To the best of our knowledge, this is the first international survey exploring attitudes towards neuroanatomy amongst neurosurgeons. While previous work has explored issues related to anatomy education among surgical trainees,7–11 and the impact of COVID-19 on surgical training,25,27–30,36,37 there has been limited investigation into the value of neuroanatomy and how it is studied. We found that neuroanatomy is highly regarded among most neurosurgeons and takes a central role in their professional identity. Common prompts to study neuroanatomy included perceived operative complexity, lack of procedure familiarity and teaching. Several grade- or nationality-dependent obstacles were identified that limited neuroanatomy learning including finances, personal commitments, and motivation. Online image searches and CBD were the most frequently used opportunities for learning outside of theatre, while surgical relevance, accessibility and image quality were considered most important when choosing a resource. The COVID-19 pandemic significantly impacted operative exposure and motivation to study neuroanatomy and led to a shift towards online resource use. This impact was also mediated by neurosurgical grade and nationality.
Most respondents agreed that expertise in neuroanatomy was important to being a neurosurgeon, and over half stated that studying it was useful in everyday clinical work. A strong evidence base exists within and outside of neurosurgery demonstrating a correlation between clinical performance and objective assessment of surgeons’ anatomical proficiency.38,39 Despite anatomy expertise representing an intrinsic aspect of the neurosurgical professional identity,40–42 around a quarter of respondents stated they did not enjoy studying neuroanatomy and a smaller fraction believed that studying neuroanatomy was not relevant. It is unclear whether carrying these sentiments may impact learning and clinical performance.
Regardless of their valence toward the subject, most neurosurgeons stated they wanted to spend more time learning neuroanatomy. This was significantly greater for trainees rather than senior consultants, and corresponded with the difference in the proportion of operations for which the operative anatomy was revised. Both these examples illustrate that the need for continuing anatomy education among consultants may be less. This could be related to their increased competency and more experience with an increasingly specific set of operations.43,44 Given their technical ability and logistical efficiency,43,44 it is somewhat unsurprising that consultants perceived the degree of operative responsibility, operative patient risks and operative duration as less of a study prompt as compared to juniors. In contrast, lack of familiarity regarding the procedure and its perceived complexity remained important factors among all neurosurgeons regardless of grade or nationality.
Barriers preventing neurosurgeons from studying neuroanatomy differed significantly by grade and nationality. Financial obstacles were a greater barrier to senior residents and fellows compared with senior consultants. Senior residents may be faced with growing professional and personal expenses which are not met by the gradually increasing scale of remuneration as training progresses.45 Concurrently, senior residents also rated cost as being most important when choosing a resource.
Universally, teaching was a significant external factor in encouraging neuroanatomy learning among all grades, in line with previous evidence which confirmed that neurosurgeons are typically active within the teaching faculty at both under- and postgraduate level.46–48 In comparison, the stressors of examinations and peer pressure as a motivation for studying were felt particularly by interns and junior registrars. Consultants are generally unencumbered with examinations and likely feel less pressure within the departmental hierarchy as compared to trainees.49,50 We would expect consultants to be less provoked by these external stresses, and accordingly, we demonstrate less likelihood of these factors in promoting anatomical learning in this group.
Neurosurgeons utilize a diverse range of resources to learn neuroanatomy. Outside of operations, those used most frequently included case-based and multidisciplinary discussions, and online search mediums. That these resources are highly accessible, surgically relevant and facilitate viewing of high-quality images, tallies with our findings that the same factors were declared as most important in the survey. Textbooks, e-learning and social media were regularly used, more so among trainees than consultants. The rise in use of social media among neurosurgical trainees specifically, has previously been well documented.51,52 International respondents chose resources which were more up-to-date and incorporated a means of assessment. Despite the availability of resources at their institutions being similar to the U.K, they also appeared to utilize certain resources with greater frequency. These differences based on nationality may reflect different training systems with emphasis on certain learning regimens or cultural preferences.53
In line with previous literature,18–21,25,30,36,37 our survey collectively highlighted fewer operative opportunities as a result of COVID-19. Nevertheless, 50% of respondents disagreed that their neuroanatomy learning was affected by COVID-19. Whereas junior and U.K.-based trainees reported being most impacted in terms of quantity or quality of learning, international neurosurgeons stated they had reduced motivation to learn due to poor health during the pandemic. These differences could represent the variable rates of infection among healthcare staff between countries, and differing levels of anatomy learning opportunities available at institutional or regional levels.54–58 Despite the positive response to online teaching during the pandemic, the inability to replicate a cadaveric or operative experience as well as technical issues and webinar overload59 means that virtual neuroanatomy learning may not suffice as a complete learning method.
We acknowledge several limitations in this work. Although responses ranged between 15–31% for certain countries, in others, only a handful of neurosurgeons answered the survey. Several methods were attempted to increase the response rate, including a two-stage mailing process, three-month survey window and promotion across social media platforms. Despite this, the final rate was below epidemiological best practice, and risks a selection bias. Furthermore, comparing all countries individually would require considerably more statistical power. We have attempted to mitigate this by a careful statistical analysis which was sensitive to factors thought to impact upon the variance, namely grade of surgeon and dichotomous location. We note, separately, that high response rates are often difficult to obtain in surveys targeted toward surgeons60,61 and our rate was well above similar work in both surgical62–65 and neurosurgical cohorts.66 We also acknowledge the discrepancy between response and completion rate, with many surgeons failing to fully answer the survey. This would need to be considered in future survey designs.
Despite these limitations, we feel this survey provides a robust baseline estimate of neurosurgical attitudes and motivations toward studying neuroanatomy that is comprehensive across both staff and training neurosurgeons, in the absence of other postgraduate data. We emphasize the global reach of the survey with responses from six continents, and from both developing and developed nations. Finally, we highlight the breadth of topics covered and the two-stage framework in accumulating this information.