Consider a 1-hour presentation attended by 20 people. The "cost" is 20 human hours times the hourly value of each person’s time. That’s a lot of time and cost not to mention the effort required for each audience member to travel to the presentation and break up their day to do so. To justify this cost, the presenter must be well prepared and the information thoughtfully presented and pertinent to the listeners’ needs.

Apologies are an unacceptable way to begin a presentation and an admission of poor preparation. "I’m sorry, but some of my slides didn’t turn out so well." "I’m sorry I spilled all my slides on the floor." "I’m sorry I left my handouts in the office." Such problems waste the audience’s valuable time and get the presentation off on the wrong foot. For the well-prepared speaker, such problems should almost never happen.

A lecture is unidirectional and is typically perceived by the audience as boring. The word "lecture" connotes a scolding or reproof. In contrast, the presentation, as defined by Ron Huff, is a commitment by the presenter to help the audience do something—and a constant, simultaneous evaluation of the worth of that commitment by the audience. This definition emphasizes the audience’s, rather than the presenter’s, self-interest. In the presentation, communication is bidirectional with the audience showing and telling the presenter how he or she is doing.

Think back to all the presentations you’ve heard. What made the best ones so memorable? What made the worst ones so forgettable? The best presenters probably incorporated some or all of the following elements—humor, entertainment, simplicity, organization, connection with the audience, depth of knowledge, and ability to communicate. The elements of not-so-great lectures probably included poor preparation, monotonous delivery, encyclopedic information, and little interaction with the audience. (Table 1 presents a more complete listing of these elements.)

Luisa Simone wrote, "Being a successful presenter means learning how to edit, structure, and illustrate your concepts in order to inform, influence – and entertain – your audience. You have to be part editor, part director, and part showman." The purposes of a presentation include conveying a message, distilling information, motivating a group, communicating a vision, and pointing the audience to additional learning resources.

To receive a message, the learner must remain awake, alert, and engaged. The presentation is not the time to become a "human encyclopedia" inflicting fact after fact on a numbed audience. Walt Whitman, in Leaves of Grass wrote, "The art of art, the glory of expression and the sunshine of the light of letters, is simplicity." Rather than say more, the presenter should say less, concentrating on 3-5 major points. Audiences appreciate distilled information and a "road map" for learning.

The key to designing an effective message is understanding who the audience is and researching their needs. The audience should be scouted in advance to determine their level of knowledge and educational needs. Put yourself in their place. What questions would you want answered? Better yet, if you have the time, conduct an informal survey of persons representative of your audience and ask them, "Which questions do you want me to address on this topic?"

I use a checklist to help me prepare for a presentation:

• What is the composition and level of training of the audience—physicians, nurses, administrators, lay public etc.?
• What is the mix of specialties and practice locations?
• What is the anticipated size of the audience?
• What is the knowledge level—student, resident, practitioner, expert?
• Why is the audience attending? Is attendance required for CME hours? Is it a mandatory educational lecture?
• How long should I speak?
• Are there any important points you would like me to reinforce?
• What equipment will be available (computer, Zip drive, CD-ROM, projector, laser pointer, etc.)

The presenter must overcome numerous diversions competing for the audience’s attention by employing techniques that make the message rise above the "background noise." Here is a listing of some of these techniques:

• Identify for the audience why this presentation is important to them (i.e., "This injury is the #1 cause of successful litigation against emergency physicians."
• Ask frequent "thought-provoking" questions, even if they’re rhetorical.
• Give a pre-presentation test where the audience must commit to an answer, then discuss the answers as a group.
• Begin with a clinical case and questions that illustrate the 3-5 major points of the presentation.
• Use a computer-based audience response system to instantly tabulate and display the audience’s answers to questions.

Instead of listing facts, tell stories. The human mind is particularly receptive to information imparted through story telling. (Before the invention of communication technologies, human knowledge and wisdom was transmitted stories, myths, and epic poetry.) Interject relevant clinical cases and anecdotes. Stimulate the audience’s imagination through imagery.

The presentation should promote long-term memory retention. Repetition of the 3-5 major points is the key to retention. Some wag once said that since the audience is paying attention only 25% of the time, the presenter must repeat everything 4 times during a 1 hour presentation.

The teacher’s role is to increase the student’s level of mental arousal and maintain their attention. The length of the lecture should as a rule be less than 55 minutes. As a courtesy, for prolonged sessions, the audience should be given a 5-10 minute stretch (ergonomic) break or "biological break" every hour. (I appoint one of the audience members to be time keeper and Champion-of-Breaks.)

