RESEARCH REPORT
Spatial Abilities of Medical Graduates and Choice of Residency Programs Jean Langlois,1,2* George A. Wells,3,4 Marc Lecourtois,5 Germain Bergeron,5 Elizabeth Yetisir,4 Marcel Martin2 1 Department of Emergency Medicine, Centre hospitalier universitaire de Sherbrooke, Sherbrooke, Quebec, Canada 2 Department of Surgery, University of Sherbrooke, Sherbrooke, Quebec, Canada 3 Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ontario, Canada 4 Cardiovascular Research Methods Center, University of Ottawa Heart Institute, Ottawa, Ontario, Canada 5 Neuropsychology Program of the Trauma and Critical Care Group, Centre hospitalier universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
Spatial abilities have been related in previous studies to three-dimensional (3D) anatomy knowledge and the performance in technical skills. The objective of this study was to relate spatial abilities to residency programs with different levels of content of 3D anatomy knowledge and technical skills. The hypothesis was that the choice of residency program is related to spatial abilities. A cohort of 210 medical graduates was enrolled in a prospective study in a 5-year experiment. Spatial abilities were measured with a redrawn Vandenberg and Kuse Mental Rotations Test (MRT) in two (MRTA) and three (MRTC) dimensions. Medical graduates were enrolled in Family Medicine (n 5 76, 36.2%), Internal Medicine (64, 30.5%), Surgery (52, 24.8%), and Anesthesia (18, 8.6%). The assumption was that the level of 3D anatomy knowledge and technical skills content was higher in Surgery and Anesthesia compared to Family Medicine and Internal Medicine. Mean MRTA score of 12.4 (6SD 4.6), 12.0 (64.3), 14.1 (64.3), and 14.6 (64.0) was obtained in Family Medicine, Internal Medicine, Surgery, and Anesthesia, respectively (P 5 0.0176). Similarly, mean MRTC score of 8.0 (64.4), 7.5 (63.6), 8.5 (63.9), and 7.9 (64.1) was obtained (P 5 0.5647). Although there was a tendency for lower MRTA score in Family Medicine and Internal Medicine compared to Surgery and Anesthesia, no statistically significant main effect of residency, year, sex, or the interactions were observed for the MRTA and MRTC. Studied sample of medical graduates was not found to choose their residency proC 2014 American Associagrams based on their innate spatial abilities. Anat Sci Educ 8: 111–119. V tion of Anatomists.
Key words: spatial abilities; gross anatomy education; technical skills; medical education; residency education; residency selection; visualization; spatial orientation; mental rotations test
*Correspondence to: Dr. Jean Langlois, Department of Emergency Medicine, Centre hospitalier universitaire de Sherbrooke, 3001, 12e Avenue Nord, Sherbrooke, Quebec, Canada J1H 5N4. E-mail: [email protected] Grant sponsor: Department of Surgery, University of Sherbrooke, Sherbrooke, Quebec, Canada (internal research fund). Received 24 October 2014; Revised 14 February 2014; Accepted 15 March 2014. Published online 20 June 2014 in Wiley (wileyonlinelibrary.com). DOI 10.1002/ase.1453 C 2014 American Association of Anatomists V
Anatomical Sciences Education
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INTRODUCTION Spatial abilities consist of visualization, orientation, and manipulation of structures in space (McGee, 1979). Spatial abilities have been related to three-dimensional (3D) anatomy knowledge using practical (identification) examination (Rochford, 1985; Provo et al., 2002; Luursema et al., 2006, 2008; Levinson et al., 2007; Lufler et al., 2012; Nguyen et al., 2012), topographical questions (Rochford, 1985; Guillot et al., 2007; Hoyek et al., 2009), 3D synthesis of twodimensional anatomical views (Rochford, 1985; Garg et al.,1999a, b, 2001, 2002), cross-sections (Provo et al., Anat Sci Educ 8:111–119 (2015)
2002; Luursema et al., 2006, 2008; Hegarty et al., 2009; Nguyen et al., 2012), and mental rotations (Stull et al., 2009; Nguyen et al., 2012) of anatomical structures. Spatial abilities have been also related to the performance in technical skills in microscopic pathology (Helle et al., 2010), interpreting 3D information in dental radiographs (Nilsson et al., 2007), clinical ultrasonography (Clem et al., 2010, 2013), clinical surgery (Schueneman et al., 1984; Gibbons et al., 1986), dental practical restorative laboratory classes (Hegarty et al., 2009), and in the simulation laboratory performing gastroscopy (Hedman et al., 2007; Schlickum et al., 2011), colonoscopy (Westman et al., 2006; Luursema et al., 2010), gastrointestinal flexible endoscopy (Ritter et al., 2006), ureteroscopy (Schlickum et al., 2011), endoscopic sinus surgery (Arora et al., 2005), sutures of fresh porcine jejunum (Steele et al., 1992), anastomosis of blood vessels by microsurgery in rats (Murdoch et al., 1994), Z-plasties on pig thighs (Wanzel et al., 2002), rigid fixation of a synthetic mandible (Wanzel et al., 2003), surgical knot tying (Brandt and Davies, 2006), and minimally invasive surgery (Risucci et al., 2000, 2001; Keehner et al., 2004, 2006; Hedman et al., 2006, 2007; Hassan et al., 2007; Rosenthal et al., 2010; Ahlborg et al., 2011, 2012; Jungmann et al., 2011; Schlickum et al., 2011; Nugent et al., 2012). Hegarty and colleagues have identified an ability model of individual differences in the performance in technical skills where success in the profession depends on spatial ability (Hegarty et al., 2007). The ability model is different from a skill model where success in the profession depends on training and experience (Hegarty et al., 2007). Examples of a skill model can be found in Medical School. Medical graduates entering their residency training programs were not found to choose an elective course of applied anatomy based on their innate spatial abilities, but rather on their training needs (Langlois et al., 2009). Also, spatial abilities in surgical residents were not related to scores of Medical College Admission Test and National Board of Medical Examiners (Schueneman et al., 1984). Finally, a relationship