Effective Use of PowerPoint in Medical Presentations

by Edward Leigh, MA

During the morning break from an all-day physician workshop, a participant approached me (while smiling) and stated, “I’m angry at you!”  He then went on to say, “I come to these seminars and always sit in the back. I open up my laptop to get work done, but you made me listen. You made me work. This is the best seminar I have attended in I don’t know how long.”  I am not sharing this story so I could simply tell you how wonderful I am at presenting programs. Rather, I am sharing the story to reveal a significant problem in medical education. The red flag here is the dependence on PowerPoint as a teaching tool. Effective learning must be an active engaging process that stimulates the learners’ minds, not a passive process of simply looking at slides.

Before you create your first slide – answer this question.  What’s your point?  What are the goals of your session?  When I coach people on their presentation skills, I always ask this question, “A month from now, what  two to three points do you want people remember from your presentation?  I am talking about the big picture take home points.” People struggle with this question often telling me they have dozens of points.  Think about your big overall goals and build your slides from that information.

PowerPoint is ONE component of a dynamic presentation. In addition to the slides, we must have a great opening, powerful close, audience involvement and THE key attribute – enthusiasm! This is your subject and you must show your passion! PowerPoint is an aide to us, we are not an aide to it. The slides are part of our program, but they should never become THE program. You and your knowledge base are the stars of the show.  In the very unexpected event of the PowerPoint not working, could you still present your program and engage the audience?

Avoid all-text slide presentations. This scenario creates an uninspiring presentation that leads to audience boredom.  Incorporate photos and charts to make the program come alive.  Periodically, add graphic elements between text slides to keep the audience interested in your presentation. A medical student told me he attended a presentation by a visiting professor, who spoke in a monotone voice and had text-only slides. When the professor was done speaking, the audience didn’t clap at first because they didn’t realize he completed his presentation! When an audience is so tuned out they don’t realize a presentation is over, that’s really bad news!

6 x 6 rule.  No more than six lines per slide.  No more than six words per line.  It is important to think in terms of “less is more.”  Each slide should contain ONE main idea.  I have attended medical presentations in which the slides were so busy and complicated most audience members were completely baffled, which led to a lot of frustration.  When coaching people on their presentation skills, the biggest issue I find is information overload.

No one learns when they are sleeping. Providing the slides to audience members and then simply reading the slides verbatim is not only a poor educational tool, it is also incredibly tedious. While attending typical medical programs, I often look around at the audience. I see few people truly engaged. Many people looking are at their smart phones, reading something else, quietly talking to a neighbor, or worse, sleeping. Since the audience can read, the presenter is not necessary. The audience members could read the slides on their own. To be truly effective, speakers must bring something more to the presentation.

Moving from passive to active audience members.  Yes, you can engage audience members with PowerPoint!  This can be done in a variety of ways. Put a question on a slide and ask the audience to briefly discuss the question with a neighbor. Then ask for responses. Show a picture and ask the audience, “What is going on here?”  These very quick engagement tools perk up the audience! Go from dull to dazzling! When I incorporate questions in my slides, I do not put the answer in the written slides. They have to attend the session and listen to get the answer!

Be consistent with fonts, colors and backgrounds.  You want the audience to focus on your content, not your ever-changing visuals.  Also, the addition of animation and sound adds variety, but should not be used excessively. They key to an excellent presentation is balance. Also, be sure there is a significant contrast between the text color and the background color. For example, dark text on a dark background is very hard to read.

Use a text size of at least 24 point.  I prefer a font size of 28 to 32 for text and 36 to 44 for titles. Try this readability test; put your slides on the screen and stand in the back of the room in which you will be presenting. Can you read the slides? I have been to many presentations in which the speakers say, “I know you can’t read this, but …” If the audience can’t read it, don’t show it.

Arrive at the program venue early to check the slides.  It is important to arrive to a presentation location early for many reasons, including checking the AV equipment. Before the audience members arrive, check to be sure your slides are working properly.  Unfortunately, I have seen many presentations start with this statement, “Does anyone know how to work this?” As a backup, even if I email my slides to the meeting planner, I always carry the slides with me on a flash drive. It is also a good idea to arrive early to meet audience members; this is helpful to gain insight as to their needs / questions.  Through my pre-program chats, I have also received excellent ideas that I incorporated into the session. Audience members love this recognition! For example, I have stated, “Just before the program, I spoke to Steve who mentioned a great idea to help patients …” I have Steve waive his hand so the audience could acknowledge his great idea.

