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A physiologic approach to scientific presentations Eugene H. Blackstone, MD.

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1 A physiologic approach to scientific presentations Eugene H. Blackstone, MD

2 Objectives (1) Essential preparation How long do I have? Who is my audience? What am I going to say? Text A physiologic approach to oral scientific presentations

3 Objectives (2) Visuals The good, the bad, and the ugly What Yahoo! taught us Delivery Presidential secrets for effective speeches Q & A What questions do you have for my answers?

4 Who cares? See one, do one, teach one Most scientific presentations are poor models Principles of a good presentation are rarely taught Most principles not intuitively obvious—until pointed out

5 Talks I have listened to… What I hated What I liked …and why!

6

7 Essential Preparation

8 Before writing the text… How long do I have? Who is my audience? What is my message?

9 How long do I have? Short Original research presentation 5 to 10 minute slide presentation Selected on basis of abstract Long Grand rounds, invited talk 15 to 50 minutes (usually slides) Assigned by organizers

10 How long do I have? Short Original research presentation 5 to 10 minute slide presentation Selected on basis of abstract Long Grand rounds, invited talk 15 to 50 minutes (usually slides) Assigned by organizers Our target

11 Who is my audience? What can I assume they know? What are they not likely to know?

12 What is my message? For short talk 2-3 sentences, often the conclusions Purpose of talk To marshal evidence supporting your message…no more, no less! Utility They dictate key points & order for objectives and results Typically takes ~ 3 hours

13 Text

14 Organizational Structure How were various talks you have heard organized? Describe different types Evaluate effectiveness What you liked, what you hated about organization How do you wish scientific talks were structured?

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16 Physiologic Approach Ears First hearing—listener doesn’t know what to expect Has to keep up—a serial process Mind can’t wander or be distracted— but you are speaking at ½ speed of thinking (~114 wpm vs. ~ 300) Relies on signposts you provide Make listening easy!

17 Easy Listening Structure clear Purpose, results, conclusions in same order with same words Just in time listening Introduce nothing before it is needed Leave no loose ends Wrap up prevents missing both current point and next point

18 Easy Listening One idea per sentence Break into absorbable bites Semi-conversational Balance formal vs. casual style Active vs. passive Emphasize message Complex methods and statistics loose audience if they are not central to the message

19 Easy Listening Connect with audience Attitude, energy, motions Be plain No bloat, unnecessary jargon, or speaking in abbreviations Keep audience in the present Pairs: on the one hand, on the other Tee up comparisons, anticipation Occasional pauses; change pace

20 Easy Listening A few specific observations Things come in 3s Talk vs. medical writing Bookends Nuggets The end

21 Easy Listening Things come in 3s Let’s get started. Together. Today. I came. I saw. I conquered. Of the people. For the people. By the people. The good; the bad; the ugly

22 From Trees to Wood and Back Eugene H. Blackstone, MD

23 Trees Patient Data

24 Information Collection of Workflow documentation Recorded observations Materials Usually Recorded as narrative Usability Low

25 Data Definition Organized values for variables Expression Symbolically (numbers, controlled vocabulary) Presentation Can be summarized by descriptive statistics

26 Bases for Medical Practice Evidence-based medicine Randomized trials Crude guidelines for therapy Information-based medicine Observational clinical data Patient-specific therapy Personalized medicine -omic studies + clinical data Tailored (n=1) therapy

27 A talk is not a manuscript! IMRD structure Introduction What question was studied? Methods How was the question studied? Results What was found? Discussion What do the results mean?

28 IMRD Introduced by Pasteur in 1870s Neither prose nor poetry A roadmap with standardized signposts

29 Why adopt IMRD? It is a standardized aid for… Selective Strategic …reading

30 Oops! Listening Not reading Not selective Not strategic It’s serial!

31 Early Listening—Bookends Story-telling Once upon a time in a land far, far away… …and they lived happily ever after!

32 Easy Listening Bookends Capture attention immediately What I am saying is important to you! Return to this at end: what it means to you!

