|Year : 2008 | Volume
| Issue : 3 | Page : 108
Using Case Scenarios and Role Plays to Explore Issues of Human Sexuality
Manipal College of Medical Sciences, Deep Heights, Pokhara, Nepal
|Date of Submission||24-Aug-2007|
|Date of Acceptance||11-Nov-2008|
|Date of Web Publication||15-Dec-2008|
P R Shankar
P.O. Box 155, Deep Heights, Pokhara
Source of Support: None, Conflict of Interest: None
Introduction: Doctors and medical students should know what to ask patients, should do so in a sensitive and caring manner and convey a supportive, non-judgmental attitude to their patients, especially with regard to sexual and reproductive issues. The Manipal College of Medical Sciences (MCOMS), Pokhara, Nepal admits students from Nepal, India, Sri Lanka and other countries to the undergraduate medical (MBBS) course. In the MBBS curriculum sexual and reproductive issues are not adequately covered.
Methods: The Department of Medical Education at MCOMS organized a voluntary Medical Humanities module and conducted a session on social issues in the use of medications. Issues regarding sexual and reproductive health were explored using case scenarios and role plays.
Results and conclusions: This manuscript describes selected case scenarios and various sexuality-related issues covered. The students and the faculty members were of the opinion that sexual and reproductive issues are a grey area in the curriculum. The case scenarios appeared to be successful in sensitizing students and faculty members about certain issues of sexuality. Participants felt the skills acquired would be useful in their future practice. Based on this experience, the module will be modified and strengthened, along with the evaluation process.
Keywords: Case scenarios, human sexuality, role play, medical students, faculty, Nepal
|How to cite this article:|
Shankar P R. Using Case Scenarios and Role Plays to Explore Issues of Human Sexuality. Educ Health 2008;21:108
Doctors and medical students should know what to ask patients, should do so in a sensitive and caring manner and convey a supportive, non-judgmental attitude to their patients, especially with regard to sexual and reproductive issues (McCance et al., 1991). These issues are often not adequately covered in the undergraduate medical curriculum. The Department of Medical Education at the Manipal College of Medical Sciences (MCOMS) organized a voluntary Medical Humanities (MH) module for interested students and faculty members (Shankar, 2008) using literature and art excerpts, case scenarios and role plays to explore various issues in MH. The participants were from the third, fifth and sixth semesters of study and interested faculty members. A session on social issues in the use of medications was also conducted. Sexual and reproductive issues (SRIs) were among the many issues explored in the MH module using case scenarios and role plays. This manuscript describes selected case scenarios and their use in exploring issues of human sexuality.
The module was conducted from May to June 2007. Twenty-one students and five faculty members participated. Three students and two faculty members joined occasionally. Participants were divided into three small groups of six or seven students. Twelve participants were male and fourteen were Nepalese. The participants were mainly from the sixth semester and the age breakdown was representative of the general student body. However, there was greater representation of female and Nepalese participants. The faculty participants were all males; three were physiologists, one was a pharmacologist and one an internal medicine specialist. The two who joined occasionally were from physiology and internal medicine.
The students discussed a scenario and formulated and performed a role play elucidating relevant learning issues. A minimum of five faculty members were present for all sessions including those dealing with human sexuality.
The case scenarios for the MH module and to explore SRIs within the module were developed by the author in consultation with faculty participants to address major learning issues. The scenarios reflected SRIs of importance to Nepal and South Asia. The major problems for which the case scenarios were developed were sexual promiscuity, unprotected intercourse, teenage pregnancy, abortion, enhancement of sexual performance and aphrodisiacs, aggressive pharmaceutical promotion, the opinion of society regarding homosexuality and promotion of safe sex. Table 1 summarizes two case scenarios used. The participants had to write three reflective essays on topics selected by the facilitator and submit them for comments and discussion. The discussion was usually held only with the writer but the essays were discussed in the larger group with all participants, after obtaining the writerï¿½s permission in certain cases.
Table 1: Examples of two scenarios dealing with sexual and reproductive issues used in Manipal College of Medical Sciences (MCOMS) Medical Humanities module
Participant opinion about the module was obtained using focus group discussions (FGD) during the last week of June 2007. Two FGDs consisted of (1) fifth and sixth semester students (n=21) and (2) faculty participants (n= 6). The objectives of the study were explained to the participants by the author (PRS) and they were invited to participate after obtaining written informed consent. The project was approved by the Academic Committee of the Manipal College of Medical Sciences.
The language of discussion was English. The facilitator (PRS) helped guide the FGD using a semi-structured format. For each subtopic, discussion continued until there was saturation of themes. The FGDs lasted for an average duration of one and half to two hours before getting to the point of saturation.
Student feedback was obtained regarding the entire MH module and the feedback on issues of human sexuality was obtained as a part of this larger study (Shankar, 2008). A detailed analysis of participant feedback of the MH module has also been accepted for publication in the journal ‘Teaching and Learning in Medicine’. Modifications and additions were carried out in consultation with the respondents, where necessary. Faculty feedback was obtained using a separate FGD.
