A Survey of the Perception of Female Surgical Residents of Their Training in the Examination of Male Genitalia in Makkah Hospitals, KSA

The basic aims of medical schools are to graduate doctors to be competent in eliciting physical signs across all body systems. Deficiency in the clinical examination skills of female surgical residents of the male groin hernia and genitalia has not been explored and not enough investigated in the Arab and Muslim communities, despite obvious cultural restrictions and religious traditions. The cultural background of the students also has had an impact on their future training and skills. Certain systems’ examination for patients is considered very sensitive to perform by students and doctors of both sexes due to their sensitive nature. This might be due to cultural issues which affect the skills on these areas. Aim of this survey was to explore the different reasons and the influence of gender on clinical examination skills of female surgical trainees to male patient intimate. Methods: A cross-sectional design based on a self-administered questionnaire which was distributed to 80 female surgical resident trainees across five Hospitals in Makkah, Holy city, Saudi Arabia. The study was carried out between the period of September 2020 to July 2021 and involved all the female surgical residents from level 1 5 (R1 to R5). Result: Our study showed that overall perception of most of female residents on their performance on clinical examinations is less than expected. This study revealed that the main factor affecting the female resident’s clinical examination of the opposite sex intimate is the gender difference. 56 (81.2%) participants stated that their gender impacted their confidence and skills in examination of intimate of opposite sex, while 13 (18.8%) stated that gender has no effect. Conclusion: In conservative community, there are numerous areas where gender influences medical student clinical learning, including clinical exposure, supervisor support and patient willingness and consents, as well as some of the undergraduate methods of learning clinical skills not aligned with the post graduates needs. How to cite this paper: Al-Sairafi, R.A., Softa, S.A., Ahmed, A.E. and Elfaki, E.A. (2021) A Survey of the Perception of Female Surgical Residents of Their Training in the Examination of Male Genitalia in Makkah Hospitals, KSA. Surgical Science, 12, 411-420. https://doi.org/10.4236/ss.2021.1212044 Received: November 16, 2021 Accepted: December 28, 2021 Published: December 31, 2021 Copyright © 2021 by author(s) and Scientific Research Publishing Inc. This work is licensed under the Creative Commons Attribution International License (CC BY 4.0). http://creativecommons.org/licenses/by/4.0/ Open Access R.A. Al-Sairafi et al. DOI: 10.4236/ss.2021.1212044 412 Surgical Science


Abstract
The basic aims of medical schools are to graduate doctors to be competent in eliciting physical signs across all body systems. Deficiency in the clinical examination skills of female surgical residents of the male groin hernia and genitalia has not been explored and not enough investigated in the Arab and Muslim communities, despite obvious cultural restrictions and religious traditions. The cultural background of the students also has had an impact on their future training and skills. Certain systems' examination for patients is considered very sensitive to perform by students and doctors of both sexes due to their sensitive nature. This might be due to cultural issues which affect the skills on these areas. Aim of this survey was to explore the different reasons and the influence of gender on clinical examination skills of female surgical trainees to male patient intimate. Methods: A cross-sectional design based on a self-administered questionnaire which was distributed to 80 female surgical resident trainees across five Hospitals in Makkah, Holy city, Saudi Arabia. The study was carried out between the period of September 2020 to July 2021 and involved all the female surgical residents from level 1 -5 (R1 to R5). Result: Our study showed that overall perception of most of female residents on their performance on clinical examinations is less than expected. This study revealed that the main factor affecting the female resident's clinical examination of the opposite sex intimate is the gender difference. 56 (81.2%) participants stated that their gender impacted their confidence and skills in examination of intimate of opposite sex, while 13 (18.8%) stated that gender has no effect. Conclusion: In conservative community, there are numerous areas where gender influences medical student clinical learning, including clinical exposure, supervisor support and patient willingness and consents, as well as some of the undergraduate methods of learning clinical skills not aligned with the post graduates needs.

Introduction
Clinical examination skills are a core component of clinical care. A graduating medical doctor is expected to be competent in physical examinations across all systems [1], and so understanding the limitations of student exposure to conducting examinations is important. Due to the conservative nature of society in KSA, training opportunities in the examination of the hernia perineum and external genitalia can be limited [2]. The sensitive nature of these examinations for patients as well as the cultures of some students, opportunities to gain skills in this area may not be readily available [3] [4].
Deficiency in the clinical examination skills of female surgical residents of the male groin, genitalia and rectum has not been explored in the Arab and Muslim context, despite obvious cultural restrictions and religious traditions. The lack of training opportunities to gain skills in examining the intimate areas of patients resulted in a declined skill of both undergraduate and postgraduate students' performance in hospital practice.
An increase in the numbers of female medical graduates in the last two decades in Saudi Arabia, has consequently led to an increase in the number of female surgical trainees. Currently, the proportion of female surgical trainees in KSA is estimated to be approximately 27% [5].
In our society, there may be considerable anxiety and embarrassment of female students and junior doctors regarding the examination of the male inguinal hernia and scrotum. Female students may be embarrassed or concerned about male patient discomfort and thus they may perform the examinations in an incomplete or rushed manner [6]. However, whether this translates to a significant difference between male and female student exposure to clinical examinations is not explored enough.

