Teaching Telepalliative Care: An Elective Rotation for Medical Students during the COVID-19 Pandemic

Dear Editor:

The COVID-19 pandemic has changed the practice of health care and medical education, with a shift from traditional face-to-face to virtual encounters. We will discuss the development of an outpatient telepalliative care elective rotation in April 2020, when medical students were otherwise restricted from clinical encounters at Emory University School of Medicine (EUSOM) due to physical distancing. Whereas other specialties such as dermatology and neurology have experience integrating telemedicine in medical education, less is known regarding how to teach telepalliative care skills to learners.^1–3

To bring the rotation into fruition, we collaborated with the outpatient palliative clinic faculty, interdisciplinary team (IDT) and staff to incorporate three students, who completed institutional telehealth trainings, into their operational workflow. We used a three-pronged approach to achieve the learning objectives, which included improving knowledge in pain and symptom management, building a framework for advance care planning and communications skills, and identifying palliative care needs in patients. First, we developed a flipped classroom approach with Canvas, which is a web-based learning management system. Students completed training modules from the Center to Advance Palliative Care (encouraged to complete all available and required to complete the pain management course).⁴ Second, students participated in one-hour lectures on various topics (Table 1) and in Bite-Sized Teaching (BST) where students presented to their peers through Zoom.⁵ In an innovative attempt to incorporate role-play, we developed an “improv session” during the weekly case debrief with faculty. In this exercise, the faculty member portrayed the role of the patient while the student acted as the physician, working through assessing symptoms and disclosing prognosis, through Zoom. Finally, students observed outpatient telemedicine encounters with 12 half-days of outpatient telepalliative care clinics, with six attending physicians and one nurse practitioner. Time permitting, the provider virtually debriefed with student between and/or after visits.

Table 1.

Didactic Sessions

Topic	Presenter
An Overview of Palliative Medicine	Ashima Lal, MD
Research in Palliative Medicine	Dio Kavalieratos, PhD
Medical Marijuana	Ali John Zarrabi, MD
Opioids	Jimi Malik, MD
Interventional Pain Management	Ravi Pathak, MD
Advance Care Planning	Laura Waddle, MD
End of Life Therapies	Jennifer Dean, PhD
A Day in the Shoes of a Palliative Social Worker	Grover Alford, MSW Rebecca Chester, LMSW Kelsey Langworthy, LMSW
Hospice	Christine Simone Koniaris-Rambaud, MD
Cases in Palliative Medicine	Jabeen Taj, MD
Role-Play and Debrief with a Palliative Chaplain	Krisha Arvin, MDiv

We found the rotation to be a feasible way to teach medical students palliative care and telehealth skills during the early phase of the pandemic. Feedback from the students was positive. They appreciated the exercise of having difficult conversations through improv sessions and practice in pain management. In addition, they developed an awareness of the strength of the IDT. However, there were unavoidable limitations, including the limited enrollment of students to balance clinical need with education and to account for faculty deployment for inpatient coverage. Although a small-volume elective was feasible, a broader mandatory elective would require further administrative support, which may be challenging due to pandemic-related fiscal constraints. Also, this elective limited learners' applied experience to observership so developing a teaching model and feedback tool that guides active participation for virtual learners remains important. We plan to incorporate a half day of telehealth into our traditional third-year clerkship with an effort to enhance primary palliative skills as the interface of practicing medicine evolves.

Funding Information

Dr. Kavalieratos receives research support from the National Heart, Lung, and Blood Institute (K01HL133466) and the Cystic Fibrosis Foundation (KAVAL19QI0). This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.