Tag Archives: presentations

To PPT or not to PPT – that is the question

Whether or not to use a (now almost “traditional”) PowerPoint (PPT) presentation when asked to run a session is certainly a good question but it’s not necessarily THE question.  There are many more important questions in education.  However, it is worth thinking about when you are asked to present on a topic to a large number of people.  In medical education, there are a minority of instances in which a single lecture is better (educationally) than a small group or a reality-anchored, case-based discussion in the clinical context.  However, there are increasing instances when budgets and logistics require it – either in person or online.

Should you use Powerpoint or not? Opinions are divided – and strong.  But sometimes the opponents seem to be opposing a straw man (the bad PPT).

With ideas or technologies (as with drugs) there is often a bit of a dialectic: a phase of enthusiasm, a phase of backlash and then a more reasoned compromise.

Powerpoint does have its proponents in education. One argument is that it helps the more modestly skilled performer to get their material across (rather than constraining them). The critics make the point that a lecture is actually a performance anyway (and should be a good performance).  I suspect those who are keen to ditch PPT probably have some natural performing skills already.

I have been around long enough to remember when the usefulness / appeal/ memorability of a lecture depended on how enthusiastic and charismatic the lecturer was. Some certainly weren’t worth going to. Others were most enjoyable and entertaining but the content dissolved into the mists of time and had no permanent impact.  This was the “BP” era – the days Before PowerPoint.  It was quite a relief when we were able to expect that a lecture would have a structure with bullet points and take home messages

The backlash

A Guardian article sums up some of the complaints about PowerPoint, claiming it is making us stupid.  https://www.theguardian.com/commentisfree/2015/sep/23/powerpoint-thought-students-bullet-points-information It has been around for thirty years and concern about it began early.  It is relevant to note how it followed on from the overhead projector and was initially geared toward desktop graphic projection in meetings.  Of course it has now moved on to the point where slides are compulsorily loaded onto websites and students feel no obligation to attend as all the information is assumed to be on the slides.  The Guardian article also notes that students have been known to demand it back when it is withdrawn.

Some critics feel it limits the way we think and oversimplifies issues. Some feel that the intrinsic nature of the design of PPT templates is to blame for poor presentations and others feel that the way information is put on slides can inhibit learning because humans are only designed to learn in a particular way. If you are interested in some of the neuropsychological arguments you could look at work by Stephen Kosslyn (book called Clear and to the Point) who has drawn more optimistic and detailed conclusions about how to structure presentations to achieve better learning outcomes.

Discussion is fairly opinionated and, of course, it is notoriously difficult to get strong, replicable and generalizable evidence about educational methods that are guaranteed to work for you.

Critics also tend to focus on the obvious failures in some presentations. This presentation by Ross Fisher is titled “Everything you know about presentations is wrong” https://www.youtube.com/watch?v=8Cl0xskA9fM and brings up many useful points including tips for improving presentations. It’s a long but listenable-to presentation. He maintains presentations often fail because of “cognitive load”.  He is a paediatric surgeon and well known to many medical professionals involved in education. His “P cubed” framework focusses on story, media and delivery http://ffolliet.com/   The aim is to keep people awake and he comments that the value of a presentation is what the audience thinks it is.

There are some interesting assumptions about how we (all) learn which it would be great to test. If someone talks and has words on a slide does this help learning or does it impede it?   Does it help some learners but hinder others?  Is it better to have an engaging picture while someone talks or is that distracting for some people?

How do we learn?  

There are theories about how we learn and numerous specific studies about the factors influencing effective learning. This article is broader than just presentations: http://result.uit.no/basiskompetanse/wp-content/uploads/sites/29/2016/07/Mayer.pdf “Applying the Science of Learning: Evidence-Based Principles for the Design of Multimedia Instruction”

demonstrates how complex may be the underlying theories. The cognitive theory of multimedia learning states that people learn more deeply when they build connections between verbal and visual representations of the same material and this paper lists studies demonstrating the success of strategies predicted to enhance this. One of the practical messages is not to overload the visual channel.

http://onlinelibrary.wiley.com/doi/10.1002/acp.3300/full This is quite a specific study on visualisers and verbalisers and the main lesson is probably that it is very complex, there are individual differences and it is very hard to apply in practice.  It was interesting that only for visualizers was learning success substantially impaired if pictures or animations were missing. Certain professions scored differently on the spatial imagery scale, the object imagery scale and the verbal scale.  There was also a suggestion of a gender influence.