The text of a speech should never be read. Reading is literally monotonous as it loses the dynamics of conversational speech. This is why "elevator music," intentionally stripped of dynamics, remains unnoticed in the background. (One notable exception to reading a lecture is the international meeting where translators need a script of the presentation.)

• Move around the room. Never hide behind a podium.
• Look around the room and shift eye contact from one individual to another. (This also allows you to estimate the attentiveness of the group.)
• Never turn the room lights down unless absolutely necessary.
• Use extra effort to engage the audience during these highly soporific situations—the early morning lecture (have plenty of coffee ready), the after lunch lecture (post-prandial stupor), and the final lecture of the day (audience burn-out and skip-out).

Rehearsal is preparation time devoted to the most crucial and difficult parts of the presentation while simulating the actual speaking conditions as closely as possible. Practice should not be going through the presentation time after time. Instead, rehearsal time should be spent on the opening and closing of the presentation, pacing and delivery, and smoothing out rough spots.

Public speaking is much like flying a plane. Once the plane’s in the air, the flight is usually smooth and on "autopilot." It’s getting the plane into the air and landing it that are the most difficult tasks. Therefore, most of your rehearsal time should be spent on getting your presentation "launch" and "landing"—the first 60-90 seconds and closing 2-3 sentences. Script out the opening and closing of the presentations to help prevent getting "tongue tied" during these crucial times. Practice smooth transitions from one slide to the next as well pauses, where appropriate, for dramatic effect.

When rehearsing, simulate the actual speaking conditions or worst case scenario you are likely to encounter as closely as possible. When a professional football team is going to be playing in a noisy domed stadium, they conduct some of their practices with a public address system blaring crowd noises at the same or higher decibel levels they are likely to encounter. Demonsthenes, the renowned Greek orator, overcame his inarticulate, stammering pronunciation by practicing with his mouth full of pebbles.

Here are some other rehearsal tips:

• If you’re practicing with slides, never rehearse by facing the screen—this is not how you will be delivering the presentation. Instead, pretend you’re facing the audience and practice turning your head to cue off the slides.
• Speak the words rather than hear them in your mind. Author Hermann Hesse said, "Everything becomes a little different as soon as it is spoken out loud."
• When possible, rehearse in front of a live audience. I find resident physicians to be the best "test" audience for new material. Knowledgeable, insightful, and not shy about pointing out the "warts" in my presentation, they are wonderful critics (in the best sense of the word).
• In the absence of a large audience, practice in front of your spouse, significant other, dog, or a mirror or video or audio tape the presentation for review.

Several "rituals" can be undertaken to reduce anxiety and bolster confidence:

• In advance of the presentation, visit the room where your presentation will be given.
• Stand at the podium and pretend you’re facing either a packed house of exuberant people or an empty hall with 3 people sound asleep. Imagine how you would handle either extreme.
• It has been suggested that the presenter imagine the audience are naked because presumably naked people are less intimidating. (Personally, my imagination is too vivid for this to work for me.)
• Avoid any caffeine for hours before the presentation. The combination of caffeine and anxiety will fill the bladder, further increasing any agitation.
• Finally, some anxious presenters swear by beta-blockers prior to the presentation when all else fails. (Be sure to trial these on a day other than your presentation!)

Just prior to your presentation, go through a pre-flight checklist:

• Note where the audio-visual equipment is located (projector remote control, lighting controls, etc.) and test that they are functioning properly.
• Test the microphone. Ask someone in the back of the room if they can hear you.
• Is your slide carrousel hub and bottom metal pan locked in place so the slides don’t fall out?
• Is your clothing neat? Is there a chive stuck between your teeth?
• Chat with members of the audience before the lecture to gauge their level of knowledge.
• If this is a scientific platform presentation, arrive early to introduce yourself to the moderator and panel discussants.

As you prepare to begin the speech, face the microphone and get "settled in." Take a few deep breaths…then smile. A smile conveys to the audience that you are having fun and happy to be with them. As we discussed earlier, never begin by apologizing as this only calls attention to shortcomings that might otherwise have been overlooked. Body language is important. Don’t lean against the podium or fidget nervously with the slide projector cord. And be aware that every time you lay something down on the podium, the microphone picks up the noise.

A strong opening, which should be assiduously rehearsed, is paramount. The presenter must establish his or her credibility, engage the audience, divert their attention from competing interests, and establish the purpose of the presentation in the first minute. If you get started without stumbling over your words, you’ll quickly gain confidence and likely "cruise on auto pilot."