33 Mitral anulus calcification: To debride or not to debride? Syed Tarique Hussain

34 Mitral Anular Calcification

35 Surgery for fungal infective endocarditis: A comparison with non-fungal cases Victor Chao

36

37 Aortic Stenosis Echo videos

38 Survival: LV Mass Index % Years <100 g·m -2 ≥185 g·m -2

39 Don't Wait for Symptoms! Watch the Ventricle Residual Hypertrophy After Aortic Valve Replacement Jocelyn Beach

40 Easy Listening—Nuggets Objectives The roadmap we’ll follow together Nuggets of discovery They follow order of objectives Include, if necessary, methods Present results—what you have discovered Discuss—wrap up the nugget

41 Example Fungal & non-fungal endocarditis

42 Objectives Compare Early and late outcomes of surgery for fungal and non-fungal endocarditis Account for Patient and disease characteristics

43 Early Outcomes

44 Morbidity Non-fungalRespiratoryinsufficiency Stroke Sepsis % 40 10 0 20 30 Fungal Unadjusted

45 Problem: Patient Characteristics Differ

46 Characteristics COPD DM Renal disease disease % 100 20 0 40 60 80 Non-fungal FungalStroke Unadjusted

47 39 Matched Pairs

48 Characteristics: Matched COPD DM Renal disease disease % 100 20 0 40 60 80 Non-fungal FungalStroke

49 Morbidity: Matched Non-fungalRespiratoryinsufficiency Stroke Sepsis % 40 10 0 20 30 FungalP=.01 P=.01

50 Late Outcomes

51 Survival: Unadjusted % Years Non- fungal Fungal 84 76 70 62 51 41

52 Survival: Matched % Years Non- fungal Fungal 80 69 65 62 51 41 P =.5

53 Easy Listening—the Message What do you want to hear at the end of a talk?

54 Easy Listening—the Message Summary? In short talk it shouldn’t be necessary Conclusions Take home message May include recommendations Clear ending Bookend Thank you!

55 Visuals (“slides”) with thanks to Yahoo!

56 Critique some slides…

57

58 Reflective of the scarcity of resource, complexities of donor organ allocation and increased number of patients awaiting cardiac transplantation, is the acuity of those undergoing the procedure. In 1988, 42.2% of patients undergoing transplant were Status II, waiting at home. In 1994, only 38.3% were called in from home.

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60 References Belelli D, Lambert JJ, Peters JA, Wafford K, Whiting PJ: The interaction of the general anesthetic etomidate with the -aminobutyric acid type A receptor is influenced by a single amino acid. Proc Natl Acad Sci U S A 1997; 94:11031–6 Mihic SJ, Ye Q, Wick MJ, Koltchine VV, Krasowski MD, Finn SE, Mascia MP, Valenzuela CF, Hanson KK, Greenblatt EP, Harris RA, Harrison NL: Sites of alcohol and volatile anaesthetic action on GABA(A) and glycine receptors. Nature. 1997; 389:385–9 Jurd R, Arras M, Lambert S, Drexler B, Siegwart R, Crestani F, Zaugg M, Vogt KE, Ledermann B, Antkowiak B, Rudolph U: General anesthetic actions in vivo strongly attenuated by a point mutation in the GABAA receptor alpha-3 subunit. FASEB J 2003; 17:250–2

61 Type I has normal motion of the leaflets and mitral regurgitation is on the basis of the leaflet perforation or annular dilatation. type II dysfunction (increased leaflet motion) the free edge of the leaflet travels above the plane of the mitral annulus during systole due to chordal elongation or rupture. Type IIIa dysfunction implies restricted opening leaflet motion during diastole and systole due to rheumatic changes. Type IIIb dysfunction correlates to restricted leaflet motion during systole secondary to papillary muscle displacement

62 NSRT Volumes + LV Mass End Diastolic Volume *p<0.05 vs baseline Wall Thickness at Mitral Valve Level Wall Thickness at Papillary Level *p<0.05 vs baseline † p<0.05 vs 1 year Left Ventricular Mass *p<0.05 vs baseline † p<0.05 vs 1 year 11090705030 mm Baseline (73+11) 1 year (59+8.8*) 2 year (53+8.7* † ) 500400300200100 gm Baseline (30+78) 1 year (223+52*) 2 year (190+58* † ) 20015010050 ml Baseline (96+19) 1 year (117+23*) 2 year (124+26*) 90705030 mm Baseline (72.4+10.5) 1 year (57.5+11*) 2 year (51.5+9* † ) *p<0.05 vs baseline † p<0.05 vs 1 year AB CD Mazur et al Circ 2001

