Telemedicine as an ethics teaching tool for medical students within the nephrology curriculum A novel patient-centered approach was used to deliver ethics curriculum to medical students. Two medical school clinicians designed a telemedicine session linking their facilities (across 2 continents). The session, Exploring the Patient Experience Through Telemedicine: Dialysis and End-Stage Renal Disease, allowed second-year medical students to explore various parameters of quality of life experienced by dialysis patients. A panel of 4 medical students interviewed a dialysis patient via Skype video connection between the medical school and the hospital’s dialysis unit. Interview questions were adapted from the Kidney Disease Quality of Life instrument. During the live video-streamed interview, the remaining 23 second-year medical students observed the session. Afterward, the 23 were offered a voluntary anonymous online feedback survey (15 responded). The 4 panelists submitted narrative responses to 2 open-ended questions about their experience. All 15 responding students “Strongly agreed” or “Agreed” that the session was an aid to their professionalism skills and behaviors; 14 of 15 “Strongly agreed” or “Agreed” that telemedicine technology contributed to their understanding of the topic; 12 of 15 “Strongly agreed” that the session improved their understanding of the psychosocial burdens of dialysis, quality of life, and human suffering, and increased their empathy toward patients; and 12 of 15 “Strongly agreed” or “Agreed” that the session encouraged reflective thinking and was an aid to improving their communication skills. Telemedicine can be an effective and feasible method to deliver an ethics curriculum with a patient-centered approach. Additionally, the cross-cultural experience exposes students to additional contextual features of medicine. (Progress in Transplantation. 2014;24:294-297)
Katrina A. Bramstedt, PhD, Melissa Prang, Sameer Dave, Paul Ng Hung Shin, Amani Savy, Richard A. Fatica, MD Bond University School of Medicine, Gold Coast, Queensland, Australia (KAB, MP, SD, PNHS, AS), Cleveland Clinic, Cleveland, Ohio (RAF) Corresponding author: Katrina A. Bramstedt, PhD, Bond University School of Medicine, University Drive, Gold Coast, QLD 4229, Australia (e-mail: [email protected]) To purchase electronic or print reprints, contact: American Association of Critical-Care Nurses 101 Columbia, Aliso Viejo, CA 92656 Phone (800) 899-1712 (ext 532) or (949) 448-7370 (ext 532) Fax (949) 362-2049 E-mail [email protected]
©2014 NATCO, The Organization for Transplant Professionals doi: http://dx.doi.org/10.7182/pit2014289
T
fact, these constructs comprise “Box 3” of the widelyused “Four-Box Method” of ethical decision making.5 Providing ethically appropriate medical care requires reflection on quality of life and human suffering because the meanings and perceptions of these matters influence patients, their families, and health care providers. Furthermore, providing medical students the opportunity to reflect on a patient’s experience of suffering and quality of life potentially allows the deconstruction of biases that might affect their provision of care. The nephrology curriculum block was chosen for this educational session because dialysis and end-stage renal disease present many opportunities to explore medical ethics through the patient’s experience. Worldwide, more than 1.7 million patients undergo dialysis, and many endure burdens of the treatment as well as their
294
Progress in Transplantation, Vol 24, No. 3, September 2014
elemedicine is well known in the clinical setting as a means to link doctors and patients across distances through electronic technologies such as e-mail, video conferencing, text messaging, and remote data capture. Telemedicine is also widely used in surgical training curricula to enable surgeons to teach medical students and other trainees through live, interactive operative sessions.1 Other segments of medical student curricula that incorporate telemedicine include psychiatry, 2 cardiovascular medicine, 3 and dermatology.4 Herein is the literature’s first report of an educational experience using telemedicine to teach various concepts of medical ethics within a medical school curriculum. Specifically, quality of life and human suffering are well-recognized constructs within medical ethics as they are elemental to ethical decision making. In
