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One of the subjects discussed at the 18th Fort de France Orthopaedics Seminar was disorders of the talus and its adjacent joints. The speaker who attracted the greatest attention was not an orthopaedist: Prof. Maurice Laude is one of France’s great anatomist. We invite you to meet this warm and articulate personality through this interview conducted by Maîtrise Orthopédique.
M.O.Mr. Laude, what are your titles and functions?
M.L.I am Professor Maurice Laude, and have been Dean of Amiens Medical School for the past 12 years. My chief function, though, is that of Professor of Anatomy and Organogenesis; my clinical work is in Rehabilitation. I have led a research team studying human and compared craniology, looking into everything and anything to do with the head and neck, for the benefit of all sorts of professionals: dentists, vets, GPs, radiologists, neurosurgeons - anyone, in fact, that is interested in the head end of the body. Over a period of 20 years or so, I have supervised 50 high-level postgraduate theses. I have taught a lot, because I am passionate about teaching. I teach between 3 and 5 hours a day, and I train the lecturers in teaching techniques, in preparation for the practical teaching demonstration they will have to give when they take their Agrégation exam on the way to becoming Readers and Professors.
M.L.Not at all. I was a gastroenterologist, and spent 10 years working in that discipline after I had come to Amiens. Then the school of physiotherapy at the orthopaedic centre at Berck-sur-Mer was closed down. The school had been an outpost of the Paris Hospital Administration, under Mr. Debeyre. So the mayor of Berck, who was himself a doctor, wanted to set up a municipal school of physiotherapy, and asked me whether I would like to be in charge of such a facility. I said yes, because, at Amiens, we had neither a rehab department nor a school of physiotherapy. In consultation with the educational authorities and the Amiens hospital administration, I spent a day a week, for 12 years, at the Berck training centre. In 1972, I opened a School of Occupational Therapy there. In 1982, we at last got our own School of Physiotherapy at Amiens, and I left Berck. At the hospital, we only had two physiotherapists at the time, and one of them was part-time only. Now, there are 27, with two departments of rehabilitation, and a school of physiotherapy. Since 1968, I have also been in charge of education, on behalf of Amiens Medical School, at the School of Senior Physiotherapy Officers at Bois-Larris. As you can see, there has been a string of opportunities for putting functional anatomy, kinesiology, and biomechanics to practical use.
M.L.Anatomy. At the time, training in Anatomy ran parallel to one’s medical training. There were several milestones. First, one would be an unpaid demonstrator - after one’s second undergraduate year, if one felt that one wanted to do Anatomy, one would go round the departments of anatomy, asking, "Could I work here as a demonstrator, to teach the new intake osteology and arthrology?" Then, one had to take an exam known as the Adjuvat, and then another called the Anatomy Prosectorat; eventually, one would become a junior lecturer in Anatomy. The work involved doing practicals and dissections with the students every working day.
M.L.Yes. This was the old system: providing one was working in the hospital in some capacity, one could take the exams leading to higher qualifications in Anatomy. That was before the present system, with its insistence on the triple function of patient care, teaching, and research.
M.L.I was much influenced by my own teachers - by Jean Minne and, above all, by Claude Libersa - who taught anatomy at Lille. I also became interested in Anatomy early on because it is such a practical science, which involves a lot of cutting up and feeling with one’s fingertips. I think that, with Physiology and Semiology - signs and symptoms -, Anatomy is one of the three fundamental disciplines on which all medicine rests. As Dean of the medical school, I often have to fight to restore these three subjects to their due place. If one wants to train good doctors, they must know their signs and symptoms; and this knowledge, in turn, presupposes a knowledge of the two disciplines that underpin clinical medicine: anatomy and physiology. Another reason why I loved Anatomy was that I was keen on drawing; also, it is a strict science, where one cannot just make things up. In other disciplines, one may, in due course, stick a CH2 group on a molecule somewhere or other. In anatomy, the midline sagittal plane goes there, and there alone.
