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\begin{document}

\title{Trainee's Perception Of Applied Anatomy Knowledge in Obstetrics and
Gynaecology: A prospective cross-sectional study}



\author[1]{Ismaiel Abu Mahfouz}%
\author[2]{Fida Asali}%
\author[3]{Heba Abu Saleem}%
\author[4]{Maha Mohammad}%
\author[5]{Salem Abu Mahfouz}%
\author[4]{Oqba Al-Kuran}%
\affil[1]{Al-Balqa' Applied University}%
\affil[2]{The Hashemite University Faculty of Medicine}%
\affil[3]{The Specialty Hospital}%
\affil[4]{The University of Jordan}%
\affil[5]{The Hashemite University}%


\vspace{-1em}



  
  \date{May 22, 2024}


\begingroup
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\selectlanguage{english}
\begin{abstract}
Abstract Objective Evaluate Obstetrics and Gynaecology (O\&G) trainees'
knowledge in surgical anatomy Designs Prospective cross-sectional study.
Setting Departments of O\&G in various hospitals Population Trainees in
O\&G recruited between 1st August to 1 December 2019 Method: Hard copy
questionnaire based study. Information regarding demographics such as
gender, year of training, attendance at applied anatomy workshop. In
addition, perception of surgical anatomy knowledge was recorded. Main
outcome measures Perception of surgical anatomy knowledge among trainees
Results We recruited 271 trainees, mean age 29.3 years, and 80.1\% rated
value of medical school course as average or above. In addition, 90.8\%
never attended anatomy workshop, and 9.6\% and 62\% of first and fifth
year residents respectively rated their knowledge as either good or very
good, and 41.7\% reported that anatomy demonstrations by senior doctors
happened sometimes. Perception of knowledge was statistically
significantly more in higher training years, higher perceived value in
medical school course, attendance at anatomy lectures, more operating
experience, and when senior doctors demonstrate anatomy more often .
Conclusion Deficiencies were identified in surgical anatomy knowledge
among resident in all years. Factors identified which may improve
knowledge include more applied undergraduate anatomy courses, more
operating sessions and anatomy workshops, and more senior colleagues'
demonstration of surgical anatomy . Overall knowledge in regards to
anatomy needs to be improved for better patient safety. Keywords:
obstetrics, gynaecology, surgical anatomy, medical students, resident
doctors Tweetable abstract Do Obstetrics and Gynaecology trainees have
adequate surgical anatomy knowledge? Funding: No funding was requited
for this study%
\end{abstract}%



\sloppy


\textbf{}

\textbf{Tweetable abstract}

Do Obstetrics and Gynaecology trainees have adequate surgical anatomy
knowledge?

\textbf{Funding:}

No funding was requited for this study

\par\null

\textbf{Introduction}

Medical education has recognised the importance of teaching anatomy to
medical students and resident doctors in training \textsuperscript{1}.
While anatomy was fully covered for hundreds of years, currently it has
been reduced in medical education curriculums \textsuperscript{2}. In
addition, there has been a change from the traditional ''hands-on''
teaching on cadavers to using imaging such ultrasound scans and magnetic
resonance imaging, living anatomy, and multimedia
resources\textsuperscript{3}. Such a change in anatomy teaching has not
been methodologically studied to see if it compromises patient
safety\textsuperscript{4}.

Toogood et al. 2 recognised a low unsafe level of teaching anatomy for
medical students and suggested that more attention to anatomy education
during residency training may bridge the knowledge gap. While applied
anatomy knowledge is necessary for safe medical practice, there has been
an increase in medical litigation attributed to the lack of appropriate
knowledge in surgical anatomy \textsuperscript{5}.

