RESEARCH REPORT

Sex Differences in Spatial Abilities of Medical Graduates Entering Residency Programs

Jean Langlois,1,2* Georges A. Wells,3,4 Marc Lecourtois,5 Germain Bergeron,5 Elizabeth Yetisir,4 Marcel Martin2 1 Department of Emergency Medicine, Centre hospitalier universitaire de Sherbrooke, Sherbrooke, Quebec, Canada 2 Department of Surgery, University of Sherbrooke, Sherbrooke, Quebec, Canada 3 Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ontario, Canada 4 Cardiovascular Research Methods Center, University of Ottawa Heart Institute, Ottawa, Ontario, Canada 5 Neuropsychology Program, Trauma and Critical Care Group, Centre hospitalier universitaire de Sherbrooke, Sherbrooke, Quebec, Canada

Sex differences favoring males in spatial abilities have been known by cognitive psychologists for more than half a century. Spatial abilities have been related to three-dimensional anatomy knowledge and the performance in technical skills. The issue of sex differences in spatial abilities has not been addressed formally in the medical field. The objective of this study was to test an a priori hypothesis of sex differences in spatial abilities in a group of medical graduates entering their residency programs over a five-year period. A cohort of 214 medical graduates entering their specialist residency training programs was enrolled in a prospective study. Spatial abilities were measured with a redrawn Vandenberg and Kuse Mental Rotations Tests in two (MRTA) and three (MRTC) dimensions. Sex differences favoring males were identified in 131 (61.2%) female and 83 (38.8%) male medical graduates with the median (Q1, Q3) MRTA score [12 (8, 14) vs. 15 (12, 18), respectively; P < 0.0001] and MRTC score [7 (5, 9) vs. 9 (7, 12), respectively; P < 0.0001]. Sex differences in spatial abilities favoring males were demonstrated in the field of medical education, in a group of medical graduates entering their residency programs in a five-year experiment. Caution should be exerted in applying our group finding to individuals because a particular female may have higher spatial abilities and a particular male may C 2013 American Association of have lower spatial abilities. Anat Sci Educ 6: 368375. V Anatomists. Key words: spatial abilities; sex differences; gross anatomy education; medical education; residency education; visualization; spatial orientation; mental rotation test

INTRODUCTION
Two distinct spatial abilities have been observed: visualization and orientation (McGee, 1979). Visualization has been defined as the ability to mentally rotate and manipulate two-

*Correspondence to: Dr. Jean Langlois, Department of Emergency Medicine, Centre hospitalier universitaire de Sherbrooke, 3001 12e Avenue Nord, Sherbrooke, Quebec, Canada J1H 5N4. E-mail: jeanlanglois@rogers.com Received 27 June 2012; Revised 31 December 2012; Accepted 18 February 2013. Published online 2 April 2013 in Wiley (wileyonlinelibrary.com). DOI 10.1002/ase.1360
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and three-dimensional stimulus objects (McGee, 1979). Orientation has been found to include the comprehension of the arrangement of elements within a visual stimulus pattern, the aptitude to remain unconfused by the changing orientations in which a spatial configuration may be represented, and an ability to determine spatial orientation with respect to ones body (McGee, 1979). Spatial abilities have been related to three-dimensional anatomy knowledge using practical examinations (Rochford, 1985; Lufler et al., 2012), topographical questions (Rochford, 1985; Guillot et al., 2007; Hoyek et al., 2009), three-dimensional synthesis of two-dimensional anatomical views (Rochford, 1985; Garg et al., 1999a,b, 2001, 2002) and cross-sections of anatomical structures (Provo et al., 2002; Hegarty et al., 2009; Nguyen et al., 2012). Spatial abilities have been also related to the performance in technical skills in clinical ultrasonography (Clem et al.,

