Low fidelity custom-made inguinoscrotal model: educational and a social indication

The aim of this paper is to highlight this model, which is easy to design and a useful teaching aid. Examination of male private parts can be an embarrassing experience for the patient and clinician, especially if it leads to erection during frequent palpation by inexperienced trainees. Simulation has shown to improve clinical skills of trainees to examine such intimate parts before clinical encounters^1–3

Although there are various models to teach intimate clinical skills examination like rectal, pelvic, urinary and breast, there are no similar simple cheap inguinoscrotal models. This new model for clinical examination of inguinoscrotal region is the first of its kind, which is cheap, efficient and easily reproducible.

Introduction

Globalisation phenomena, which touched all aspects of human life, have not spared medical service or medical education. Introduction of accreditation as a benchmarking global quality standard has led to drastic changes in medical practice and medical education. Patient safety and patients' rights have become a central issue. With increasing practice of day surgery, medical students are further denied sufficient exposure to clinical cases. Therefore, to bridge the gap between knowledge and practice, simulation is becoming increasingly used. Many studies have demonstrated its value in teaching and assessing clinical knowledge, procedural skills, attitudes and communication skills.¹ Now, medical schools are increasingly incorporating simulation in their teaching curricula.² The simulators used ranged from low to high fidelity reflecting the state–of-the-art 21st century technology. Cost is a limiting factor in the choice of a desired simulator. Apart from its quest as an educational tool, simulators might serve to solve conflicting social issues in conservative oriental communities. An example of that is teaching clinical examination of private parts when patients might be uncomfortable or unwilling to be examined so much so if the examiner is from the opposite sex. This process is, however, greatly complicated by the fact that physical examination is an interaction between two (or sometimes more) individual human beings, each bringing to the interaction his or her own knowledge, experience, beliefs, attitudes, status and cultural context.³ In our institute Dubai Medical College for girls, our trainees have frequently faced the problem of examining inguinoscrotal region due to embarrassment especially when frequent examination by inexperienced trainees lead to erection. To get around this problem we searched the markets to obtain a suitable model for teaching clinical examination of that region, but failed to find a suitable model. Most of the models found pertain to anatomical description rather than clinical examination. To get over that we used the expertise of our anaplastology department and succeeded to build a custom made model of the inguinoscrotal region cast on a real patient with an inguinoscrotal hernia.

Details of the model

The model was made of silicon. The silicon paste was cast over the inguinoscrotal hernia after taking the patient's consent to produce this model. Two testes with epididymis and vas were prepared and placed in the scrotal cavity. To mimic the hernia the model has undergone a series of modifications. Initially the cavity on the site of the inguinoscrotal hernia was filled with sponge (figure 1A). In the second version the cavity was filled with air using a syringe. In the third version, the cavity was filled with a pneumatic cuff of a paediatric sphygmomanometer, which allows inflation and deflation (figure 1B). The model cost $50–100.

Figure 1.

(A) First version hernia model hanged from intravenous fluid stand. (B) Pneumatic cuffed hernia model hanged from intravenous fluid stand. (C) First version hernia model examined hanged from intravenous fluid stand. (D) Pneumatic cuffed hernia model examined on a simulated patient. (E) Pneumatic cuffed hernia model examined on a simulated patient.

How to use?

The model is either hanged from an intravenous fluid stand or placed on simulated patient (figures 1C −1E) Students will learn the principles of the clinical examination of the inguinoscrotal region. They will then practice examining the hernia model. The model allows the students to repeat the practice until the technique is mastered which will ease their approach to a live case.

Effectiveness of the model?

Since this is the first time for us to use this new model, we were just able to make observations on the performance of a group of medical students for whom inguinal hernia was a clinical case in their final medical clinical test. The external examiner was not aware whether the students had practiced on the model or not as he was not aware of its existence at all. After the examination, the impression of the examiner about the performance was noted. Twenty-four students were examined in the hernia case. Only five students had both practiced clinical examination on the model and had the actual chance to examine a real hernia case once before. The remaining 19 had only practiced on the model and this clinical encounter was their first to examine a real patient. All the students have passed on this clinical station with good scores. The examiner was quite satisfied with the clinical performance of the students.

Discussion

Student discomfort with the experience of learning intimate physical examination skills may be common and has ongoing repercussions for students and patients⁴ (several studies have shown that simulation decreases discomfort and improves learning of clinical skills of intimate physical examination).

Apart from the standard utility of simulators as teaching or assessment tools, sociocultural issues might call for their usage as adjuncts, as in our situation. Since this is the first time use of this model, which we believe is the first of its kind, we did not have the time to test its validity or efficacy in a statistical manner but rather made a general opinion. That was in keeping with similar other studies where evidence was mostly collected in terms of self-report of efficacy and comfort.¹ However, as a low fidelity model we can extrapolate from the study by Munshi F that it will be of value.⁵

Conclusion

Simulation in medical education had gained wide acceptance worldwide, particularly in North America. We believe our low fidelity model represents the first of its kind. Apart from being an educational tool, it has sociocultural value especially in conservative communities. It is simple, custom made, and cheap. Although we are confident about its efficacy, further assessment remains to be carried out. With emerging three-dimensional printing more efficient models are likely to prevail.