Exam Room Research Articles

Evaluation of 30-Minute Office Blood Pressure in a Diverse Urban Population.

Previous studies have shown benefits of 30-minute office blood pressure (OBP-30) but did not report on race and gender. The purpose of this study was to determine if similar effects are seen in a diverse urban population. Patients with diabetes and/or cardiovascular disease (age 18-89) were invited to participate. Blood pressure was measured using standard procedure (SOBP). Patients were left alone in an exam room connected to an automated office blood pressure monitor which obtained BP readings every 5 minutes for 30 minutes. The last 5 measurements were averaged for the OBP-30 measurement. Primary outcomes were BPs measured using SOBP and OBP-30. Multivariate logit methods were used to estimate the average probability of having a BP measured <140/90 mm Hg (BPM <140/90) for the 2 measurement methods. Differences were computed across methods, in total and by sex and race, all other factors held constant. The adjusted probability of having a BPM <140/90 was 47.1% using SOBP and 66.7% using OBP-30 (P < 0.01). Using SOBP, females had a 26.2 PP lower probability of having a BPM <140/90 (P < 0.001) than males. Relative to white patients, Black patients had a 43.9 PP lower (P < 0.001) and other races a 38.5 PP lower (P < 0.001) probability of having a BPM <140/90 using SOBP. Using OBP-30, these differences narrowed and became statistically insignificant. OBP-30 may increase the probability of BPM meeting goals, especially in females and patients who are Black, indigenous, or persons of color.

Exploring women's perspectives on prenatal screening for adverse childhood experiences.

To learn more about women's views on screening for adverse childhood experiences (ACEs) during healthcare visits in pregnancy. Mixed methods with an online survey. A convenience sample of 154 womenwith a history of one or more pregnancies was recruited through public health department social media pages in one predominantly rural region of a Midwest state. Quantitative measures includeddemographic variables, ACE scores, and preferences regarding screening format, strategies, and resources. Additional perspectives were captured through open-ended questions. Women's mean ACE score was 2.56 (SD=2.37) with 68% reporting 0-3 ACEs and 32% reporting four or more. Routine screening for ACEs during prenatal care was supported by 67.5% of women with 9.1% indicating sometimes, 20.8% unsure, and 2.6% against. Strong preference was indicated for screening by one's physician or midwife (80.3%), in an exam room (83.1%), using an independently completed questionnaire (64.2%). Preferred approaches for screening and post-screening interventions also were identified with qualitative themes providing additional insights. Findings inform strategies for efficiently and sensitively screening for ACEs during pregnancy, highlight the importance of using a trauma-informed approach, and provide direction for educational and interventional resource development.

Evaluating and contextualizing the efficacy of portable HEPA filtration units in small exam rooms

BackgroundAmbulatory clinics attend to COVID-19 patients, often in spaces with less than ideal ventilation. Testing and treatments can often include aerosol-generating procedures. Portable high efficiency particulate air (HEPA) filtration units have been used to remove airborne contaminants in these areas.MethodsA particle counter was used to evaluate the effectiveness of portable HEPA filtration units when a proxy airborne contaminant (powder) was actuated into the air. The Center for Disease Control and Prevention's (CDC) Airborne Contaminant Removal table served as a basis for initial particle readings at 6 minutes.ResultsPercent decrease was calculated post powder actuation at the 6-minute and 12-minute mark. There was a statistically significant decrease in smaller particles at the 6-minute and 12-minute mark when the HEPA filtration units were used.ConclusionAs an adjunct infection control intervention, portable HEPA filtration units can make outpatient exam rooms safer for patients and staff by decreasing cumulative airborne particles.

How pharmacy can start to solve the inequity puzzle

How pharmacy can start to solve the inequity puzzle

Microbial bioburden of inpatient and outpatient areas beyond patient hospital rooms.