Let me confess something. I was probably a serious teenager and I used to attend church to hear sermons that were not short homilies. I enjoyed hour long lectures on topics I liked and had no problem concentrating but now we advise stopping after ten or twenty minutes because of the general issue of concentration span.  I assume a lot of it was to do with motivation, expectations and sub-cultural factors.  I can still remember  the title (but not the content) of a sermon of the 19th century preacher Spurgeon that I read in a rather lengthy collection:  “Hope yet no hope, no hope yet hope.”  I remember it because my great Auntie Ethel saw it over my shoulder when I was reading it and read it out in a broad Yorkshire accent commenting “It’s enough to give you brain fever!”  There are now similar concerns that Powerpoint, in a different way, is giving us “brain paralysis”.  We have certainly moved from a very wordy culture to a more graphic one – although prior to literacy there was much supporting illustration on church walls for instance. A perusal of 19th century newspapers or novels suggests the population was accustomed to more “wordiness” without pictures (even still ones).  When I reflect I realise that I prefer to read a book than listen to an audio version and I compulsively read ahead on PPT slides.

The synthesis / compromise – what works

I am never going to be a dynamic presenter. Just an adequate one.  But it shouldn’t be all about me anyway!  Perhaps we can still structure effective learning experiences.  There are some common themes that emerge from all the reading (and viewing) I have done – in terms of the principles for effective presentations.

This study on Presentation vs Performance: Effects of lecturing style in Higher Education on student preference and student learning  https://eric.ed.gov/?id=EJ959028 actually seemed to examine the differences between a “good” and a “bad” presentation.  The basic PPT presentation describes PPT at its worst.  The Performance approach included slides with much less text, more images, relaxed manner and varying tone of the speaker, use of personal anecdote and audience interaction.  Needless to say it was more popular and more effective.

Ross Fisher’s positive tips were not too different from the earlier advice for good powerpoint presentations or the article on presentation vs performance. He suggests the slide set, handout and script should be different, he notes the importance of story and suggests a “star moment” in a presentation. He alludes to font size, not being distracted by logos or too many words and he emphasises the importance of any performance: projecting to the audience and practising.

The following are two nice brief pages from University of Leicester of practical hints about presentations.



This readable article reviews some of the evidence regarding the learning outcomes of lectures with and without powerpoint. http://www.hagerstowncc.edu/sites/default/files/documents/14-fletcher-powerpoint-research-review.pdf  It indicates that PowerPoint has no significant impact on learning – but students like it.  However, the way it is used affects learning.     An assertion-evidence approach is best (read the article for the details) and with or without PowerPoint, lectures are less effective than methods using active learning. This is a good warning to not be seduced into providing only lectures, however good, and to assess your goals, the audience size, the topic, the venue and so forth as you choose an appropriate method.  It is an encouragement to continue the broader task of structuring  learning experiences in all the contexts of learning.

Currently I am preparing a PechaKucha presentation (a style originating in a Japanese architecture office) and trying to apply a few of the principles above – quite a challenge!

Eyes only – visual variety in presentations

This is my fortieth post so I thought I would veer away from the serious and look at some visual distraction. Dermatology is very visual and I have often interspersed presentations of skin pathology with various bits of nature with tangential connections. I’m not sure if this has made the diagnoses any more memorable but it has meant that I still can’t observe some natural features without making the connections.  Just recently I couldn’t help but comment on a keratoacanthoma at the beach.

And just for a diversion see if you can give some diagnoses to the following lovely tree trunks:


A colleague sent an interesting photo of lichen recently.  Whether on rocks or trees, there are certainly dermatological echoes of lichenification.

If you stretch the analogy, here are some floral versions of various pink and erythematous rashes (and similarly all looking the same to the untrained eye of my spouse, apparently, despite their very different appearances and contexts)!

       And here is a polymorphic eruption, on a less than clear day.