63 Unadjusted Outcome for Selected Variables Reoperation432255.84.6-7.2.8419.58.0-11.3 Emergency272238.56.7-10.6.06391412-17<.0001 Aortic dissection439255.64.6-7.1.750119.8-13.006 Aortic aneurysm711344.84.0-5.8.04496.95.9-8.0.04 Aortic atherosclerosis301289.37.6-11.4.008237.66.1-9.6.6 Aortic calcification278279.77.9-11.9.004269.47.5-12.5 Previous aortic graft7134.21.9-8.3.857.03.9-12.8 Ascending aortic repair only802445.54.7-6.4.3567.06.0-8.0.02 Aortic arch**4152564.8-7.57.9409.68.1-11.3 Descending aortic repair only1071211.28.0-15.0214139.7-17.07 Aortic valve procedure770435.64.7-6.6.446.15.2-7.1.0005 CABG474367.66.3-9.1.08428.97.5-10.6 Mitral Valve Replacement4281913-27.00036168.6-22.16 VariablenNo.%CL(%)P*No.%CL(%)P* Stroke Hospital Mortality KEY: CABG, coronary artery bypass grafting; CL, confidence limits (68%) *P for presence of the variable in comparison to other patients with the variable absent **Only or in combinatin with ascending or descending aortic repair

64 End-systolic Wall Stress 0 50 100 150 200 250 ESWS (10 3 dynes/cm 2 ) P <0.05 P <0.001 Meridional Stress 0.334 x P x LVID = h(1 + h / LVID) Baseline Acute Change Test (n=5)Control (n=4) P <0.001 vs Control Acute Change * *

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67 Results Stroke 6.1% (CL 5.4% - 6.8%) - AX/SCA+SG 4% versus Other 6.7% P=.05 (Propensity matched) Hospital Mortality 8.3% (CL 7.6% - 9.2%) - Femoral 11% versus AX/SCA+SG 7% P=.02 (Propensity matched) Stroke 6.1% (CL 5.4% - 6.8%) - AX/SCA+SG 4% versus Other 6.7% P=.05 (Propensity matched) Hospital Mortality 8.3% (CL 7.6% - 9.2%) - Femoral 11% versus AX/SCA+SG 7% P=.02 (Propensity matched)

68 27 patients: 21 (78%) repaired, 6 (22%) replaced repaired patients: 17 male, 4 female (average age 38.4) replaced patients: 6 male (average age 48.5) repaired fusions: partial: RCC-LCC (14, 66%), RCC-NCC (2, 10%) complete: RCC-LCC (3, 0.14%), RCC-NCC (2, 10%) replaced fusions: partial: RCC-LCC (3, 50%), RCC-NCC (2, 33%) complete: RCC-LCC (1, 0.17%) Results Bicuspid Valves repair 21 replace 6

69 Can we do better than this?

70 Purpose What is the purpose of slides? Are they always needed? Must they be visible all the time?

71 Purpose Who’s the driver? The talk? The slides? Opinion: Ideas drive the visuals and not the reverse Entertainment? Parallel / supplemental information? Talk to the slides?

72 Color Background / foreground Give audience a break! Contrast, but not stark Easiest on the eyes in dark room is darker background, lighter letters Reverse for light room Example Blue background Yellow and white letters

73 Problem Colors Red Can stand out Can disappear--unpredictable Pastels Can be perfect Can be bland and be indistinguishable from white

74 Background Keep it plain! No distractions—nothing, absolutely nothing, extraneous on slide Avoid textured and watermarked backgrounds If shading used: darker on top, lighter on bottom Avoid “cute” transitions

75 Reflective of the scarcity of resource, complexities of donor organ allocation and increased number of patients awaiting cardiac transplantation, is the acuity of those undergoing the procedure. In 1988, 42.2% of patients undergoing transplant were Status II, waiting at home. In 1994, only 38.3% were called in from home.

76 Word Slides Use as few as possible Simple graphs & simple figures more effective One thought “package” per slide Avoid complete sentences & articles

77 Word Slides Layout Avoid multiline titles 3 or fewer major heads / slide First level needs no bullet Implications “One concept per slide” Fewest possible words Minimize depth of “indents”

78 MVRr with LV Reconstruction The combination of LV reconstruction, MV repair, and coronary revascularization provides significant reduction in LV volumes and improvement in LV ejection fraction The combination of LV reconstruction, MV repair, and coronary revascularization provides significant reduction in LV volumes and improvement in LV ejection fraction Sustained for at least 1 year with a cardiac event free survival of 84% at the first year. Sustained for at least 1 year with a cardiac event free survival of 84% at the first year. MV repair, if successful, may prevent LV redilation, as patients with recurrent MR demonstrate increases in LV volumes and less functional improvement MV repair, if successful, may prevent LV redilation, as patients with recurrent MR demonstrate increases in LV volumes and less functional improvement Importance of the mitral valve repair in patients with ischemic mitral regurgitation. Importance of the mitral valve repair in patients with ischemic mitral regurgitation. Further studies are needed to address the causes and effects of recurrent MR in patients with LV reconstruction. Further studies are needed to address the causes and effects of recurrent MR in patients with LV reconstruction. Gillinov et.al. Circulation. 2003;108[suppl II]:II-241-II-246.

