National Journal of Clinical Anatomy

: 2021  |  Volume : 10  |  Issue : 4  |  Page : 209--213

Comparison of illustrative handouts and self-drawing on learning outcomes from anatomy lectures

Suresh Narayanan1, Nachiket Shankar2,  
1 Associate Professor, Department of Anatomy, Sri Manakula Vinayagar Medical College and Hospital, Puducherry, India
2 Professor, Department of Anatomy, St-Johns Medical College, Bengaluru, Karnataka, India

Correspondence Address:
Suresh Narayanan
Department of Anatomy, Sri Manakula Vinayagar Medical College, Puducherry - 605 107


Background: Illustrative handouts and self-drawing have been shown to improve learning outcomes from lectures. The objective of this study was to compare the test scores among students taught using these two methods in anatomy lectures and to assess the students' perceptions about the same. Methodology: This was a quasi-experimental pre- and post test study done among 1st-year medical undergraduates to evaluate the effectiveness of illustrated handouts. For two of the lectures (Group 1 lectures), students were asked to draw along with the teacher, while for the other two lectures (Group 2 lectures), they were given illustrative handouts and were required to progressively color and label. The multiple-choice questions were administered prior to the lectures and 4 months after completion of the lectures. The paired t-test, Wilcoxon signed-rank test, and Mann–Whitney U-test were used to estimate score differences. Students' perceptions were assessed using a questionnaire. Results: There was a significant improvement in post test scores for both handout and self-drawing sessions. The score improvement was significantly higher for the handout session when compared to the self-drawing session. No significant gender differences were noted. More than 80% of the students had positive opinions about all aspects of the handouts that were assessed. Conclusion: Supplementing lectures with illustrative handouts resulted in higher knowledge retention when compared to self-drawing. Students felt that illustrated handouts facilitated their learning from lectures.

How to cite this article:
Narayanan S, Shankar N. Comparison of illustrative handouts and self-drawing on learning outcomes from anatomy lectures.Natl J Clin Anat 2021;10:209-213

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Narayanan S, Shankar N. Comparison of illustrative handouts and self-drawing on learning outcomes from anatomy lectures. Natl J Clin Anat [serial online] 2021 [cited 2022 Jul 4 ];10:209-213
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Lectures remain the common mode of instructional delivery in medical curriculum. However, it is often criticized for its passive didactive approach lacking interaction.[1] Hence, increasing efforts are being made to transform didactic lectures into student-centered active learning sessions.[2],[3] In anatomy lectures, the complex arrangement of the structures is often taught using images from standard textbook/atlas or by drawing diagrams in the blackboard. The anatomical knowledge acquired during these sessions is vital in understanding the disease pathology and clinical practice.[4] Since the effectiveness of the classroom practice is critical in determining the learning outcome, it is vital to identify the effective instructional strategy in imparting anatomy knowledge to medical students.

The previous studies have used progressive drawing techniques to actively engage the learner in large group teaching.[5],[6] A study has reported that the students who received draw-along teaching techniques showed significant improvement in scores as compared to those who received mind maps as handouts in histology lectures.[5] Another study has found that the actual drawing of histological images could be used as a tool to improve long-term knowledge retention.[6] The better knowledge retention demonstrated in the studies was attributed to the generation of the mental model during the learning activity.[5],[6]

In our institution, students have raised concerns that the instructor's blackboard drawing lacked clarity and they faced difficulty in sketching the diagram due to the time constraints. Hence, in an effort to minimize the note-taking behavior, illustrative handouts were introduced in anatomy lectures. The routine handouts used in medical education include written material which could be complete or partial and are given either before or after the lecture.[7],[8] In literature, a study has reported that the preclinical medical students were more handout dependent and there was a reduction in note-taking behavior when handouts were not provided.[8] However, the comparison of learning outcome following self-drawing and assisted with an illustrative handout has not been investigated.

This study aims to determine whether incorporating illustrative handouts during anatomy lectures has any impact over the student learning outcome. This intervention was attempted to promote the student participation and to reduce the time spent during the sketching process. The objective of the study was to compare the test scores among 1st-year undergraduate students taught using self-drawing and illustrative handouts in an animation-based lecture, and to assess the students' perceptions about the use of illustrative handouts.