between spatial abilities and interest in spatially intense medical disciplines on entry to medical school did not persist to the time of application and acceptance into residency training programs (Brandt and Wright, 2005). Unlike Medical Schools, Dental Schools in North America are currently using an ability model with a Perceptual Ability Test related to spatial abilities as part of the Dental Admission Test administered by the American Dental Association and the Canadian Dental Association (Ranney et al., 2005). The inclusion of the Perceptual Ability Test was based on evidence of relationship to the performance in the first two preclinical years of Dental School including technical courses that does not extend to the final two clinical years of Dental School (Ranney et al., 2005). Fitts and Posner’s theory describing three stages (cognitive, associative, and autonomous) in motor skill acquisition (Fitts and Posner, 1967) and Ackerman’s theory of ability determinants of skilled performance (Ackerman, 1988) were used to explain the findings (Gray and Deem, 2002; Gray et al., 2002). Dental preclinical laboratory technique courses requiring tasks that are novel, first-time experienced, and nonrepetitive in nature were related to the cognitive phase of learning procedural skills characterized by a high cognitive load involving a spatial ability component (Gray and Deem, 2002). The final clinical years of Dental School requiring a significant amount a repetitive tasks were related to the associative phase of learning related more with perceptual speed and task practice rather 112
than spatial abilities (Gray et al., 2002). “Perceptual ability are best viewed as screening rather than predictive tools and could be used to set baseline scores below which further consideration would not be given to a candidate” (Ranney et al., 2005). Dentistry in North America has adopted an ability model that ensures success in the early part of its Dental School as a prerequisite to the final part of its curriculum. The role of assessment in spatial abilities for the selection in residency training program has been discussed in Surgery (Grace, 1989; Risucci and Tortolani, 1990; Anastakis et al., 2000; Romano, 2002; Wanzel et al., 2002; Hamstra, 2006; Tansley et al., 2007; Gallagher et al., 2009) and Radiology (Smith and Berbaum, 1991; Corry, 2011). At the University of Toronto, Ontario, Canada, the use of neuropsychological testing in the selection process of residents in surgery is not currently recommended because practice and experience could supplant the influence of spatial abilities over time, although they may be useful in identifying residents with lower spatial abilities who might benefit from supplementary instruction (Wanzel et al., 2002). At the Royal College of Surgeons of Ireland, all short-listed candidates for Higher Surgical Training now undergo formal testing of both technical skills and fundamental abilities, such as psychomotor skills, visuospatial ability, and depth perception (Gallagher et al., 2009). Research is needed to define the importance of spatial abilities, not only in the selection process, but also in teaching, learning, and maintaining the quality of spatial anatomy knowledge and technical skills. There is a need to know if residents are selecting their residency training program based on their innate spatial abilities. The objective of this study was to assess the relationship of spatial abilities to residency programs with different levels of content of 3D anatomy knowledge and technical skills. The hypothesis was that the choice of residency program is related to spatial abilities.
METHODS Study Design A prospective cohort study was done and the institutional ethics committee on human research approved the protocol.
Setting and Participants The study was conducted at the Faculty of Medicine of Sherbrooke in May 2005–2008 and 2010. There was no study in 2009. Medical graduates entering their residency programs were offered an elective preparatory 1-month rotation to the residency program entitled “What to Do in an Emergency?”. A drawing course (1 week), an applied anatomy course (1 week), a prerequisite workshop including applied physiology and pharmacology courses (1 week), and resuscitation courses (1–2 weeks) were included in the rotation. Preference for inclusion in this rotation was given to residents in Surgery, Anesthesia, and Emergency Medicine, and the remaining positions were given to Family Medicine and Internal Medicine (including Neurology and Infectious Disease) residents. Radiology residents were included only in 2010.
Study Protocol Medical graduates entering their residency programs enrolled in the rotation “What to Do in an Emergency?” were invited Langlois et al.
to enter research studies during plenary sessions in May. After the written informed consent was obtained, the participants were subjected to a psychometric test in spatial abilities at the beginning of every study conducted from 2005 to 2010.
Measures Age and residency program chosen were ascertained from the office for postgraduate education at the Faculty of Medicine of Sherbrooke in 2005 and from the written consent from 2006 to 2010. Sex was obtained from the written consent. Vandenberg and Kuse (1978) psychometric test of mental rotations discriminates highly for the spatial abilities as opposed to the verbal abilities. The redrawn 24-items Vandenberg and Kuse Mental Rotations Test for spatial abilities was administered (Peters et al., 1995). The Mental Rotations Test A (MRTA) was based on the original Vandenberg and Kuse set requiring a mental rotation around the vertical axis and was also made more difficult by adding the Mental Rotations Test C (MRTC) requiring a mental rotation in the vertical and horizontal axis (Peters et al., 1995). Each test was administered in 9 minutes; 3 minutes for each 12-items subset separated by a 3-minute break. The easier MRTA was administered before the MRTC and the maximum score on each of these tests was 24.