To investigate the frequency of environmental contamination in hospital areas outside patient rooms and in outpatient healthcare facilities. Culture survey. This study was conducted across 4 hospitals, 4 outpatient clinics, and 1 surgery center. We conducted 3 point-prevalence culture surveys for methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, Clostridioides difficile, Candida spp, and gram-negative bacilli including Enterobacteriaceae, Pseudomonas aeruginosa, Acinetobacter baumanii, and Stenotrophomonas maltophilia in each facility. In hospitals, high-touch surfaces were sampled from radiology, physical therapy, and mobile equipment and in emergency departments, waiting rooms, clinics, and endoscopy facilities. In outpatient facilities, surfaces were sampled in exam rooms including patient and provider areas, patient bathrooms, and waiting rooms and from portable equipment. Fluorescent markers were placed on high-touch surfaces and removal was assessed 1 day later. In the hospitals, 110 (9.4%) of 1,195 sites were positive for 1 or more bacterial pathogens (range, 5.3%-13.7% for the 4 hospitals) and 70 (5.9%) were positive for Candida spp (range, 3.7%-5.9%). In outpatient facilities, 31 of 485 (6.4%) sites were positive for 1 or more bacterial pathogens (range, 2% to 14.4% for the 5 outpatient facilities) and 50 (10.3%) were positive for Candida spp (range, 3.9%-23.3%). Fluorescent markers had been removed from 33% of sites in hospitals (range, 28.4%-39.7%) and 46.3% of sites in outpatient clinics (range, 7.4%-82.8%). Surfaces in hospitals outside patient rooms and in outpatient facilities are frequently contaminated with healthcare-associated pathogens. Improvements in cleaning and disinfection practices are needed to reduce contamination.

The Display of Medical Information: Content, Format, and Subjective Experience.

To address a gap in the literature by investigating the subjective experience of participants to the form and content of medical information displayed in a healthcare setting. Artwork can enhance the experience of patients, but much less is known about how individuals react to displays of medical information in the form of posters or pamphlets, especially those about unsettling conditions (e.g., skin cancer). In a 2 × 2 × 2 between-subjects design, researchers investigated the content of medical information (skin cancer vs. skin care) that was on display in a simulated exam room, whether the form was a pamphlet or a poster, and reason for the visit (routine annual skin check or evaluating a mole) on measures of subjective experience, including anxiety. Viewing material about skin cancer produced greater anxiety and greater arousal than did viewing material about sunscreen, and given the choice of four images (pamphlet and poster for sunscreen, pamphlet and poster for skin cancer), the sunscreen poster was recommended to improve the patient's experience and lower stress. In terms of display format, posters are judged to provide more visual engagement than are pamphlets. Exam rooms should offer multiple opportunities for visual engagement without images that produce anxiety. More research is needed to understand the subjective experience of the patient's interaction with the content and format of medical information.

Effects of patient education to reduce antibiotic prescribing rates for upper respiratory infections in primary care.

Antibiotic stewardship programs in primary care are necessary to reduce the estimated 30% of inappropriately written antibiotic prescriptions and reduce the spread of microbial resistance. Most programs focus on educating prescribers, but this intervention focused on educating patients. To develop and implement an antibiotic stewardship program in a primary care clinic to educate patients with upper respiratory infections (URIs) about antibiotic use and to assess the effectiveness of the program through antibiotic prescribing rates. Using materials from the Centers for Disease Control and Prevention (CDC) Be Antibiotics Aware program, posters on antibiotic use were placed in the exam rooms, graphic interchange formats (GIFs) and memes were displayed on exam room monitors, patient-provider discussions on antibiotic use were held, and written information for symptom management of URIs was provided. Retrospective chart reviews were conducted to assess antibiotic prescribing rates by four prescribers in a primary care clinic for September and October 2020 and compared to the same time period for 2019. The rate of total antibiotic prescriptions decreased by 12.6% (P = 0.044) and the rate of repeat consultation antibiotic prescriptions decreased by 12.2% (P = 0.007), whereas the rate of antibiotics prescribed at the time of the visit remained unchanged (P = 0.937). All providers had decreased rates of antibiotic prescribing after the intervention. Results of this study indicate that providing education about antibiotics to patients in need of treatment for URIs may reduce the rate of antibiotics prescribed in primary care; however, further research is warranted.

Efficiency and Teamwork in Emergency Departments: Perception of Staff on Design Interventions.