Then there are the evocative descriptive terms such as spider naevi, serpiginous rash, cobblestone papillae, strawberry tongue and geographic tongue or descriptive words that have Greek or Latin for illustratable things like coins, tear drops, bran or nets (nummular, guttate, pityriasis, reticular) that could be in the corner of your slide as an aide memoire.. The list is endless.

And what does this, on my local rock platform, make you think of? I could go on, but I won’t. Spicing up presentations with apposite holiday snaps with visual metaphors can be quite diverting and make the task a little more creative.



Evaluation – How do we know we are doing a good job?

There are multiple approaches to evaluation and many are related to predicting outcomes in training or to issues of Quality Improvement.  As professionals, medical educators aim to do their job well and benefit from evaluating what they do.  At a higher level, Program Evaluation is an important issue.  At all levels, evaluation helps you decide where to focus energy and resources and when to change or develop new approaches. It also prevents you from becoming stale. However, it needs curiosity, access to the data, expertise in interpreting it and a commitment to acting on it and there needs to be organisational support.

Doing it better next time

So, at the micro level, I get asked to give a lecture on a particular topic, to run a small group or to produce some practice quiz questions for exam preparation.  How do I know if I do it well or even adequately?  How can I know how to do it better next time?

There are many models of evaluation, particularly at higher levels of program evaluation (if you are keen you could look at AMEE guides 27 and 29 or this http://europepmc.org/articles/PMC3184904 or https://www.researchgate.net/publication/49798288_BEME_Guide_No_1_Best_Evidence_Medical_Education ).  They include the straightforward Kirkpatrick hierarchy (a good example of how a 1950’s PhD thesis in industry went a long way) which places learner satisfaction at the bottom, followed by increased knowledge then behaviour in the workplace and, finally, impact on society – or health of the population in our context.  There are very few studies able to look at the final level as you can imagine.

Some methods of evaluation

The simplest evaluation is a tick box Likert Scale of learner satisfaction.  Even this has variable usefulness depending on the way questions are structured, the response rate of the survey and the timeliness of the feedback.  The conclusions drawn from a survey sent out two weeks after the event with a response rate of 20% are unlikely to be very valid.  Another issue with learner satisfaction is the difference between measuring the presenter’s performance versus the educational utility of the session.  I well recall a workshop speaker who got very high ratings and who was a “brilliant speaker” but none of the learners could list anything that they had learnt that was relevant to their practice.  You could try to relate the questions to required “learning objectives” but these can sometimes sound rather formulaic or generic.  It is certainly best if the objectives are the same as those intended by the presenter and they should be geared towards what you actually intended to happen as a result of the session. When evaluating you need to be clear about your question. What do you want to know?

reflectionIf you add free comments to the ratings with a request for constructive suggestions you are likely to get a higher quality response and one that may influence future sessions.  It is also possible to ask reflective questions at the end of a semester about what learners recall as the main learning points of a session.  After all we are really wanting education that sticks!

Another crucial form of evaluation is review with your peers. Ask a colleague to sit in if this is not a routine happening in your context.  Feedback from informed colleagues is very helpful because we can all improve how we do things.  It is hard to be self-critical when you have poured a large amount of effort into preparing a session and outside eyes may see things we cannot.

To progress up the hierarchy you could administer a relevant knowledge test at a point down the track or ask supervisors a couple of pertinent questions about the relevant area of practice.

Trying out something new

If you want to try an innovative education method or implement something you heard at a conference it is good practice to build in some evaluation so that you can have a hint as to whether the change was worth making.

An example

A couple of years ago I decided to change my Dermatology and Aged Care sessions into what is called Flipped Classroom so I put my powerpoint presentations and a pre workshop quiz online as pre-viewing for registrars.  I then wrote several detailed discussion cases with facilitator notes for discussion in small groups.  I did a similar style with a Multmorbidity session where I turned a presentation into several short videos with voice over and wrote several cases to be worked through at the workshop.