Telemedicine as an ethics teaching tool for medical students disease.6 The noncompulsory session, Exploring the Patient Experience Through Telemedicine: Dialysis and End-Stage Renal Disease, allowed second-year medical students to explore various parameters of quality of life and human suffering (components of medical ethics) experienced by dialysis patients. Methods The activities described were part of a quality improvement educational endeavor in November 2012, not a research project, thus no review by the Human Research Ethics Committee was required. Two medical school clinicians (1 clinical ethicist and 1 nephrologist) designed a 1-hour telemedicine session linking their 2 facilities (across 2 continents, 14 852 km). The session, Exploring the Patient Experience Through Telemedicine: Dialysis and End-Stage Renal Disease had 2 learning objectives: (1) discuss the parameters of quality of life experienced by dialysis patients and (2) identify and record the most meaningful insight gained from interviewing a dialysis patient. The session consisted of a panel of 4 second-year medical students who sequentially interviewed a dialysis patient via a Skype video connection between the medical school and the hospital’s dialysis unit. Three (1 male, 2 females) of 4 students were selected by first-come, first-served voluntary e-mail response to an announcement from the clinical ethicist about the session. One male student was directly approached by the ethicist for his voluntary participation. Interview questions (Table 1) were adapted from the Kidney Disease Quality of Life (KDQOL) instrument.7 Questions regarding sexual function were not included because of the lack of privacy of the open (full classroom) setting. The nephrologist selected a patient from the nighttime dialysis cohort so as to facilitate the time zones of the 2 linking facilities. The patient was apprised of the general nature of the KDQOL survey questions, as well as the design and purpose of the educational session, and provided consent to participate. A Skype connection test between the 2 facilities (medical school teaching amphitheater, hospital dialysis clinic) was conducted before the live teaching session. Additionally, about a week before the live session, the ethicist posted an electronic bulletin to the cohort reminding them of the upcoming session and announcing the ground rules (including professional attire for all students, no late admissions to the classroom, and patient confidentiality requirements). On the day of the event, signs were placed on the amphitheater doors restating the ground rules and administrative personnel were staffed at all doors to monitor dress code and timeliness. No visitors were permitted. Just before the start of the session, the ethicist reminded all students that audio and video recording of the session was not permitted. At the onset of the telemedicine session, the Progress in Transplantation, Vol 24, No. 3, September 2014
Table 1 Interview questionsa Student number
Questions
1
Eleven questions focused on the physical signs and symptoms and cognitive impact of dialysis and end-stage renal disease
2
Sixteen questions focused on how dialysis and end-stage renal disease affect the patient’s sleep quality, ability to work and be active, and his level of dependence
3
Seven questions focused on stress and worry in the patient’s life and his reflection on waiting for a kidney transplant
4
Eight questions focused on social supports and satisfaction with health care services
a The
exact question list may be obtained from the authors by written request.
patient was greeted by the clinical ethicist and advised that participation was voluntary, the patient could refuse to answer any question, and the patient could cease participation in the telemedicine session at any time. During the live video-streamed interview, the second-year cohort who volunteered to attend observed the patient’s interview. The patient was interviewed from a private room at the dialysis clinic to allow freedom of discourse away from the general population of dialysis patients. Additionally, the patient’s attending physician remained in an adjacent area in the event that the patient needed any clinical or other assistance. After the session, the patient was sent a thank you card and small gift from the students for his participation. Additionally, the observing students were given the opportunity to complete an anonymous 10-question online feedback survey about the session (Table 2, www.TooFast.ca). The 4 interviewing panelists submitted narrative responses to 2 open-ended questions about their experience (What is your response to the telemedicine session? What is your response to the concept of using telemedicine as a method to teach medical students?) Learning objective 2 (see Methods section) was assessed by exploring the routine PBL (problem-based learning) weekly qualitative feedback reports in which PBL groups (n = 12) answer 4 open-ended questions: What activities contributed most to the group’s learning? What activities contributed most to the group’s professional development? Which individuals contributed most to the group’s learning? Which individuals contributed most to the group’s professional development? Results In November 2012, the Bond University School of Medicine semester 5 (year 2) cohort consisted of 79 medical students. Per school policy, large group resource sessions (eg, lectures, tutorials) are noncompulsory, as was this telemedicine session. Four students
295
Bramstedt et al
Table 2 Student feedback questions
Table 3 Cohort problem-based learning feedback
1. Overall, the quality of my learning experience in this session was (Likert scale responses)
Q1, 2. What activities contributed most to the group’s learning? What activities contributed most to the group’s professional development?
