research presentation skills pdf

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• v.17(12); 2021 Dec

Ten simple rules for effective presentation slides

Kristen m. naegle.

Biomedical Engineering and the Center for Public Health Genomics, University of Virginia, Charlottesville, Virginia, United States of America

Introduction

The “presentation slide” is the building block of all academic presentations, whether they are journal clubs, thesis committee meetings, short conference talks, or hour-long seminars. A slide is a single page projected on a screen, usually built on the premise of a title, body, and figures or tables and includes both what is shown and what is spoken about that slide. Multiple slides are strung together to tell the larger story of the presentation. While there have been excellent 10 simple rules on giving entire presentations [ 1 , 2 ], there was an absence in the fine details of how to design a slide for optimal effect—such as the design elements that allow slides to convey meaningful information, to keep the audience engaged and informed, and to deliver the information intended and in the time frame allowed. As all research presentations seek to teach, effective slide design borrows from the same principles as effective teaching, including the consideration of cognitive processing your audience is relying on to organize, process, and retain information. This is written for anyone who needs to prepare slides from any length scale and for most purposes of conveying research to broad audiences. The rules are broken into 3 primary areas. Rules 1 to 5 are about optimizing the scope of each slide. Rules 6 to 8 are about principles around designing elements of the slide. Rules 9 to 10 are about preparing for your presentation, with the slides as the central focus of that preparation.

Rule 1: Include only one idea per slide

Each slide should have one central objective to deliver—the main idea or question [ 3 – 5 ]. Often, this means breaking complex ideas down into manageable pieces (see Fig 1 , where “background” information has been split into 2 key concepts). In another example, if you are presenting a complex computational approach in a large flow diagram, introduce it in smaller units, building it up until you finish with the entire diagram. The progressive buildup of complex information means that audiences are prepared to understand the whole picture, once you have dedicated time to each of the parts. You can accomplish the buildup of components in several ways—for example, using presentation software to cover/uncover information. Personally, I choose to create separate slides for each piece of information content I introduce—where the final slide has the entire diagram, and I use cropping or a cover on duplicated slides that come before to hide what I’m not yet ready to include. I use this method in order to ensure that each slide in my deck truly presents one specific idea (the new content) and the amount of the new information on that slide can be described in 1 minute (Rule 2), but it comes with the trade-off—a change to the format of one of the slides in the series often means changes to all slides.

Top left: A background slide that describes the background material on a project from my lab. The slide was created using a PowerPoint Design Template, which had to be modified to increase default text sizes for this figure (i.e., the default text sizes are even worse than shown here). Bottom row: The 2 new slides that break up the content into 2 explicit ideas about the background, using a central graphic. In the first slide, the graphic is an explicit example of the SH2 domain of PI3-kinase interacting with a phosphorylation site (Y754) on the PDGFR to describe the important details of what an SH2 domain and phosphotyrosine ligand are and how they interact. I use that same graphic in the second slide to generalize all binding events and include redundant text to drive home the central message (a lot of possible interactions might occur in the human proteome, more than we can currently measure). Top right highlights which rules were used to move from the original slide to the new slide. Specific changes as highlighted by Rule 7 include increasing contrast by changing the background color, increasing font size, changing to sans serif fonts, and removing all capital text and underlining (using bold to draw attention). PDGFR, platelet-derived growth factor receptor.

Rule 2: Spend only 1 minute per slide

When you present your slide in the talk, it should take 1 minute or less to discuss. This rule is really helpful for planning purposes—a 20-minute presentation should have somewhere around 20 slides. Also, frequently giving your audience new information to feast on helps keep them engaged. During practice, if you find yourself spending more than a minute on a slide, there’s too much for that one slide—it’s time to break up the content into multiple slides or even remove information that is not wholly central to the story you are trying to tell. Reduce, reduce, reduce, until you get to a single message, clearly described, which takes less than 1 minute to present.

Rule 3: Make use of your heading

When each slide conveys only one message, use the heading of that slide to write exactly the message you are trying to deliver. Instead of titling the slide “Results,” try “CTNND1 is central to metastasis” or “False-positive rates are highly sample specific.” Use this landmark signpost to ensure that all the content on that slide is related exactly to the heading and only the heading. Think of the slide heading as the introductory or concluding sentence of a paragraph and the slide content the rest of the paragraph that supports the main point of the paragraph. An audience member should be able to follow along with you in the “paragraph” and come to the same conclusion sentence as your header at the end of the slide.

Rule 4: Include only essential points

While you are speaking, audience members’ eyes and minds will be wandering over your slide. If you have a comment, detail, or figure on a slide, have a plan to explicitly identify and talk about it. If you don’t think it’s important enough to spend time on, then don’t have it on your slide. This is especially important when faculty are present. I often tell students that thesis committee members are like cats: If you put a shiny bauble in front of them, they’ll go after it. Be sure to only put the shiny baubles on slides that you want them to focus on. Putting together a thesis meeting for only faculty is really an exercise in herding cats (if you have cats, you know this is no easy feat). Clear and concise slide design will go a long way in helping you corral those easily distracted faculty members.

Rule 5: Give credit, where credit is due

An exception to Rule 4 is to include proper citations or references to work on your slide. When adding citations, names of other researchers, or other types of credit, use a consistent style and method for adding this information to your slides. Your audience will then be able to easily partition this information from the other content. A common mistake people make is to think “I’ll add that reference later,” but I highly recommend you put the proper reference on the slide at the time you make it, before you forget where it came from. Finally, in certain kinds of presentations, credits can make it clear who did the work. For the faculty members heading labs, it is an effective way to connect your audience with the personnel in the lab who did the work, which is a great career booster for that person. For graduate students, it is an effective way to delineate your contribution to the work, especially in meetings where the goal is to establish your credentials for meeting the rigors of a PhD checkpoint.

Rule 6: Use graphics effectively

As a rule, you should almost never have slides that only contain text. Build your slides around good visualizations. It is a visual presentation after all, and as they say, a picture is worth a thousand words. However, on the flip side, don’t muddy the point of the slide by putting too many complex graphics on a single slide. A multipanel figure that you might include in a manuscript should often be broken into 1 panel per slide (see Rule 1 ). One way to ensure that you use the graphics effectively is to make a point to introduce the figure and its elements to the audience verbally, especially for data figures. For example, you might say the following: “This graph here shows the measured false-positive rate for an experiment and each point is a replicate of the experiment, the graph demonstrates …” If you have put too much on one slide to present in 1 minute (see Rule 2 ), then the complexity or number of the visualizations is too much for just one slide.

Rule 7: Design to avoid cognitive overload

The type of slide elements, the number of them, and how you present them all impact the ability for the audience to intake, organize, and remember the content. For example, a frequent mistake in slide design is to include full sentences, but reading and verbal processing use the same cognitive channels—therefore, an audience member can either read the slide, listen to you, or do some part of both (each poorly), as a result of cognitive overload [ 4 ]. The visual channel is separate, allowing images/videos to be processed with auditory information without cognitive overload [ 6 ] (Rule 6). As presentations are an exercise in listening, and not reading, do what you can to optimize the ability of the audience to listen. Use words sparingly as “guide posts” to you and the audience about major points of the slide. In fact, you can add short text fragments, redundant with the verbal component of the presentation, which has been shown to improve retention [ 7 ] (see Fig 1 for an example of redundant text that avoids cognitive overload). Be careful in the selection of a slide template to minimize accidentally adding elements that the audience must process, but are unimportant. David JP Phillips argues (and effectively demonstrates in his TEDx talk [ 5 ]) that the human brain can easily interpret 6 elements and more than that requires a 500% increase in human cognition load—so keep the total number of elements on the slide to 6 or less. Finally, in addition to the use of short text, white space, and the effective use of graphics/images, you can improve ease of cognitive processing further by considering color choices and font type and size. Here are a few suggestions for improving the experience for your audience, highlighting the importance of these elements for some specific groups:

• Use high contrast colors and simple backgrounds with low to no color—for persons with dyslexia or visual impairment.
• Use sans serif fonts and large font sizes (including figure legends), avoid italics, underlining (use bold font instead for emphasis), and all capital letters—for persons with dyslexia or visual impairment [ 8 ].
• Use color combinations and palettes that can be understood by those with different forms of color blindness [ 9 ]. There are excellent tools available to identify colors to use and ways to simulate your presentation or figures as they might be seen by a person with color blindness (easily found by a web search).
• In this increasing world of virtual presentation tools, consider practicing your talk with a closed captioning system capture your words. Use this to identify how to improve your speaking pace, volume, and annunciation to improve understanding by all members of your audience, but especially those with a hearing impairment.

