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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.
Icfai University Press
Dr. Rima Namhata
Rules, patterns or be it format, cannot always frame a piece of writing. Articles written can even be beyond the formal structure of writing. This article is no exception to it. This article explains the points of a good presentation. Presentation in any form is nowadays not new to anyone be it class lectures, debates, extempores, impromptu, group discussions, interviews, sales presentation, etc. The list is endless. Plenty of books and articles have focused on the concept of how to be a good presenter and giving the do’s and don’ts. There may be many articles on good presentation skills and the other nitty-gritties related to presentation, but this article is just an attempt in smoothening the delivery skills and preparing the content for the new comers in the world of public speaking or who are habitual presented yet somewhere the phobia lies in a deep corner of the mind. This article is based on experience, books and websites.
Research and Innovation in Applied Linguistics-Electronic Journal
La Ode Rasmin
This book is not for generic business presentation tips. However, it provides several tried-and-tested presentation elements. It will help the presenter to enlighten, influence, and excite the audience. Each chapter is segmented into “Know” and “How” sections to help you grasp the idea and use it in your business presentation. This book will help you maximize your presentations to a group, relevant stakeholders, or a digital/online presentation. For example, learning to promote yourself professionally, amaze your audience, start, end, and transition your presentation. It also includes ideas on designing a presentation outline, practicing, and presenting. This book presents eight golden steps for delivering business presentations: 1) understanding the target audience’s viewpoints, 2) mastering the topic of the presentation, 3) outlining the presentation (e.g., topics, structure, rules), 4) summarizing the presentation, 5) handling the questions effectively and straightforwardly, 6) c...
ANNALS OF THE ORADEA UNIVERSITY. Fascicle of Management and Technological Engineering.
Ioana Horea
Studies in Humanities and Cultures
Niall Walsh
This paper addresses the need for more informed pedagogical practices that enable Japanese students to make impactful presentations. In recent years the ESL classroom in Japan, especially at the tertiary level, has seen a requirement for students to not only critically analyze various topics but also to discuss and present their opinions on these topics. The paper shares practical presentation enhancement techniques for teachers in any subject who want their students to hone and sharpen their presentation skills. Features such as planning and delivering presentations including mind maps and shadowing which are explained and demonstrated. On conclusion of this paper, teachers should be better informed and equipped to deliver comprehensive presentation training to their students.
International Journal of Learning and Teaching
Rizaldy Hanifa
The importance of being able to perform a good oral presentation is undeniably necessary for academician nowadays, including students of higher education. To show their capacity, the students need to be prepared in delivering their presentation. However, the current students' presentation skill is still far from the expectation. Therefore, this article aims at sharing several facts dealing with presentation skill in terms of preparations, problems faced during presentation, and the ways to cope with the problems. This study was conducted as a qualitative research with descriptive approach. Questionnaire and interview were distributed and performed to five respondents to gather the data needed. The findings show that preparation involving content mastery and practice are the keys to be successful in presentation. Meanwhile, the problems faced are highly related to the respondents' nervousness due to time limitation and audiences, which cause losing idea while performing. To overcome these, some strategies such as believing in their abilities, skipping less important points, and anticipating possible questions from the audiences were employed. Based on the research results, it is suggested that speaker should be trained to be more aware of the preparations and strategies needed for presentation since the main keys to the success of delivering good presentation are highly determined by knowing how to prepare well and being able to use the strategies more appropriately and frequently.
Emese Pozdena
Due to the increase of international trade, business presentations have gained importance as means to convey business information and to promote sales. This empirical study examines business presentations through the eyes of three Hungarian expert presenters from different fields of business (Information technology, Finance / Accounting, Human Resources). The aim of the study is to give an insight into successful business presentations both for teachers of business English and for learners of presentation skills, including both preservice and in service students. The research has revealed that business people give high priority to establishing confidence with their audience in order to achieve their business aim. It also concludes that business people invest time, energy and money in developing their PS; consequently, it gives a rationale for teachers of business English to focus on this emerging market demand, and develop and specialise accordingly. Furthermore, the study explores the possible advantages of merging business English courses with presentation skills courses and adding expert presenters' experience to be promoted to businesses. The thesis also offers mutually beneficial cooperation between tertiary educational presentation skills courses lacking authenticity and contextual business background and the business world searching for new employees.
Michael R. Luthy
The teaching of presentation skills is no longer the exclusive purview of communications courses. Their central role in a variety of business courses, ranging from marketing, entrepreneurship, and management to accounting, finance, and strategy mirrors their use by professionals in all fields. This paper presents and discusses a number of unusual and unique techniques useful for enhancing students' presentation skills.
Abdelrahman elhaj
David John Abhishek
Transferable skills are the most talked about in recent times. These are skills that you can take with you into your future. Among these set of skills, public speaking skills is even more valuable because the ability to speak well, persuade or influence an audience is a major asset that one can cherish all throughout his or her life. Enhancing your ability to speak in front of an audience is one of the greatest benefits that one can achieve through time. The word "enhancing" is used because it is very likely that one would have prior experiences of giving a talk at any point in life. Practise will help to gain expertise which is essential for your future endeavours. Given appropriate practise one could speak effectively in a range of situations and also in front of audiences of varying backgrounds.
Peter Malvicini
Simple planning and a little discipline can turn an ordinary presentation into a lively and engaging event.
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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
© 2024
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.
Subject: Primary science
Age range: 7-11
Resource type: Lesson (complete)
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21 August 2024
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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.
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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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.
The data of the current study are available on reasonable request from the corresponding author.
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
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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
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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.
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.
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
The authors declare that they have no competing interests.
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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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Background 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 ...
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