Separation of handout from slides. I speak at hundreds of medical conferences, and I am usually the only presenter that separates the slides from the handout. The handout is given to participants; the handout has all the information well organized into sections. The slides are highlights of key points, including graphics.  There are also surprise questions and mini quizzes. The audience is constantly engaged.  Granted, it takes more work to present in this manner.  However, it is time well spent since I know people are engaged and learning. We do what’s best for our audiences, not what’s easiest for us.

Make PowerPoint work for you to create memorable presentations. You are brilliant, you are the expert – that is the reason you are making the presentation. The spotlight should be on you and your vast knowledge, not the slides.

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Edward Leigh, MA, is the Founder and Director of the Center for Healthcare Communication. The Center focuses on increasing patient satisfaction, improving compliance and decreasing the risk of medical errors. The Center offers high-impact training, consulting and one-on-one coaching. Edward Leigh’s new book, Engaging Your Patients, is due out in the Spring of 2014. http://www.CommunicatingWithPatients.com or 1-800-677-3256

Stop Devaluing Your Patients! The Illusion of “Patient Centered” Care

In healthcare, we always talk about, “patient-centered care.”  I do believe healthcare organizations have the best intentions, however, in reality, I find just the opposite both in my work as a healthcare speaker / consultant and with my own experiences as a patient.

“Just a Patient”

I have been a healthcare professional for over 20 years, however in 1999 I became a patient after being diagnosed with Stage III Colon cancer (I am well today). After treatment was completed, I recall going to my oncologist’s office for a follow up visit. I was wearing a suit as I was on my way to a client meeting. In the office, I was talking to a pharmaceutical representative. During my conversation, a nurse ran up to the representative and said to him, “You don’t need to talk to him. He is just a patient.”  Immediately another nurse (who knew me), ran up to the nurse who made the comment and said, “I can’t believe you said that him! He teaches healthcare professionals how to communicate with patients and now he will use us as a bad example!”  The second nurse then said to me, “You aren’t going to mention this story, are you?”  I told her, “Of course I will not mention the story.”  Ha!

Are the people you serve, “Just patients?”

Discouraging Patients from Taking an Active Role in Their Care

In healthcare, we discuss patients being their own advocates and taking an active role in their care.  Once again, what is said and reality are often not the same.  In my work at coaching healthcare professionals, I have seen patients bring print outs from their Internet research, only to be told, “Don’t worry about the Internet, I know what is best.”

When patients come to you with Internet print outs, the first words out of your mouth should be, “THANK YOU!”  We need to encourage people to take an active role in their health, not discourage them.  The conversation should then follow up with a discussion of legitimate websites (e.g., NIH) versus quack websites.

Patients Matter

When I speak at healthcare events, I always position myself as a healthcare professional who also happened to be a patient.  For one event, I made the mistake of first discussing my patient experiences and then I saw just how poorly patients are seen in the healthcare system.  The meeting coordinator said to me, “How nice you want to share your story. However, this is a program for professionals only. No patients are invited.”  Even though I explained I was a healthcare professional, once they saw me as a patient, I immediately had no value. I felt like I was verbally patted on the head and told to “run along.”

Let’s stop talking about putting patients first and just do it!

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Edward Leigh, MA, is the Founder and Director of the Center for Healthcare Communication.  The Center focuses on increasing patient satisfaction and decreasing the risk of medical errors. We offer high-impact training, consulting and one-on-one coaching. Contact us today!
http://www.CommunicatingWithPatients.com or 1-800-677-3256

Match Your Patients Energy Level

 

When people come into the healthcare system, it is a safe bet that they are not doing cartwheels in your hallways. They don’t feel well and their energy levels are probably low.  However, if we are high energy (which is great!), that would actually overwhelm people. Patients may be turned off by healthcare professionals that are busting at the seams with enthusiasm. A friend of mine told me her daughter who was hospitalized with pregnancy complications. Her daughter was in significant pain.  The daughter mentioned one nurse who used to bounce in the room full of energy; the daughter found this boundless energy too much for her.