Rule 8: Design the slide so that a distracted person gets the main takeaway

It is very difficult to stay focused on a presentation, especially if it is long or if it is part of a longer series of talks at a conference. Audience members may get distracted by an important email, or they may start dreaming of lunch. So, it’s important to look at your slide and ask “If they heard nothing I said, will they understand the key concept of this slide?” The other rules are set up to help with this, including clarity of the single point of the slide (Rule 1), titling it with a major conclusion (Rule 3), and the use of figures (Rule 6) and short text redundant to your verbal description (Rule 7). However, with each slide, step back and ask whether its main conclusion is conveyed, even if someone didn’t hear your accompanying dialog. Importantly, ask if the information on the slide is at the right level of abstraction. For example, do you have too many details about the experiment, which hides the conclusion of the experiment (i.e., breaking Rule 1)? If you are worried about not having enough details, keep a slide at the end of your slide deck (after your conclusions and acknowledgments) with the more detailed information that you can refer to during a question and answer period.

Rule 9: Iteratively improve slide design through practice

Well-designed slides that follow the first 8 rules are intended to help you deliver the message you intend and in the amount of time you intend to deliver it in. The best way to ensure that you nailed slide design for your presentation is to practice, typically a lot. The most important aspects of practicing a new presentation, with an eye toward slide design, are the following 2 key points: (1) practice to ensure that you hit, each time through, the most important points (for example, the text guide posts you left yourself and the title of the slide); and (2) practice to ensure that as you conclude the end of one slide, it leads directly to the next slide. Slide transitions, what you say as you end one slide and begin the next, are important to keeping the flow of the “story.” Practice is when I discover that the order of my presentation is poor or that I left myself too few guideposts to remember what was coming next. Additionally, during practice, the most frequent things I have to improve relate to Rule 2 (the slide takes too long to present, usually because I broke Rule 1, and I’m delivering too much information for one slide), Rule 4 (I have a nonessential detail on the slide), and Rule 5 (I forgot to give a key reference). The very best type of practice is in front of an audience (for example, your lab or peers), where, with fresh perspectives, they can help you identify places for improving slide content, design, and connections across the entirety of your talk.

Rule 10: Design to mitigate the impact of technical disasters

The real presentation almost never goes as we planned in our heads or during our practice. Maybe the speaker before you went over time and now you need to adjust. Maybe the computer the organizer is having you use won’t show your video. Maybe your internet is poor on the day you are giving a virtual presentation at a conference. Technical problems are routinely part of the practice of sharing your work through presentations. Hence, you can design your slides to limit the impact certain kinds of technical disasters create and also prepare alternate approaches. Here are just a few examples of the preparation you can do that will take you a long way toward avoiding a complete fiasco:

• Save your presentation as a PDF—if the version of Keynote or PowerPoint on a host computer cause issues, you still have a functional copy that has a higher guarantee of compatibility.
• In using videos, create a backup slide with screen shots of key results. For example, if I have a video of cell migration, I’ll be sure to have a copy of the start and end of the video, in case the video doesn’t play. Even if the video worked, you can pause on this backup slide and take the time to highlight the key results in words if someone could not see or understand the video.
• Avoid animations, such as figures or text that flash/fly-in/etc. Surveys suggest that no one likes movement in presentations [ 3 , 4 ]. There is likely a cognitive underpinning to the almost universal distaste of pointless animations that relates to the idea proposed by Kosslyn and colleagues that animations are salient perceptual units that captures direct attention [ 4 ]. Although perceptual salience can be used to draw attention to and improve retention of specific points, if you use this approach for unnecessary/unimportant things (like animation of your bullet point text, fly-ins of figures, etc.), then you will distract your audience from the important content. Finally, animations cause additional processing burdens for people with visual impairments [ 10 ] and create opportunities for technical disasters if the software on the host system is not compatible with your planned animation.

Conclusions

These rules are just a start in creating more engaging presentations that increase audience retention of your material. However, there are wonderful resources on continuing on the journey of becoming an amazing public speaker, which includes understanding the psychology and neuroscience behind human perception and learning. For example, as highlighted in Rule 7, David JP Phillips has a wonderful TEDx talk on the subject [ 5 ], and “PowerPoint presentation flaws and failures: A psychological analysis,” by Kosslyn and colleagues is deeply detailed about a number of aspects of human cognition and presentation style [ 4 ]. There are many books on the topic, including the popular “Presentation Zen” by Garr Reynolds [ 11 ]. Finally, although briefly touched on here, the visualization of data is an entire topic of its own that is worth perfecting for both written and oral presentations of work, with fantastic resources like Edward Tufte’s “The Visual Display of Quantitative Information” [ 12 ] or the article “Visualization of Biomedical Data” by O’Donoghue and colleagues [ 13 ].

Acknowledgments

I would like to thank the countless presenters, colleagues, students, and mentors from which I have learned a great deal from on effective presentations. Also, a thank you to the wonderful resources published by organizations on how to increase inclusivity. A special thanks to Dr. Jason Papin and Dr. Michael Guertin on early feedback of this editorial.

Funding Statement

The author received no specific funding for this work.

Princeton Correspondents on Undergraduate Research

How to Make a Successful Research Presentation

Turning a research paper into a visual presentation is difficult; there are pitfalls, and navigating the path to a brief, informative presentation takes time and practice. As a TA for  GEO/WRI 201: Methods in Data Analysis & Scientific Writing this past fall, I saw how this process works from an instructor’s standpoint. I’ve presented my own research before, but helping others present theirs taught me a bit more about the process. Here are some tips I learned that may help you with your next research presentation:

More is more

In general, your presentation will always benefit from more practice, more feedback, and more revision. By practicing in front of friends, you can get comfortable with presenting your work while receiving feedback. It is hard to know how to revise your presentation if you never practice. If you are presenting to a general audience, getting feedback from someone outside of your discipline is crucial. Terms and ideas that seem intuitive to you may be completely foreign to someone else, and your well-crafted presentation could fall flat.

Less is more

Limit the scope of your presentation, the number of slides, and the text on each slide. In my experience, text works well for organizing slides, orienting the audience to key terms, and annotating important figures–not for explaining complex ideas. Having fewer slides is usually better as well. In general, about one slide per minute of presentation is an appropriate budget. Too many slides is usually a sign that your topic is too broad.

Limit the scope of your presentation

Don’t present your paper. Presentations are usually around 10 min long. You will not have time to explain all of the research you did in a semester (or a year!) in such a short span of time. Instead, focus on the highlight(s). Identify a single compelling research question which your work addressed, and craft a succinct but complete narrative around it.

You will not have time to explain all of the research you did. Instead, focus on the highlights. Identify a single compelling research question which your work addressed, and craft a succinct but complete narrative around it.

