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Corresponding author at: Department of Obstetrics and Gynaecology, Maastricht University Medical Centre+, P.O. Box 5800 6202, AZ, Maastricht, The Netherlands.
Department of Obstetrics and Gynaecology, Maastricht University Medical Centre+, The NetherlandsGROW - School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, The Netherlands
Department of Obstetrics and Gynaecology, Maastricht University Medical Centre+, The NetherlandsGROW - School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, The Netherlands
School of Medical Sciences, Amsterdam UMC, Amsterdam, The NetherlandsAthena Institute for Trans-Disciplinary Research, VU University, Amsterdam, The Netherlands
International validation of the Dutch Delphi study about which anatomical structures should be taught to ensure safe and competent practice among general gynaecologists.
Study design
Validation study with gynaecologists and trainees in gynaecology from academic, non-academic teaching and non-academic, non-teaching hospitals worldwide.
The relevance of 123 items included in the Dutch Delphi study was scored on a Likert scale between 1 (not relevant) and 5 (highly relevant). Consensus was defined when ≥70 % of the panellist scored the item as relevant or very relevant and the average rating was ≥4.
Results
A total of 192 gynaecologists and trainees from seven countries (Belgium, Germany, Norway, Oceania, Sweden, United Kingdom and United States) completed the questionnaire. Of the 123 structures, 72 (58.5%) were internationally relevant. When the 72 relevant structures from the international Delphi study were compared with the 86 relevant structures from the Dutch Delphi study, 70 (81.4%) structures matched.
Conclusions
This study identified 70 anatomical structures that should be taught for safe and competent practice of general gynaecologists based on national and international validation. The results of our study identify the learning needs (i.e., the content) for an international anatomy curriculum. The development of the curriculum (i.e., the form) can be determined by each country and used to standardize and guide postgraduate training in gynaecology. This is an important step in the era of international teaching and training.
Initially, in the process of defining which anatomical structures should be taught to ensure safe and competent practice among general gynaecologists a national Delphi study was performed in the Netherlands. The content for the Delphi procedure was defined through focus groups and an individual interview with trainees (years 4–6) and specialists from four specialties: surgery, urology, obstetrics & gynaecology and radiology. After the focus groups and one interview a list of 123 items was send through the Delphi procedure to gynaecologists and trainee’s gynaecology from academic, non-academic teaching and non-academic, non-teaching hospitals working in the Netherlands. In the Netherlands this resulted in a consensus on 86 clinically relevant structures. The primary selected 123 anatomical items were also used for this international validation process.
Introduction
Trainees across the world are educated to become skilled and competent gynaecologists. Each country has its own curriculum, which not only differ in terms of length of education, but also in terms of structure and content [
Garofalo M, Aggarwal R. Competency-based medical education and assessment of training: review of selected national obstetrics and gynaecology curricula. J Obstet Gynaecol Can. 2017;39(7):534-44.e1.
]. However, the difference in content might influence the quality of care. A study in the United States assessed 107 obstetrics and gynaecology (O&G) residency programs in terms of patient outcomes. Substantial variation in maternal complications was found. These findings are the first empirical support of the clinical implications of variation in medical education and not seems to benefit patient safety [
]. This ties in with the results of a scoping review which aimed to understand motivations and challenges for the development of global curricula. It was found that nearly-one-fifth of the articles stated improvement of quality or safety of training as an important purpose for the development of a global medical curriculum and it was the second most cited motivation. The most mentioned purpose was to define common speciality-specific standards [
Also, on a political level there is a call for global standards in medical education. Already in 1999 by the World Health Organizations Institute for International Medical Education (IIME) founded the goal of developing global minimal essential requirements for physicians around the world in order to promote quality improvement [
]. Furthermore, from the (lack of) knowledge perspective there is a call for standardization as well. A widespread concern that the curricular pendulum has swung too far away from providing medical students with a firm foundation, of anatomical knowledge in this case, has led to a European consensus document which calls for the definition of a core of morphological knowledge [
Resolution from the European Consensus Conference on Morphological Sciences (Anatomy, Histology and Embryology), held by the European Federation for Experimental Morphology in Bologna, 18th November, 2007.