Statistical Analyses Variables considered included the discrete variables sex and residency program chosen; and the continuous variables age, MRTA and MRTC scores. Descriptive statistics included frequencies and percents for the discrete variables with group comparisons using Fisher’s exact test. Values for continuous outcomes are reported as means 6 standard deviation (6SD) with group comparisons using analysis of variance (ANOVA) and correlations using Pearson coefficient (r). A three-way ANOVA was used to assess spatial abilities as related to the main effect of residency, year, sex, and their interactions. The Nelson–Hsu adjusting procedure (Hsu and Nelson, 1998) for multiple pairwise comparisons was used in the post hoc analysis. The level of significance for all tests was < 0.05 (two-tailed). Analyses were performed with SAS statistical software, version 9.2 (SAS Institute, Cary, NC).
RESULTS In 2005, 2006, 2007, 2008, and 2010, there were 62, 65, 65, 64 and 49 medical graduates, respectively, enrolled in the rotation “What to Do in an Emergency?”. Of these 305 graduates, 214 (70.2%) were enrolled in research studies: 59 (95.2%), 54 (83.1%), 18 (27.7%), 34 (53.1%), and 49 (100%) for years 2005, 2006, 2007, 2008, and 2010, respectively. Written consent was signed by all 214 graduates. Four medical graduates entering a residency program of Radiology were excluded because of the small number and they were only enrolled in 1 year (2010). The study cohort consisted of 210 (100%) graduates. The mean age was 23.5 (1.9) years and there were 130 (61.9%) female graduates. Medical graduates were enrolled in Family Medicine (n 5 76, 36.2%), Internal Medicine (64, 30.5%), Surgery (52, 24.8%), and in Anesthesia (18, 8.6%). The only Emergency Medicine resident was included in Family Medicine. The investigators had Anatomical Sciences Education
MARCH/APRIL 2015
no indication that participants were exposed to previous spatial abilities testing from 2005 to 2008. Four of the graduates in the 2010 sample had previous exposure to the test, but these students did not differ significantly from the other participants in MRTA or MRTC scores. MRTA and MRTC scores were significantly correlated (Pearson coefficient r) in 2005 (P < 0.0001), 2006 (P < 0.0001), 2007 (P 5 0.0157), 2008 (P 5 0.0004), 2010 (P < 0.0001), and from 2005 to 2010 (P < 0.0001). A mean MRTA score of 12.4 (4.6), 12.0 (4.3), 14.1 (4.3), and 14.6 (4.0) was obtained by medical graduates entering the residency training programs of Family Medicine, Internal Medicine, Surgery, and Anesthesia (Table 1), respectively, and the difference over all 5 years was statistically different (P 5 0.0176). A mean MRTC score of 8.0 (4.4), 7.5 (3.6), 8.5 (3.9), and 7.9 (4.1) was obtained by medical graduates entering the residency training programs of Family Medicine, Internal Medicine, Surgery, and Anesthesia (Table 1), respectively, but the differences over all 5 years was not statistically different (P 5 0.5647). From 2005 to 2010, a higher ratio of female medical graduates chose the residency programs of Family Medicine and Internal Medicine compared to Surgery and Anesthesia (Table 2) and this difference was statistically different (Fisher’s Exact Square P 5 0.0119). Although trends by sex (P 5 0.05) and residency by year interaction (P 5 0.08) were observed, no statistically significant effect of residency, year, sex, or the interactions were found for MRTA. In post hoc analysis, a statistically significant difference was found for female graduates in Internal Medicine (P 5 0.0190) and male graduates in Surgery (P 5 0.0103) for the year 2010. Similarly, although there was a trend for a sex by year interaction (P 5 0.0874), no statistically significant main effect of residency, year, sex, or the interactions were observed for the MRTC. In post hoc analysis, trends were found for male graduates in 2005 in Family Medicine (P 5 0.0685) and in 2010 in Surgery (P 5 0.0940). Figures 1 and 2 show the distribution of individual MRTA and MRTC scores, respectively, for residency programs. There is a wide variation in individual MRTA and MRTC scores for all residency programs. Figures 3 and 4 show residency program differences in MRTA and MRTC scores from 2005 to 2010.
