1. Presentation is Everything Elma I. LeDoux, MD, FACP, FACC Professor of Medicine January 29, 2015 Elma I. LeDoux, MD, FACP, FACC Professor of Medicine January 29, 2015

2. At the conclusion of this presentation, the attendee should be able to: recognize the importance of coordinating format/venue/target audience enhance a presentation by augmenting with materials that are linked historically, culturally, and/or artistically to topic create effective educational vignettes which foster emotional engagement and pique a broad range of interests

3. What is the value of doing this? * Stimulates multiple senses linking diverse neural pathways of learner facilitating retention and recall of information (crossmodal perception) *Engages the learner emotionally, not just intellectually, maintaining focus on topic *Exposes the learner to a variety of perspectives and encourages deductive reasoning *Sensory input reinforced by learner’s past experiences. (The neglected engagers in medical education are olfactory and musical stimuli)

4. Is “engagement” successful? Soap operas are intellectually flat but emotionally engaging in 15 min increments, employing mood music and teasers as part of their technique. They have maintained a huge audience for decades. The TV series CSI has exposed viewers to over a decade of laboratory techniques coupled with clinical problem-solving and emotional engagement with the characters. During the first three years of its run (2000-2003) forensic programs at Florida International University and UC Davis doubled in size.

5. Preparation Checklist Target audience: (level of knowledge, age, experience, voluntary vs mandatory) Number of participants: (group dynamic) * Venue: (time of day, room size, lay-out, ambience/personality, seating, external distractions, lighting, media console) * Length of presentation: (15 min increments) * Style/Content of presentation: focus of today’s presentation

6. My Vignette Formats 1. Image detail recall 2. Analogous pattern linkage 3. Clinical reasoning mysteries 4. Cultural icon references 5. Addition of emotional linkages 6. Use of variable historical contexts 7. Inclusion of olfactory and musical material

7. 1. Image Detail Recall You are sitting in clinic, having just evaluated 76 year old patient W.W. for an operative procedure. The surgery resident is now looking for the patient to obtain her consent for the procedure. HIPPA laws prevent him from calling out her name in the waiting room, so he asks you to describe exactly what she looks like. In reenacting this scene, you will have five seconds to view the following photo of her and then describe her abnormal findings as well as you can… using diagnostic terminology whenever possible…

8. Patient W.W.

9. This exercise also employed use of a (Disney) cultural icon, adding an element of surprise and recognition. The patient is a thin woman appearing her stated age of 76. Her findings are as follows: Kyphosis, due to osteoporosis/compression fractures Proptosis and widened palpebral fissures Papule of nose; rosacea of nose; disparity of hair/eyebrow color; virtually edentulous; Osteoarthritis of hands…and, by your history: Psychosis (delusions of grandeur): “Magic mirror on the wall……”

10. 2. Analogous pattern linkage In this exercise, students must recall patterns in nature that mimic histological/pathological samples. In doing so, it requires the learner to focus on the details of the pattern---its artistic structure---rather than its function. The student can be asked to expand the exercise by linking analogous structures within each pair and by describing the function of the structures…

11. Micro/Macro: an exercise in visual flexibility Name an anatomic structure that closely resembles the pattern seen in Solitude, shown below.

12. Tracheobronchial tree or Renal Microvasculature

13. What is the shared structural feature, and what is its purpose?

14. Arborization Increased surface area More efficient nutrient delivery to distal areas Modulation of pressure gradients Can you think of other structures in nature-- macro or micro– that demonstrate arborization?

