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.