The goal of this study is twofold: (1) identifying design strategies that enhance efficiency and support teamwork in emergency departments (EDs) and (2) identifying design features that contribute to the spread of COVID-19, based on staff perception. Due to increasing ED visits annually, an efficient work environment has become one of the main concerns in designing EDs. According to the literature, an efficient work environment and teamwork improve healthcare outcomes and positively impact staff satisfaction. During the COVID-19 pandemic, EDs faced various changes such as workflow and space usage. Few studies explored staff perceptions about the influence of design features on efficiency, teamwork, and the COVID-19 spread. An online survey with 14 open- and closed-ended questions was distributed among ED staff members to collect data about unit design features that impact efficiency, teamwork, and the COVID-19 spread. The central nursing station was one of the preferred configurations that increased efficiency and teamwork in EDs. Decentralizing disposal rooms in small-size EDs and decentralizing the medication room in large-size EDs with more than 65 exam rooms can decrease staff walking steps. Flexibility to expand treatment spaces on demand, one-way track circulation path, and changing the air pressure in COVID-19 treatment areas were some of the staff suggestions for future EDs. The findings of this study contribute to the body of knowledge that EDs' physical environments can impact efficiency and teamwork among staff and, consequently, healthcare outcomes. Compartmentalization of the ED layout can reduce the spread of COVID-19.

What is the real risk of COVID transmission during oxygenation?

Recently, I was called up to the intensive care unit (ICU) to intubate a hypoxic patient with coronavirus disease (COVID). Walking into the patient's room, I noted lots of people in personal protective equipment (PPE), most of whom I knew to be fully vaccinated. The patient was, indeed, hypoxic on high flow nasal cannula (HFNC). Could we put him on bi-level positive airway pressure (BiPAP) for better pre-oxygenation before rapid sequence intubation (RSI)? Nope. Hospital policy prevented the use of BiPAP (but not HFNC) on COVID patients. So, we had to accept sub-optimal pre-oxygenation because of a policy understandably designed to protect staff but that was not in the patient's best interest. Experiences like this really beg several important clinical questions: what is the risk associated with different approaches to oxygenation and how well does the PPE we wear work? Fortunately, 2 recent papers in JACEP Open address these questions. They give us additional data to help better understand our actual risk when treating patients with COVID. Emily Pearce and her colleagues at the University of New Mexico report on an experiment in which they estimate the exposure from different approaches to oxygen administration (aerosol generation with various approaches to oxygenation in healthy volunteers in the emergency department [ED]).1 They had 8 healthy volunteers, including the researchers themselves, breath normally in a positive pressure ED exam room while receiving oxygen from 3 devices: HFNC, non-rebreather mask (NRB), and continuous positive airway pressure (CPAP). The HFNC was tested at 15, 30, and 60 L/min flow. They used a spectrometer to measure both large and small droplet aerosols. Finally, they placed a procedural mask over the HFNC and NRB to evaluate the impact of the common approach of mask-over-oxygen device. Ultimately, they demonstrated that higher flow oxygen led to higher aerosol generation, and CPAP was actually associated with lower aerosol generation. Masks were helpful for reduction of small particulates but not with larger ones, at least not statistically with only 8 subjects. These findings help us understand that CPAP is actually relatively low risk, certainly less than HFNC, and placing a mask over the devices may help lower exposure risk. So, we now have more information about aerosol generation, but what about the extent to which PPE protects us against infection? Dr. Darren Braude and colleagues looked at this with a pragmatic approach. In their paper “Safety of air medical transport of patients with COVID-19 by personnel using routine personal protective equipment” they used an 8-base regional air medical consortium to describe the rate of infection among transport personnel after flying patients with COVID.2 They included only patients with known or suspected COVID and then describe oxygen therapy. Most patients were receiving some form of oxygen, but only 30% were intubated. Among 108 transport staff, the overall rate of COVID infection was under 2%. This is consisted with other descriptions of PPE effectiveness among EMS personnel.3 Taken together, these 2 papers provide additional information we can use to guide our approach to caring for COVID patients with respiratory distress while still protecting ourselves and our colleagues. It appears that CPAP is a relatively low risk approach to respiratory support, certainly it looks like a lower risk than HFNC or NRB. In addition, we have additional reassurance that the PPE we are using provides substantial protection against infection.

Automated Audiometry in Quiet and Simulated Exam Room Noise for Listeners with Normal Hearing and Impaired Hearing.

