Giving a Grand Rounds Presentation

Introduction

The scenario: you are a new junior faculty member in the Division of Palliative Medicine at an academic medical center and have been asked to give Grand Rounds to the Department of Surgery. You were recommended as a speaker to the department chair by one of the surgeons after a positive interaction on a recent patient case. Although there are 6 weeks to prepare, you experience some trepidation. As a resident, you conducted teaching sessions for morning report and gave two formal presentations during your last 2 years of training. These went well, but you feel unprepared for the elevation to Grand Rounds speaker. You could use specific guidance to ensure that your presentation skills and pedagogy conform to high academic standards.

For the subspecialist in hospice and palliative medicine, the opportunity to give a Grand Rounds has importance beyond personal recognition and the didactic imperative. It offers a key venue to define and market an emerging discipline, promote institutional culture change, and educate about domains of care that may otherwise be neglected. It increases the stature of the field by strengthening the academic foundation of this new subspecialty and may demonstrate institutional support for palliative care curricular initiatives ¹ and the extent to which they have penetrated the institutional culture. Moreover, giving Grand Rounds is a measure of faculty advancement, a component of academic currency and an undeniable stepping stone for junior faculty. ²

Grand Rounds has a rich tradition in medicine. Historically perceived as the most valuable format in which to learn clinical medicine, ³ these clinician gatherings were originally grounded in an apprenticeship model of training. ⁴ Led by a department chair, the core discussion was modeled by senior faculty.^4–6 The topic focused on a specific disorder or biomedical issue and a patient was often present for interview and examination.^3–5,7,8

Over time, this interactive, patient-focused, and problem-based model evolved into a didactic, topic-oriented lecture most often supported by slides.^3–6,9–12 This shift may have advantages when the objective is to transmit a large amount of information appropriately critiqued in terms of level of evidence.^5,13 As a pedagogic strategy, however, the current didactic presentation may be relatively limited. Compared to other educational approaches, the didactic lecture may be less able to engage the learner,^9,10,14 support knowledge retention or the acquisition of skills, ¹⁰ or motivate professionals to follow learning with practice change.^9,10

Concerns about the shift from active to passive learning suggest that Grand Rounds pedagogy must continue to evolve. The challenge for junior faculty is to honor the tradition of the Grand Rounds presentation while overcoming the common barriers to learning that may arise when a didactic presentation is used. There is promise in the coalescing of the old and new, in bringing learner-centered strategies to the Grand Rounds experience to support a new, more effective approach. Ultimately, Grand Rounds should remain both an academic touchstone and an effective means to improve the knowledge, skills, and attitudes of the clinicians in attendance, ultimately translating to best practices and better patient outcomes.

This article provides a framework to guide those preparing to give a Grand Rounds and those teaching and supporting others to do so. The principles can be adapted to fit any presentation or teaching situation, or integrated into structured curriculum development and evaluation. Drawing on lessons from the literature, the framework aims to overcome current barriers, including those imposed by a passive learning environment. It also promotes both the presentational elements that respect the Grand Rounds tradition and the pedagogic elements that drive optimal learning and promote academic rigor. The potential for creative engagement and enjoyment is large for both learner and presenter.

Lessons from the Literature

Concerns about the utility of traditional Grand Rounds as an instrument of medical education gain limited empirical support in the continuing medical education (CME) literature. Although some studies suggest that CME might alter physician behaviors, ¹² others more strongly suggest that a didactic approach results in little change in physician response and almost no shift in patient outcomes.^10,11 Unfortunately, the relatively poor quality of the evidence provided by these studies precludes a definitive understanding about the pedagogic value of didactics. ¹² Many publications pertaining to CME and Grand Rounds in particular advocate for more interactive presentation methods as a means to improve the educational value of formal lectures.^{3–6,9–12,15,16}

