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Reimagining palliative care learning during a pandemic

In response to the pandemic, one determined Stanford Medicine team built on its online expertise to reimagine palliative care learning.

Last March, when it looked like medical students would not be able to complete an in-person palliative medicine clerkship, one of the clinical rotations offered during the final two years of medical school, Laura Lundi, who coordinates the program, had an idea.

Why not use Palliative Care Always, an online course offered through Stanford Online and recently launched on Coursera?

Since its inception in 2016, the online course has garnered a large global audience -- at its launch, more than 3,712 people from 126 countries participated, and interest continues to grow.

Palliative Care Always was not designed as a clerkship. However, palliative care oncologist Kavitha Ramchandran, MD, who co-developed the program, and her team drew on their knowledge of both online and in-person environments to develop a virtual palliative medicine clerkship to provide Stanford medical students the training they need.

Building on online palliative care education

Palliative care focuses on relieving the symptoms, pain and the mental stress of a serious or life-limiting illness. Palliative medicine students learn how to show empathy and compassion, communicate in emotionally charged situations and manage difficult conversations about critical -- and sometimes end-of-life -- care.

Pre-pandemic, students spent some clerkship time shadowing Ramchandran or other instructors to work directly with patients. The team structured the new course to allow medical students, health care providers and faculty to participate from home.

In some cases, that meant juggling logistics to accommodate participants logging on from around the country and world. During their second meeting, a request by medical student Charles Lee prompted a course schedule change. Lee had returned to his family's home in Korea and his original class start time was 3 a.m.

During their sessions, students used a virtual case study to learn palliative care skills and practice with each other in Zoom break-out sessions. They were excited to connect and learn to provide palliative care, a practice that offers an extra layer of support from a patient's care team to improve the quality of life for patients and their families.

Tuning in to patient needs

The end result worked well for learners as well, several students said.

Student Suchita Rastogi said that being online instead of in the room with patients didn't impede her ability to read their verbal and nonverbal cues, understand and respond to their concerns, and show she cared not just about their disease but also about them.

"In some ways, the virtual experience heightened my attunement to these things, since virtual encounters are heavily weighted to the interview and de-emphasize the physical exam," she said. "It helped bring the focus back to the psychosocial aspects of illness."

The format's flexibility also helped Rastogi complete the clerkship even as she struggled with her own chronic illness, she said, allowing her to pace work around periods of time when sometimes debilitating symptoms called for her to rest and care for herself.

That aligns with palliative care's focus on the whole person, for patients as well as for their health providers. "We sometimes forget that palliative medicine also has the power to improve our lives as doctors, and health care practitioners," Ramchandran said.

Looking forward

The course continues to evolve. Currently, students can be paired -- in person or online -- with mentors in their clinics. Students still meet with each other and instructors online and learn from the Palliative Care Always course.

Separated by pandemic restrictions, the clerkship has provided a window for participants to consider the kinds of important questions palliative care can help patients explore: What gives us meaning? How do we connect with loved ones? How do we create space for gratitude in a difficult and challenging world?

"As we connected weekly with students sitting at home, around the globe, we found moments to share stories and build bonds," Ramchandran said. "For those hours, even if alone, we were not lonely."

Jan DeNofrio is the program manager for Palliative Care Always. She developed this piece in collaboration with Laura Lundi, a clinical research coordinator associate for the Cancer Clinical Trials Office, and Kavitha Ramchandran, MD, associate professor of medicine -- oncology.

Image by BillionPhotos.com

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