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2010), clinical surgery (Schueneman et al., 1984, Gibbons et al., 1986), dental practical restorative laboratory classes (Hegarty et al., 2009) and in the simulation laboratory suturing fresh pig jejunum (Steele et al., 1992), performing microsurgical anastomosis of blood vessels on rats (Murdoch et al., 1994), Z-plasties on pig thighs (Wanzel et al., 2002), rigid fixation of a synthetic mandible (Wanzel et al., 2003), minimally invasive surgery (Risucci et al., 2000, 2001; Haluck et al., 2002; Gallagher et al., 2003; Keehner et al., 2004, 2006; Stefanidis et al., 2006), colonoscopy (Ritter et al., 2006; Westman et al., 2006; Hedman et al., 2006; Luursema et al., 2010) and surgical knot tying (Brandt and Davies, 2006). Fitts and Posners theory of motor skill acquisition has described three stages: cognitive, associative, and autonomous (Fitts and Posner, 1967). Ackermans theory of ability determinants of skilled performance has related spatial abilities to the cognitive phase involved in learning novel first time experienced nonrepetitive tasks (Ackerman, 1988, 1992). Medical graduates entering their specialist residency training programs are subjected to a high cognitive load of three-dimensional anatomy and technical skills during the early years of their programs. There is a need to assess factors related to individual differences in their spatial abilities because it might have an impact on the learning and teaching strategies of spatial anatomy and technical skills. An interesting attribute for spatial abilities that has been discussed is sex. It has been recognized for some time that there are sex differences in the performance on some spatial tests (Maccoby and Jacklin, 1974). Tests in mental rotations have been found to produce the most robust difference (Voyer et al., 1995). Sex differences in mental rotations tests has been confirmed in a study involving more than 250,000 subjects (Peters et al., 2007). The issue of sex differences in spatial abilities has not been addressed formally in the medical field. University students in sciences programs have been found to have higher spatial abilities than that of university students in social sciences, arts, and humanities programs (Peters et al., 1995, 2006). Medical students are admitted in Canadian medical school based on a highly competitive grade point average (Yeatman, 2012). It is possible that medical students might self-select based on higher spatial abilities and that only women with higher spatial abilities would choose a medical career. There is a need to assess sex differences in spatial abilities in the medical field. The objective of this study was to assess sex differences in spatial abilities in the field of medical education and to test an a priori hypothesis of sex differences in spatial abilities in a group of medical graduates entering their residency programs over a five-year period.

There was no study done in 2009. Medical graduates entering their residency programs were offered a preparatory rotation to the residency program entitled What to do in an emergency?. A drawing course, an applied anatomy course, a prerequisite workshop including applied physiology and pharmacology courses and resuscitation courses were included in the rotation. Preference for inclusion in this rotation was given to residents in Surgery, Anesthesia and Emergency Medicine, and the remaining positions were given to Family Medicine and Internal Medicine (including Neurology and Infectious Disease) residents. Radiology residents were included only in 2010.

Study Protocol
Medical graduates entering their residency programs enrolled in the rotation What to do in an emergency? were invited to enter research studies during plenary sessions in May. After the written informed consent was obtained, the participants were subjected to a psychometric test in spatial abilities at the beginning of every study conducted from 2005 to 2010.

Measures
Variables age and residency program chosen were ascertained from the office for postgraduate education at the Faculty of Medicine of Sherbrooke in 2005 and from the written consent from 2006 to 2010. Sex was obtained from the written consent. Vandenberg and Kuse (Vandenberg and Kuse, 1978) psychometric test of mental rotations discriminates highly for the spatial abilities as opposed to the verbal abilities. The redrawn 24-items Vandenberg and Kuse Mental Rotations Test for spatial abilities was administered (Peters et al., 1995). The Mental Rotations Test A (MRTA) was based on the original Vandenberg and Kuse set requiring a mental rotation around the vertical axis and was also made more difficult by adding the Mental Rotations Test C (MRTC) requiring a mental rotation in the vertical and horizontal axis (Peters et al., 1995). Each test was administered in nine minutes: three minutes for each 12-items subset separated by a three minutes break. The easier MRTA was administered before the MRTC and the maximum on each of these tests was 24.