2. I found the session intellectually stimulating (Likert scale responses) 3. The session improved my understanding of the topic (psychosocial burdens of dialysis, quality of life, human suffering) (Likert scale responses) 4. The use of telelmedicine technology contributed to my understanding of the topic (psychosocial burdens of dialysis, quality of life, human suffering) (Likert scale responses) 5. I would like telemedicine to be used in other course sessions (yes/no) 6. The session helped me enhance/improve my empathy toward patients (Likert scale responses) 7. The session is an aid for my professionalism skills and behaviors (Likert scale responses)
“The telemedicine lecture was very insightful.” “Telemedicine session allowed us rare insight into the lives of patients with dialysis.” “The dialysis telemedicine conference was very good. Helped us understand and empathize with dialysis patients.” “Dialysis teleconference helped give a good insight into patients who are on dialysis.” “The teleconference with a dialysis patient was very well received and everyone found that it was an eye-opening experience to talk to someone currently dealing with these problems and listening to his perspective on life.” “Forum this morning was very good. We need more of those….”
8. The design of the session encouraged reflective thinking (Likert scale responses)
Q3, 4. Which individuals contributed most to the group’s learning? Which individuals contributed most to the group’s professional development?
9. The session is an aid to my communication skills (working with patients) (Likert scale responses)
“…the dialysis patient from the Skype conference.”
10. I would recommend this noncompulsory session to my peers (yes/no)
“…the dialysis patient from Cleveland Clinic was able to give the students a good insight on how to deal with patients in his situation and give more considerations and support toward the patients other than just medically.”
volunteered to participate in interviewing the patient, and 23 observed the patient’s interview (34.2% class participation). Afterward, 15 of 23 students (65.2%) who had observed the session completed an anonymous online feedback survey. All 15 students “Strongly agreed” or “Agreed” that the session was an aid to their professionalism skills and behaviors; 14 of 15 “Strongly agreed” or “Agreed” that telemedicine technology contributed to their understanding of the topic; 12 of 15 “Strongly agreed” that the session improved their understanding of the psychosocial burdens of dialysis, quality of life, and human suffering, and improved their empathy toward patients; and 12 of 15 “Strongly agreed” or “Agreed” that the session encouraged reflective thinking, and was an aid to improving their communication skills. Furthermore, as shown in Table 3, the cohort consistently reported positive feedback (through reflective PBL work), indicating that the telemedicine session and the patient himself had affected their learning and professional development. The 4 interview panelists submitted overwhelmingly positive narrative responses to 2 open-ended questions about their experience. A snapshot of their feedback is presented in Table 4. In general, the quality of the Skype video session was good; however, at times, there was image graininess and audio freezes. The root cause of these events is unknown, and they did not detract from the educational impact of the session for the cohort (they did not
“[the patient] was very knowledgeable and engaged well, which contributed to our learning.”
296
“[the patient] from the Cleveland Clinic gave a very good insight into the life of a patient on dialysis and helped us to understand the needs of the patient, not just physically and medically, but also mentally and socially.”
