These courses employ a wide variety of educational activities and assessments as described below. Table 2 summarizes these specific activities and the associated resources/IT tools needed for implementation. Also contained in Table 2 are additional measures that were taken to facilitate each activity in the online environment and to quickly recover from technology disruptions.
With Zoom replacing the classroom and conference room settings, lectures, discussions, and student exit interviews were converted to the online environment without altering the course’s original learning objectives.
During the Capstone, the final project and teaching presentations were converted to an online format using Zoom. The students presented their projects and conducted their teaching by using the ‘share screen’ feature. In addition, the question-and-answer period for each was conducted through Zoom using the ‘raise your hand’ feature. The conversion to an online format did not necessitate alterations to the content or the duration of the presentations. The primary change was to the mechanism for student assessment. In the onsite Capstone, the faculty would complete hardcopies of a checklist and would submit them to the instructor. This year, we used Google forms to convert all the checklists to an online format. The faculty were emailed a link to the appropriate form. This conversion made the process of collecting faculty feedback more efficient than in previous years. The primary instructor for the Capstone had almost instantaneous access to the faculty scores of student presentations.
Mock ethics committee meeting
Practice of real-time, live clinical moral reasoning usually took the form of a “Mock Ethics Committee Meeting” in the Practicum. Because our group for this year’s course involved only three students, we modified the activity into a “Mock Ethics Consultation” as these typically only have two or three consultants present. This year, despite the COVID-19 pandemic, we were still able to schedule five clinicians to present their cases via video conferencing. The switch to consults on Zoom in our online course mirrored the real-life move to online ethics consultation due to the pandemic. The Mock Ethics Consult also permitted a complementary revision for the Practicum’s written assignment. In the past, students submitted an ethics analysis of a situation they witnessed on their clinical site visits; this year, they were asked to submit an ethics consult chart note on one of their Mock Ethics Consults. This change allowed the learning objectives to be achieved without the requirement of onsite clinic visits. The main challenge we faced in the conversion of this activity was scheduling clinician presenters during an unprecedented health crisis. The fact that the consultations were online may have assisted with scheduling as our guests did not have to travel to the course site.
Conducting an interview
We were able to use our usual assortment of cases for skills practice in the “Conducting an Interview” activity. It proved simple to have a second faculty member join the session, so one faculty member could play the interviewee role while a second observed and critiqued students’ clinical moral reasoning process.
Communication skills sessions
All the interpersonal communication skills instruction was conducted on Zoom. Converting the introductory lecture on interpersonal communication skills fundamentals was simple; the faculty member used the share screen function on Zoom to lecture accompanied by a slide show. Students could ask questions and receive clarification in real time. This learning activity maintained the same learning objectives as past live iterations.
These workshops provide students a chance to practice marrying their interpersonal communication skills with their clinical reasoning ones. They interview an SP actor playing a clinician, patient, or family member with an ethical dilemma and they must help the character arrive at a conclusion about what he or she should do by assessing values, pertinent law, surrogacy decisions, and ethical principles. Each encounter is designed so students can reason to a resolution about what should be done and draw the encounter to a close. In the onsite Practicum, the SPs come to classrooms at Icahn School of Medicine at Mount Sinai, but in the online Practicum, they joined over Zoom.
The interactive interpersonal skills workshops posed more logistical challenges than the lecture. As we were developing our strategy to use Zoom as a major feature in our conversion of the Practicum, the security of the meetings became an issue due to the ‘Zoombombing’ phenomenon. Certain security features were set by default for Zoom meetings hosted by our institution. Specifically, only other Clarkson University accounts could join a meeting through a link; if you did not have a Clarkson University account, you needed the meeting ID number and password to join. We set up the Zoom sessions with passwords to accommodate the SPs. And, we had to confirm with the SPs and guest lecturers that they understood how to join a meeting this way. SPs typically rehearse their characters for us in person at the Morchand Center, so rehearsal occurred on Zoom, which allowed us to verify their fluency with the technology.
Our first online SP workshop followed the same format as past in-person workshops: students took turns in the role of interviewer to practice their interview skills, and they or the faculty could pause the interview to ask questions and review their progress. Because these sessions maintained our original learning objectives despite the change in delivery mode, they fostered the same learning outcomes in our students as the in-person format.
During past Practica, students expressed a wish to conduct a whole interview on their own, from beginning to end, without taking turns with their peers. The volume of students and the schedule precluded this in the past, but for this online Practicum, we decided to experiment and include this in our curriculum. These independent workshops were scheduled simultaneous to the ethical analysis review of past Mount Sinai Hospital ethics cases.