Statistical Analyses
Variables included the discrete variable sex and residency program chosen; and the continuous variables age, MRTA and MRTC scores. Descriptive statistics included frequencies and percentages for the discrete variable; values for continuous outcomes are reported as medians and lower/upper quartiles as well as means 6 standard deviation (SD). Two-group comparisons were done using Wilcoxon sign-rank test and correlations using Spearman coefficient (r). Cohens d effect was calculated. Analyses were performed with SAS statistical software, version 9.2 (SAS Institute, Cary, NC).

METHODS
Study Design
A prospective cohort study was conceived and implemented. The ethics committee on human research from the Faculty of Medicine of Sherbrooke and the Centre hospitalier universitaire de Sherbrooke approved the protocol.

Setting and Participants

The study was conducted at the Faculty of Medicine of Sherbrooke in May 2005, 2006, 2007, 2008, and 2010.
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RESULTS
There were 62, 65, 65, 64, and 49 medical graduates enrolled in the rotation What to do in an emergency? in 2005,
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2006, 2007, 2008, and 2010, respectively. There were 54 (87.1%), 59 (90.8%), 18 (27.7%), 34 (53.1%), and 49 (100%) medical graduates enrolled in research studies in 2005, 2006, 2007, 2008, and 2010, respectively. Written consent was signed by 214 (100%) medical graduates which constituted the study cohort. The mean age was 23.4 years and there were 131 (61.2%) female graduates. Most graduates were enrolled in Family Medicine [76 (35.5%)], Internal Medicine [64 (29.9%)] and Surgery [52 (24.3%)], and the others were in Anesthesia [18 (8.4%)] and Radiology [4 (1.9%)]. The only graduate enrolled in Emergency Medicine was included in Family Medicine. There was no indication that our participants in the 2005 to 2008 samples had previous exposure to spatial tests. Four of the graduates in the 2010 sample did have such experience but their performance did not differ significantly from that of the other participants in the MRTA or MRTC scores. MRTA and MRTC median scores were significantly correlated (Spearman coefficient r) in 2005 (P < 0.0001), 2006 (P < 0.0001), 2007 (P 5 0.0157), 2008 (P 5 0.0004), 2010 (P < 0.0001), and from 2005 to 2010 (P < 0.0001). Median MRTA score of 12 (8, 14) and 15 (12, 18) was obtained by 131 females and 83 males from 2005 to 2010 (Table 1), respectively (Wilcoxon sign-rank P < 0.0001). Similarly, there was a difference in MRTC scores with medians of 7 (5, 9) and 9 (7, 12), respectively (Wilcoxon sign-rank P < 0.0001). Overall MRTA score was higher in males (P < 0.0001), and this difference was consistent over the five years and statistically significant for the majority of the years (P 5 0.0081, 0.0071 and 0.0145 in 2005, 2006 and 2010, respectively). Similarly for MRTC, males scored higher overall (P < 0.0001) and for each year of the study, these differences were statistically significant for 2006 (P 5 0.0034) and 2010 (P 5 0.0084) and approaching significance in 2005 (P 5 0.0964). For both MRTA and MRTC, the differences were not significant for 2007 (P 5 0.4602 and 0.2983, respectively) and 2008 (P 5 0.3254 and 0.6152, respectively). For both these years, the sample size was smaller, nevertheless the males scored higher. Figures 1 and 2 show the distribution of individual MRTA and MRTC scores, respectively, for both sexes. Although the medians MRTA and MRTC scores of female and male graduates were statistically different (P < 0.0001 and 0.0001, respectively), Figures 1 and 2 show a wide variation in individual MRTA score from 0 to 22 in female and from 5 to 23 in male medical graduates and similarly in individual MRTC score from 1 to 16 in female and from 1 to 22 in male medical graduates. Figures 3 and 4 show sex differences in MRTA and MRTC scores from 2005 to 2010.