Up to 80% of audiograms could be automated which would allow more time for provision of specialty services. Ideally, automated audiometers would provide accurate results for listeners with impaired hearing as well as normal hearing. Additionally, accurate results should be provided both in controlled environments like a sound-attenuating room but also in test environments that may support greater application when sound-attenuating rooms are unavailable. Otokiosk is an iOS-based system that has been available for clinical use, but there are not yet any published validation studies using this product. The purpose of this project was to complete a validation study on the OtoKiosk automated audiometry system in quiet and in low-level noise, for listeners with normal hearing and for listeners with impaired hearing. Pure tone air conduction thresholds were obtained for each participant for three randomized conditions: standard audiometry, automated testing in quiet, and automated testing in noise. Noise, when present, was 35 dBA overall and was designed to emulate an empty medical exam room. Participants consisted of 11 adults with hearing loss and 15 adults with normal hearing recruited from the local area. Thresholds were measured at 500, 1,000, 2,000, and 4,000 Hz using the Otokiosk system that incorporates a modified Hughson-Westlake method. Results were analyzed using descriptive statistics and also by a linear mixed-effects model to compare thresholds obtained in each condition. Across condition and participant group 73.6% of thresholds measured with OtoKiosk were within ± 5 dB of the conventionally measured thresholds; 92.8% were within ± 10 dB. On average, differences between tests were small. Pairwise comparisons revealed thresholds were ∼3.5-4 dB better with conventional audiometry than with the mobile application in quiet and in noise. Noise did not affect thresholds measured with OtoKiosk. The OtoKiosk automated hearing test measured pure tone air conduction thresholds from 500 to 4,000 Hz at slightly higher thresholds than conventional audiometry, but less than the smallest typical 5 dB clinical step-size. Our results suggest OtoKiosk is a reasonable solution for sound booths and exam rooms with low-level background noise.

Response of a Radiology Department to the SARS-CoV-2 Pandemic: The Experience of the Hospital “Policlinico Tor Vergata” in Rome

The dissemination of severe acute respiratory syndrome linked to the novel coronavirus, SARS-CoV-2, prompted all health services to provide adequate measures to limit new cases that could affect healthcare professionals. Due to the large number of suspected patients subjected to CT scans and the proximity of radiologists to the patient during exams, radiologists as well as the entire staff of the radiology department are particularly exposed to SARS-CoV-2. This article includes the emergency management procedures, the use of personal protective devices, and the rearrangement of exam rooms and of human resources in the department of radiology at “Policlinico Tor Vergata” in Rome performed during the SARS-CoV-2 pandemic. We introduce the management measures that our department has taken to cope with the influx of patients while still ensuring the proper management of other emergencies and time-sensitive exams.

Latinx Family Perspectives on Social Needs Screening and Referral during Well-Child Visits.

To understand Latinx parent perspectives on screening and referral approaches to identify social determinants of health and address social and material needs during well-child visits and to identify techniques that promote their engagement with these approaches. We investigated parent perspectives and engagement with social needs screening and referral practices during well-child visits using focus group methodology. We conducted 17 focus groups (n = 134 parents and other primary caregivers) with families receiving care at sites operated by eight pediatric primary care clinics. Adding social needs screening and referral shifted the social context of well-child visits for Latinx parents. Participants reported greater engagement with the practices where they perceived an emotional connection with nurses and other clinicians and cultural brokering to ensure their screening responses accurately reflected family needs and priorities. Participants highlighted the importance of having a personal patient-provider relationship as many preferred to discuss social needs outside of the exam room. Nurses and other clinicians play a critical role in establishing systems needed to systematically screen and refer families for social needs. Future policy development should consider implications for nursing practice and leadership in adopting these approaches.

The impact of patient shadowing on service design: Insights from a family medicine clinic

A central tenet of patient-centered care is to truly and deeply understand how patients experience health care. One particular qualitative method, patient shadowing, holds the promise of seeing things through the patient’s eyes in real time. The purpose of this research is to utilize patient shadowing to capture the realities of patient experiences in an outpatient family medicine clinic and to report opportunities for improvement to clinic leadership. A total of twenty (20) patients were shadowed at a family medicine outpatient clinic over the course of eight (8) different days, providing a variety of circumstances including staffing levels, shift changes, patient volume, and other factors. Patient shadowing revealed many interesting observations, capturing many best practices in delivering patient experiences as well as a short list of recommendations that could improve patients’ and staff experiences. Areas for improvement include helping patients better understand the entire process, wayfinding from the exam room to check-out, and creating a checklist for patient follow-up items. Patient shadowing presents many benefits to health care organizations and employees, including enhanced communication and teamwork, a greater connection with patient experiences and hardships, and the opportunity to redesign processes to optimize efficiency and service quality. Experience Framework This article is associated with the Innovation & Technology lens of The Beryl Institute Experience Framework (https://www.theberylinstitute.org/ExperienceFramework). Access other PXJ articles related to this lens. Access other resources related to this lens

