A Survey of Essential Anatomy from the Perspective of Anesthesiology, Emergency Medicine, Obstetrics and Gynecology, and Orthopedics Resident Physicians

A Survey of Essential Anatomy from the Perspective of Anesthesiology, Emergency Medicine, Obstetrics and Gynecology, and Orthopedics Resident Physicians | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article A Survey of Essential Anatomy from the Perspective of Anesthesiology, Emergency Medicine, Obstetrics and Gynecology, and Orthopedics Resident Physicians Derek J. Harmon, Mark H. Hankin, James R. Martindale, Iuliana Niculescu, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4509478/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 23 Oct, 2024 Read the published version in BMC Medical Education → Version 1 posted 4 You are reading this latest preprint version Abstract Background Recent changes in anatomy curricula in undergraduate medical education (UME), including pedagogical changes and reduced time, pose challenges for foundational learning. Consequently, it is important to determine the essential content for an effective anatomy curriculum. Methods This study surveyed 55 non-primary care residents in anesthesiology (AN; N = 6), emergency medicine (EM; N = 15), obstetrics and gynecology (OB; N = 13), and orthopedics (OR; N = 21) to assess the importance of 907 anatomical structures across all anatomical regions. Survey ratings by participants were converted into a post-hoc classification system to provide end-users of this data with an intuitive and useful classification system for categorizing individual anatomical structures (i.e., essential, more important, less important, not important). Results Significant variability was observed in the classifications of essential anatomy: 29.1% of all structures were considered essential by OB residents, 37.6% for AN residents, 41.6% for EM residents, and 72.0% for OR residents. Significant differences (with large effect sizes) were also observed between residency groups: OR residents rated anatomy of the back, limbs, and pelvis and perineum anatomy common to both sexes significantly higher, whereas OB residents rated the pelvis and perineum anatomy common to both sexes and anatomy for individuals assigned female at birth highest. Agreement in classifications of importance among residents was observed for selected anatomical structures in the thorax, abdomen, pelvis and perineum (assigned male at birth-specific anatomy), and head and neck. As with the ratings of anatomical structures, OR residents had the highest classification across all nine tissue types (p < 0.01). Conclusions The present study, in combination with Hankin et al. ( 2023 ), which surveyed primary care residents, contributes to a database of anatomical structures assessed from a clinical perspective that may be considered when determining foundational anatomy for UME curriculum, as well as for graduate medical education. Medical education undergraduate medical education graduate medical education medical curriculum curriculum development anatomy education Figures Figure 1 Background Over the past few decades, significant changes have occurred in undergraduate medical education (UME) and, in particular, within anatomical education. These changes include reduced instructional time for anatomy in the United States (U.S.) and several other countries (Heylings 2002 ; Gartner, 2003 ; Leveritt et al., 2016 ; McBride and Drake, 2018 ; Pan et al., 2020 ; Attardi et al., 2022), vertical integration as suggested in Cooke et al. ( 2010 ), and transitioning from traditional lectures to new pedagogical approaches, including flipped classrooms (Morton and Colbert-Getz, 2017 ; Fleagle et al., 2018 ) and problem-based learning (Azer, 2011 ; Potu et al., 2013 ). The laboratory portion of the anatomy learning experience has decreased dramatically from an average of 191 hours in 1967 (Gartner, 2003 ) to 76 hours in 2018 (McBride and Drake, 2018 ), which represents an overall decrease of 60%. Even dissection, a traditional foundation of anatomical education, has been augmented or replaced entirely with other modalities including prosections (Williams et al., 2019 ), plastinated specimens (Klaus et al., 2018 ; Chytas et al., 2019 ; New York University, 2020; Kaiser Permanente School of Medicine, 2023 ), and virtual reality (University of Nevada Las Vegas School of Medicine, 2016; Case Western Reserve University, 2020; New York University, 2020; Kaiser Permanente School of Medicine, 2023 ). The curricular reform resulting from these changes has compelled some clinicians to express concerns over students’ lack of anatomical knowledge and the possible downstream effects on safe clinical practice (Cottam, 1999 ; Waterston and Stewart, 2005 ; Turney, 2007 ; Ahmed et al., 2010 ). Such concerns have been reported by 60% of residency program directors and 43% of residents (Fillmore et al., 2015 ). The combination of recent curricular reforms and revisions at many medical schools with clinicians’ concerns about a lack of anatomy knowledge raise a core question: What anatomy content is essential in the preclinical curriculum to prepare medical students for clinical training during UME (i.e., for clerkships and electives), graduate medical education (i.e., for residency), and ultimately, for safe and effective clinical practice? Systematic efforts to define the gross anatomy knowledge considered “essential” for UME have been advanced over the last three decades, with different scopes of study and utilizing different research methods. These efforts have fallen into two categories: (1) studies that developed comprehensive syllabi comprised of topic lists or sets of formal learning objectives, and (2) studies that assessed the importance of specific anatomical topics or structures, either for a given body region(s) or organ system. The three studies that comprise the first category (Leonard et al., 1996 ; McHanwell et al., 2007 ; Smith et al., 2016 ; Balta et al., 2019 ), conducted under the auspices of professional anatomical societies, presented comprehensive syllabi comprised of anatomical topics or formal learning objectives that are particularly useful for course organization and guiding student learning in general. However, it is difficult to derive a complete list of individual anatomical structures that should be covered in medical curricula from these studies, although the proposal by Leonard et al. ( 1996 ) comes closest. Three studies in the second category used the consensus-building modified Delphi panel approach described in Moxham et al. ( 2014 ). Each of these studies included 20–30 anatomists and clinicians from several countries: for the head and neck, Tubbs et al. ( 2014 ) assessed a total of 1,730 items (1,188 individual structures and 542 relevant pathologies); for the thorax, Moxham et al. ( 2020 ) evaluated 628 anatomical topics or structures; and for the musculoskeletal (MSK) system, Webb et al. ( 2019 ) assessed a total of 2,260 items (389 concepts, 438 vertebral column structures, 663 upper limb structures, and 770 lower limb structures). These studies, which generated granular lists of anatomy, had two notable limitations: first, the perspectives of anatomists and clinicians were combined, making it impossible to distinguish the opinions of each and, second, they focused on specific regions (head and neck and thorax) or body systems (MSK) and did not consider all body regions. Several additional studies in the second category focused on the perspectives of clinicians. Using a modified Delphi approach, 37 practicing Canadian physiatrists identified 361 MSK structures as clinically relevant for an anatomy curriculum for physical medicine and rehabilitation residency (Lisk et al., 2014 ). It should be noted that this study focused on one body system (MSK) and the anatomical structure list was less granular than Webb et al. ( 2019 ). Three additional studies utilized survey methodology to gather perspectives from clinicians regarding broad anatomical topics. In Orsbon et al. ( 2014 ), 93 clinicians from 18 specialties at the University of Chicago rated the importance of 215 broad anatomical course topics (e.g., structure, function, vasculature, innervation, lymph) across all body regions for their practices. While this study did not examine individual structures, it did highlight the fact that physicians from different specialties agreed about the overall importance of anatomy. In Leveritt et al. ( 2016 ), 113 medical students in the clinical curriculum, 66 junior doctors (equivalent to residents in the U.S.), and 20 consultants in 18 clinical specialties (equivalent to “attending physicians” in the U.S.) were recruited from a single site in the United Kingdom. These participants evaluated broad anatomical knowledge (e.g., osteology, innervation of dermatomes and muscles, lymphatic drainage) that medical students should learn during preclinical training. Most recently, Keim et al. ( 2023 ) reported the survey responses of 525 clinical faculty at 24 U.S. allopathic medical schools regarding the importance of 97 anatomical structure groups across all body regions. These studies provide important insight into the clinical perspective, although their less granular focus or emphasis on a specific body region or system makes it difficult to directly implement this data into anatomy curricula. What these previous studies have not done is to assess a granular list of anatomical structures across all body regions based solely on the perspective of clinicians. Since clinicians treat patients, they are in an optimal position to provide informed opinions of the anatomy they use and consider most important for safe clinical practice. Consequently, the collective clinical perspective is essential for creating an evidence base from which to build anatomical curricula for medical trainees during residency, clerkships and electives, as well as for the preclinical phase of UME. The main aims of the study were to determine: (1) the importance of specific anatomical structures and groups of structures based on the perspective of a sampling of non-primary care residents, and (2) whether residents’ ratings of essential anatomical structures differed significantly between specialties, and/or tissue classifications (e.g., blood vessels, nerves). Methods This study received exempt status by the Institutional Review Board of the Beaumont Health (IRB #2014/374). Survey development As noted in O’Reilly-Shah ( 2017 ), survey fatigue leads to a large drop-off in completion and less than thoughtful answers, which can lead to a “straight-lining” of responses. A survey that included all anatomical structures of the human body, as cataloged in Terminologia Anatomica (Federative International Programme on Anatomical Terminologies, 1998 ; Drukker and Walvoort, 2000 ), would consist of over 7,500 + terms. A more curated list, based on the anatomical terms indicated in bold text in Grant’s Dissector (Tank, 2009 ), would include approximately 2,200. Distributing a survey with greater than 2,000 individual items would very likely lead to severe survey fatigue. To balance the objective of assessing a granular list of anatomical structures and limiting survey fatigue, the initial survey list of anatomical structures was based on those required for dissection in the Oakland University William Beaumont School of Medicine (OUWB) anatomy course. This list was reviewed and modified by the resident co-investigators (co-authors: A.A., S.R.C., P.E.E., C.M.P., K.K.) to further reduce the length and streamline the format of the survey. The final survey list included individual structures (blood vessels, nerves, fascia, anatomical spaces, and specific surface anatomy features) and major structure groups (skeleton, muscles, and organs). While this created different levels of organization and granularity within the survey, this was balanced by the practicality of asking residents to complete a large survey. The entire survey is provided in Supplemental File A . The first three questions of the survey asked respondents to indicate their terminal medical degree (M.D., D.O.), medical specialty, and postgraduate year (PGY). The remainder of the survey included 907 anatomical items organized by body region: (1) back, including the vertebral column, spinal cord, and meninges ( n = 55), (2) upper limb ( n = 171), (3) lower limb ( n = 137), (4) thorax ( n = 92), (5) abdomen ( n = 140), (6) pelvis and perineum ( n = 136), and (7) head and neck ( n = 176). Anatomical structures in the pelvis and perineum region included those common to both sexes ( n = 70), i.e., individuals assigned female or male at birth - AFAB and AMAB, respectively, and those specific to AFAB or AMAB individuals ( n = 33 for each group). The structures included in each region were organized hierarchically in the following manner: Major anatomical topics (e.g., nerves, plexuses, ganglia) Anatomical subtopics (e.g., course, branches, composition) Individual structures or groups of structures (e.g., facial nerve) A 4-point Likert-type rating scale was used for this survey, with the minimum and maximum ratings of “1” and “4” designated as “Not important” and “Essential”, respectively (ratings of “2” or “3” were not assigned descriptors). Participants were provided with the prompt: “Based on your clinical experience, please indicate your opinion of the relevance of each anatomical item.” This prompt was intended to ask respondents to consider whether each survey item was closely connected with, or appropriate to, their specific clinical specialty and then to give their opinion of its importance using