Several reports in obstetrics and gynaecology (O\&G) discussed the
importance of applied anatomy education during postgraduate training.
Sgori et al. \textsuperscript{6} evaluated trainees' perceptions of the
level of anatomical knowledge in O\&G training programs and recognised
limitations in applied anatomy knowledge among trainees at all levels of
training. In addition, they suggested formal applied anatomy courses
during residency training. Furthermore, such limitations were also
recognised among first year gynaecology oncology fellows, where 40\% of
fellows were not able to identify relevant anatomical structures during
surgical operations \textsuperscript{7}. Such a report from a fellowship
program further emphasized the perception of inadequate knowledge in
surgical anatomy during residency training.

There are several abdominal, pelvic, and perineal anatomical structures
relevant to O\&G that resident doctors are expected to have appropriate
knowledge about.

The primary aim of our study was to evaluate O\&G resident doctors'
knowledge in surgical anatomy in all the five training years. Secondary
aims included studying variables that could influence this knowledge
such as age, gender, value of medical student O\&G anatomy course, and
attendance at formal applied anatomy lectures and workshops. In
addition, monthly surgical procedures they attended or performed and how
often senior colleagues demonstrate anatomy during operating theatre
sessions were evaluated.

\textbf{Methods}

This study was a prospective cross-sectional questionnaire-based study
involving resident doctors in O\&G between 1st August 2019 and 1st
December 2019. Inclusion criteria required the resident doctor to be
currently in a training program and willing to take part in the study.

The questionnaire was designed by the research team with modification
based on a previously published report \textsuperscript{6}. Prior to
approving the final version, face validity was established where 38
Fellows and Members of the Royal College of Obstetricians and
Gynaecologists (RCOG) in Jordan were invited to comment on the draft
questionnaire, and their comments were considered. In addition, a group
of 15 resident doctors in O\&G in various training years were asked to
review the questionnaire, and their comments were also considered in the
final version of the questionnaire which was used in the study. The
questionnaire which included a list of 54 anatomical structures was
distributed to the various hospitals where there are O\&G residency
programs and the study was left open for four weeks. In addition,
resident doctors were invited to take part in the study where
participation was voluntary and personal identification data were not
collected. Furthermore, a reminder to take part in the study was sent to
the various departments fourteen days after the start of the study.

Data collected included age, gender, and overall surgical anatomy
knowledge as rated by the resident doctors using a five-point Likert
scale (very poor, poor, average, good, and very good) along with if the
residents ever attended formal surgical anatomy lectures or workshops
and if the trainee would like to attend a formal workshop. In addition,
they were asked to rate the value of medical school anatomy courses
relevant to O\&G training using a five-point Likert scale (no value,
limited value, average value, much value, and extreme value).

Moreover, resident doctors were asked about the average number of common
O\&G surgical procedures they assisted in or performed either
independently or supervised every month. They were also asked to report
the frequency of receiving demonstrations of surgical anatomy by senior
colleagues during operating theatre sessions using a five-point Likert
scale (hardly ever, occasionally, sometimes, frequently, and almost
always).

Resident doctors were finally asked to rate their knowledge about the
defined 54 anatomical structures on a five-point Likert scale (very
poor, poor, average, good, and very good). The anatomical structures are
shown in Table S 1.

\textbf{Sample Size Calculation}

The study population included resident doctors in O\&G currently in the
training programs in both public and private hospitals. Formal
information was obtained from the various training programs and showed
that the total number of O\&B residents in the various hospitals at the
time of running the research was 522. For a confidence level of 95\% and
confidence interval of 5, the sample size was calculated to be 222.
Ethical approval was granted locally by the Institutional Review Board
of the Specialty Hospital.

\textbf{Statistical Analysis}

Descriptive statistics were performed for normally-distributed data
using mean \selectlanguage{ngerman}± SD, for non-normally distributed and Likert scale data
using median and interquartile range, and for count data using
frequencies and percentages. A total questionnaire score out of 270 was
calculated by summing the responses of all the 54 anatomical structure
questions.

Within-subjects t-test was used to compare differences in total
questionnaire scores between resident doctors based on gender, formal
surgical anatomy lectures or workshops attended during residency
training, and the number of surgical procedures they attended or
performed every month.