The use of strategies to enhance interaction during educational programming is consistent with well-established adult learning theory. The adult comes to a learning opportunity with both personal experiences and expectations that create internal dynamics for motivation.^4,14 Teaching and learning methods that are relevant to these internal dynamics, have practical and real-time linkages to existing competency domains, and involve the learner in planning and/or evaluating the experience are likely to have high value and be more efficacious. ¹⁴

A number of strategies can be implemented to enhance learner-centeredness and potentially improve the effectiveness of the presentation. These strategies are generally more time- and resource-intensive than didactics, and for this reason, must be planned thoughtfully. Although they may be more successful in achieving shared objectives, ¹⁷ the effort involved is not justified unless the resources are available and the goals of the session are clearly defined.

Among the many learner-centered strategies, the use of a case-based approach^4,8,16 and the inclusion of “enabling” elements—materials or methods that facilitate adaptation of new learning to the practice setting,^10,13 like the offer of standardized checklists, patient education materials and web-based resources—are widely appreciated. Other approaches focus on planned changes in teaching methods during a session. For example, some have recommended so-called “microburst teaching,” which involves changing methods or presentation styles every 10–15 minutes during an educational session. ¹⁸ This model, which is based on data showing that medical students have a 10–15 minute attention span ¹⁹ also may address the potential variability in preferred learning style among learners. Other learner-centered strategies may be engaged either before or after the actual presentation. These include proactively working with conference coordinators to define the learners' expectations and traditions, ²⁰ performing a needs assessment to engage learners and create focus for the presenter,^5,7,9,10 intentionally sequencing a series of presentations with complementary themes to repeat and expand key points,^9,10 and communicating a commitment to change learner behavior to learners. ⁹

Studies report that the evaluation component of Grand Rounds is neglected in many settings.^3–5 An astute presenter can support evaluation efforts as another strategy to engage the learner through a commitment to improve the quality and impact of educational programming. Simply stating an example of how evaluation data have been or will be used to tailor aspects of a presentation can put this strategy in motion. Actively gathering specific feedback from learners, with transparency of purpose, goes even further.

Palliative Care and Grand Rounds

Presenting a Grand Rounds on a topic related to subspecialist palliative care may be more difficult than presenting about other areas. Palliative care is a new field that remains poorly understood on a cultural level. The range of potential topics is diverse and includes some, such as bereavement, that may be considered outside the purview of practitioners or uncomfortable to discuss. Equally important, most topics have a poor evidence base supporting current practice. This combination of factors means that presenters may be challenged as an expert on multiple fronts. Preparation and competence in the area discussed are critical characteristics in this setting.

Although a presentation that closely hews to tradition may enhance acceptance, the challenges inherent in describing an area of practice about which there is little familiarity and poor quality evidence may particularly benefit from more innovative teaching techniques. A sophisticated educational approach may be particularly important in engendering respect through tradition while concurrently offering a strong learning opportunity. Whatever the approach selected, the presenter must acknowledge that a positive outcome is not preordained when the educational session involves an emerging subspecialty that some perceive as foreign, or a specific focus that some perceive lacks clinical relevance. Flexibility and resilience, and a willingness to learn from evaluations of the experience, are other important characteristics for presenters in this area.

The Process: Preparing and Delivering a Grand Rounds Presentation

The planning of a Grand Rounds presentation may involve both the preparation for the session itself and the paperwork necessary for CME accreditation. When accepting the invitation to present, it is important to determine whether CME credit will be offered. If so, acceptance implies the willingness to provide documentation by specific deadlines. This usually includes learning objectives, speaker biography, attestations and financial disclosures, and the actual presentation on slides or in a document. A session handout for learners may also be requested or recommended. To ensure communication about this material and other issues, it is important to identify the administrative contact person who will collect information and forms. Even if not requested by the contact person, it is advisable to forward a speaker biography as a way to provide an accurate and pertinent introduction for the presentation. There will typically be a faculty contact as well, especially if CME is provided.

