An online literature search was conducted on articles/abstracts published from 2000 to 2020 in databases like PubMed Central, Medline, Scopus, Google Scholar, using the MeSH terms like medical, education, innovative teaching, use of three-dimensional technology, competency-based curriculum, learner characteristics, future trends in medical education, globalisation/privatisation of medical education. A total of 113 articles and 23 abstracts were identified. The inclusion and exclusion criteria for the shortlisting of articles were established. Articles written by both domestic and foreign authors on innovative teaching methods, use of 3D technology, future trends in medical education were included and remaining were excluded. After applying inclusion and exclusion criteria, 49 articles were shortlisted. Finally, after reading the full text/abstract of the articles, 38 articles were selected that met the criteria for the synthesis of the present review and hence, were included in the study as presented in [Table/Fig-1] [4-41].

The Medical Council of India (MCI) was established by Ministry of Health and Family Welfare as a statutory body under the provisions of the Indian Medical Council Act (IMC Act), 1933, which was later, replaced by the Indian Medical Council Act (IMC), 1956 and was subsequently amended in 1964, 1993 and 2001 [2]. By its powers, the establishment of a new medical college requires mandatory recognition by MCI, but during the inspection, MCI focuses only on documentation of infrastructure and human resources. There is no inspection of infrastructure proposed for research activities by the institution neither evaluation nor monitoring of student admission procedures, training, teaching-learning strategies, assessment system, student facilities and faculty adequacy, is conducted. (Establishment of Medical College Regulations, 1999: Amendment: July 2018).

Medical institutions in India struggle with issues like inadequate infrastructure/facilities, inadequate medical/nonmedical personnel, inadequate cadaver availability, inadequate patient intake, inadequate availability of drugs, etc. The MCI, in 2019 implemented Competency-Based Medical Education (CBME) in the medical curriculum [2,3].

This is important because it directly or indirectly influences the development of curriculum, deciding on teaching methods, and guiding students [4,5]. Buja LM in 2019 proposed that today’s students score higher on assertiveness, self-liking, narcissistic traits, high expectations, and some measures of stress, anxiety, and poor mental health, and also lower on self-reliance [6]. Changes in the culture and society have led to these generational characteristics which are inbuilt in the students right at the beginning when they enter medical college [7,8]. Motivation can become dysfunctional so that high levels of dedication to a previously enjoyed activity can result in burnout. Burnout is alarmingly high among today’s medical students and residents [9,10]. Perfectionism, defined as a combination of high standards and high self-criticism is also on the rise [11,12]. The two may intensify one another. The attributes of the present clinical understudies including their qualities and weaknesses, present exceptional difficulties for workforce occupied with their instruction [13-15]. While these understudies have high IQs, they regularly show little effort [6]. The suggestion for instructive plan (teaching method) is that these understudies probably have advantage from an organised, yet additionally more intelligent learning experience and that guidance should be conveyed in shorter sections and maybe fuse more material in media, for example, recordings and an intuitive organisation. However, in any event, when the study hall hour is utilised for alleged dynamic learning draws near, for example, the flipped homeroom, participation is still frequently poor [16]. Many of today’s medical students are opting for elective perusal online of previously recorded lectures and the use of various study aids while minimising direct classroom interaction with professors [6].

Teaching human anatomy using audio-visual aid is routine. Teacher centric (didactic) approach of conventional classroom lectures is replaced by innovative newer techniques with the incorporation of advanced technology [6].

a. Flip classroom model

In the flip classroom model, a prerecorded video of a concerning topic that is to be taught is posted on a digital platform (well in advance) to the students. Related content is also taught through this platform outside the classroom. Inside the classroom, an active, collaborative, interactive session on the same topic is conducted. To incorporate this model, many premier institutes have formed a digital platform of learning management system like google classroom, zoom, etc. This model has revolutionised the learning of human anatomy. The disadvantage of this model is that the preparation of flipped videos takes enormous time and effort. Few resistant students who come to class unprepared even after prior instructions, spoil the interactive sessions occasionally [17].

Cabi E suggested that understudy’s inspiration and status level to learn outside the homeroom ought to be recognised and fundamental game plans are done before applying the flip classroom model [17].

b. Three-dimensional virtual reality-based technology

Learning anatomy through cadaveric dissection is undoubtedly the best method. The new idea of problem-based learning or clinically-oriented learning demands a constant correlation between normal and pathological anatomical conditions. Three-dimensional virtual reality-based technology complements the classical classroom teaching and is immensely helpful in studying cross-sectional anatomy, three-dimensional images, surface anatomy, radiological anatomy and to study the relationship between anatomical structures. CT images from actual patients in normal and pathologic conditions can be uploaded in the system and correlated.