Craft a compelling research narrative

After identifying the focused research question, walk your audience through your research as if it were a story. Presentations with strong narrative arcs are clear, captivating, and compelling.

• Introduction (exposition — rising action)

Orient the audience and draw them in by demonstrating the relevance and importance of your research story with strong global motive. Provide them with the necessary vocabulary and background knowledge to understand the plot of your story. Introduce the key studies (characters) relevant in your story and build tension and conflict with scholarly and data motive. By the end of your introduction, your audience should clearly understand your research question and be dying to know how you resolve the tension built through motive.

• Methods (rising action)

The methods section should transition smoothly and logically from the introduction. Beware of presenting your methods in a boring, arc-killing, ‘this is what I did.’ Focus on the details that set your story apart from the stories other people have already told. Keep the audience interested by clearly motivating your decisions based on your original research question or the tension built in your introduction.

• Results (climax)

Less is usually more here. Only present results which are clearly related to the focused research question you are presenting. Make sure you explain the results clearly so that your audience understands what your research found. This is the peak of tension in your narrative arc, so don’t undercut it by quickly clicking through to your discussion.

• Discussion (falling action)

By now your audience should be dying for a satisfying resolution. Here is where you contextualize your results and begin resolving the tension between past research. Be thorough. If you have too many conflicts left unresolved, or you don’t have enough time to present all of the resolutions, you probably need to further narrow the scope of your presentation.

• Conclusion (denouement)

Return back to your initial research question and motive, resolving any final conflicts and tying up loose ends. Leave the audience with a clear resolution of your focus research question, and use unresolved tension to set up potential sequels (i.e. further research).

Use your medium to enhance the narrative

Visual presentations should be dominated by clear, intentional graphics. Subtle animation in key moments (usually during the results or discussion) can add drama to the narrative arc and make conflict resolutions more satisfying. You are narrating a story written in images, videos, cartoons, and graphs. While your paper is mostly text, with graphics to highlight crucial points, your slides should be the opposite. Adapting to the new medium may require you to create or acquire far more graphics than you included in your paper, but it is necessary to create an engaging presentation.

The most important thing you can do for your presentation is to practice and revise. Bother your friends, your roommates, TAs–anybody who will sit down and listen to your work. Beyond that, think about presentations you have found compelling and try to incorporate some of those elements into your own. Remember you want your work to be comprehensible; you aren’t creating experts in 10 minutes. Above all, try to stay passionate about what you did and why. You put the time in, so show your audience that it’s worth it.

For more insight into research presentations, check out these past PCUR posts written by Emma and Ellie .

— Alec Getraer, Natural Sciences Correspondent

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• DOI: 10.1093/femsle/fnx235
• Corpus ID: 7526699

Effective presentation skills

• Robert Dolan
• Published in FEMS Microbiology Letters 29 December 2017

15 Citations

Enhancing learners’ awareness of oral presentation (delivery) skills in the context of self-regulated learning, positive effects of a programme on oral presentation skills: high- and low-proficient learners’ self-evaluations and perspectives, determining presentation skills gaps among healthcare professionals, importance of presentation skills in contemporary business, using english in presentation skills for personal and professional endeavors in the multicultural setting, developing virtual communication skills in online learning based on modified pbl during the covid-19 pandemic, developing presentation skills in the esp course for students majoring in control systems and robotics, evaluation of students’ feedback after neonatal immediate care and basic resuscitation cooperative learning course, the influences of “public speaking-attractive training” to the public speaking anxiety (psa), the effect of public speaking training on students’ speaking anxiety and skill, related papers.

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Countway Practical Presentation Skills

Presentation Slides

Story Telling

Presentation Software

Body Language

• Showtime! (Tips when "on stage")
• Upcoming Classes & Registration

On this page you will find many of the tips and common advice that we cover within our Practical Presentation Skills Workshop.

If you are hoping to attend a workshop in the future, please check the schedule of upcoming classes, and reserve your spot. Space does fill up each week, so please register early!

Creating slides to accompany your presentation can be a great way to provide complimentary visual representation of your topic. Slides are used to fill in the gaps while you tell the story.

Start your presentation with a brief introduction- who you are and what you are going to talk about. 

Think about your presentation as a story with an organized beginning (why this topic), middle (how you did the research) and end (your summary findings and how it may be applicable or inform future research). You can provide a brief outline in the introduction so the audience may follow along. 

Keep it simple with a few key concepts, examples and ideas.

Make sure your audience knows the key takeaway points you wish to get across.

A good way to practice this is to try and condense your presentation into an elevator pitch- what do you want the audience to walk away know? 

Show your enthusiasm!

If you don’t think it is interesting- why should your audience?

Some Good Alternatives to PowerPoint:

• Google Slides
• Keynote (Mac)  
• Prezi  
• Zoho Show  
• PowToon  
• CustomShow  
• Slidebean  
• Haiku Deck  
• Visme  
• Emaze  
• and more…  

Your body language speaks volumes to how confident you are on the topic, how you are feeling up on stage and how receptive you are to your audience. Confident body language, such as smiling, maintaining eye contact, and persuasive gesturing all serve to engage your audience.

• Make eye contact with those in the audience that are paying attention and ignore the rest!
• Speak slower than what you would normally, take a moment to smile at your audience, and project your voice. Don’t rush, what you have to say is important!
• Don’t’ forget to breathe. Deep breaths and positive visualization can helps slow that pounding heart.
• Work on making pauses where you can catch your breath, take a sip of water, stand up straight, and continue at your practiced pace.
• Sweaty palms and pre-presentation jitters are no fun. Harness that nervous energy and turn it into enthusiasm! Exercising earlier in the day can help release endorphins and help relieve anxiety.
• Feeling shaky? Practicing confident body language is one way to boost your pre-presentation jitters. When your body is physically demonstrating confidence, your mind will follow suit. Standing or walking a bit will help you calm those butterflies before you go on stage.
• Don’t be afraid to move around and use the physical space you have available but keep your voice projected towards your audience.
• Practice, practice, practice! Get to the next Practical Presentation Skills workshop in Countway Library http://bit.ly/countwaypresent and practice your talk in front of a supportive and friendly group!

• Excessive bullet points
• Reading your slides instead of telling your story
• Avoid excessive transitions and gimmick
• Numerous charts (especially all on the same slide)
• Lack of enthusiasm and engagement from you
• Too much information and data dump
• Clutter and busy design
• Lack of design consistency 

Now you are on stage!

When delivering the talk, watch out for these bad habits:

•  Avoiding eye-contact
• Slouching or bad posture
• Crossed arms
• Non-purposeful movement
• Not projecting your voice
• Speaking away from the microphone
• Speaking with your back to the audience (often happens when reading slides)
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• URL: https://guides.library.harvard.edu/presentation

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Presentation skills are crucial for the nowadays managers and business people. This article aims to examine different traditional and unconventional methods for enhancing and perfecting presentation skills. It provides suggestions on how to structure a presentation, what type of verbal language to include, and pays significant attention to body language during presentations, as well as to the relation between the presenter and the audience. The paper highlights a variety of instruments and techniques applicable to every individual in search for presentation perfection.