give negative feedback on this matter). Two of 4 interview panelists commented on the technical glitches, most likely because technical disruptions have the potential to affect interviewing of patients. Discussion There are many ways to teach medical students about medical ethics, including lectures, PBL cases, and small-group discussions.8 Notable, however, is the fact that generally, although these methods might involve discussion of patient’s cases, or perhaps incorporate standardized patients, they generally do not involve real patients to bring concepts in medical ethics alive for students. We have shown that patients can deliver “the patient experience” directly to medical students through telemedicine, and this method can be effective for teaching medical ethics content such as professionalism, quality of life, suffering, doctorpatient communication, and empathy. These concepts, in addition to the general principles of medical ethics (beneficence, nonmaleficence, autonomy, justice) are important to building a therapeutic alliance for the delivery of ethically appropriate care. Progress in Transplantation, Vol 24, No. 3, September 2014
Telemedicine as an ethics teaching tool for medical students
Table 4 Narrative feedback from 4 interview panelists Q1. Your response to the telemedicine session: “I found the telemedicine session to be very eye opening as it provided significant insight into the life of a [chronic kidney disease] patient.” “The session gave me the opportunity to practice my communication skills and act in a professional manner.” “…direct [patient] contact further increased my interest and level of engagement….” “The fact that a condition was being explained from the perspective of a real patient and not via that of a doctor or lecturer who had never suffered from the condition in question made me find the session extremely interesting and engaging.” “…the session was an invaluable learning experience….” Q2. Your response to the concept of using telemedicine as a method to teach medical students: “…[telemedicine] allows for international teaching opportunities….” “…[telemedicine] is a fun and engaging way to liven things up in the lecture room.” “…[telemedicine] would be a great way to get a patient’s point of view about a condition in a nonthreatening manner . . . telemedicine appeared to keep the patient at ease as well as the students.” “…[telemedicine] offers the advantage of being a dynamic session.” “…[telemedicine] gives rise to so many opportunities . . . on an international scale or even just locally. . . .” “It would be good to expose all medical students to telemedicine. . . .”
Telemedicine technology enables actual patients to come to students without the hindrances of geography or distance. Additionally, patients who might feel anxious or otherwise uncomfortable telling their story directly in front of an ocean of medical students can do so via the seclusive qualities that telemedicine fosters. Specifically, patients speak to one video camera rather than a room full of students. This can create the semblance of a one-on-one conversation, as the patient him/herself is not surrounded by a crowd of medical students. The reach of telemedicine also facilitates bringing clinical experiences into the preclinical medical education years (generally years 1 and 2 of an MD or MBBS program). For programs that are affected by cost, access, or other logistical matters that prevent classes of students from going out to see patients in these early years, bringing patients directly to the students can be facilitated through the generally inexpensive technology of telemedicine. For example, Skype connection fees are free when both parties are registered as “Skype Contacts,” and medical schools generally already have video cameras (portable or fixed) as program capital.
Progress in Transplantation, Vol 24, No. 3, September 2014
As with our session, a clinical monitor (physician, nurse) should be near the patient during an interview in the event that clinical or emotional assistance is needed. Patients should provide consent to participate before the session and should be reminded of the voluntariness of the session at onset, as well as the option to skip questions and cease interviewing at any time. Interviewers should be sensitive to the reactions of their patients, observing for signs that patients might need a rest break (eg, fatigue, distraction, loss of concentration) or that session termination is warranted (medical or emotional crisis). At no time should the educational session take priority over the patient’s health and safety. Clinicians are generally not information technology specialists, so offering these sessions requires the support of information technology staff (testing connections, optimizing audio and video feeds, etc). Software technology, adjunctive to Skype, offers the means to record telemedicine sessions (audio + video) for archived broadcast to additional cohorts; however, doing so would require specific written consent from participating patients. Although our telemedicine session did not include a formal debriefing afterward to discuss the event, attendees were given the opportunity to reflect on the session during the “Reflection” portion of their weekly PBL meeting. In the future, we might consider adding a formal debriefing session to the teaching schedule or perhaps a reflective writing assignment that incorporates self-directed learning. Acknowledgment The authors thank the patient for his enthusiastic participation in the education session. Financial Disclosures None reported. References 1. Gosman AA, Fischer CA, Agha Z, Sigler A, Chao JJ, Dobke MK. Telemedicine and surgical education across borders: a case report. J Surg Educ. 2009;66(2):102-105. 2. Miriam J, Szeftel R, Sulman-Smith H, Mandelbaum S, Vargas M, Ishak W. Use of telepsychiatry to train medical students in developmental disabilities. Acad Psychiatry. 2011;35(4):268-269. 3. Strehle EM, Earle G, Bateman B, Dickinson K. Teaching medical students pediatric cardiovascular examination by telemedicine. Telemed J E Health. 2009;15(4):342-346. 4. Shaikh N, Lehmann CU, Kaleida PH, Cohen BA. Efficacy and feasibility of teledermatology for paediatric medical education. J Telemed Telecare. 2008;14(4):204-207. 5. Jonsen AR, Siegler M, Winslade WJ. Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine. 6th ed. New York, NY: McGraw Hill; 2006:7, 109-117. 6. B. Braun Melsungen AG. Hemodialysis. 2013. http:// www.bbraun.com/cps/rde/xchg/bbraun-com/hs.xsl/hemodialysis -01.html. Accessed December 31, 2013. 7. RAND Corporation. Kidney Disease and Quality of Life (KDQOL-SF 1.3). Phoenix, AZ: University of Arizona; 1995. 8. Heidari A, Adeli SH, Taziki SA, et al. Teaching medical ethics: problem-based learning or small group discussion? J Med Ethics Hist Med. 2013;6:1.
