Monday, December 14, 2009

A Break in the Action: Holiday Time and a Few Movies

This is the last full week of work before we all have a much needed break, so I thought that since such weeks tend to be somewhat low key (though not to look at my schedule, to be sure!), I would offer up a bit of holiday break information. To that end, I wish to suggest some truly great movies for you to watch during your time away. These are all fairly recent, and can be found on NetFlix or at a local rental store.

1. Knowing: I am not normally a fan of Nicholas Cage, but he is just right for his role here. This film, which was written by Alex Proyas (who also wrote and directed the marvelous film Dark City), is far better than its promo would suggest. Cage plays a theoretical physicist grappling with whether the universe is random or deterministic. Cage feels the latter must be the case; he has, after all, just lost his wife. In the film, Cage’s son becomes the recipient of a sheet of paper taken from an elementary school time capsule planted 50 years earlier. The sheet is covered in numbers, which Cage comes to interpret, with terrifying implications. More than this I cannot say; the movie moves relentlessly to a staggering climax and lyrical coda. [Trailer:]

2. The Secrets: This film is a true surprise, the story of how one young woman in a religious world comes into her own as a spiritual leader. Noemi is the daughter of an important Orthodox Jewish rabbi, able to hold her own with him in discussions of religious texts. With the recent loss of her mother, and pledged by her father to marry a student scholar who is held in high esteem by him, she asks instead to spend a year studying in a woman’s seminary in one of Israel’s holiest cities. She ends up paired with a student from Paris, Michelle, who is your typical troubled teenaged girl. The two end up providing care to a local woman shunned by others for having murdered her lover. This woman, played by the great Fanny Ardent, wishes to be cleansed of sin, and asks the two yeshivah students to help her. In this, Noemi creates her own ceremonies (known as tikkun), improvised from her own knowledge of Torah. Much happens along the way, as Noemi and Michelle fall in love, Michelle also falls for a local klezmer musician, and the world catches up to them. The ending is perfect. [Trailer:]

3. The Band’s Visit: Another Israeli film, this concerns the story of an Egyptian police band accidently getting off a bus in the wrong town, one located in isolation deep in the desert and occupied only by Israeli citizens. The next bus will not come until tomorrow, but a local woman helps organize friends to put the band members up. The night is spent with interactions between the band and town members, some humorous, some deeply poignant. A beautiful film, well worth visiting. [Trailer:]

4. Happy-Go-Lucky: A film by the wonderful British filmmaker Mike Leigh (Secrets & Lies, Life is Sweet, Topsy Turvy). Sally Hawkins rightfully earned an Oscar nod for her portrayal of Poppy, a woman who is simply happy, but not simple. This woman exudes happiness and goodness and attempts to infect the rest of the world with it. Initially seen as a bit odd, as the movie progresses we see exactly how perceptive she is. Then she decides to take driving lessons and meets Scott, the instructor, a man as angry as she is happy. Their interactions form the heart of this movie, which is so full of heart itself it just bursts. [Trailer:]

5. Encounters at the End of the World: A film by Werner Herzog, one of the world’s greatest filmmakers. A documentary, it examines the lives of people working at Murdo Station in Antarctica, and is a deeply thoughtful commentary on how we are facing the end of life- the title can be read in two ways. The conversations with the people he interviews are fascinating, and we watch as divers enter the sea to study life in the water, but do not take rope with them to find their way back to the hole they dug to get in the water. There is but one penguin here, and as Roger Ebert says, once you see that penguin the image will not leave you. [Trailer:]

6. Let the Right One In: The best movie I have seen in several years. Vampires as they should be done, not sparkly things with inhuman good looks, but real and dangerous. But that it is a vampire story is beside the point; it is really a story of two children in jeopardy. Oskar is a lonely 12-year-old whose parents, now divorced, have no time for him; Eli (pronounced el-ee) is the (we think) young girl who moves in next door. They meet one night at a jungle gym in their isolated apartment complex, in the snow. Eli has no coat, nor shoes, and smells sort of bad. Oskar asks if she is a vampire. Yes. Fine. Can they be friends? Well, maybe not. But friends they become, and Oskar asks her to be his girlfriend. She tells him she is not a girl. Oh. Oskar is bullied at school, but with Eli’s help he begins to stand up for himself, until one day his tormenters try to kill him. At times like that it is good to have a vampire as your friend. There is more going on, but this is a remarkable film, with some remarkable images in it, and an ending that can be seen as uplifting or perhaps depressing. I will say no more. [Trailer:]

There you have it, a few films to get you through the snow and cold certainly coming. When we return from break, I will return to writing.

Best wishes to you all for these coming holidays and New Year.

Monday, December 7, 2009

Continuing the Psychology of PowerPoint

One of the points made by Kosslyn (1) is that designing a PowerPoint presentation is similar to designing an agenda for a meeting. That is, it needs to be organized in a way that leads your audience into its flow, and it should lead to a logical and concise ending. However, unlike meetings, the presentation should have a single overall theme and mission, which is supported by its parts. This theme should be explicit from the outset and it helps provide the organization for what then follows. In terms of designing your presentation, you need to keep in mind that it is a presentation; it is not a written report, so it will not have the detail and precision of a written report. What it should, or will, do is engage your audience; that is its goal.

Kosslyn suggests 8 guidelines for the overall structure of a presentation.

1. Prepare to speak to a particular audience. You should tailor your presentation to their knowledge, goals and beliefs; thus, you should keep mindful of what information is important to them and what level of presentation is important to them. Typically, for us in education, answering a question about our audience is easy; they are our students, and we know what level of knowledge they have. Were this for an outside audience, we would need to account for this.

2. Show and tell. By doing so we help reinforce memory of our presentation, since we invoke different areas of the brain in the processing of the information we present. Practically, this means combining graphics and text. Provide variety as well (i.e., use video clips, etc.).

3. Plan in advance how you will direct the audience’s attention. This means more than just knowing your content. It means looking at your slides and ensuring they help reinforce learning. Keep the text minimal, and highlight in some fashion the important message on a slide (for example, by using a different font color).

4. Don’t lose your basic message by providing either too much or too little information. Again, keep in mind the information you are trying to present. Put up only the information necessary to achieve that goal. We typically want to give more information than we have to, so don’t. You want the audience to process information, not search for it in too much text.

5. Prepare your slides to function as your notes; don’t rely on your memory. This is hard; we know our content and the slides allow us a chance to show it. But we can forget material. You need to build in prompts in your slides to remind you, the speaker, about the content you are covering. Kosslyn does not recommend using the built-in PowerPoint note set as a reminder, since it is hard to read and people will see you scanning your notes as you present them.

6. Use the full range of communication options. Some topics don’t lend themselves to bullet lists or graphics. PowerPoint is meant to add to other forms of communication; don’t forget you have readings and assignments for your students as well, and your slides should not be the only tool in your box.

7. Build in breaks that allow the audience to “come up for air.” Use breaks in your presentation, such as a slide of a cartoon or joke, to give people some time to process and catch their breath. Stop continual force feeding of content.

8. Prepare for questions. Getting them is a sure indication that you have engaged them. So, master your material and be prepared for questions; anticipate the thorny ones that might arrive. Be ready to seed the audience with a question to get them started.

This is just a quick overview of how you should look toward developing your next presentation. When you do, don’t focus on the content; that part is the part you know. Focus on the medium and the technology and harness it in favor of reinforcing learning.


1. Kosslyn SM. Clear and to the point: 8 psychological principles for compelling PowerPoint presentations. New York, NY; Oxford University Press, 2007

Monday, November 30, 2009

The Psychological Basis of PowerPoint

Whenever I visit the annual conference of the American Public Health Association, I make time to visit the vender area in order to visit all the book publishers to see what new texts have been published. This year, two texts caught my eye. One was entitled “Bioethics at the Movies” and a second was “Clear and to the Point.” Given I had limited funds with me, I ended up buying the second book (1), which is subtitled “8 Psychological Principles for Compelling PowerPoint Presentations.” This text is a fascinating explanation of how you can use insightful observations about human psychology to craft better and more effective slide presentations. The text describes how to most effectively communicate a message, looking at issues such as design, colors, legibility, graphical display and so on. But the techniques used in the book are based on just three major goals.

Goal 1: Connect with your audience. Kosslyn states that you will effectively communicate when you focus the audience’s attention on a specific message. Put another way, the goal here is not to try and pack in as much information as you can in the presentations you make. When you do, you will lose your audience quite rapidly. You should tailor your presentation to the needs of the audience, and put your material into a context that is of interest to them. For people, for example, who teach a basic science, this might mean putting your information into a context that is more clinical in nature, understanding that the reason people are in your class is not solely because they need to learn your discipline, but because their ultimate goal is to become effective practitioners and your course is a means to that end. As Kosslyn states, “You need to speak to your audience, not speak at them.” Thus, the idea is to present not too much, nor too little information. Further, your communication has to be based on prior knowledge of important concepts and jargon.