It is the responsibility of the entity sponsoring the Grand Rounds to provide a moderator for the session. The moderator may or may not be the faculty contact, and if the speaker has a specific request for the moderator, it will be important to identify this person well before the session. Traditionally, the moderator welcomes and introduces the speaker, oversees the organization of the conference, and assists with troubleshooting. He or she will be the timekeeper, may assist with the flow of a question-and-answer period, and should express an official thank you at adjournment. An effective moderator enhances the experience for both the speaker and audience. Junior faculty can also develop the skill set for this important role.

In planning the Grand Rounds, it is critical to determine the expectations for the presentation. If the invitation was prompted by a specific event or problem, this should be addressed in the session. Formal speaker guidelines, ideally in written form, should be requested and reviewed. If the presenter is asked to define the topic, it may be possible to access needs assessment data collected by the sponsoring entity. If not, the faculty contact or others can be questioned in an effort to clarify needs and expectations.

Given the option of selecting the topic, most speakers consider their own comfort level, the perceived knowledge gaps in the audience, and institutional needs. Among the diverse topic areas that may be selected by the subspecialist in hospice and palliative medicine are communication skills (e.g., breaking bad news), pain management (e.g., opioid prescribing), non-pain symptom management (e.g., approach to dyspnea), care of the imminently dying (e.g., culturally sensitive care), and bioethics and advanced illness (e.g., decisional capacity). Depending on the background of the presenter, and goals for the particular audience, the lecture may be chosen to be relatively practical, such as opioid therapy for pain; more philosophical or systems-oriented, such as the changing status of palliative care or the medical approach to suffering; or more controversial, such as palliative sedation. Similar considerations are important in choosing the title of the talk. Generally, creativity and learner engagement must be balanced by clarity and formality.

It is also important to characterize the likely audience. When possible, attend a session of the same Grand Rounds series prior to the lecture. The number of attendees, the disciplines, the proportions of trainees and senior faculty, and the topics of recent Grand Rounds each can inform planning. The academic culture of the department may be explored in terms of the overall formality and flow of the session, the expectations about the presentation of data, the value placed on practical guidelines or the inclusion of case material, the degree to which other disciplines are included, the openness to behavior change and controversial points, and the time that should be left for interaction at the end of the presentation. Slides may be expected. For some presenters, the question of commercial sponsorship may be important to clarify, even before accepting the invitation. When invited to present at an outside institution or in an unfamiliar venue that cannot be scouted in advance, request these details from conference planners or colleagues in that setting. The more information one can gather, the more prepared and strategic one can be in planning for success.

From the perspectives of curriculum development and pedagogy, it is best to use a structured approach when preparing the presentation (Table 1). Ideally, this includes the following steps: (1) identify what topic is requested and assess general needs for the setting and audience, (2) perform a targeted needs assessment, (3) define goals and learning objectives, (4) select the educational methods and presentation approach, (5) create and deliver the session, and (6) evaluate the product and process. ¹⁷ Commonly, learning objectives drive this creative process, and less experienced presenters may find this structure particularly useful.

More on Assessing Needs

A presenter who can respond to perceived learning needs is more likely to engage the audience and answer the ever-present question: “What's in this for me?” The general needs assessment is a first step, but a targeted needs assessment can be more useful by bringing a practical focus to a broader topic, even for a single presentation. If existing needs assessment data are nonspecific, it may be possible to conduct a more targeted needs assessment before the session using a written, oral or computer-generated survey of learners. Results could be advertised in marketing the Grand Rounds or engaging the audience. Another alternative for a more experienced and flexible presenter is to undertake a written, oral, or audience response system needs assessment at the beginning of the presentation itself, e.g., pretest or choice of format or objectives. Obviously, this requires some ability to adjust the presentation in real-time according to the data obtained. With motivation and creativity, any of these strategies can also be used for presentations in unfamiliar venues, whether local or out of town.

