Lectures are traditionally a large part of undergraduate, graduate and continuing medical education. Throughout medical school, the average student spends thousands of hours participating in lectures, which typically rely on presentation slides ( 1 ). There are many “best practices” for slide preparation from business, design and education literature that provide guidance on slide background, font size, color choice, headings, text and images ( 2 , 3 ).

The visual design of presentation slides may affect learner outcomes ( 4 ). Mayer and colleagues propose two assumptions in multimedia learning: humans process pictorial and verbal material through separate systems (dual channel assumption) and each channel is limited in the volume of material that can be processed (limited capacity assumption) ( 5 ). The cognitive theory of multimedia learning suggests that our memory is present in three stores: sensory, working and long term memory. These stores work together as an active processing system, with inherent limits to the working memory store. Thus, a key learning tenet is to reduce the demands of cognitive processing through effective multimedia design ( 4 ).

The steps of selecting, organizing, and integrating require increasing amounts of cognitive processing, and as there is a limited or fixed capacity, any additional burdens can disrupt learning. In other words, if one type of processing is increased, then another type has to be decreased to compensate. Extraneous processing is cognitive processing that does not support the instructional goal and is caused by poor design of the multimedia presentation. Minimizing extraneous processing will ensure that more cognitive capacity is available for essential processing. Excess extraneous processing results in decreased learning. Essential processing is the cognitive processing required to select words/images and represent them in working memory. The more complex the material, the more essential processing required, thereby limiting the amount of cognitive capacity available for generative processing. Increased essential processing results in rote learning, which is characterized by good retention, but poor transfer. Generative processing is the cognitive processing required to make sense of the material, accomplished by organizing material and integrating it with prior knowledge ( 6 ).

In summarizing the key research in multimedia principles that decrease cognitive load (coherence, signaling, redundancy, spatial contiguity and temporal contiguity), Mayer and Fiorella found educationally significant median effect size on problem-solving transfer tests when these design principles were applied to learners in the experimental setting ( 4 ). This suggests that better design has a positive effect on learning. Mayer principles of multimedia design that demonstrated statistically significant positive effects are summarized in Table 1.

It is important to highlight that most of the empirical data on multimedia design, specifically by Mayer ( 6 ), are based on experimental studies using produced multimedia lessons. These are lessons created for the purpose of the study, administered in a study setting, and often contained visual images and spoken word. The literature on captured multimedia lessons – lessons given in real, non-experimental classroom settings – is not as robust, though some studies are applicable here.

According to Strauss et al., several design techniques may minimize cognitive overload during slide presentations: text emphasis, relevant visuals, full sentence titles, and minimizing the volume of text/bullet points ( 7 ). Inoue-Smith and colleagues showed that college students had higher preference for slides that chose a solid color background; had limited content, avoided long sentences, did not use all capital letters, and included images and graphics ( 8 ). Garner and Alley found that students had better comprehension and retention from slides that adhere to an assertion-evidence structure, which incorporates six principles of multimedia learning (multiple representation, contiguity, redundancy, modality, coherence and signaling). Slides that abide by assertion-evidence slide structure display a succinct text headline (assertion) with graphic evidence that supports or explains the assertion ( 9 ). Figure 1 displays some of these principles including spatial contiguity (relevant on-screen text is in close physical proximity to the related images or tables), coherence (only relevant information present) and signaling (topic and take-away point from the slide is highlighted and differentiated).

Faculty development may be used to educate instructors on sound principles for slide design. A rubric may be an important tool to assist faculty in recalling these concepts. Hung, et al. crafted a design rubric as a formative assessment tool for English learners’ presentation slides. This rubric asked the following questions related to visual design:

They were able to show that students who received formative feedback from the rubric had significant improvement in presentation performance ( 10 ). However, in our opinion, many of Hung’s slide rubric questions were subjective, not grounded in multimedia theory and may not be useful as a rapid evaluation method of slide design. We believe that a more objective, granular and comprehensive evaluation tool may allow for frequent, useful feedback for improving presentation performance.

The purpose of this study was to develop a rubric that addresses multiple aspects of slide design, grounded in evidence-based, multimedia principles. Such a rubric, whether used as an evaluation tool or best practice checklist, makes these multimedia principles accessible to educators and enables objective evaluation of slide design. The literature demonstrates that multimedia design, and therefore slide design, has a statistically significant positive impact on learning ( 10 ). We feel that it is imperative that instructors leverage this empirical data to help their learners learn.

Overall, respondents rated elements of slide design favoring minimalism, such as busy-ness of slide and appropriate emphasis on key information, as most important. This aligns well with many of Mayer’s multimedia principles including the split-attention principle, redundancy principle, the signaling principle and other techniques to minimize extraneous processing (coherence, redundancy, and spatial contiguity) ( 4 ) While best practices from the business literature ( 2 ) and Duarte ( 11 ) focus on stylistic choices such as color schemes transitions and font, our results suggest that these aspects of slide design are less important. This is not surprising and likely due to the fact that medical educators weigh content over style.

While Mayer and Duarte created a framework and best practices guidelines for multimedia and slide design, our literature review did not find any previous studies that attempt to prioritize these components. Our findings also suggest that medical educators prefer to focus on components of slide design that are directly related to evidence-based multimedia principles, while more stylistic characteristics were deemed less important. This would imply that further faculty development and training in slide design should emphasize the importance of Mayer’s principle in designing slides. This should include the basics in ensuring readability, relevance and emphasis when designing multimedia presentations.  While many novice educators may be overwhelmed with the idea of improving slide “design,” our tool can be used as an evidenced based checklist and takes no formal training in visual design to implement.

Our survey data also shows there seems to be a correlation between the frequency of design elements selected as “important” and the relative rank of that item. Because high frequency items are also highly ranked, this could indicate that our survey was reliable in identifying important factors in slide design.

Free responses from the survey offered support for these conclusions, i.e., common themes focused on “busy-ness”, number of words on slides and presentations. Survey respondents most commonly mentioned the importance of decreasing slide busy-ness, decreasing words and bullet points on slides and the idea of simplicity, which we felt was already included as an element in the survey. Such responses may suggest that medical educators value decreasing busy-ness so heavily that even though it was included as an item for ranking they wished to emphasize its importance by including in free responses as well.

Our goal was to create a slide design rubric that assesses the quality of slide decks for medical educators. While the initial components were selected by an expert panel of medical educators based on established multimedia principles and expert opinion, we developed the survey to collect further information from the medical educator community to ensure various aspects of the rubric were appropriately weighted. With this information we have applied values to the various aspects of the rubric for a total score of 100. This study reports the initial results of that data. 

We hope that this rubric can be used for self-assessment or to evaluate and improve slides for educators. Future research will be focused on implementing and validating the slide design survey and ensuring it is easily usable with a high inter-rater reliability. Specifically, we plan to implement our rubric by targeting lectures given at a national medical education conference, establishing various reliability and validity measures. Longer term studies will evaluate whether self-assessment with the rubric improves presentation content and design and improves education quality. 

All authors contributed equally to design, data collection, writing and editing of the manuscript. No financial disclosures or sponsors.

Conflict of Interest: None declared.