The Art and Science of Quality CME Presentations:

Creating Impact and Driving Outcomes

Donald S. Nelinson, PhDAmerican College of Osteopathic Internists

Annual Convention and Scientific Sessions

October 31, 2019

Disclosure

I have no commercial interests in any product or company to disclose.

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Objectives

Apply 7 key tenets of adult learning to the design of outcomes-driven CME

01Actively engage physician learners in the educational process

02Summarize presentation characteristics associated with improved audience retention including those aligned with Mayer’s cognitive theory of multimedia learning

03Review practical tips for developing effective CME presentations

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After actively participating in this convention and follow-up learning activities, participants will be able to:

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Physician as Adult Learner: Knowles Knew!

• Physician (adult) learners have well-established sense of self

• Past experiences play pivotal role in physician learning

• Physician learning is purpose driven

• Physician learning relies on readiness to learn

• Physician learners driven by internal motivation

• Mistakes are often most valuable teacher

• Physician learners must play active role in learning activity design

Manning PR, Clintworth WA, Sinopoli LM, Taylor JP, Krochalk PC, Gilman NJ, Denson TA, Stufflebeam DL, Knowles MS.

A method of self-directed learning in continuing medical education with implications for recertification. Ann Intern Med. 1987 Dec;107(6):909-13. PubMed PMID: 3688682.

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Physician (adult) learners have well-established sense of self

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Autonomy demands a “say” in content, format, faculty

The consequences are disengagement and/or boredom

“OK Don….how do we ensure engagement?”Needs assessment

• Not just surveys!

Self-directed learning

• What have you done that engaged you and advanced your knowledge or skills?

Case-centricity

• Cases as an “also ran” don’t work!

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Past experiences play a critical pivotal role in physician learning

Clash of the experiential titans!

If new data clashes with the learner’s existing knowledge base, they’re not likely to accept it!

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Learning must relate to the learner’s experience

INVITE CHALLENGING CASES UTILIZE PEERS PRESENT CLINICAL VIGNETTES AND SOLICIT RESPONSES

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Physician learning is purpose driven

It’s a choice, not a duty

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Learning must be goal-oriented

• Measurable learning objectives

• System for learner to gauge progress

How do we do this?

• Simulations

• Real-world, case-centric models (ACOI-OCC)

• Provide opportunities to see how skills optimize patient care and/or overcome a challenge

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Physician learning relies on readiness to learn

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I’ll tell you what I need to know……if you ask!

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Multiple models fuel more effective behavior change

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Prochaska’s Transtheoretical Model/Stages of Change

While all treaters will not start at the earliest stage, sequential progression is inevitable and differentiated communication is essential.

Roger’s Theory of Diffusion of Innovation

Roger’s theory reveals how innovation occurs within a community by agents of change and resistance. Leveraging this knowledge in combination with the stages of change will further our ability to communicate in a customized fashion and accelerate adoption of innovation.

Physician Self-Efficacy

(Krupat, Frankel, Nelinson and Meldrum, et al)

Self-efficacy is referred to as the confidence (emotional) and competence (rational) to effect a change. As we move our treaters through the roles and stages referenced above, enhancing self-efficacy should be a guiding objective

Prochaska’s Transtheoretical/Stages of Change Model

Norcross JC, Krebs PM, Prochaska JO. Stages of change. J Clin Psychol. 2011 Feb;67(2):143-54. doi: 10.1002/jclp.20758. PubMed PMID: 21157930 Parker K, Parikh SV. J Eval Cl Prac, 2001.Valente TW. Network models of the diffusion of innovations, 1995.Nelisnon DS & Meldrum H. In search of a perfect storm: Provider self-efficacy, patient centered care, and medical education. Poster presented at WONCA; July 5, 2012; Vienna, AT.

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Physician learners driven by internal motivation

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Focus on problem-solving

SIMULATIONS CONTEXTUAL, CASE-BASED ROLE PLAY

TRANSLATE ONLINE LEARNING INTO REAL LIFE

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Mistakes are often most valuable teacher

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Physician learners must play active role in learning activity design

The goal is to provide resources that allow learners to immediately

apply what they’ve learned and address individual pain points

WHAT DOES THIS LOOK LIKE?

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What is in a name?

• Docere = to teach (Latin)

• Teaching is the facilitation of learning

• Physicians teach every day

• Were we adequately taught the principles of effective teaching and learning?

– Is knowledge base alone adequate?

Stull MJ, Duvivier RJ. Acad Med. 2017;92(4):432-433.

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Educator vs. presenter, faculty, etc

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Active learning: Engaged learner vs engaged faculty

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Older Doesn’t Always Mean Wiser: Clinical Experience Is Not Associated with Increased Knowledge

Emergency Contraception

(N=233)

Blood Product

Transfusion (N=122)

In a Systematic Review of 12 Studies, All Demonstrated a Negative Association Between Knowledge and Experience1

General Medical Knowledge

(N=3356; 1947; 289)

General Surgical

Knowledge (N=478)

HIV

(N=473; 1000; 1271)

Hypertension

(N=56)

MI

(N=1211)

Non-Small-Cell Lung

Cancer (N=1010)

1. Choudhry NK, et al. Ann Intern Med. 2005;142(4):260-273; 2. VanNieuwenborg L, et al. Postgrad Med J. 2016;92(1086):217-222.