Setting Goals and Objectives

Defining learning goals and objectives helps focus the presenter on content, learner level, and teaching points. The presenter commonly becomes more teacher-centered in this step; reflecting back to learner needs at regular intervals is important. Goals are general statements of learning outcomes while objectives are more specific and have clear, measurable behavioral outcomes. Objectives clarify “who will be able to do what by when.” Individual learning objectives usually focus on one of three domains: knowledge, skills, or attitudes. For example, “At the end of this session, the learner will be able to discuss three common side effects of opioid medications” (knowledge) or “deliver difficult news to a patient” (skills).

Two or three learning objectives are usually sufficient for planning 40–45 minutes of content in an hour-long Grand Rounds presentation. They may be used in defining “take-home points” that can be stated at the outset of the presentation and repeated during a summary at the end. In this manner, objectives can provide the substance for the adage: “Tell them what you're going to tell them, tell them, then, tell them what you told them.”

Choosing Methods

The teaching method should provide content that is framed by the goals and objectives, and incorporate an interactive format, if possible (Table 2). If the presentation is a didactic lecture, a mixed method may include some opportunity for interaction. Different teaching methods may be used for each learning objective and varied options may be considered in terms of the experience and skill of the presenter and information about the academic culture and learning needs of the audience. Combinations of audio and visual strategies may address those who learn more effectively in one way or the other.

Interactive formats comprise many potential strategies. A didactic portion may be balanced by a topic-directed discussion after the lecture, a breakout session for small group discussion, a guided case discussion for the large group, a role play that illustrates a key teaching point, or an interdisciplinary panel discussion. If the decision to use a format that is entirely new to the audience, like a small group role play, would pose too great a risk, more subtle approaches may still be possible to increase the engagement of the audience.

Presentations may benefit from specific efforts to engage and entice the audience. Starting with a quiz, needs assessment, or vignette may create a useful tension for learning and grab the attention of learners. Similarly, simple shifts in presentation format, perhaps to emphasize a specific learning objective, may engage the audience with change in flow and expectations, e.g., moving from slides to a flip chart. Technology offers unique opportunities because innovation often draws attention. For example, if resources permit, the Grand Rounds can be augmented by the use of an audience response system or a visit to a website.

Creating the Presentation

Content must be creatively tied to the method of presentation and starting early allows important time for the development process. A written outline of the content may help define its scope, areas in need of deeper coverage, points in need of data presentation, and a presentational flow that includes a beginning, middle and end. The challenge of a diverse learner group can be approached by varying the level of sophistication or aiming for the typical member. The outline also can assist in linking the presentation to the learning objectives.

In essence, the presenter is a storyteller, giving a narrative flow to concepts and information, with transitions between points that are timed to support the objectives of the session. Transitional cues, including a direct statement, change in the title of a slide, or a change in learning method, can help the audience prepare for new messages.

The amount and depth of data included in a talk are important decisions. For some audiences, the data, and their critique, have the greatest value. For others, the clear presentation of concepts is the focus, and data provide a useful back-story. When data are presented, they should illustrate the most critical points, especially when challenging current practice. For example, the admonition against the use of meperidine or propoxyphene would be best supported by relevant data on the side effect liability of the active metabolites. It is important that the presenter be very familiar with the data presented and be able to support points with methodological details, limitations, and strengths.

The presentational flow may vary widely in linking content and learning methods. For example, a formal didactic lecture might structure a beginning, a middle, and an end by specific reference to an introduction (e.g., objectives or background information), the main points for discussion, and a summary (with take-home points and conclusion), respectively. Each section and transition could be guided by slides. In contrast, a more interactive lecture might include an audience response quiz followed by slides for the objectives and background, guided discussion of three cases presented on slides with flip chart for recording of key points, and a set of take home points guided by flip chart and final side. Diverging from the lecture format, a skills practice session with role play could involve an opening faculty role play with objectives and background content guided by a handout, small group role play of two scenarios with facilitation and debriefing, and large group discussion defining take home points or a conclusion from flip chart.