297
Katrina A. Bramstedt, PhD, Melissa Prang, Sameer Dave, Paul Ng Hung Shin, Amani Savy, Richard A. Fatica, MD Bond University School of Medicine, Gold Coast, Queensland, Australia (KAB, MP, SD, PNHS, AS), Cleveland Clinic, Cleveland, Ohio (RAF) Corresponding author: Katrina A. Bramstedt, PhD, Bond University School of Medicine, University Drive, Gold Coast, QLD 4229, Australia (e-mail: [email protected]) To purchase electronic or print reprints, contact: American Association of Critical-Care Nurses 101 Columbia, Aliso Viejo, CA 92656 Phone (800) 899-1712 (ext 532) or (949) 448-7370 (ext 532) Fax (949) 362-2049 E-mail [email protected]
©2014 NATCO, The Organization for Transplant Professionals doi: http://dx.doi.org/10.7182/pit2014289
T
fact, these constructs comprise “Box 3” of the widelyused “Four-Box Method” of ethical decision making.5 Providing ethically appropriate medical care requires reflection on quality of life and human suffering because the meanings and perceptions of these matters influence patients, their families, and health care providers. Furthermore, providing medical students the opportunity to reflect on a patient’s experience of suffering and quality of life potentially allows the deconstruction of biases that might affect their provision of care. The nephrology curriculum block was chosen for this educational session because dialysis and end-stage renal disease present many opportunities to explore medical ethics through the patient’s experience. Worldwide, more than 1.7 million patients undergo dialysis, and many endure burdens of the treatment as well as their
294
Progress in Transplantation, Vol 24, No. 3, September 2014
elemedicine is well known in the clinical setting as a means to link doctors and patients across distances through electronic technologies such as e-mail, video conferencing, text messaging, and remote data capture. Telemedicine is also widely used in surgical training curricula to enable surgeons to teach medical students and other trainees through live, interactive operative sessions.1 Other segments of medical student curricula that incorporate telemedicine include psychiatry, 2 cardiovascular medicine, 3 and dermatology.4 Herein is the literature’s first report of an educational experience using telemedicine to teach various concepts of medical ethics within a medical school curriculum. Specifically, quality of life and human suffering are well-recognized constructs within medical ethics as they are elemental to ethical decision making. In
Telemedicine as an ethics teaching tool for medical students disease.6 The noncompulsory session, Exploring the Patient Experience Through Telemedicine: Dialysis and End-Stage Renal Disease, allowed second-year medical students to explore various parameters of quality of life and human suffering (components of medical ethics) experienced by dialysis patients. Methods The activities described were part of a quality improvement educational endeavor in November 2012, not a research project, thus no review by the Human Research Ethics Committee was required. Two medical school clinicians (1 clinical ethicist and 1 nephrologist) designed a 1-hour telemedicine session linking their 2 facilities (across 2 continents, 14 852 km). The session, Exploring the Patient Experience Through Telemedicine: Dialysis and End-Stage Renal Disease had 2 learning objectives: (1) discuss the parameters of quality of life experienced by dialysis patients and (2) identify and record the most meaningful insight gained from interviewing a dialysis patient. The session consisted of a panel of 4 second-year medical students who sequentially interviewed a dialysis patient via a Skype video connection between the medical school and the hospital’s dialysis unit. Three (1 male, 2 females) of 4 students were selected by first-come, first-served voluntary e-mail response to an announcement from the clinical ethicist about the session. One male student was directly approached by the ethicist for his voluntary participation. Interview questions (Table 1) were adapted from the Kidney Disease Quality of Life (KDQOL) instrument.7 Questions regarding sexual function were not included because of the lack of privacy of the open (full classroom) setting. The nephrologist selected a patient from the nighttime dialysis cohort so as to facilitate the time zones of the 2 linking facilities. The patient was apprised of the general nature of the KDQOL survey questions, as well as the design and purpose of the educational session, and provided consent to participate. A Skype connection test between the 2 facilities (medical school teaching amphitheater, hospital dialysis clinic) was conducted before the live teaching session. Additionally, about a week before the live session, the ethicist posted an electronic bulletin to the cohort reminding them of the upcoming session and announcing the ground rules (including professional attire for all students, no late admissions to the classroom, and patient confidentiality requirements). On the day of the event, signs were placed on the amphitheater doors restating the ground rules and administrative personnel were staffed at all doors to monitor dress code and timeliness. No visitors were permitted. Just before the start of the session, the ethicist reminded all students that audio and video recording of the session was not permitted. At the onset of the telemedicine session, the Progress in Transplantation, Vol 24, No. 3, September 2014