In the past decades several specialties have made attempts to establish such international standards for specific procedures. Examples are global curricula for robotic surgery and urolithiasis in urology, an international curriculum for headache in neurology and the global curriculum in surgical oncology [
]. For obstetrics and gynaecology, the European Board and College of Obstetrics and Gynaecology is committed to the harmonization of European postgraduate training in O&G. An example of their activities is the Project of Achieving Consensus in Training (PACT) [
]. The PACT training curriculum sets out defined goals for training all gynaecologists in Europe and provides a structure to design training programmes on a local basis. However, anatomy training and assessment and their application to surgical O&G are not defined in this training program or in other national curricula [
]. Anatomy can be considered one of the basic pillars of medical training and therefore a good level of anatomical knowledge is mandatory to become a skilled and competent gynaecologist [
]. During development of a curriculum, a systematic approach is required, starting with the identification of learning needs. A core curriculum, including what knowledge trainees are expected to acquire, contributes positively to adequate anatomical knowledge [
]. In a previous national Delphi study conducted in the Netherlands, we identified a list of anatomical structures relevant for safe and competent practice of general gynaecologists [
]. The aim of the present study was to create international consensus on the list of relevant anatomical structures in order to aid in the harmonization of global postgraduate training in O&G.
Materials and method
Survey list
In a previous national Delphi study performed in the Netherlands, we assembled a survey list of 123 anatomical structures, divided into nine categories, of which 86 were identified as clinically relevant for safe and competent practice of general gynaecologists [
For the validation procedure, gynaecologists and trainees in gynaecology were approached. To acquire an appropriate and heterogenous sample of panellists, panellists from all subspecialties, general gynaecologists and trainees from all years of training programs and from all types of hospitals (academic teaching hospitals, non-academic teaching hospitals and non-academic non-teaching hospitals) were recruited. We used our network to conduct the survey in as many countries as possible. We employed the ‘oil slick’ principle. Specifically, we asked our contacts to complete the survey and forward it to people in their networks, who could be in their hospital or in neighbouring hospitals, specialist colleagues or students, and subsequently ask the next panellist to do the same.
A country was included when at least ten surveys were completed. After 3 months, the number of completed surveys in each country was counted. If there were fewer than ten completed surveys, our contacts were recontacted and asked to forward the survey again. After another 3 months, the survey was closed.
The results for New Zealand and Australia as well as Great Britain and Ireland were combined and reported as the results for Oceania and the United Kingdom, respectively. This choice was made, since the number of responses for the individual countries of New Zealand (NZ), Australia and Ireland did not reach the minimum of ten surveys. Australia and NZ are united in one college, the RANZCOG. The college accredits all training sites offering FRANZCOG basic Training throughout Australia and New Zealand. Therefore, it was found plausible to amalgamate those two countries together. Although Ireland and Great Britain are two different countries with different training schemes, by taking them together the valuable input from Ireland could be used in the overall results.
Validation procedure
Each panellist received an invitation to participate in an online survey (**SurveyMonkey1; San Mateo, USA). Panellists were asked to rank all items on a Likert Scale from 1 (not relevant) to 5 (highly relevant). The survey list was divided into nine categories: bones, ligaments, organs, anatomical spaces and structures, general muscles, pelvic floor muscles, arteries and veins, nerves and imaging. An empty text box was included at the end of each category to capture qualitative comments or to add items. The order in which the categories and anatomical structures were listed was the same for each panellist. The survey was returned anonymously and therefore no reminders could be sent.
Consensus about the relevance of an item was achieved when ≥70 % of panellists scored the item as relevant or very relevant and the average rating was ≥4. If an item was scored as relevant or very relevant by <50 % of panellists and the average rating was <4, it was deemed to be non-relevant for general gynaecologists. When only one of these criteria was met or the item was scored to be relevant or very relevant by 50–70 % of panellists, the item was deemed to be possibly relevant, but there was no consensus [
The medical ethics committee of Maastricht University Medical Centre / University Maastricht confirmed that the Medical Research Involving Human Subjects Act (WMO) did not apply to the primary Dutch Delphi study or therefore to this validation study. The date of approval was April 29, 2019 and the reference number was 2019–1119.
Results
Validation panel
Initially, panellists from 20 countries (Austria, Belgium, Canada, Denmark, Finland, France, Germany, Greece, Hungary, Israel, Italy, Norway, Oceania, Poland, Portugal, Slovenia, Spain, Sweden, United Kingdom and United States) were asked to participate. A total of 202 panellists from ten countries responded. Ten or more surveys were (partially) completed in seven countries, with 192 surveys completed in total. The baseline characteristics of the included panellists are presented in Table 2.
Table 2Baseline characteristics.