Never end a presentation with a feeble statement such as "Well, I guess that’s all I have" or conclude with an "Any Questions?" final slide. This is not the message you want the audience to take home. Instead, script out and practice a strong, slightly emotional concluding statement that leaves the audience with a vivid mental image.

There’s an old proverb that says, "It always takes a person much longer to tell you what he thinks than what he knows." As a corollary, the shorter the speech, the more difficult the preparation. In the case of the scientific oral platform presentation, each word and slide must be carefully chosen to stay within the allotted 10-minute time frame.

Practice to finish in less than the allotted time—nobody ever got mad at a speaker for finishing too soon. Never try to cram 11 minutes worth of material into a 10 minute space by speaking faster. Instead, take out slides, especially those where you have to explain a lot of bulleted points.

Be enthusiastic and interactive and let your personality show! One of the reasons the audience is listening to you (rather than reading the information) is they want to see your personality and hear your perspective. Be interesting, but avoid over-entertaining which may obscure your message. Finally, put as much energy into presenting to a group of 3 as you would to a group of 300.

Handouts help promote long term retention and provide a reference source for the audience. Preparing handouts also compels the presenter to prepare the information of the speech well in advance. Handouts free the audience to listen (rather than scribble notes) and allow them to make supplemental notes in the margin. Handouts also help clarify detailed information (such as formulas or lists).

The best audio-visual aid is you, the speaker. Presentations don’t need slides to be effective. Imagine what it must have been like to see and hear Mark Twain standing in front of an audience, without slides, microphone, or props, captivating the audience with humor, wit, and story telling.

The use of slides, either 35 mm photographic slides or computer projection slides, is ubiquitous. These presentation technologies are the double-edged sword of presentations. Used effectively, such technology can enhance the transmission of the message. Used ineffectively, presentation technology can obscure or bury the message. A badly organized speech cannot be salvaged by 4-color graphics.

Computer projection systems, composed of a computer, presentation software such as PowerPoint, and a projection system, are increasingly being used in favor of 35 mm film slides. There are several advantages to computer projection. Changes can be made at the last minute. Messages can be broken into smaller units since cost per slide is not an issue as it is with 35 mm film slides. Computer projection permits the use of multimedia including sound and motion graphics (video). And other programs, such as a live Medline search or CD-ROM images, can be projected. Computer projection systems have also introduced new problems and last minute wrinkles. The ability to make last minute change can lead to procrastination and poor preparation, such systems are more complex than 35 mm slide projectors, and not all venues have the proper equipment or connectors

Here are some elements of style for designing effective slides:

• Slides should amplify the spoken message.
• Slides should not be used as teleprompters.
• 1 major idea per slide.
• A maximum of 15-25 words per slide.
• The "Burma Shave Rule"—Don’t pack any more into a visual than you could read off a billboard driving by at highway speed.
• The type should be readable from the back of room (typically at least 28 points in size).
• Choose type for readability and avoid novelty type faces.
• Stay away from all caps—the most readable type is an initial capital letter followed by lower case.
• Avoid red type which is difficult to read. Red is also an inflammatory color—just ask any bull.
• Flush left and ragged right alignment (not justified) is best for readability.
• One of the most readable color combinations is yellow title, yellow bullets, and white text on a blue background.

Have you ever watched a TV commercial you thought was extremely clever and entertaining then realized that you had no idea whatsoever what product or company it was advertising? The message was somehow missing, overshadowed by the presentation. Don’t obscure the message with gimmicks, avoid cliché, and always attempt to simplify. Before adding another element to a slide, ask "Does this element amplify the message or detract from it?" and "Is it consistent with the message?" Notorious gimmicks that can obscure the message include cheesy clip art, complex slide backgrounds, flamboyant color schemes, and vacation pictures.

Computer projection has opened up a new world of special effects, formerly limited to Hollywood, to the rest of us. These effects include animation, slide builds (where bulleted points fly into the picture one-by-one), and electronic transitions (where one slide fades or dissolves into the next). Used sparingly, builds and transitions create movement that can engage the audience’s attention. Overuse, however, can induce vertigo, nystagmus, and nausea. When it comes to employing electronic effects, simplicity again rules. "Just because we can doesn’t mean we should."

In conclusion, effective presentations are based on the following 5 key principles:

1. Designing the message.
2. Understanding the audience and defining their needs.
3. Using techniques to engage the audience.
4. Telling stories and showing pictures.
5. Employing presentation technology to enhance rather than detract from the message.

If you have previously found public speaking difficult or anxiety provoking, I believe the application of these 5 key principles will help bring success to your future presentations.