DISCUSSION Differences in MRTA scores between the residency programs of Family Medicine, Internal Medicine, Surgery, and Anesthesia were statistically significant. In a multivariable analysis, there was no main effect of residency and year, but trends for sex and the residency by year interaction were observed. In post hoc analysis, a difference was found between females in Internal Medicine and males in Surgery for the year 2010. Differences in MRTC scores between the residency programs of Family Medicine, Internal Medicine, Surgery, and Anesthesia were not statistically significant. In a multivariable analysis, there was no main effect of residency, sex and year, but there was a trend for the sex by year interaction. In post hoc analysis, trends were found for males in 2005 in Family Medicine and in 2010 in Surgery. The MRTC score was highly related to the MRTA score in the current study. The MRTC is more difficult than the MRTA as a rotation in a different direction was included. That could explain why a difference was not found with the 113
Table 1. Mental Rotations Test Scores and Residency Programs (2005–2010) Residency programs a
Year, n MRT
Anesthesia
P-valueb
All
Family medicine
Internal medicine
Surgery
2005 MRTA MRTC
59 12.5 (64.0) 7.7 (63.9)
30 13.2 (64.5) 8.7 (64.7)
16 10.8 (63.1) 5.9 (62.5)
10 12.3 (62.9) 6.7 (62.5)
3 16.3 (63.8) 9.3 (62.1)
0.0909 0.0872
2006 MRTA MRTC
54 11.9 (64.3) 6.9 (63.8)
23 11.4 (64.4) 6.4 (63.1)
15 11.4 (63.4) 6.4 (63.5)
11 12.6 (65.3) 8.9 (65.3)
5 13.6 (64.1) 6.4 (63.4)
0.6622 0.2787
2007 MRTA MRTC
18 14.6 (64.4) 7.8 (63.4)
2 17.0 (64.2) 9.5 (62.1)
6 10.8 (63.6) 7.0 (62.6)
7 16.0 (64.4) 7.7 (64.4)
3 17.0 (62.0) 8.7 (64.0)
0.0707 0.8242
2008 MRTA MRTC
34 13.8 (64.1) 8.2 (63.6)
5 10.6 (64.0) 6.0 (61.9)
18 15.2 (64.1) 9.4 (63.7)
9 13.2 (63.8) 7.7 (63.0)
2 12.0 (62.8) 5.0 (65.7)
0.3254 0.6152
2010 MRTA MRTC
45 13.2 (65.2) 9.5 (64.5)
16 12.3 (64.8) 9.4 (65.4)
9 9.4 (65.6) 8.2 (64.6)
15 15.9 (64.0) 10.3 (63.2)
5 14.2 (65.4) 9.2 (65.5)
0.0191 0.7543
2005–2010 MRTA MRTC
210 12.9 (64.5) 8.0 (64.0)
76 12.4 (64.6) 8.0 (64.4)
64 12.0 (64.3) 7.5 (63.6)
52 14.1 (64.3) 8.5 (63.9)
18 14.6 (64.0) 7.9 (64.1)
0.0176 0.5647
a
Mean (6SD). MRT score versus residency programs (ANOVA).
b
MRTC score compared to the MRTA score. As scores will be consistently smaller, only smaller differences of importance can be identified which would require larger sample sizes to detect. Sex differences in spatial abilities favoring males have been described in the literature of cognitive psychology (Maccoby and Jacklin, 1974; Voyer et al., 1995; Peters et al., 2007). This finding was confirmed in the medical field using a priori hypothesis (Langlois et al., 2013) and also a posteriori in other studies (Garg et al., 1999a, b; Lufler et al., 2012; Vorstenbosch et al., 2013). There was a higher ratio of female graduates in Family Medicine and Internal Medicine compared to Surgery and Anesthesia in current study. Sex differences in spatial abilities were likely responsible for the differences found for the MRTA score and also in post hoc analysis between females in Internal Medicine and males in Surgery for the year 2010. Similarly, sex differences in spatial abilities were also responsible for the differences found for the MRTC score in post hoc analysis for males in Family Medicine in 2005 and Surgery in 2010. MRTA and C scores of graduates in this study were not related to the level of 3D anatomy knowledge and technical skills content in the chosen residency program. The assumption was that the level of 3D anatomy knowledge and technical skills content was higher in Surgery and Anesthesia compared to Family Medicine and Internal Medicine. Wide variations in individual spatial abilities were found within residency programs with a higher level in 3D anatomy and technical skills content, such as Surgery and Anesthesia. Se114
veral graduates with lower spatial abilities were found to enter Surgery and Anesthesia and graduates with higher spatial abilities were found to enter Family Medicine and Internal Medicine. It is possible that graduates in Family Medicine may enter a practice of Emergency Medicine and/or Critical Care Medicine with a higher level of 3D anatomy and technical skills content. It is also possible that some graduates entering Internal Medicine may enter a practice in a subspecialty with a higher level of 3D anatomy and technical skills content, such as interventional cardiology or gastroenterology. Spatial abilities have been related to the performance of gastroscopy (Hedman et al., 2007), colonoscopy (Westman et al., 2006; Luursema et al., 2010), and gastrointestinal flexible endoscopy (Ritter et al., 2006). Residents could also ignore their own spatial abilities or express their innate spatial abilities in other aspects of their life. Graduates entering residency training programs of Internal Medicine and Family Medicine had lower MRTA scores and a higher ratio of females than Surgery and Anesthesia, but the statistical analysis was not able to confirm significant differences. There was no evidence with the MRTC score that graduates were selecting their programs based on their innate spatial abilities. It is important to note that MRTA and MRTC scores were widely distributed within programs. The sample of medical graduates was not found to choose their residency programs based on their innate spatial abilities. Self-selection on the basis of innate spatial abilities has not been related to chosen residency programs in one study relating trainees in Surgery, Psychiatry, Anesthesia, and Medicine Langlois et al.