To facilitate this session, students had to leave that Zoom meeting to join a different Zoom meeting for the independent workshop. This meant that we had to have two Zoom links in that day’s Moodle module, while ensuring that students would not be confused about which meeting they were supposed to be in and at what time. Setting up a second Zoom meeting also meant that a second faculty member had to host the independent communication skills workshop; this was easy to do. The Moodle module also had to be clear about when students should leave the ethical analysis exercise meeting to enter their private workshop meeting and return to the former. Finally, these sessions had to be private, so students couldn’t join another student’s session and learn the case resolution before they started - that would undermine the workshop’s educational value. Because we couldn’t start a new meeting for each workshop session, we had to restrict access to the Zoom meeting to ensure privacy and integrity. To do this, we created three outgoing Moodle links that all directed to the same Zoom meeting and used a Moodle function to restrict their visibility to students - they could only see the link when it was their turn for the independent workshop. A connectivity issue on the part of an SP made one private session go over time. To prevent the next student from interrupting, one of the faculty members in the session had to update the time restriction on Moodle and communicate the change of schedule to the next student. This response worked surprisingly well.
These independent workshops were an excellent addition to the curriculum because it most closely approximated the SP assessment exercise described in the next section, and it helped students know what to expect in it. In addition, solving the ethical dilemma without aid from classmates boosted their confidence for the SP assessment. Finally, because the independent workshops were recorded on Zoom, students could receive links to the recording to review their performance before the assessment, which allowed for a means to improve student learning and engagement with the material (Nikopoulou-Smyrni and Nikopoulos 2010, Brame 2016). If we can scale the independent workshops to our in-person Practicum, we hope to make this a permanent feature of the curriculum. It may not be possible to provide students with video recordings at the in-person Practicum, but many classrooms are being renovated to have lecture-capture technology, so this may be possible.
The SP encounters are one of the distinguishing features of the Practicum and Capstone and, in our opinion, one of the best ways to assess a student’s competence in the knowledge and skills a bioethicist should possess. Students stand in a hallway outside a simulated examination room, and they are given a brief “presenting” document that tells them the name of the person they are meeting and basic details about the reason for the consultation. Then, students enter the examination room and conduct a clinical ethics consultation with an SP over 20 min, while being observed by faculty on a closed-circuit video. Faculty use a checklist to score the encounters. These encounters are also recorded so students can review their performance alongside their scored checklist. Recreating this assessment exercise on Zoom was the essential and biggest challenge to successfully converting the Practicum and Capstone to an online format.
We used Zoom’s breakout rooms and recording features to recreate the assessment. We created a special Zoom meeting link for these assessment exercises so we could configure the meeting in advance. We first settled on how many breakout rooms we would need: five total - two for the exam rooms, one for a student lounge, one for a faculty lounge, and one for an SP lounge. We needed two exam rooms because each student must complete two separate SP encounters as part of the assessment, each with a different case portrayed by a different SP. We needed a lounge for students to wait in before the encounters began. This space would be used to brief students on what to expect during the assessment. An SP lounge provided a place that we could move SPs to in between encounters to give them notes on their performance, which we didn’t want to record in the exam room. And we needed a faculty lounge so that faculty who were observing and scoring the SP encounters would also have a space to confer on student performance and what feedback to provide without being recorded. We consulted our instructional designers to review the meeting set-up.
Once we had the Zoom meeting space created, we needed to establish the crew to host the meeting and be responsible for moving students, SPs, and faculty between the relevant breakout rooms. The meeting hosts cannot record what is occurring in a breakout room that they are not in; the meeting host had to remain in the main Zoom meeting space in case technical difficulties caused a student or faculty member to lose connection and rejoin the meeting - the host would have to send him or her back to the right breakout room. In addition, the host would use a broadcast message function to tell each breakout room to begin simultaneously. That meant that we needed a host for each breakout room to record the session and to make time announcements. Our bioethics program Director, the Senior Graduate Program Coordinator, and the campus IT Director volunteered to assume these roles. Finally, we needed someone to post the “presenting” information in Zoom’s chat window right after students were moved into the SP encounter room. We decided not to ask the breakout room hosts to do that to minimize distractions, so they would not forget to start recording; we asked the faculty evaluators to post the “presenting” information. Several of the crew members had never been involved with the SP encounters before. To ensure they understood their roles, we composed a manual that identified each person’s role and included a time-coded schematic for each session. The manual included a step-by-step guide for when and where students, faculty, and SPs should be moved, when the breakout room host should start recording, and a time-coded script for the timing announcements. This manual was an asset for the SP encounter sessions.
Several steps were taken to ensure the sessions ran smoothly and we could recover quickly in the event of technology failures. To be prepared for connectivity issues that interrupted an SP encounter, we padded the schedule for the sessions. We inserted a 30-minute buffer between the two groups of students. In addition, the manual contained email addresses and cell phone numbers for the crew and faculty in case an alternate means of communication was needed. Once we had the Zoom meeting prepared with breakout rooms and the crew identified, we conducted a rehearsal so that everyone understood their role and how to use the technology to perform it.
We were pleased with how closely this modality approximated the in-person SP encounters. One student did lose connectivity in the middle of his encounter, and we needed to use part of the time buffer to finish his session.