Informal verbal feedback was obtained during discussions with the participants before the beginning of each session. The participants were observed during the sessions for their involvement in the module and group activities. Feedback was provided by the facilitator. Formal assessments were not carried out. During the module, the participant was assessed by other participants using a format developed by the author. The different attributes assessed were professional values, empathy, participation in group activities, contribution to session, comfortable to be with, leadership skills, creativity, willingness to work hard, writing skills and attitude towards the medical humanities. Each of these attributes was scored from 1 to 10 (1 being the least and 10 being the maximum). The facilitator gave general feedback about what the participant was doing well and which areas needed strengthening. Feedback was given three times during the module and care was taken to provide only constructive criticism. SRIs were discussed during five sessions.
For scenario 1 (see Table 1), the group enacting the role play explored a number of issues. In Nepal, the abortion law has recently been liberalized; as the fetus in the scenario was six weeks old, there were fewer problems in offering an abortion. The student playing the role of the doctor counseled Leena about maintaining proper sexual behavior in consonance with prevailing social norms and channeling her energy into other avenues through hobbies and social service. Effective contraceptive measures were explained and the risk of HIV and other sexually transmitted diseases were stressed.
Scenario 2 addressed aggressive pharmaceutical promotion. Medicines are increasingly available for conditions which have been regarded as a natural result of aging or as part of the normal range of human emotions (Shankar & Subish, 2007). Drug treatment is being made available for enhancing normal functioning. Direct to consumer advertising of drugs (DTCA) is presently legal only in the United States and New Zealand (Mintzes et al., 2002). Strong lobbying efforts to have DTCA allowed in Europe and Canada are underway (European Public Health Alliance, 2004). The role play concentrated on explaining to the patient that the clinical trial may not be properly designed and using a drug for enhancing or improving normal functioning is not recommended. The issue of human sexuality being a marketable condition was also discussed.
The case scenarios appeared successful in sensitizing students to certain issues regarding sexuality. A young, female student states: "Sexual issues are not commonly covered in our curriculum. Whatever little teaching is there is theoretical and we find it difficult to translate it into practice. This method of exploring issues of human sexuality using case scenarios and role plays was interesting. We acted out the scenario and communicated with a simulated patient. Though the scenarios were limited they will be useful in helping us deal with these issues during our clinical postings and future practice." A faculty member not associated with the module was of the opinion that the student participants have started obtaining a more comprehensive history of the patient and have begun to consider sexual and reproductive issues while taking history. Objective evidence of effectiveness was not obtained.
Students opined that the scenarios reflected South Asian society and the module would help them deal with these issues in future. It can be argued that there is a tendency in South Asia to brush sexual issues "under the carpet," to not openly address them. Perhaps related to this, there seemed to be a certain amount of initial hesitancy in discussing SRIs. However, the students were encouraged by the matter-of-fact and frank discussion among participants. Also, faculty participants were extremely friendly and student participants reported not feeling inhibited by them.
The module was voluntary and both student and faculty participants appeared keenly interested and enthusiastic. The participants had a favorable opinion and no one had a negative (dissenting) opinion. As the module progressed, the participants became less inhibited and became more proficient in exploring SRI through role plays. They also felt more comfortable writing about these issues during the reflective writing assignments. This was a subjective observation of the facilitator (PRS) on reading the participants' reflective essays. Participants indicated that the sessions had given them broad guidelines on dealing with SRI and were confident in using these guidelines for designing their own scheme of communication. The limitation was that this was a subjective opinion of the participants that was not assessed. However, both students and faculty desired more sessions in future.
Overall, participants felt the module was successful in sensitizing them to certain issues of sexuality. Students occasionally played the role of a person of the opposite gender. They did not feel uncomfortable playing these roles and obtained their cues about their behavior from the mass media and observing friends and relatives. The scenarios made students more comfortable with and skilled in discussing SRI. They felt that this would be useful in their future practice.
SRIs are important for doctors and medical students everywhere. In many traditional societies, these issues are not openly discussed and there are many misconceptions. Common cultural beliefs and behaviors of South Asians about sexuality and childbirth include the role of the individual patient's duty to society, lack of formal sexual education, prearranged marriages, little premarital contraceptive education, dominance of the husband in contraceptive decisions and the predominant role of women and lack of role for men (including the husband) in the childbirth process (Fisher et al., 2003). Medical educators in Nepal and elsewhere can use case scenarios and role plays to explore these issues with medical and health science students. Exchange of ideas and information can further develop and refine the learning process.
Limitations of the project were the teaching that may not have been conducted in a structured manner. The enactment of role plays may have reflected the beliefs of the group members and may have been judgmental in certain cases. Knowledge, skills and attitudes of the participants were not examined before or after the module and much of the evidence for effectiveness are anecdotal. Nevertheless, based on this experience plans are underway to start a similar, voluntary Medical Humanities module (incorporating SRIs) for interested students at a new medical school in the Kathmandu Valley.
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