Table 2. Sex and Chosen Residency Programs at the Faculty of Medicine of Sherbrooke (2005–2010) Residency programs P-valuea
Year, n sex, n
All
Family medicine
Internal medicine
Surgery
2005 Female Male
59 42 17
30 23 7
16 15 1
10 4 6
3 0 3
Spatial Abilities of Medical Graduates and Choice of Residency Programs Jean Langlois,1,2* George A. Wells,3,4 Marc Lecourtois,5 Germain Bergeron,5 Elizabeth Yetisir,4 Marcel Martin2 1 Department of Emergency Medicine, Centre hospitalier universitaire de Sherbrooke, Sherbrooke, Quebec, Canada 2 Department of Surgery, University of Sherbrooke, Sherbrooke, Quebec, Canada 3 Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ontario, Canada 4 Cardiovascular Research Methods Center, University of Ottawa Heart Institute, Ottawa, Ontario, Canada 5 Neuropsychology Program of the Trauma and Critical Care Group, Centre hospitalier universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
Spatial abilities have been related in previous studies to three-dimensional (3D) anatomy knowledge and the performance in technical skills. The objective of this study was to relate spatial abilities to residency programs with different levels of content of 3D anatomy knowledge and technical skills. The hypothesis was that the choice of residency program is related to spatial abilities. A cohort of 210 medical graduates was enrolled in a prospective study in a 5-year experiment. Spatial abilities were measured with a redrawn Vandenberg and Kuse Mental Rotations Test (MRT) in two (MRTA) and three (MRTC) dimensions. Medical graduates were enrolled in Family Medicine (n 5 76, 36.2%), Internal Medicine (64, 30.5%), Surgery (52, 24.8%), and Anesthesia (18, 8.6%). The assumption was that the level of 3D anatomy knowledge and technical skills content was higher in Surgery and Anesthesia compared to Family Medicine and Internal Medicine. Mean MRTA score of 12.4 (6SD 4.6), 12.0 (64.3), 14.1 (64.3), and 14.6 (64.0) was obtained in Family Medicine, Internal Medicine, Surgery, and Anesthesia, respectively (P 5 0.0176). Similarly, mean MRTC score of 8.0 (64.4), 7.5 (63.6), 8.5 (63.9), and 7.9 (64.1) was obtained (P 5 0.5647). Although there was a tendency for lower MRTA score in Family Medicine and Internal Medicine compared to Surgery and Anesthesia, no statistically significant main effect of residency, year, sex, or the interactions were observed for the MRTA and MRTC. Studied sample of medical graduates was not found to choose their residency proC 2014 American Associagrams based on their innate spatial abilities. Anat Sci Educ 8: 111–119. V tion of Anatomists.
Key words: spatial abilities; gross anatomy education; technical skills; medical education; residency education; residency selection; visualization; spatial orientation; mental rotations test
*Correspondence to: Dr. Jean Langlois, Department of Emergency Medicine, Centre hospitalier universitaire de Sherbrooke, 3001, 12e Avenue Nord, Sherbrooke, Quebec, Canada J1H 5N4. E-mail: [email protected] Grant sponsor: Department of Surgery, University of Sherbrooke, Sherbrooke, Quebec, Canada (internal research fund). Received 24 October 2014; Revised 14 February 2014; Accepted 15 March 2014. Published online 20 June 2014 in Wiley (wileyonlinelibrary.com). DOI 10.1002/ase.1453 C 2014 American Association of Anatomists V
Anatomical Sciences Education
MARCH/APRIL 2015
Online
Library
INTRODUCTION Spatial abilities consist of visualization, orientation, and manipulation of structures in space (McGee, 1979). Spatial abilities have been related to three-dimensional (3D) anatomy knowledge using practical (identification) examination (Rochford, 1985; Provo et al., 2002; Luursema et al., 2006, 2008; Levinson et al., 2007; Lufler et al., 2012; Nguyen et al., 2012), topographical questions (Rochford, 1985; Guillot et al., 2007; Hoyek et al., 2009), 3D synthesis of twodimensional anatomical views (Rochford, 1985; Garg et al.,1999a, b, 2001, 2002), cross-sections (Provo et al., Anat Sci Educ 8:111–119 (2015)
2002; Luursema et al., 2006, 2008; Hegarty et al., 2009; Nguyen et al., 2012), and mental rotations (Stull et al., 2009; Nguyen et al., 2012) of anatomical structures. Spatial abilities have been also related to the performance in technical skills in microscopic pathology (Helle et al., 2010), interpreting 3D information in dental radiographs (Nilsson et al., 2007), clinical ultrasonography (Clem et al., 2010, 2013), clinical surgery (Schueneman et al., 1984; Gibbons et al., 1986), dental practical restorative laboratory classes (Hegarty et al., 2009), and in the simulation laboratory performing gastroscopy (Hedman et al., 2007; Schlickum et al., 2011), colonoscopy (Westman et al., 2006; Luursema et al., 2010), gastrointestinal flexible endoscopy (Ritter et al., 2006), ureteroscopy (Schlickum et al., 2011), endoscopic sinus surgery (Arora et al., 2005), sutures of fresh porcine jejunum (Steele et al., 1992), anastomosis of blood vessels by microsurgery in rats (Murdoch et al., 1994), Z-plasties on pig thighs (Wanzel et al., 2002), rigid fixation of a synthetic mandible (Wanzel et al., 2003), surgical knot tying (Brandt and Davies, 2006), and minimally invasive surgery (Risucci et al., 2000, 2001; Keehner et al., 2004, 2006; Hedman et al., 2006, 2007; Hassan et al., 2007; Rosenthal et al., 2010; Ahlborg et al., 2011, 2012; Jungmann et al., 2011; Schlickum et al., 2011; Nugent et al., 2012). Hegarty and colleagues have identified an ability model of individual differences in the performance in technical skills where success in the profession depends on spatial ability (Hegarty et al., 2007). The ability model is different from a skill model where success in the profession depends on training and experience (Hegarty et al., 2007). Examples of a skill model can be found in Medical School. Medical graduates entering their residency training programs were not found to choose an elective course of applied anatomy based on their innate spatial abilities, but rather on their training needs (Langlois et al., 2009). Also, spatial abilities in surgical residents were not related to scores of Medical College