the Likert scale (ranging from “1 - Not important” to “4 - Essential”). Expanding the Likert scale to accommodate other answers such as “don’t know” or “no opinion” was not considered because the survey asked participants’ opinions and, if a participant “did not know” a particular structure then, it was highly likely that structure was, in their opinion, “not important”. All participants, regardless of residency specialty, received the same survey. It may be argued that certain specialties would only rate anatomy highly that supports their specialization (e.g., obstetrics and gynecology would likely focus on pelvic and abdominal anatomy). However, by giving different surveys to each group of residents based on a preconceived idea of what would, or would not, be important would create an unnecessary bias. Therefore, it was a philosophical underpinning of this study that the participants’ responses should inform what they considered to be important. Survey dissemination and participation The present study surveyed a sample of resident physicians in four non-primary care specialties, including anesthesiology (AN), emergency medicine (EM), obstetrics and gynecology (OB), and orthopedics (OR), at Beaumont Hospital in Royal Oak and Troy, Michigan, which are the teaching hospitals of OUWB. A convenience sample of these programs was based on two factors: (1) each identified a senior resident who was designated as a co-investigator for the study, and (2) each program provided dedicated time (90–120 minutes) for residents to complete the survey during a regularly scheduled program meeting (e.g., morning rounds, noon conference). Residents who were not present at the regularly scheduled meeting (due to clinical or other commitments) received the survey to complete independently. Collectively, the four programs had a total population of 109 residents (AN = 18, EM = 42, OB = 24, OR = 25). The survey was voluntary and was presented to participants in paper-based format as a single packet, and resident co-investigators were available to answer questions. All surveys were submitted anonymously, although minimal essential information such as medical degree (M.D. or D.O.), residency program, and PGY were retained for the study. For tracking purposes during subsequent data entry, each survey was assigned a unique number. Data analysis Survey responses were entered into Microsoft Excel (Microsoft Corp., Redmond, WA) by the resident co-investigators (A.A., S.R.C., P.E.E, C.M.P., K.K.S.) and cross-checked for accuracy by one of the co-first authors (M.H.). The data collected from Likert scales are ordinal and, thus, have no assumption of equality between each numerical rating category (i.e., 1, 2, 3, or 4). Furthermore, the subjective interpretation of a given rating value may vary from person to person, and it is generally considered inappropriate to use parametric descriptive statistics such as means and standard deviations with ordinal data (Allen and Seaman, 2007 ). Therefore, to interpret this study's findings, a post-hoc classification system first described by Hankin et al. ( 2023 ) was utilized to account for the limitations associated with ordinal data. This classification system first collapsed the 4-points in the rating scale into a binary variable: ratings of 1 and 2 were combined to form the lower component and ratings of 3 and 4 formed the higher component of the variable (the higher component will be referred to as “3 + 4%”). Subsequently, the 3 + 4% ratings were used to categorize each structure into one of four classifications of importance: Essential 3 + 4% ratings ≥ 75.0% More important 3 + 4% ratings 50.0–74.9% Less important 3 + 4% ratings 25.0–49.9% Not important 3 + 4% ratings < 25% It is important to note that a classification of not important or essential did not correspond directly to a Likert-scale rating of “1” (“not important”) or “4” (“essential”) in the actual survey. Rather, a classification of not important indicated that less than 25% of respondents rated a structure a “3” or “4”, and a classification of essential indicated that at least 75% rated a structure a “3” or “4”. It should be emphasized that collapsing the 4-point scale to a binary variable was not done for statistical reasons. Rather, the goal was to provide the end-users (e.g., anatomists, curriculum developers, medical deans) with an intuitive and useful classification system ( essential , more important , less important , not important ) for categorizing individual anatomical structures. Ideally, this list of classified structures could be useful when making curricular decisions regarding inclusion or exclusion of a given anatomical topic. The Kruskal-Wallis nonparametric ANOVA was used to determine whether group differences existed between the residency groups regarding the rating of clinical importance across the seven anatomical regions. Seven analyses were conducted using clinical specialty as the categorical independent variable and the combined mean ratings for all anatomical structures or groups of structures for each major anatomical topic in each region as the dependent variable. For example, for the upper limb, there were nine major anatomical topics for which means were assessed: skeleton, joints, fascia, muscles, nerves, blood vessels, lymphatics, anatomical spaces, and surface anatomy. A Bonferroni correction was applied to the a priori alpha level in order to account for the potential increase in type 1 error due to multiple testing: starting with an overall experiment-wise error rate of 0.05, an adjusted alpha level of 0.007 was used to compare the seven anatomical regions. Each anatomical structure was assigned by two authors (M.H., D.H.) to one of the nine major tissue or structure types: skeleton, muscle, nerve, fascia, anatomical space, blood vessel, lymphatic, organ, and surface anatomy. The Kruskal-Wallis nonparametric ANOVA was used to determine whether group differences existed between the residency groups regarding the rating of structures based on their major tissue or structure type classification. A Bonferroni correction was applied to the a priori alpha level in order to account for the potential increase in type 1 error due to multiple testing: starting with an overall experiment-wise error rate of 0.05, an adjusted alpha level of 0.0056 was used to compare the nine tissue types. All statistical analyses were performed using the SPSS statistical package, version 28 (IBM Corp., Armonk, NY). The distribution of classifications of importance was assessed for each resident group and internal consistency was assessed with an ordinal Cronbach alpha. The resulting alpha value is considered to have sufficient internal consistency at a minimum value of 0.70, but a value above 0.90 for educational or clinical purposes is more desirable (Gadermann et al., 2019 ). Effect size for this study was assessed through eta-squared, with values of 0.01 equating to a small effect, values of 0.06 a medium effect, and > 0.14 a large effect (Richardson, 2011 ). Results All parts of the survey were completed by a total of 55 residents. Response rates were calculated based on the total number of residents across PGY in each program. AN residents – Response rate = 33.3% (6 out of 18 total residents across all PGY) Total n = 6: PGY-2 ( n = 1); PGY-3 ( n = 2); PGY-4 ( n = 3) EM residents – Response rate = 35.7% (15 out of 42 total residents across all PGY) Total n = 15: PGY-1 ( n = 8), PGY-2 ( n = 4); PGY-3 ( n = 3) OB residents – Response rate = 54.2% (13 out of 24 total residents across all PGY) Total n = 13: PGY-1 ( n = 2), PGY-2 ( n = 4), PGY-3 ( n = 4), PGY-4 ( n = 3) OR residents – Response rate = 84.0% (21 out of 25 total residents across all PGY) Total n = 21: PGY-1 ( n = 3), PGY-2 ( n = 5), PGY-3 ( n = 4), PGY-4 ( n = 6), PGY-5 ( n = 3) The combined response rate for all residents who participated was 50.5%, (55 total participants out of a total of 109 residents across the four programs). Ordinal Cronbach’s alpha values were used as measures of internal consistency for each of the seven anatomical regions surveyed collectively, as well as individually within specialties. Alpha values for each anatomical region with all four residency groups combined were above the generally accepted threshold of 0.90 (back = 0.91; upper limb = 0.97; lower limb = 0.95; thorax = 0.96; abdomen = 0.96; pelvis and perineum = 0.98; head and neck = 0.98), indicating the survey instrument had acceptable internal consistency (Gadermann et al., 2019 ). Essential anatomy by residency group Table 1 shows the statistically significant differences between residencies for each anatomical region in top-level ratings (i.e., major anatomical topics). Residents in OR rated structures significantly higher than OB and EM in the back, and OB, EM, and AN in the limbs. Residents in OB rated structures significantly higher than EM and AN in all categories of the pelvis and perineum, except for AMAB-specific anatomy. Eta-squared effect sizes were calculated for each of the regions that had significant differences between residencies: back, 0.58; upper limb, 0.62; lower limb, 0.52; pelvis and perineum all anatomy, 0.30; AFAB-specific pelvis and perineum, 0.35; pelvis and perineum common to AFAB and AMAB individuals, 0.41. All regions had large effect sizes (Richardson, 2011 ). Table 1 Statistically significant differences between residencies in the ratings of anatomical topics for each anatomical region. Region Significant Differences Between Residency Groups Back OR > OB (P = 0.001), EM (P = 0.001) Upper Limb OR > OB (P = 0.001), AN (P = 0.001), EM (P = 0.003) Lower Limb OR > OB (P = 0.001), EM (P = 0.001), AN (P = 0.002) Thorax NS NS Abdomen NS NS Pelvis and Perineum All anatomy OB > EM (P = 0.004), AN (P = 0.032) Pelvis and Perineum Anatomy common to both sexes OB > OR > EM (P = 0.001), AN (P = 0.026) EM (P = 0.002) Pelvis and Perineum Anatomy in AFAB individuals OB > AN (P = 0.001), EM (P = 0.001), OR (P = 0.005) Pelvis and Perineum Anatomy in AMAB individuals NS NS Head and Neck NS NS Abbreviations: NS, not statistically significant at corrected alpha = 0.007; AN, anesthesiology; EM, emergency medicine; OB, obstetrics/gynecology; OR, orthopedics; AFAB, assigned female at birth; AMAB, assigned male at birth Figure 1 shows the distribution of classifications for each group of residents for each survey item in each anatomical region. Supplemental File B shows the 3 + 4% rating response frequency and corresponding classifications of importance by anatomical region for each anatomical structure or group of structures. Anesthesiology residents. For AN residents, 37.6% ( n = 341) of anatomical structures across all body regions were classified as essential , 34.2% ( n = 310) as more important , 15.2% ( n = 138) as less important , and 13.0% ( n = 118) as not important . The percentage of structures classified as essential was highest for the back, thorax, and head and neck (Fig. 1 ). For most regions of the body, a majority of structures were classified as essential or more important for AN residents: back, 78.2% (44/55); upper limb, 53.8% (92/171); lower limb, 63.5% (87/137); thorax, 91.3% (84/92); abdomen, 77.8% (109/140); and head and neck, 96.6% (170/176). In the pelvis and perineum, 47.8% (65/136) of structures were classified as essential or more important . Emergency medicine residents. For EM residents, 41.6% ( n = 377) of anatomical structures across all body regions were classified as essential , 26.5% ( n = 240) as more important , 21.5% ( n = 195) as less important , and 10.5% ( n = 95) as not important . The percentage of structures classified as essential was highest for the limbs, thorax, and head and neck (Fig. 1 ). For all regions of the body, a majority of structures were classified as essential or more important for EM residents: back, 56.4% (31/55); upper limb, 79.0% (135/171); lower limb, 64.3% (88/137); thorax, 73.9% (68/92); abdomen, 59.3% (83/140); pelvis and perineum, 59.6% (81/136); and head and neck, 73.9% (120/176). Obstetrics and gynecology residents. For OB residents, 29.1% ( n = 264) of anatomical structures across all body regions were classified as essential , 22.9% ( n = 208) as more important , 35.7% ( n = 324) as less important , and 12.2% ( n = 111) as not important . For these residents, the percentage of structures classified as essential was highest for the abdomen and pelvis and perineum (Fig. 1 ). Those structures in the pelvis and perineum common to both sexes and those specific to AFAB individuals were all classified as essential , whereas those specific to AMAB individuals were almost uniformly classified as less important . For most regions of the body, a majority of structures were classified as essential or more important for OB residents: back, 54.6% (30/55); lower limb, 57.7% (79/137); thorax, 66.3% (61/92); abdomen, 77.8% (108/140); and pelvis and perineum, 79.4% (108/136). In the upper limb and head and neck, a minority of structures were classified as essential or more important : upper limb, 17.6% (30/171); and head and neck, 34.7% (49/176). Orthopedics residents. For OR residents, 72.0% ( n = 653) of anatomical structures across all body regions were classified as essential , 27.9% ( n = 253) as more important , and 0.1% ( n = 1) as less important . The percentage of structures classified as essential were highest (at or near 100%) for the back and limbs (Fig. 1 ). Virtually one hundred percent of structures in the thorax (92/92), abdomen (139/140), pelvis and perineum (136/136), and head and neck (176/176) were classified by these residents as either essential or more important . However, within each region the distribution of these classifications was different: thorax (73.9% essential and 26.1% more important ), abdomen (37.1% essential and 61.4% more important ). pelvis and perineum (46.3% essential and 53.7% more important ), and head and neck (61.9% essential and 38.1% more important ). Based on the Likert-scale ratings, there was a concurrence of classifications of importance as either essential or more important for a limited number of structures in several anatomical regions ( Supplemental File C ). Classifications of importance by structure and tissue type Table 2 shows the statistically significant differences between residencies for anatomical tissue types. Residents in OR had the highest number of significant differences for the nine tissue types compared to other residents, with at least one significant difference in each category; residents in AN, on the other hand, had no significant differences in tissue types compared to other residents. Table 2 Statistically significant differences between residency groups in ratings of anatomical tissue types. Region Significant Differences Between Residency Groups Skeleton EM > AN (P AN (P < 0.001), EM (P OB (P < 0.001), EM (P AN (P AN (P < 0.001), EM (P < 0.001), OB (P AN (P < 0.001), OB (P < 0.001), EM (P AN (P AN (P AN (P < 0.001), EM (P < 0.001), OB (P EM (P < 0.001), AN (P AN (P < 0.001), EM (P < 0.001), OB (P AN (P AN (P EM (P < 0.001), OB (P < 0.001), AN (P AN (P EM (P EM (P EM (P AN (P < 0.001), OB (P AN (P EM (P < 0.001), AN (P AN (P < 0.001), OB (P < 0.001), EM (P < 0.01) Abbreviations: AN, anesthesiology; EM, emergency medicine; OB, obstetrics/gynecology; OR, orthopedics Discussion The present study, which followed the research design of Hankin et al. ( 2023 ), surveyed a sample of non-primary care resident physicians in anesthesiology, emergency medicine, obstetrics and gynecology, and orthopedics at Beaumont Hospital/OUWB regarding their opinion of the anatomy considered most important for their specialties. The response rates varied from 33.3% for AN residents to 84.0% for OR, with a combined response rate of 50.5%, which was similar to those reported in Wilson et al., ( 2024 ) for students (52.0%), and slightly lower for healthcare professionals and faculty (59%). There were significant differences between residencies in their ratings of the major anatomical topics, with OR residents consistently rating structures and groups of structures higher across most body regions than the other residents. Residents in OB rated the anatomy of the pelvis and perineum specific to AFAB individuals higher than the other residents. There was considerable variability in the percentage of the total structures classified as essential for each residency, ranging from 29.2% for OB to 72.0% for OR. Viewed by anatomical region, the structures classified as essential were different for each residency group. The percentages of essential structures for AN residents were highest in the back, thorax, and head and neck, which are consistent with anatomy emphasized in a number of anatomy review texts for anesthesiology (Georgiou et al., 2014 ; Ellis and Lawson, 2013 ). For OB residents, the emphasis was on the anatomy of the pelvis and perineum (anatomy common to both sexes and, predictably, the anatomy specific to AFAB individuals) and the abdomen, which is similar to the findings in Orsbon et al. ( 2014 ). These regions include structures related to female anatomy as well as relevant abdominal structures that extend into the pelvic cavity (Koppes et al., 2020 ; Asali et al., 2021 ) that may be encountered in obstetric and gynecological procedures. For OR residents, more structures were essential in the back and limbs, which is consistent with the various procedures and surgical interventions related to bones, muscles, tendons, and joints in these regions (Gehrig, 2011 ). For EM residents, an obvious majority of structures that were classified as essential was not seen for any particular body region, which likely reflects the fact that EM physicians diagnose and treat conditions affecting all body regions (Hooker et al., 2019 ; Lane et al., 2020 ). Considering all four residencies together in the present study, only a small number of structures were classified as essential (4.7%; n = 43), with the percent concurrence for individual regions ranging from 0.0% for the upper limb, and the head and neck to 18.5% for the thorax ( Supplemental File C ). A low percentage of structures were also classified as essential in Hankin et al., ( 2023 ) for family medicine and internal medicine residents (17.0%, n = 154; ranging from 10% for upper limb, lower limb, and pelvis and perineum, to 35% for thorax). If all structures classified as essential by a majority of the six groups of residents in the present study and Hankin et al. ( 2023 ) were combined, this would only include 23.2% ( n = 210) of structures. These relatively low values raise the obvious concern for medical curricula that only including the anatomy classified as essential would be too limiting and would likely not provide a sufficient foundation to prepare medical students for clinical training. Instead, expanding the criteria in the present study to include structures classified as either essential or more important would capture 33.3% ( n = 302) of structures, ranging from 9.1% for structures specific to AMAB individuals to 52.2% for the thorax ( Supplemental File C ). While 33.3% is still quite low compared to Hankin et al. ( 2023 ), in which 75% of structures were considered essential or more important for residents in family medicine and internal medicine, it illustrates the differences in regional focus between primary and non-primary care specialties. If, however, the structures classified as either essential or more important by a majority of all six groups of residents from both studies are compiled, this yields 77.5% ( n = 703) of the surveyed items ( Supplemental File D ). Therefore, it is reasonable to suggest using these structures as a starting point for inclusion in UME anatomy curricula. Alternatively, when developing or updating graduate medical education curricula, this database can be utilized on an individual specialty basis to directly inform the content included in anatomical reviews or workshops. Comparison with previous studies Direct comparisons between the current study and previous studies (Orsbon et al., 2014 ; Tubbs et al., 2014 ; Leveritt et al., 2016 ; Webb et al., 2019 ; Moxham et al., 2020 ) are challenging due to different research designs, levels of granularity, and systems for classification. It is, nevertheless, instructive as a starting point, to note that the percentage of total structures classified in the highest category in each of these studies showed a considerable range: 3.7% in Orsbon et al. ( 2014 ), 4.7% in the present study, 17.0% in Hankin et al. ( 2023 ), 24.3% in Tubbs et al. ( 2014 ), 43.2% in Moxham et al. ( 2020 ), and 49.2% in Webb et al. ( 2019 ). Drilling down a bit more, there were a number of structures that were classified in the highest category in the current study as well as in the previous studies that assessed corresponding body regions, including the dura mater, internal and external carotid, and middle meningeal arteries, all cranial nerves, the brachial plexus, the sternocleidomastoid muscle, and the thoracic wall and diaphragm. This selective list suggests that more understanding is needed regarding how to determine the importance of anatomical structures. Recommendations for medical educators With the various changes in anatomy education within UME curricula, including fewer instructional hours, it becomes increasingly important to make realistic decisions about what content can and should be included. At this juncture, it is challenging for medical educators to know how to utilize the data from the collective body of work to arrive at a granular understanding of the anatomy considered most important to include during the different stages of medical education. The authors suggest a multi-stage approach from which some decisions may be made. First, anatomy educators can refer to the published learning objectives to establish the overall organization of the anatomy curriculum. Following this, the authors suggest that anatomists consider structures classified as essential or more important in the present study and in Hankin et al. ( 2023 ). Inclusion of this content will likely also be based on the specific curricular focuses and capabilities at individual institutions, this baseline of structures can be amended to either include more structures (i.e., those classified as less important ) or to selectively remove some of the more important structures. Future Directions As noted previously, a number of studies have assessed anatomical content using various research designs with different scopes, yielding different classifications and recommendations. A meta-analysis across all previous studies could provide a helpful integration of the various perspectives. In addition, the current survey should be distributed more broadly to increase both the total number of clinicians among the represented specialties, as well as to collect data from specialties that have not yet contributed. While knowing what is considered essential for clinicians is an important first step, it would be worthwhile to eventually expand this data to understand what about a given structure is essential and, thereby, what about it should be taught. Finally, it is important to recruit anatomy educators to complete the same survey and compare the classifications to those of clinicians. Limitations A number of limitations should be considered for this study. First, all respondents were residents at a single institution and the findings of this study may not be generalizable beyond Beaumont Hospital/OUWB. It is also evident that the findings in the present study were based on only four groups of residents and not on a broad sample from across the institution. In addition, the relatively small and unequal numbers of survey respondents from each group of residents could have skewed the results. It also should be acknowledged that the participants in the study were residents and not attending (academic) physicians or physicians in private practice. Therefore, it is possible that the ratings by these residents reflected what they were using most in their training at the time and that the knowledge required beyond residency may be different. It is important to note that the survey asked respondents to rate the “relevance” of structures based on their “clinical experience”, which could potentially have led to a different response if the prompt had, instead, used the word “importance”. Although this was a non-incentivized voluntary survey, it is possible that a response bias resulted from the fact that participants may have had a higher interest in anatomy compared to those who did not participate (the four resident co-investigators who were co-authors also completed the survey). Such a bias could not be assessed directly in this study but, if it did exist, it may have reflected the perspectives of individual residents, or even those based on program bias or selection criteria for different clinical specialties. Limitations related to the survey must be acknowledged. The long survey used in this study, and in Hankin et al. ( 2023 ), could have resulted in a degree of fatigue and the potential for straight-lining (i.e., a form of habituation where respondents select the same response for multiple questions). However, straight-lining was not immediately obvious and the extent to which it occurred was not evaluated in this study. In addition, the survey design had different levels of “granularity”, with some structures listed individually (blood vessels, nerves, and structures related to surface anatomy) while others were “bundled” into logical groups (skeleton, muscles, and organs) that were evaluated in terms of their location, structure, anatomical relationships, function, and neurovasculature. In large part, this “bundling” was done to limit the length of the survey and prevent fatigue and straight-lining. Conclusions Recent changes to gross anatomy education in current UME curricula have led to the need to establish the essential gross anatomy content that all students should understand upon graduation. The present study, which utilized the method described in Hankin et al., 2023 , assessed the perspective of a sample of non-primary care resident physicians in four different specialties regarding the importance of gross anatomical structures across all body regions. This study demonstrated significant differences in the ratings of anatomy between the four participant groups. This result stands in contrast to the observations from Hankin et al. ( 2023 ), which showed agreement about essential anatomy between primary care residents. In combination, the database derived from these studies not only provides a clinical view of anatomy but also can inform how anatomy curricula can be most efficiently and effectively incorporated in the context of limited curricular hours. Abbreviations UME – Undergraduate Medical Education AN – Anesthesiology EM – Emergency Medicine OB – Obstetrics and Gynecology OR – Orthopedics US – United States MSK – Musculoskeletal OUWB – Oakland University William Beaumont School of Medicine PGY – Postgraduate Year AFAB – Assigned Female at Birth AMAB – Assigned Male at Birth ANOVA – Analysis of Variance Declarations Ethics approval and consent to participate: This project was deemed exempt from full IRB approval by the Oakland University William Beaumont School of Medicine IRB. All ethical standards have been met. Consent for publication: Not applicable. Availability of data and materials: The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests: Not applicable. Funding: Not applicable. Authors’ contributions: D.H. and M.H. wrote the main manuscript text, with help from J.M. in the methodology and statistical analysis. M.H. prepared all the figures and tables. I.N., A.A., R.H., A.K., S.C., P.E., C.P., and K.K. reviewed and edited the manuscript. Acknowledgements: The authors would like to thank the residents at Beaumont Health who participated in the survey and took the time to complete it thoughtfully and fully. Thanks also to Dr. Kelly Harrell (Department of Anatomy and Neurobiology, Virginia Commonwealth University) for her thoughtful comments on the manuscript. References Ahmed K, Rowland S, Patel V, Khan RS, Ashrafian H, Davies DC, Darzi A, Athanasiou T, Paraskeva PA. Is the structure of anatomy curriculum adequate for safe medical practice? Surgeon. 