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 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.9. Their results showed that medical students’ knowledge was poor in abdominal cavity, pelvic organs, urogenital development, and pregnancy. In addition, another report10 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 trial11 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 skills12. 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 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 Trainer14. 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 residents15.
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.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 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 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 theatre16. Furthermore, in the Wood et al. study17 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 10. In addition, medical students described a lack of visualization as a barrier to theatre based learning 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 complications19. 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 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 21. Another report showed that specialists’ involvement in the operating theatre sessions was associated with reduced morbidity and mortality 22. However, operating sessions are not enough. Resident doctors may consider attending formal applied anatomy workshops which were perceived by residents as important 23.