Admission Test and National Board of Medical Examiners (Schueneman et al., 1984). Finally, a relationship between spatial abilities and interest in spatially intense medical disciplines on entry to medical school did not persist to the time of application and acceptance into residency training programs (Brandt and Wright, 2005). Unlike Medical Schools, Dental Schools in North America are currently using an ability model with a Perceptual Ability Test related to spatial abilities as part of the Dental Admission Test administered by the American Dental Association and the Canadian Dental Association (Ranney et al., 2005). The inclusion of the Perceptual Ability Test was based on evidence of relationship to the performance in the first two preclinical years of Dental School including technical courses that does not extend to the final two clinical years of Dental School (Ranney et al., 2005). Fitts and Posner’s theory describing three stages (cognitive, associative, and autonomous) in motor skill acquisition (Fitts and Posner, 1967) and Ackerman’s theory of ability determinants of skilled performance (Ackerman, 1988) were used to explain the findings (Gray and Deem, 2002; Gray et al., 2002). Dental preclinical laboratory technique courses requiring tasks that are novel, first-time experienced, and nonrepetitive in nature were related to the cognitive phase of learning procedural skills characterized by a high cognitive load involving a spatial ability component (Gray and Deem, 2002). The final clinical years of Dental School requiring a significant amount a repetitive tasks were related to the associative phase of learning related more with perceptual speed and task practice rather 112
than spatial abilities (Gray et al., 2002). “Perceptual ability are best viewed as screening rather than predictive tools and could be used to set baseline scores below which further consideration would not be given to a candidate” (Ranney et al., 2005). Dentistry in North America has adopted an ability model that ensures success in the early part of its Dental School as a prerequisite to the final part of its curriculum. The role of assessment in spatial abilities for the selection in residency training program has been discussed in Surgery (Grace, 1989; Risucci and Tortolani, 1990; Anastakis et al., 2000; Romano, 2002; Wanzel et al., 2002; Hamstra, 2006; Tansley et al., 2007; Gallagher et al., 2009) and Radiology (Smith and Berbaum, 1991; Corry, 2011). At the University of Toronto, Ontario, Canada, the use of neuropsychological testing in the selection process of residents in surgery is not currently recommended because practice and experience could supplant the influence of spatial abilities over time, although they may be useful in identifying residents with lower spatial abilities who might benefit from supplementary instruction (Wanzel et al., 2002). At the Royal College of Surgeons of Ireland, all short-listed candidates for Higher Surgical Training now undergo formal testing of both technical skills and fundamental abilities, such as psychomotor skills, visuospatial ability, and depth perception (Gallagher et al., 2009). Research is needed to define the importance of spatial abilities, not only in the selection process, but also in teaching, learning, and maintaining the quality of spatial anatomy knowledge and technical skills. There is a need to know if residents are selecting their residency training program based on their innate spatial abilities. The objective of this study was to assess the relationship of spatial abilities to residency programs with different levels of content of 3D anatomy knowledge and technical skills. The hypothesis was that the choice of residency program is related to spatial abilities.
METHODS Study Design A prospective cohort study was done and the institutional ethics committee on human research approved the protocol.
Setting and Participants The study was conducted at the Faculty of Medicine of Sherbrooke in May 2005–2008 and 2010. There was no study in 2009. Medical graduates entering their residency programs were offered an elective preparatory 1-month rotation to the residency program entitled “What to Do in an Emergency?”. A drawing course (1 week), an applied anatomy course (1 week), a prerequisite workshop including applied physiology and pharmacology courses (1 week), and resuscitation courses (1–2 weeks) were included in the rotation. Preference for inclusion in this rotation was given to residents in Surgery, Anesthesia, and Emergency Medicine, and the remaining positions were given to Family Medicine and Internal Medicine (including Neurology and Infectious Disease) residents. Radiology residents were included only in 2010.
Study Protocol Medical graduates entering their residency programs enrolled in the rotation “What to Do in an Emergency?” were invited Langlois et al.
to enter research studies during plenary sessions in May. After the written informed consent was obtained, the participants were subjected to a psychometric test in spatial abilities at the beginning of every study conducted from 2005 to 2010.
Measures Age and residency program chosen were ascertained from the office for postgraduate education at the Faculty of Medicine of Sherbrooke in 2005 and from the written consent from 2006 to 2010. Sex was obtained from the written consent. Vandenberg and Kuse (1978) psychometric test of mental rotations discriminates highly for the spatial abilities as opposed to the verbal abilities. The redrawn 24-items Vandenberg and Kuse Mental Rotations Test for spatial abilities was administered (Peters et al., 1995). The Mental Rotations Test A (MRTA) was based on the original Vandenberg and Kuse set requiring a mental rotation around the vertical axis and was also made more difficult by adding the Mental Rotations Test C (MRTC) requiring a mental rotation in the vertical and horizontal axis (Peters et al., 1995). Each test was administered in 9 minutes; 3 minutes for each 12-items subset separated by a 3-minute break. The easier MRTA was administered before the MRTC and the maximum score on each of these tests was 24.
