Article

Sailing smoothly across the cultural divide: Constructing effective behavioral science presentations for medical audiences

The International Journal of Psychiatry in Medicine 2015, Vol. 50(1) 115–127 ß The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0091217415592370 ijp.sagepub.com

Linda Myerholtz1, Julie Schirmer2, and Mary Anne Carling3

Abstract Beginning behavioral science faculty, who are critical residency program contributors, face significant immediate challenges that often diminish their effectiveness and increase the time it takes to translate and reformat their expertise into relevant and meaningful educational presentations. Residency program culture and competency-based learning are quite different from the educational objectives and teaching environments found in most behavioral health training programs. The goal of this article is to provide beginning behavior science faculty, who are typically on their own and learning on the job, with a guide to the core educational perspectives and skills required as well as key resources that are available to them. Since a significant portion of behavioral science faculty’s teaching time revolves around small and large group presentations, our guide focuses on how to incorporate key strategies and resources into relevant, evidenced-based and, most importantly, effective behavioral health presentations for the program’s resident physicians. Specifically, our recommendations include selection of content, methods of content organization, techniques for actively engaging resident physicians in discussing the significance of the topics, and descriptions of numerous Internet resources for the primary mental health topics that concern family medicine trainees. Finally, it is emphasized that the relevant and effective use of these recommendations is dependent upon the 1

Department of Family Medicine, University of North Carolina, Chapel Hill, NC, USA Department of Family Medicine, Tufts/Maine Medical Center School of Medicine, Portland, ME, USA 3 Family Medicine Residency Program, Methodist Health System, Dallas, TX, USA 2

Corresponding Author: Linda Myerholtz, Department of Family Medicine, University of North Carolina, 590 Manning Dr. CB# 7595, Chapel Hill, NC 27599, USA. Email: [email protected]

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behavioral science faculty educator’s first understanding and appreciating how physicians’ think, speak, and prioritize information while caring for their patients. Keywords Medical education, residency education, physician trainee, behavioral science education, training techniques

Introduction The goal of this article is to introduce key skills, strategies, and resources for creating effective behavioral health presentations for primary care medical education audiences. In the United States, behavioral sciencea faculty teaching in medical graduate education settings often have mental health or counseling backgrounds rather than medical degrees. Their perspective and expertise in specialty mental health enrich the training and care provided by medical providers. Because they may not be medical providers themselves, behavioral science faculty must learn to organize and present material in a way that is different from presentations to behavioral health provider audiences. Behavioral science educators need to understand how physicians think, speak, and prioritize information in order to be effective teachers. According to multiple Internet sites, the average medical student learns 13,000–15,000 new words in medical school.1 There are no citations proposing the number of new words learned in schools of psychology or social work. This is just one example of the cultural differences between the professions, highlighting the value that medical providers give to data, measurement, and precision. In addition, one of the more profound differences is that physicians carry a unique burden that behavioral health providers do not carry—the burden of sometime causing irreparable harm to others. It is difficult for physicians to acknowledge this burden to anyone other than themselves or other physicians. Behavioral science faculty need to acknowledge this burden to gain the trust of their medical learners. In this article, three behavioral science educators share insights and tips to minimize the ‘‘bumps in the road’’ and to sail smoothly across this cultural divide between professions. The intended audience for this article are faculty in residency programs teaching primary care physicians. We begin with recommendations for the organization, content, and processes for effective behavioral health presentations. We then describe some key Internet resources for mental health content, tools to enhance presentations, and tools to engage participants. We do not intend for this to be an in-depth review of teaching methods and strategies but rather an introductory guide for faculty looking for ways to enhance their behavioral science teaching effectiveness.

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Presentation organization and content The content we recommend including in behavioral health presentations for medical education will vary depending on the topic, but for a general outline, we suggest using four learner-centered questions to organize the presentation: 1. 2. 3. 4.