DISCUSSION
This is the first study with an a priori hypothesis addressing the issue of sex differences in spatial abilities in the field of medical education. Indeed, sex differences favoring males were observed in spatial abilities in a group of medical graduates entering their residency programs which conforms with the findings in the literature of cognitive psychology (Voyer et al., 1995; Peters et al., 2007). Our effect size of 0.79 obtained in MRTA is comparable with various effect sizes reported in the literature, namely: 0.66 in subjects over 18 years in Mental Rotations Tests; 0.94 in Mental Rotations Test scored out of 20 (Voyer et al. 1995); and 0.95 in MRTA (Peters et al., 2006). Our effect
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size of 0.76 obtained in MRTC is also comparable to the literature reporting an effect size of 0.62 in MRTC (Peters et al., 2006). It is also worth pointing out that the performance of our medical students is comparable with that of Canadian university students in science programs but higher than that of university students in social sciences, arts, and humanities programs (Peters et al., 1995, 2006). Reports of sex differences favoring males in spatial abilities in medical students have been found a posteriori in studies relating spatial abilities to three-dimensional anatomy knowledge (Garg et al., 1999a,b; Lufler et al., 2012). Caution should be exerted in applying our group finding favoring males in spatial abilities to individuals. As shown in Figures 1 and 2, a particular female student may have higher spatial abilities and a particular male student may have lower spatial abilities using MRTA and MRTC. This is explained by the fact that many covariables such as genetic, hormonal, environmental and neurological factors have been involved in individual differences in spatial abilities (McGee, 1979). Those factors were not formally assessed in our study. Given that MRTA and MRTC were highly related, the cause for a nonsignificant difference with MRTC, when assessing the relationship of sex to spatial abilities in 2005, was believed to be a power issue to identify a difference related to a small sample size. No statistically significant difference in median Mental Rotations Test score between female and male medical graduates was observed in 2007 and 2008 for the MRTA and MRTC. A power issue could be involved given the small sample size but it is also possible that spatial abilities of individual male and female medical graduates had a tendency to be closer in terms of values in 2007 and 2008. However, males still scored higher in these years for both MRTA and MRTC as shown in Figures 3 and 4. It is reasonable to assume that the fluctuations between sex differences are due to sample size characteristics interacting with statistical power. A paper and pencil Mental Rotations Test is an imperfect indirect measure of spatial abilities because the nature of the task in a Mental Rotations Test is solved using spatial and nonspatial processing strategies (Hegarty and Kozhevnikov, 1999; Thompson and Kosslyn, 2000; Thomsen et al., 2000; Kozhevnikov et al., 2002; Weiss et al., 2003). A more direct measure of spatial abilities could be a structure-function correlation relating a spatial task to a neural pathway. Sex differences in brain activation patterns in solving mental rotation tasks has been found using neuroimaging studies suggesting sex differences in strategies used in solving mental rotation tasks (Thomsen et al., 2000; Jordan et al., 2002; Weiss et al., 2003). A more direct measure of spatial abilities could also be a functional analysis of the strategy used in solving a spatial task. The visual processing system has been related with at least two types of mental imagery: spatial imagery related to schematic representations that encode spatial relations and visual imagery related to pictorial representation that encode visual appearance (Hegarty and Kozhevnikov, 1999; Kozhevnikov et al., 2002). Several residency programs incorporate a high cognitive load of three-dimensional anatomy and technical skills. Therefore, spatial abilities are an important prerequisite for mastery in residency programs that aim to teach spatial anatomy and technical skills. Fitts and Posners cognitive phase of motor skills acquisition is related to learning novel first time
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Table 1.
Sex Differences in Mental Rotations Test score (20052010) Participants All N, Median (Q1, Q3) Mean (6SD) 59 13 (10, 15) 12.5 6 4.0 MRTC 7 (5, 10) 7.7 6 3.9 2006 MRTA 54 11.5 (9, 14) 11.9 6 4.3 MRTC 6 (5, 8) 6.9 6 3.8 2007 MRTA 18 15 (12, 17) 14.6 6 4.4 MRTC 8 (6, 9) 7.8 6 3.4 2008 MRTA 34 14 (10, 16) 13.8 6 4.1 MRTC 8.5 (6, 10) 8.2 6 3.6 2010 MRTA 49 14 (9, 17) 13.5 6 5.2 MRTC 9 (7, 12) 9.7 6 4.5 TOTAL 20052010 MRTAb 214 13 (10, 16) 13.0 6 4.5 MRTCc 7 (5, 10) 8.0 6 4.0
a

