Monday, June 30, 2008

A Few Excellent References

I thought I would take an opportunity to list here some texts which I find to be of immense help. I highly recommend each of these books.

1. Guyatt G, Rennie D, Meade MO, Cook DJ. Users’ guides to the medical literature: a manual for evidence-based clinical practice. New York, NY; McGraw Hill, 2008.
This is simply the best text there is about evidence-based medicine. I was able to meet two of the authors during my recent visit to McMaster University, and one (Dr. Cook) was a member of the small-group team for which I was a member. This book provides a complete and thorough overview of EBM, from the initial steps of question formulation and literature searching, through understanding articles about therapy, harm, diagnosis and prognosis, and to how to summarize evidence and apply it to practice. This is a peerless text in the field and one that everyone should have in their personal library. I cannot even begin to state how much use I get out of this book.

2. Haneline M. Evidence-based chiropractic practice. Sudbury, MA: Jones and Bartlett, 2007.
Dr. Haneline is one of ours, a faculty member at Palmer College of Chiropractic West Campus. His text takes the concepts of the Users’ Guide (above) and applies them directly to chiropractic. He is able to synthesize difficulty concepts, and chooses to discuss the most common of the methods delineated in the text by Guyatt and colleagues. Because he chooses to stick to foundational concepts, this is an excellent text to use in teaching and to introduce yourself to the ideas and concepts of evidence-based care.

3. Peat J, Elliott E, Baur L, Keena V. Scientific writing: easy when you know how. London, UK; BMJ Books, 2002.
There are a number of good texts about effective writing for science, but this text by Peat and colleagues is one of the best I have seen. It provides the reader with information covering every aspect of the publication process, from developing concepts and ideas, to preparing a manuscript and writing it, the peer review process and proper grammar. Though I spent nearly 20 years editing chiropractic journals, I find something new in this text every time I look through it. For the novice writer, this is a great source book to help walk you through the process of preparing a paper for publication.

4. Reynolds G. Presentation zen. Berkely, CA; New Riders, 2008.
I’ve noted this book in an earlier blog post, but I think it bears noting again. The use of PowerPoint is endemic in education, but often people do not more than transfer their lectures onto slides as pure test, and then read them to their class, perhaps while slightly improvising what they say. This text provides a new way to consider how to use PowerPoint in the classroom, so that we all move away from bullet points and headline-style presentations. It inspires creativity in the classroom.

5. Beauchamp T, Childress JF. Principles of biomedical ethics, 5th edition. New York,, NY; Oxford Press, 2001.
Okay, this is near and dear to my heart. But it is simply the foundational text in modern bioethics debate, the text around which nearly the entire discipline swirls, and incredibly influential. Discussions of beneficence, nonmaleficence, justice and autonomy were codified here and have taken center stage in the field of biomedical ethics. One cannot do research without taking a look through this text, and one cannot treat patients without doing the same. A dense read, but essential.

Monday, June 23, 2008

The Evidence-Based Teaching Program, Part 2

During the course of the training program at McMaster University, we had both large-group and small-group sessions. Since the primary goal of the program was to provide skill sets for physicians and others involved in health care for use in training either faculty or medical residents, these small and large-group meetings were showcases for various teaching methodologies. I thought I would discuss in brief some of the tactics that were used.

The large-group sessions were held in a standard teaching classroom. At each session, there were approximately 100 people in attendance, and each instructor used various methods for involving and engaging the audience. For example, all instructors commonly asked directed questions at the audience, and allowed time for a number of responses to be received, to be recognized and to be debated. Even when an audience member was way off the mark on a response, their answer was treated with respect, and they were questioned to guide them toward a more proper response. In this way, the fear of being wrong was reduced and this led to more people willing to offer their thoughts.

In the small group sessions (approximately 10 people per group), the main tactic was to ask each participant to present a scientific paper. The paper was organized according to type- therapy, prognosis, diagnosis, systematic review, meta-analysis- and to then discuss that paper with the group via a presentation. There was a checklist provided with each paper that guided, or could help guide, the discussion. In each case, a clinical scenario was used to drive the presentation. For example, we might have been addressing a case where a patient appears to have a condition, and there is a new paper about a new diagnostic test that could be used- for example, beta-natriuretic peptide for differentiating congestive heart failure from lung disease in patients who have dyspnea. What made this challenging is that we had to resolve the clinical question by analyzing the paper for concepts, and then present that to the small group. And we could not use PowerPoint, just a white board. As time went on, presentations became more and more novel, so as not to repeat a method someone else had used. At the end, each presenter was asked to self-critique their performance, then heard the thoughts of the other participants, and finally received comments from group facilitators.