Goal 2: Direct and hold attention. You should lead the audience to pay attention to what is important in your presentation. Kosslyn makes this point: in the past, before we had PowerPoint, we used to provide our audience handouts of our lectures. Of course, what happened is that people would then simply read the handout and not pay any attention to the speaker. The corollary today is that not only might we give a handout of our slides now, we also gussy up our slides so that the audience is busy looking at everything on the slide, but are not listening to us when we speak. Since a slide show occurs over time, and because people cannot go back to read over something at their own pace, we have to present material is a way that leads the audience step-by-step to where we want them to be, but that does not lose them along the way. Thus, the slide show has to hold the audience’s attention. Kosslyn offers three tactics to help accomplish this: the principle of salience, the principle of discriminability, and the principle of perceptual organization. These refer to how we actually make sense out of words and symbols on a projected image; for further detail, see pages 7-8 of his text.

Goal 3: Promote understanding and memory. A presentation should be easy to follow and easy to remember. This is where I myself need more training, since I think my own slides do not accomplish this as well as I might like. But if you understand just a little bit about how humans process information into memory, it may help in how you craft your slide presentations. A message is easiest to understand when its form is compatible with its meaning. In a classic experiment, if you project the words “red,” “blue” or “green” first in the same color as the word, people can easily state the right color when asked, but if you use other colors (such as projecting the word “blue” in red ink) it is much harder for people to get it right all the time. Another dictum is that people can process only so much information at once, so you should work to ensure that your message does not present too much information at a given time.

These three principles drive the better part of the complete text for this excellent little book. PowerPoint is not just about using a technology to present as much information in a given period of time as possible; it is about using that technology to help process that information for later use. Applying psychological principles can help do just that.


1. Kosslyn SM. Clear and to the point: 8 psychological principles for compelling PowerPoint presentations. New York, NY; Oxford University Press, 2007

Monday, November 23, 2009

Strategies for Using Evidence-Based Practice in Clinical Teaching

On Thursday and Friday November 19-20, I attended a workshop on evidence-based practice with members of the PCC Davenport Clinician Early Adopter Group, which was held at the University of Iowa Medical School. The course spent much of its time introducing faculty clinicians to a set of concepts drawn from evidence-based practice, including sensitivity and specificity of diagnostic tests, likelihood ratios, relative risk and odds ratios. All were presented in the context of clinical training. This workshop was led by Dr. Mark Wilson, the director of graduate medical education for University of Iowa. Mark has devoted much of the past decade to becoming an excellent instructor in EBP, and he has played a role in the development of the program on teaching EBP at McMaster University. As part of the program, Mark focused on strategies to help weave EBP into clinical teaching, and the following ideas are drawn from his work and should be credited to him. Mark has offered the following points among others he suggests (1):

1. To teach EBP, you have to use it in your own clinical practice. This is an important point, which recognizes that you will become better at teaching this concept as you become more comfortable with using it yourself. As you progress in your knowledge and confidence, you will find better ways in which to approach how you can teach. Familiarity breeds better responses from you when questioned by your students.

2. Assess your learner’s EBP readiness. Keep mindful that your initial enthusiasm may not be matched by your student’s. Learn to gauge their readiness on a daily basis.

3. Diagnosis both the patient and the learner. You, as a clinical teacher, need to be attuned to the information your patient gives the learner, and you need to be equally attuned to how the learner processes what they are told. You are therefore focusing on diagnosing the patient, while at the same time doing something similar for the student’s learning.

4. Select which clinical question(s) to pursue. When working up a patient, realize that it may not be possible to consider every issue you might want. Help your student interns focus on ones that they need to answer, and which serve as wise learning points.

5. Cultivate curiosity by showing your own and celebrating it in others. It is okay to note that you do not have an answer, but that you will look it up and share it with others; when you do so, be enthusiastic so that you model a form of behavior which will serve the learner well in practice.

6. Bite off less than you can chew. I remember Mark making this point quite clearly. He is recognizing that we have only so much time to do what we need, and he recommends that we keep the learning to manageable amounts. And tailor this to each individual student.

7. Use pre-appraised evidence resources. There are numerous excellent sources of evidence and information that we can direct our students to. For example, the LRC just added DynaMed to its battery of online resources, and this is an excellent source of summarized information about hundreds of medical conditions. Better yet, it can be used at point of care.

8. Emphasize interpreting and applying evidence. Show your students how you use the evidence you find. Model the best clinical behavior so that others can see how this is done well.
9. Exploit the learning opportunity, not the learner. Share in the activity of gathering and applying evidence.

10. And last, mark suggests that you “be fearless.” Get out there and do it, and don’t worry if you feel you lack mastery; you have to start and get going. You’ll get better the more you do it.

As we get ready for a short break this week, I would like to wish you all a happy holiday and a restful few days off.


1. Wilson M, Richardson WS. Top strategies to weave EBM into your clinical teaching. Handout. Palmer teaching faculty, November 20, 2009

Monday, November 16, 2009

Clinical Questions Continued

Sackett and colleagues provide a set of 10 central issues in clinical work that lead to clinical questions. This information can be found in a table on page 19 of their small text (1). Among them are:

1. Clinical findings: this refers to the need to gather information about a patient and then be able to understand and interpret the information, which comes from the physical examination and the patient history.

2. Etiology: this refers to the need to understand the cause of disease.

3. Clinical manifestation of disease: this refers to knowing about how a disease causes the clinical manifestations seen in the patient and how a clinician can use that information to help classify the patient’s illness.

4. Differential diagnosis: after a patient has arrived for examination and treatment, how do we work through the list of possible diagnoses that may be present and decide which among them are most likely?

5. Diagnostic tests: what tests should we use for a given patient? How do we interpret the results that we receive? What do we know about the precision of the test, its sensitivity and specificity, and how do we come up with a pre-test probability for the presence of a disease in order to use a likelihood ratio to find the post-test probability?

6. Prognosis: how well can we predict the course of care and patient response to our treatment? How well can we predict the complications that might occur?

7. Therapy: How do we know which treatment to offer the patient, so that we help them rather than harm them? How do we know whether the costs justify offering a given treatment?

8. Prevention: Can we identify risk factors for a given disease? Can we create interventions to help reduce those risk factors? Can we find valid and effective screening procedures?

9. Experience and meaning: How well can we understand what our patients are experiencing as they progress through the course of their illness? Can we empathize with them as they do so? Can we appreciate the meaning the find in what they undergo? Can we understand how that meaning may help or hinder their response to our care?

10. Self-improvement: how can we use the cases we see to help keep us up-to-date and to help improve our clinical skills?

As you can see, a doctor-patient interaction creates fertile ground for the generation of clinical questions which can help drive an evidence-based practice. In terms of chiropractic education, this helps create an environment where every patient is a potential source of learning beyond the singular treatment of that patient. Our education is geared toward the time our students enter clinic; once in clinic, their patients should drive their education. This model helps do just that.

1. Sackett D, Straus SE, Richardson WS, Rosenberg W, Haynes RB. Evidence-based medicine: how to practice and teach EBM. New York, NY; Churchill Livingstone, 2000:19

Friday, November 6, 2009

Where and How Clinical Questions Arise

In the practice of evidence-based chiropractic, there is a significant amount of attention paid to developing good clinical questions. Part of the approach used to teach EBP is to focus on the development of a so-called PICO question; that is, a question that asks us to determine what the population of interest is (for example, middle-aged women), what the intervention of interest is (for example, adjustment), what a comparison intervention might be (for example, exercise or physical therapy) and what the outcomes of interest are (for example, decreased pain and disability). As you can see, this is all contextualized around the patient, not around formal content.

Sackett and colleagues (1) note that it is their experience, not based on data from clinical trials, that it is helpful to formulate clinical questions clearly, because in their experience it helps find evidence faster, finds better evidence, and is used more wisely in clinical care. The find that well-formulated question help then in the following ways:

1. It helps them focus their scare time resources on evidence directly related to patient need.

2. It helps focus on evidence that addresses the knowledge needs of their learners and of themselves.

3. It can help develop better search strategies.

4. It helps suggest the form that useful answers might take.

5. It can help with better communication between colleagues if referral is needed.

6. It can help model appropriate learning behaviors and adaptive processers among learners.

7. Answering questions is itself something that helps reinforce our own curiosity, restores our cognitive resonance and makes us happier as clinicians and/or teachers.