2010;8(6):318–24. Allen IE, Seaman CA. Likert scales and data analyses. Qual Prog. 2007;40(7):64–5. Asali F, Abu Mahfouz I, Abu Saleem H, Abu Mahfouz S, Mohammad MT, Al-Kuran O. Applied anatomy knowledge in gynaecology and obstetrics: the trainees’ perception. Gynacol Surg. 2021;18:10–7. 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Additional Declarations No competing interests reported. Supplementary Files SupplementalFileA.pdf SupplementalFileB.pdf SupplementalFileC.pdf Cite Share Download PDF Status: Published Journal Publication published 23 Oct, 2024 Read the published version in BMC Medical Education → Version 1 posted Editorial decision: Revision requested 24 Jun, 2024 Editor assigned by journal 20 Jun, 2024 Submission checks completed at journal 20 Jun, 2024 First submitted to journal 31 May, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Pokropek","email":"","orcid":"","institution":"Mission Obstetrics and Gynecology","correspondingAuthor":false,"prefix":"","firstName":"Catherine","middleName":"M.","lastName":"Pokropek","suffix":""},{"id":318210671,"identity":"db734180-2f2c-4e90-9377-490bc66de7ab","order_by":10,"name":"Ksenia Koltun","email":"","orcid":"","institution":"Northstar Anesthesiology and Beaumont Health","correspondingAuthor":false,"prefix":"","firstName":"Ksenia","middleName":"","lastName":"Koltun","suffix":""}],"badges":[],"createdAt":"2024-05-31 14:01:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4509478/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4509478/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12909-024-06185-5","type":"published","date":"2024-10-23T15:57:16+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":60599419,"identity":"dd859a5b-cd09-4c88-a1f2-003981a73af9","added_by":"auto","created_at":"2024-07-18 15:57:35","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":588617,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend.\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4509478/v1/37437a9979813aecb41af649.jpg"},{"id":67681752,"identity":"9fc353b1-656d-4195-aa8f-1c76d4fae336","added_by":"auto","created_at":"2024-10-28 16:09:59","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1379728,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4509478/v1/b8b078f9-48fb-485d-948d-8552c9d6d9dc.pdf"},{"id":60599420,"identity":"c19ced2f-e53e-486c-a5b3-4c338e9420e3","added_by":"auto","created_at":"2024-07-18 15:57:35","extension":"pdf","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":593043,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementalFileA.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4509478/v1/3c8b13599cf794516799f3c2.pdf"},{"id":60599422,"identity":"c7f18fc4-236a-41a4-943a-e02c9126e3d5","added_by":"auto","created_at":"2024-07-18 15:57:35","extension":"pdf","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":1103346,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementalFileB.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4509478/v1/9e9af1dc8629911b059777d7.pdf"},{"id":60602337,"identity":"69c6a2ac-2677-4858-86b5-44c073e4e38c","added_by":"auto","created_at":"2024-07-18 16:13:35","extension":"pdf","order_by":6,"title":"","display":"","copyAsset":false,"role":"supplement","size":72942,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementalFileC.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4509478/v1/e9cee138acb18c97f21f544f.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"A Survey of Essential Anatomy from the Perspective of Anesthesiology, Emergency Medicine, Obstetrics and Gynecology, and Orthopedics Resident Physicians","fulltext":[{"header":"Background","content":"\u003cp\u003eOver the past few decades, significant changes have occurred in undergraduate medical education (UME) and, in particular, within anatomical education. These changes include reduced instructional time for anatomy in the United States (U.S.) and several other countries (Heylings \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2002\u003c/span\u003e; Gartner, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2003\u003c/span\u003e; Leveritt et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; McBride and Drake, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Pan et al., \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Attardi et al., 2022), vertical integration as suggested in Cooke et al. (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2010\u003c/span\u003e), and transitioning from traditional lectures to new pedagogical approaches, including flipped classrooms (Morton and Colbert-Getz, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Fleagle et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2018\u003c/span\u003e) and problem-based learning (Azer, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2011\u003c/span\u003e; Potu et al., \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). The laboratory portion of the anatomy learning experience has decreased dramatically from an average of 191 hours in 1967 (Gartner, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2003\u003c/span\u003e) to 76 hours in 2018 (McBride and Drake, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2018\u003c/span\u003e), which represents an overall decrease of 60%. Even dissection, a traditional foundation of anatomical education, has been augmented or replaced entirely with other modalities including prosections (Williams et al., \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e2019\u003c/span\u003e), plastinated specimens (Klaus et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Chytas et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; New York University, 2020; Kaiser Permanente School of Medicine, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), and virtual reality (University of Nevada Las Vegas School of Medicine, 2016; Case Western Reserve University, 2020; New York University, 2020; Kaiser Permanente School of Medicine, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). The curricular reform resulting from these changes has compelled some clinicians to express concerns over students\u0026rsquo; lack of anatomical knowledge and the possible downstream effects on safe clinical practice (Cottam, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e1999\u003c/span\u003e; Waterston and Stewart, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e2005\u003c/span\u003e; Turney, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e2007\u003c/span\u003e; Ahmed et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2010\u003c/span\u003e). Such concerns have been reported by 60% of residency program directors and 43% of residents (Fillmore et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). The combination of recent curricular reforms and revisions at many medical schools with clinicians\u0026rsquo; concerns about a lack of anatomy knowledge raise a core question: What anatomy content is essential in the preclinical curriculum to prepare medical students for clinical training during UME (i.e., for clerkships and electives), graduate medical education (i.e., for residency), and ultimately, for safe and effective clinical practice?\u003c/p\u003e \u003cp\u003eSystematic efforts to define the gross anatomy knowledge considered \u0026ldquo;essential\u0026rdquo; for UME have been advanced over the last three decades, with different scopes of study and utilizing different research methods. These efforts have fallen into two categories: (1) studies that developed comprehensive syllabi comprised of topic lists or sets of formal learning objectives, and (2) studies that assessed the importance of specific anatomical topics or structures, either for a given body region(s) or organ system. The three studies that comprise the first category (Leonard et al., \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e1996\u003c/span\u003e; McHanwell et al., \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2007\u003c/span\u003e; Smith et al., \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Balta et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2019\u003c/span\u003e), conducted under the auspices of professional anatomical societies, presented comprehensive syllabi comprised of anatomical topics or formal learning objectives that are particularly useful for course organization and guiding student learning in general. However, it is difficult to derive a complete list of individual anatomical structures that should be covered in medical curricula from these studies, although the proposal by Leonard et al. (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e1996\u003c/span\u003e) comes closest.\u003c/p\u003e \u003cp\u003eThree studies in the second category used the consensus-building modified Delphi panel approach described in Moxham et al. (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). Each of these studies included 20\u0026ndash;30 anatomists and clinicians from several countries: for the head and neck, Tubbs et al. (\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e2014\u003c/span\u003e) assessed a total of 1,730 items (1,188 individual structures and 542 relevant pathologies); for the thorax, Moxham et al. (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) evaluated 628 anatomical topics or structures; and for the musculoskeletal (MSK) system, Webb et al. (\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e2019\u003c/span\u003e) assessed a total of 2,260 items (389 concepts, 438 vertebral column structures, 663 upper limb structures, and 770 lower limb structures). These studies, which generated granular lists of anatomy, had two notable limitations: first, the perspectives of anatomists and clinicians were combined, making it impossible to distinguish the opinions of each and, second, they focused on specific regions (head and neck and thorax) or body systems (MSK) and did not consider all body regions.\u003c/p\u003e \u003cp\u003eSeveral additional studies in the second category focused on the perspectives of clinicians. Using a modified Delphi approach, 37 practicing Canadian physiatrists identified 361 MSK structures as clinically relevant for an anatomy curriculum for physical medicine and rehabilitation residency (Lisk et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). It should be noted that this study focused on one body system (MSK) and the anatomical structure list was less granular than Webb et al. (\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Three additional studies utilized survey methodology to gather perspectives from clinicians regarding broad anatomical topics. In Orsbon et al. (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2014\u003c/span\u003e), 93 clinicians from 18 specialties at the University of Chicago rated the importance of 215 broad anatomical course topics (e.g., structure, function, vasculature, innervation, lymph) across all body regions for their practices. While this study did not examine individual structures, it did highlight the fact that physicians from different specialties agreed about the overall importance of anatomy. In Leveritt et al. (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2016\u003c/span\u003e), 113 medical students in the clinical curriculum, 66 junior doctors (equivalent to residents in the U.S.), and 20 consultants in 18 clinical specialties (equivalent to \u0026ldquo;attending physicians\u0026rdquo; in the U.S.) were recruited from a single site in the United Kingdom. These participants evaluated broad anatomical knowledge (e.g., osteology, innervation of dermatomes and muscles, lymphatic drainage) that medical students should learn during preclinical training. Most recently, Keim et al. (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) reported the survey responses of 525 clinical faculty at 24 U.S. allopathic medical schools regarding the importance of 97 anatomical structure groups across all body regions. These studies provide important insight into the clinical perspective, although their less granular focus or emphasis on a specific body region or system makes it difficult to directly implement this data into anatomy curricula.\u003c/p\u003e \u003cp\u003eWhat these previous studies have not done is to assess a granular list of anatomical structures across all body regions based solely on the perspective of clinicians. Since clinicians treat patients, they are in an optimal position to provide informed opinions of the anatomy they use and consider most important for safe clinical practice. Consequently, the collective clinical perspective is essential for creating an evidence base from which to build anatomical curricula for medical trainees during residency, clerkships and electives, as well as for the preclinical phase of UME.