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Regulatory Science Symposium: “Keys to a Clinical Trial: Management and Operations” Session 5 - Project Management: Managing Research Studies as Projects… How and Why? (2024)

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Competencies: Project Management, Regulatory Science, Regulatory and Quality Sciences, Clinical Research, Clinical Trials

Course Syllabus/Topics:

• Key Takeaways:
• Clinical and translational research can be framed as projects handled in an organized way.
• Highlight values and transferrable asset.
• Careful planning and clear communication are key to any project’s success.
• Defining Projects
• A project is a temporary endeavor undertaken to create a unique product, service or result.
• Project Management is the practice of using knowledge, skills, tools and techniques to complete a series of tasks to deliver value and achieve a desired outcome.
• Project manager (PM) Role
• Why learn PM? Growing recognition of value, growing labor force (+33%) and efficiency will translate to patient health.
• High demand for PMs
• PM skills (highly transferable skill set):
• Problem solving
• Communication
• Organization
• Other roles: mediator, cheerleader, pinch hitter (be able to stand-in if needed and qualified), secretary, Johnny on the spot (resourceful, know where to locate information)
• Methodologies
• Project Phases
• Initiate: capture requirements, documentation
• Plan: define scope, assign roles, deciding timeline, project charter approved (shared and measurable expectations)
• Execute: Implement and Monitor (tasks, e.g., IRB Approval, Recruitment, Monitoring)
• Close: New way of working, lessons learned captured
• What makes a good milestone?
• A task of zero duration/ point in time – something is achieved
• Important achievement/ signifier of change
• Signposts/sequence of events
• Constraints-The Iron Triangle
• Time; how long it will take
• Budget; how much it will cost
• Scope; what will be included
• Scope creep; new ideas or tasks, stretch project resources
• Google Drive
• SC CTSI Project Management Charter
• What are common scope creep issues in research? Ideas for addressing them?
• Key Takeaways

Acknowledgements Accompanying text created by: Roxy Terteryan, Project Administrator, SC CTSI ( [email protected] ) Rushaanaaz Sokeechand, Student Worker

NIH Funding Acknowledgment: Important - All publications resulting from the utilization of SC CTSI resources are required to credit the SC CTSI grant by including the NIH funding acknowledgment and must comply with the NIH Public Access Policy.

• Introduction
• Conclusions
• Article Information

VCA indicates video-based communication assessment.

Video-based communication assessment feedback components include the case text and video prompt available for review (A), personal overall rating from the panel of crowdsourced raters (orange) and peer average (blue) (B), buttons that play the recorded response to this vignette and an exemplar response from a highly rated peer (C), and learning points derived from crowdsourced advice about what they would like the physician to say in this situation (D). Reprinted with permission from the National Board of Medical Examiners.

The vertical line represents the median, the white bar represents the IQR, the horizontal line represents 1.5 times the IQR, and the dots represent outliers. The curve represents an estimation of the distribution shape of the data.

Trial Protocol and Statistical Analysis Plan

eTable 1. Video communication assessment cases used in a randomized controlled trial of an intervention designed to improve resident adverse event communication skills

eTable 2. Demographics of laypeople crowdsourced via Amazon Mechanical Turk (MTurk) who provided attentive ratings of resident adverse event communication skills

eTable 3. VCA ratings at Time 1 (baseline)

eTable 4. ANCOVA table for the impact of feedback and disclosure exposure on time 2 scores

Data Sharing Statement

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White AA , King AM , D’Addario AE, et al. Crowdsourced Feedback to Improve Resident Physician Error Disclosure Skills : A Randomized Clinical Trial . JAMA Netw Open. 2024;7(8):e2425923. doi:10.1001/jamanetworkopen.2024.25923

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Crowdsourced Feedback to Improve Resident Physician Error Disclosure Skills : A Randomized Clinical Trial

• 1 Department of Medicine, University of Washington School of Medicine, Seattle
• 2 National Board of Medical Examiners, Philadelphia, Pennsylvania
• 3 Collaborative for Accountability and Improvement, University of Washington School of Medicine, Seattle
• 4 Department of Medicine, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
• 5 Department of Pediatrics, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
• 6 Department of Bioethics, University of Washington School of Medicine, Seattle
• 7 Department of Medicine, UMass Chan Medical School, Worcester, Massachusetts

Question   Is crowdsourced feedback from laypeople an effective educational intervention to improve resident physicians’ error disclosure communication skills?

Findings   In this randomized clinical trial including 146 second-year internal medicine and family medicine residents, practice with simulation software followed by feedback from crowdsourced laypeople was associated with a modest increase in communication ratings on a 5-point scale among residents who reviewed their feedback.

Meaning   The findings from this trial suggest that self-directed review of crowdsourced feedback is an effective way for residency programs to address their requirement to prepare trainees for communicating with patients after medical harm.

Importance   Residents must prepare for effective communication with patients after medical errors. The video-based communication assessment (VCA) is software that plays video of a patient scenario, asks the physician to record what they would say, engages crowdsourced laypeople to rate audio recordings of physician responses, and presents feedback to physicians.

Objective   To evaluate the effectiveness of VCA feedback in resident error disclosure skill training.

Design, Setting, and Participants   This single-blinded, randomized clinical trial was conducted from July 2022 to May 2023 at 7 US internal medicine and family medicine residencies (10 total sites). Participants were second-year residents attending required teaching conferences. Data analysis was performed from July to December 2023.

Intervention   Residents completed 2 VCA cases at time 1 and were randomized to the intervention, an individual feedback report provided in the VCA application after 2 weeks, or to control, in which feedback was not provided until after time 2. Residents completed 2 additional VCA cases after 4 weeks (time 2).

Main Outcomes and Measures   Panels of crowdsourced laypeople rated recordings of residents disclosing simulated medical errors to create scores on a 5-point scale. Reports included learning points derived from layperson comments. Mean time 2 ratings were compared to test the hypothesis that residents who had access to feedback on their time 1 performance would score higher at time 2 than those without feedback access. Residents were surveyed about demographic characteristics, disclosure experience, and feedback use. The intervention’s effect was examined using analysis of covariance.

Results   A total of 146 residents (87 [60.0%] aged 25-29 years; 60 female [41.0%]) completed the time 1 VCA, and 103 (70.5%) completed the time 2 VCA (53 randomized to intervention and 50 randomized to control); of those, 28 (54.9%) reported reviewing their feedback. Analysis of covariance found a significant main effect of feedback between intervention and control groups at time 2 (mean [SD] score, 3.26 [0.45] vs 3.14 [0.39]; difference, 0.12; 95% CI, 0.08-0.48; P  = .01). In post hoc comparisons restricted to residents without prior disclosure experience, intervention residents scored higher than those in the control group at time 2 (mean [SD] score, 3.33 [0.43] vs 3.09 [0.44]; difference, 0.24; 95% CI, 0.01-0.48; P  = .007). Worse performance at time 1 was associated with increased likelihood of dropping out before time 2 (odds ratio, 2.89; 95% CI, 1.06-7.84; P  = .04).

Conclusions and Relevance   In this randomized clinical trial, self-directed review of crowdsourced feedback was associated with higher ratings of internal medicine and family medicine residents’ error disclosure skill, particularly for those without real-life error disclosure experience, suggesting that such feedback may be an effective way for residency programs to address their requirement to prepare trainees for communicating with patients after medical harm.

Trial Registration   ClinicalTrials.gov Identifier: NCT06234085

Following harmful medical errors, physicians often feel ill-equipped to communicate with patients and families. 1 - 4 Incomplete or poor physician communication magnifies the pain and uncertainty experienced by patients and impairs efforts to improve patient safety. 5 , 6 To better prepare physicians, the Accreditation Council for Graduate Medical Education requires that all residents receive training and practice in adverse event disclosure to patients. 7 However, 23% of US residencies provided no such training in 2021. 8 Most other programs provided only informal training or lectures, approaches that are necessary but likely insufficient. Lectures do not ensure communication skill acquisition, and informal training falls short because real-life disclosure is unpredictable and often concludes without formative feedback from supervisors or harmed patients. 9 - 12 To supplement lectures and bedside learning, educators need practical tools for residents to practice simulated medical error disclosure and receive reliable, patient-centered formative feedback. The video-based communication assessment (VCA) is software for this purpose, but limited evidence exists regarding its effectiveness.