Why should I care? How will I know it when I see it? What do I do? When and how do I ask for additional assistance?

First, we need to answer, ‘‘Why should I care?’’, letting our audience know why the topic is important in medical settings. This can consist of general rationale such as the importance of prevention and early identification in managing the course of a behavioral health condition and how treatment of behavioral health issues can improve comorbid conditions such as diabetes and heart disease. This section can also include some basic epidemiology. Keep this section brief. Having a few key points on prevalence in medical settings, for example, can help get buy-in from learners who respond to data and wish to maximize outcomes. Next, we need to answer the question, ‘‘How will I know it when I see it?’’ Here, we are teaching how to recognize various mental health concerns as they present in medical settings. Teach about appropriate standardized screening tools, limitations and advantages of using such tools, and diagnostic criteria for specific mental health conditions. Include a discussion about the potential ramifications of misdiagnosis and medical illnesses that present similarly to mental health diagnoses, such as hypothyroidism and depression. Once learners can recognize a behavioral health condition, they need to know their possible roles in managing the concern. Clinicians may avoid screening for behavioral health issues due to uncertainty of what they should do if the screen is positive. Medical learners seek practical strategies for screening, assessment, treatment, and on-going care. While medically oriented audiences may have an inclination to focus on pharmacological interventions, it is critical that we also teach nonpharmacological interventions. There are many brief interventions that can be easily adapted to a primary care or hospital settings that can lead to meaningful improvements in symptoms (i.e., relaxation breathing, guided imagery, mindfulness exercises for anxiety disorders). Finally, we should help learners recognize when they may want to request assistance from a behavioral health specialist. For example, providing guidance on evidence-based mental health treatments and guidelines can help learners talk knowledgeably with their patients about various treatment options. In addition, learners need to know what behavioral health treatment options are available in

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their community, how to access these services, and how to work collaboratively with mental health providers.

Content resources: The Behavioral Science Basics Wiki There are an overwhelming number of electronic sources for behavioral health content, including the PubMed, UpToDate, or the National Institute of Mental Health websites, that make it extremely challenging for behavioral science educators, especially those who are just beginning their career, to locate and select the most relevant and informative resources. This difficulty is compounded by the fact that the majority of the professionally oriented publications cited in these resources take a psychiatric perspective when it comes to the education of resident physicians about behavioral health conditions and issues. This concentration makes assessing and utilizing the volumes of available resources, cited on these websites, problematic for the novice behavior science faculty member who is rarely medically trained or a psychiatrist. Furthermore, a significant number of the remaining cited resources are directed at the general public and have limited evidenced-based value in a professional education setting such as a family medicine training program. Finally, with regard to the online megaresources cited previously, we have been surprised and disappointed at the paucity of citations of education materials specifically developed for the primary care physicians or behavioral science educators teaching in residency training programs. The overwhelming total number of available resources combined with the reality that these resources have either a medical or lay public focus create a substantial and daunting obstacle to the new behavioral scientist trying to distill and organize material for use in primary care settings. It is our opinion that this represents a significant information gap that needs to be filled in order to make both evidence-based content and relevant patient contexts accessible and easily identifiable for behavioral science educators who are looking for learning resources to develop teaching materials for the first time. In response to this obvious need, a team of behavioral scientists who are teaching in family medicine residency programs created the ‘‘Behavioral Science Basics Wiki.’’2 The wiki is an Internet-based resource that is free to all who are in search of relevant, engaging, up-to-date content to include in their teaching and presentations. Like Wikipedia, the ‘‘Behavioral Science Basics Wiki’’ is a web-based collection of pages that can be easily edited by users to meet their own specific needs and purposes. The power of a wiki is that many knowledgeable specialists can collectively collaborate on a page and collectively produce a constantly evolving document that reflects the pooled and growing wisdom of its contributing collaborators. The ‘‘Behavioral Science Basics Wiki’’ is organized around three core content areas: (1) the behavioral science curriculum, (2) specific mental health conditions, and (3) patient context domains. In addition, there