\u003c/p\u003e \u003cp\u003eThe main aims of the study were to determine: (1) the importance of specific anatomical structures and groups of structures based on the perspective of a sampling of non-primary care residents, and (2) whether residents\u0026rsquo; ratings of essential anatomical structures differed significantly between specialties, and/or tissue classifications (e.g., blood vessels, nerves).\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e This study received exempt status by the Institutional Review Board of the Beaumont Health (IRB #2014/374).\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSurvey development\u003c/h2\u003e \u003cp\u003eAs noted in O\u0026rsquo;Reilly-Shah (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2017\u003c/span\u003e), survey fatigue leads to a large drop-off in completion and less than thoughtful answers, which can lead to a \u0026ldquo;straight-lining\u0026rdquo; of responses. A survey that included all anatomical structures of the human body, as cataloged in Terminologia Anatomica (Federative International Programme on Anatomical Terminologies, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e1998\u003c/span\u003e; Drukker and Walvoort, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2000\u003c/span\u003e), would consist of over 7,500\u0026thinsp;+\u0026thinsp;terms. A more curated list, based on the anatomical terms indicated in bold text in Grant\u0026rsquo;s Dissector (Tank, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e2009\u003c/span\u003e), would include approximately 2,200. Distributing a survey with greater than 2,000 individual items would very likely lead to severe survey fatigue. To balance the objective of assessing a granular list of anatomical structures and limiting survey fatigue, the initial survey list of anatomical structures was based on those required for dissection in the Oakland University William Beaumont School of Medicine (OUWB) anatomy course. This list was reviewed and modified by the resident co-investigators (co-authors: A.A., S.R.C., P.E.E., C.M.P., K.K.) to further reduce the length and streamline the format of the survey. The final survey list included individual structures (blood vessels, nerves, fascia, anatomical spaces, and specific surface anatomy features) and major structure groups (skeleton, muscles, and organs). While this created different levels of organization and granularity within the survey, this was balanced by the practicality of asking residents to complete a large survey. The entire survey is provided in \u003cb\u003eSupplemental File A\u003c/b\u003e.\u003c/p\u003e \u003cp\u003eThe first three questions of the survey asked respondents to indicate their terminal medical degree (M.D., D.O.), medical specialty, and postgraduate year (PGY). The remainder of the survey included 907 anatomical items organized by body region: (1) back, including the vertebral column, spinal cord, and meninges (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;55), (2) upper limb (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;171), (3) lower limb (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;137), (4) thorax (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;92), (5) abdomen (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;140), (6) pelvis and perineum (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;136), and (7) head and neck (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;176). Anatomical structures in the pelvis and perineum region included those common to both sexes (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;70), i.e., individuals assigned female or male at birth - AFAB and AMAB, respectively, and those specific to AFAB or AMAB individuals (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;33 for each group). The structures included in each region were organized hierarchically in the following manner:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eMajor anatomical topics (e.g., nerves, plexuses, ganglia)\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eAnatomical subtopics (e.g., course, branches, composition)\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eIndividual structures or groups of structures (e.g., facial nerve)\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eA 4-point Likert-type rating scale was used for this survey, with the minimum and maximum ratings of \u0026ldquo;1\u0026rdquo; and \u0026ldquo;4\u0026rdquo; designated as \u0026ldquo;Not important\u0026rdquo; and \u0026ldquo;Essential\u0026rdquo;, respectively (ratings of \u0026ldquo;2\u0026rdquo; or \u0026ldquo;3\u0026rdquo; were not assigned descriptors). Participants were provided with the prompt: \u0026ldquo;Based on your clinical experience, please indicate your opinion of the relevance of each anatomical item.\u0026rdquo; This prompt was intended to ask respondents to consider whether each survey item was closely connected with, or appropriate to, their specific clinical specialty and then to give their opinion of its importance using the Likert scale (ranging from \u0026ldquo;1 - Not important\u0026rdquo; to \u0026ldquo;4 - Essential\u0026rdquo;). Expanding the Likert scale to accommodate other answers such as \u0026ldquo;don\u0026rsquo;t know\u0026rdquo; or \u0026ldquo;no opinion\u0026rdquo; was not considered because the survey asked participants\u0026rsquo; opinions and, if a participant \u0026ldquo;did not know\u0026rdquo; a particular structure then, it was highly likely that structure was, in their opinion, \u0026ldquo;not important\u0026rdquo;. All participants, regardless of residency specialty, received the same survey. It may be argued that certain specialties would only rate anatomy highly that supports their specialization (e.g., obstetrics and gynecology would likely focus on pelvic and abdominal anatomy). However, by giving different surveys to each group of residents based on a preconceived idea of what would, or would not, be important would create an unnecessary bias. Therefore, it was a philosophical underpinning of this study that the participants\u0026rsquo; responses should inform what they considered to be important.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eSurvey dissemination and participation\u003c/h2\u003e \u003cp\u003eThe present study surveyed a sample of resident physicians in four non-primary care specialties, including anesthesiology (AN), emergency medicine (EM), obstetrics and gynecology (OB), and orthopedics (OR), at Beaumont Hospital in Royal Oak and Troy, Michigan, which are the teaching hospitals of OUWB. A convenience sample of these programs was based on two factors: (1) each identified a senior resident who was designated as a co-investigator for the study, and (2) each program provided dedicated time (90\u0026ndash;120 minutes) for residents to complete the survey during a regularly scheduled program meeting (e.g., morning rounds, noon conference). Residents who were not present at the regularly scheduled meeting (due to clinical or other commitments) received the survey to complete independently. Collectively, the four programs had a total population of 109 residents (AN\u0026thinsp;=\u0026thinsp;18, EM\u0026thinsp;=\u0026thinsp;42, OB\u0026thinsp;=\u0026thinsp;24, OR\u0026thinsp;=\u0026thinsp;25).\u003c/p\u003e \u003cp\u003eThe survey was voluntary and was presented to participants in paper-based format as a single packet, and resident co-investigators were available to answer questions. All surveys were submitted anonymously, although minimal essential information such as medical degree (M.D. or D.O.), residency program, and PGY were retained for the study. For tracking purposes during subsequent data entry, each survey was assigned a unique number.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eSurvey responses were entered into Microsoft Excel (Microsoft Corp., Redmond, WA) by the resident co-investigators (A.A., S.R.C., P.E.E, C.M.P., K.K.S.) and cross-checked for accuracy by one of the co-first authors (M.H.).\u003c/p\u003e \u003cp\u003eThe data collected from Likert scales are ordinal and, thus, have no assumption of equality between each numerical rating category (i.e., 1, 2, 3, or 4). Furthermore, the subjective interpretation of a given rating value may vary from person to person, and it is generally considered inappropriate to use parametric descriptive statistics such as means and standard deviations with ordinal data (Allen and Seaman, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2007\u003c/span\u003e). Therefore, to interpret this study's findings, a post-hoc classification system first described by Hankin et al. (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) was utilized to account for the limitations associated with ordinal data. This classification system first collapsed the 4-points in the rating scale into a binary variable: ratings of 1 and 2 were combined to form the lower component and ratings of 3 and 4 formed the higher component of the variable (the higher component will be referred to as \u0026ldquo;3\u0026thinsp;+\u0026thinsp;4%\u0026rdquo;). Subsequently, the 3\u0026thinsp;+\u0026thinsp;4% ratings were used to categorize each structure into one of four classifications of importance:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eEssential\u003c/em\u003e 3\u0026thinsp;+\u0026thinsp;4% ratings\u0026thinsp;\u0026ge;\u0026thinsp;75.0%\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eMore important\u003c/em\u003e 3\u0026thinsp;+\u0026thinsp;4% ratings 50.0\u0026ndash;74.9%\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eLess important\u003c/em\u003e 3\u0026thinsp;+\u0026thinsp;4% ratings 25.0\u0026ndash;49.9%\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eNot important\u003c/em\u003e 3\u0026thinsp;+\u0026thinsp;4% ratings\u0026thinsp;\u0026lt;\u0026thinsp;25%\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eIt is important to note that a classification of \u003cem\u003enot important\u003c/em\u003e or \u003cem\u003eessential\u003c/em\u003e did not correspond directly to a Likert-scale rating of \u0026ldquo;1\u0026rdquo; (\u0026ldquo;not important\u0026rdquo;) or \u0026ldquo;4\u0026rdquo; (\u0026ldquo;essential\u0026rdquo;) in the actual survey. Rather, a classification of \u003cem\u003enot important\u003c/em\u003e indicated that less than 25% of respondents rated a structure a \u0026ldquo;3\u0026rdquo; or \u0026ldquo;4\u0026rdquo;, and a classification of \u003cem\u003eessential\u003c/em\u003e indicated that at least 75% rated a structure a \u0026ldquo;3\u0026rdquo; or \u0026ldquo;4\u0026rdquo;.\u003c/p\u003e \u003cp\u003eIt should be emphasized that collapsing the 4-point scale to a binary variable was not done for statistical reasons. Rather, the goal was to provide the end-users (e.g., anatomists, curriculum developers, medical deans) with an intuitive and useful classification system (\u003cem\u003eessential\u003c/em\u003e, \u003cem\u003emore important\u003c/em\u003e, \u003cem\u003eless important\u003c/em\u003e, \u003cem\u003enot important\u003c/em\u003e) for categorizing individual anatomical structures. Ideally, this list of classified structures could be useful when making curricular decisions regarding inclusion or exclusion of a given anatomical topic.\u003c/p\u003e \u003cp\u003eThe Kruskal-Wallis nonparametric ANOVA was used to determine whether group differences existed between the residency groups regarding the rating of clinical importance across the seven anatomical regions. Seven analyses were conducted using clinical specialty as the categorical independent variable and the combined mean ratings for all anatomical structures or groups of structures for each major anatomical topic in each region as the dependent variable. For example, for the upper limb, there were nine major anatomical topics for which means were assessed: skeleton, joints, fascia, muscles, nerves, blood vessels, lymphatics, anatomical spaces, and surface anatomy. A Bonferroni correction was applied to the a priori alpha level in order to account for the potential increase in type 1 error due to multiple testing: starting with an overall experiment-wise error rate of 0.05, an adjusted alpha level of 0.007 was used to compare the seven anatomical regions.\u003c/p\u003e \u003cp\u003eEach anatomical structure was assigned by two authors (M.H., D.H.) to one of the nine major tissue or structure types: skeleton, muscle, nerve, fascia, anatomical space, blood vessel, lymphatic, organ, and surface anatomy. The Kruskal-Wallis nonparametric ANOVA was used to determine whether group differences existed between the residency groups regarding the rating of structures based on their major tissue or structure type classification. A Bonferroni correction was applied to the a priori alpha level in order to account for the potential increase in type 1 error due to multiple testing: starting with an overall experiment-wise error rate of 0.05, an adjusted alpha level of 0.0056 was used to compare the nine tissue types. All statistical analyses were performed using the SPSS statistical package, version 28 (IBM Corp., Armonk, NY).