Nothing Much to Lose

Reading the ER Stories blog is often a guilty pleasure for me. Today's post, however, struck a nerve: 

Very often I ask patients about their recent visits to other doctors.  While I am taking a history, it’s important for me to know if you’ve recently been seen by another provider for the same or similar complaints and what they did, what they diagnosed you with, what they prescribed, etc.  
I often get a kind of irritated response such as “Oh, he didn’t do anything” or “he said it was nothing” or “he didn’t say anything to me”.  Although I know my share of layzee doctors, I bet the vast majority of times, the doctor DID do something and DID say something.
Just not what the patient either wanted to hear or that their perception or comprehension was wrong.  ...
... Now, maybe he is not a good communicator. Maybe he doesn’t have the time to sit there and explain the pathophysiology of viruses or something like benign peripheral vertigo  – and thus you feel short changed. After all he “just asked me a few questions, listened to my lungs and told me to go home and rest”.
Early on in my training I was fortunate to be taught that proper communication is the responsibility of both doctor and patient. So when a patient shows up in my ED and says their last doctor "did nothing"  -- when I can see with a few clicks that they got labs, a CT, and two prescriptions -- well, there's a failure to communicate. And the other doctor carries at least some of the blame for this.
Certainly, the patient is dissatisfied (because they're still seeking care, in an ED). You could argue that they're consciously downplaying what was done elsewhere in the hopes we enthusiastic ED docs can take a fresh look at the case. Maybe that's it -- but I bet from the patients' perspective, since they've still got a complaint, they've figured that nothing successful was done. 
From the ED physician's perspective, however, ruling out a bunch of life threatening conditions is a success. Or at the very least, not nothing. Same with providing symptomatic relief until clinic followup.
Communicating this to patients takes time, and constant effort. So many things in the department are working against a meaningful conversation about the visit -- the interruptions, the stress, the duty to document. Even discharge, which should be a chance to clarify and communicate, is often a rush job. A colleague of mine has a first-author paper in Annals this month, on what gets said when discharge instructions are provided. The sobering stat: 
"Only 22% of providers confirmed patients' understanding of instructions."
I would have thought that the emergency medicine, which is gifted with so many talented bloggers and podcasters, would do better at communicating with patients. If comprehension of discharge instructions is so infrequently done (and there's supporting evidence), it's not hard to imagine how hours of complex diagnostic workup gets interpreted by the patient as "the doctor did nothing."

What can help reverse this situation? I don't want to be Johnny-One-Note with my espousal of technology, but the iPad is proving helpful in reviewing a visit with a patient, at the bedside. You can go over lab reports, show x-rays, and clarify prescriptions before they're printed. I think it seems more tangible to the patient than just saying "everything came back normal."

Even the iPad, efficient as it is, requires time. And there are certainly some shifts where time isn't readily available. So another thing some of my friends in EM have done is share their email addresses in discharge summaries, and invite followup questions on their care.

This used to give me pause, for a lot of reasons. But when I think about the fair chunk of my non-clinical time I spend on quasi-medical communication -- to colleagues, in print, and on blogs and social media, I've got to ask: what kind of communication is most important? Wouldn't some of that time be better spent going clarifying care, with my patients?

After all, while composing this blog post, plenty of people could say "this doctor did nothing."

Present Tense

I made my first PowerPoint presentation in 1997, and actually used Microsoft's application to prepare 35mm Kodachrome slides for a carousel projector. Since then, I've seen thousands of PowerPoint presentations (and a few dozen Keynotes), and had a hand in creating many, myself.

Not since a conference a decade ago have I needed to make Kodachrome slides. Yet almost everyone still uses software built around printing slides, making a linear progression of topics. The impact of this format on human thought is substantial -- PowerPoint was fingered as contributing to the Columbia disaster and has spawned a lot of discussion and linkage, even here, regarding effective communication (probably all conceived of during dull PowerPoint presentations).

While compelling presentations are possible with Powerpoint (using the Lessig Method, for example) those kinds of talks require planning, and a mastery of the material. And some great stock photos. My experience in school and training is that the PowerPoint is often made as the presenter is learning the content and so is bound to lack the organization and expertise necessary for a Lessig-style presentation. People procrastinate about public speaking, and when crunch time comes it's just too easy to flip through a a textbook, call up a Pubmed abstract, and churn out another verbose PowerPoint slide. With practice, it's possible to whittle down the number of words and bullets per slide -- but who has time for that? Much easier to read the talk from the slide itself.

While I strive for Lessig-like clarity and impact in my talks, it's rare that I can eliminate all the slides with three or more bullet-points on them. PowerPoint, even though it's based on making Kodachromes for obsolete carousel projectors, is just too much of a crutch.

Which is why I was relieved to see Prezi come along. If you could imagine what presentations should look like with modern computers and digital projectors, Prezi is pretty much that -- more like a mind map than a slide deck.

Prezis can still be a linear progression of images, text, bullets, etc. But even linearly, it's easy to make big concepts stand out, and parenthetical points diminutive and aside from the main progression. Tangents can literally be tangential. Related ideas can be visually grouped, and you can easily give your audience the bird's eye view, for perspective. Most significantly, though -- Prezis needn't be linear. A presentation can go in various directions, based on audience input or presenter's whim. I think this will ultimately lead to much more interactive, engaging presentations.

Furthermore, Prezis just look great. I was always trained to avoid flashy animations and effects -- my grad school advisor wisely counseled, "Let your data do the dazzling." And I agreed with him, especially whit PowerPoint's cheap, tacked-on effects. But Prezi's more fluid animations have purpose -- they are literally moving the audience's focus along, from one concept to another, or to multiple ideas.

I gave my first Prezi presentation last week (here's the public version, stripped of many incriminating screenshots and some diversions). It was a challenge, and I still have a lot to learn, but I think it was more compelling than I could've made the material, in PowerPoint. And coming at the end of a long conference, I think people were ready for something different.

It wasn't easy, though. It took a while to get the hang of the zebra circle controller. There are still some things about frames that baffle me (no resize option? really?) But the greatest hurdle was old habits: Prezi forced me to think much more about the outline of my talk, up front. I couldn't just churn out some slides to get the ball rolling, but really had to plan where I'd take the audience.

Other thoughts:

  • A poorly planned PowerPoint will bore the audience. A poorly planned Prezi could make the audience violently ill. 
  • PowerPoint encourages and even rewards procrastination. With Prezi, it's hard to make (as many) last-second rearrangements without disrupting the carefully-laid path.
  • Getting videos to reliably display in Prezis is easier than in PowerPoint. Images should be as easy, but there are quirks -- .png files look pixelated, and pdf's don't yet display on the iPad app. 
  • We are pretty close to the point where a presenter can walk around with an iPad and control (or let an audience member control) a Prezi projected on the big screen (this may already be possible with extra hardware, but the Prezi iPad app doesn't faithfully reproduce the Flash-based web Prezis, and doesn't yet allow Prezis over AirPlay).
Even though my talk was (mostly) linear, I'm looking forward to trying some choose-your-own-adventure style presentations, which could be especially useful for talks on medical decision-making. When you think about how many hours people spend looking at PowerPoints, it's easy to get excited about the potential for Prezi. Other Academic EM types are experimenting with Prezi  -- and someone has gone and made a Prezi touting its advantages. Finally, inevitably, there's now a blog about Prezi tips.