The VCA provides physicians with practice and feedback on their communication skills. 13 It presents videos of vignettes and prompts users to audio-record what they would say to the patient. Recorded responses are rated by web-based panels of laypeople responding as if they were the patient in the scenario. 14 The laypeople are recruited via Amazon Mechanical Turk (MTurk), a crowdsourcing website with a large and diverse participant population. 15 , 16 Physicians receive feedback reports with summary ratings of their performance, average peer scores, learning points derived from raters’ comments, and audio of highly rated peer responses. VCA feedback reports are designed to support self-directed communication skill learning through multiple aspects of deliberate practice. 17 - 19 First, learning points reinforce desired behaviors and help learners to reconstruct task knowledge around the approach desired by patients. Second, listening to exemplars aids the conceptualization of ideal performance on specific communication subtasks. For example, cases are organized around challenging questions raised by patients that physicians may struggle to address without training and practice 1 (eg, “Why did this happen?” or “Who is going to pay for this care?”). Third, personal ratings help learners to gauge relative performance and determine areas for further practice.

In prior studies, 20 , 21 the VCA proved highly acceptable and feasible for preparing learners for common communication scenarios, and raters generated high-quality, actionable feedback. For VCA cases presenting harmful medical errors, panels of crowdsourced laypeople provided ratings that were consistent with those of patients with personal experience with harmful error. 22 In a single-site pre-post pilot study involving paid resident volunteers from 3 specialties, standalone VCA practice without a didactic curriculum was associated with an increase in ratings of residents’ error disclosure skills. 23 Because the effectiveness of the VCA has not been assessed, we sought to test the effect of formative feedback delivered by VCA with a large multisite cohort as part of an error disclosure curriculum. This article describes a randomized clinical trial to test the hypothesis that residents’ error disclosure skills, as assessed by laypeople, would improve after reviewing reports with personal performance feedback and recommendations for effective error disclosure.

From July 2022 through May 2023, we conducted a single-blinded, multicenter, randomized clinical trial of the effect of crowdsourced ratings and feedback on postgraduate year 2 (PGY2) internal medicine (IM) and family medicine (FM) resident physicians’ medical error communication skills (see the trial protocol in Supplement 1 ). The University of Washington institutional review board ruled this study exempt from review. Participants were not compensated. No VCA results were shared with residency faculty. Risks and benefits were explained verbally; participation was considered to indicate consent. Residents could participate in the training and opt out of research. This report follows the Consolidated Standards of Reporting Trials ( CONSORT ) reporting guideline for randomized studies. 24

Participants attended IM and FM residencies at 7 US academic medical centers: University of Washington, Seattle (IM and FM); University of Washington, Boise (IM); Washington State University, Everett (IM); Beaumont University (IM at Dearborn and Royal Oak, FM at Wayne and Troy); Dartmouth-Hitchcock Medical Center (IM); University of Massachusetts, Worcester (IM); and Washington University, St. Louis (IM). Each residency participated during a 4- to 8-week window chosen by program leaders to optimize PGY2 residents’ availability. Before the study, none of the residencies provided programwide required error disclosure training. We chose IM and FM residencies because of their large size and shared familiarity with medical cases involving adults. We enrolled only PGY2 residents to control for years of training and simplify scheduling. Residents were eligible for the study if they were on any clinical or nonclinical rotation that provided protected time to attend the teaching conference chosen by their program for VCA practice. Residents were not eligible if they were on leave at the time of the study.

Programs assigned all eligible PGY2 residents to attend a 75-minute teaching session at time 1, consisting of 50 minutes of lecture about communication with patients after medical errors, 20 minutes of VCA practice with 2 cases (containing 4 and 3 sequenced vignettes, respectively), and 5 minutes of debrief. At time 2, residents attended a session consisting of 25 minutes of lecture about institutional programs to support clinicians with error disclosure and 20 minutes of VCA practice with 2 additional cases (3 sequenced vignettes each). The recommended duration between time 1 and time 2 was 4 weeks, although the conference schedule at 2 residencies required an interval of 5 to 8 weeks for some residents. The training took place during regularly scheduled conferences for PGY2 residents. The lectures were delivered over video conference by investigators experienced with communication skills training (A.A.W. and T.H.G.). The lecture was adapted from published curricula and modified to highlight site-specific event review policies and clinician support systems. 25 , 26 Residents were encouraged to complete the VCA during the allocated conference time, but could complete it within 5 days if necessary. The study ended when all teaching conferences organized by programs had concluded.

Residents who completed the VCA at time 1 were randomized in 1:1 fashion to either receive feedback before time 2 (intervention) or after time 2 (control) ( Figure 1 ). Block randomization was performed centrally in variable block sizes, before time 1 responses were scored, by a coinvestigator (A.E.D.) with access to lists of the nonidentifying coded usernames of residents who completed time 1. Investigators and raters were blinded to assignments. Residents were unblinded after feedback was released. Intervention residents received automated emails when their feedback was available, instructing them to review it in the application (app) before the next teaching session and VCA practice. Feedback was typically provided 2 weeks after VCA use to allow for completion of rating and data quality checks. Reports presented an interactive feedback display within the VCA app for each vignette ( Figure 2 ). We asked residents receiving the intervention not to discuss feedback with colleagues to avoid contamination.

The VCA app used in this study has been described previously. 13 , 18 Users entered the app with a personal login and password to access vignettes or review feedback. This study used 4 cases, including 2 previously described cases (a delayed diagnosis of breast cancer and an anticoagulant overdose). 20 , 21 We created 2 new cases depicting a delayed diagnosis of sepsis and the development of a pressure sore (eTable 1 in Supplement 2 ). The cases were tested and refined with feedback from 6 faculty members in IM or FM to improve relevance, clarity, and believability. We designed all cases to reflect serious safety events of equivalent preventability and harm severity. Professional actors portrayed each patient or family member.

Residents provided audio responses to each vignette through the VCA software. Audio responses were bundled into rating tasks on MTurk for raters who were US residents aged 18 years or older and able to speak and read English. Raters answered demographic questions, read a vignette description in lay language, viewed the patient video, and listened to resident responses. They rated each response on 6 items covering domains related to accountability, honesty, apology, empathy, caring, and overall response, using a previously described instrument. 21 Items used a 5-point scale anchored with the labels poor, fair, good, very good, and excellent. After rating a set of responses, the rater responded in free text to the question, “What would you want the provider to say if you were the patient in this situation?” A power analysis based on previous research 23 with a moderate η p 2 of 0.09, determined that a sample of 96 PGY2 residents was needed to achieve a power of 0.85 at α = .05 for the analysis of covariance (ANCOVA) to effectively test the study hypotheses.

We sought at least 6 raters per response after removing raters with indications of low contributions to reliability. 27 To eliminate inattentive raters from quantitative analysis, open-ended responses were analyzed for quality. One analyst reviewed all responses and flagged responses that bypassed the question (eg, none, good, or NA [not applicable]), were generic, repetitive for multiple vignettes, or were copied and pasted from the ratings task questions (eg, “the provider understood how I was feeling”). A second analyst reviewed and confirmed all exclusions.

Residents completed questionnaires in the VCA application before proceeding to cases. The survey at time 1 asked about age, gender, race, the number of times the resident had personally participated in disclosure of a harmful error to a patient or family, and their highest level of involvement during disclosure of a harmful medical error. Data on race were included in this study because this information would be valuable for future analyses to address racial concordance between users and raters. Before time 2, residents who had received feedback were asked, “Approximately how many minutes did you spend reviewing your feedback?” (response options in 5-minute ranges), “How many of your own responses did you replay?”, and “How many of the exemplar (highly rated peer) responses did you play?” (response options of 0, 1-2, 3-4, and ≥5). Residents responded to 4 additional items about the usefulness of each feedback component (scores, personal recordings, exemplar recordings, and learning points) using a 5-point scale with labels from not at all to extremely.