M.L.Yes. I owe my career to my teacher Claude Libersa, who was an anatomist and an ENT specialist. The way one was taught by him was a true apprenticeship. At the crucial point when I was preparing for my Agrégation, with the formidable teaching demonstrations that one had to give, he left his wife and kids in Lille and spent a month with me in Paris, sleeping in a room next-door to mine, so as to be able to provide moral support and to take me through mock demonstrations every day. I took the exam under the old system, back in 1962. However, there were no vacancies at Lille, so I was appointed to a post at Caen. In 1964, a professorship became vacant at Amiens Medical School, and I asked for a transfer, so as to be closer to my roots and my teachers, and in order to get a proper Department of Anatomy going at Amiens. At the time, there was no laboratory, and only 30 students.
M.L.Not at all. The way I was trained, and the way I teach my students and my staff, one has to be able to deal with anatomy in its entirety. In order to ensure that, we swap around every year. So, Daniel Le Gars, my Reader, a neurosurgeon, is currently lecturing on the pelvic organs in the female. Despite his own specialization in neurosurgery, he can lecture at will on the female perineum, the thyroid, or the limbs. All those who work under or with me have been trained in the same way. It takes 10 to 12 years to get someone to the stage where they can cover the whole of Anatomy.
M.L.They were morphological anatomists, which perhaps did a bit of a disservice to Anatomy. They were meticulous describers, who did not necessarily try to find the practical applications of what they had observed. They produced marvellously accurate and detailed drawings. Now, a correct drawing of the head of the radius will show that this structure is not completely round - one of its diameters is 4 mm wider than the others. That is a crucial detail, because the difference in diameters is vital for supination. That is the sort of detail that has a practical value. However, these earlier anatomists did not recognize that; they just taught that there was a difference, full stop. Their attention to minute detail may not have helped the cause of Anatomy, which came to be seen as the equivalent of entomology, where similarly inclined searchers get everybody’s back up with a host of itsy-bitsy details that have no practical application whatsoever.
M.L.Where I see myself? I teach bread-and-butter Anatomy. Firstly, by referring to medical imaging, because all the CT and MR scans are merely the good old anatomical sections that people had forgotten about. It was the radiologists who rediscovered the importance of anatomy. I had foreseen this at the time I was still in gastroenterology, when I did a treatise on coeliac and mesenteric arteriography, with my colleagues from Radiology. At that time, there was a lot of abdominal arteriography being done, and I was struck by the importance of Anatomy in medical imaging, and by the many anatomical variants encountered. In some parts of the body, these variants can be very frequent. This is why we have to teach them, especially to those who want to be surgeons; we have to tell them that the common hepatic artery may arise from the superior mesenteric artery, and that cutting this structure will be disastrous. Similarly, there may be aberrant hepatic veins, and, in liver transplants, unfamiliarity with this pattern can lead to disaster.
Also, I am not only Professor of Anatomy, but also of Organogenesis. After all, morphogenesis is a very important subject. One has to know how an organ or a vascular system comes to assume its final shape. If one does not know the morphogenesis of the heart, how on earth would one understand the transposition of the great vessels? And, finally, Anatomy must always be related to the clinical context. Take the pancreas: I describe the gland, its position deep in the abdomen, its relations with the coeliac plexus. Among the 100 undergraduates to whom I am lecturing, there are maybe five who will be surgeons, and only one of those will be doing gastrointestinal surgery; the others will be GPs, psychiatrists, or paediatricians. However, in order to understand the signs and symptoms of an acute upper abdomen, to understand the pattern of deep epigastric pain radiating into the back, one must be familiar with the deep relations of the pancreas. I then show them sections of the pancreas of the kind they will see on CT scans when they will be doing their clinical training. Anatomy also has to be functional - but the amount taught will depend on the needs of one’s audience. I provide 75 hours of lectures on a limb for physiotherapists, and 18 hours, on the same limb, for medical undergraduates. That makes sense, considering the fields in which the respective students are going to work. However, when it comes to lectures on the interosseous muscles of the hand for physiatrists, there is a need for that audience to know exactly how these muscles work; which means that I go into all the expansions, all the slips and connections with Landsmeer’s ligament, and the entire nerve supply, so that they can really understand what an ulnar palsy is all about.