It would seem to make sense that energy and enthusiasm are excellent characteristics of a healthcare professional.  They are!  However, when establishing rapport with patients we have to think about matching energy levels.  If our energy level is very high and  the patent’s energy is very low, we could experience a communication disconnect. This is exactly what happened with my friend’s daughter. The nurse though being high energy would be a good way to establish rapport.

We need to meet patients where they are. We need to meet then at their level of energy. Does this mean that if a patient is depressed and low energy we need to become depressed? Of course not!  However, what we need to do is lower our energy a bit so we do not cause a communication disconnect.

Mirroring and matching are techniques used to establish rapport at the unconscious level. This is created by becoming like the person with whom you need to make a connection. We need to make a connection with patients! When talking to patients look at their gestures and vocal inflexions. In a subtle way try to “match” these behaviors.  Subtle is the key word; we do not want to make it obvious or the patient may think we are mocking  them. People feel more comfortable with people who act like them.  For example, if your patient uses a lot of certain hand gestures, you may need to increase your level of these hand gestures.

If you look at people in the workplace or social situations who seem to be very engaged, notice they most likely have similar body language and tone of voice.  They are in sync.  We need to be in sync with our patients through the the strategies of matching and mirroring.

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Edward Leigh, MA, is the Founder and Director of the Center for Healthcare Communication.  The Center focuses on increasing patient satisfaction and decreasing the risk of medical errors. We offer high-impact training, consulting and one-on-one coaching. Contact us today!
http://www.CommunicatingWithPatients.com or 1-800-677-3256

Study Reveals HUGE Communication Gap Between Patients and Physicians

The Archives of Internal Medicine recently published a study that surprised many physicians who thought they were communicating effectively with patients. A group of Yale researchers study results are very concerning.

Several findings revealed a very significant communication disconnect between patients and physicians.  The gap is alarming.  Here are two examples:

Physician Name — Study found that:

Patient Survey: More than 80% of patients did not know the physician taking care of them.
vs.
Physician Survey: The majority of doctors thought the patients knew their name.

Admission Diagnosis — Study found that:

Patient Survey: About  50% of patients did not know their admission diagnosis.
vs.
Physician Survey: The vast majority of doctors thought the patients had understood their diagnosis.

These results indicate significant works need to be done to narrow the gap between what healthcare professionals say and what patients understand.  This comes through education.

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Edward Leigh, MA, is the Founder and Director of the Center for Healthcare Communication.  The Center focuses on increasing patient satisfaction and decreasing the risk of medical errors. We offer high-impact training, consulting and one-on-one coaching. Contact us today!
http://www.CommunicatingWithPatients.com or 1-800-677-3256

The Cleveland Clinic Improves the Patient Experience … by Improving the Hospital Gown!

The hospital gown. They have become a standard joke among comics who talk about being in hospitals.  If patients do not fasten them just right, their derrieres (or other body parts) may be on display for all to see!

The Cleveland Clinic wants to change the hospital gown and they have enlisted the help of a glamorous fashion designer! Fashion icon Diane von Furstenberg created a unisex patient-friendly, comfortable, wraparound apparel that looks good on everyone.

Jeanne Ryan, committee chair, stated, “The original goal had been to improve patients’ hospital experiences. We wanted to provide people with some dignity. They come to the hospital, it’s very stressful and then we ask them to take off their clothes. People said they feel exposed.” The gowns are expected to become available to all patients in the Cleveland Clinic’s Ohio facilities sometime in 2011.

Everything a hospital does creates either a negative or positive “patient experience.”  This initiative certainly enhances the patient experience.  From my work at enhancing the patient experience, I know that these little changes have a big impact. Bravo to the Cleveland Clinic!

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Edward Leigh, MA, is the Founder and Director of the Center for Healthcare Communication.  The Center focuses on increasing patient satisfaction and decreasing the risk of medical errors. We offer high-impact training, consulting and one-on-one coaching. Contact us today!
http://www.CommunicatingWithPatients.com or 1-800-677-3256

MD Anderson Cancer Center Offers Innovative Patient-Professional Communications Program

The Interpersonal Communication And Relationship Enhancement (I*CARE) programs are excellent educational tools developed to enhance the communication skills of oncology professionals. The program is part of MD Anderson’s Department of Faculty Development. The program developers strongly believe that “skillful communication is a competency that can be taught and learned.”