One-way analysis of variance (ANOVA) was used to compare differences in
total questionnaire scores between residents based on the year of the
residency, their rating of the value of medical school anatomy courses
relevant to their current training in O\&G, and receiving demonstration
of anatomical structures from senior colleagues during surgical
procedures. In case of significant differences, pot-hoc pairwise
comparisons with Bonferroni corrections were done.

To compare the ability of residents to identify anatomical structures
across the different years of the residency, a Kruskal-Wallis test was
done with post-hoc pairwise comparisons in case of significant
differences.

The level of significance was set at \selectlanguage{greek}α \selectlanguage{english}\textless{} 0.05. Data were
analyzed using SPSS for Windows (Version 22, SPSS Inc., Chicago,
Illinois).

\textbf{Results}

\textbf{Data Analysis: General}

The questionnaire was completed by 271 resident doctors representing
51.9\% of all residents in Jordan. Of those, there were 189 (69.7\%)
females and 82 (30.3\%) males. The average (SD) for age was 29.3 (3.0)
years. During their residency program, while the majority of the
residents never attended formal applied anatomy lectures (n = 152;
56.1\%) or workshops (n = 246; 90.8\%), 236 (87.1\%) expressed their
interest in attending future workshops.

In addition, 147 (54.2\%) residents reported that the value of a medical
school anatomy course was average, and 217 (80.1\%) rated the value
between average and extremely valuable for their current O\&G training.
When asked how often senior colleagues demonstrated anatomical
structures during surgical procedures, 113 (41.7\%) residents responded
that this happened sometimes and 71 (26.2\%) residents responded that
this happened often. Table 1 summarizes the demographics of the
respondents.

The surgical procedures that were most commonly attended or performed by
resident doctors every month were caesarian section, vaginal delivery,
and episiotomy repair with a median number of attended procedures per
month at 15, 20, and 10, respectively. For all other procedures, the
number of residents who did not attend or perform any per month ranged
between 102 (for ovarian cystectomy) to 214 (for vaginal vault repair).
Table S2 shows a summary of procedures attended or performed by resident
doctors every month grouped according to the year of training.

The average (SD) of the total questionnaire score for all residents was
198.8 (39) and the scores ranged between 91 and 265. Furthermore, 21.2\%
and 9.6\% of first and fifth year residents, respectively, rated their
overall anatomy knowledge as either very poor or poor while 9.6\% and
62\% of first and fifth year residents, respectively, rated their
knowledge as either good or very good (Table 2).

\textbf{Data Analysis: Total Questionnaire Scores for Surgical Anatomy
Knowledge and Various Variables}

Data analysis showed no significant differences in total questionnaire
scores between female (197.4 \selectlanguage{ngerman}± 38.8) and male residents (202 ± 39.7)
with t (269) = 0.898 and p = 0.37.

The results also showed that there were significant differences in total
questionnaire scores across the years of the residency program (F {[}4,
266{]} = 31.9, p \textless{} .001). Pairwise comparisons revealed
significant differences between first year residents (165.3 ± 39.1) and
third (208.7 ± 33.0) along with fourth (215.5 ± 26.1) and fifth years
(222.3 ± 30.6); all ps \textless{} 0.001. Similarly, there were
significant differences between second year residents (177.3 ± 31.6) and
third, fourth, and fifth years; all ps \textless{} 0.001. Figure 1 shows
the averages of the total questionnaire scores for all five years of the
residency program.

When the residents' ability to identify individual anatomical structures
were compared across the five years of the residency program, there were
significant differences in all structures (all ps \textless{} 0.05)
except the normal breast anatomy (p = 0.09). The most frequent
significant pairwise comparisons in the ability to identify anatomical
structures were between first and fifth years (in 92.5\% of the
structures), followed by first and fourth years (in 84.9\% of the
structures), second and fifth years (in 77.4\% of the structures), first
and third years (73.6\%), second and fourth (66\%), and lastly second
and third years (43.4\%) as seen in Table S 3.