Norway
Sweden
United Kingdom
Belgium
Germany
Oceania
United States
Overall
N = 24
N = 42
N = 30
N = 54
N = 18
N = 14
N = 10
N = 192
Gender
Woman
20 (83.3)
34 (81)
19 (63.3)
40 (74.1)
12 (66.7)
8 (57.1)
9 (90)
142 (74.0)
Man
4 (16.7)
8 (19)
11 (36.7)
14 (25.9)
6 (33.3)
6 (42.9)
1 (10)
50 (26.0)
Current position
Resident
11 (45.8)
30 (71.4)
13 (43.3)
44 (81.5)
8 (44.4)
0 (0)
0 (0)
106 (55.2)
Medical doctor
9 (37.5)
9 (21.4)
12 (40.0)
8 (14.8)
7 (38.9)
10 (71.4)
10 (100)
65 (33.8)
Other*
4 (16.7)1
3 (7.2)2
5 (16.7)3
2 (3.7)4
3 (16.7)5
4 (28.6)6
0 (0)
21 (11.0)
Workplace
Academic teaching
20 (83.3)
36 (85.7)
18 (60)
19 (35.2)
5 (27.8)
9 (64.3)
10 (100)
117 (61.0)
Non-academic
4 (16.7)
6 (14.3)
8 (26.7)
34 (63.0)
11 (61.1)
5 (35.7)
0 (0)
68 (35.4)
Non-academic non-teaching
0 (0)
0 (0)
4 (13.3)
1 (1.8)
2 (11.1)
0 (0)
0 (0)
7 (3.6)
Subspecialty
Obstetrics
6 (25)
4 (9.5)
5 (16.7)
14 (25.9)
6 (33.3)
0 (0)
0 (0)
35 (18.2)
Fertility
2 (8.3)
2 (4.8)
0 (0)
2 (3.7)
0 (0)
0 (0)
0 (0)
6 (3.1)
Oncology
3 (12.5)
1 (2.4)
2 (6.7)
5 (9.3)
3 (16.7)
5 (35.7)
1 (10)
20 (10.4)
Urogynaecology
1 (4.2)
3 (7.1)
6 (20.0)
7 (13.0)
4 (22.2)
3 (21.4)
4 (40)
28 (14.6)
Benign gynaecology
3 (12.5)
4 (9.5)
4 (13.3)
0 (0)
0 (0)
3 (21.4)
5 (50)
19 (10.0)
No subspeciality
9 (37.5)
28 (66.7)
13 (43.3)
26 (48.1)
5 (27.8)
3 (21.4)
0 (0)
84 (43.8)
Rating of anatomical knowledge
Inadequate
3 (12.5)
6 (14.3)
2 (6.7)
9 (16.7)
4 (22.2)
2 (14.3)
0 (0)
26 (13.5)
Adequate
14 (58.3)
25 (59.5)
19 (63.3)
29 (53.7)
8 (44.4)
9 (64.3)
0 (0)
104 (54.2)
Good
7 (29.2)
10 (23.8)
8 (26.7)
14 (25.9)
5 (27.8)
2 (14.3)
5 (50)
51 (26.6)
Excellent
0 (0)
1 (2.4)
1 (33.3)
2 (3.7)
1 (5.6)
1 (7.1)
5 (50)
11 (5.7)
Numbers in brackets are percentages.
Other positions*:
1. PhD candidate and teacher of medical students in obstetrics/gynaecology, gynaecologist, Professor Emerita and fellow.
2. Specialist physician, intern and postgraduate, not yet a resident.
Of the 123 structures, 72 (58.54 %) were internationally relevant. Ten (8.13 %) structures were non-relevant and 41 (33.33 %) were possibly relevant, but there was no consensus. When the 86 relevant structures from the Dutch Delphi study were compared with the 72 relevant structures from the international Delphi study, 70 (81.4 %) structures matched. The two additional relevant structures in the international validation were the ovarian vein and uterosacral ligament from the imaging category. No new structures were mentioned to add.
Difference between the Dutch Delphi and the international validation
In the category general muscles only two of the seven muscles were found relevant in the international validation study compared to the Dutch Delphi study. Four of the five muscles that were not relevant, all abdominal wall muscles, had mean ratings of 3.9 and 66–70 % of panellists scored them as relevant or very relevant.
In the category organs, four organs (liver, transverse colon, small intestine and kidney) were found relevant in the Dutch Delphi study but not in the international validation.
Another discrepancy was seen in the imaging category. In this category, two structures, the ovarian vein and uterosacral ligament, were internationally accepted immediately while not found relevant in the Dutch Delphi. Furthermore, 14 structures were labelled as possibly relevant but were not relevant in the Dutch Delphi study in the first round.