Data analysis was performed from July to December 2023. We averaged ratings across items and raters to create an overall rating of each response. We then averaged response ratings across all 7 vignettes at time 1 to create an overall time 1 score, and across all 6 vignettes at time 2 to create a time 2 score. We created a dichotomous disclosure exposure variable by combining disclosure involvement level and the number of times participated in disclosure.

To address our primary study question about the effect of the intervention (ie, access to VCA feedback), we conducted a factorial ANCOVA examining the impact that the intervention and prior disclosure exposure had on the primary outcome, time 2 scores, while adjusting for time 1 scores. We conducted a modified intention-to-treat analysis, including all residents with both time 1 and time 2 data. However, those who did not complete time 2 were necessarily excluded from analysis because they did not provide data for the main outcome. Post hoc tests examining the difference between the intervention and control group for each level of prior disclosure exposure were conducted using the Bonferroni correction. We used a Wilcoxon rank sum test to compare performance across specialties on overall scores. We used logistic regression to investigate whether time 1 scores were associated with the likelihood that participants returned for time 2. All statistical analysis was performed in R statistical software version 4.1.2 (R Project for Statistical Computing), with a 2-sided P  < .05, except with ANCOVA, which is inherently 1-sided.

Programs identified 181 PGY2 residents available to attend educational conferences protected for VCA use (25 FM and 156 IM). Of these, 146 completed the VCA at time 1 before randomization (87 [60.0%] aged 25-29 years; 60 female [41.0%]; 77 male [53.0%]; 2 nonbinary [1.0%]) ( Figure 1 ). Of the 146 residents randomized, 103 (70.5%) completed the VCA at time 2 (53 randomized to intervention, and 50 randomized to control). All responses of these 103 residents were rated by at least 6 raters. Of the 43 who only completed time 1, we omitted 10 whose responses were rated by 5 or fewer raters to ensure adequate reliability of scores. Table 1 shows participants’ demographic characteristics. We recruited 592 raters via MTurk. Of these, 187 (32.0%) were removed for providing poor-quality data consistent with inattentiveness, resulting in a final rater sample of 405 (eTable 2 in Supplement 2 ). After removing inattentive raters, each response was rated by 6 to 18 laypeople (mean [SD], 9.50 [1.60] individuals).

The 53 participants in the intervention group completed surveys about interacting with the VCA feedback available before time 2. Two surveys lacked data because of electronic storage errors. Of the 51 residents with survey data, 28 (54.9%) reported that they had reviewed their feedback before the survey, reporting variable total periods of time in review; 7 (13.7%) spent less than 5 minutes, 12 (23.5%) spent 6 to 10 minutes, 5 (9.8%) spent 11 to 16 minutes, 3 (5.9%) spent 16 to 20 minutes, and 1 (2.0%) spent 21 to 25 minutes in review. Residents reported listening to variable numbers of their own or exemplar responses, but reported listening to more exemplar responses ( Table 2 ). Residents rated the usefulness of the 4 feedback components similarly ( Table 2 ).

Figure 3 displays the distribution of crowdsourced ratings by intervention assignment (eTable 3 in Supplement 2 presents time 1 ratings). High performers were rated 2 points higher than low performers on a 5-point scale. The ANCOVA model, which included time 1 scores as a covariate, showed a significant main effect of the intervention; the mean (SD) time 2 overall scores were 3.26 (0.45) for the intervention group and 3.14 (0.39) for the control group (difference, 0.12; 95% CI, 0.08-0.48; η p 2  = 0.04; P  = .01). We also detected a significant interaction between the intervention (ie, feedback availability) and prior exposure to disclosure conversation (η p 2  = 0.05; P  = .03) after adjusting for time 1 scores (eTable 4 in Supplement 2 ). Post hoc comparisons using Bonferroni correction revealed that when residents had no prior disclosure exposure, those in the feedback intervention group scored significantly higher than those in the control group (mean [SD] score, 3.33 [0.43] vs 3.09 [0.44]; difference, 0.24; 95% CI, 0.01-0.48; P  = .007) at time 2.

We did not observe a significant difference in communication skill performance between IM and FM residents (mean [SD] score, 3.24 [0.44] vs 3.26 [0.27]). Logistic regression found a significant association between time 1 scores and the likelihood that a participant returned for time 2, such that a 1-unit increase in time 1 scores corresponded to a 2.89-fold increase in the odds of participants completing time 2 (odds ratio, 2.89; 95% CI, 1.06-7.84; P  = .04).

This multisite, randomized clinical trial found that using VCA to provide crowdsourced feedback to PGY2 IM and FM residents about error disclosure skills was associated with an improvement in these skills. Feedback was most impactful among residents who reported they had not been exposed to error disclosure in clinical care, suggesting this intervention could be particularly beneficial at an earlier phase of training. Our findings highlight the potential for the VCA as a scalable practice tool for training that would be logistically challenging to replicate with standardized patients.

Despite these encouraging findings, surveys revealed that many residents either did not review or spent minimal time reviewing their feedback, which likely blunted the intervention’s effect. To optimize the VCA’s efficacy, future research should investigate and resolve barriers to residents’ use of crowdsourced feedback. Possible barriers in this trial included the delay between practice and feedback, the lack of protected time to review feedback, a need for adjunctive coaching, unidentified shortcomings of the feedback content and presentation, or the need for more practice repetitions. If confirmed, some of these potential barriers can be addressed with technical or curricular changes, such as providing dedicated time for feedback review or a paired faculty coach. However, using crowdsourcing to incorporate the layperson’s voice in statistically reliable feedback currently requires at least 2 to 3 days, making it difficult to provide instantaneous results.

To our knowledge, this study represents the largest assessment of medical error communication skills among IM and FM residents using a standardized instrument. Although all participants received a lecture on practical error disclosure skills, we observed significant variation in their performance, with high performers rated 2 points higher than low performers on a 5-point scale. Self-reported disclosure exposure did not explain this variation. These findings suggest that common teaching approaches leave at least a subset of residents unprepared for effective error disclosure and affirms the Accreditation Council for Graduate Medical Education’s requirement that residents practice these skills.

The reliability of VCA scores for comparative assessment may be useful for residency directors evaluating milestone progress within their programs. Yet, the VCA was intended for formative use by individuals and should first be optimized for uses that residents find engaging and psychologically safe. Of particular concern, we found that worse performance at time 1 was associated with not completing time 2. One possible explanation is that participants who found the exercise difficult left discouraged. The departure of individuals with the most room for improvement highlights a difficulty for educators and health system leaders tasked with preparing all physicians for effective error disclosure. Future work should determine approaches that better engage low performers in deliberate practice, including repetition and coaching.

Our work has limitations. First, statistical power was reduced by both nonparticipation with the intervention and dropout before the second VCA use. Second, survey results may be affected by social desirability and recall bias. Third, there is no established score benchmark for competence or mastery, limiting contextualization of the observed effect size. Fourth, we relied on self-report of feedback review, rather than direct measurement; the software does not currently track time spent in feedback activities. Because of the timing of survey administration, residents who reported not reviewing feedback could have theoretically chosen to delay taking the VCA to review feedback instead. However, if this had occurred, it would have diminished, not increased, the effect size. Fifth, reviewing layperson responses to remove those with low contribution to reliability requires effort that may not scale to very widespread use. Sixth, the crowdsourced laypeople were predominantly White and non-Hispanic; lack of racial diversity in the rating pool may introduce unmeasured bias in the results. Seventh, unmeasured confounders missing from analysis may have affected the results. The study has important strengths, including a large geographically diverse cohort with robust participation, suggesting the findings may generalize to other IM and FM residencies.