Thus, the context for teaching EBP should center around the patient. This may seem a challenge if you are someone teaching a first or second trimester course, but you can always set up scenarios that involve a simulated patient to drive home a learning lesson about a basic science topic. As students progress through the DC program, more and more of their time ends up focused on clinical training specifically. It is likely, therefore, that we as teachers and educators could anticipate that many questions will now arise related to clinical issues: clinical findings, etiology and prognosis, differential diagnosis, diagnostic tests, therapy, prevention, and patient experience and meaning. A later blog will probe these issues.

(Note: I am posting this today rather than on Monday, November 9, as I will then be attending the annual conference of the American Public Health Association. The next post will occur on November 16.)

1. Sackett D, Straus SE, Richardson WS, Rosenberg W, Haynes RB. Evidence-based medicine: how to practice and teach EBM. New York, NY; Churchill Livingstone, 2000:19

Monday, November 2, 2009

Setting Direction with Learning Outcomes

The excellent text “Learner-Centered Assessment on College Campuses: Shifting the Focus from Teaching to Learning” (1) offers a nice overview of how to set direction on outcomes as the means of recognition of learning. The note that learning outcomes can be developed at the level of a single course, an academic program or the entire institution. And they note that a typical initial response to the question of how you would describe your current teaching goal might be for you to say that you are trying to provide the best course you can, or an opportunity for students to learn. This puts the focus on you as an instructor, rather on the student as a learner. It might be better to think of the answer to that question as based on what your students should know and understand, and what they should be able to do with that knowledge when the course ends.

There are three benefits to formulated intended learning outcomes. The first is that intended learning outcomes form the basis of assessment at the course, program and institutional levels. We have intentions about what students in the program should learn, we develop collective expressions of our intentions, and we then develop our curricula and instructional experiences so that students learn what we want them to. A second benefit is that intended learning outcomes provide direction for all instructional activities. They form the basis of our planning process, and they help us know what your students should look like when they graduate. A third benefit is that learning outcomes informs students about the intentions of the faculty. This can help them best take advantage of the learning opportunities the institutions offers.

Huba and Freed propose a number of specific characteristics of effective intended learning outcomes. They should be student-focused rather than professor-focused. They should focus on the learning resulting from an activity rather than the activity itself. They should reflect the institution’s mission and the values it represents. Intended learning outcomes should be in alignment at the course, academic program and institutional levels; these should like and relate to one another. Learning outcomes should focus on important, non-trivial aspects of learning of importance to the public. Certainly, we would with this for chiropractic health care as taught by Palmer College of Chiropractic. Learning outcomes should focus on skills and abilities central to the discipline and based on professional standards of excellence. We this now with our work on professional standards as taught within the Palmer system. Learning outcomes should be general enough to capture important learning but clear and specific enough to be measurable. Certainly, work by administrative personnel such as Drs. Percuoco, Haan and derby attest to this fact. Finally, learning outcomes should focus on aspects of learning that will develop and endure but that can be assessed in some fashion right now. While we have goals for how our graduates will practice years from now, we need to assess them right now, right here.

In the end, we need to collect data to see how well our students are learning. Tests help to do this but are not the only mechanism that exists. All of us have engaged in the process of developing learning outcomes, and will continue to do so. This helps to better define our graduate and his or her skills.

1. Huba ME, Freed JE. Learner-centered assessment on college campuses: shifting the focus from teaching to learning. Boston, MA; Allyn and Bacon, 2000:91-119

Monday, October 19, 2009

And Now for Something Completely Different

Following the long tradition which I have only just now created, and given that it is the end of the term here at the Palmer Davenport campus, I have decided that this last post of the term shall be dedicated to a series of fun and interesting video clips rather than to a discrete educational topic. It has, in reality, been a long and difficult term for those of us here, so as we get set for break- and as those at Palmer West and Palmer Florida do not- here are a collection of completely unrelated, funny, or novel clips from youtube. They are of no educational import whatsoever, but are just some serious fun. When I return to this blog in a couple of weeks, I’ll be back to posting on education, scholarship and research, but for today, enjoy!

1. This first clip is from the late and lamented comedy show “Whose Line is It? The show often featured a skit where the comedic improvisers had to riff on some outlandish occupation, and in this one they skewer chiropractic.

2. This second clip features one of the most incredible musical engineering machines I have ever seen. I thought it was real, but recently learned it is a computer animation. Nonetheless, it still inspires awe in me.

3. This clip is entitled “little girl catches big fish.” Boy, does she ever. Who doesn’t love a little girl catching a big fish, especially when she just picks it up out of the water?

4. And who doesn’t love crazy basketball shots. These guys are masters at this game, and no one has ever shown these are not real. This is their “summer camp” version. You will see why, and I am guessing at the camp they are seen as kings.

5. I have an interest in extreme musical instruments. I figure you should as well. Here is something you have never seen before, a subcontrabass flute; in fact, this is the world’s largest flute.

6. And here is a contrabass saxophone. I’ve actually seen one played in concert, by the jazz musician Anthony Braxton, and all I can say is it sounds like an elephant. In heat.

7. As long as our current theme is music, I also find appealing people who find new ways to play their instrument. Working in a traditional medium, the guitarist Stanley Jordan uses two-hand tapping to create interlocking counterpoint, as he does here on the jazz standard “Autumn Leaves.”

8. And here is another guitarist, with a different method of doing two-hand tapping, here to create percussion counterpoint. This is Preston Reed, performing “Rainmaker.”

9. No amount of humor can ever get enough of Monty Python. I consider this clip the funniest clip the Pythons ever did, and it features John Cleese as the Minister of Silly Walks.

10. Hey, it’s my blog, so we get a Buffy clip; this time, of outtakes. Watch carefully for the one where Charisma Carpenter forgets she is supposed to be in character as Cordelia Chase and actually introduces herself as… herself.

And that's all folks. For now. PCCD, enjoy the break. PCCW and PCCF, enjoy the work. Soon enough, it'll be your turn again. Best wishes to all of you!

Monday, October 12, 2009

The Belmont Report

In the annals of research ethics within the United States, the importance of the Belmont Report ( cannot be overstated. It was an outgrowth of the National Research Act of 1974, which came about because of a series of events that had occurred in the 30 years leading up to the implementation of the Act. While the initial impetus came from the discovery of the Nazi atrocities in World War II, the fact was that even in the US there were research ethics violations, including the Willowbrook hepatitis study (involving retarded children), the Jewish Chronic Disease Hospital study (involving chronically ill but demented patients), the Tuskegee syphilis study (involving elderly Black sharecroppers), the thalidomide crisis, and other events. The Belmont Committee was charged with developing a framework for the ethical conduct of research, protecting those people who would be willing to participate as research subjects. Three principles emerged from the conference: (1) Respect for persons; (2) Beneficence; and (3) Justice.

Respect for Persons: Two issues arise with regard to respect to persons. One is that individuals are to be treated as autonomous agents, and the second is that those with diminished autonomy would require additional protection. This makes sense in that some of the most egregious violations that had occurred involved vulnerable populations- the poor, children, the elderly. Thus, the issue here is autonomy, or the right of people to self-determination. Embedded in this precept is the concept of informed consent. That is, no one should consent to being a research participant without being informed about the risks and benefits of that involvement. For a competent person, this requires disclosure of information and then an ability to make a decision to participate free from any force or coercion. In the case of someone with diminished competency or who is not competent (such as children, who are not legally competent), a surrogate (such as a parent) must make that decision.

Beneficence: This means more than simply do no harm; it means that efforts must be taken to reduce the risks for participation while doing what you can to enhance the benefits, if any are there. Today, the leading ethical framework for bioethics (1)- principlism- has broken the harm aspect out from the benefit aspect, so that one might talk about beneficence and nonmaleficence, to do good and to do no harm, but they are obviously different sides of the same coin. One of the issues that arises in clinical research is known as the therapeutic misconception, which occurs when patients confuse the goals of research (generalizable knowledge) with the goals of clinical practice (doing all you can to help the patient). Researchers are constrained by research protocols which they must follow, meaning that they cannot do all they can for a specific patient, something most patients initially do not grasp.

Justice: This relates to more than simply how we disburse health care resources. In the context of research, it also addresses the need that everyone share equally in risk if everyone will end up sharing in the benefit. Thus, we should not always look to local impoverished populations as research subjects because we know they are easily available and likely to find a small enticement more desirable than a wealthier potential research base. Our research should not systematically select specific classes or types of individuals because they have a compromised position in society.

The Belmont Report was an influential development in research ethics, and one that is very much a part of today’s research environment. Anyone considering conducting research should familiarize themselves with its precepts.