Professional experience must be supplemented

with lifelong learning2

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Becoming a….

• Doctor– 4 years medical school + residency

• School teacher– 300 hours of field-based practicum experience (in MA)

• PowerPoint expert

• Medical writer

• Medical editor

• Public speaker

1. Massachusetts Department of Elementary and Secondary Education. http://www.doe.mass.edu/lawsregs/603cmr7.html;

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The Most Common CME Teaching Methods Are the Least Effective

• Learning – not merely educating – results in a change in clinical practice

• Lectures and printed material– Increase knowledge (but may not change behavior)

– Role play or practice sessions more effective

– Multiple sessions > single session

• Online courses

Case studies

Interactivity

Flexible schedule

Individualized

ProsCons

Social isolation

Cost

Technical problems

VanNieuwenborg L, et al. Postgrad Med J. 2016;92(1086):217-222.

Slide-Based Presentations

MedPage Today. The Worst Slide Show Ever. https://www.medpagetoday.com/publichealthpolicy/generalprofessionalissues/69422

MedPage Today. The Worst Slide Show Ever. https://www.medpagetoday.com/publichealthpolicy/generalprofessionalissues/69422

MedPage Today. The Worst Slide Show Ever. https://www.medpagetoday.com/publichealthpolicy/generalprofessionalissues/69422

MedPage Today. The Worst Slide Show Ever. https://www.medpagetoday.com/publichealthpolicy/generalprofessionalissues/69422

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A Word About Slide Colors and Slide Sizes

Do you still have your television from 1987?

• Early monitors/projectors

– 4:3 aspect ratio

– Limited color palettes

– Lower pixel density

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Just Because You Can…

Doesn’t mean you should

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Just Because You Can…

…doesn’t mean you should

Transitions

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Just Because You Can…

…doesn’t mean you should

Ani mat i o n

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Mayer’s Cognitive Theory of Multimedia Learning

People Learn Better from Words+Pictures Than from Words Alone

Mayer RE. Journal of Computer Assisted Learning. 2017,33:403– 423. Image from https://medium.com/learning-matters/series-influential-educators-richard-mayers-cognitive-theory-of-multimedia-learning-9c1db2f0805c

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Select Principles

1. Mayer RE. Journal of Computer Assisted Learning. 2017,33:403– 423; 2. Nagmoti JM. Indian J Med Microbiol. 2017;35(2):199-203

Reduce Extraneous Processing

BOPTIONS

Manage Essential

Processing

Foster Generative Processing

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Select Principles

1. Mayer RE. Journal of Computer Assisted Learning. 2017,33:403– 423; 2. Nagmoti JM. Indian J Med Microbiol. 2017;35(2):199-203

Reduce Extraneous Processing

BOPTIONS

Manage Essential

Processing

Foster Generative Processing

Eliminate extraneous material (coherence principle)

Highlight essential material (signaling principle)

Key on-screen text benefits narration (redundancy principle)

Place pictures and text near each other (contiguity principles)

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Select Principles

1. Mayer RE. Journal of Computer Assisted Learning. 2017,33:403– 423; 2. Nagmoti JM. Indian J Med Microbiol. 2017;35(2):199-203

Reduce Extraneous Processing

BOPTIONS

Foster Generative Processing

Break lessons to allow self-pacing (segmenting principle)

Provide pre-training on key terms (pre-training principle)

Narration preferred (vs text) (modality principle)

Manage Essential

Processing

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Select Principles

1. Mayer RE. Journal of Computer Assisted Learning. 2017,33:403– 423; 2. Nagmoti JM. Indian J Med Microbiol. 2017;35(2):199-203

Reduce Extraneous Processing

BOPTIONS

Use conversational language (personalization principle)

Draw graphics as you explain (embodiment principle)

Manage Essential

Processing

Foster Generative Processing

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Implementing Multimedia Principles

Issa N, et al. Med Educ. 2011;45(8):818-826.

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Implementing Multimedia Principles

Issa N, et al. Med Educ. 2013;47(4):388-396.

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Does it Work?