Of the 16 additional relevant structures in the Dutch Delphi study, only one (the posterior superior iliac spine) was non-relevant in the international validation. In the Dutch Delphi study, this structure was labelled as possibly relevant and thus considered for a second round. It remained possibly relevant, with 77.2 % of panellists scoring it as relevant or very relevant and an average rating of 3.8. Only one other structure, the sciatic foramen, was considered for a third round. It was not considered appropriate to perform a third Delphi round for these two structures and therefore they were both accepted as relevant.
This study reported an internationally validated list of 70 structures that are relevant for safe and competent practice of general gynaecologists. Based on the opinions of 192 panellists from seven international countries, 72 structures were validated and therefore found to be clinically relevant for general gynaecologists on an international scale. Of the 86 relevant structures in the Dutch Delphi study, 16 were possible relevant or non-relevant internationally. Conversely, only two internationally relevant structures, both of which were in the imaging category, were not relevant nationally, meaning that 70 relevant structures matched.
Interpretation
Anatomy is the cornerstone of good clinical practice. As less time and fewer resources are devoted to anatomical education, defining what is essential knowledge helps to provide a sufficient knowledge base [
]. The importance of a so-called core anatomy curriculum is well-described in the literature. A core curriculum ensures that topics of real clinical relevance are covered and that students gain an understanding of the relationship between structure and function [
With this internationally validated list of anatomical structures that are relevant for safe and competent practice of gynaecologists, we have defined essential anatomical knowledge for a general gynaecologist. This can therefore be seen as a first step in the development of an international anatomy curriculum. Effective curriculum development requires a systematic approach, starting with identification of the learning needs, followed by curriculum development, during which the training structure and environment can be defined, and subsequently validation, implementation and assessment of patient outcomes (Fig. 1) [
]. The results of our study identify the essential learning needs (i.e., the content). The development of the curriculum (i.e., the form) can be determined by each country.
It requires much more than anatomical knowledge to become a skilled and competent gynaecologist. Assembly of this international list is valuable at several levels. First, standardization of curricula content will enhance the quality of training programs and subsequently patient care [
]. Second, identification of learning needs is time-consuming and requires considerable resources. This core list means countries do not have to face these challenges, avoids repeating work and circumvents pitfalls already encountered [
Besso J, Bhagwanjee S, Takezawa J, Prayag S, Moreno R. A global view of education and training in critical care medicine. Crit Care Clin. 2006;22(3):539-46, x-xi.
]. If gynaecologists all achieve the expected competencies, which are internationally agreed, regulatory bodies can develop consistent approaches across countries. Subsequently, easier movement of gynaecologists between countries will facilitate exchange of knowledge and skills, which will help to improve the quality of patient care and training.
As mentioned in the Results section, there were a few differences between the results of the Dutch Delphi study and the international results. In the international Delphi study less structures were found relevant compared to the Dutch Delphi. This difference can be viewed from a general perspective as well as at a detailed level of the separate categories and individual structures. From a more general perspective, it would be interesting to investigate if this difference is for example related to the country, workplace or current position of the participants. This would give insight into the role that anatomy plays in the daily practice and education of a specific workplace or position and hence can help to implement an international anatomy core curriculum. Unfortunately, the number of responders in each group are too low to perform statistical tests to investigate this thoroughly. Nevertheless, the differences between the participants of the Dutch Delphi and the international validation study can provide some insight into the differences found.
The international validation showed a higher percentage of residents and of doctors from academic teaching hospitals that fulfilled the questionnaire. In terms of subspecialisation, less specialist from obstetrics and fertility participated in the international validation compared to the Dutch Delphi. By our knowledge there is no literature available discussing the relation between a doctor’s degree (i.e. resident, fellow, medical doctor), subspecialisation or work place and how anatomy is valued. In general, when less is known about a subject, the risk (of not knowing) or added value of certain knowledge can be estimated less well [
] With this in mind, it could be reasoned that residents might not be fully aware of all anatomical structures which might be important and therefore less anatomical structures were found important in the international validation study. However, in the focus groups prior to the Delphi study in the Netherlands, the opposite was found: residents found more structures important than specialists [results not published]. The fact that fewer structures were found relevant in the international validation can also be interpreted as more selective scoring. The difference in subspecialisation and workplace could be underlying to this. Specialists working in an academic teaching hospital are in general more subspecialised compared to specialist working in general hospitals. The division in subspecialist for the international validation showed more surgical orientated subspecialist. It is plausible that surgical orientated subspecialists attach more value to anatomical knowledge and better estimate which structures are essential since they perform surgical procedures with and around those structures.