Table 1 Interview questionsa Student number
Questions
1
Eleven questions focused on the physical signs and symptoms and cognitive impact of dialysis and end-stage renal disease
2
Sixteen questions focused on how dialysis and end-stage renal disease affect the patient’s sleep quality, ability to work and be active, and his level of dependence
3
Seven questions focused on stress and worry in the patient’s life and his reflection on waiting for a kidney transplant
4
Eight questions focused on social supports and satisfaction with health care services
a The
exact question list may be obtained from the authors by written request.
patient was greeted by the clinical ethicist and advised that participation was voluntary, the patient could refuse to answer any question, and the patient could cease participation in the telemedicine session at any time. During the live video-streamed interview, the second-year cohort who volunteered to attend observed the patient’s interview. The patient was interviewed from a private room at the dialysis clinic to allow freedom of discourse away from the general population of dialysis patients. Additionally, the patient’s attending physician remained in an adjacent area in the event that the patient needed any clinical or other assistance. After the session, the patient was sent a thank you card and small gift from the students for his participation. Additionally, the observing students were given the opportunity to complete an anonymous 10-question online feedback survey about the session (Table 2, www.TooFast.ca). The 4 interviewing panelists submitted narrative responses to 2 open-ended questions about their experience (What is your response to the telemedicine session? What is your response to the concept of using telemedicine as a method to teach medical students?) Learning objective 2 (see Methods section) was assessed by exploring the routine PBL (problem-based learning) weekly qualitative feedback reports in which PBL groups (n = 12) answer 4 open-ended questions: What activities contributed most to the group’s learning? What activities contributed most to the group’s professional development? Which individuals contributed most to the group’s learning? Which individuals contributed most to the group’s professional development? Results In November 2012, the Bond University School of Medicine semester 5 (year 2) cohort consisted of 79 medical students. Per school policy, large group resource sessions (eg, lectures, tutorials) are noncompulsory, as was this telemedicine session. Four students
295
Bramstedt et al
Table 2 Student feedback questions
Table 3 Cohort problem-based learning feedback
1. Overall, the quality of my learning experience in this session was (Likert scale responses)
Q1, 2. What activities contributed most to the group’s learning? What activities contributed most to the group’s professional development?
2. I found the session intellectually stimulating (Likert scale responses) 3. The session improved my understanding of the topic (psychosocial burdens of dialysis, quality of life, human suffering) (Likert scale responses) 4. The use of telelmedicine technology contributed to my understanding of the topic (psychosocial burdens of dialysis, quality of life, human suffering) (Likert scale responses) 5. I would like telemedicine to be used in other course sessions (yes/no) 6. The session helped me enhance/improve my empathy toward patients (Likert scale responses) 7. The session is an aid for my professionalism skills and behaviors (Likert scale responses)
“The telemedicine lecture was very insightful.” “Telemedicine session allowed us rare insight into the lives of patients with dialysis.” “The dialysis telemedicine conference was very good. Helped us understand and empathize with dialysis patients.” “Dialysis teleconference helped give a good insight into patients who are on dialysis.” “The teleconference with a dialysis patient was very well received and everyone found that it was an eye-opening experience to talk to someone currently dealing with these problems and listening to his perspective on life.” “Forum this morning was very good. We need more of those….”