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are recommended resources on ways to enhance teaching and professional development. Each content area has its own web page containing recommended books, articles, websites, and handouts that may be used for developing a presentation. The mental health page also has word documents listing online resources covering common behavioral health conditions identified and treated by primary care doctors (currently includes depression, anxiety, post traumatic stress disorder, and attention-deficit/hyperactivity disorder). The ‘‘Behavioral Science Basics Wiki’’ is housed on the Society for Teachers of Family Medicine (STFM) website: http://www.fmdrl.org/group/ index.cfm?event¼c.showWikiHome&ld¼85. Individuals do not have to be STFM members to access wiki resources. However, to comment or participate in the development of the wiki’s resources library, it is necessary to be a member of the STFM.

Teaching process Once we have identified the basic content to include for a medical audience, we need to consider how to effectively teach the information. Despite evidence that lecture-based presentations are not particularly effective, this learning modality continues to often be relied upon in medical education.3–5 We encourage educators to learn and apply principles of adult learning to their teaching. Educational psychologist, Robert Gagne, studied learning process and conditions that foster skill attainment.6–8 He outlined nine ‘‘events of instruction’’ to be followed sequentially to enhance retention of material and meet individual learning preferences. 1. 2. 3. 4. 5. 6. 7. 8. 9.

Gain attention Inform learners of objectives Stimulate recall of prior learning Present the content Provide ‘‘learning guidance’’ Elicit performance (practice) Provide feedback Assess performance Enhance retention and transfer to the job

Gaining attention is designed to engage the learner’s interest and to help answer the ‘‘Why should I care?’’ question. It can be accomplished in a variety of ways, such as using a humorous story, video clip, or emotionally charged personal anecdote. Next, informing learners of the objectives of the learning activity lets them know what outcomes to expect, cues learning, and can motivate them to stay mentally engaged. Informing learners that they will be ‘‘tested’’ on the material (including a reminder that similar material is likely to appear on

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board and in-service exams) can also be a strong motivator to attend to the presentation. Explicitly recognizing and using the learner’s prior experience can enhance the learning and acquisition of new skills. Using activities that stimulate recall of prior learning helps learners organize new knowledge in ways that are more easily retrievable. Next, present content in a way that is engaging. This can involve use of demonstrations, video clips, and other multimedia formats. Since the attention span of medical students has been shown to begin to fade after 10 min, it is important to strategically organize the relevant information.9 Chunking the information into manageable related elements can improve attention and prevent learning overload. The goal of providing guidance or coaching is to assist the learner to encode the new knowledge into long-term memory and prevent frustration in practicing skills incorrectly. This can be achieved using case examples and mnemonics, for example. Active practice is a critical learning element that allows for immediate feedback on performance. This should include the identification and correction of errors as well as reinforcement for correct skill usage. Participants can practice the newly developing skills through case-based question and answer sessions, role-play, pairing and sharing, or formal simulation experiences. For optimal retention, learners practice the skills, receive specific feedback, and have their performance reassessed through a posttest or formal patient simulation event such as the employment of standardized patients to determine the learner’s mastery of the material. Retention and generalization can be enhanced by asking the learners to apply their newly acquired knowledge to similar problems or to imagine other situations into which they might transfer their new knowledge and skill. Table 1, adapted from Ring and Nyquist,10 lists additional teaching strategies that can be used for the various Gagne ‘‘events.’’

