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Changing Course

A Spotlight on an Innovation in Instruction

Palliative care clerkship arises from online course

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Illustration of a physician reaching out from a computer screen to offer palliative  care to a patient.

Stanford University School of Medicine now offers its palliative care clerkship in a hybrid format, a combination of online and in-person learning. Jan DeNofrio, a medical school lecturer and a program leader, recently presented research findings about the effort and its history at the May 11 Post-Pandemic Research Symposium. After the talk, Stanford Digital Education communications director Jonathan Rabinovitz asked her five questions via email about the initiative. 

1. How was the hybrid clerkship structured?

Jan DeNofrio: The medical students spend a few days in the clinic or virtually through telemedicine with two preceptors. They also work through our online course, Palliative Care Always, which has didactic lecture videos, case studies and an online discussion board.

Jan DeNofrio, lecturer at Stanford medical school
Jan DeNofrio

My role is to work with them on the online course. We meet each week and practice having difficult conversations such as discussing goals of care with a patient. It gives them a safe space to practice conversations. We also debrief on their patient interactions. 

We began offering this version of the clerkship in October 2020, and it has worked out great. Having both online content and face-to-face patient interactions give the students a comprehensive experience. The students spend a few days in the clinic or virtually through telemedicine with two preceptors. The students learn the core concepts online, and they have the opportunity to watch the preceptors practice these skills. The feedback we have received from students has been incredibly positive.

2. Could you trace the origins of the clerkship for us? 

JD: Access to palliative care is quite limited worldwide. One way to improve access is to improve education. About six or seven years ago, Dr. Kavitha Ramchandran assembled a team of palliative care experts — palliative care physicians and nurses, social workers, chaplains and psychiatrists — with the goal of providing free online education in palliative care.

Dr. Kavitha Ramchandran of Stanford Medicine
Dr. Kavitha Ramchandran

The group designed the course with the help of the former Office of the Vice Provost for Teaching and Learning, and it was very popular; they ran it three times. People reached out to Dr. Ramchandran to see if it was possible to adapt the course to their needs, which is when I came onboard. We were able to modify the course for hepatologists, for oncologists in India, and even build a CME and CE accredited Coursera course, Palliative Care Always Specialization.  It’s been amazing to see how we have been able to evolve and diversify from one course.

When the pandemic hit, medical students were no longer allowed in the hospital.  Our clerkship coordinator suggested we should use Palliative Care Always to continue the clerkship experience for them. We had the course approved by the Medical Director for clerkships and opened it to the students. 

3.  What was the response to the online clerkship from the students?

JD: The response was amazing. Previously when the students were on campus, we only had the bandwidth to have one or two students per clerkship period. With the virtual clerkship we could have up to 12. We also had the flexibility to teach exactly what the students wanted to learn.  We used the didactic videos in the online course to cover concepts like physical and psychological symptom management. Then we spent the virtual sessions doing deep dives on the students' questions and practicing patient-provider conversations on challenging topics — for example how do you start a discussion with a patient about hospice. This setup provided us the flexibility to meet the students’ needs. 

What surprised me the most is when we asked the students how we can improve the clerkship they suggested more online sessions to practice conversations! They found the small group Zoom sessions a safe way to role play conversations and learn from each other. This was really helpful to those students who were still early year medical students and didn’t have many interactions with patients yet. I could really see a difference in the students from the first week to the last and was really proud of them all.

4. Is there something about palliative care that makes it well suited for online learning?

JD: Palliative medicine is focused on communicating and listening to the patient. Right now, much outpatient palliative care is done through telehealth, so the online component of our clerkship and the practice sessions, both remote and in-person, help students get comfortable talking with patients “screen to screen”. 

In general med students are comfortable with talking to patients face to face, but what they had zero experience with until Covid is telehealth. They never had to show empathy with limited opportunity to use non-verbal communication (like putting an arm on someone's shoulder in support or leaning in to show you are actively listening), so this screen-to-screen experience is really valuable.

A manuscript with our findings is under review, and I’m hoping to give a talk at Grand Rounds so we can share our experience with the Stanford Medicine community. We would love to talk with any department that is interested in learning more. This model would work well for specialties such as immunology, nephrology and rheumatology, where telehealth has become increasingly common.

5. Anything else you would like to add? 

JD: I would like to thank the original Palliative Care Always team. The work that they put in to create a quality course really shows. Many people think an online course is a one and done thing but you need to do it with strategy, vision and operational support for delivery of the content. 

You can make a great course but without support it won’t go far. Conversely, you can have someone there to manage the course but if the content isn’t high quality, then you need to put much more effort in if you want to move forward. You need great content, strategy, vision and importantly operational support to diversify and manage a hybrid learning opportunity. 

Published June 8, 2022

This is the second installment in Stanford Digital Education’s “Changing Course” feature, which spotlights innovative ways in which members of the Stanford community are leveraging digital education techniques to better meet their learning goals and enrich students' experiences. If you would like to be showcased, please reach out to Jonathan Rabinovitz,