On the level of the individual structures the posterior superior iliac spine was the only structure found relevant in the Dutch Delphi but not relevant in the international validation study. This might be due to that in the Dutch Delphi we choose to accept this structure since after two rounds it was still labelled as possible relevant. The finding that the posterior superior iliac spine was not an important anatomical structure in the international study makes the decision to accept this structure as relevant in the national study questionable.
Differences between findings of the national and international Delphi studies were most striking for items in the general muscle category, where only two of the seven muscles were relevant, but similar results were seen in other categories. Structures such as the liver, transverse colon, kidney, transversalis fascia and renal artery/vein were not relevant in the international Delphi study, with mean ratings of 3.8–3.9. This might be due to interpretation of the instructions sent with the survey. We asked panellists to assess to what extent the named structure is relevant on a scale from 1 to 5 (1 = not relevant, 3 = neutral and 5 = highly relevant). Whereby, it is important for the structures to be assessed on the level of a general gynaecologists who have just finished their training. A gynaecologist will not operate on the pyramidalis muscle or liver, but may encounter these structures during gynaecological surgery. Therefore, it is debatable whether it is or is not necessary to know about these structures. Another potential explanation is that a doctor may be expected to know about these structures from their medical education because they are so general.
Another discrepancy was seen in the imaging category. We cannot fully explain this difference in importance of these structures in the imaging category. Undergraduate radiology education, radiology curricula and radiology pedagogy vary widely between disciplines and between colleges within disciplines [
]. In the Netherlands, radiology is taught in medical school, usually in combination with anatomy, and radiology examinations are readily available and widely performed in daily clinical practice. However, there is no formal radiology course or teaching in postgraduate gynaecology. To our knowledge, this is neither the case in other countries.
Strengths and limitations
The main strength of the study is diversity. There was broad international engagement in the development process, ensuring that our results are comprehensive and representative. There was diversity in the included countries, with 192 responses from panellists in seven countries across the world. In addition, there was diversity in workplace (academic teaching hospitals, non-academic teaching hospitals and non-academic non-teaching hospitals) and subspecialty. Finally, there was diversity due to the involvement of trainees and medical doctors with different levels of experience and education. This diversity makes it more likely that the list will be included in national training programmes [
The design of the entire process, from the primary list to the international validation, is also a strength. We first developed a list of essential structures using textbooks related to gynaecological examination and surgery. Through focus groups and structured interviews, a survey list of 123 items was developed. This list was nationally and internationally validated, yielding 70 validated structures.
A limitation of this study is that the results were all from Western countries. Although we invited panellists from both Western and non-Western countries to participate in our study, the survey was not completed or was completed by fewer than ten panellists in non-Western countries. Therefore, we could not ascertain the degree to which these results address non-Western or local needs in anatomy. In general, the female body is universal but there are country specific conditions. An example is fistula surgery, which is much more common in non-western countries compared to western countries and requires a more detailed and broader anatomical knowledge. Therefore, our results will probably not be fully applicable in non-Western countries.
To obtain as many responses as possible, we used the oil slick principle. However, this meant it was impossible to perform a second round for structures labelled as possibly relevant. In the first round of the Dutch Delphi study, 74 structures were relevant, 24 were non-relevant and 25 were possibly relevant, while 12 more structures were relevant after the second round. The numbers were similar in the international validation, meaning that more structures would have been labelled as relevant if a second round had been possible.
Conclusion
This study identified 70 anatomical structures that are relevant for safe and competent practice of general gynaecologists based on a national and international validation. The results of our study identify the learning needs (i.e., the content) for an international anatomy curriculum. The development of the curriculum (i.e., the form) can be determined by each country and used to standardize and guide postgraduate training in gynaecology. This is an important step in the era of international teaching and training.
Declaration of Competing Interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Acknowledgements
We would like to thank all the gynaecologists and trainee gynaecologist who participated in our focus group and Delphi study. Special thanks to our contact persons in the several countries. Due to ensure anonymity we will not thank them by name.
No funding was received.
Details of ethics approval
Medical ethics committee of azM/UM confirmed that the Medical Research Involving Human Subjects Act (WMO) does not apply to the above-mentioned study.
Funding
No funding.
References
Garofalo M, Aggarwal R. Competency-based medical education and assessment of training: review of selected national obstetrics and gynaecology curricula. J Obstet Gynaecol Can. 2017;39(7):534-44.e1.
Resolution from the European Consensus Conference on Morphological Sciences (Anatomy, Histology and Embryology), held by the European Federation for Experimental Morphology in Bologna, 18th November, 2007.
Besso J, Bhagwanjee S, Takezawa J, Prayag S, Moreno R. A global view of education and training in critical care medicine. Crit Care Clin. 2006;22(3):539-46, x-xi.
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