A phenomenon often noted at conferences is the seeming unconsciousness or unresponsiveness of members of the audience. Interestingly it is not typically the speaker that notes this finding but rather other members of the audience. This may have something to do with the dulcet tones of someone next to you snoring away that interrupts the otherwise efficient note-taking that you are there for.

Lectures, it is said, are the means of transferring notes from the pages of the speaker to the pages of the audience without going through the mind of either. As such, sleeping during meetings may not necessarily impede this process. The speaker can of course drone on and on and on without as much as a break in the flow unaware of the passing slumber of his audience.

Recent ground breaking research involved an analysis of this phenomenon at a 2 day internal medicine lecture series.¹ The three observers noted the occurrence of “nod-off episodes per lecture” (NOELs) that happened in the audience during the lectures. Being Canadians, they counted only one nod-off episode per listener colleague per lecture—a fact that may underestimate the incidence of truly boring speakers. Nodding off episodes were used rather than “sleeping” as the observers felt that it may be too intrusive to check whether an audience member was truly asleep whilst the lecture was in progress. It may be worth mentioning as well that NOELs were distinguished from nodding in agreement (NIA) episodes by the coexistence of snoring, drooling, and gasping. Subsequently they asked the audience members who had nodded off to complete a brief questionnaire.

The median rate on an incident density analysis was 16 NOELs per 100 attendees with a range from three to 24 NOELS per 100 attendees. This latter figure is really quite an interesting statistic and suggests that at least a quarter of the audience were sleeping during the lectures.

Risk factors for this phenomenon were noted. Although one assumes that environmental factors would be important (dark room, dim lighting, comfy chairs) none of these factors were statistically significant. Nor were circadian factors, such as time of day, post-prandial lecture, significant.

The only statistically significant risk factors were speaker related—monotonous tone (OR 6.8), tweed jacket (OR 2.1), losing place in the lecture (OR 2.0), poor slides (OP 1.8), and a failure to speak into the microphone (OR 1.7). There was some concern raised by the authors that in particularly monotonous talks, observer inattention or a fugue state was induced by the speakers tone and undercounting of the NOELs may have ensued.

There were some surprising findings. Lectures that should be intrinsically boring (obscure topics, few data, absent analyses) had unexpectedly low NOEL rates. This was attributed to the bizarreness of the presentation. Speaker factors such as stage wandering, raving, or dropping the microphone also helped keep the physicians awake.

Having been at hundreds of sports medicine meetings over the past 20 years or so, I have witnessed this phenomenon over and over. In many cases, I have been the NOEL-er. Rarely can I claim jet lag or a previous late night drinking session as the basis of this (mea maxima culpa) but more often than not it is the quality (or lack of quality) of the talk that induces this soporific state.

We emphasise to our sports medicine trainees the need to gain experience and confidence giving talks. Start with something simple we say. Lectures to other registrars, trainers, coaches, and then local meetings, national meetings, and finally the international stage. That approach can certainly breed confidence but does it bring quality except by default? There is no doubt that some folks are better public speakers than others. Clarity of ideas, interesting topic, clinical experience all factor into this.

Can we then train conference speakers to be better? This is done in business as a matter of routine. Professional celebrity speakers are trained in these arts and groomed for a lucrative speaking career after they leave their sport or political livelihood. In sports medicine, similar advice is often limited. Conference organizers sometimes send round some paperwork with some general presentation advice when you submit an abstract. This probably gives some detail. I wouldn’t know as I never read it. Straight in the wastepaper bin has been my practice. Unless the information grabs my attention instantly then it is lost in the morass of paper crossing my desk each day. If you want to look at some clever AV work, go to the apple website (www.apple.com) and look at the various online presentations from their CEO, Steve Jobs. He had to invent the AV technology to keep up with his presentations! More importantly look at his slides—layout, information, data—and appreciate a real expert at work.

I am also continually frustrated by the fact that medical conference presenters are usually set behind a lectern (and standing on the podium for those language nitpickers) with a fixed microphone and a screen that is typically set behind them forcing them to turn around and hence become inaudible. Recently in Prague, we as the conference organizers, had to physically restrain the set up crew from building a stage and screen in the wrong place for our speakers. The set up crew were briefed by the hotel conference management team and were following instructions. What became increasingly clear was the fact that the hotel management team had never given any real thought to the stage layout and speaker requirements.

Some university departments and larger sports medicine clinics suggest practice talks before the real presentation. Helpful for one’s confidence and timing but not necessarily a path to presentation quality.

I have often thought that the best talks are given by a person who has (a) a detailed knowledge and experience of the topic being presented, and (b) has organised his or her thoughts on the topic. This latter point cannot exist without the initial understanding of the problem. Furthermore someone who studies a topic inside out often is passionate about it. Passion and enthusiasm comes across to the audience very clearly.

In the words of that new age guru, Dame Edna Everage, colour and movement is critical. Add knowledge, passion, and good slides, and you have the full package.