In summary, this study found that self-directed review of crowdsourced feedback was associated with error disclosure skill improvement in IM and FM residents who had already received a lecture on the topic. The VCA has the potential to solve a widely unmet need for graduate medical education patient safety educators. Future work should determine the viewpoints of residency leaders and residents about how the tool can be improved for curricular adoption, and eventually to evaluate its effect on patient-reported communication outcomes.

Accepted for Publication: June 6, 2024.

Published: August 7, 2024. doi:10.1001/jamanetworkopen.2024.25923

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2024 White AA et al. JAMA Network Open .

Corresponding Author: Andrew A. White, MD, Department of Medicine, University of Washington School of Medicine, Box 356429, 1959 Pacific St, Seattle, WA 98195 ( [email protected] ).

Author Contributions: Dr White had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: White, King, D’Addario, Gallagher.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: White, King, D’Addario, Bradley, Gallagher.

Critical review of the manuscript for important intellectual content: White, D’Addario, Brigham, Bradley, Mazor.

Statistical analysis: D’Addario, Bradley, Mazor.

Obtained funding: White.

Administrative, technical, or material support: King, D’Addario, Brigham, Bradley.

Supervision: White, King, D’Addario, Gallagher.

Conflict of Interest Disclosures: Dr White reported receiving grants from the National Board of Medical Examiners (NBME), the Agency for Healthcare Research and Quality (AHRQ), and the National Institute on Aging outside the submitted work. Dr King reported having a patent issued (10 860 963 B2). Dr Gallagher reported receiving grants from the AHRQ outside the submitted work. Dr Mazor reported serving as a paid consultant to the NBME, including consultation on the development and implementation of the video-based communication assessment. No other disclosures were reported.

Funding/Support: This study was supported by the NBME.

Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Data Sharing Statement: See Supplement 3 .

Additional Contributions: Art Riba, MD (Oakland University William Beaumont School of Medicine), and Chenwei Wu, MD (University of Washington), assisted with residency program engagement in this study. They did not receive compensation, and both provided written permission to include their names here.

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SHARKS - Animal Research Project (Google Slides™)

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Presentation of mitral valve cleft with concurrent atrial septal defect and ventricular septal defect detected by three-dimensional transesophageal echocardiography: a case report

• Azin Alizadehasl 1 ,
• Ehsan Amini-Salehi 2 ,
• Seyedeh Fatemeh Hosseini Jebelli 1 ,
• Kaveh Hosseini 3 ,
• Azam Yalameh Aliabadi 1 ,
• Rosa Yazzaf 1 &
• Sara Nobakht 2  

Journal of Medical Case Reports volume  18 , Article number:  387 ( 2024 ) Cite this article

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Cleft in the mitral valve leaflet is a primary cause of congenital mitral regurgitation, stemming from developmental anomalies in the mitral valve and frequently associated with other congenital heart defects. Concurrent presence of cleft in mitral valve leaflet with atrial septal defect and ventricular septal defect is relatively rare. Echocardiography, especially transesophageal echocardiography, is essential in diagnosing cleft mitral valve leaflet and related congenital heart defects, providing critical, detailed imagery for accurate assessment. This study presents a young female patient whose anterior mitral cleft, along with atrial septal defect and ventricular septal defect, was revealed through three-dimensional transesophageal echocardiography.

Case presentation

A 25-year-old Iranian female, experiencing progressive dyspnea and diminished physical capacity over 3 months, was referred to our hospital. Initial examination and transthoracic echocardiography indicated severe mitral regurgitation. Further evaluation with transesophageal echocardiography corroborated these findings and identified a cleft in the anterior mitral valve leaflet, coupled with mild left ventricular enlargement and significant left atrial enlargement. The complexity of the patient’s condition was heightened by the diagnosis of cleft mitral valve leaflet in conjunction with atrial septal defect and ventricular septal defect, showing the complex nature of congenital defects.

This case emphasizes the critical role of transthoracic echocardiography in diagnosing cleft of mitral valve leaflet and associated cardiac anomalies, showcasing its superiority over transthoracic echocardiography for detailed visualization of cardiac structures. The identification of multiple congenital defects highlights the necessity for a comprehensive diagnostic approach to manage and treat patients with complex congenital heart diseases effectively. Future research should aim to refine diagnostic methodologies to enhance patient outcomes for cleft of mitral valve leaflets and related congenital conditions.

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Introduction

Cleft mitral valve leaflet (CMVL) represents the predominant cause of congenital mitral regurgitation (MR), a condition characterized by improper closure of the mitral valve, leading to backward flow of blood from the left ventricle into the left atrium. Originating from congenital anomalies in the mitral valve’s development, specifically mitral hypoplasia, CMVL frequently coexists with other congenital heart defects. The most common of these are atrioventricular septal defects, which underscore the complex nature of congenital cardiac anomalies [ 1 , 2 , 3 , 4 , 5 , 6 ].

The clinical manifestation of CMVL varies widely, with the severity of MR ranging from mild to severe. In its initial stages, particularly in younger patients, CMVL may only induce mild MR, often going undetected owing to the absence of significant symptoms. However, as patients age, the severity of MR can escalate, leading to more significant cardiac complications [ 3 , 7 ].

Echocardiography is essential for diagnosing mitral valve anomalies, but transthoracic echocardiography (TTE) has limitations [ 8 , 9 , 10 , 11 ]. Transesophageal echocardiography (TEE), however, offers a more direct and detailed view of the mitral valve and cardiac structures, overcoming the shortcomings of TTE and providing crucial imaging for identifying complex cardiac abnormalities such as CMVL, atrial septal defect (ASD), and ventricular septal defect (VSD) [ 12 , 13 , 14 , 15 ].

In this report, we explore the case of a young female patient presenting with severe symptoms of MR. Utilizing TEE, we identified not only an anterior mitral cleft but also concurrent ASD and VSD, illustrating the complex interplay of congenital defects in patients with CMVL.

We report the case of a 25-year-old female Iranian patient who was referred to our clinic with 3-month history of progressive dyspnea and limitations in daily activities. The patient described a gradual onset of symptoms, which had increasingly interfered with her ability to perform routine tasks.

Upon initial evaluation, the patient appeared in mild distress due to dyspnea. Other vital signs were within normal limits, with a blood pressure of 110/70 mmHg and a heart rate of 90 beats per minute. Physical examination was notable for a 2–3/6 grade holosystolic murmur best heard at the left sternal border, suggesting valvular heart disease as a potential underlying cause.

Given the clinical presentation and the physical examination findings, the patient underwent a TTE to further evaluate the suspected valvular pathology. In the TTE evaluation, the findings were as follows: The ejection fraction (EF) was 55%, indicating preserved systolic function. There was mild left ventricular enlargement with left ventricular end-diastolic volume index (LVEDVI) of 69 cc/m 2 . Severe left atrial (LA) enlargement was noted, with left atrial volume index (LAVI) of 48 cc/m 2 . The mitral valve (MV) appeared myxomatous, with suspicion of the flail of the posterior mitral valve leaflet (PMVL), leading to MR evidenced by two distinct regurgitant jets. Additionally, moderate tricuspid regurgitation (TR) was observed.

Following the initial diagnostic evaluation with TTE, which suggested severe MR among other findings, a comprehensive TEE was performed to enable a more detailed assessment of the mitral valve anatomy and associated cardiac structures. The procedure was carried out under local anesthesia and mild conscious sedation, following proper preparation and draping of the patient.

