

Table 1. Details of search strategy by databases

Goals of Study: This study’s primary objective was to investigate the effect of blended learning on teaching anatomy to medical students.

Inclusion criteria

• English studies.
• Studies reported the efficacy of using blended learning to teach anatomy to medical students.

Exclusion Criteria

• Lack of access to the article's full text.
• Non-English language articles.
• Articles that were not original, such as review articles, systematic reviews, letters to the editor, short communication, books, and commentaries.

Process of Study Selection: Related studies were reviewed through title and abstract screening by two authors independently.

Disagreements were mentioned and resolved through consensus in a joint meeting with the third reviewer. Then, the authors checked the full text of the articles based on the eligibility criteria, and finally, the information was extracted from the articles and collected in the relevant tables.

Data Extraction: Two investigators independently summarized and extracted the following data from the included publications: author, year, country, study aim, population, domain, intervention, study design, sample size, and main outcomes. The collected information is organized in the relevant tables.

Results

Our comprehensive search strategy resulted in the retrieval of 351 articles. After screening the articles and selecting the articles based on the inclusion criteria,
22 articles were eligible and included in the study. The details of the study selection process are presented in Figure 1. Most of the studies were conducted in India
(n = 5), China (n = 2), United Kingdom (n = 2), and Portugal (n = 2). The distribution of articles in each country is presented in Figure 2 and Table 2.

Table 2. Frequency of reviewed articles per country

According to the results obtained, the highest peak of the use of blended learning was in 2022. The frequency of articles published in different years is presented in Figure 3.

Also, most of the studies were experimental, the details of which are presented in Table 3. Since the study aimed to confirm the blended learning method in anatomy education, the investigated sub-branches of anatomy included histology, knee and shoulder anatomy, brainstem anatomy, gross anatomy, musculoskeletal and cardiovascular anatomy, anatomy pathology, nerve and head, and face radiology.

In the reviewed studies, different learning methods have been used, such as the flipped classroom, a variety of hybrid methods, online platforms, and electronic learning modules. The details of the learning models are presented in Figure 4.

Figure 1. The process of selecting articles

Figure 2. Distribution of articles per country

Figure 3. Frequency of articles by publication year

Figure 4. Frequency of blended learning models used in studies

Table 3. Summary of characteristics of the included studies

One of the criteria that can be used to measure the quality and effectiveness of teaching and learning is the satisfaction of learners (38). In this study, the effectiveness is the subjective understanding that students have
about the desired results of blended learning programs, that if they are successful in the blended learning program, they will be more satisfied than others (39). In some studies
(15, 20, 25, 34), students' use of blended learning method has satisfied them significantly. In addition, in several studies (22, 31), a large proportion of students (more than half) participating were satisfied with blended learning methods.

Another criterion for evaluating the effectiveness of learning methods is improving learners' performance (40). Researchers used different methods to investigate performance improvement. The noteworthy point is that in the studies (15, 19, 21, 22, 24, 25, 27-29, 31-33, 35), performance improvement when working with a blended learning environment has been reported, indicating the correlation of performance with blended learning methods.

According to the review of articles in the last 5 years, several studies (17, 21, 23, 24, 32, 37) investigated the use of blended learning during the outbreak of COVID-19, all of which reported the positive effect of using this method. The most important finding of all reviewed articles was the effectiveness of blended learning, which is mentioned as an effective method for teaching anatomy.

Discussion

This study aimed to investigate the effectiveness of blended learning methods on the learning level of medical anatomy students. To this end, we focused on different learning methods and their impact on anatomy learning.

The search conducted yielded 351 results, of which we identified and included 22 unique papers. Overall, the studies sought to describe the development of hybrid
e-learning interventions (19, 33), compare the efficacy of such interventions to traditional learning (17, 18, 32), and validate students’ perceptions of hybrid e-learning
(19, 22, 26, 37). These studies and the increasing number of papers published over the past five years indicate that the blended learning field is still evolving, with the primary emphasis on intervention efficacy and acceptability evaluation (17, 18, 20, 24, 35, 36). Because anatomy is a fundamental medical science course and anatomy learning programs are typically taught to medical students in their first and second years of study, most reviewed interventions were primarily designed to educate first-year medical students (17, 18, 27). Interactive electronic modules were the most prevalent form of blended learning in the studies (15, 19, 21, 24, 34).

There were many functional similarities between the reviewed interactive e-modules, including the collection of clinical cases to aid student learning, the provision of interactive questions to encourage active participation, the recording of student progress for tracking student progress and performance, and the provision of individualized feedback to prevent students from making possible mistakes. However, developed interventions do not seem the same in different medical areas. For example, in neuroscience and surgery fields, more sophisticated features such as virtual reality and augmented reality have been introduced compared to other fields. This could be due to the more complicated nature of those fields in terms of domain and user-specific requirements (34, 41, 42).

Based on our study, two studies (32, 37) investigated the effect of blended learning in the COVID-19 crisis, pointing out the favorable effect of the blended learning method. According to the obtained results, it is inferred that the blended learning method is a practical and promising approach for the post-corona era (43). Restrictions on access to cadavers during the pandemic may affect the teaching and learning of anatomy. Therefore, digital learning may replace real cadavers shortly (44).

Blended learning has been used in various areas of anatomy education, such as histology, shoulder and knee anatomy, brainstem anatomy, gross anatomy, musculoskeletal and cardiovascular anatomy, radiological anatomy, head, face, and neck. In most cases, the results have been reported to be favorable. These results suggest that in addition to face-to-face training, using blended learning may promote active learning in different educational fields. Blended learning had an overall positive effect. Various techniques were used to teach anatomy, such as flipped classrooms,
e-Learning modules, simulators, online blended courses, mobile learning, videos, computer-assisted learning, and three-dimensional software. All these techniques somehow improved the skills of medical students. According to Karbasi and Niakan, new educational methods are very effective in this field, considering the importance of medical education. New technologies have provided new opportunities for anatomy education (45).

Therefore, it can be claimed that blended learning is an effective process to increase the motivation of students to learn and participate, thereby improving the effectiveness of medical education.

Limitation: Based on the review and knowledge of the authors, this is the first systematic review of the effect of blended learning methods on anatomy learning for medical students. Hence, it is challenging to compare the results between studies. Since we investigated the effectiveness of anatomy on medical students, it limited the search results based on the keywords of combined learning and synonyms.

Conclusion

Blended learning can improve performance and increase satisfaction and motivation in students. Identifying suitable learning resources with medical students’ abilities improves learners’ knowledge. Applying new learning methods can be very effective as some conditions, such as the COVID-19 crisis, limit access to corpses and physical presence. Using the
face-to-face method and new teaching methods and their combination can positively affect learning due to its high flexibility. It is suggested to conduct other studies to deal with various blended learning methods and compare them in another discipline.