M.L.You may be right; however, I have been training people like that for the past 15 years or so. If you were to do Anatomy at Lille, for example, with Christian Fontaine or Antoine Drizenko; or at Nantes, with Jean-Michel Rogez or Roger Robert; at Limoges, with Denis Valex; at Marseilles, with Christian Brunet; at Rennes, with Pierre Darnaud; or at Bordeaux, with Philippe Caix and Dominique Midy - they have all been through this medical school, and they all teach the way I have been telling you. Of course, there are still many who teach Anatomy for want of something better, as a temporary career move. They have been told, "There is no vacancy in your speciality at the moment, but if you go and do a bit of Anatomy in the meantime, we’ll see what we can do for you." This is how you get a situation where one teaches the anatomy of the heart, and another that of the neck, and yet another that of the limbs; with each one saying, "The rest of the body I’m not interested in." And as soon as possible, they will get out, and return to their clinical speciality practice. These people aren’t "proper" anatomists at all.
MLTo be honest, while there were still Anatomy questions included, they did not really do that much good. People would mug something up, and regurgitate it in the examination room, without ever seeing the practical applications of what they had learnt. There was a time, particularly in Paris, when every junior surgeon had to be a prosector. That was at the time of Cordier: everybody had to have done Anatomy, because dissection is the sine qua non of operative surgery. Nowadays - well, you know how abysmal the junior surgeons’ knowledge of anatomy is. Some are brave enough to tell us, "When I was at my teaching hospital in Paris, we could choose between the head and neck or the limbs, and I opted for the limbs, because they are easier; but now I know nothing of the head and neck." During an ENT procedure, one of them asked whether the oesophagus was in front or behind the trachea. At least he had the courage to ask: there are others who haven’t, and whose ignorance is just as great. It’s a tragedy. As you rightly point out, Anatomy, with Physiology and Histology, used to be the keystone, at the turn of the century and up to the ‘40s and ‘50s. However, in those days, there was no Immunology, no Microbiology, no Pharmacology, no Genetics. All these sciences have mushroomed, and they have had to be fitted somehow into the medical school curriculum. Also, we are seeing now that the school-leavers we get sent up to medical school are not particularly well educated. We are being asked to teach them general studies, English, statistics, and information technology. So Anatomy is being squeezed out. However, it is not our job to make up for the shortcomings of the secondary level, from which we are getting an unfinished product. Your remarks echo what I am hearing everywhere, whenever I go to a learned society to lecture on the third ventricle of the brain, on the mesorectum, or on the biomechanics of pronation and supination. People wonder why it is that everybody needs Anatomy and yet nobody has the courage to get tough and demand a compulsory anatomy module for junior doctors, before they can take their specialty finals.
M.L.I think it is one of the unintentional yet adverse effects of the 1958 Debré reform, which required those who teach in a teaching hospital to be also practising clinicians. Health is now dipping into the pockets of Education, to pay for professors who, but for their professorial salaries from the medical school, would be off into private practice. What has to be borne in mind is that their retirement pensions are calculated on their medical school salaries, not on their hospital earnings. However, they spend 99% of their time in their clinical practice, and 1% in their university functions. So you have someone who is Professor of Anatomy/neurosurgeon; Professor of Anatomy/orthopaedic surgeon; Anatomy/cardiovascular surgeon; Anatomy/radiologist; Anatomy/ENT; etc. And these people run a department of neurosurgery, or orthopaedic surgery, etc. And they say to themselves, "I haven’t got time any more to deal with Anatomy; and anyway, Anatomy is not a money-spinner." So, if anatomical research is down, it is largely due to this system. There aren’t many people left in the Anatomy laboratories. Overall, most of those who teach the subject just muddle along: if they are orthopods, they teach the limbs, and ask a neurosurgeon, a gynaecologist, or a cardiologist to fill the gaps they are leaving. This has made a nonsense of the teaching hospital principle that requires those who work there to teach, look after patients, and do research. Our European colleagues - and we do need to see what is happening elsewhere in Europe - laugh when they see us. They say, "We find it difficult to cope with two functions; so how do you, in France, hope to cope with three?" It’s not difficult: you spend 90% of your time looking after patients, and in the remaining 10% you do a bit of teaching; research doesn’t even get mentioned. However, this system also has its good sides, because it has allowed us to keep in touch with our patients. Italian, German, and Belgian anatomists are not involved in patient care; they work 8 hours a day in their laboratories, and publish beautifully detailed dissections with umpteen photographs. However, they have no contact with patients, and are reverting to the level of obsessively descriptive ivory-tower Anatomy. The Debré reform has allowed us, at the teaching hospitals, to keep in touch with patients. That is vital. Unfortunately, Anatomy has lost out in the process.
