communication — Blog — mcdreeamie-musings

Last week the very last episode of Game of Thrones was broadcast. I was surrounded by friends and loved ones all doing everything they could to avoid hearing the ending before they’d seen it; even it this meant fingers in the ears and loud singing. I’ve only ever seen one episode so don’t worry I won’t spoil the ending for you. But actually that wouldn’t be as bad as you think. Spoiler alert: we actually love spoilers. And knowing this improves we way we communicate.

For all we complain if someone ‘spoils the ending’ of something the opposite is true. In 2011 a series of experiments explored the effect of spoilers on the enjoyment of a story. Subjects were given twelve stories from a variety of genres. One group were told the plot twist as part of a separate introduction. In the second the outcome was given away in the opening paragraph and the third group had no spoilers. The groups receiving the spoilers reported enjoying the story more than the group without spoilers. The group where the spoiler was a separate introduction actually enjoyed the story the most. This is known as the spoiler paradox.

Understanding the spoiler paradox is to understand how human beings find meaning. This is known as ‘theory of mind’. This means we like giving meaning and intentions to other people and even inanimate objects. As a result we love stories. A lot. Therefore we find stories a better way of sharing a message. The message “don’t tell lies” is an important one we’ve tried to teach others for generations. But one of the best ways to teach it was to give it a story: ‘The Boy Who Cried Wolf’. Consider Aesop’s fables or the parables of Jesus. Stories have a power.

Therefore, if we know where the story is going it becomes easier for us to follow. We don’t have to waste cognitive energy wondering where the story is taking us. Instead we can focus on the information as it comes. Knowing the final point makes the ‘journey’ easier.

Think how often we’ll watch a favourite movie or read a favourite book even though we know the end. We all know the story of Romeo and Juliet but will still watch it in the theatre. We’ll still go to see a film based on a book we’ve read. Knowing the ending doesn’t detract at all. In fact, I’d argue that focusing on twists and spoilers actually detracts from telling a good story. If you’re relying on spoilers to keep your audience’s attention then your story isn’t going to stand up to much. As a fan of BBC’s Sherlock I think the series went downhill fast in Series 3 when the writers focused on plot twists rather than just telling a decent updated version of the classic stories.

So, how can knowing about the spoiler paradox shape the way we communicate?

In healthcare we’re encouraged to user the ‘SBAR’ model to communicate about a patient. SBAR (Situation, Background, Assessment and Recommendation) was originally used by the military in the early 21st century before becoming widely adopted in healthcare where it has been shown to improve patient safety. In order to standardise communication about a patient SBAR proformas are often included by phones. There’s clear guidance about the content for each section of SBAR.

Situation:

Why I’m calling

Background:

What led to me seeing this patient

Assessment:

What I’ve found and done

Recommendation:

What I need from you

Handing over a patient on the phone to a senior is regularly included as a core skill to be assessed in examinations.

You’ll notice that right at the very beginning of the proforma in this photo (taken by me in the Resus room at Queens Medical Centre, Nottingham) it says ‘Presenting Complaint’. In other proformas I’ve seen this is also written as ‘Reason for call’. This makes a big impact on how easy the handover is for the other person. For example:

“Hi, is that the surgical registrar on call? My name is Jamie I’m one of the doctors in the Emergency Department. I’ve got a 20 year old man called John Smith down here who’s got lower right abdominal pain. He’s normally well and takes no medications. The pain started yesterday near his belly button and has moved to his right lower abdomen. He’s been vomiting and has a fever. His inflammatory markers are raised. I think he has appendicitis and would like to refer him to you for assessment.”

“Hi, is that the surgical registrar on call? My name is Jamie I’m one of the doctors in the Emergency Department. I’d like to refer a patient for assessment who I think has appendicitis. He’s a 20 year old man called John Smith who’s got lower right abdominal pain. He’s normally well and takes no medications. The pain started yesterday near his belly button and has moved to his right lower abdomen. He’s been vomiting and has a fever. His inflammatory markers are raised. Could I please send him for assessment?”

Both are the same story with the same intended message - I’ve got a patient with appendicitis I’d like to refer. But which one would be easier for a tired, stress surgeon on call to follow?

Or:

We can use this simple hack to make our presenting more effective as well. Rather than our audience sitting their trying to formulate their own ideas and meaning, which risks them either taking the wrong message home or just giving up, we must be explicit from the beginning.

“Hello my name is Jamie. I’m going to talk about diabetic ketoacidosis which affects 4% of our patients with Type 1 Diabetes. In particular I’m going to focus on three key points: what causes DKA, the three features we need to make a diagnosis and how the treatment for DKA is different from other diabetic emergencies and why we that it is important.”

Your audience immediately knows what is coming and what to look out for without any ambiguity. Communication is based on stories. Knowing what is coming actually helps us follow that story. The real spoiler is that we love spoilers. Don’t try and pull a rabbit from the hat. Punchlines are for jokes. Be clear with what you want.

Thanks for reading

- Jamie

The space shuttle Columbia disintegrating in the atmosphere (Creative Commons)

We’ve all sat in those presentations. A speaker with a stream of slides full of text, monotonously reading them off as we read along. We’re so used to it we expect it. We accept it. We even consider it ‘learning’. As an educator I push against ‘death by PowerPoint’ and I'm fascinated with how we can improve the way we present and teach. The fact is we know that PowerPoint kills. Most often the only victims are our audience’s inspiration and interest. This, however, is the story of a PowerPoint slide that actually helped kill seven people.