The optimal structuring and illustration of content is a challenge and can be accomplished with varied levels of sophistication. It may be helpful to identify a content or teaching/presentation skills mentor to help guide preparation. Depending on offerings at a specific institution, a presenter might be able to enroll in local faculty development courses in slide design, use of technology, or teaching pedagogy. National level offerings also may be relevant. Less experienced presenters should accept every opportunity to teach and should try new approaches to gain experience. Finally, keeping a teaching or presentation journal may be useful in recording one's own and others' observations and ideas for improving presentations over time.

When using a slide presentation format, awareness of the limitations and strengths of such a tool is critical. Critics of PowerPoint emphasize that the structural design of the software results in an oversimplified approach to presentations that is a barrier to more effective communication. ²¹ More specifically, it can reinforce overuse of text, bullet points, and generic templates. Supporters counter that the tool is not meant to replace communication between speaker and audience and argue for “intelligent use” of PowerPoint to enhance visual display of information. ²¹

If slides are used, they must be error-free and optimize clarity and simplicity through the contrast, format, and font. Please refer to the Appendix for Web-based resources on creating slide presentations. Generally accepted guidelines support using 1 slide per minute of presentation and a minimum font size of 20. This font size is recommended for citations and pasted tables and figures, as well. In designing individual slides, a common approach encourages avoiding full sentences and limiting text to 4–5 lines per slide; bulleting, highlighting and illustrations can be useful. However, the “alternative design” approach ²¹ advocates sentence headlines instead of bullets and visual displays that substitute for the bulk of explanatory text.

Although cartoons, pictures, graphics, and other additions are engaging and can add emphasis, noises, gizmos, and movements may be distracting. A pointer also can be distracting, unless stabilized by good motor control and used selectively to support the flow of the lecture. Graphs, figures, and tables should be “walked through” to allow the audience to understand the meaning and interpretation of data. Given differences in projectors, the look of the slides—particularly those with graphs, figures or data—should be previewed in the Grand Rounds venue, if possible.

Giving the Presentation

To assume the appropriate demeanor of authority and approachability, the presenter must achieve a comfort level in the role. For this reason, new presentations, especially if given by less experienced presenters, should be practiced. Extremely useful feedback may be elicited if a presentation is piloted with a group of knowledgeable observers, such as departmental colleagues. Whomever the observer, presenters should request specific feedback on content, style, and potential audience questions.

Videotaping of presentations with self-review, or preferably guided-review with peer or mentor feedback, is an additional and very potent tool that can be implemented in the practice phase or for the Grand Rounds itself. Formal peer observation is another similar tool, available in some settings. This resource ideally allows the presenter to enter a structured process of review with a trained peer; the colleague observes a presentation after identifying requested areas for critique and subsequently provides specific and comprehensive oral and written review. With all types of practice, the ability to rehearse in the planned venue is valuable to ensure comfort with the audiovisual equipment and the setting.

Presenters should have a plan to cope with a technological glitch or other problem that disrupts the planned presentation. Ideally, familiarity with the material is such that the presentation can still be given without slides, perhaps using a white board instead. Alternatively, it may be possible to speak from a handout, present other cases, or extend a question-and-answer period. Again, the need to plan for alternatives emphasizes that slides are best used as a tool to complement the presenter, rather than as the presentation itself.

Experienced presenters may develop a sense of “cognitive centeredness” when giving a presentation and younger colleagues should aspire to this. A speaker or teacher who embodies the precepts of mindfulness ²² is focused on the present, is without distraction from the task at hand, can react to the audience's responses in real time, and is most likely to connect with learners. Although even very experienced speakers may memorize the first part of a talk to help establish the flow of the presentation and overcome initial jitters, the goal is to interact with the audience unit one-on-one, “read” their responses, and adjust the presentation to optimize engagement and information exchange. A specific role for mindfulness in medical education has been proposed, ²² perhaps with the potential to increase the efficacy of the teacher–learner interaction.