 Materials and Methods

This was a quasi-experimental study with a single group pre- and posttest design. The study was approved by the institutional ethics committee (EC/44/2018, dated November 27, 2018). The study group included 1st-year MBBS students of Sri Manakula Vinayagar Medical College and Hospital, Puducherry. Written informed consent was obtained from the participants before data collection, and subject confidentiality was maintained throughout the study. Based on the feedback from the previous batch of students, the topics which the students found difficult to understand and replicate as diagrams during examinations were obtained. Among the gross anatomy topics, the students perceived anatomy of the facial nerve, middle ear, larynx, inguinal canal, peritoneum, and perineal pouches as difficult to understand and draw during examinations. For the purpose of this study, four lectures were selected. These lectures were divided into two groups with a comparable difficulty level. Group 1 lectures consisted of the anatomy of the facial nerve and the external anatomy of the heart. Group 2 lectures included blood supply of the heart and anatomy of the inguinal canal.

Prior to the lectures, twenty multiple-choice questions (MCQs) (five from each lecture) were administered. These MCQs had a mix of recall, interpretation, and problem-solving question types and were checked for face and content validity. For Group 1 lectures, all the 150 students were requested to draw and label diagrams progressively in their notebook during the animated lecture presentation. For Group 2 lectures, all the 150 students were given printed material containing unlabeled diagrams (schematics used in the animations) at the beginning of the lecture and were requested to progressively color and label the diagrams [Figure 1]. The four lectures were separated by a gap of 1 week, the Group 1 lectures preceding the Group 2 lectures. The same MCQs were administered after 4 months as a post test without any prior notice.{Figure 1}

For all the lectures, rough sketches were designed by the first author and validated by two senior anatomists for their anatomical accuracy, orientation, simplicity, and reproducibility. Based on the rough sketches, schematic animations were designed in Microsoft PowerPoint software using Mayer's multimedia principles to minimize the intrinsic cognitive load.[9] To provide in-depth perception to the animation, color transparency variations in the shapes or dotted lines were used. Arrow tools were used to represent the direction or path of the anatomical structures. The topographical orientation to the animation was explained using arrows on the top right corner of the slide. Important terms related to the class were introduced before the animation. The various components of the animation were brought on sequentially, and the related concepts were explained to augment the visual content.[9] Appropriate colors were used in the animations to delineate structures for proper understanding. The labels of the anatomical structures were positioned close to the depicted structures and were presented as the structures were visualized. As a part of each lecture, clinical case scenarios were discussed to provide a clinical context for learning.

At the end of the write as post-test session, a questionnaire was administered to the students to explore their perceptions regarding the use of handouts during animated lectures. The questionnaire was tested for internal consistency (Cronbach's alpha = 0.739) in a group of 16 students prior to its administration. The questionnaire utilized a 5-point Likert scale to assess the perceptions of the students regarding the following aspects of the handouts: (1) quality, (2) usefulness, (3) facilitation of interaction, (4) help in maintaining attention during lectures, (5) preference for use as study material during examinations, and (6) recommendations for future use. Additionally, the students' preferred mode of drawing diagrams during lectures (self-drawing/using handouts/no preference for either method) was elicited. Two open-ended questions on the merits and limitations of illustrative handouts were added for qualitative assessment.

A paired t-test was used to estimate the difference between pre- and posttest scores for Group 1 and Group 2 lectures. The score improvement for each student was calculated as the difference between post- and pretest scores. This was done for both Group 1 and Group 2 lectures. The difference in score improvement between self-drawing and handout sessions was estimated using the Wilcoxon signed-rank test. The Mann–Whitney U-test was used to estimate gender differences in score improvement. The statistical analysis was done using SPSS version 17.0, and P < 0.05 was considered statistically significant.


The study group comprised 150 students 60 male (40%) and 90 females (60%). Scores from 135 students who attended all the four test sessions were taken into consideration for statistical analysis. There was a significant improvement in posttest scores for both Group 1 and Group 2 lectures [Table 1]. The score improvement was significantly higher for the handout session when compared to the self-drawing session [Table 2]. There were no significant differences in score improvement between male and female students for both Group 1 and Group 2 lectures [Table 3] and [Table 4].{Table 1}{Table 2}{Table 3}{Table 4}