15. Name this tissue and an animal whose markings would resemble it.

16. Thyroid tissue Reticulated Giraffe

17. Name this tissue and a common metal device which resembles it.

18. Hepatocytes and Bicycle chain

19. Based upon its appearance, what skin lesion does Mount Vesuvius (below) most closely resemble?

20. Choices of Skin lesions: A)Compound nevus B)Granuloma annulare C)Sebaceous cyst*** D)Tinea corporis E)Squamous cell carcinoma of the skin 2014 vs. 79 AD

21. 3. Clinical reasoning mystery (with additional historical context)

22. Historical context… Attached is a photo of a WWII British soldier who is receiving therapy from a nurse. He had been evacuated from Dunkirk, France in May of 1940. (The Germans had invaded France and overwhelmed both the French and British armies, forcing them to the coast. 330,000 troops were rescued, many by British civilian vessels that ferried them back across the English Channel.) Many troops were also captured by the German army and spent the remainder of the war in German prison camps; the British Expeditionary Force was devastated... Ultimately, a lend/lease agreement with the US (who did not enter the war until the bombing of Pearl Harbor on December 7, 1941) helped to replace weapons and material needed for England's defense. Examine the photo closely to determine the nature and extent of his injuries. How do you explain the pattern of his injuries? Using these clues, what do you think he was doing when he was injured? For instance, what is it about his injuries that make it unlikely that he was a foot soldier? (scroll down for discussion)

23. Battle of Dunkirk: 26 May-4June 1940

24. He was a member of the Royal Tank Corps The soldier's left hand and right ear are badly burned. His face is also burned, with sparing of the scalp, eyes and the bridge of the nose...injuries consistent with protection provided by a helmet and goggles. An infantry soldier would not ordinarily wear goggles; pilots and tank personnel normally wore these. His burns are more c/w a flash burn, rather than flammable liquid which would have penetrated under the goggles and helmet. Because his chest appears spared, he is unlikely a pilot. A pilot, when his cockpit was struck, usually suffered extensive burns (and usually of both hands) due to being trapped in a cockpit in flames. This man likely had only his head and left hand exposed outside the tank hatch; the tank protected the rest of his body; The British left behind more than 700 tanks when Dunkirk was evacuated. You can use deductive reasoning like this to ascertain the nature of many types of pathology--e.g. fractures, burns, gait disturbances, skin cancers…something that can be practiced in the privacy of your own head while at sporting events, the grocery store, etc. Just keep your eyes open and practice this reasoning process! (Because of it’s length, I would normally present this case as an emailed “Mystery Case” so that the student would have the time to work through it.)

25. Clinical Reasoning-Case #2 On the next slide, you will view Domenico Ghirlandaio’s painting “An Old Man and His Grandson” (1490, tempura on wood, The Lourve) The old man suffers from rhinophyma, caused by hypertrophy of the sebaceous glands. How can you tell that this disease is chronic and not acute?

27. Look at the child’s expression! If this were acute, the child would be frightened or alarmed by the appearance of his nose. Instead, the child accepts the old man without question and looks at him lovingly.

28. 4. Cultural Icon References You are seeing a patient in clinic who has a BP of 160/100 and a blood sugar of 345mgms%. He rarely exercises and you notice a can of soda and chips in the pocket of his jacket. He is happy about the upcoming football season and doesn’t seem motivated by your concerns. This patient’s behavior most closely resembles that of: A)Darth Vader B) Winne-the-Pooh C)Eeyore D) Yoda E) Piglet F) Tigger

29. Answer B: Winnie-the-Pooh British author A. A. Milne based his Hundred Acre Wood characters on people he knew. Consideration of similarities between fictional characters and real patients is useful for several reasons: it makes us consciously consider their personalities, and that insight can then be applied to partnerships with them in treatment. Cultural icon references are useful when you are speaking to a diverse group and you need a unifying point of reference. Make it clear to the learner that no disrespect is meant here…

30. 5. Emotional linkages The patient is a 84 year old widowed bricklayer who was found unconscious in his home after a neighbor decided to check in on him. The neighbor says that he heard “loud rock music” blaring from the house but the patient did not answer the door and no one had seen him since yesterday.

31. Emotional linkages-version 2 The patient is a 84 year old widowed bricklayer who was found unconscious in his home after a neighbor decided to check in on him. The neighbor says that he heard “loud rock music” blaring from the house but the patient did not answer the door and no one had seen him since yesterday.

32. How did the photos of the houses affect your feelings about this case? Do you think the house photos caused you to have more empathy for one patient over the other? Did the photos create any sense of incongruity with respect to the patient’s history? Is there anything odd about the history? Would this case be just as interesting if the photos were not used?