M.L.I have some misgivings, but I think this is the way forward. The young people coming up to university are computer-literate, and the computer has become a teaching instrument. This means that the textbook is no longer the medium of instruction. Also, in the first year, before the examinations to reduce student numbers to the numerus clausus, we are having to cope with more and more undergraduates, without sufficient funds to pay for more demonstrators for the practicals. Interactive CD-ROMs can replace a demonstrator at least to some extent, since, with the use of an audio-visual library, students can self-assess their progress. Also, CDs can take the user through a step-by-step programme. These are no longer the drawings by Arnould Moreau, in the Rouvière textbook of anatomy - which were beautiful, but so detailed as to put students off. What we now have is the study of a structure layer by layer. Thanks to Filmed, we now have 2,600 teaching films. Our students have access to one of the largest medical audio-visual collections in France. However, this will never replace dissection and the study of anatomy on the living body. No matter how many videos one has seen, one will not know how to palpate a liver until one has been told by one’s clinical teacher, "You put your hands there like this," on a real abdomen, in a real patient. One can watch umpteen procedures done by the world’s greatest expert in a given technique - it is only when one holds the knife oneself that one learns how to do it. There is no substitute for learning by doing, under expert supervision. However, present-day IT and the audio-visual medium of the CD are certainly a useful adjunct, which will enable us to cope with the huge influx of undergraduates.
M.L.FILMED is a non-profit-making organization that is part of the medical school. Its main purpose is to promote communication and the use of audio-visual techniques in medicine and the allied health professions. To this end, it organizes a competition every other year, with over 300 films entered each time round; it also runs an audio-visual library with more than 2,600 films and CD-ROMs, for the undergraduates, the doctors, other health care professionals, and also for use by the general public.
In co-operation with the Jules Verne University of Picardie, and ten peripheral hospitals in the Picardie region, it has set up a videoconference system to allow the live transmission of lectures, continuing education, and all forms of educational, cultural, and scientific interchange.
M.L.It depends on where you are in France, and on the commitment of whoever is responsible at a given medical school. Some of my colleagues find it a great nuisance. Admittedly, finding bodies is a lot of bother; so, they give up and do nothing about it. Then, there are no bodies to dissect, so one doesn’t have to spend whole afternoons in the dissecting room any more, and can stay in one’s clinical department. I myself have over 700 promised bodies on file, with more being added every week. Of course, one needs a well-equipped laboratory, with pumps for the embalming fluid, cold storage rooms, vats of formalin for the preservation of the bodies, and facilities for the burial or cremation of the remains, in conformity with the wishes of the dead person’s family. All this is very labour-intensive and expensive. As Dean of the Medical School, I know that manpower is not an extensible resource. When the leading-edge sciences such as Immunology, Haematology, Genetics, and Molecular Biology came in, with their sophisticated laboratory equipment that needs an awful lot of personnel to run it, people just said that if one needed another assistant, one could always go to Anatomy - they got them there and they were not doing very much any more. So we have had our staff pinched and poached right, left and centre; we have lost the people that helped to inject and preserve the bodies. However, it is inconceivable that future GPs should never have seen a dead body, a corpse. Otherwise, if they come across one on their first locum job, they may faint. It has been known. And even those who do not want to go in for surgery should have seen a frozen shoulder or an entrapment of the median nerve at the wrist, at some stage of their medical training. I think this sort of thing is vital for any future doctor. Otherwise, it’s as if a motor mechanic had never looked under the car bonnet before. The progress in Surgery is only making the problem more acute: with minimal-access surgery, familiarity with the anatomical relations of the different organs is more vital than ever. The surgeon who does a lap chole and injures the common bile duct, with bile leaking everywhere in the peritoneal cavity, will need to convert to open. The older surgeons still know how to convert; the younger ones don’t; and without a grounding in anatomy, there will be a disaster.
M.L.We issue a piece of paper, a form, which says, "I Mr/Ms XY, being of sound mind and body, declare in the presence of two witnesses, who are not members of my family, that I wish to leave my body to science. I wish that the Department of Anatomy be informed in the event of my death. Signed and dated."