Statistical Analyses Variables considered included the discrete variables sex and residency program chosen; and the continuous variables age, MRTA and MRTC scores. Descriptive statistics included frequencies and percents for the discrete variables with group comparisons using Fisher’s exact test. Values for continuous outcomes are reported as means 6 standard deviation (6SD) with group comparisons using analysis of variance (ANOVA) and correlations using Pearson coefficient (r). A three-way ANOVA was used to assess spatial abilities as related to the main effect of residency, year, sex, and their interactions. The Nelson–Hsu adjusting procedure (Hsu and Nelson, 1998) for multiple pairwise comparisons was used in the post hoc analysis. The level of significance for all tests was < 0.05 (two-tailed). Analyses were performed with SAS statistical software, version 9.2 (SAS Institute, Cary, NC).
RESULTS In 2005, 2006, 2007, 2008, and 2010, there were 62, 65, 65, 64 and 49 medical graduates, respectively, enrolled in the rotation “What to Do in an Emergency?”. Of these 305 graduates, 214 (70.2%) were enrolled in research studies: 59 (95.2%), 54 (83.1%), 18 (27.7%), 34 (53.1%), and 49 (100%) for years 2005, 2006, 2007, 2008, and 2010, respectively. Written consent was signed by all 214 graduates. Four medical graduates entering a residency program of Radiology were excluded because of the small number and they were only enrolled in 1 year (2010). The study cohort consisted of 210 (100%) graduates. The mean age was 23.5 (1.9) years and there were 130 (61.9%) female graduates. Medical graduates were enrolled in Family Medicine (n 5 76, 36.2%), Internal Medicine (64, 30.5%), Surgery (52, 24.8%), and in Anesthesia (18, 8.6%). The only Emergency Medicine resident was included in Family Medicine. The investigators had Anatomical Sciences Education
MARCH/APRIL 2015
no indication that participants were exposed to previous spatial abilities testing from 2005 to 2008. Four of the graduates in the 2010 sample had previous exposure to the test, but these students did not differ significantly from the other participants in MRTA or MRTC scores. MRTA and MRTC scores were significantly correlated (Pearson coefficient r) in 2005 (P < 0.0001), 2006 (P < 0.0001), 2007 (P 5 0.0157), 2008 (P 5 0.0004), 2010 (P < 0.0001), and from 2005 to 2010 (P < 0.0001). A mean MRTA score of 12.4 (4.6), 12.0 (4.3), 14.1 (4.3), and 14.6 (4.0) was obtained by medical graduates entering the residency training programs of Family Medicine, Internal Medicine, Surgery, and Anesthesia (Table 1), respectively, and the difference over all 5 years was statistically different (P 5 0.0176). A mean MRTC score of 8.0 (4.4), 7.5 (3.6), 8.5 (3.9), and 7.9 (4.1) was obtained by medical graduates entering the residency training programs of Family Medicine, Internal Medicine, Surgery, and Anesthesia (Table 1), respectively, but the differences over all 5 years was not statistically different (P 5 0.5647). From 2005 to 2010, a higher ratio of female medical graduates chose the residency programs of Family Medicine and Internal Medicine compared to Surgery and Anesthesia (Table 2) and this difference was statistically different (Fisher’s Exact Square P 5 0.0119). Although trends by sex (P 5 0.05) and residency by year interaction (P 5 0.08) were observed, no statistically significant effect of residency, year, sex, or the interactions were found for MRTA. In post hoc analysis, a statistically significant difference was found for female graduates in Internal Medicine (P 5 0.0190) and male graduates in Surgery (P 5 0.0103) for the year 2010. Similarly, although there was a trend for a sex by year interaction (P 5 0.0874), no statistically significant main effect of residency, year, sex, or the interactions were observed for the MRTC. In post hoc analysis, trends were found for male graduates in 2005 in Family Medicine (P 5 0.0685) and in 2010 in Surgery (P 5 0.0940). Figures 1 and 2 show the distribution of individual MRTA and MRTC scores, respectively, for residency programs. There is a wide variation in individual MRTA and MRTC scores for all residency programs. Figures 3 and 4 show residency program differences in MRTA and MRTC scores from 2005 to 2010.