Strategies and tools for increasing audience involvement and engaging learners Adult pedagogy has evolved from the ‘‘empty pot’’ metaphor used to describe much of the teaching in the 1950s and 1960s in the United States. Even so, many medical school lecturers today continue this process, where learners sit quietly while their professors pour knowledge into the ‘‘empty’’ receptacles of their brains, after which the learner pours out this information on-demand during an examination. Educational research has demonstrated that active, engaged learners are more likely to improve and retain knowledge and skills.11 The methods discussed in previous sections describe important learning principles and content resources. This section covers key tools and resources to enhance presentations and engage learners. Readers can experience much of what is to follow by accessing our online presentation through the URL or Quick Response (QR) code in the following paragraphs. Our intent is to illustrate,

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Adapted from Ring and Nyquist.10 Fish bowl—one role-play takes place in front of audience as participants observe and later share their observations and feedback (generally guided). c OSCE—Observed Structured Clinical Exam—live observed simulations using simulated patients or computerized technology. d Think-pair-share—participants are given time to individually reflect upon a dilemma or question(s), then are paired with another participant to share their individual reflections.

b

a

Independent activity Use of cases Role-play Fish bowlb Simulation Standardized patients  Teaching OSCEc  Web search  Flipped classroom

 Elicit commitment to act/change  Facilitation  Narrative/reflective writing  Learner presentation

     

Pre/posttests Portfolios Quizzes Self-assessments Elicit take-home points from audience

    

       

Strategy

Cartoons Quotes Stories Video clips Brainstorms Best/worst scenarios Prezi.com QR codes

 Enhance retention

 Stimulate recall of prior learning  Enhance retention  Provide guidance  Provide feedback  Progressive disclosure case  Small group activities  Think-pair-shared  Team-based learning

    

 Assess performance  Enhance retention

 The ‘‘hook’’ to catch audience attention  Stimulate recall of prior learning

Purpose

Inform objectives Present content Elicit performance Provide feedback Enhance retention

Intensifiers

Catalysts

Skill builders

Trackers

Grabbers

Table 1. Teaching strategies for Gagne’s events of instructional design.a

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supplement, and deepen your knowledge of what is described throughout the remainder of this article. Over the last 10 years, the Internet has experienced an exponential increase in information and resources, contributing to tremendous global innovation and learning. Table 2 lists innovative educational tools and resources that enhance presentations. In the first citation in Table 2, Chris Anderson, the founder of Ted Talks, models a Prezi presentation, chosen because of its platform and its content. Chris discusses how the Internet drives innovation by (1) increasing the audience, (2) shedding ‘‘light’’ on new ideas, and (3) increasing the desire and motivation to continue to learn. The Prezi presentation platform engages audiences in ways that are not feasible with slides or PowerPoint presentations. Through the use of images, drawings, movement, and transitions, Chris Anderson skillfully uses his Prezi to set the context of his talk, show different perspectives, and apply symbolism and metaphor to create meaning. He connects his ideas to developed and developing world audiences through images, video, and animated drawings. The authors’ Prezi presented in the article uses a diving board template to organize the material, metaphorically encouraging learners to ‘‘dive into’’ experimentation, using the materials and tools described. It illustrates how to engage learners during the presentation and beyond. At the time of the presentation, participants worked in small groups to outline primary care presentations on specific mental health topics (depression, anxiety, attention deficit disorder, posttraumatic stress disorder, and substance use disorders). Specific objectives, timeline, and engagement activities that resulted from these work-groups to the Prezi format are available at: http://prezi.com/b5z6lde1ht8i/?utm_campaign¼ share&utm_medium¼copy&rc¼ex0share. The QR or Quick Response tool cited in Table 2 can be used to connect participants to information on the Internet. Participants can go to their App Store and download a free QR scanner, which connects them to the information by scanning the QR code. Presenters go to the Kaywa site in Table 2, to then obtain free QR codes and connect the code to targeted Internet sites. QR codes are effective, if used selectively and meaningfully in presentations. In addition, they can be placed on posters, documents, or websites to connect learners to instructional materials you want reviewed prior to entering the classroom. The last two resources in Table 2 describe ways to enhance the communication effectiveness of the teacher. The video by Amy Cuddy, PhD, a social psychologist, describes evidence that shows how body language effects an individual’s stress reaction and performance. The Naked Presenter by Garr Reynolds provides modeling and instruction on avoiding the pitfalls of over-relying on presentation ‘‘tools,’’ to the detriment of the message.12 He models and demonstrated the power of using ‘‘naked’’ slides with intense images and limited words. The audience focus then is toward the message and not the medium.