79 Summary: Protecting the Spinal Cord Diminish ischemia with distal perfusion Passive shunt Atrial-femoral bypass Femoral- femoral bypass with oxygenator Increase collateral flow - diminish ischemia Maintain proximal pressure Intrathecal papavarine Decrease intrathecal pressure CSF drainage ? Progressive occlusion of intercostals Protect cord during ischemia Cold Deep systemic hypothermic circulatory arrest Local (intrathecal) cold Pharmacologic intervention (papaverine, lidocaine, etc.) Prevent post-operative ischemia Reimplantation of intercostal arteries

80 Myosplint Safety Studies 20 patients implanted worldwide 17 in Europe 9 Myosplint sole therapy 8 concomitant with mitral repair/replacement 3 in the US All concomitant with mitral repair

81 Word Slides Format Keep words in same location, even if the slide looks bare! Avoid centering Avoid unique spacing from slide to slide Rationale Minimize work of audience!

82 Example Fungal & non-fungal endocarditis

83 Another Later Example Cues Identify before talking Keep colors consistent

84 Example Fungal & non-fungal endocarditis

85 Another Later Example Cues Identify before talking Keep colors consistent

86 Word Slides Font Mixed upper- & lower case most readable Sans serif At the moment: Arial Font size Minimum 32 point A new kid on the block! Clearview

87 Creeping Cellulitis LCx RCA LVOT

88 Creeping Cellulitis LCx RCA LVOT

89 The problem with I Is it Personal pronoun: I? Letter after k: l? Number one: 1?

90 Old & New: Clearview

91 Clearview Highway Signs

92 Clearview

93 Physiologic Approach Minimize Fewest words Simplest graphs Visual order Top to bottom Left to right Clockwise

94 Survival % Years AVR AVR + CABG

95 Patients 1990 to 2008 n = 2,277 Left-sided Valve Lesion With Functional TR

96 CAD Re-op 40 20 10 0 30 Patient Characteristics PAD Carotid % Simple valve Allograft

97 Anterior Leaflet Repairs Ring 100 40 2008060 Chordae: Transfer Shorten Artificial

98 TV Procedures Rigid ring deVega / Kay Edge-to-edge PeriGuard Flexible ring 46% 3.5% 17% 26% 7.5%

99 TV Procedures Rigid ring PeriGuard Edge-to-edge deVega / Kay Flexible ring 46% 3.5% 17% 26% 7.5%

100 Physiologic Approach Cues Identify before talking Keep colors consistent

101 Morbidity: Matched Pts Non-fungalRespiratoryinsufficiency Stroke Sepsis % 40 10 0 20 30 FungalP=.01 P=.01

102 Survival: Matched Pts % Years Non- fungal Fungal 80 69 65 62 51 41 P =.5

103 Physiologic Approach Distractions Minimize “entertainment” that can obscure message No jumping slides Non-obvious title centering

104 SURVIVAL BY AKINETIC/DYSKINETIC DOR PROCEDURES 7/97 - 03/00 0 0 369121518 369121518 100 MONTHS

105 SURVIVAL AND EVENT-FREE SURVIVAL DOR PATIENTS 7/97 - 03/00 0 0 369121518 369121518 MONTHS 100

106 0 0 369121518 369121518 MONTHS

107 Survival: Unadjusted % Years Non- fungal Fungal 84 76 70 62 51 41

108 Survival: Matched % Years Non- fungal Fungal 80 69 65 62 51 41 P =.5

109 Survival: Matched % Years Non- fungal Fungal 80 69 65 62 51 41 P =.5

110 Survival: Matched % Years Non- fungal Fungal 80 69 65 62 51 41 P =.5

111 Tables Eliminate If information essential Convert to graphical display If table can’t be avoided Everything on table must have a purpose Everything must be discussed (That should cure you!)

112 Unadjusted Outcome for Selected Variables Reoperation432255.84.6-7.2.8419.58.0-11.3 Emergency272238.56.7-10.6.06391412-17<.0001 Aortic dissection439255.64.6-7.1.750119.8-13.006 Aortic aneurysm711344.84.0-5.8.04496.95.9-8.0.04 Aortic atherosclerosis301289.37.6-11.4.008237.66.1-9.6.6 Aortic calcification278279.77.9-11.9.004269.47.5-12.5 Previous aortic graft7134.21.9-8.3.857.03.9-12.8 Ascending aortic repair only802445.54.7-6.4.3567.06.0-8.0.02 Aortic arch**4152564.8-7.57.9409.68.1-11.3 Descending aortic repair only1071211.28.0-15.0214139.7-17.07 Aortic valve procedure770435.64.7-6.6.446.15.2-7.1.0005 CABG474367.66.3-9.1.08428.97.5-10.6 Mitral Valve Replacement4281913-27.00036168.6-22.16 VariablenNo.%CL(%)P*No.%CL(%)P* Stroke Hospital Mortality KEY: CABG, coronary artery bypass grafting; CL, confidence limits (68%) *P for presence of the variable in comparison to other patients with the variable absent **Only or in combinatin with ascending or descending aortic repair