8. The design of the session encouraged reflective thinking (Likert scale responses)
Q3, 4. Which individuals contributed most to the group’s learning? Which individuals contributed most to the group’s professional development?
9. The session is an aid to my communication skills (working with patients) (Likert scale responses)
“…the dialysis patient from the Skype conference.”
10. I would recommend this noncompulsory session to my peers (yes/no)
“…the dialysis patient from Cleveland Clinic was able to give the students a good insight on how to deal with patients in his situation and give more considerations and support toward the patients other than just medically.”
volunteered to participate in interviewing the patient, and 23 observed the patient’s interview (34.2% class participation). Afterward, 15 of 23 students (65.2%) who had observed the session completed an anonymous online feedback survey. All 15 students “Strongly agreed” or “Agreed” that the session was an aid to their professionalism skills and behaviors; 14 of 15 “Strongly agreed” or “Agreed” that telemedicine technology contributed to their understanding of the topic; 12 of 15 “Strongly agreed” that the session improved their understanding of the psychosocial burdens of dialysis, quality of life, and human suffering, and improved their empathy toward patients; and 12 of 15 “Strongly agreed” or “Agreed” that the session encouraged reflective thinking, and was an aid to improving their communication skills. Furthermore, as shown in Table 3, the cohort consistently reported positive feedback (through reflective PBL work), indicating that the telemedicine session and the patient himself had affected their learning and professional development. The 4 interview panelists submitted overwhelmingly positive narrative responses to 2 open-ended questions about their experience. A snapshot of their feedback is presented in Table 4. In general, the quality of the Skype video session was good; however, at times, there was image graininess and audio freezes. The root cause of these events is unknown, and they did not detract from the educational impact of the session for the cohort (they did not
“[the patient] was very knowledgeable and engaged well, which contributed to our learning.”
296
“[the patient] from the Cleveland Clinic gave a very good insight into the life of a patient on dialysis and helped us to understand the needs of the patient, not just physically and medically, but also mentally and socially.”
give negative feedback on this matter). Two of 4 interview panelists commented on the technical glitches, most likely because technical disruptions have the potential to affect interviewing of patients. Discussion There are many ways to teach medical students about medical ethics, including lectures, PBL cases, and small-group discussions.8 Notable, however, is the fact that generally, although these methods might involve discussion of patient’s cases, or perhaps incorporate standardized patients, they generally do not involve real patients to bring concepts in medical ethics alive for students. We have shown that patients can deliver “the patient experience” directly to medical students through telemedicine, and this method can be effective for teaching medical ethics content such as professionalism, quality of life, suffering, doctorpatient communication, and empathy. These concepts, in addition to the general principles of medical ethics (beneficence, nonmaleficence, autonomy, justice) are important to building a therapeutic alliance for the delivery of ethically appropriate care. Progress in Transplantation, Vol 24, No. 3, September 2014
Telemedicine as an ethics teaching tool for medical students
Table 4 Narrative feedback from 4 interview panelists Q1. Your response to the telemedicine session: “I found the telemedicine session to be very eye opening as it provided significant insight into the life of a [chronic kidney disease] patient.” “The session gave me the opportunity to practice my communication skills and act in a professional manner.” “…direct [patient] contact further increased my interest and level of engagement….” “The fact that a condition was being explained from the perspective of a real patient and not via that of a doctor or lecturer who had never suffered from the condition in question made me find the session extremely interesting and engaging.” “…the session was an invaluable learning experience….” Q2. Your response to the concept of using telemedicine as a method to teach medical students: “…[telemedicine] allows for international teaching opportunities….” “…[telemedicine] is a fun and engaging way to liven things up in the lecture room.” “…[telemedicine] would be a great way to get a patient’s point of view about a condition in a nonthreatening manner . . . telemedicine appeared to keep the patient at ease as well as the students.” “…[telemedicine] offers the advantage of being a dynamic session.” “…[telemedicine] gives rise to so many opportunities . . . on an international scale or even just locally. . . .” “It would be good to expose all medical students to telemedicine. . . .”