Speaker etiquette on the day of the presentation has specific requirements (Table 3). The presenter should arrive early, know the order of events, and identify the moderator. The moderator can clarify any final questions about logistics or flow, the plan for introducing the presenter, the procedures used to keep on time, and whether the question-and-answer period will be moderated or not. It often is advisable to specifically request that the moderator signal when five minutes are left in the main portion of the presentation.

Although presentational styles vary, the effort to engage is a common thread. Some simple techniques, like using short and long pauses, moving around the room, introducing humor, and creating a high level of energy, may engage and communicate emphasis. Smiling, making eye contact, and being enthusiastic are all important. At the end of the presentation, a strong closing statement with a transitional phrase, such as “in summary” may enhance the audience's retention. As noted, this ending may be an opportunity to repeat take-home messages derived from the learning objectives. After the formal presentation and an expression of appreciation, questions usually are invited. Questions should be repeated and clarified if needed; if an answer is not known, this should be stated clearly.

Evaluating the Teaching and Learning

To address the full rigor of the academic teaching process, an evaluation component for Grand Rounds should be planned and completed. For clinician-educator faculty, in particular, evaluation data become an important part of a teaching portfolio and will play a role in the promotion and tenure process. ²³ If CME is offered, there is likely to be an evaluation component conducted by the sponsoring institution. Even if this is the case, the presenter can be proactive, clarifying ahead of time when the data will be available and what it will include. If the data collected in this way will not be meaningful or sufficient for the presenter, a separate evaluation can be employed. The presenter can create a new evaluation or use a validated instrument for the setting. ²³ Those collecting evaluation data for a teaching portfolio are encouraged to embrace this approach.

Constructing one's own evaluation scheme is another skill set to learn and an area for potential creativity and flexibility. The format can vary; verbal, written or computer-based evaluation may be possible. At the simplest level, a written survey, sometimes called a “minute-paper,” can be distributed and collected at the end of a session. This is often 3–5 questions that can be completed in a minute or less to lessen the burden of completion. At a more comprehensive level, a peer could provide written and oral feedback. The content and focus of evaluation must also be determined. The assessment can focus on overall learner satisfaction, the achievement of learning objectives, presentation skills, or the effectiveness of the presenter. Those committed to an academic path or improving their skills may benefit most from data on the effectiveness of the presenter and the teaching strategies. The ideal goal would be to receive expected formative feedback on areas designated by the presenter with documentation for a teaching portfolio.

After the Presentation

The key task after a presentation is to evaluate the session in order to identify lessons learned for future opportunities. Ideally, an evaluation plan with multiple data points would be in place, as discussed above. All feedback should eventually be gathered and time should be set aside for specific reflection. As with the evaluation itself, reflection can be more or less formalized; it is usually a personal endeavor. At a very basic level, one might ask: What went well? What did not go well? What might I do differently next time? The extra step of metacognition, or reflection on one's own thoughts and feelings, while the presenter looks critically at her or his performance, is thought to be important in rounding out this feedback cycle. ²⁴ On a more practical level, reflection can provide the basis for a more formal quality improvement approach to health professions education; it represents the study step in the plan-do-study-act cycle. ²⁵

Conclusion

The opportunity to present a Grand Rounds places the palliative medicine subspecialist in a time-honored setting. The occasion is characterized by respect and a chance to advance the field while favorably influencing the attitudes, knowledge, skills, and performance of colleagues. To do this well, adult learning principles must be thoughtfully incorporated into a presentation style and method appropriate to the venue. For those pursuing academic careers, giving Grand Rounds is academic currency that motivates teaching expertise and personal growth. Room for creativity exists at every step and can add enjoyment and challenge along the way.