113 Physiologic Approach Keep it natural If a slide does not feel right, it probably is not right

114 “A power connection across the body wall is less than ideal since (1) infection, necrosis & air leaks may occur about the power line and (2)unanticipated traction of tension may produce tearing of tissue, bleeding & possible interruption of the power line itself.” CONCEPT OF COMPLETELY IMPLANTABLE LVAD Bert Kosserow 1960

115 “A power connection across the body wall is less than ideal since (1) infection, necrosis & air leaks may occur about the power line and (2)unanticipated traction of tension may produce tearing of tissue, bleeding & possible interruption of the power line itself.” Bert Kosserow 1960 CONCEPT OF COMPLETELY IMPLANTABLE LVAD

116 Delivery

117 Delivery Memorize? Read? Wing it?

118 Cameron Speech Box Used By presidents from at least Nixon through Clinton

119 Cameron Speech Box Format 20-point Times Every sentence a paragraph Underscores for emphasis— not italics Arrow for sliding paper to left

120 Delivery Let’s practice!

121 The Future of Healthcare Delivery A View from Inside and Outside the Box

122 National Health Expenditure 4.25 200520072009201120132015 3.75 3.25 2.75 2.25 1.75 Trillion $

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127 Future of Healthcare Delivery 3 themes… Importance of data Importance of analytics Importance of people …and their potential contribution to the future of healthcare delivery

128 A Christmas Carol “You don't believe in me,” observed the Ghost. “I don't,” said Scrooge. “What evidence would you have of my reality beyond that of your senses?” “I don't know,” said Scrooge…”

129 Lies, D…d Lies, & Statistics

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132 Physiology of Delivery Eyes Up at beginning of sentence Down in middle Up again at end Exceptions Quotes: eyes down, eyes up when finished Names & numbers: eyes up

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134 Q & A With Thanks to Richard Butterfield

135 Q & A Characterize Q & A period you have liked Characterize those you have hated What is terrifying? What should you say? What shouldn’t you say? Is there a strategy here???

136

137 Q & A Reality, attitude, and opportunity It is a part of your presentation

138 Dangers Saying too much Over-elaboration Wandering off target Flubbing a question …for which you are unprepared Loosing control To hostile or aggressive questioning Promissory notes

139 Preparation Anticipation Anticipate and prepare for questions You’re not alone Get help from knowledgeable source Arm yourself Against hostility

140 Mind Set You are not a schoolchild trying to please the teacher! This is your opportunity to drive home your message — to say what you want to say Because it comes last, it constitutes the audience’s lasting impression of you

141 Learn from politicians… What questions do you have for my answers? You don’t have to answer the question asked Answer the question they should have asked Answer most questions with something you have already said — repeat key messages

142 Learn from politicians… What questions do you have for my answers? There’s a bigger issue… What may not be apparent here… We have been more interested in… I’d like to return to what’s really important…

143 You! Confidence You are the expert You know what you know You know what you don’t know Danger Not knowing what you don’t know!

144 You! Body language Open posture Sparkle a bit! Pretend audience is your friend not your enemy

145 You! Tone & attitude Confident Inspired, informative, interactive Address questioner at first, then deliver message to audience

146 You! Non-defensive Deflect the “negative” questioner Admit limitations But!!! …drive toward a positive focus on what you have discovered

147 You! Golden Rule: Think of others Don’t waste time Make the point Stop — let others ask a question

148 Caught off Guard! Buy yourself some time Repeat question Rephrase question to the way you want to answer it Pause and think, answer deliberately and honestly “I don’t have a good answer right now, but…” …transition to message, not a promissory note!

149 Special Situations Non-questions Hostile questioner There are no questions

150

151 The Non-Question Temptation “Thank you for sharing your experience.” Instead Tie it to your message

152 Hostile Questioner Manage the hostility Correct clear false statements Choose non-inflammatory terms: “limitation” not “fatal flaw” Stay on track with message No sarcasm — be careful about jokes Stick to the truth, and nothing but the truth

153 No Questions! For shame! The moderator is unprepared! Opportunity to reinforce message “You may be wondering…” “One question I’ve been thinking about…” This approach Encourages audience to ask questions


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