January 16th 2003. NASA Mission STS-107 is underway. The Space Shuttle Columbia launches carrying its crew of seven to low orbit. Their objective was to study the effects of microgravity on the human body and on ants and spiders they had with them. Columbia had been the first Space Shuttle, first launched in 1981 and had been on 27 missions prior to this one. Whereas other shuttle crews had focused on work to the Hubble Space Telescope or to the International Space Station this mission was one of pure scientific research.

The launch proceeded as normal. The crew settled into their mission. They would spend 16 days in orbit, completing 80 experiments. One day into their mission it was clear to those back on Earth that something had gone wrong.

As a matter of protocol NASA staff reviewed footage from an external camera mounted to the fuel tank. At eighty-two seconds into the launch a piece of spray on foam insulation (SOFI) fell from one of the ramps that attached the shuttle to its external fuel tank. As the crew rose at 28,968 kilometres per hour the piece of foam collided with one of the tiles on the outer edge of the shuttle’s left wing.

Frame of NASA launch footage showing the moment the foam struck the shuttle’s left wing (Creative Commons)

It was impossible to tell from Earth how much damage this foam, falling nine times faster than a fired bullet, would have caused when it collided with the wing. Foam falling during launch was nothing new. It had happened on four previous missions and was one of the reasons why the camera was there in the first place. But the tile the foam had struck was on the edge of the wing designed to protect the shuttle from the heat of Earth’s atmosphere during launch and re-entry. In space the shuttle was safe but NASA didn’t know how it would respond to re-entry. There were a number of options. The astronauts could perform a spacewalk and visually inspect the hull. NASA could launch another Space Shuttle to pick the crew up. Or they could risk re-entry.

NASA officials sat down with Boeing Corporation engineers who took them through three reports; a total of 28 slides. The salient point was whilst there was data showing that the tiles on the shuttle wing could tolerate being hit by the foam this was based on test conditions using foam more than 600 times smaller than that that had struck Columbia. This is the slide the engineers chose to illustrate this point:

NASA managers listened to the engineers and their PowerPoint. The engineers felt they had communicated the potential risks. NASA felt the engineers didn’t know what would happen but that all data pointed to there not being enough damage to put the lives of the crew in danger. They rejected the other options and pushed ahead with Columbia re-entering Earth’s atmosphere as normal. Columbia was scheduled to land at 0916 (EST) on February 1st 2003. Just before 0900, 61,170 metres above Dallas at 18 times the speed of sound, temperature readings on the shuttle’s left wing were abnormally high and then were lost. Tyre pressures on the left side were soon lost as was communication with the crew. At 0912, as Columbia should have been approaching the runway, ground control heard reports from residents near Dallas that the shuttle had been seen disintegrating. Columbia was lost and with it her crew of seven. The oldest crew member was 48.

The shuttle programme was on lock down, grounded for two years as the investigation began. The cause of the accident became clear: a hole in a tile on the left wing caused by the foam let the wing dangerously overheat until the shuttle disintegrated.

The questions to answer included a very simple one: Why, given that the foam strike had occurred at a force massively out of test conditions had NASA proceeded with re-entry?

Edward Tufte, a Professor at Yale University and expert in communication reviewed the slideshow the Boeing engineers had given NASA, in particular the above slide. His findings were tragically profound.

Firstly, the slide had a misleadingly reassuring title claiming that test data pointed to the tile being able to withstand the foam strike. This was not the case but the presence of the title, centred in the largest font makes this seem the salient, summary point of this slide. This helped Boeing’s message be lost almost immediately.

Secondly, the slide contains four different bullet points with no explanation of what they mean. This means that interpretation is left up to the reader. Is number 1 the main bullet point? Do the bullet points become less important or more? It’s not helped that there’s a change in font sizes as well. In all with bullet points and indents six levels of hierarchy were created. This allowed NASA managers to imply a hierarchy of importance in their head: the writing lower down and in smaller font was ignored. Actually, this had been where the contradictory (and most important) information was placed.

Thirdly, there is a huge amount of text, more than 100 words or figures on one screen. Two words, ‘SOFI’ and ‘ramp’ both mean the same thing: the foam. Vague terms are used. Sufficient is used once, significant or significantly, five times with little or no quantifiable data. As a result this left a lot open to audience interpretation. How much is significant? Is it statistical significance you mean or something else?

Finally the single most important fact, that the foam strike had occurred at forces massively out of test conditions, is hidden at the very bottom. Twelve little words which the audience would have had to wade through more than 100 to get to. If they even managed to keep reading to that point. In the middle it does say that it is possible for the foam to damage the tile. This is in the smallest font, lost.

NASA’s subsequent report criticised technical aspects along with human factors. Their report mentioned an over-reliance on PowerPoint:

“The Board views the endemic use of PowerPoint briefing slides instead of technical papers as an illustration of the problematic methods of technical communication at NASA.”

Edward Tufte’s full report makes for fascinating reading. Since being released in 1987 PowerPoint has grown exponentially to the point where it is now estimated than thirty million PowerPoint presentations are made every day. Yet, PowerPoint is blamed by academics for killing critical thought. Amazon’s CEO Jeff Bezos has banned it from meetings. Typing text on a screen and reading it out loud does not count as teaching. An audience reading text off the screen does not count as learning. Imagine if the engineers had put up a slide with just: “foam strike more than 600 times bigger than test data.” Maybe NASA would have listened. Maybe they wouldn’t have attempted re-entry. Next time you’re asked to give a talk remember Columbia. Don’t just jump to your laptop and write out slides of text. Think about your message. Don’t let that message be lost amongst text. Death by PowerPoint is a real thing. Sometimes literally.

Thanks for reading

- Jamie

Spoiler Alert: why we actually love spoilers and what this tells us about communication

So, how can knowing about the spoiler paradox shape the way we communicate?

Death by PowerPoint: the slide that killed seven people