IMPLEMENTASI SISTEM INFORMASI REKAPITULASI ABSENSI PERKULIAHAN MAHASISWA PADA STIKOM DINAMIKA BANGSA

“Attendance is usually used as a marker of someone's presence in an activity or event. Attendance can be applied in various activities, one of which is in the world of education, namely attendance at teaching and learning activities. In terms of teaching at STIKOM Dinamika Bangsa it also applies an attendance system to students. Students do attendance in every lecture they take. Attendance is done by signing the attendance list paper provided by the academic. This attendance is used as a condition for students to take the final semester exams. Students who can take the final semester exams must take no less than 75% of the total number of meetings for each subject. To find out the number of student attendance in lectures, at the end of each semester the attendance will be recapitulated by the study program staff. Student lecture attendance data is inputted using the MS application. Excel. Recording student lecture attendance data using the MS application. This Excel raises several problems. For example, BAAK takes a long time to make announcements on the names of students who cannot take the final semester exams, it requires a lot of paper to make announcements for students who cannot take the final semester exams, students will also be late in getting information about the final semester examination room. With this research, it has resulted in an information system application that can assist BAAK in processing student lecture attendance recapitulation data and help students to get lecture attendance recapitulation information and final semester exam room information.”&#x0D;

Twelve tips for teaching and supervising post-graduate trainees in clinic

By providing quality teaching and supervision, medical educators can contribute to productive and fulfilling outpatient experiences for postgraduate trainees (sometimes called residents, registrars, or GP trainees). The recent literature addressing practical steps to improve outpatient teaching is limited. Here we present specific trainee-centric behaviors, techniques, and language that educators can employ to enhance their teaching in the outpatient clinic, in the form of twelve tips. The first two tips pertain to navigating the patient-trainee-supervisor dynamic in the exam room, the next four address listening to an oral presentation, and the last six are tips on being an effective teacher and coach.

Challenges of Using Videos in Exam Rooms of Safety-Net Clinics to Encourage Patient Self-Disclosure of Intimate Partner Violence and to Increase Provider Screening.

Identifying intimate partner violence (IPV) in clinics allows for early intervention. We tested a comprehensive approach in five safety-net clinics to encourage female victims to self-identify and providers to screen. The main components were (a) short, multilingual videos for female patients; (b) provider training; and (c) management tools. Although videos were viewed 2,150 times, only 9% of eligible patients watched them. IPV disclosure increased slightly (6%). Lack of internal champions, high turnover, increased patient load, and technological challenges hindered outcomes. Safety-net clinics need feasible methods to encourage IPV screening. Management champions and IT support are essential for video-based activities.

The medical response to climate change

The growing mass of colorless and odorless greenhouse gases high in earth's atmosphere may be about as far away from a hospital bedside or clinic exam room as any concern imaginable. Despite this, the challenges of climate change have progressively moved nearer to the work of all those in health care. From sinister storms, fires, and heat waves that imperil our patients, facilities, and supplies to the outsized contribution of medical care to air pollution, the motivations and needs for a medical response to climate change are many and clear.

Listening for horses.

Right before graduating college, I began experiencing ascending paresthesias in the distal extremities after recovering from a cold. My medical student friend thought it seemed consistent with Guillain-Barré Syndrome (GBS), so I went to a clinic. They seemed especially interested in the fact that I was stressed over not being accepted to medical school. They said to go to the emergency department (ED) if it got worse. It did. In the ED I was diagnosed with somatic symptom disorder from my stress over medical school. After following up with the clinic for a benzodiazepine prescription, I went home questioning my sanity. Was I even mentally stable enough to pursue medicine if my stress was causing me to go paralyzed?

Effects of Waiting Room and Feline Facial Pheromone Experience on Blood Pressure in Cats.