\u003c/p\u003e \u003cp\u003eThe distribution of classifications of importance was assessed for each resident group and internal consistency was assessed with an ordinal Cronbach alpha. The resulting alpha value is considered to have sufficient internal consistency at a minimum value of 0.70, but a value above 0.90 for educational or clinical purposes is more desirable (Gadermann et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Effect size for this study was assessed through eta-squared, with values of 0.01 equating to a small effect, values of 0.06 a medium effect, and \u0026gt;\u0026thinsp;0.14 a large effect (Richardson, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2011\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eAll parts of the survey were completed by a total of 55 residents. Response rates were calculated based on the total number of residents across PGY in each program.\u003c/p\u003e \u003cp\u003eAN residents \u0026ndash; Response rate\u0026thinsp;=\u0026thinsp;33.3% (6 out of 18 total residents across all PGY)\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eTotal \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;6: PGY-2 (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1); PGY-3 (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;2); PGY-4 (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3)\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eEM residents \u0026ndash; Response rate\u0026thinsp;=\u0026thinsp;35.7% (15 out of 42 total residents across all PGY)\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eTotal \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;15: PGY-1 (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;8), PGY-2 (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;4); PGY-3 (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3)\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eOB residents \u0026ndash; Response rate\u0026thinsp;=\u0026thinsp;54.2% (13 out of 24 total residents across all PGY)\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eTotal \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;13: PGY-1 (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;2), PGY-2 (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;4), PGY-3 (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;4), PGY-4 (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3)\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eOR residents \u0026ndash; Response rate\u0026thinsp;=\u0026thinsp;84.0% (21 out of 25 total residents across all PGY)\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eTotal \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;21: PGY-1 (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3), PGY-2 (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;5), PGY-3 (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;4), PGY-4 (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;6), PGY-5 (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3)\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eThe combined response rate for all residents who participated was 50.5%, (55 total participants out of a total of 109 residents across the four programs).\u003c/p\u003e \u003cp\u003eOrdinal Cronbach\u0026rsquo;s alpha values were used as measures of internal consistency for each of the seven anatomical regions surveyed collectively, as well as individually within specialties. Alpha values for each anatomical region with all four residency groups combined were above the generally accepted threshold of 0.90 (back\u0026thinsp;=\u0026thinsp;0.91; upper limb\u0026thinsp;=\u0026thinsp;0.97; lower limb\u0026thinsp;=\u0026thinsp;0.95; thorax\u0026thinsp;=\u0026thinsp;0.96; abdomen\u0026thinsp;=\u0026thinsp;0.96; pelvis and perineum\u0026thinsp;=\u0026thinsp;0.98; head and neck\u0026thinsp;=\u0026thinsp;0.98), indicating the survey instrument had acceptable internal consistency (Gadermann et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2019\u003c/span\u003e).\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eEssential anatomy by residency group\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows the statistically significant differences between residencies for each anatomical region in top-level ratings (i.e., major anatomical topics). Residents in OR rated structures significantly higher than OB and EM in the back, and OB, EM, and AN in the limbs. Residents in OB rated structures significantly higher than EM and AN in all categories of the pelvis and perineum, except for AMAB-specific anatomy. Eta-squared effect sizes were calculated for each of the regions that had significant differences between residencies: back, 0.58; upper limb, 0.62; lower limb, 0.52; pelvis and perineum all anatomy, 0.30; AFAB-specific pelvis and perineum, 0.35; pelvis and perineum common to AFAB and AMAB individuals, 0.41. All regions had large effect sizes (Richardson, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2011\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eStatistically significant differences between residencies in the ratings of anatomical topics for each anatomical region.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRegion\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eSignificant Differences Between Residency Groups\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBack\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOR \u0026gt;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOB (P\u0026thinsp;=\u0026thinsp;0.001), EM (P\u0026thinsp;=\u0026thinsp;0.001)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eUpper Limb\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOR \u0026gt;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOB (P\u0026thinsp;=\u0026thinsp;0.001), AN (P\u0026thinsp;=\u0026thinsp;0.001), EM (P\u0026thinsp;=\u0026thinsp;0.003)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLower Limb\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOR \u0026gt;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOB (P\u0026thinsp;=\u0026thinsp;0.001), EM (P\u0026thinsp;=\u0026thinsp;0.001), AN (P\u0026thinsp;=\u0026thinsp;0.002)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eThorax\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAbdomen\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePelvis and Perineum\u003c/b\u003e\u003c/p\u003e \u003cp\u003eAll anatomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOB \u0026gt;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEM (P\u0026thinsp;=\u0026thinsp;0.004), AN (P\u0026thinsp;=\u0026thinsp;0.032)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePelvis and Perineum\u003c/b\u003e\u003c/p\u003e \u003cp\u003eAnatomy common to both sexes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOB \u0026gt;\u003c/p\u003e \u003cp\u003eOR \u0026gt;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEM (P\u0026thinsp;=\u0026thinsp;0.001), AN (P\u0026thinsp;=\u0026thinsp;0.026)\u003c/p\u003e \u003cp\u003eEM (P\u0026thinsp;=\u0026thinsp;0.002)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePelvis and Perineum\u003c/b\u003e\u003c/p\u003e \u003cp\u003eAnatomy in AFAB individuals\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOB \u0026gt;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAN (P\u0026thinsp;=\u0026thinsp;0.001), EM (P\u0026thinsp;=\u0026thinsp;0.001), OR (P\u0026thinsp;=\u0026thinsp;0.005)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePelvis and Perineum\u003c/b\u003e\u003c/p\u003e \u003cp\u003eAnatomy in AMAB individuals\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHead and Neck\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003eAbbreviations: NS, not statistically significant at corrected alpha\u0026thinsp;=\u0026thinsp;0.007; AN, anesthesiology; EM, emergency medicine; OB, obstetrics/gynecology; OR, orthopedics; AFAB, assigned female at birth; AMAB, assigned male at birth\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows the distribution of classifications for each group of residents for each survey item in each anatomical region. \u003cb\u003eSupplemental File B\u003c/b\u003e shows the 3\u0026thinsp;+\u0026thinsp;4% rating response frequency and corresponding classifications of importance by anatomical region for each anatomical structure or group of structures.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eAnesthesiology residents.\u003c/b\u003e For AN residents, 37.6% (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;341) of anatomical structures across all body regions were classified as \u003cem\u003eessential\u003c/em\u003e, 34.2% (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;310) as \u003cem\u003emore important\u003c/em\u003e, 15.2% (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;138) as \u003cem\u003eless important\u003c/em\u003e, and 13.0% (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;118) as \u003cem\u003enot important\u003c/em\u003e. The percentage of structures classified as \u003cem\u003eessential\u003c/em\u003e was highest for the back, thorax, and head and neck (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). For most regions of the body, a majority of structures were classified as \u003cem\u003eessential\u003c/em\u003e or \u003cem\u003emore important\u003c/em\u003e for AN residents: back, 78.2% (44/55); upper limb, 53.8% (92/171); lower limb, 63.5% (87/137); thorax, 91.3% (84/92); abdomen, 77.8% (109/140); and head and neck, 96.6% (170/176). In the pelvis and perineum, 47.8% (65/136) of structures were classified as \u003cem\u003eessential\u003c/em\u003e or \u003cem\u003emore important\u003c/em\u003e.\u003c/p\u003e \u003cp\u003e \u003cb\u003eEmergency medicine residents.\u003c/b\u003e For EM residents, 41.6% (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;377) of anatomical structures across all body regions were classified as \u003cem\u003eessential\u003c/em\u003e, 26.5% (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;240) as \u003cem\u003emore important\u003c/em\u003e, 21.5% (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;195) as \u003cem\u003eless important\u003c/em\u003e, and 10.5% (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;95) as \u003cem\u003enot important\u003c/em\u003e. The percentage of structures classified as \u003cem\u003eessential\u003c/em\u003e was highest for the limbs, thorax, and head and neck (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). For all regions of the body, a majority of structures were classified as \u003cem\u003eessential\u003c/em\u003e or \u003cem\u003emore important\u003c/em\u003e for EM residents: back, 56.4% (31/55); upper limb, 79.0% (135/171); lower limb, 64.3% (88/137); thorax, 73.9% (68/92); abdomen, 59.3% (83/140); pelvis and perineum, 59.6% (81/136); and head and neck, 73.9% (120/176).\u003c/p\u003e \u003cp\u003e \u003cb\u003eObstetrics and gynecology residents.\u003c/b\u003e For OB residents, 29.1% (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;264) of anatomical structures across all body regions were classified as \u003cem\u003eessential\u003c/em\u003e, 22.9% (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;208) as \u003cem\u003emore important\u003c/em\u003e, 35.7% (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;324) as \u003cem\u003eless important\u003c/em\u003e, and 12.2% (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;111) as \u003cem\u003enot important\u003c/em\u003e. For these residents, the percentage of structures classified as \u003cem\u003eessential\u003c/em\u003e was highest for the abdomen and pelvis and perineum (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Those structures in the pelvis and perineum common to both sexes and those specific to AFAB individuals were all classified as \u003cem\u003eessential\u003c/em\u003e, whereas those specific to AMAB individuals were almost uniformly classified as \u003cem\u003eless important\u003c/em\u003e. For most regions of the body, a majority of structures were classified as \u003cem\u003eessential\u003c/em\u003e or \u003cem\u003emore important\u003c/em\u003e for OB residents: back, 54.6% (30/55); lower limb, 57.7% (79/137); thorax, 66.3% (61/92); abdomen, 77.8% (108/140); and pelvis and perineum, 79.4% (108/136). In the upper limb and head and neck, a minority of structures were classified as \u003cem\u003eessential\u003c/em\u003e or \u003cem\u003emore important\u003c/em\u003e: upper limb, 17.6% (30/171); and head and neck, 34.7% (49/176).\u003c/p\u003e \u003cp\u003e \u003cb\u003eOrthopedics residents.\u003c/b\u003e For OR residents, 72.0% (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;653) of anatomical structures across all body regions were classified as \u003cem\u003eessential\u003c/em\u003e, 27.9% (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;253) as \u003cem\u003emore important\u003c/em\u003e, and 0.1% (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1) as \u003cem\u003eless important\u003c/em\u003e. The percentage of structures classified as \u003cem\u003eessential\u003c/em\u003e were highest (at or near 100%) for the back and limbs (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Virtually one hundred percent of structures in the thorax (92/92), abdomen (139/140), pelvis and perineum (136/136), and head and neck (176/176) were classified by these residents as either \u003cem\u003eessential\u003c/em\u003e or \u003cem\u003emore important\u003c/em\u003e. However, within each region the distribution of these classifications was different: thorax (73.9% \u003cem\u003eessential\u003c/em\u003e and 26.1% \u003cem\u003emore important\u003c/em\u003e), abdomen (37.1% \u003cem\u003eessential\u003c/em\u003e and 61.4% \u003cem\u003emore important\u003c/em\u003e). pelvis and perineum (46.3% \u003cem\u003eessential\u003c/em\u003e and 53.7% \u003cem\u003emore important\u003c/em\u003e), and head and neck (61.9% \u003cem\u003eessential\u003c/em\u003e and 38.1% \u003cem\u003emore important\u003c/em\u003e).