Three-Dimensional Virtual Reality (3D-VR) is a software program that can be installed on smartphones and tablets, by the students. Alharbi Y et al., proposed 3D-VR to be an effective learning tool for short- and long-term knowledge retention among medical students compared to the traditional method. In his study, medical students described 3D-VR as a learning tool, with a great deal to offer in learning human anatomy as compared to traditional methods and helped improve their comprehension and knowledge retention, promoted teacher-student learning engagement, and helped students have real-like, self-directed learning experiences [18].

c. Teaching through simulation:

Simulation tools are routinely used for teaching anatomy and follow the basic principle of bioethics ‘first do no harm,’ as students get many attempts at trying new procedures and can practice without any kind of apprehension. Low-tech simulations (which don’t contain advanced technology) include the use of nondigital physical three-dimensional organ models like skeletal models, heart, lung, larynx, etc. are already in use. Basic plastic mannequins are used for conducting training on physical examination and interventional training. Animal models for training of physiology [19].

High-tech simulations (which contain advanced technology) include Screen-Based Simulations which are computer-assisted education. Rasmussen M et al., presented the three-dimensioned structure of the temporal bone virtually which made the difficult and complex structure of this bone easier and comprehensible by the virtual media [19]. Langrana N et al., generated a simulator that enabled the examination of a variety of cancer types [20].

Realistic, high-fidelity procedural simulators: These simulators imitate human body parts and focus on certain responsibilities [21-23].

Realistic high-tech interactive human simulator: These are models resembling human and using computer assistant, they give the opportunity of managing these complex clinical situations to the students [23].

Virtual reality and haptic systems: This requires high-level computer assistance which is used especially in surgery education [22,23].

d. Education using cast models and plastination

The use of three-dimensioned plastic models in anatomy education raises the learning performance [24]. Gultiken ME suggested that subjects presented by plastic models are simpler to be learned and grasped by the understudy contrasted with bodies arranged by formaldehyde [24]. The utilisation of virtual materials in training makes the ideas concrete, straightforward, and encourage the opportunity of perception and re-utilising [24].

Plastination is a method that is formed by banishing oil and water from the subscribed body tissues and replacing them with polymerised materials and hardening the samples by shaping them out. Being unwatered, scentless, and substantial, the plastinised samples preserve even their structural properties at the histologic level [25]. Past studies indicate that students are more sensitive to models that are prepared by plastination. At the same time, it is concluded that the material prepared by plastination increases the learning ability [26]. Another determining fact is that the plastinates are less damaged than plastic models [27].

e. Innovative methods of teaching-learning

An online independent digital learning module for providing educational instructions to the students should be created in addition to classroom teaching. Maggio MP et al., found that such practice kept students positively engaged. Three-dimensional computer anatomical models of complex joints of the human body or embryonic foetal development should be prepared and shared with the students on a digital platform [28]. Garg AX et al., stated that they have an obvious educational advantage over standard 3-D view book presentation [29]. A Virtual Human Dissector software incorporated in a computer suite should be developed and can be used for giving self-directed learning activities to students for studying cross-sectional anatomy [30]. Knobe M et al., proposed that short arthroscopy tutorials held by medical experts using simulators should be added to the standard macroscopic dissection sessions in the first year undergraduate medical course. Such tutorials have shown to increase anatomical knowledge of students particularly regarding complex joint anatomy compared to standard macroscopic dissection sessions. In addition to this, first-year students should be taught basic skills in musculoskeletal ultrasound performed by medical experts. Such arthroscopy and ultrasound tutorials certainly raise their interest in surgery [31]. Phillips AW et al., proposed direct co-relation sessions of radiologic and cadaveric structures to teach anatomy. In such sessions, students reviewed pre-specified structures in both radiographic images (on X-ray view box) and cadavers every day for 20 minutes during dissection in small groups focusing on the three-dimensional spatial relationships and tissue densities in both [32].

Medical care in India is currently directed towards population health outcomes. This needs to transform and become patient-centered care or family-focused consideration. This will energise dynamic cooperation and the shared-dynamic between patients, families, and suppliers. Therefore, medical education should be restructured to expose students to the patient and their families early in the curriculum.