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The Naked Presenter—Garr Reynolds

Smartphone QR scanner app How Your Body Shapes Who You Are—Amy Cuddy, PhD

QR Scanner App for Smartphones QR or ‘‘Quick Response’’ Codes

https://www.youtube.com/watch?v¼Z4yOJpE6vfc http:// www.presentationzen.com/presentationzen/2010/09/ this-new-ted-talk-by-ted-curator-chris-anderson-is-oneof-my-favorites-chris-used-technology-prezi-withembedded-video-bu.html

http://reader.kaywa.com/getit http://www.ted.com/talks/ amy_cuddy_your_body_language_shapes_who_you_are

http://qrcode.kaywa.com

Search for QR Reader or Scanner in App Store on phone.

http://www.prezi.com

http://www.ted.com/talks/chris_anderson_how_web_video_powers_global_innovation?language¼en#t-142123

An effective use of Prezi by Chris Anderson, the founder of Ted Talks, who discusses how the Internet is changing how we learn and teach (19 min) Presentation software and storytelling tool for presenting ideas on a visual canvas. Free to educators Free smartphone app that scans QR codes to access websites. Offers free quick response codes, free apps and an optional paid management plan to place QR codes in presentations, which can then be scanned by participants to immediately access the specific website and materials A free application to scan QR codes A presentation describing the evidence on how body language effects stress hormones and performance (21 min) Instructions and principles on how to maximize presenter effectiveness and minimize dependence on slides (19 min)

Ted Global 2010: How web videos power global innovation—Chris Anderson

Prezi

Internet address

Description

Resource

Table 2. Key Internet resources to enhance presentations.

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A journal article and a video illustrating the principles and potential for flipping the classroom (13 min)

Provides hardware and software to create online presentations, depicting the presentation and the presenter Instructions on how to create voice narrated PowerPoint presentations (3 min) Provides definitions and resources for teambased learning processes for medical educators, along with a 12 min-video that explains Team-Based Learning A web-based audience response system- free to use for up to 40 audience responders

The Flipped Classroom

Echo 360

Poll Everywhere

PowerPoint Voice Narration Team-Based Learning

Description

Resource

Table 3. Key Internet tools and resources to engage participants.

http://www.polleverywhere.com/

http://teambasedlearning.org http://www.utexas.edu/aca demic/ctl/largeclasses/#tbl

http://www.youtube.com/watch?v¼3uk4CU7uobM

http://online.wsj.com/news/articles/SB10001424052748704 101604576248713420747884 https://www.khanacademy. org/talks-and-interviews/key-media-pieces/v/khan-academythe-future-of-education http://echo360.com

Internet address

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Regardless of the tools used, a presentation loses its effectiveness if too much information is attempted to be covered or if there is an over-reliance on the presentation medium. After determining the content and presentation method, we encourage educators to consider ways to meaningfully engage learners in the educational process. Table 3 lists some key methods and Internet resources to actively involve learners. The Flipped Classroom methodology has learners study instructional materials prior to the classroom time and apply the material to clinical cases and situations during class.13 The Echo 360 and PowerPoint Voice Narration are two tools used to ‘‘flip the classroom.’’ These platforms allow you to present and record key content ahead of time and then post on an organizational website or send to learners to access on their own time. Team-Based Learning (TBL) is a systematic, prescribed way to ‘‘flip the classroom’’ and design processes that engage learners who are part of a formal team. Evidence illustrates that TBL enhances critical thinking, retention, and future application of the material.14 The TBL components include an existing team, an assessment that participants have reviewed materials ahead of time, engagement activities, and peer evaluation. Poll Everywhere is a web-based audience response system that allows participants to respond from their phone, tablet, or computer, producing immediate graphs of collective responses. Using an audience response system is an excellent way to engage learners by asking them to respond to various types of questions including quizzes and opinion surveys. It can be used for pre and posttesting. As in any of the above techniques, they are effective if used selectively during a presentation.