1. Beauchamp TL, Childress JF. Pricniples of biomedical ethics, 6th edition. New York, NY; Oxford University Press, 2009

Monday, October 5, 2009

Epidemiological and Clinical Research Strategies and Designs

As a reminder, note that the single most important hallmark of a scientific theory is that its hypotheses are capable of being disproved. Experimental studies, when done, can be excellent tests of hypotheses that we could not otherwise examine were we to simply try to observe naturally occurring events. But it is equally important to note that the kind of questions we ask in research cannot all be answered using the same exact research design; the design we use when trying to understand the factors that lead to, say, low back pain is very different from the design we use when trying to see which of two interventions is more effective at decreasing the pain seen with that same low back pain. Thus, knowing a bit about design is very helpful when you read journal articles, because the design of the study is a key to looking at what the study is about.

Generally speaking, we can classify research designs into two broad categories: descriptive (or analytic) designs and experimental. This is a broad classification, because there are also quasi-experimental designs, and non-experimental designs which can be used in clinical research, but this larger classification breaks the study designs down nicely. Descriptive studies are done when for whatever reason we cannot have control over the independent variable. For example, we might look to see if vibration from driving a truck leads to a higher incidence of low back pain- but the interval to do so here might run into years between exposure and outcome, and we would not want to set this up as a clinical trial where we expose some people to vibration over the course of a year and compare them to controls who were not exposed. In experimental designs, the intervention is under the control of the researcher, and this helps limits threats to validity.

The following is by no means all-inclusive, but is an introduction to common research designs. Descriptive designs include cross-sectional studies, case-control studies and cohort studies. Experimental designs include randomized clinical trials and cross-over designs.

Cross-Sectional: This assesses health status and exposure levels of individuals within a population at one point in time. By this, I mean that we are collecting this from each person at one point in time, not that we gather all the data at a single point in time. The classic example of a cross-sectional study is a survey. What we are looking for is a potential association between some causal factor and a condition of interest. For example, we might ask to see if people who have more than 3 drinks per day have higher rates of liver disease than those who do not. We cannot say if one causes the other, only that they are associated with one another.

Case-Control: In a case-control study, we look backward in time (retrospectively) to examine exposure factors between a group of people with the condition of interest (the cases) and those without (the controls). So we are likely looking at patient records in doing so, and we are trying, as much as possible, to ensure our populations are matched on all factors save for the presence of the condition of interest. These kinds of studies cannot determine the risk of developing a disease, but can determine the odds of doing so. An odds ratio can be calculated providing this information- this was discussed in an earlier blog post. Here, the OR is simply the ratio of odds of the cases being exposed divided by the odds of the controls being exposed to some factor.

Cohort: In a cohort study we follow patients forward in time and compare outcomes after one group is exposed to some suspected factor of disease while the other group is not. Such studies can last for many years, and the benefit of this design is that it is capable of detecting whether an exposure precedes an outcome; that is, does drinking 3 glasses of alcohol per day lead to a higher rate of liver disease? Thus, in a cohort study, we can determine a risk level, in this case a relative risk of developing the condition of interest between the group exposed and the group not so exposed. This is a particularly strong epidemiological design to use.

Randomized Clinical Trial: This is the classic pre-test/post-test randomized experimental design used in clinical trial research. It begins with two groups that are as similar in all important demographics as possible, and then subjects one to an intervention the other does not get, and finally compares the outcomes between the two groups. This design permits the statistical comparison of the two groups. It can be set as a factorial design when there are several explanatory variables involved.

Cross-Over: This design provides a treatment to one group while the other receives either a placebo or alternative treatment, and then switches those assignments at some specified point in time. There is usually a wash-out period involved to allow for time so that the initial treatment does not influence the alternative treatment. This is a complicated design that carries a high risk for drop-outs due to the time necessary to conduct the study.

As always, the idea is to use the proper design to answer the question, the best tool for the job, so to say. This is but an overview of the topic, but may help you as you read journal articles.

Monday, September 28, 2009

Establishing the Positive Classroom Climate

I often find myself wondering how it is that we’ve come to where we are. By which I mean, I contrast my own experiences as a student in chiropractic college (1976-1979), my experiences in 2 master’s program taught by distance education (one using course packets, and one online), and that of my students in my 9th trimester course in Evidence-Based Chiropractic. Certainly, the world has changed; the technology is vastly different now. When I began teaching, in 1980, to project something to the class required me to first make a copy of the image, then transfer it using a copier onto a transparency sheet. It was a time heavy process, and I still have my originals acetates that I used back then. Today, of course, we can use PowerPoint to the same effect, and we have invested heavily in the infrastructure to host a variety of technological advances in our classrooms. But this simply affects the means of delivery; we still need to take learning style and expectation into account.

One of the ways we can help begin to do so is to set a classroom climate. According to Linda Hilsen (1), “connecting learning and living is the purpose of education. Establishing and sustaining a positive classroom climate will result in more effective teaching” as well as a more satisfying experience for students. To that end, she has produced information to help aid in setting that climate. Some of these suggestions are common sense, but all are designed to help set the stage for how you will conduct your class and what your expectations are. I offer but a few and refer you to the chapter for the full detail.

- Get to class early and speak with your students as they arrive. I do this every class.

- The first 15 minutes of your first class session is critically important in helping students decide what kind of teacher you are and what they will experience in your class. It is important here to demonstrate enthusiasm about your course. Be prepared and carefully structure that first session. I use a lot of humor in this first 15 minutes, in order to release tension, demonstrate that I know they work hard, and that I share their concerns and understand them.

- A small amount of self-disclosure can help humanize you in your students eyes. I do this by noting a few comments about my kids (who are the same age as my students now), and by noting my interest in cultural benchmarks such as Buffy the Vampire Slayer. Yes, this seems silly, but what it does is show that I exist outside the classroom, that I have interests and am interesting and that I am willing to make fun of myself.

- Let your students know you are available. You can discuss your office hours, but also note that you are free at other times and are always willing to meet with them. Be flexible, and work out times for meetings.

- Describe your goals for the course and your expectations for your students. I do this, and I also spend some time with certain expectations regarding issues such as attendance, phones in the classroom, bringing children, needing to leave early, etc.

- Learn student names. This is a problem I have had because I have only a single session with my students each week, early on Thursday morning. But I work hard at attempting to link names with faces, and then address students by name. And it never hurts to ask a name.

- Hang around when class ends for those students who want to follow up on an issue. I simply do this each class session.

- Look students in the eye in the classroom as you lecture or as you discuss issues. Be positive.

As I said, this is all common sense, but is often forgotten. I can remember fondly those instructors I have had who took the time to know me, to treat me with respect, and to care about what I was learning. We have all been there, and even now, we are all still there. Keep up all the good work.


1. Hilsen LR. A helpful handout: establishing and maintaining a positive classroom climate. In: Gillespie KH, editor. A guide to faculty development: practical advices, examples and resources. San Francisco, CA; Anker Publishing, 2002:146-155

Wednesday, September 23, 2009

The New York Times and “Cracking the Spine of Libel”

I thought I would diverge from discussing educational issues to look at a new article just posted in the New York Times, on the 16 September, 2009. The article, which is actually an entry in the blog by scientist Dr. Olivia Judson reports on efforts by the British Chiropractic Association to sue scientist and author Simon Singh for libel. You can read the full article here:

Singh is a co-author, along with Dr. Edzard Ernst of the University of Exeter, of a book entitled “Trick or treatment: alternative medicine on trial.” Singh is a particle physicist by training, and Ernst is a research scientist and also the editor for the journal Focus on Alternative and Complementary Therapies (Disclosure: I am on the editorial board for that publication). The suit revolves around comments that Singh made about claims he found on the BCA website regarding chiropractic treatment for pediatric conditions. I think you can likely infer a potential bias after reading that title.

At issue is a statement that Singh made. He said this, in an article published in The Guardian, one of England’s most respected newspapers: “The British Chiropractic Association claims that their members can help treat children with colic, sleeping and feeding problems, frequent ear infections, asthma and prolonged crying, even though there is not a jot of evidence. This organisation is the respectable face of the chiropractic profession and yet it happily promotes bogus treatments” The BCA complained about this comment to the Guardian, and asked that the comment be retracted. After this was refused, the Guardian offered the BCA a chance to publish a counterpoint to Singh's comments, which they turned down. The suit then ensued, under Britain’s libel laws, which differ from those here in the United States. The use of the word “bogus” seems to imply that the BCA knowingly lied to the public in its comments, and in fact, happily did so. Necessarily, people are looking to see how this case plays out, since it has implications related to the normal scientific criticism that is part of the world we live in; some feel it will have a chilling effect. I disagree.