\u003c/p\u003e \u003cp\u003eBased on the Likert-scale ratings, there was a concurrence of classifications of importance as either \u003cem\u003eessential\u003c/em\u003e or \u003cem\u003emore important\u003c/em\u003e for a limited number of structures in several anatomical regions (\u003cb\u003eSupplemental File C\u003c/b\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eClassifications of importance by structure and tissue type\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows the statistically significant differences between residencies for anatomical tissue types. Residents in OR had the highest number of significant differences for the nine tissue types compared to other residents, with at least one significant difference in each category; residents in AN, on the other hand, had no significant differences in tissue types compared to other residents.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eStatistically significant differences between residency groups in ratings of anatomical tissue types.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRegion\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eSignificant Differences Between Residency Groups\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eSkeleton\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEM \u0026gt;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAN (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOB \u0026gt;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAN (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), EM (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOR \u0026gt;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOB (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), EM (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eMuscles\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEM \u0026gt;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAN (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOR \u0026gt;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAN (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), EM (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), OB (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFasciae\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOR \u0026gt;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAN (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), OB (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), EM (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eBlood Vessels\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEM \u0026gt;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAN (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOB \u0026gt;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAN (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOR \u0026gt;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAN (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), EM (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), OB (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eLymphatics\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOB \u0026gt;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEM (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), AN (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOR \u0026gt;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAN (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), EM (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), OB (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eNerves\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEM \u0026gt;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAN (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOB \u0026gt;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAN (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOR \u0026gt;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEM (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), OB (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), AN (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eOrgans\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEM \u0026gt;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAN (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOB \u0026gt;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEM (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOR \u0026gt;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEM (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eAnatomical Spaces\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOB \u0026gt;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEM (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOR \u0026gt;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAN (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), OB (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eSurface Anatomy\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEM \u0026gt;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAN (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOB \u0026gt;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEM (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), AN (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOR \u0026gt;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAN (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), OB (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), EM (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003eAbbreviations: AN, anesthesiology; EM, emergency medicine; OB, obstetrics/gynecology; OR, orthopedics\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe present study, which followed the research design of Hankin et al. (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), surveyed a sample of non-primary care resident physicians in anesthesiology, emergency medicine, obstetrics and gynecology, and orthopedics at Beaumont Hospital/OUWB regarding their opinion of the anatomy considered most important for their specialties. The response rates varied from 33.3% for AN residents to 84.0% for OR, with a combined response rate of 50.5%, which was similar to those reported in Wilson et al., (\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) for students (52.0%), and slightly lower for healthcare professionals and faculty (59%). There were significant differences between residencies in their ratings of the major anatomical topics, with OR residents consistently rating structures and groups of structures higher across most body regions than the other residents. Residents in OB rated the anatomy of the pelvis and perineum specific to AFAB individuals higher than the other residents.\u003c/p\u003e \u003cp\u003eThere was considerable variability in the percentage of the total structures classified as \u003cem\u003eessential\u003c/em\u003e for each residency, ranging from 29.2% for OB to 72.0% for OR. Viewed by anatomical region, the structures classified as \u003cem\u003eessential\u003c/em\u003e were different for each residency group. The percentages of \u003cem\u003eessential\u003c/em\u003e structures for AN residents were highest in the back, thorax, and head and neck, which are consistent with anatomy emphasized in a number of anatomy review texts for anesthesiology (Georgiou et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Ellis and Lawson, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). For OB residents, the emphasis was on the anatomy of the pelvis and perineum (anatomy common to both sexes and, predictably, the anatomy specific to AFAB individuals) and the abdomen, which is similar to the findings in Orsbon et al. (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). These regions include structures related to female anatomy as well as relevant abdominal structures that extend into the pelvic cavity (Koppes et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Asali et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) that may be encountered in obstetric and gynecological procedures. For OR residents, more structures were \u003cem\u003eessential\u003c/em\u003e in the back and limbs, which is consistent with the various procedures and surgical interventions related to bones, muscles, tendons, and joints in these regions (Gehrig, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2011\u003c/span\u003e). For EM residents, an obvious majority of structures that were classified as \u003cem\u003eessential\u003c/em\u003e was not seen for any particular body region, which likely reflects the fact that EM physicians diagnose and treat conditions affecting all body regions (Hooker et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Lane et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eConsidering all four residencies together in the present study, only a small number of structures were classified as \u003cem\u003eessential\u003c/em\u003e (4.7%; \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;43), with the percent concurrence for individual regions ranging from 0.0% for the upper limb, and the head and neck to 18.5% for the thorax (\u003cb\u003eSupplemental File C\u003c/b\u003e). A low percentage of structures were also classified as \u003cem\u003eessential\u003c/em\u003e in Hankin et al., (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) for family medicine and internal medicine residents (17.0%, \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;154; ranging from 10% for upper limb, lower limb, and pelvis and perineum, to 35% for thorax). If all structures classified as \u003cem\u003eessential\u003c/em\u003e by a majority of the six groups of residents in the present study and Hankin et al. (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) were combined, this would only include 23.2% (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;210) of structures. These relatively low values raise the obvious concern for medical curricula that only including the anatomy classified as \u003cem\u003eessential\u003c/em\u003e would be too limiting and would likely not provide a sufficient foundation to prepare medical students for clinical training. Instead, expanding the criteria in the present study to include structures classified as either \u003cem\u003eessential\u003c/em\u003e or \u003cem\u003emore important\u003c/em\u003e would capture 33.3% (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;302) of structures, ranging from 9.1% for structures specific to AMAB individuals to 52.2% for the thorax (\u003cb\u003eSupplemental File C\u003c/b\u003e). While 33.3% is still quite low compared to Hankin et al. (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), in which 75% of structures were considered \u003cem\u003eessential\u003c/em\u003e or \u003cem\u003emore important\u003c/em\u003e for residents in family medicine and internal medicine, it illustrates the differences in regional focus between primary and non-primary care specialties. If, however, the structures classified as either \u003cem\u003eessential\u003c/em\u003e or \u003cem\u003emore important\u003c/em\u003e by a majority of all six groups of residents from both studies are compiled, this yields 77.5% (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;703) of the surveyed items (\u003cb\u003eSupplemental File D\u003c/b\u003e). Therefore, it is reasonable to suggest using these structures as a starting point for inclusion in UME anatomy curricula. Alternatively, when developing or updating graduate medical education curricula, this database can be utilized on an individual specialty basis to directly inform the content included in anatomical reviews or workshops.\u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eComparison with previous studies\u003c/h2\u003e \u003cp\u003eDirect comparisons between the current study and previous studies (Orsbon et al., \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Tubbs et al., \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Leveritt et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Webb et al., \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Moxham et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) are challenging due to different research designs, levels of granularity, and systems for classification. It is, nevertheless, instructive as a starting point, to note that the percentage of total structures classified in the highest category in each of these studies showed a considerable range: 3.7% in Orsbon et al. (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2014\u003c/span\u003e), 4.7% in the present study, 17.0% in Hankin et al. (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), 24.3% in Tubbs et al. (\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e2014\u003c/span\u003e), 43.2% in Moxham et al. (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2020\u003c/span\u003e), and 49.2% in Webb et al. (\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Drilling down a bit more, there were a number of structures that were classified in the highest category in the current study as well as in the previous studies that assessed corresponding body regions, including the dura mater, internal and external carotid, and middle meningeal arteries, all cranial nerves, the brachial plexus, the sternocleidomastoid muscle, and the thoracic wall and diaphragm. This selective list suggests that more understanding is needed regarding how to determine the importance of anatomical structures.