A total of 140 students completed the perception questionnaire. The students' perception of the handouts were tabulated [Table 5]. It was noted that more than 80% of the students were favorably inclined (answered either agree or strongly agree) to all six aspects of the handouts that were assessed. There was a strong preference for students to draw using handouts (123 of 140 students, 87.8%). Twelve (8.6%) students preferred to draw on their own and five (3.6%) students did not have a preference for either method. The students' responses to the open-ended questions yielded the following themes regarding the handouts: (1) they were useful in understanding concepts, (2) drawn structures could be conveniently labeled, (3) helpful during examination preparation, and (4) request to share soft-copies of the handout to facilitate repeated practice.{Table 5}


In the present study, gross anatomy was taught using schematic diagrams with and without the use of handouts in a large group setting. A significant increase in post test scores as compared to pretest scores was noted for handout and self-drawing sessions. The score improvements were significantly greater for the handout sessions as compared to the self-drawing sessions. No significant gender differences in the scores were noted. The students' perceptions about the use of illustrative handouts were positive, and a large majority of them preferred illustrative handouts over self-drawing.

In a study conducted in South Africa among 1st-year health science students, it was observed that draw-along mapping techniques incorporated in histology lectures significantly improved student outcomes. The authors suggest that these improved learning outcomes were the result of active learning and critical thinking facilitated by such methods. The students could potentially use these learning techniques throughout their course and beyond. Additionally, the draw-along maps created during the lecture classes provided the students with a valuable resource that could be used in the practical slide viewing sessions that followed.[5]

Another study conducted among 3rd-year medical students in a medical college in India showed significantly higher posttest scores among students who attended orthopedics lectures in which incomplete handouts were used, as compared to lectures without them. The handouts were given to the students a day prior to the lecture and had outlines of notes, figures, and diagrams that the students had to complete during the lecture. The authors propose that the use of incomplete handouts during lectures confers the dual benefit of students being able to listen to the PowerPoint presentation and concurrently engage in meaningful active learning by progressively completing the handouts.[10]

The present study shows that both “draw-along” techniques and illustrative handouts improve learning outcomes from lectures. However, the knowledge gain from lectures utilizing illustrative handouts was significantly greater as compared to lectures with draw-along techniques. It is likely that the use of illustrative handouts serves both as an encoding and external storage function.[11] Encoding in the context of this study refers to the ability of the students to make sense of the lectures. Handouts also serve as a ready reckoner for revision after the lecture which constitutes their external storage function. When students are asked to draw along with the teacher, it is likely that their ability to listen and draw at the same time may impose an excessive cognitive load which reduces the efficiency of encoding. Illustrative handouts, on the other hand, may provide students with a better balance between listening and actively engaging with the learning material by completing the handouts.

In the present study, a large majority of the students opined that the illustrative handouts facilitated their learning both during and after the lectures. These findings are similar to other studies that reported positive student perceptions about the use of handouts as a part of the educational process.[7],[8] A study conducted in Thailand among 1st- to 5th-year undergraduate medical students indicated that the use of handouts was associated with increased levels of concentration in the class, decreased absenteeism, and facilitated note-taking.[8] In another study conducted in Portugal among 2nd-year undergraduate medical students pursuing a clinical anatomy course, handouts were provided at least 1 week prior to the teaching and learning sessions. The perceptions of the students indicated that they found the handouts useful for their learning not only during and after the classes but also in preparing for them.[12]

Previous studies have suggested that the beneficial effects of drawing on knowledge retention should be assessed by free recall questions rather than MCQs.[13] However, MCQs were chosen in the present study because of their feasibility to simultaneously assess a large number of students. Their objectivity and ability to sample a wider domain of knowledge were added advantages. Gender differences have previously been described in study habits, academic outcome, and motivation to learn anatomy by cadaveric dissection.[14],[15] However, no gender differences in learning outcomes were observed in this study.

The present study has some limitations. An ideal study design to compare the two interventions used in the study would have been a randomized crossover design. However, due to logistic considerations, this was not possible. Although an attempt was made to match the difficulty levels of the topics covered in Group 1 and Group 2 lectures, there is a possibility that differences in these levels could have influenced the learning outcomes.


This study demonstrated that supplementing animation-based lectures with illustrative handouts resulted in higher knowledge retention when compared to self-drawing. It was also observed that illustrated handouts facilitated learning both during and after lectures. This suggests that illustrated handouts are a valuable tool in the armamentarium of a medical educator that merit more widespread use. Future studies could focus on the most suitable learning content for the use of such handouts.


The authors would like to acknowledge the undergraduate students for their participation in this research project.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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