Real patient learning practices should be integrated into preclinical classes which will enable them to examine actual patients and contextualise the theory classes. Medical student-faculty collaborative clinics should be started which will allow students to engage in the systems-based practice, design care processes first-hand, and create solutions for inefficiencies in clinic operations through a patient visit tracker tool [33]. A student-driven undergraduate research committee can be established in the institution which will encourage research-oriented thinking within the students and mentor them accordingly. Patient and family interactive programs should be incorporated in the curriculum of third and final year students in which the students would regularly have real case discussions with patients, their families in the presence of the attending physician/surgeon or nurse. This will improve the communication skills of the students and prove beneficial to them in interacting with the patient and their families [34]. Death-and-Dying discussions: Medical students would interact with family members of the recently deceased and with mental health and psychiatric medicine faculty members. This will help students to comprehend end-of-life issues and will inculcate empathy in their minds for the patients [35]. Community-based service project should be longitudinally incorporated in student curriculum in which the students (under the able guidance and with proper permission) will regularly interact with the community by conducting health surveys, organising health awareness camps, organising voluntary organ/body donation camps, participating as volunteers in various government-run health programs, etc. This will promote relationship-based leadership qualities in the students making them realise the importance of mindfulness and coordination as characteristics of effective and resilient leaders [36].

Lee HS stated that in Korea the medical degree program involves academic education based on research allowing the medical students to complete these two different types of programs simultaneously. This pattern has inevitably resulted in a structural shortcoming with the poor quality of both leading to a crisis in academic education and the research function of graduate schools thereby, seriously hindering the development of medical science in Korea [37].

In the United States, advances in medical care and technology are the driving forces that are declining the relevance of traditional curriculum and shifting it to competency-based education, time-based medical education, an accelerated medical education. The ideal is a fully integrated curriculum in place of the traditional curriculum, characterised by spiral integration encompassing both horizontal and vertical integration combining integration across time and disciplines [5].

In Japan, an integrated medical education curriculum was proposed by the ‘Coordinating Council on the Reform of Medical and Dental Education’ in 2001 and implemented in 2005 in the majority of the medical schools. Problem-based learning was implemented as early as 1990. The standard Japanese undergraduate medical education program is six years long (India’s- 5.5 years) and is composed of four years of preclinical medical education followed by two years of clinical training. Regarding student assessment, a Common Achievement Test (CAT) was established in 2005 composed of two phases: a Computer-Based Testing (CBT) phase and an Objective Structured Clinical Examination (OSCE) [38].

Wijnen-Meijer M et al., described six different models of medical education systems across the world and stated the education received and the level of the medical student or graduate can’t be judged by merely comparing the stages and degrees of each country as the nomenclature of each stage and degree varies country to country [39].

In China, a multitiered education system is functional to train physicians since the 1950s which has led to substantial differences in the quality of medical education. The first tier (degree-oriented medical education program) which provides five years of undergraduate medical studies followed by three years of residence. The second tier (tertiary medical education) which provides a vocational diploma after the candidate completes three years of study after high school. The third tier (secondary-level medical education) which provide medical training after junior middle school imparting a secondary vocational diploma. This multi-tiered medical education system was advantageous to China as it quickly trained the doctors, but it lowered the overall quality of physician training and hence, the quality of healthcare [40].

In Europe, an average medical doctor spends four to six years in medical school, followed by a competitive specialist training scheme lasting from three to six years. Only a few European institutes provide exceptionally good learning approaches in terms of methodology and infrastructure. All the European countries adhere to this heterogeneous nature of medical education where incorporation of research into the curriculum is deficient as a result of which medical students with an interest in research are often identified very late or are presented with insufficient career options that encourage them to pursue training in basic medical research. There is no single overarching institution to ensure coherence and global quality controls. There are also no comparable standards among countries or even among schools within the same country in Europe, potentially leading to heterogeneous educational outputs [41].

Medical education should resolve to produce medical students with profound knowledge, skills, and professional behaviour with a humanistic approach to patients. Amendment in the student curriculum and selection of teaching-learning methods should be considered after thoroughly understanding the student characteristics. Modern technology should be used rationally in teaching-learning methods thereby, restricting its negative impact on the students. Further studies on the application of three-dimensional technology in teaching-learning methods are required to develop a pedagogical technology to enhance student’s learning skills. Long-term and comprehensive research studies are required on medical students, medical educators, and medical college administrators to get a deeper insight into the quality of medical education imparted and the competency of physicians produced.