Conclusion As Plutarch wrote, ‘‘Education is not the filling of a pail, but the lighting of a fire.’’15 Our intent is to ignite that fire in behavior science educators. We encourage you to explore, learn, and contribute to the collective knowledge of the principles, educational tools, and resources described in this article. Let us know what you think and share your recommended presentation tools and resources by visiting and commenting on our Prezi page or on the Behavior Science Basics Wiki.

Authors’ note This article is presented at the 35th Forum for Behavioral Science in Family Medicine, Chicago, IL, September 2014.

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Conflict of interest None declared.

Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Note a. For the purposes of this article, the term behavioral ‘‘science’’ or ‘‘scientist’’ is used when referring to the faculty person teaching medical learners. The term behavioral ‘‘health’’ refers to the content area and the person providing clinical services in this area.

References 1. O’Dowd G. Building a medical vocabulary: a guide for students [Internet], http:// www.academia.edu/5586017/Building_a_Medical_Vocabulary_A_Guide_for_ Medical_Students (accessed 20 January 2015). 2. Behavioral Science Basics Wiki [Internet]. Society of teachers of family medicine, http://www.fmdrl.org/group/index.cfm?event¼c.showWikiHome&ld¼85 (accessed 20 January 2015). 3. Doyal T and Zakrajsek T. Learner centered teaching: putting the research on learning into practice. Sterling, VA: Stylus Publishing, 2013. 4. Stahl SM and Davis RL. Best practices in medical teaching. New York, NY: Cambridge University Press, 2011. 5. White HB. Do you teach the way you learn? Biochem Mol Biol Educ 2013; 41: 187–188. 6. Gagne R. Mastery learning and instructional design. Perform Improv Q 1988; 1: 7–8. 7. Gagne R and Driscoll M. Essentials of learning for instruction, 2nd ed. Englewood Cliffs, NJ: Prentice-Hall, 1998. 8. Gagne R, Briggs L and Wager W. Principles of instructional design, 4th ed. Fort Worth, TX: HBJ College Publishers, 1992. 9. Stuart J and Rutherford RD. Medical student concentration during lectures. Lancet 1978; 312: 514–516. 10. Ring J and Nyquist J. Pulling the plug on power point: five techniques for enhancing teaching. Presented at the society of teachers of family medicine annual conference, Seattle, WA, http://www.fmdrl.org/index.cfm?event¼c.beginBrowseD#3941 (2012, accessed 12 June 2015). 11. Medina J. Brain rules: twelve principles for surviving at work, home and school, 2nd ed. Seattle, WA: Pear Press, 2014. 12. Reynolds G. The Naked Presenter: delivering powerful presentations with or without slides (Voices Matter). Berkeley, CA: New Riders, 2010. 13. Kahn S. Turning the classroom upside down why not have lectures at home and ‘homework’ at school. The Wall Street Journal On-Line [Internet], http://online.wsj.com/news/articles/SB10001424052748704101604576248713420747884 (2011, accessed 20 January 2015).

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14. Parmelee DX and Michaelsen LK. Twelve tips for doing effective team-based learning (TBL). Med Teach 2010; 32: 118–122. 15. Sweeney JJ. Vision and image: a way of seeing. Series: credo perspectives. New York, NY: Simon and Schuster, 1968, p.119.

Sailing smoothly across the cultural divide: Constructing effective behavioral science presentations for medical audiences.

Beginning behavioral science faculty, who are critical residency program contributors, face significant immediate challenges that often diminish their...
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