I think the BCA was correct in not accepting the offer from the Guardian. From my perspective, all that would do is (a) keep the case in the public eye, similar to what we saw two weeks ago with Rep. Joe Wilson yelling “You lie” to the President, and (b) confuse the public with a “he said, she said” argument that they cannot help but not completely understand. What is patently clear is that even though Singh says there “is not a jot of evidence,” that appears factually incorrect. I know; I was editor for the Journal of Manipulative and Physiological Therapeutics when it published articles examining the effectiveness of chiropractic manipulation for conditions such as otitis media, infantile colic, and other conditions. Now, this research might be criticized on methodological grounds- all research can be- but it does comprise evidence. Singh likely meant to be making a hyperbolic statement, but doing so in a public setting does not necessarily let him off on free speech grounds, not when he potentially damages an entire profession by his factually incorrect words- the ruling was that he was offering a statmement of fact, not an opinion. Or, to be clear, this is how I feel; I cannot speak to the legality of what he said as it might be interpreted by British law. I am offering only my opinion here.

It will also be illustrative to read the comments that follow. Initially, they start out generally negative toward chiropractic, but then switch to speak more in favor; however, the negative comments are really negative- one refers to “chiroquaxtery” and another to “chiropractry.” I commented under the screen name Dana5140, and others in our profession have added words as well. I would say “enjoy,” but that may be the wrong word here; however, please do read this and get a sense of the issues that arise.

Monday, September 14, 2009

The Palmer Institutional Review Board Website

Over the past few weeks, I have had a number of conversations designed to help faculty plan small-scale projects such as surveys, in preparation of the upcoming ACC-RAC conference in March 2010. Because of these interactions, I can see some areas where a little guidance can help you prepare IRB applications and plan for your projects. I wanted to therefore discuss what is present on our IRB website.

The website is located at, and as I write this I should note that the IRB is undergoing some change after its move from the Research Department to the Office of Strategic Development, where it is part of the overall college compliance function. Thus, some additional changes to the site may occur in the near future. When you log on to the home page, you will see a list of personnel to contact for information, as well as a set of links on the left side of the page. These links are to (1) IRB forms, (2) IRB meeting schedule, (3) IRB member’s toolkit, (4) Policies and procedures, and (5) Researcher’s Toolkit. In addition, there is a link to frequently asked questions (FAQs- this link has yet to be populated with information). Let me hold for a moment on the forms link, since that is the one you need for submitting an application. The meeting schedule will be useful for you in planning; you will need to submit your completed application 2 weeks ahead of a meeting for it to be included in that meeting. Plan accordingly. The IRB member’s toolkit provides some information for IRB members, including links to the CONSORT document, the online training program at NIH for IRB members, and a set of other links about proper IRB function and law. It is still under construction at present. Policies and procedures is a link to PCC policies about research, as well as a link to the Office of Human Research Protection (OHRP). The researcher’s toolkit provides a set of links that can be of help to the novice researcher, including a link to the NIH training program in clinical research that should take if you desire to conduct research.

But of main interest is the link to the IRB forms. If you wish to conduct a study on campus, such as survey of students in a course you teach, you must complete the IRB application form, which is listed as the first link in the material on this page. When you click that link, it will allow you download a form that makes it possible for you to input information. Take this form very seriously and think about the questions it asks you. You will need to provide some detail, and you will have to provide a thoughtful plan for what you plan to do. This includes information on how you will recruit your participants, how you will analyze data, how you will protect confidentiality and let people know they do not have to participate in what you are doing, what methods you are using, and so on. Each question must be answered on the form. Question 5 is critically important, and it has many sub-questions (5a-5i). Questions 8, 9 and 11 are also quite important. Note also that the final page requires your signature as well as that of your supervisor.

I know that this seems burdensome, but it is not. It is designed to ensure that (1)all participants in research at Palmer College are properly protected, (2) Palmer College is in compliance with 45CFR46, the so-called “Common Rule” governing the use of human subjects in research, and (3) you have thought through your project and can complete it with success. It is part of the process of conducting research. As always I am ready to help you in this regard. Look over the material and let me know any questions you have.

Tuesday, September 8, 2009

Designing a Website

Few us working in academia are trained to be web designers. But most of us can visit a website and decide whether or not we feel that the site is designed intelligently or not. We may now even know what criteria we use to make that decision. And even there we know that many of these sites use professional designers to create the site. So what can we do?

Bell (1) starts with one thought in mind: content before design. By this he means that you should gather all the content you want to place on your site and use that to guide your design decisions. So if you are building a site for your class, consider the content first. What information do you want your students to have? Would you include your syllabus, background readings, links to pertinent websites, study guides, even your CV? All of this will guide how you design your site.

One suggestion offered by Bell is to visit sites that link to winners of web designer awards, to provide you new ideas you can incorporate into your own website. All of these will link you to sites that are creative and easy to use. He suggests you look at:

- Webby Awards:
- Website Design awards:
- LevelTen Interactive:
- Avenue A/

Bell discusses the importance of color. Color creates mood and can make a site interesting and bold or dull and boring. Beyond that, our eye will find some color combinations more appealing and easier to read than others; also, some of your students may potentially be color blind. I will not mention here how to locate the Html hex color, but will note that what you want to have is a color scheme, a set of colors on your site that complement one another. There are websites which can aid you in developing color schemes, and among them are:

- Colorcombos:
- Color Palette Generator:
- ColorBlender:

As for fonts, Bell recommends that you avoid all fancy fonts and select system fonts that display well on web pages. I know that some of us like to use fancy fonts because they are different, but remember that different does not necessarily mean good or better. It is still best to use black text on white backgrounds; moving to the use of color here can easily make your text harder to read unless you ensure a reasonable amount of contrast (such as green text on a black background, instead of yellow text on an orange background).

A few short rules: include images, but not an excess amount. Keep the design simple so you don’t overwhelm your visitors. Don’t use attention grabbers, such as flashing text. And be consistent from page to page. This is just a start on good design, which is critical to usability.

1. Bell M. Build a Website for Free. Indianapolis, IN; Que Books, 2009

Monday, August 31, 2009

Planning a Website

Mark Bell, in his text Build a Website for Free (1), notes that the central question you need to answer before you begin the process of developing a website is: Why do you want to build a website? While it may seem obvious to you that you wish to build a website to provide a means to share information with your students about the classes they take with you, it is not quite that simple. Knowing the answer to this question can help you with the design of your site, with the information you provide on it, and with its functionality.

Bell notes that there are several types of sites that you might build: business, personal, social or informational. Typically, we would consider an educational website as an informational site; that is, its purpose is to provide information to your students. Bell suggests you revisit the last few websites you have visited and ask yourself what type of site each is, and then consider why you feel that is the correct answer. As you do so, you should begin to see the differences in how each site is organized and what it is attempting to do.

Then, ask yourself what the overall goal of the website is. What do you want to accomplish? How would you structure your website to achieve those goals? What elements do you see in other websites that would help you do so?

Once you have the goals firmed up, you need to organize the site. You should consider how you will links elements of site to each other, and indeed what elements you feel you should place on your site. Keep mindful that all a website is is a series of pages linked to each other in various ways. You should sit down and sketch out your plan for your site. From the home page, what do you think should be the main secondary page links? From those links, what other links should be present? One example might be to place main links to the courses you teach on your home page, and then once each new page opens for a specific class, you can link to the main documents for that course, such as syllabus, policies, etc. You should also begin to consider how the design elements of your page may allow for ease of use.

Best practices for website development include the following: (1) Keep the website simple. Simple websites allow your message and goals to be easily understood. We have been to websites so busy and complex we cannot find the information we are looking for. (2) Keep the website consistent. Make it a unified whole. Your pages should all contain the same design elements, and the information should appear in the same location on each page. Keep the pages uncluttered. Make sure headers and footers always appear in the same location. (3) Keep your website easy to maintain. A website is a living document requiring constant monitoring and updating. Links to other pages can go dead, your course syllabus may change every term, you may find new information to share, etc. The better designed your website is, the easier it is to maintain.

This is a first step to creating websites that will be of great use to you in communication more effectively with your students. Consistency is important, as this enhances communication. If you have a website, look at it and ask if it is consistent in its presentation; if you do not, remember to work on this as you move forward in developing your new website.

1. Bell M. Build a Website for Free. Indianapolis, IN; Que Books, 2009

Monday, August 24, 2009

Creating a Website

A number of us here at Palmer College maintain our own websites, upon which we place information about the courses we teach, provide links to information, and update so that our students can obtain course syllabi, and so on. The quality of these sites ranges from relatively modest to good, but more importantly we are taking advantage of this technology, of which most of us are regular users, to become creators in an attempt to enhance student learning. But in saying this, I also must note that most of us have done this on our own, perhaps with help from the CTL, but often without a real understanding of how best to accomplish the creation of a meaningful site. Let me offer here some thoughts on this.