Aim & Objectives
Our study, aims to assess the perception and confidence of female surgical residents in clinical examination of inguinal hernia and intimate of opposite sex in five hospitals, Makkah holy city. We also sought to shed light on the barriers and the impact of different teaching modalities that are currently used in undergraduate education.

Methods
The study is an observational cross-sectional design based on a self-administered close and open ended questionnaire. The questionnaire designed by the au-thors after focus group exercise were used to explore themes that trainees face related to gender bias and self-confidence on intimate examination of opposite sex. Eleven female surgical trainees of different level R1 -R5 (i.e., junior (R1, R2 and R3) and senior R4 and R5), participated in the focus groups, in addition to two female surgeons and the authors, then it was distributed to all the available female residents who fulfilled the inclusion criteria at the time of the study. The questionnaire (see the appendix) was distributed to all 80 female surgical resident trainees across the five Hospitals in Makkah, Holy city, Saudi Arabia. The study was carried out between the periods of September 2020 to July 2021 and involved all the available female surgical residents from level 1 -5 (R1 to R5) who were enrolled in the Saudi Surgical board training programme. The selection criteria of the study used all the female members of the Saudi Board general surgical programme who were working in Makkah five hospitals training centers. All female residents (R1 -R5) who fulfilled the inclusion criteria were participated in this study. The questionnaire, included questions regarding the confidence and skills of the female residents in inguinal hernia and intimate examination of adult male, female residents' perceptions regarding factors that may impact the development of clinical skills related to gender, the method of training in the undergraduate curriculum, the frequent of examinations performed during their undergraduate training and the educational environment. The questionnaire was also looking at attitudes to patient centered care, and learning experiences on hernia and intimate examination of opposite sex.
We analyzed the data with SPSS statistical software version 16.0 for Mac. Microsoft Excel 2004 version 11.5.5.

Results
A total of sixty-nine 69 (86.25%) female surgical residents completed the survey out of 80 distributed questionnaires (Table 1). This study revealed that overall female residents were feeling not confident on examining the intimate of opposite sex and feel less than expected, 22 (31.9%) were not confident at all, 34 (49.28%) some time while 13 (18.84%) feel confident enough. 56 (81.2%) feel gender affect their intimate examination skills, while 13 (18.8%) never feel the gender effect on their skill (Table 3). Regarding the male patient refusal to give consent for examination, 36 (52.17%) of the participants said patient refused to be examined by the female residents, while 33 (47.83%) never have this experience. In this study 24 (34.8%) of participants mentioned they were less exposed to the hernia and intimate examination of male patient, while 30 (43.5%) participants were frequently exposed and 15 (21.7%) more frequently exposed. Among those who completed the survey 5 (7.2%) had never performed intimate clinical examinations before.
Related to the barriers which impacted the intimate and hernia examination, out of the 69 responded, 21 (30%) were relating it to Shyness/embarrassment,  while 27 (39.13%) to Cultural/religious and 17 (24.6%) due to lack of training and 3 (4.34%) to misunderstanding. The majority (55%) of the female residents who responded to our questionnaire acknowledged the reality of the strong support of their supervisors and mentors in their workplace (Table 3).

Discussion
Medical school would seem the logical place to learn the art of the physical examination. In the last decade the intake of female to medical schools has increased greatly and averaged approximately 51%. Despite this, a disproportionate number of women continue to choose non-surgical over surgical specialties [7]. To our knowledge, this survey is the first of its kind in the conservative setting of Makkah holy city. We have shed light on the gender, tradition, religious and environmental barriers that continue to limit the training of female surgeons.   (Table 3).This can also be attributed to general overall decline in clinical examinations skills [12].
In spite of the variety of teaching methods for clinical examination, however, the bedside teaching is seen as one of the most important modalities in acquiring clinical skills for the medical profession, but its use is declining. Impediments to bedside teaching need to be overcome if this teaching modality is to remain a valuable educational method for durable clinical skills. 49 (71%) residents thought that their undergraduate training in this area was insufficient and that no training modality was superior to the other. In our study all participants reported they spend short period before they joined the training programme and may be cause for their deline in examination skill (Table 2).
In our study the gender is an issue factor for self-confidence and limitation of the clinical examination of intimate ( study [16]. Limitation of the study: The small sample size was due to that: 1) The study was carried out during the era of COVID19 period which restricted the number of patients attending the hospitals.
2) Only the female surgical residents enrolled in the Saudi Surgical Board from level 1 -5 (R1 to R5) were included, and exclusion of all service surgical program which restricted the number.

Conclusion
Our study revealed the declined of female surgical trainees on opposite sex intimate examination. Also the study showed the clear effects of conservative cultures community traditions and religious believes in Makkah community. This study serves as a call-to-action to increase collective effort towards gender inclusivity which will significantly improve future health outcomes. Suggestion for future studies is: A larger sample size study is needed to explore this issue more. Other Saudi hospitals in the western region of Saudi Arabia should be involved.