Telemedicine technology enables actual patients to come to students without the hindrances of geography or distance. Additionally, patients who might feel anxious or otherwise uncomfortable telling their story directly in front of an ocean of medical students can do so via the seclusive qualities that telemedicine fosters. Specifically, patients speak to one video camera rather than a room full of students. This can create the semblance of a one-on-one conversation, as the patient him/herself is not surrounded by a crowd of medical students. The reach of telemedicine also facilitates bringing clinical experiences into the preclinical medical education years (generally years 1 and 2 of an MD or MBBS program). For programs that are affected by cost, access, or other logistical matters that prevent classes of students from going out to see patients in these early years, bringing patients directly to the students can be facilitated through the generally inexpensive technology of telemedicine. For example, Skype connection fees are free when both parties are registered as “Skype Contacts,” and medical schools generally already have video cameras (portable or fixed) as program capital.
Progress in Transplantation, Vol 24, No. 3, September 2014
As with our session, a clinical monitor (physician, nurse) should be near the patient during an interview in the event that clinical or emotional assistance is needed. Patients should provide consent to participate before the session and should be reminded of the voluntariness of the session at onset, as well as the option to skip questions and cease interviewing at any time. Interviewers should be sensitive to the reactions of their patients, observing for signs that patients might need a rest break (eg, fatigue, distraction, loss of concentration) or that session termination is warranted (medical or emotional crisis). At no time should the educational session take priority over the patient’s health and safety. Clinicians are generally not information technology specialists, so offering these sessions requires the support of information technology staff (testing connections, optimizing audio and video feeds, etc). Software technology, adjunctive to Skype, offers the means to record telemedicine sessions (audio + video) for archived broadcast to additional cohorts; however, doing so would require specific written consent from participating patients. Although our telemedicine session did not include a formal debriefing afterward to discuss the event, attendees were given the opportunity to reflect on the session during the “Reflection” portion of their weekly PBL meeting. In the future, we might consider adding a formal debriefing session to the teaching schedule or perhaps a reflective writing assignment that incorporates self-directed learning. Acknowledgment The authors thank the patient for his enthusiastic participation in the education session. Financial Disclosures None reported. References 1. Gosman AA, Fischer CA, Agha Z, Sigler A, Chao JJ, Dobke MK. Telemedicine and surgical education across borders: a case report. J Surg Educ. 2009;66(2):102-105. 2. Miriam J, Szeftel R, Sulman-Smith H, Mandelbaum S, Vargas M, Ishak W. Use of telepsychiatry to train medical students in developmental disabilities. Acad Psychiatry. 2011;35(4):268-269. 3. Strehle EM, Earle G, Bateman B, Dickinson K. Teaching medical students pediatric cardiovascular examination by telemedicine. Telemed J E Health. 2009;15(4):342-346. 4. Shaikh N, Lehmann CU, Kaleida PH, Cohen BA. Efficacy and feasibility of teledermatology for paediatric medical education. J Telemed Telecare. 2008;14(4):204-207. 5. Jonsen AR, Siegler M, Winslade WJ. Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine. 6th ed. New York, NY: McGraw Hill; 2006:7, 109-117. 6. B. Braun Melsungen AG. Hemodialysis. 2013. http:// www.bbraun.com/cps/rde/xchg/bbraun-com/hs.xsl/hemodialysis -01.html. Accessed December 31, 2013. 7. RAND Corporation. Kidney Disease and Quality of Life (KDQOL-SF 1.3). Phoenix, AZ: University of Arizona; 1995. 8. Heidari A, Adeli SH, Taziki SA, et al. Teaching medical ethics: problem-based learning or small group discussion? J Med Ethics Hist Med. 2013;6:1.
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