Using Papaya as a simulation based training tool to develop competency in IUCD insertion & removal in interns - Perspective of teachers and students

Introduction

Simulation based medical education allows acquisition of clinical skills through practice.1, 2, 3, 4 A student can make mistakes and learn from them without the fear of harming or distressing the patient.5, 6 According to Medical Council of India’s new curriculum based on CBME, insertion and removal of Intrauterine contraception device (IUCD) is a competency which an Indian Medical Graduate has to acquire - ‘ OG35.15: Demonstrate the correct technique to insert and remove an IUD in a simulated/ supervised environment’.7

Learning IUCD insertion and removal through lectures and observation is not as effective as doing.8, 9, 10, 11 Performing in supervised environment is not possible for all the students. Only few students get the opportunity to learn in a patient under supervision. Training through simulators increases confidence and interest.11, 12, 13, 14, 15, 16, 17 Hence we need a simulator to practice this skill. A simulator for learning and practicing IUCD insertion and removal can be bought and kept in skills lab of a college and used. But it is costly and is not affordable by all colleges and cannot be provided for individual students.

Hence there is need for a cost-effective way of learning this skill. The idea of using papaya as a simulation based model to learn intrauterine procedures has been introduced and done in few US based study.18, 19, 20 But still it has not been used in the colleges of our country and its pedagogical impact has not been fully evaluated yet. Hence we planned this study to use papaya as a simulation based model for teaching IUCD insertion and removal for the interns, and assess the perspective of teachers and students on the effectiveness of the new teaching method.

Aim

To assess the perspective of teachers and students on the usage of papaya as a model for learning IUCD insertion and removal.

Objectives

Materials and Methods

The study population selected was the interns of Government Thoothukudi Medical College. Institutional ethical committee approval was obtained and a workshop was conducted to all the 158 interns of Government Thoothukudi Medical College. They were divided into 15 groups. In the workshop all the students were given a short introduction and demonstration of the IUCD insertion and removal using a IUD simulator by a faculty. Then the students were given an opportunity to practice the procedure in papaya individually. Feedback was obtained from the interns and also from the teachers by a structured questionnaire which had questions on its realism and questions to gauge the perception and acceptance of papaya as a simulation. Satisfaction of the students and faculty were also evaluated and analyzed.

Results and Discussion

The feedback was analyzed to assess the reaction, knowledge and skill development, fidelity and transfer of the knowledge by students and teachers.

Figure 1

Papaya with IUCD inserted

Figure 2

Reaction assessing question

The reaction of the students and the teachers were analysed by a question in the structured feedback as ‘ How much did you enjoy this training?’ and they were asked to give a score of 0-5. 84% of students and 100% of teachers gave a score of 4 and 5 respectively. Thus majority of the students and all the teachers enjoyed the training session.

Figure 3

Knowledge assessing question

During IUCD insertion we use ‘Withdrawal technique’ to insert the device in the uterus. Initially both the IUCD and the insertion tube are introduced into the uterus and then the insertion tube is withdrawn. This causes opening of the arms of the device to T position. Then the insertion rod is removed. Even though we teach the students about this Withdrawal technique they do not understand it till they perform it individually. In this study all the students had an opportunity to practice the procedure individually in a papaya and there was a window created in the papaya so that the student can see what happens inside the uterus (papaya) as shown in Figure 1. 85% of students and 95% of teachers gave a score of 4 and 5 respectively for the question ‘How well did this help you to understand the term “Withdrawal technique”?’ Thus, the term ‘Withdrawal Technique’ was understood well by this training.

Figure 4

Fidelity assessing question

Fidelity refers to the degree of realism created by the selected simulation equipment, the setting and the experience. High fidelity of a simulator is important for the success of a simulation based teaching and learning.21, 22, 23 To assess the fidelity of the simulator as perceived by the students and teachers in our study, we had asked the question – ‘How well did the “papaya” simulate a real uterus?’ 94% of students and 95% of teachers gave a score of 4 and 5 respectively.Thus, majority of students and teachers were convinced that papaya simulated an uterus in shape and structure and it can be used as a simulator with high fidelity.

Figure 5

Teacher’s overall scoring of the training

The teachers were asked to score the overall training in a range of 1-10. 35% of teachers gave a score of 10, 30% gave a score of 9 and remaining 35% gave a score of 8. This shows that all the teachers involved in the training liked and recommend this method of using papaya as a simulator to teach IUCD insertion and removal.

Skill development by the students was assessed by a self-scored confident level (0-5) before and after the training. It was analyzed by paired t-test and it showed a significant rise (p < 0.05)

Limitations

Even though the papaya has many similarities with the uterus, it is not a perfect realistic model. It does not mimic some features like the attachment of the IUCD to the uterus, the tone and texture of the stem is not the same as cervix – it cannot be held and handled with a speculum.

Papaya is relatively inexpensive and it is available in most houses and shops in all tropical regions. In places where it is not available, other fruits such as melons and avocado can be used and adapted as models.

Future Perspectives

Transfer of the acquired knowledge shall be assessed by a feedback from the same interns at the end of their internship on how this training helped them to do the procedure in real life situation with comfort and gave them confidence for counseling the patients.

Conclusion

This hands-on training on IUCD insertion & removal using papaya is found to have high fidelity and is very useful for the students to acquire knowledge and skill and is also approved and appreciated by the teaching faculty. It can be also used to teach the procedure with individual hands on training to undergraduate medical students, interns, post graduate students, nursing students and also nursing assistants. Even if they do not do the procedure on real patients, this training will help them to gain confidence and interest in women health. This can be included as a routine part of the curriculum for final year students and in Intern orientation programs.

Conflict of Interest

There are no conflicts of interest in this article.

Source of Funding

None.