There were significant differences in total questionnaire scores between
residents based on their rating of the value of a medical school anatomy
course (F {[}4, 266{]} = 4.23, p = 0.002). Pairwise comparisons revealed
that the total questionnaire scores for residents who viewed the course
as helpful (212.6 ± 34.4) were significantly higher than those for
residents who viewed the course of limited value (186.3 ± 40.5, p =
0.003). Figure S 1 shows the averages of the total questionnaire scores
based on the residents' ratings of the value of a medical school anatomy
course.

Data analysis showed a statistically significant difference in total
questionnaire scores between residents who attended formal anatomy
lectures during their residency and those who did not with t (266) =
2.78 and p = 0.006. Total scores for residents who attended anatomy
lectures (206 ± 35.6) were significantly higher than those who did not
(193.1 ± 40.8). On the other hand, there were no significant differences
in total questionnaire scores between residents who attended a formal
anatomy workshops during their residency (212.9 ± 36.7) and those who
did not (197.4 ± 39.1) with t (269) = 1.906 and p = 0.058.

Total questionnaire scores were compared between residents based on the
average numbers of different surgical procedures they attended or
performed every month. For this purpose, we performed two comparisons.
In the first, we compared total questionnaire score with the procedures
that were commonly attended by residents where we examined the
differences at each year between residents who attended the surgeries
more often (\selectlanguage{english}[?] median) and those who attended less often (\textless{}
median). The results showed significant differences in total
questionnaire scores between residents in second year for the vaginal
delivery, third year for all three surgeries, and fourth year for repair
of episiotomy (Table S 4) . In the second comparison, we compared the
scores based on whether the resident attended the procedures or not in a
month. The results showed significant differences in total questionnaire
scores in all surgeries except instrumental deliveries and sub-urethral
tapes (Table S 5).

There were significant differences in total questionnaire scores between
residents based on how often they received demonstrations of surgical
anatomy structures from senior colleagues during surgical operations (F
{[}4, 265{]} = 10.8, p \textless{} 0.001). Pairwise comparisons revealed
that total scores for residents who received demonstrations frequently
(218.1 +- 28.9) were significantly higher than those who received the
demonstrations hardly ever (169.1 +- 36.8, p \textless{} 0.001),
occasionally (185 +- 40.6, p \textless{} 0.001), and sometimes (200.3 +-
38.4, p \textless{} 0.018). Also, total scores for residents who
received demonstrations sometimes were significantly higher than those
who received the demonstrations hardly ever (p = 0.003). Figure 2 shows
the averages of the total questionnaire scores based on the frequency of
receiving demonstrations during surgeries.

\textbf{Discussion}

\textbf{Main finding}

There were 271 residents who completed the questionnaire with the
response rate of 51.9\%. The mean age was 29.3 years and 69.7\% were
females. In addition, 54.2\% of residents reported that the value of
medical school anatomy courses was average, and 80.1\% rated the value
of these courses as average or above average. Furthermore, 56.1\% and
90.8\% of residents never attended a formal applied anatomy lecture or
workshop, respectively. In addition, 21.1\% and 51.7\% of first and
fifth year residents rated their overall anatomy knowledge as good,
respectively, and 41.7\% reported that anatomy demonstrations by senior
doctors happened sometimes. Furthermore, the overall score of surgical
anatomy knowledge was significantly higher for residents in the higher
training year, and for residents who perceived value in medical school
anatomy courses, attended or performed more surgical procedures,
attended formal applied anatomy lectures, and who witnessed senior
doctors demonstrating anatomy more often during operating theatre
sessions.

\textbf{Interpretation of results}

The response rate which was 51.9\% reflects a moderate rate which is in
keeping with a published report about the response rate in questionnaire
based medical research \textsuperscript{8}. Not achieving a higher
response rate is probably related to the wide geographical distribution
of public hospitals and the difficulty in reaching all training sites
for logistic reasons.