I wanted to compare these with the established method so I compared the ratings to those of the previous year’s lecture session (the learning objectives were very similar).  Bear in mind there is always the problem of these being different cohorts.  I also asked specific questions about the usefulness of the quiz and the small group sessions and checked on how many registrars had accessed the online resources prior to the session.  It was interesting to me that the quiz and the small groups were rated as very useful and the new session had slightly higher ratings in the achievement of learning objectives.  Prior access to the online material made little difference to the ratings.  I also assessed confidence levels at different points in subsequent terms. In an earlier trial of a new method of teaching I also assessed knowledge levels.

Education research is often “action research”.  There is much you can’t control and you just do the best you can. However, if you read up on the theory, discuss it with colleagues and see changes made in practice then it all contributes to your professional development.  Sharing it with colleagues at a workshop adds further value.

warningSome warnings

Sometimes evaluations are done just because they are required to tick a box and sometimes we measure only what is easy to measure.  Feedback needs to be collected and reviewed in a timely fashion so that relevant changes can be made and it is not just a paper exercise. There is no point having the best evaluation process if future sessions are planned and prepared without reference to the feedback.  It would be good if we applied some systematic evaluation to new online learning methodologies and didn’t just assume they must be better!

Evaluation is integral to the Medical Educator role

A readable article on the multiple roles of The Good Teacher is found in AMEE guide number 20 at http://njms.rutgers.edu/education/office_education/community_preceptorship/documents/TheGoodTeacher.pdf

Evaluation is a crucial part of the educator role and the educator’s role is diminished and the usefulness of any evaluation is curtailed when the two (education and evaluation) are separated.  Many things have an influence on training outcomes including selection into training, the content and assessment of training and the processes and rules around training. As an educator you may have increasingly less influence over decisions about selection processes and even over the content of the syllabus.  However, you may still have some say in what happens during training.  I would suggest that the less influence educators have in any of these decisions the less engaged they are likely to be.

At the level of program evaluation by funders, these tasks are more likely to be outsourced to external consultants with a consequent limitation in the nature of the questions asked, a restriction in the data utilised and conclusions which are less useful.  “Statistically significant” results may be educationally irrelevant in your particular context..  Our challenge is to evaluate in a way which is both useful and valid and helps to advance our understanding as a community of educators.  A well thought out study is worth presenting or publishing.


Some thoughts on large group presentations

The “lecture” has had a chequered history in terms of use and popularity. Here’s where I confess that I went to the University of Newcastle in its early days.  It was committed to Problem Based Learning to such a degree that even the few lectures that were programmed had to be called Fixed Resource Sessions instead. How we craved a bit of “spoon feeding” in spite of educational theory!

Historically lectures can be seen as a means of transmitting oral tradition. In medicine, teaching was initially by apprenticeship and then “modern” lectures were introduced in the mid nineteenth century.  By the early 20th century there were concerns that lectures were too passive and were just a means of memorisation and cramming of knowledge.  It is still a staple of many undergraduate courses which vary between countries.  Some older publications talk a fair bit about lectures and note taking but the latter is barely relevant in these days of online PowerPoints and students taking photos of slides when needed.  However, PowerPoint itself is already an object of criticism, particularly in terms of the tendency to merely read from the slides.

Are lectures an effective method in medical education and how do they compare to other methods? Thinking educationally, it is useful to step back first and to consider the part of the curriculum which is being addressed and to choose your method according to its appropriateness for the content.  There is some evidence that effectiveness may be best overall with mixed methods.

forestLectures can efficiently deliver large amounts of information to large groups.  Effectiveness is another issue and there are obviously good and bad lectures.  There is a readable summary in Matheson, C. The educational value and effectiveness of lectures The Clinical Teacher Vol 5 Issue 4 Dec 2008 pp218-21

The general criticism of lectures is that it is a passive form of learning, most students’ attention wanes after twenty minutes or so and they are unlikely to remember much of it if this is checked later.  I have another confession. I actually enjoy listening to an interesting lecture and I have a long attention span – but I still don’t remember the content a few months later.  I’m often surprised to read notes if I discover them at a later date.

The standard lecture is generally an expert speaking on a prescribed topic and it is a favourite of many students and registrars. Within GP training there is a relevant debate about whether the presenters should be other specialists or GPs with expertise in the area.  This often raises issues of credibility (but also relevance) which can impact on how a lecture is rated.