Creating a website is really a 5-step process. I think that it is important to site and first plan out the site, then design it, build it, test it and finally publish it and maintain it. Planning is critically important. Questions you might ask yourself are: What are the site’s functions? What are its goals? Will people be expected to use the site regularly or come to it only infrequently? Sit down and consider what you want to offer on the site, and then map it out on paper. On my site, I provide links to syllabi and other course material, as well as information about myself, and links to papers and other sites I wish to share.

Design is not something most of us are trained to consider. And note that design is more than simply how the website looks; it takes into account how you organize each page, how you link those pages and whether or not you use programming language or a WYSIWYG web developer. You should consider looking at other sites to get ideas for the design elements you want to see in your own. Design is important, too, in terms of making the site visually appealing, which helps make it easier to read and to navigate around. We have all visited sites that are hard to understand when we first open them up; we should not create sites that do the same to others.

Often, people actually begin to build their site before they properly plan it out or consider the best design. Building the site includes creating pages, editing graphics and making links, creating scripts where necessary or desirable, and including other elements you wish to see. Fortunately, building the site has become much easier today. If you know html, you can write in that format, but it is not necessary to know html (hypertext markup language) to develop and build a site. Programs such as FrontPage allow you to build the site without the need to write in code.

Testing is often overlooked. What this means is that before you go live, you work your way through the site, making sure that all your links are active and take the reader to the correct location, that your graphics load quickly and properly and are placed on the screen appropriately (have you ever opened a site that loads up and is printed with some text on top of other text? That site was not tested properly). You can make sure that your navigation links are set up properly, so that a reader does not have to use the back button to maneuver back to a page that allows him or her to access other pages. This frustrates the user and often leads them to not come to your page again.

Finally, you can publish the site, and make it “go live.” But this is not the end of the story; you need to constantly update the site and maintain it. For example, I test links on the CTL on a fairly regular basis (though often, not regularly enough). It is frustrating to look up something, find the link, click on it, and then find out the page no longer exists. I have to remove these links and find new ones. I also have to change out course syllabi every term, to make sure my students get the correct dates for their class work. And I constantly read about web design issues in order to take advantage of the findings as I update my site, which I am never quite happy with.

For those of you without a website, you should consider creating one. They can ease your teaching burden in significant ways, and can provide an efficient means to communicate with our class. It takes just planning and consideration to do it right, and the CTL can always help if you wish it. An excellent book you may consider using is: Bell M. Build a website for free. Indianapolis, IN; Que Books, 2009.

Monday, August 17, 2009

Just a Little More on Office 2007

I have one last entry on some of the nice little touches found in Office 2007. Consider these:

Live Preview: This is a nifty little addition to the bag of tools Office provides. If you are in, for example, Word, you can see changes in your document without applying them for real. Here is how it works in action: select a paragraph of text from one of your Word documents, by highlighting the text. Then, go the font command (which will be listing the font you are currently using) and open the dropdown menu listing all the available fonts. Drag down onto any of the fonts in the menu, and you will then see that paragraph presented in that font. This can be done as well for the font size, and for the styles menu which appears to the right of the font command box. You can see how the material will appear before you decide if you wish to apply the changes.

Styles: With regard to styles, this command allows you to easily format a document without having to apply a series of many commands to lay out paragraph indents, heading weights, and so on. To begin, you should understand that when you open a new document in Word, what you are really doing is opening a template called Normal.dotx (or, if you have macros included, it would be Normal.dotm). This document has a set style in it, but most of us don’t realize that when we begin working on it. Now, if you look at the ribbon (the former toolbar, at the top of the screen), you will see (1) a set of styles already listed- these are known as Quick Styles; (2) a command to change styles, with a small down arrow in it, and (3) a bar at the bottom of the command entitles “Styles” with its own down arrow. If you move your cursor over the quick styles, you will see you document (if all is highlighted), or some part of it (usually the paragraph where your cursor is located), appear in that style, similar to Live Preview above. You will also see a small down arrow for this command as well, which if selected will simply provide your access to additional styles. I would suggest opening a document and playing with this for a while to see how the styles are applied, and then decide if you find one appealing. If you click on the “Change Styles” button, you will see a small screen appear. This will allow you to change a style(using “Style Set”), a color theme (using “Colors”) or change fonts (using “fonts” command). Finally, clinking on the Style bar will allow you to find the commands you are used to seeing , such as the “clear all” command.

Clearing Styles: This is a really useful command. Often I find that I cannot remove style commands that others have embedded in their documents; as a result, I cannot, for example, get bullet points to line up properly. In such cases, I can just use the “clear all” command to remove all style formatting. Once I do that, I can then use a Quick Style to reformat the entire document in a way that makes the information appear the way I wish it to.

These commands also appear in both Excel and PowerPoint, making switching between them all the easier. And it lowers the time necessary to make documents, spreadsheets and slides look professional. Since out students are pretty visually savvy, this can help them more easily understand the message our documents are designed to spread. This is all to the good.

Monday, August 10, 2009

Creating a Rule in MS Outlook 2007

I’ve just upgraded my computer files from MS Office 2003 to Office 2007. This had led to no small amount of existential angst on my part, since there are many changes in how things get done between the two versions, but overall, I think the upgrade was necessary and will lead to greater productivity. I had reached a point where a lot of the student files that I received were unable to be opened, since they were created on a newer version of Office/Word than I had available for my use. And my home computer, a Mac, runs Office 2008 for Mac. So, now I have to go and learn some new skills. Much fun will ensue!

But I have already found one very useful tool in the MS Office package, relating to Outlook. This venerable mail/scheduling program has more depth to it than simply delivering your mail. It can actually do things to your mail, and ease the burden you have of deleting the 30th post of the day letting you know you won the lottery in Nigeria, and offering to send you several million dollars if you will simply send them some basic information. Like your social security number, bank account number (so they can wire that money to you) and the names of all your kids. This is the “Rules and Alerts” entry in the program. It can automate functions for you to help organize all your email.

The “Rules and Alerts” menu is found under the basic “Tools” pull-down menu in the main Outlook screen. When you click on “Rules and Alerts,” it opens up a new screen in which you have a choice of two main tabs, one not surprisingly for “Rules” and the second for “Alerts.” We will open the tab for “Rules.” When you do, it brings up a screen that offers you a number of options, and you can read those over at your own leisure. But for now, let me use one example: you wish to have all of the Nigerian lottery emails sent to your "Junk Mail" folder without you having to take the time to do so one by one as they come in. So you can click on the line that says “Move messages with specific words in the subject to a folder.” Then click “next” on the bottom on the window. This brings up a second screen in which you can set the conditions for how you wish this to be done. Again, as an example, I will click on the line that says “with specific words in the subject.” You will note this instruction appears in the higher of two boxes in the window. Once you click that instruction, go to the lower box, and click the underlined words “specific words.” This opens a screen where you can type in the words you wish the system to track. For our purposes, type in the word “lottery.” Then, again that lower box, click on the word “specified” to denote which folder you want these emails to be sent. When the new window opens, click “Junk Email” and then “okay.” Once you do all this, you can click “next” on the screen. You will then be coached to list any exceptions to your rule. We don’t want one, so we leave everything unchecked and again click “next.” You will have to give this rule a name, so we call it “Lottery Rule.” Click on the box instructing the system to turn the rule on, and then click “Finish.” You are returned to the main “Rule” screen where your new rule appears in the window. Click “Okay” and your new rule is now operational. As every new email announcing your lottery winnings appears, it will be sent to your junk mail folder and will not appear in your main email window.

You can make all sorts of rules. You can make one so that all emails from your immediate supervisor are sent to its own menu, or are flagged for your attention. This is limited only by your needs and your creativity, but it can be a wonderful time saver. I no longer get much spam mail in my main window, and I can then just delete the contents of the junk mail folder once a day. It is a nice little feature, but not one I see a lot of people using. Consider taking a look at it. And if my instructions are confusing, here is a link to a video explaining how to create your own rules:

Monday, August 3, 2009

Really Simple Syndication

I’ve just upgraded my computer to Office 2007 (from the 2003 version which most people here still use) and one of the better features in this upgrade is the addition of a RSS feed to my Outlook system. In the 2007 version of Outlook, the RSS feed is located in the folder menu, under your Inbox. If you click on the folder, it will open a message in your view screen describing the features it offers. It is then an easy operation to click and add RSS feeds to your Outlook system.