Improved1,2:

• Immediate retention

• Delayed retention

• Transfer

1. Issa N, et al. Med Educ. 2011;45(8):818-826; 2. Issa N, et al. Med Educ. 2013;47(4):388-396.

• Age <50 years with DM and 1 additional

risk factor for atherosclerosis

• Age 50–64 years with risk factors for

atherosclerosis or family history of PAD

• Age ≥65 years

• Individuals with known atherosclerotic

disease in another vascular bed

Patients at Increased Risk for PAD

Fatal, intracranial, or bleeding with

hemodynamic compromise requiring

intervention

GUSTO Severe

Bleeding requiring transfusion of whole

blood or packed red blood cells without

hemodynamic compromise

GUSTO Moderate

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Different Ways of Presenting the Same Content (1)P

ati

en

ts W

ith

an

Eve

nt

(%)

0

20

30

10

Arm 1

0 1 2 3 4 5

Arm 2

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Different Ways of Presenting the Same Content (1)P

ati

en

ts W

ith

an

Eve

nt

(%)

0

20

30

10

Arm 1

0 1 2 3 4 5

Arm 2

28.3%

23.2%

HR (95% CI)

0.75 (0.52–0.80)

P<0.001

ARR –5.1%

−25%RRR

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Different Ways of Presenting the Same Content (2)

• An Estimated 750,000 Adults Will Have an MI in 2016

• Within 5 years of an MI

– 22% of patients ≥65 years of age will have a recurrent MI or fatal CHD

– 22% of women 45–64 years of age will have a recurrent MI or fatal CHD

– 15% of men 45–64 years of age will have a recurrent MI or fatal CHD

– 8% of women ≥65 years of age will have a stroke

– 5% of men ≥65 years of age will have a stroke

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Different Ways of Presenting the Same Content (2)

An Estimated 750,000 Adults Will Have an MI in 20161

Within 5 Years Following an MI2

of patients ≥65 years of

age will have a

recurrent MI or

fatal CHD

45–64 years of age will

have a recurrent MI or

fatal CHD

≥65 years of age will

have a stroke

22%22%

(of women)15%

(of men)

8%(of women)

5%

(of men)

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Graphical Assistance Is Readily (and Affordably) Available

Subscription Services Offering Slide Assistance

Templates Royalty-free images

Customizable animations Maps

GraphsTables

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Visual Abstracts

• Visual summary of the information found within the abstract portion of an article

• Meant to convey the key findings of the article

– Not a substitute for the article and does not contain all of the details

• Associated with increased dissemination and readership1,2

• Used >50 journals, organizations, and institutions3

1. Colbert GB, et al. Kidney Int Rep. 2018;3(3):519-529; 2. Ibrahim AM, et al. Ann Surg. 2017;266(6):e46-e48; 3. Ibrahim AM. Visual Abstract Primer 4th Edition. https://static1.squarespace.com/static/5854aaa044024321a353bb0d/t/5a527aa89140b76bbfb2028a/1515354827682/VisualAbstract_Primer_v4_1.pdf.

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Visual Abstract Example 1

https://twitter.com/i/web/status/1091743052794945538

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Visual Abstract Example 2

https://resident360.nejm.org/visual-abstract/four-treatment-choices-for-actinic-keratosis

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Visual Abstract Example 3

http://www.nephjc.com/news/2017/6/20/canvas-visual-abstract

Non-Linear Presentations

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Zoomable User Interface

• Single visuospatial canvas– A blackboard of infinite dimensions

– Navigated by zooming and panning

– User (Presenter? Audience?) defined path

• Prezi (and to some extent PowerPoint)

• Allows enhanced visuospatial integration

“Whereas PowerPoint's linear slide format might reduce cognitive load, focus attention, and promote logical analysis, Prezi's map-like canvas format and heavy reliance on animation might facilitate visuospatial

processing, conceptual understanding, and narrative storytelling .”Moulton ST, et al. PLoS One. 2017;12(7):e0178774.

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Three Major Syndromes of Atherothrombosis1,2

Coronary artery disease (CAD)

1. AlMahameed A. In: Bhatt DL, ed. Atherothrombosis in Clinical Practice. New York, NY: Oxford University Press; 2013:79-94; 2. Benjamin EJ et al. Circulation. 2017;135(10):e146-e603.

Cerebrovasculardisease (CVD)

Peripheral artery disease (PAD)

~790,000 US adults ≥35 y have an MI annually2

580,000 – first MI,210,000 – recurrent MI2

Benjamin EJ et al. Circulation. 2017;135(10):e146-e603.

Three Major Syndromes of Atherothrombosis1

~531,000 US adults experience an initial

ischemic stroke annually2

Benjamin EJ et al. Circulation. 2017;135(10):e146-e603.

Three Major Syndromes of Atherothrombosis

~8.5 million US adults ≥40 y are affected by PAD2

Benjamin EJ et al. Circulation. 2017;135(10):e146-e603.

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Non-Traditional CME Modalities: TED Talks

• TED talks

– Short

– “unstructured” storytelling

– Few slides and almost no text

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Non-Traditional CME Modalities: Trends

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Presentations You Didn’t Develop

• Know your audience

– What is their background and knowledge base?

– What outcome are you looking for?

• How many slides/points do you think the audience will remember?

– Pick which information you emphasize

– Orient audiences to the slide

Embedded PowerPoint Video

One Last Tip

Finish on Time

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Questions, comments, crtitiques…