Year/Test 2005 MRTA

Female N, Median (Q1, Q3) Mean (6SD) 42 12 (9, 14) 11.6 6 3.8 7 (5, 9) 6.9 6 3.1 43 10 (8, 14) 11.0 6 3.8 6 (4, 8) 5.9 6 2.6 9 13 (10, 17) 13.7 6 5.3 7 (5, 8) 7.4 6 4.5 12 13 (10, 15.5) 13.0 6 4.4 7.5 (6, 9.5) 7.8 6 2.5 25 12 (8, 15) 11.6 6 5.0 8 (5, 11) 7.9 6 3.3 131 12 (8, 14) 11.7 6 4.2 7 (5, 9) 6.9 6 3.1

Male N, Median (Q1, Q3) Mean (6SD) 17 15 (12, 18) 14.9 6 3.7 8 (6, 11) 9.5 6 5.1 11 15 (12, 19) 15.3 6 4.5 8 (7, 16) 10.7 6 5.2 9 15 (14, 16) 15.4 6 3.4 8 (8, 9) 8.2 6 2.0 22 14.5 (12, 16) 14.2 6 4.0 9 (6, 11) 8.4 6 4.1 24 16 (13, 19.5) 15.5 6 4.9 11 (8.5, 15.5) 11.7 6 4.8 83 15 (12, 18) 15.0 6 4.2 9 (7, 12) 9.9 6 4.6

P-valuea

0.0081

0.0964

0.0071

0.0034

0.4602

0.2983

0.3254

0.6152

0.0145

0.0084

< 0.0001

< 0.0001

Wilcoxon sign-rank. b Cohens d 5 0.79. c Cohens d 5 0.76.

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Figure 1.
Distribution of Mental Rotations Test A Score. The MRTA score varies from 0 to 22 in female and from 5 to 23 in male medical graduates. The median (Q1, Q3) MRTA score of female and male medical graduates was statistically different (P < 0.0001).

experienced nonrepetitive tasks (Fitts and Posner, 1967). Ackermans theory of ability determinants of skilled performance has related spatial abilities to the cognitive phase (Ackerman, 1988, 1992). The issues related to spatial abilities, three-dimensional anatomy and technical skills with respect to sex are complex. It is important to translate the basic sciences knowledge of sex differences in spatial abilities into the field of residency education as it may have potential

implications in learning and teaching strategies of spatial anatomy and technical skills.

LIMITATIONS
Our study was not done on a full cohort of medical graduates entering their residency training programs. Our study was based on inclusion criteria of our elective rotation What

Figure 2.
Distribution of Mental Rotations Test C score. The MRTC score varies from 1 to 16 in female and from 1 to 22 in male medical graduates. The median (Q1, Q3) MRTC score of female and male medical graduates was statistically different (P < 0.0001).