I should note the use of what is called educational gaming. This was an aid in large-group sessions. In simple, it is the use of a “game” in the classroom. In one care, we were all given red and pink index cards, and these were initially used to write short answers to questions, which were then shared with someone not sitting right next to you. These were later used to hold “votes” about the answers to various questions. Another use of a game was an instructor awarding “prizes” to people who correctly answered questions asked of the large group. The prizes were silly, ranging from a pack of gum to, as time went on, a roll of toilet paper, but it engaged the audience for all its simplicity.

The point here is simply that everything that was done in the classroom setting, whether in large or small group, had purpose and truly engaged the learner. It was not a passive learning experience, not at any time.

Thursday, June 12, 2008

The Evidence-Based Medicine Teaching Program

I thought I would take an opportunity during one of our breaks to post here about the course of our conference. I am in Hamilton, Ontario taking a week-long course on how to effectively teach the concepts of evidence-based medicine or evidence-based practice. It is being taught or facilitated by some of the leaders in this discipline, including Gordon Guyatt, Deborah Cook and Tom McGinn. The program is organized into both large-group and small-group sessions, usually with the large-group meetings held earlier in the morning, and the small group sessions from mid-morning until late afternoon. Because I am the sole chiropractor here, I have been involved with the small group that is comprised of medical internal medicine specialists, and they have been a warm and welcoming group with a sincere interest in knowing about chiropractic.

The large-group sessions touch on general topics, but the real work takes place in the small-group setting. Each physician is asked to make a presentation to their group, in which they take a pre-assigned paper and go through its elements with the group. They are provided feedback on how well they teach that material, the strategies they use in teaching the information, how well they draw out members of the group, and how well they make sense of difficult concepts. We have had a heavy emphasis in our group on certain EBM concepts, notably relative risk, number needed to treat, and the difference between intention-to-treat analysis and loss to follow-up. These jargon terms sound complicated, but working through each paper helps to illuminate the importance of these concepts and how they can be used to inform decision-making in clinical practice. I chose to present a systematic review, since I have some experience with them, and I was also allowed to replace the medical review with one I selected from the chiropractic literature. It took more than 90m minutes to critique the paper, during which a great many questions came about issues such as translating the dense information into clinical action, how to conduct meaningful reviews, and how to evaluate the quality of the literature that is selected from inclusion. It went quite well.

Ultimately, the tools, strategies and approaches I learn here will be an aid to helping our own faculty gain mastery over these concepts and then apply them in the clinical setting or the classroom. I am looking forward to that. It has been an incredibly intense time here, but it has also been great fun. And our instructors certainly practice what they preach, both in the classroom and in clinical practice. 

Friday, June 6, 2008

Time Away is Time Well Spent

Tomorrow I leave for McMaster University in Hamilton, Ontario to attend a week-long program on how to teach evidence-based medicine in the classroom and the clinic. The program is led by some of the main individuals involved in the EBM movement, including Dr. Mark Wilson (from University of Iowa) and Dr. Gordon Guyatt, and looks to be a fairly intensive educational experience, one I am looking forward to, albeit with some trepidation. After all, because I am the sole chiropractor to attend, I have been assigned to work in collaboration with the family medicine specialists. After that program ends, I get to spend some time with family, both in Detroit and in Vancouver, BC Canada. So the next couple of weeks will combine business with pleasure, and I will be largely unable to update this blog during that time.

But that allows me to note how important it is that all of us have time to relax, as well as time to enhance our skills. I think the two go together in important ways. Grabbing the time to relax came hard to me; I spent years working days, nights and weekends and only later in my life did I learn to let some of these times go, that not working was important as well. Like most of us, I have outside interests not related to my professional life. It is always interesting to me to hear what people do in their spare time, what they collect, what they are passionate about. While still a member of the research department and attending a regular weekly research council meeting shortly after Dr. Choate had arrived, she opened the meeting by asking people to describe something they collect. What a interesting meeting that was! Even though I worked closely with the people in that group, there were interesting things about them I never knew- and in some cases there were commonalities in their interests and mine that led to better relations among us. In the end, what that means is more productivity, better relationships and more effective collaboration, all important in our high-pressure setting.

At the Davenport campus, we are all soon heading for some time off; the other campuses work on different schedules but also either will have or just did have time away. The time away will let each of us recharge our batteries and return ready for a new term. It’s necessary. I think we work better when we have some time to not work at all. To pursue our interests, whatever they are. In my case, I get passionate about a lot of things; music, for example. Over the course of 40 years of collecting, I’ve amassed a collection of LPs, cassette tapes and CDs of over 5000 items. Much of it is jazz and unusual forms of music: energy jazz, avante-garde classical music, Zeuhl music (a branch of French progressive music spear-headed by the legendary progressive band Magma). I read tons of media analysis, for programs such as Buffy the Vampire Slayer, CSI, Lost and House. I’m into photography. And so my time at home is spent pursuing these activities- which often means I am watching television. But with that critical media eye, of course!

