Musings of a Cancer Doctor
Wide-ranging views and perspective from George W. Sledge, Jr., MD

Tuesday, February 28, 2017

Schola Medica Powerpointica

Looking through my files, I find that I gave 13 lectures in 2016, or just over one a month. Using that number as a rough annual average, this would imply somewhere over 400 lectures during the course of my career, though this could be off by 100 or so, plus or minus. Each of those lectures involved several hours of prep time, and some few involved tens of hours of preparation, so I've devoted a fair amount of my life to their creation and presentation.               

My colleagues who teach "real" medical school courses would scoff at these efforts, of course, but some of these talks were defining moments of my career, and therefore important to me, even if others barely noticed. Being an academic physician means many things, but one commonality involves flying somewhere, standing behind a lectern, and proceeding through a PowerPoint presentation.

In doing so, we represent part of a long chain that stretches back centuries. The very first medical school, the Schola Medica Salernitana, dates to sometime in the 10th century. While very little is known about its origins, at its peak between the 10th and 12th centuries the Schola Medica Salernitana was the center of learning for medicine in the Western world. Legend has it that the school was founded by a Greek, a Jew, a Latin, and a Muslim. Medical schools have always been cosmopolitan places, and Salerno, located on the Tyrrhenian Sea in the south of Italy, stood at a crossroads between civilizations.

Constantine Africanus, born in North Africa and a convert to Christianity, came to Salerno in 1077 and translated ancient Arab medical texts—themselves translations from even older Greek texts—into Latin, forming the basis of the curriculum in Salerno. In the image below, he is lecturing to 11th-century medical students.

Medical students often don't bother to attend lectures these days, due to the ubiquity of note-takers and the filming of talks. This is nothing new: some of our first manuscripts from Salerno represent notes taken by students and then sold on to others. Skipping class also has a long, if undocumented, lineage.

Some of the most boring hours of my life were spent sitting in lecture halls. There are few things worse on this earth than a turgid, remorselessly dull lecture. Hell, if it exists, is probably full of lecture halls. How much did you learn from years of lectures, compared to the number of hours spent listening to them? The return on investment of time is undoubtedly low, which is why those who study knowledge acquisition rarely have kind things to say about medical pedagogy.

But things could be worse. In fact, they were. Throughout much of the Middle Ages, anatomy classes involved three individuals: a lector, who sat on a pulpit and read from an anatomy text; an ostensor, who pointed to the body parts being dissected, and a sector, who did the actual dissections. The problem, aside from the boring bit about being read to from a Latin anatomy text, was that the text was wrong. Galen, the ancient Roman father of anatomy, had done his work on animals, not humans.

Andreas Vesalius of Padua, the first modern anatomist, was important not only because he dissected humans, but because he got rid of the tripartite lector-ostensor-sector thing, lecturing as he dissected. In the image below, he is surrounded by his students.

Well, they won't let me bring tumors to my talks. Instead, we use the moderm paraphenalia of lectures. The speaker stands behind the lectern (from the Latin lectus, past participle of legere, "to read"), which in turn is situated on a podium (from the Greek pod- for foot, since you are standing on it), a raised surface that allows the speaker to look down at the audience. The lectern serves several purposes: the speaker can place notes there, he can grip the lectern for support, and (if broad enough at the base) it can hide knocking knees of first-time speakers.

Lecterns have their own dangers. At one ASCO event, the lectern was placed near the back of the stage, for some reason. One speaker fell off the dais, saving the audience (statistically speaking) 15 minutes of boredom.

For those speakers who prefer not to hide behind the lectern, the conference organizers may offer the use of a lavalier mike, a small microphone clipped to the tie or coat, attached to a transmitter.

Why it is called a lavalier microphone? The term comes from the jewelry business, where a lavalier is a pendant suspended from a necklace. And why do jewelers call it a lavalier? In memory of the Duchesse Louise de la Valliere, mistress of King Louis XIV of France. She bore him five children and ended her life in a convent, but before that she made the eponymous jewelry popular. I like to think, as a regular user of the lavalier mike, that Louise did not take a vow of silence when she entered the convent. Or maybe she did, if she lectured the King using PowerPoint presentations.

I am dating myself, but I remember when slides were slides. Slide shows have their own history. The first slide shows were in the 1600s when hand-painted pictures on glass were projected onto a wall using a so-called "magic lantern". These, in turn, became the "lantern slides" used by 19th century speakers. By the early 20th century photographic images replaced painted images on glass, and then in 1936 the introduction of 35mm Kodachrome film led to the standard 2 X 2 inch slides that I used as an assistant professor.

These were, in contrast to current practice, "real" slide shows. I have difficulty making oncology fellows who grew up on PowerPoint understand what these involved. Today, speakers work on their talks right up until they walk on stage, but in my youth one prepared talks weeks in advance. You had to. One took carefully typed pieces of paper or pictures to the Medical Illustration department, where they were photographed and slides prepared, at an often-substantial price. Towards the end of the 1990s I gave a plenary lecture at ASCO that was projected on five different screens, requiring five sets of slides. The data came in late. I remember it costing $600.

These slide shows could be adventures. If the slide projector overheated the slides might warp or melt. Or, if the Kodak carousel top came loose, your entire talk might fall out. I saw this happen once. The speaker picked up the slides, placed them back in the slide carousel in no particular order, and gave his talk in no particular order. Hilarity ensued. Ah, those were the days.

My plenary session talk was virtually the last one I gave using "real" slides. Shortly thereafter PowerPoint presentations became standard, almost simultaneously with the internet. Now I drag images off the web (someone somewhere on this earth has already made the point I want to make), never visit Medical Illustration (if they still exist), and go on my happy way.

PowerPoint has its detractors. PowerPoint templates lead to the dreaded "Death by PowerPoint" talks with their unimaginative, sterile, repetitive slides that pollute Grand Rounds around the world. Microsoft has sold hundreds of millions of copies of PowerPoint software, which in turn have led to trillions of slides.

Was this what Constantine Africanus had in mind when he first got up to speak at the Schola Medica Salernitana? I don't know, but I suspect, given the rate of technologic change, that later 21st century lecturers will tell their junior colleagues that "when I was an Assistant Professor we used 'real' slide shows, something called PowerPoint."

How will they lecture? Some three-dimensional extravaganza? Direct porting of knowledge to embedded cerebral implants? Will lecture halls disappear entirely, turned into office space or new laboratories? Will all the talks be virtual, rather than in-person? But that's a talk for another time.