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Figure 3.
Sex differences in Mental Rotations Test A score (20052010). Sex differences by year in Mental Rotation Test A scores are reported graphically in box plots using maximum, upper quartile (Q3), median, lower quartile (Q1) and minimum values. A statistically significant difference in median (Q1, Q3) MRTA score between female and male medical graduates was observed in 2005 (P 5 0.0081), 2006 (P 5 0.0071), and 2010 (P 5 0.0145). No statistically significant difference in median (Q1, Q3) MRTA score between female and male medical graduates was observed in 2007 (P 5 0.4602) and 2008 (P 5 0.3254).

to Do in an Emergency? accepting only medical graduates entering residency programs of Family Medicine, Internal Medicine, Surgery, Anesthesia, Radiology and Emergency Medicine. Spatial abilities of females and males have been reported to peak in the twenties and decay afterward (Wilson et al., 1975; Maylor et al., 2007; Peters et al., 2007). Our study

was not designed to assess sex differences in spatial abilities in older age range.

CONCLUSIONS
Sex differences favoring males in spatial abilities were demonstrated in the field of medical education in a group of medical

Figure 4.
Sex Differences in Mental Rotations Test C score (20052010). Sex differences by year in Mental Rotation Test scores are reported graphically in box plots using maximum, upper quartile (Q3), median, lower quartile (Q1) and minimum values. A statistically significant difference in median (Q1, Q3) MRTC score between female and male medical graduates was observed in 2006 (P 5 0.0034) and 2010 (P 5 .0084). No statistically significant difference in median (Q1, Q3) MRTC score between female and male medical graduates was observed in 2005 (P 5 0.0964), 2007 (P 5 0.2983) and 2008 (P 5 0.6152).

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graduates entering their residency programs in a five-year experiment. Caution should be exerted in applying our group finding favoring males in spatial abilities to individuals because a particular female may have higher spatial abilities and a particular male may have lower spatial abilities.

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ACKNOWLEDGMENTS
The authors would like to acknowledge Denis Bisson (Prosector in Charge) and Claudia Beaulieu (Prosector) from the Anatomy Laboratory in the Department of Surgery, Faculty of Medicine, Sherbrooke, Quebec, Canada for their help during the administration of this study. The Mental Rotations Tests were provided by Michael Peters, Ph.D., Department of Psychology, University of Guelph, Guelph, Ontario, Canada.

NOTES ON CONTRIBUTORS
JEAN LANGLOIS, M.D., M.Sc. (Anatomy), C.S.P.Q., F.R.C.P.C. (Emergency Medicine), is an active member in the Department of Emergency Medicine, Centre hospitalier universitaire de Sherbrooke, Sherbrooke, Quebec, Canada. He is also a lecturer in applied anatomy in the Department of Surgery, University of Sherbrooke, Sherbrooke, Quebec, Canada and the Division of Clinical and Functional Anatomy, University of Ottawa, Ottawa, Ontario, Canada. GEORGE A. WELLS, Ph.D. (Biostatistics and Epidemiology), is a professor in the Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ontario, Canada. He is also Director of the Cardiovascular Research Methods Center at the University of Ottawa Heart Institute, Ottawa, Ontario, Canada. MARC LECOURTOIS, M.Ps. (Psychology), is a former intern at the Neuropsychology Program of the Trauma and Critical Care Group, Centre hospitalier universitaire de Sherbrooke, Sherbrooke, Quebec, Canada. He is now a clinical psychologist at the Centre de sant e et des services sociaux de la Haute-Yamaska, Granby, Quebec, Canada. GERMAIN BERGERON, M.Ps. (Psychology), is a clinical psychologist in the Neuropsychology Program of the Trauma and Critical Care Group, Centre hospitalier universitaire de Sherbrooke, Sherbrooke, Quebec, Canada. ELIZABETH YETISIR, M.Sc. (Statistics), is a statistical analyst in the Cardiovascular Research Methods Center at the University of Ottawa Heart Institute, Ottawa, Ontario, Canada. MARCEL MARTIN, M.D., F.R.C.S.C. (General Surgery), is a retired professor in the Department of Surgery, University of Sherbrooke, Sherbrooke, Quebec, Canada.
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