This is done in duplicate. One copy goes to me; the other goes to the police department, if the donor lives in a town of more than 2,000 inhabitants, or to the mayor’s office, if he or she lives in a smaller town or a village. When that person dies, I am informed by the agency that holds the other copy. We then go out and collect the body, unless the family objects because they did not know about the arrangements. If the family objects, we would be legally entitled to collect the body, and could prove that it was the deceased person’s will, since we have got the documents. However, in the presence of a grief-stricken family, we cannot behave like vultures, so we do not insist upon our rights. Where the family goes along with the dead person’s wishes, a religious ceremony, of whichever denomination, may be held around a bier and an empty coffin; later, when all the dissection work has been done, the remains are placed in a coffin, and returned to the family for burial or cremation. There are proper rules governing all this. At Amiens, we pay for the transport of the body, but not for the cremation. If the departed had stated that he or she wanted to be cremated, it is for the family to attend to this wish. It is a myth that we buy bodies. It was rumoured once that down-and-outs sold their bodies to us.
M.L.All the time. My lectures are just chalk and talk. Chalk is easy to get hold of, it’s cheap, and it will never let you down. All my lectures are done that way - no paper, no slides. The students draw with me, which gives them a healthy respect of the lectures. When they go home, they have all the teaching material that they need; and they never argue about exam questions, because they know that their teachers know what they are talking about. This is not the case with all my colleagues: some of them have been pelted with lumps of cream cheese, because they keep their audience in a dark lecture theatre and bombard them with stacks of back-projections and complicated formulae.
M.L.At present, we have 600 undergraduates, and the lecture theatre will only seat 300. However, thanks to Filmed, the medical school is now fully cabled, and the 300 that cannot be accommodated are put in 120-seat theatres, to which the lectures are transmitted live, in full colour, and on large screens. This way, the students in the small theatres get a better view than those in the large one, because the camera can zoom in on details of the drawings. Also - and this came as a complete surprise - the smaller theatres are quieter. When we first had to split the students into different lots, I thought the ones in the smaller theatres would spend their time snogging or raising Cain, since they were totally unsupervised. However, not a sound. And the reason it’s so quiet in there is that you cannot rag a screen. If you have a real lecturer in front of you, you can rag him, you can tell him that he makes a better door than a window, because you cannot see the blackboard. You can chant, you can pelt him, you can shout - until he gives up. But if you are in front of a screen, you may behave as badly as you like, the show will go on; and, after all, there are exams at the end of term. That produces an astonishing self-discipline.
M.L.That is a very, very important question. At present, every medical school is hell-bent on finding people with endless initials after their names, to teach the undergraduates. For the candidates, it’s an obstacle race, trying to get more and more qualifications and degrees. Also, the way things are at present in virtually all departments, if you haven’t been to the States, to work on some rats, you are out of the race. What every university is after is potential Nobel laureates. So they pick people who are first-class researchers but who cannot teach preclinical undergraduates. I am on the examination committee for the Anatomy Professorship exams. In this capacity, I am less interested in how much a particular candidate has published, and what level journals his or her work has appeared in. What I want to know is how many hours a week they spend teaching, and how they teach. This is why we put them up against a blackboard and listen to them lecturing, and then we watch them do a dissection. If they fail that test, it doesn’t matter how many papers they have had in the top-flight American papers - they are out. Last time round, we had four candidates, of whom only one passed. The three who were failed were excellent in their clinical disciplines, but useless as teachers. If you go into a lecture theatre merely with your research-derived knowledge, you won’t last more than 5 minutes. Professors are supposed to teach, and teaching is a skill that can be learned.
M.L.Indeed. We have a course leading to a University Diploma in Communication and Teaching. This course is taken by all the juniors who want to get on. As Professor of Anatomy, I provide teaching instruction every week. Ten years ago, I set up a University Diploma in the Teaching of Anatomy, and all the junior lecturers and lecturers from all over France come here to attend the course. They call it "going to the Somme." They have to lecture on a given subject, and then their performance at the blackboard is taken to pieces, with detailed comments such as "This colour chalk should not be used for this sort of drawing," or "That was not the right term to use," etc. It takes a lot of time. I have spent thousands of hours training the younger generation; but then I have a passion for teaching. When I meet them again, later on, they say, "Prof, thanks to you, we can go into a lecture theatre and be treated with respect."
(Transl KRMB)