33. I presented this case to students, and here are the results: 70% of students felt much more empathy for the patient whose home interior was shown. It gives a more intimate view of the patient’s life and thus creates emotional bonds/empathy. The students’ feelings toward the case with the home exterior shown were described as “neutral” or “confused”; the confusion arose from this older patient’s humble background juxtaposed to the affluent-appearing home. The other incongruity lies in the “blaring rock music” emanating from the house. That would not be expected from someone that age….is there foul play? This exercise serves as a reminder that our judgment can be easily influenced at a subconscious level and may be swayed by personal experience, bias, and stereotyping.

34. 6. Teaching Using Historical Contexts What physical abnormality is noted in the far left photo? How can this occur? What relationship does it have to the other images shown here?

35. Kaiser Wilhelm II of Germany suffered a shoulder dystocia at birth, causing a “withered” left arm due to a brachial plexus injury. He blamed his mother’s British obstetricians for his injury and, by extension, he resented Britain in general. Portraits and photos cleverly disguised the arm. He and King George V of Britain were both grandsons of Queen Victoria; Czar Nicolas II of Russia was a grandson-in-law. Despite his family ties, Wilhelm’s resentment of Britain certainly contributed to German-British hostilities in WWI.

36. Using historical/societal contexts in medical education demands a shift in the student’s typical perspective For example, students learn to determine a baby’s age by noting which milestones have been attained; likewise, abnormal growth and development is diagnosed by the failure of the child to attain those milestones within the expected time-frame. But what happens if we are faced with making those assessments within a different historical or societal context? As you can see from the next slide, using different contexts can challenge the learner to develop an expanded reasoning process!

37. Place in correct order according to age

38. 1 2 3 4

39. The active climbers in the Bouguereau painting (4) are clearly the oldest. The Elizabethan baby (1) is swaddled (as was the custom of the time), so we cannot assess the motor skills. We must default to the two month age shown on the plaque in the painting, making her the youngest. The pre-Columbian (Olmec tribe) figure (2) is crawling, but the modern baby (3) can manipulate an object with both hands and appears to show a fear of strangers.

40. Assuming Xrays were available for any of those shown, which one would be most likely to demonstrate this? For which one would it be impossible?

41. The xray shows a coin lodged in the esophagus. Answer: the children in the Bouguereau painting due to age and opportunity (so many for her to watch!) The pre-Columbian (Olmec tribe) child could not ingest a coin because iron metallurgy had not been yet developed. (1,100 BCE)

42. 7. Inclusion of Musical/Olfactory Data Mitral stenosis, usually a result of rheumatic valvular heart disease, produces an opening snap and low-pitched diastolic rumbling murmur at the apex. It heard best with the patient in the left lateral position.

43. Late Romantic Conductor and Composer Gustav Mahler had severe MS and died from Infective Endocarditis in 1911 He reproduced the sound of his MS murmur in his 9 th symphony, using the murmur as a motif for not only his own death but for the impending “death” of the 20 th century as a result of war (Leonard Bernstein, Harvard Lecture, 1973)

44. Diastolic Murmur S1 S2

45. Listen to the murmur of Mitral Stenosis #1 Classic recording made from patient #2 Mahler’s version in his 9 th symphony as conducted by Leonard Bernstein (YouTube)

46. Use of Olfactory sense: stimulus passes directly to olfactory bulb bypassing thalamus and activating limbic system and hippocampus (memory). Ancient and even early 20 th century physicians actively used the sense of smell to make diagnoses. Smells evoke memories instantly, making them a useful learning tool.

47. Match the scents in column A with those of column B 1 Diabetic ketoacidosis 2 Fetor hepaticus 3 Gangrene 4 Infected sebaceous cyst 5 Pseudomonas sp. But what does a GI bleed smell like? _1_ Juicy fruit gum _2_ Dirty aquarium _3_ Katrina refrigerator _4_ Goats at petting zoo _5_ Old tennis shoes

48. This can be reproduced artificially and shared with your T2 preceptor group (small group activity)

49. Only in New Orleans…only at Tulane Future Superdome area Hutch 1935