There are now many variations on the theme of lectures such as online lectures in Massive Open Online Courses (MOOCS) or in the form of video or PowerPoint with voice-over (for use in “flipped classrooms”).

Traditional lectures have also been compared to interactive lectures. The latter aim to engage the learners at various points during the lecture.  Lectures are rarely presented without some sort of audio-visual support these days (PowerPoints are ubiquitous, appearing even at weddings and funerals). Some hints for this:

  • There are lots of sources of advice for how to present information on PowerPoint slides and there are strong opinions about whether to talk around pictures versus the usual bullet points. Personally, as an audience member, I quite like to be able to read the bullet points myself during a lecture but different people have different preferred learning styles
  • The one unarguable advice would be to ensure all the audience can read what you put on the slide so avoid busy tables scanned from publications
  • One of the hardest things is to pace the presentation correctly and to feel confident enough to take sufficient time.
  • There are different ways of structuring a presentation and it may depend on the topic. If cases are included as illustrations it is a good idea to not leave them to the end. It can almost be guaranteed that you won’t get through them all and learners will feel they have missed out on something crucial – even if they haven’t.
  • It is crucial to be appropriate for the audience (and student feedback will let you know). Delivering an under-graduate lecture to post-graduate doctors can be perceived as condescending and playing numerous videos of new surgical or imaging techniques to a bunch of GPs may be seen as less than relevant.
  • It’s often helpful to flag the aims or learning objectives at the start (so they know where you are all heading) and to highlight a couple of take home messages at the end. You can try asking the audience at the end what they felt the take home message was for them
  • Some pre-reading, pre-viewing or pre-session quiz can increase the value of a lecture but be prepared for 50% participation or less in on-line resources. This may not be as important as you think. The non-participants may catch up later, may know it anyway or may be the ones who would have checked their Facebook through the standard lecture.
  • Be aware that a good presentation requires a significant amount of time for preparation and even updating clinical content for an existing presentation is not always a quick task.

Ways to break up a long lecture include

  • short videos (but not if the technology is unreliable or if you don’t have a support person to troubleshoot)
  • occasional cartoons
  • At points during a lecture you can divide a large group into pairs for a couple of minutes to answer a question or discuss something. This has the added value of encouraging interaction with peers and doesn’t involve too much chair moving
  • If you are confident in the topic area you could begin by collecting, and writing down, a list of questions collected from the audience and tick them off visibly as they are covered by your pre-prepared material.
  • If you have access to electronic key pads you can run quick multiple-choice questions for the participants. They will be happier to volunteer opinions when anonymous and it will give everyone an often surprising visual on the group’s opinions or knowledge. This can be especially useful in ethical topics for instance.
  • If you are feeling confident or brave you can try lots of different activities – often learned when watching your peers presenting.

There are a few summary points on lectures in this post http://www.mededworld.org/reflections/reflection-items/September-2014/Lecture-in-Medical-Education.aspx

Feedback is important but not easy to interpret

Student feedback is important but often over-rated. Constructive and thoughtful comments are much more useful (for implementing improvements) than rating scales.  The construction of the most useful feedback questions is challenging.  Do you concentrate on Learning Objectives (and what do you expect them to have achieved by the end of the lecture?) or do you ask them how useful it was?  Did your talk have specific goals such as raising curiosity?  In rating the presenter (or even the presentation) the learner is often rating the presenter’s performance and this is different to educational effectiveness.  Not all presenters are natural performers but don’t be too discouraged if this is you.  Registrars sometimes comment that a presentation was hugely enjoyable but not all that relevant to their learning. Enthusiastic feedback is comforting but the learning outcome is more important and skills can be learnt.  But style is not necessarily substance!  Have a look at this short but amusing video http://www.thenewsminute.com/article/ted-talks-spoof-how-be-thought-leader-and-get-standing-ovations-saying-nothing-all-44739

The evaluative process is importantgum

Peer evaluation is useful and this can be formal or informal. Being able to take the time to sit in on the sessions run by other educators is a very valuable part of professional development.  There is a lot of combined wisdom in a group of educators and after timely evaluation by a group of those involved (and review of feedback), the important next step is to act on the observations and make it better next time.