The value of medical school anatomy courses as relevant to O\&G was
rated as average or above average by over 80\% of residents in our
study. This reflects the importance of undergraduate anatomy education.
Surgical anatomy knowledge among medical students who started their
clinical surgical training in O\&G was reviewed by Jurjus et
al.\textsuperscript{9}. Their results showed that medical students'
knowledge was poor in abdominal cavity, pelvic organs, urogenital
development, and pregnancy. In addition, another
report\textsuperscript{10} showed that 92\% of trainees in O\&G were not
satisfied with the anatomy knowledge they gained during their
undergraduate medical education. The differences between our results and
the published report may be due to differences in anatomy teaching
methods.

Our results showed that 56.1\% and 90.8\% of residents never attended a
formal applied anatomy lecture or workshop, respectively. Furthermore,
there was a statistically significant difference in total questionnaire
scores between residents who attended formal anatomy lectures during
their residency training and those who did not but not between residents
who attended formal anatomy workshops and those who did not. This
probably is related to the small number of residents who ever attended a
formal anatomy workshop. A randomized controlled
trial\textsuperscript{11} showed that resident doctors' attendance at
structured pelvic anatomy reviews using cadaveric dissection was
associated with better performance in both written and practical
examinations of pelvic anatomy. In addition, participants in a
postgraduate surgical skills training program of the Flemish Society of
Obstetrics and Gynaecology reported that the hands-on cadaver workshop
was helpful for both clinical practice and also helped in improving
their anatomy knowledge and laparoscopic surgical
skills\textsuperscript{12}. The minimally invasive surgical training of
the Dutch obstetrics and gynaecology residency curriculum required
resident doctors to attend a basic surgical skills course followed by
further surgical training on simulators \textsuperscript{13}. This
reflects the importance of formal applied anatomy courses and workshops
in O\&G training

Over 87\% of the residents in our study expressed an interest in
attending formal surgical anatomy training. If, however, such workshops
are not available, other teaching modalities may be implemented and was
shown to be of value. A multicenter, randomized controlled trial
reported significant improvement in laparoscopic hysterectomy skills of
O\&G residents after using the Laparoscopic Hysterectomy
Trainer\textsuperscript{14}. Another method is joining clay modeling
with lectures which was shown to be an effective method of teaching
female pelvic anatomy and abdominal hysterectomy procedure for junior
residents\textsuperscript{15}.

While 21.2\% and 6.9\% of first and fifth year residents rated their
overall anatomy knowledge as either very poor or poor, 9.6\% and 62\%
rated their knowledge as either good or very good. Similar trends in
overall surgical anatomy knowledge were shown by Sgroi et
al.\textsuperscript{6} where 11\% of O\&G resident doctors reported
their surgical anatomical knowledge as adequate at the beginning of
training while 77\% reported adequate knowledge by the final year of
training. In addition, final year residents were more able to identify
structures compared to first year residents. Furthermore, a survey of
gynaecology oncologists involved in fellowship training in the United
States reported that 40 \% of their new fellows could not recognize
anatomy and tissue planes \textsuperscript{7} . Both reports reflected
deficiencies of surgical anatomy knowledge at different levels of O\&G
training.

The results of our study showed that residents who attended and/or
performed surgical procedures more often rated their surgical anatomy
knowledge higher. Another report showed that resident doctors' surgical
anatomy knowledge was related to the number of procedures they performed
as primary surgeons \textsuperscript{6}.

Our results showed that 41.7\% and 24.7\% of resident doctors reported
that senior colleagues demonstrate anatomy sometimes and frequently,
respectively. This reflects a deficiency in operating theatre teaching
sessions. In most training programs, trainees learn anatomy through
self-guided reading and direct experiences in the operating
theatre\textsuperscript{16}. Furthermore, in the Wood et al.
study\textsuperscript{17} that involved residents and specialists, they
reviewed the unmet operative learning requirements and resident doctors'
ability to perform surgery in O\&G. Their results showed that residents
relied on ``advice from colleagues'' as an essential learning resource.
In addition, 75\% of specialists reported surgical anatomy as the most
common unmet resident learning need. An earlier report showed that 92\%
of residents were not satisfied with the anatomy knowledge they gained
during undergraduate medical training \textsuperscript{10}. In addition,
medical students described a lack of visualization as a barrier to
theatre based learning \textsuperscript{18}. This reflects a teaching
deficiency at different levels of medical education which should be
addressed to improve knowledge and skills.