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eRecommendations for medical educators\u003c/h2\u003e \u003cp\u003eWith the various changes in anatomy education within UME curricula, including fewer instructional hours, it becomes increasingly important to make realistic decisions about what content can and should be included. At this juncture, it is challenging for medical educators to know how to utilize the data from the collective body of work to arrive at a granular understanding of the anatomy considered most important to include during the different stages of medical education. The authors suggest a multi-stage approach from which some decisions may be made. First, anatomy educators can refer to the published learning objectives to establish the overall organization of the anatomy curriculum. Following this, the authors suggest that anatomists consider structures classified as \u003cem\u003eessential\u003c/em\u003e or \u003cem\u003emore important\u003c/em\u003e in the present study and in Hankin et al. (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Inclusion of this content will likely also be based on the specific curricular focuses and capabilities at individual institutions, this baseline of structures can be amended to either include more structures (i.e., those classified as \u003cem\u003eless important\u003c/em\u003e) or to selectively remove some of the \u003cem\u003emore important\u003c/em\u003e structures.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eFuture Directions\u003c/h2\u003e \u003cp\u003eAs noted previously, a number of studies have assessed anatomical content using various research designs with different scopes, yielding different classifications and recommendations. A meta-analysis across all previous studies could provide a helpful integration of the various perspectives. In addition, the current survey should be distributed more broadly to increase both the total number of clinicians among the represented specialties, as well as to collect data from specialties that have not yet contributed. While knowing what is considered essential for clinicians is an important first step, it would be worthwhile to eventually expand this data to understand what about a given structure is essential and, thereby, what about it should be taught. Finally, it is important to recruit anatomy educators to complete the same survey and compare the classifications to those of clinicians.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eA number of limitations should be considered for this study. First, all respondents were residents at a single institution and the findings of this study may not be generalizable beyond Beaumont Hospital/OUWB. It is also evident that the findings in the present study were based on only four groups of residents and not on a broad sample from across the institution. In addition, the relatively small and unequal numbers of survey respondents from each group of residents could have skewed the results. It also should be acknowledged that the participants in the study were residents and not attending (academic) physicians or physicians in private practice. Therefore, it is possible that the ratings by these residents reflected what they were using most in their training at the time and that the knowledge required beyond residency may be different. It is important to note that the survey asked respondents to rate the \u0026ldquo;relevance\u0026rdquo; of structures based on their \u0026ldquo;clinical experience\u0026rdquo;, which could potentially have led to a different response if the prompt had, instead, used the word \u0026ldquo;importance\u0026rdquo;.\u003c/p\u003e \u003cp\u003eAlthough this was a non-incentivized voluntary survey, it is possible that a response bias resulted from the fact that participants may have had a higher interest in anatomy compared to those who did not participate (the four resident co-investigators who were co-authors also completed the survey). Such a bias could not be assessed directly in this study but, if it did exist, it may have reflected the perspectives of individual residents, or even those based on program bias or selection criteria for different clinical specialties.\u003c/p\u003e \u003cp\u003eLimitations related to the survey must be acknowledged. The long survey used in this study, and in Hankin et al. (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), could have resulted in a degree of fatigue and the potential for straight-lining (i.e., a form of habituation where respondents select the same response for multiple questions). However, straight-lining was not immediately obvious and the extent to which it occurred was not evaluated in this study. In addition, the survey design had different levels of \u0026ldquo;granularity\u0026rdquo;, with some structures listed individually (blood vessels, nerves, and structures related to surface anatomy) while others were \u0026ldquo;bundled\u0026rdquo; into logical groups (skeleton, muscles, and organs) that were evaluated in terms of their location, structure, anatomical relationships, function, and neurovasculature. In large part, this \u0026ldquo;bundling\u0026rdquo; was done to limit the length of the survey and prevent fatigue and straight-lining.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eRecent changes to gross anatomy education in current UME curricula have led to the need to establish the essential gross anatomy content that all students should understand upon graduation. The present study, which utilized the method described in Hankin et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2023\u003c/span\u003e, assessed the perspective of a sample of non-primary care resident physicians in four different specialties regarding the importance of gross anatomical structures across all body regions. This study demonstrated significant differences in the ratings of anatomy between the four participant groups. This result stands in contrast to the observations from Hankin et al. (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), which showed agreement about essential anatomy between primary care residents. In combination, the database derived from these studies not only provides a clinical view of anatomy but also can inform how anatomy curricula can be most efficiently and effectively incorporated in the context of limited curricular hours.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cstrong\u003eUME\u003c/strong\u003e \u0026ndash; Undergraduate Medical Education\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAN\u003c/strong\u003e \u0026ndash; Anesthesiology\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEM\u003c/strong\u003e \u0026ndash; Emergency Medicine\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOB\u003c/strong\u003e \u0026ndash; Obstetrics and Gynecology\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOR\u003c/strong\u003e \u0026ndash; Orthopedics\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eUS\u003c/strong\u003e \u0026ndash; United States\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMSK\u003c/strong\u003e \u0026ndash; Musculoskeletal\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOUWB\u003c/strong\u003e \u0026ndash; Oakland University William Beaumont School of Medicine\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePGY\u003c/strong\u003e \u0026ndash; Postgraduate Year\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAFAB\u003c/strong\u003e \u0026ndash; Assigned Female at Birth\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAMAB\u003c/strong\u003e \u0026ndash; Assigned Male at Birth\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eANOVA\u003c/strong\u003e \u0026ndash; Analysis of Variance\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u0026nbsp;\u003c/strong\u003eThis project was deemed exempt from full IRB approval by the Oakland University William Beaumont School of Medicine IRB. All ethical standards have been met.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u0026nbsp;\u003c/strong\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions:\u003c/strong\u003e D.H. and M.H. wrote the main manuscript text, with help from J.M. in the methodology and statistical analysis. M.H. prepared all the figures and tables. I.N., A.A., R.H., A.K., S.C., P.E., C.P., and K.K. reviewed and edited the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003eThe authors would like to thank the residents at Beaumont Health who participated in the survey and took the time to complete it thoughtfully and fully. Thanks also to Dr. Kelly Harrell (Department of Anatomy and Neurobiology, Virginia Commonwealth University) for her thoughtful comments on the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAhmed K, Rowland S, Patel V, Khan RS, Ashrafian H, Davies DC, Darzi A, Athanasiou T, Paraskeva PA. Is the structure of anatomy curriculum adequate for safe medical practice? Surgeon. 2010;8(6):318\u0026ndash;24.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAllen IE, Seaman CA. Likert scales and data analyses. 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Prosection or Dissection: Which is best for teaching the anatomy of the hand and foot? Anat Sci Educ. 2019;12(2):173\u0026ndash;80.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWilson AB, Brooks WS, Edwards DN, Deaver J, Surd JA, Pirlo OJ, Byrd WA, Meyer ER, Beresheim A, Cuskey SL, Tsintolas JG, Norrell ES, Fisher HC, Skaggs CW, Mysak D, Levin SR, Escutia Rosas CEE, Cale AS, Karim MN, Pollock J, Kakos NJ, O'Brien MS, Lufler RS. Survey response rates in health sciences education research: A 10-year meta-analysis. Anat Sci Educ. 2024;17(1):11\u0026ndash;23.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Medical education, undergraduate medical education, graduate medical education, medical curriculum, curriculum development, anatomy education","lastPublishedDoi":"10.21203/rs.3.rs-4509478/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4509478/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eRecent changes in anatomy curricula in undergraduate medical education (UME), including pedagogical changes and reduced time, pose challenges for foundational learning. Consequently, it is important to determine the essential content for an effective anatomy curriculum.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis study surveyed 55 non-primary care residents in anesthesiology (AN; N\u0026thinsp;=\u0026thinsp;6), emergency medicine (EM; N\u0026thinsp;=\u0026thinsp;15), obstetrics and gynecology (OB; N\u0026thinsp;=\u0026thinsp;13), and orthopedics (OR; N\u0026thinsp;=\u0026thinsp;21) to assess the importance of 907 anatomical structures across all anatomical regions. Survey ratings by participants were converted into a post-hoc classification system to provide end-users of this data with an intuitive and useful classification system for categorizing individual anatomical structures (i.e., essential, more important, less important, not important).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eSignificant variability was observed in the classifications of essential anatomy: 29.1% of all structures were considered essential by OB residents, 37.6% for AN residents, 41.6% for EM residents, and 72.0% for OR residents. Significant differences (with large effect sizes) were also observed between residency groups: OR residents rated anatomy of the back, limbs, and pelvis and perineum anatomy common to both sexes significantly higher, whereas OB residents rated the pelvis and perineum anatomy common to both sexes and anatomy for individuals assigned female at birth highest. Agreement in classifications of importance among residents was observed for selected anatomical structures in the thorax, abdomen, pelvis and perineum (assigned male at birth-specific anatomy), and head and neck. As with the ratings of anatomical structures, OR residents had the highest classification across all nine tissue types (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe present study, in combination with Hankin et al. (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), which surveyed primary care residents, contributes to a database of anatomical structures assessed from a clinical perspective that may be considered when determining foundational anatomy for UME curriculum, as well as for graduate medical education.\u003c/p\u003e","manuscriptTitle":"A Survey of Essential Anatomy from the Perspective of Anesthesiology, Emergency Medicine, Obstetrics and Gynecology, and Orthopedics Resident Physicians","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-18 15:57:30","doi":"10.21203/rs.3.rs-4509478/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-06-24T09:30:37+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-06-20T11:57:32+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-06-20T11:56:38+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2024-05-31T13:59:35+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"31d4ac17-7646-48fd-9118-1137ff0d2501","owner":[],"postedDate":"July 18th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-10-28T16:00:04+00:00","versionOfRecord":{"articleIdentity":"rs-4509478","link":"https://doi.org/10.1186/s12909-024-06185-5","journal":{"identity":"bmc-medical-education","isVorOnly":false,"title":"BMC Medical Education"},"publishedOn":"2024-10-23 15:57:16","publishedOnDateReadable":"October 23rd, 2024"},"versionCreatedAt":"2024-07-18 15:57:30","video":"","vorDoi":"10.1186/s12909-024-06185-5","vorDoiUrl":"https://doi.org/10.1186/s12909-024-06185-5","workflowStages":[]},"version":"v1","identity":"rs-4509478","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4509478","identity":"rs-4509478","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}