The TEE findings corroborated some of the TTE results and provided additional insights into the patient’s cardiac condition. Mild left ventricular enlargement was confirmed, with LVEDVI of 69 cc/m 2 , and EF remained stable at 55%, indicating preserved systolic function. Severe LA enlargement was observed, with LAVI of 48 cc/m 2 , consistent with the volume overload from severe MR. Small size primum ASD (6 mm) with a left-to-right shunt and a tiny perimembranous VSD were also observed. The MV was noted to be thickened with a cleft in the anterior mitral valve leaflet (AMVL). Moderate TR was also noted. The pulmonary to systemic flow ratio (Qp:Qs ratio) was 1.1 (Figs.  1 , 2 , 3 , 4 ).

Mid-esophageal four-chamber view showing small-size atrial septal defect (6 mm) with left to right shunt

Mid-esophageal long-axis view showing central mitral valve regurgitation

Mid-esophageal commissure view showing severe mitral valve regurgitation due to anterior mitral valve cleft

Three-dimensional echocardiography at the end face mitral valve view showing a profound indentation (cleft) at 2 o’clock position

Despite the Qp:Qs ratio being below 1.5 with no significant shunt, indicating no significant right-to-left shunt, the patient was a candidate for surgery owing to the presence of severe MR caused by a cleft, and EF below 60%.

Clefts, which are narrow openings or imperfections, are believed to stem from a partial manifestation of an endocardial cushion defect, primarily affecting the anterior mitral valve leaflet, with a frequency of 1:1340 in children. In adults, this condition is rare and accounts for 33% of congenital mitral valve regurgitation cases [ 16 , 17 ]. However, if the atrioventricular junction is intact and MR is minor, individuals can remain symptom-free for an extended period, and the mitral cleft might be discovered incidentally [ 8 ]. Although cleft is the primary cause of MR, it is frequently exacerbated by anterior leaflet restriction and annular dilatation. The degree of regurgitation is the result of interactions between the papillary muscles, accessory chordal attachment, left atrium, and free wall of the left ventricle [ 7 , 8 ].

Several instances of mitral cleft have been documented. For example, Mohammadi et al . described a case involving a woman experiencing heart failure symptoms during her eighth decade of life. A more detailed investigation uncovered a rare occurrence of clefts in both anterior and posterior segments of the mitral valve [ 17 ]. Similarly, Muller et al . reported on a unique case featuring isolated multiple mitral clefts, with the patient having two clefts in the posterior and one in the anterior segment of the mitral valve [ 18 ]. The term “isolated mitral cleft” refers to a condition where the mitral valve cleft exists without any association with an atrioventricular septal defect or a common atrioventricular junction [ 19 ].

One important aspect of defects is their co-occurrence with other congenital anomalies. As an example, partial anomalous pulmonary venous connection (PAPVC) is often associated with ASD. PAPVC can be isolated or occur with other cardiac congenital diseases, including ASD, VSD, or PDA. The type and location of PAPVC can influence the severity of symptoms and the likelihood of associated anomalies. For example, PAPVC with superior anomalous drainage is frequently associated with superior sinus venosus ASD, while PAPVC with inferior anomalous drainage is often linked to inferior sinus venosus ASD. Accurate diagnosis and early management are crucial to address complex cardiac anomalies and optimize outcomes.

Echocardiography stands as the premier choice for imaging when evaluating congenital anomalies of the mitral valve, providing intricate details on the valve’s anatomy and morphology, as well as the mechanism and extent of mitral regurgitation. While two-dimensional (2D) echocardiography might present challenges in assessing mitral clefts, three-dimensional (3D) echocardiography can offer a more detailed and sophisticated analysis of the valve’s three-dimensional structure [ 1 ]. Three-dimensional echocardiography enhances the visualization of the mitral leaflets and annulus, the subvalvular apparatus, and their spatial relationships with surrounding structures, offering real-time anatomical views of the mitral valve [ 20 ].

The integration of 2D and 3D echocardiography techniques is particularly beneficial for diagnosing clefts and providing precise guidance for repair surgeries. Surgeries informed by this combined echocardiographic approach have demonstrated a high success rate of 93% [ 21 , 22 ]. In the case under discussion, echocardiography played a crucial role in diagnosing the cleft.

In our study, although an experienced echocardiographer performed TEE, it is essential to consider the utility of magnetic resonance imaging (MRI) in identifying congenital abnormalities. MRI demonstrates significant advantages over TEE in this regard. Its superior spatial resolution and excellent soft tissue contrast allow for detailed visualization of complex anatomical structures and small intracardiac lesions [ 23 , 24 , 25 ]. MRI provides a comprehensive, three-dimensional view of the heart and surrounding structures, free from the limitations of acoustic windows that affect TEE, facilitating a more holistic assessment of both cardiac and extracardiac anomalies. Additionally, MRI is noninvasive, which makes it safer and more patient-friendly, particularly for pediatric patients. Unlike TEE, which is invasive and can cause discomfort and risks such as esophageal injury, MRI offers a more comfortable and risk-free alternative for patients [ 26 , 27 ].

This study highlights a rare case of AMVL with ASD and VSD, illustrating the importance of detailed imaging. However, its nature as a single case report limits the ability to generalize the findings. While TEE was essential for the diagnosis, it may not be available in all settings.

Conducting thorough cardiac imaging, particularly through TEE, is crucial for identifying valvular abnormalities, especially in specific patients presenting with symptoms suggestive of significant valvular pathology. While TTE is an initial and valuable screening tool, TEE offers enhanced visualization and can reveal pathologies that may be missed or inadequately characterized on TTE alone.

In the case presented, the patient’s symptoms of severe MR prompted initial evaluation with TTE, which provided valuable information but did not fully outline the other coexisting cardiac abnormalities. However, TEE, with its superior spatial resolution and ability to obtain closer proximity to the heart structures, offered a more detailed assessment, revealing additional abnormalities.

Data availability

The data of the current study are available on reasonable request from the corresponding author.

Abbreviations

• Atrial septal defect

Cleft mitral valve leaflet

Ejection fraction

Left atrial

Left atrial volume index

Left ventricular end-diastolic volume index

Mitral regurgitation

Posterior mitral valve leaflet

Transesophageal echocardiography

Transthoracic echocardiography

Tricuspid regurgitation

• Ventricular septal defect

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Acknowledgements

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Cardio-Oncology Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Science, Tehran, Iran

Azin Alizadehasl, Seyedeh Fatemeh Hosseini Jebelli, Azam Yalameh Aliabadi & Rosa Yazzaf

Guilan University of Medical Sciences, Razi Hospital, Sardar-Jangle Ave., P.O. Box 41448-95655, Rasht, Iran

Ehsan Amini-Salehi & Sara Nobakht

Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran

Kaveh Hosseini

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Contributions

A.A. and S.F.H. diagnosed and treated the patient. E.A.S. and S.N. identified the patient’s record and drafted the manuscript. R.Y. designed the graphics and drafted the manuscript. All authors read and approved the final manuscript.

Corresponding authors

Correspondence to Ehsan Amini-Salehi or Sara Nobakht .

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The study was approved by the institutional board review at Tehran University of Medical Sciences and was assigned the ethics code IR.RHC.REC.1397.084.

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Alizadehasl, A., Amini-Salehi, E., Jebelli, S.F.H. et al. Presentation of mitral valve cleft with concurrent atrial septal defect and ventricular septal defect detected by three-dimensional transesophageal echocardiography: a case report. J Med Case Reports 18 , 387 (2024). https://doi.org/10.1186/s13256-024-04704-y

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Received : 17 May 2024

Accepted : 12 July 2024

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DOI : https://doi.org/10.1186/s13256-024-04704-y

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