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