Wednesday, June 4, 2008

Death by PowerPoint, Part 2

I should note at the outset that I am guilty of nearly everything I am about to discuss. I suspect that just about all of use have used PowerPoint incorrectly at one point or another, but here I am going to list a few common problems that we engage in or issues we confront.

1. Content is king. This is important because all too often we believe that selecting the right design is important. As Edward Tufte (1) says “If your words or images are not on point, making them dance in color won’t make them relevant.” The entire point of this technology is to communicate information. While design can be used to help do just that, it is the content that fundamentally matters.

2. PowerPoint is not a word processing program. I am surprised to see how frequently presenters continue to pack their slides dense with text. It is certainly common to attend presentations where the speaker simply reads back the words which are projected on the slide. In all honestly, I’ve done that, out of nervousness I might forget something important I felt I needed to say. Of course, I forget that the audience does not know what the important things are that I am going to say, so that if I forget it, they will never know. Slides should be used as a trigger for what you wish to communicate, and the fewer words you use to that extent, the better. Truth is, as well, that if you are going to stand up there and read the slides, I can read them faster than you can speak them so you might as well just print them out and let me go on my way and read them at my leisure.

3. Pictures convey far more meaning than words. In material I have read about PowerPoint, this case has been made very forcefully. The author of an article showing good and bad slides, for example, shows a typical PowerPoint slide, with title, bullet points, sub-bullet points, etc. It’s boring. And then the author shows a pictorial slide used to demonstrate the same ideas made in the first slide. And it is far more powerful and communicates concepts better. The best PowerPoint presentations I have ever seen, such as those by the chiropractic researcher Greg Kawchuk, insert off-kilter graphics and even videoclips to use as support for the real educational issues being discussed. I doubt you can actually remember what you think is the best PowerPoint presentation you have ever seen, but I also bet anyone at the ACC-RAC Conference a few years ago can recall Dr. Kawchuk’s video that included a clip of chiropractic researchers emulating the controversy at the Olympics ice-skating competition. That’s the mark of a creative and effective presentation.

4. Practice your presentation. It helps you figure out your transitions, how much time you need, what you wish to say, and it also allows you to run through your presentation and determine whether you need to revise it. Don’t present information cold. You are presenting a logical flow with your slides, and linking them together is important.

PowerPoint is an amazing tool that is rarely used as effectively as possible. There are many instruction books out there that will show you how to make slides, but fewer about how to think about your presentation. One good one I recommend is: Reynolds G. Presentation Zen. Berkeley, CA: New Riders, 2008.

1. Tufte E. PowerPoint is evil., accessed June 2, 2008

Monday, June 2, 2008

Death by PowerPoint

While I can’t take credit for the title here, I think it encapsulates the dangers that the use of PowerPoint can create. When I think back to my career as an educator within chiropractic, now nearly 3 decades old, I can fondly remember the smell of the mimeograph machine when I used it to make copies of material for classroom use. When copiers became part of my life, I used the copy machine for that same purpose. I remember making overheads for classroom use by first making a copy onto white paper, then making a second copy onto special clear overhead material. I would go to class carrying my teaching notes and my overheads, which I had to coordinate with my notes (I used to put little numbers in the text, which were keyed to the overheads). Then came PowerPoint, which allowed me to make slides on my computer and to easily bring them to class. And I did, in large number.

But I had a bit of a wake-up call this past weekend, and it is one that fits in to literature I have been reading. I made my final examination open book; students were free to bring in whatever material they wanted, including copies of classroom slides I make available on my website. One student came to me when the final had ended to ask about one answer on the test. I gave him the answer, to which he then stated “but that was not covered in the notes.” My response to him was that he was correct; it was not in the notes, but was something we had talked about in the course of the class. But after he left I felt bothered, and it occurred to me why: students brought those slides to the test thinking that the only material that mattered was the information contained in those slides. This is not and should never be the case. I am therefore rethinking my use of my PowerPoint.

And let me quote a harsh critic of PowerPoint, Edward Tufte (1), who is acknowledged as a leader in the visual display of information. He says” In a business setting, a PowerPoint slide typically shows 40 words, which is about eight seconds’ worth of silent reading material. With so little information per slide, many, many slides are needed. Audiences consequently endure a relentless sequentiality…” Matt Christian (2) says “Little did they know that they were creating a program that would cause more people to communicate less effectively and less efficiently.”

Okay, we’ll stop here for now, now that I’ve got you hooked. More to come on this…

1. Tufte E. PowerPoint is evil., accessed June 2, 2008
2. Christian M. Death by PowerPoint of twelve steps to better e-presentations., accessed June 2, 2008