But that begs the question. What is an RSS feed? RSS stands for “really simple syndication” and it represents a means for websites to easily share headlines and stories from other sites. Those of us surfing the web then can use something called an “aggregator” to collect those feeds and read them at our leisure. The Outlook program has its own aggregator, so that it can collect stories from the sites you tell it to. In my case, I have stories that come in from MicroSoft on the use of PowerPoint, Excel, and Word, and I also have the New York Times, Washington Post and MSN news linked. The stories go into folders for each newspaper and program, and I can then open and read at my pleasure, or simply delete a story if I do not want to read it.

RSS was actually invented by Netscape as a means to have an XML format to obtain news stories from other sites (because if they relied only their own reporters, of which they had few if any, there would be no stories to post). In order for a web story to be able to become an RSS feed, it has to have certain characteristics, which for the purpose of this article I need not describe (but which can be seen at What we are concerned with is adding the feed to our Outlook system, and for that purpose let me quote the system:

“Really Simple Syndication (RSS) is a way for content publishers to make news, blogs, and other content available to subscribers. You can view RSS content in Microsoft Office Outlook 2007. Using RSS, publishers can make content and updates available for download by subscribers automatically. The content on all Web sites is not available as an RSS Feed, but the list is growing daily.

How does RSS work in Microsoft Office Outlook 2007?
RSS readers, such as the one built into Office Outlook 2007, allow you to subscribe to RSS Feeds and then read content or follow links for additional information. Whenever you see a link to a feed, or an RSS icon such as the one at the top of this page, just click. Microsoft Office Outlook 2007 will automatically subscribe you to that RSS Feed.

Get started
Using Microsoft Office Outlook 2007 to subscribe to an RSS Feed is quick and easy and does not involve a registration process or fee. After you subscribe to an RSS Feed, headlines will appear in your RSS folders. RSS items appear similar to mail messages. When you see a headline that interests you, just click or open the item. For more information, read how to add an RSS feed to Microsoft Office Outlook 2007 and how to read your subscribed RSS feeds. Below is a sample of the many feeds you can subscribe to from around the world. Click on the links that interest you and Outlook will subscribe to them.”

This is an easy way for you to keep up with all new feeds from whatever sites you frequent, and I highly recommend you take advantage of this tool to do so. It is a huge timesaver.

Monday, July 27, 2009

RAGBRAI and Education?

I’ve just returned from riding my 5th straight RAGBRAI. For those who do not know what this is, it is the Register’s Annual Great Bicycle Ride Across Iowa. This is the nation’s largest and oldest cross-state bicycle ride, attracting between 12-13,000 riders per day each day of its week-long length, along with another 12,000 support personnel. The ride wends its way from the west side of Iowa at the Missouri River (this year beginning at Council Bluff, and ending at the east side of the state and the Mississippi River (this year at Burlington). I ride with a couple of other Palmer faculty and administrators as part of the larger Bicyclists of Iowa City. But as I rode those long miles (449 this year), it gave me time to think of some lessons from RAGBRAI which could equally apply to education.

1. Training matters. When I first began riding this year, back in March, I felt sore and uncomfortable during my initial rides. But I kept plugging away, riding 12 or 14 miles per day, not too much, and within a few weeks my legs felt better, my derriere was not hurting, and my wind got better. Now, I can ride for miles on end and I was able to finish the daily rides, even those of 80 miles, by just past noon each day. I am not skinny, for sure but I never ended up feeling too tired. Point being, the more we engage ourselves in what we do, the more comfortable we get at it, whether it is teaching, engaging in clinical practice, or our other work. Practice really does make perfect.

2. Working with a group matters. I think we see this best in the peloton of the Tour de France. In the peloton, it has been found that the energy need to keep riding at race pace is 40% less than that of a break-way group of smaller riders. Over the course of a 100-mile ride, that leaves the peloton with a huge energy surplus compared to the lead group as the race comes to its final miles, and invariably the peloton swallows up that lead group a few miles from the end, leaving the race wide open for sprinters who have huge amounts of energy left for the final 500 meters. Same in education, collaboration with your colleagues can lessen your own work load, can provide you assistance and can leave you with energy to devote to your own interests. We have a great wealth of talent in this institution, and collaborating with our colleagues is but one way to help you actualize your own abilities and talents.

3. Planning matters. RAGBRAI is a daily grind leading to a good result: completion of the ride. It requires a rider, especially one like me who is at best modestly competent on a bike, to think about the best way to complete the ride. Each day is marked by benchmarks- towns are so far apart, and nutrition is important. Do I eat first and ride, or ride for 10 miles and then eat? Should I get out early and avoid heat and wind or ride a bit later and avoid crowds? Even my thinking matters- if I start out thinking, wow, I have 76 miles to ride today, it sounds daunting. Maybe it is better to think, it is 12 miles to the next town; then, when I get to that town, I think now it is 10 miles to the next town. Breaking it down that way can reduce the larger tension of knowing I will be in saddle all day long. The obvious corollary here is in the work we do- when we look at the larger picture it can stop us cold and we might never even get started because what we plan to do is so complex. But looking at smaller pieces of our plan, and meeting each part, leads to small success but helps keep momentum.

4. You can do the impossible. This is some of what I saw this year on the route: a man riding RAGBRAI on a bicycle without a seat, so that he had to stand and ride the entire distance. People riding RAGBRAI on unicycles- how do they get up the hills? People roller blading RAGBRAI. A woman who was running the entire route, on a daily basis- that averages to 70 miles per day! A man riding a bicycle with a sail on in, the so-called Pterosail. People on single, fixed gear bicycles. 80-year old women riding the route. A 5-year old riding. If you set your mind to something and you work to make it happen, more often than not it will, it will.

I know the above may seem banal, but in fact I find that it posits a nice mechanism for helping me to accomplish my goals and to keep continually updating my abilities. It is a microcosm of a larger worldview, but one I find helpful. It helps me have faith in myself.

Ride on!

Monday, July 13, 2009

The Six Secrets of Change

A new book by Michael Fullan (1) looks at how leaders help organizations go through change. The six processes he described address what he refers to as large-scale reform, wherein the goal is to change whole systems or organizations. He notes that these six “secrets” are synergistic, feeding upon one another, and that they are heavily nuanced. By this he means that they require thought and consideration before being used. He suggests a need for motivational embedding, in order to motivate people to invest time and energy to get results. Finally, he notes the presence of tension, wherein a good leader will keep all of these six secrets in balance.

His secrets, in short are:

- Love your employees. An institution or organization should invest as much energy toward its employees as it does its customers. Translated to an educational setting, this would mean as much energy toward the faculty and staff as it does toward its students. And he places great importance on continual learning, so that people also continue to find meaning in their work and to their relation to their company or institution.

- Connect peers with purpose. Fullan discusses what he calls the “too tight – too loose” dilemma. This is the attempt to find balance between how much you delegate power during times of change; people may feel constrained if you tighten requirements too much, but if you let power devolve too far you may get uneven results. He suggests that it is necessary for leaders to build strategies that encourage what he calls purposeful peer interaction. People enjoy working with their peers and this can foster learning that leads to results.

- Capacity building prevails. This is where leaders invest in developing individuals and group efforts to enhance the efficacy of the group as a whole. People learn new skills and competencies and as a result undergo new motivation. Doing so requires a leader to avoid intimidation and negative judgment, but also to rely on peers to help drive the process.

- Learning is work. He feels that there is too little learning going on in formal training courses that institutions offer, and not enough that occurs while actually doing the work. He feels that good institutions link working and learning very effectively.

- Transparency rules. It is necessary for institutions to have clear and regular discussions of results, and continual access to practice. He states that continuous improvement is not possible without good data, which is part of being transparent. Finally, he suggests that transparency creates positive pressure to do better.

- Systems learn. He feels that systems can learn, and that using these processes you will increase both knowledge and commitment. But to do so, people need to have their motivation constantly stimulated so that it is deepened.

His text goes on to expand upon each of these ideas, and I found it a fascinating read that suggests new approaches we can all use in addressing change.

NOTE: I will be off campus next week so the next post will occur the week after. RAGBRAI beckons.

1. Fullan M. The six secrets of change. San Francisco, CA; Jossey-Bass, Inc., 2008

Monday, June 8, 2009

Team-Based Learning

Team-based learning is “an instructional strategy that is “based on procedures for developing high performance learning teams that can dramatically enhance the quality of student learning.” (1) Put another way, it is the use of small groups in college teaching. Most of us are familiar with small-group learning at some level, either by being a member of a small group in our education, or by fashioning them for use in a class that we teach. Why are we seeing a growth in such forms of teaching?