Complications may result from the proximity of the gynaecological organs
to the urinary tract, bowel, nerves, and vasculature. A 3.8\% overall
prevalence rate of complications for gynaecological surgery was reported
while 1.8\% were major and 2\% were minor
complications\textsuperscript{19}. To perform safe surgery, O\&G doctors
should have adequate surgical anatomy knowledge particularly in
situations where anatomy is distorted by adhesions or surgical bleeding
\textsuperscript{20}.

Surgical skills are usually passed from senior to junior doctors during
operating theatre sessions. While the presence of residents in the
operating theatre with the specialists was associated with an increased
risk of blood transfusion and longer operating time, their presence was
not associated with increased risk of injuries to adjacent organs or
unplanned reoperations \textsuperscript{21}. Another report showed that
specialists' involvement in the operating theatre sessions was
associated with reduced morbidity and mortality \textsuperscript{22}.
However, operating sessions are not enough. Resident doctors may
consider attending formal applied anatomy workshops which were perceived
by residents as important \textsuperscript{23}.

\textbf{Strengths and limitation}

The main strengths our study or are the moderate response rate, the
representative sample which covered most training sites in Jordan. In
addition, we included all the five training years. Furthermore, the
variable that we studied covered various factors which may affect the
perception of surgical anatomy knowledge, and the results showed a
significant association between there factors and the rating of
knowledge in surgical anatomy. We acknowledge the limitations of our
study; the method that we used for evaluating surgical anatomy knowledge
was subjective, we included surgical structure which probably are not of
high significance to obstetrics and gynaecology, in addition, we did not
include structures such as nerves

\textbf{Interpretation and recommendations}

Obstetrics and gynaecology residents should have education in applied
anatomy throughout their training program. In addition, introducing
modern teaching media such as anatomy videos may improve the anatomical
knowledge gained through books, lectures, and cadaveric
dissections\textsuperscript{10}. Furthermore, emphasis on anatomic
education in the residency programs will help prepare the next
generation of pelvic surgeons to face the challenges of modern medicine
\textsuperscript{24}.

Further research is suggested where specialist may objectively evaluate
trainee's knowledge in surgical anatomy while operating and across all
the training years; This may provide more information about anatomy
knowledge among trainees and also identify areas for improvement through
establishing core training program in surgical anatomy relevant to each
training years

\textbf{Conclusion}

Our results identified deficiencies in surgical anatomy knowledge among
resident doctors in all residency years. In addition, the results
identified various factors which may improve knowledge such as more
applied undergraduate anatomy course, more frequent operating theatre
sessions, attending at formal anatomy work and more senior colleagues'
demonstration of surgical anatomy during theatre sessions. Improve
overall knowledge that will be reflected on patient's safety

\textbf{Acknowledgment}

The authors would like to thank all Obstetrics and Gynaecology trainees
who contributed to this study, and also all specialists at various
training sites who facilitated the smooth run of the study

\textbf{Disclosure of interest:}

The authors declare no conflict of interest

\textbf{Contribution to authorship}

The manuscript has been read and approved by all authors. In addition,
all authors contributed to the preparation of the manuscript. I A, F A
and O K conceived and deigned he study, drafted and edited the
manuscript. H A and S A undertook data collection, data entry, prepared
tables and figures and edited the manuscript. T M revised the methods,
performed statistical analysis and edited the manuscript. I A supervised
all aspects of the study

\textbf{Ethical approval details}

Ethical approval was granted by the Institutional Review Board of the
Specialty Hospital

Number:99288/\selectlanguage{english}t/1/5

\textbf{Funding:}

None

\textbf{Supporting information}

Additional supporting information may be found on line in the Supporting
Information Section at the end of the article

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