DISCUSSION Differences in MRTA scores between the residency programs of Family Medicine, Internal Medicine, Surgery, and Anesthesia were statistically significant. In a multivariable analysis, there was no main effect of residency and year, but trends for sex and the residency by year interaction were observed. In post hoc analysis, a difference was found between females in Internal Medicine and males in Surgery for the year 2010. Differences in MRTC scores between the residency programs of Family Medicine, Internal Medicine, Surgery, and Anesthesia were not statistically significant. In a multivariable analysis, there was no main effect of residency, sex and year, but there was a trend for the sex by year interaction. In post hoc analysis, trends were found for males in 2005 in Family Medicine and in 2010 in Surgery. The MRTC score was highly related to the MRTA score in the current study. The MRTC is more difficult than the MRTA as a rotation in a different direction was included. That could explain why a difference was not found with the 113
Table 1. Mental Rotations Test Scores and Residency Programs (2005–2010) Residency programs a
Year, n MRT
Anesthesia
P-valueb
All
Family medicine
Internal medicine
Surgery
2005 MRTA MRTC
59 12.5 (64.0) 7.7 (63.9)
30 13.2 (64.5) 8.7 (64.7)
16 10.8 (63.1) 5.9 (62.5)
10 12.3 (62.9) 6.7 (62.5)
3 16.3 (63.8) 9.3 (62.1)
0.0909 0.0872
2006 MRTA MRTC
54 11.9 (64.3) 6.9 (63.8)
23 11.4 (64.4) 6.4 (63.1)
15 11.4 (63.4) 6.4 (63.5)
11 12.6 (65.3) 8.9 (65.3)
5 13.6 (64.1) 6.4 (63.4)
0.6622 0.2787
2007 MRTA MRTC
18 14.6 (64.4) 7.8 (63.4)
2 17.0 (64.2) 9.5 (62.1)
6 10.8 (63.6) 7.0 (62.6)
7 16.0 (64.4) 7.7 (64.4)
3 17.0 (62.0) 8.7 (64.0)
0.0707 0.8242
2008 MRTA MRTC
34 13.8 (64.1) 8.2 (63.6)
5 10.6 (64.0) 6.0 (61.9)
18 15.2 (64.1) 9.4 (63.7)
9 13.2 (63.8) 7.7 (63.0)
2 12.0 (62.8) 5.0 (65.7)
0.3254 0.6152
2010 MRTA MRTC
45 13.2 (65.2) 9.5 (64.5)
16 12.3 (64.8) 9.4 (65.4)
9 9.4 (65.6) 8.2 (64.6)
15 15.9 (64.0) 10.3 (63.2)
5 14.2 (65.4) 9.2 (65.5)
0.0191 0.7543
2005–2010 MRTA MRTC
210 12.9 (64.5) 8.0 (64.0)
76 12.4 (64.6) 8.0 (64.4)
64 12.0 (64.3) 7.5 (63.6)
52 14.1 (64.3) 8.5 (63.9)
18 14.6 (64.0) 7.9 (64.1)
0.0176 0.5647
a
Mean (6SD). MRT score versus residency programs (ANOVA).
b
MRTC score compared to the MRTA score. As scores will be consistently smaller, only smaller differences of importance can be identified which would require larger sample sizes to detect. Sex differences in spatial abilities favoring males have been described in the literature of cognitive psychology (Maccoby and Jacklin, 1974; Voyer et al., 1995; Peters et al., 2007). This finding was confirmed in the medical field using a priori hypothesis (Langlois et al., 2013) and also a posteriori in other studies (Garg et al., 1999a, b; Lufler et al., 2012; Vorstenbosch et al., 2013). There was a higher ratio of female graduates in Family Medicine and Internal Medicine compared to Surgery and Anesthesia in current study. Sex differences in spatial abilities were likely responsible for the differences found for the MRTA score and also in post hoc analysis between females in Internal Medicine and males in Surgery for the year 2010. Similarly, sex differences in spatial abilities were also responsible for the differences found for the MRTC score in post hoc analysis for males in Family Medicine in 2005 and Surgery in 2010. MRTA and C scores of graduates in this study were not related to the level of 3D anatomy knowledge and technical skills content in the chosen residency program. The assumption was that the level of 3D anatomy knowledge and technical skills content was higher in Surgery and Anesthesia compared to Family Medicine and Internal Medicine. Wide variations in individual spatial abilities were found within residency programs with a higher level in 3D anatomy and technical skills content, such as Surgery and Anesthesia. Se114
veral graduates with lower spatial abilities were found to enter Surgery and Anesthesia and graduates with higher spatial abilities were found to enter Family Medicine and Internal Medicine. It is possible that graduates in Family Medicine may enter a practice of Emergency Medicine and/or Critical Care Medicine with a higher level of 3D anatomy and technical skills content. It is also possible that some graduates entering Internal Medicine may enter a practice in a subspecialty with a higher level of 3D anatomy and technical skills content, such as interventional cardiology or gastroenterology. Spatial abilities have been related to the performance of gastroscopy (Hedman et al., 2007), colonoscopy (Westman et al., 2006; Luursema et al., 2010), and gastrointestinal flexible endoscopy (Ritter et al., 2006). Residents could also ignore their own spatial abilities or express their innate spatial abilities in other aspects of their life. Graduates entering residency training programs of Internal Medicine and Family Medicine had lower MRTA scores and a higher ratio of females than Surgery and Anesthesia, but the statistical analysis was not able to confirm significant differences. There was no evidence with the MRTC score that graduates were selecting their programs based on their innate spatial abilities. It is important to note that MRTA and MRTC scores were widely distributed within programs. The sample of medical graduates was not found to choose their residency programs based on their innate spatial abilities. Self-selection on the basis of innate spatial abilities has not been related to chosen residency programs in one study relating trainees in Surgery, Psychiatry, Anesthesia, and Medicine Langlois et al.
Table 2. Sex and Chosen Residency Programs at the Faculty of Medicine of Sherbrooke (2005–2010) Residency programs P-valuea
Year, n sex, n
All
Family medicine
Internal medicine
Surgery
2005 Female Male
59 42 17
30 23 7
16 15 1
10 4 6
3 0 3