Obtaining accurate blood pressure measurements in cats is challenging due to the stressful nature of clinic visits. The objective of this study was to evaluate the effects of veterinary clinic waiting experiences and a feline pheromone spray on blood pressure in the cat. We hypothesized that reduced stress associated with bypassing the waiting room and use of synthetic feline facial pheromone (FFP) spray would result in lower blood pressure. A 2 × 2 factorial design involved two rooms and two FFP treatments. Thirty-nine healthy adult cats were recruited and were systematically assigned to four treatment combinations administered over four visits in 2016 and 2017. Cats were kept in the hospital waiting room or were taken directly to the exam room, with or without FFP treatment. All cats were then acclimated to the exam room for an additional 10 min, where vocalizations were recorded manually, before blood pressure measurements were collected using Doppler ultrasonography. Data were analyzed using generalized linear mixed models, with room × FFP interaction, visit, sex, and trial year in the model. There was no significant effect of waiting room by FFP interaction on blood pressure (n = 0.95). Mean blood pressure was significantly higher at visit 1 than visits 2 and 4 (P < 0.01), but higher at visit 3 than visit 2 (n = 0.02). Mean blood pressure was higher in males (n = 0.01), and males were more likely to be categorized as borderline hypertensive/hypertensive or severely hypertensive (n = 0.01). Number of vocalizations was significantly associated with waiting room by FFP interactions (P < 0.01), with fewer vocalizations associated with bypassing the waiting room and when FFP was provided. In conclusion, although we found some behavioral evidence supporting stress reduction when feline patients bypass the waiting room and are provided with FFP, these interventions did not result in lower blood pressure in a clinical setting.

A perfect illusion.

On the morning of my Ph.D. qualifying exam, I rolled out of bed, showered, and slid into my navy blue blazer and matching checkered pants. Next came the makeup. I brushed on a layer of foundation and drew thick black lines around my eyes—a look that signified the boldness I wanted to embody during my presentation. I put on heels and walked around my apartment, a test drive to ensure I wouldn't collapse on the floor in pain. After a few laps, I looked in the mirror. I felt confident—ready to face the members of my Ph.D. committee and answer whatever questions they threw at me. It's a strategy I developed thanks to an unlikely inspiration: Lady Gaga. > “My naturally shy and quiet personality was not exactly ideal for public speaking.” I've always struggled with being confident. As an undergraduate, my heart pounded whenever I raised my hand to answer questions posed by professors. I knew the material, but the prospect of getting the answer wrong in front of all my classmates was daunting. Later, in graduate school, I especially feared giving presentations about my research. Beforehand, I would practice for hours on end. I knew I risked sounding rehearsed and boring, but calming my nerves was more important. The practice helped somewhat, but on presentation day, I still sounded flustered. I pored over books to find the best ways to format and outline a presentation. If I had clear slides, I reasoned, maybe then I'd have the courage to speak with authority. I ended up with well-designed slides, but I could not present them any better. Unlocking the key to my confidence was much more difficult than I anticipated. I realized I couldn't expect to wake up one day, look in the mirror, and say, “OK, today is the big day; today I am going to be confident.” But perhaps I could find a creative solution that would work for me. The breakthrough came during the month before my qualifying exam—a major milestone in my Ph.D. program that triggered waves of self-doubt—when I listened to a Lady Gaga album titled Joanne . As an avid fan, I noticed it sounded completely different from her past albums. She had switched from her usual dance-pop to soft rock and country, and her outfits—now cowgirl getups—had changed as well. I was intrigued. Lady Gaga was taking a huge professional risk, but she was confident in the music she released, confident in herself, and confident in her ability to adopt a new image. That got me thinking: Could I do something similar before I stepped on stage? My naturally shy and quiet personality was not exactly ideal for public speaking, so I thought about the traits and the image I wanted my professional self to possess. I pictured a steady, clear voice and a tall, commanding stance. I imagined myself as the expert in the room who wasn't afraid to say, “I'm not sure.” I thought about the moments when I felt the most put together, when I wore professional clothing and highlighted my features through makeup. To me, makeup wasn't a mask. It signified boldness, femininity, and self-assurance—all traits I associated with strength and power. I experimented with the idea during a practice presentation at home. I stood next to my laptop in professional attire, speaking loudly and fluidly—a sharp contrast to my usual practice routine, which involved sitting at my desk in pajamas speaking quietly. It was a promising start. I decided to give my new presenter persona a try at my qualifying exam. When I walked into the exam room, I was pleased to discover I had a newfound confidence. Sure, I was nervous, but an unfamiliar sense of calm rushed through me as soon as I began my talk. I was able to answer questions without a quaver in my voice, and I took ownership of the work I presented. Finally, I was the expert. At that moment, I realized that we either succumb to feelings of doubt or find innovative ways to overcome them. In the years since, my presenter persona has given me confidence during many talks and interviews, and I've become more comfortable transforming into this role when necessary. There's no surefire way to become a confident presenter. But thanks to Lady Gaga, I now have a strategy that works.