In part, I think it is due to the fact that younger learners are more conversant with technology, are less tolerant of lecture settings, and are tired of passive learning settings. Small groups not only enhance learning, but they also foster interpersonal skill development. And finally, small groups can be an exciting new method for teachers to use to help engage their learners. According to Fink, small-group learning is transformational, driving four separate kinds of transformation:

- Transforming small groups into teams
- Transforming technique into strategy
- Transforming the quality of learning
- Transforming the joy of teaching

Further, Fink also notes that there are three different ways to use small groups: casual use, cooperative learning, and team-based learning. Casual use represents the first use by an instructor, where perhaps after delivering a short lecture the instructor then asks students to pair up with the person sitting next tot hem to discuss a question or solve a problem. After allowing a short period of time to pass, the instructor then calls on some of those students to provide a response. Cooperative learning is a bit more complex. It requires advance planning, regular use of small groups, role assignment, and so on. However, it does not require any significant change in the current structure or format of the course in which it occurs. The small group activities simply are fit into that structure. The pinnacle, then, is team-based learning. Here, the structure of the course in changed in order to most effectively take advantage of what are now called learning teams. These teams require commitment from students and a desire to solve problems beyond the abilities of any single member. (1, p. 7)

Fink notes that for learning teams to be used, a course need only have a body of information that students need to understand, and that the students learning how to apply the content by solving problems or resolving issues. A classic example of this approach could be embodied in the small group process of problem-based learning in healthcare education. Lastly, Fink defines team-based learning as “a particular instructional strategy that is designed to (a) support the development of high performance learning teams and (b) provide opportunities for these teams to engage in significant learning tasks.” (1, p. 9)

It is likely we all use at least a small measure of team-based learning in our teaching; the question is how to systematize doing so at a higher level. The text by Michaelson, Knight and Fink provides a detailed examination in how to do so.


1. Michaelson LK, Knight AB, Fink LD, editors. Team-based learning: a transformatice use of small groups in college teaching. Sterling, VA; Stylus Publishing 2004:vi

Monday, June 1, 2009

The American Public Health Association

I’ve been a member of the American Public Health Association for nearly 15 years now, and am among only perhaps a few hundred people from our profession to join and participate. I’d like to take a little time here to describe APHA and advocate for you to consider joining as a member of the Chiropractic Health Care section. Information I present here can also be found on the APHA website, at

APHA is the oldest and largest public health organization in the world, and has been in existence since 1872. As the website notes, “the Association aims to protect all Americans and their communities from preventable, serious health threats and strives to assure community-based health promotion and disease prevention activities and preventive health services are universally accessible in the United States.” Amongst its members are practitioners, educators and health care professionals of an amazing diversity, and this diversity includes several hundred chiropractors. The vision of APHA is a healthy global society, and it has worked ceaselessly to that end for more than a century. Its mission is to “Improve the health of the public and achieve equity in health status.” APHA gives voice to the underserved and the forgotten, ensuring that our efforts at improving national health leaves no one behind.

Advocacy is a major activity of APHA, and it regularly publishes legislative updates of its actions; the latest can be read at

APHA has 25 sections, each comprised of major public health disciplines. Sections are the primary professional unit of APHA, and it is through its sections that much of its work is accomplished. I am pleased to note that one of the 25 sections is the Chiropractic Health Care section. As it is described on the website, the CHC “enhances public health through the application of chiropractic knowledge to the community by conservative care, disease prevention and health promotion.” The existence of this section is a result of the work of a number of people, but none more so than Dr. Rand Baird, who has been an APHA member for more than 25 years and was instrumental in growing the chiropractic membership. Palmer College has an active number of faculty and administrators among the members of this section.

It is important that we have this voice. Chiropractors serve on APHA’s Governing Council, and have made important input into public health policy. But our numbers are few and more should join. Please consider it. The investment of money pays off in influence, and our influence needs to be heard at the highest levels of our government. APHA can help make that happen.

Tuesday, May 26, 2009

Organizational Culture in Higher Education

In the business community, the focus on organizational culture really took off in the 1980, with the publication of books like Peters and Waterman In Search of Excellence. But since that time, there has been little agreement on how to view culture, and a number of theories have evolved. What is incontrovertible is that culture does play a role in aiding and resisting change. Change is, of course, inevitable in education.

Institutions are influenced not only by outside forces (ie, the economy) but by inside forces as well. This internal dynamic “has its roots in the history of the organization and derives its force from the values, processes, and goals held by those most intimately involved in the organization’s workings.” (1) Decisions and actions are a reflection of the organization’s culture. For those that have been in the culture for some time, the cultural values are part of the air they breath, not often considered consciously but almost always followed nonetheless. It is only when we break the codes of our culture that we find ourselves aware that they are there. But culture is a driver in educational organizations, and as our challenges become more difficult that there is a need to look at culture as a means to help address these challenges.

Tierney notes that organizational culture encourages members to:
- Consider conflict in the broad canvas of organizational life
- Recognize contradictions that create organizational tension
- Implement decisions with an awareness of their role on the culture
- Understand the symbolic dimensions of decisions and actions
- Consider why different groups have different perceptions about performance

Thus, Tierney offers a framework for looking at culture. In this framework, he considers:

- Environment: how does the organizational define its environment and what is its attitude toward that environment?

- Mission: how do we define the mission, articulate it, and use it for decision making? How much agreement is there?

- Socialization: How do new faculty (or staff or administrators) becomes socialized? How do we find out what we need to know to survive and thrive in our new environment?

- Information: What is information, who has it, and how do I get it?

- Strategy: How are decisions made? Who makes them? What happens if I make a bad decision?

- Leadership: What does the organization wants from its leaders? Who are they? Are there informal leaders as well as formal ones?

Our culture is conveyed in the relationships we have with our colleagues, and how we view what we see happening. No organization can be immune to the effects of culture, and understanding it is critical to aiding in innovation and change.


1. Tierney WG. The impact of culture on organizational decision making: theory and practice in higher education. Sterling, VA; Stylus Publishing 2008:24

Monday, May 18, 2009

Likelihood Ratios

Imagine that in trying to gather information about a particular patient you are seeing you come across an article that describes a diagnostic test that may help better confirm your suspected diagnosis. For example, let us assume that your patient is suffering from back pain, and you suspect that she might have a herniated intervertebral disc. You believe this because your work-up for that patient has found that there is pain in the low back which radiates down the leg and into the lateral side of the foot, that certain motions are quite painful, that this came on after a doing physical labor, and that it has worsened over the past three days. In addition, you have a number of positive diagnostic tests which have occurred, but they seem mildly contradictory and you feel that it may be due to the severe pain the patient is experiencing. What can you do to get a better handle on what is happening?

You can look at the likelihood ratio for one of the diagnostic tests you did. Why look at this? Well, the main reason is that doing so will help move you from your estimate of the likelihood the patient has a disc herniation (also called the pre-test probability) to a more accurate estimate (called the post-test probability of the target disorder). The likelihood ratio is a tool which moves us from pre-test probability to post-test probability.

Consider: the presence of a positive straight leg raise test is seen as indicative of a disc herniation. But it is not conclusive and there may be other possible explanations for its presence. But certainly, with the other information you have collected from your patient, a large likelihood ratio will likely move to you a more positive confirmation of disc herniation, and also may lead you to consider either diagnostic imaging or to a particular management protocol.

A likelihood ratio is the relative likelihood that a given test would be expected to be positive (or negative) in a patient with a disorder as opposed to one without (1). Likelihood ratios can be calculated easily from 2x2 contingency tables used to calculate sensitivity and specificity; a likelihood ratio is actually [Sensitivity/(1- Specificity)]. For the actual math involved, please see

But here is the key to understanding a likelihood ratio. It indicates the extent to which a diagnostic test will increase (or decrease) the pretest probability of the target disorder. LRs of 1 mean that the pre and post-test probabilities are exactly the same; if greater than 1, it indicates an increase in the probability that the target disorder is present (and the greater this number, the greater the probability), while the converse is true for likelihood ratios of less than 1. With a likelihood ratio, you can use a nomogram (such as the one found at to convert the pretest probability to a post-test probability.

In our case, let’s begin by assuming that the pre-test probability of the presence of herniated disc is 50%; this is based on our own clinical expertise plus any literature we may have read. From the paper we found, we see that the likelihood ratio for a straight leg raise is 12. Plugging this into the online nomogram shows us that the post-test probability of a disc herniation is now 94%. One could feel quite comfortable that this patient does indeed have a disc herniation, and can proceed accordingly.

You can find tables of likelihood ratios derived from the scientific literature, such as those seen in the Rational Clinical Examination series from JAMA. They are the most valuable test we have for the use of diagnostic tests.


1. Guyatt G, Rennie D, Meade MO, Cook DJ. Users’ Guides to the medical literature: a manual for evidence-based clinical practice, 2nd edition. New York, NY; McGraw Hill, 2008:426-430
2. Sackett D, Rennie D. The science of the art of the clinical examination. JAMA 1992;267:2650-2652