The I*CARE program mission: “Most cancer clinicians have not had the opportunity to develop their skills in managing difficult patient encounters such as those where there are strong emotions, stressed families or uncomfortable conversations when transitioning a patient to palliative care or discussing end of life. Oncology providers want to extend their role beyond treating disease to establishing a therapeutic and supportive alliance with the patient and family. Our goal is to assist you in sharpening the skills necessary to manage these challenging encounters.”

I*CARE PROGRAM INITIATIVES

I*CARE Website

The website, http://www.mdanderson.org/icare, contains the MD Anderson Cancer Center’s Video Library of Clinical Communication Skills and is an educational resource for communication skills development. The video library helps with understanding the basic principles of communication and advanced skills such as discussing end-of-life issues and error disclosure by providing specific protocols that can be used and illustrating them with video re-enactments.  Free Continuing Medical Education (CME Ethics credit is available) and Risk Management credits are available to physicians enrolled in The University of Texas Professional Liability Insurance Plan. People may download materials for teaching purposes.

Programs

There are many program options, including fellow & faculty forums, interactive workshops, train-the trainer sessions, conferences and the quarterly Achieving Communication Excellence (ACE) lecture series.  One program, “On Being An Oncologist,” features actors William Hurt and Megan Cole who assume the personas of various doctors. Using dialogue gathered by physician focus groups, they share their feelings about the stress of caring for patients with life-threatening illness; the time pressures; the challenge of breaking bad news; the need to keep hope alive; the balancing of sympathy and empathy and keeping personal boundaries, as well as dealing with both the patient’s and their own emotional reactions.  A workbook with reflective exercises can be downloaded for both teaching and learning purposes.  In the Spring of 2011, there will be a new program launched for patients and families to learn how to communicate their needs to their medical team, and specific information on the cultural aspects of communicating with patients. 
One-on-one Coaching

Trainers observe healthcare professionals with patients and feedback is provided.

Research Opportunities

There are many ongoing research projects such as assessing aspects of the patient / oncologist relationship through audio taping clinical encounters and the impact of empathic statements on a patient’s emotional state.
These outstanding initiatives are making a big impact in helping oncology professionals successfully connect with patients on an interpersonal level.

Walter F. Baile, M.D., is the I*CARE Program Director and Cathy Kirkwood,
M.P.H., is the I*CARE Project Director. For more information about I*CARE, visit: http://www.mdanderson.org/icare

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Edward Leigh, MA, is the Founder and Director of the Center for Healthcare Communication.  The Center focuses on increasing patient satisfaction and decreasing the risk of medical errors. We offer high-impact training, consulting and one-on-one coaching. Contact us today!
http://www.CommunicatingWithPatients.com or 1-800-677-3256

Houston’s St. Joseph Medical Center offers Innovative Method to Communicate with Non-English Speaking Patients

St. Joseph Medical Center (http://www.sjmctx.com) recently became Houston’s’ first hospital to use a unique translation system.

A special phone is set up with two handsets, one for the patient and one for the professional.  Based on the language requested, a trained medical interpreter is immediately brought on the line to help the patient and professional communicate.

The phone system is produced by CyraCom (http://www.cyracom.com) and offers interpreters specializing in 150 languages.  The trained interpreters are familiar with medical terminology, which is critical when speaking about healthcare topics.

If the language is not immediately obvious, patients review a card attached to the phone that has questions in their language. They can use this card to select their language.

Every patient room at St. Joseph has one of the phones. The sets are also located in the medical records department, triage and the front desk. There are a total of 400 phones throughout the hospital.

In healthcare, clear and concise communication is critical. This innovative tool helps avoid language-related issues to provide the best care to patients.

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Edward Leigh, MA, is the Founder and Director of the Center for Healthcare Communication.  The Center focuses on increasing patient satisfaction and decreasing the risk of medical errors. We offer high-impact training, consulting and one-on-one coaching. Contact us today!
http://www.CommunicatingWithPatients.com or 1-800-677-3256

Patient Advocates Help Healthcare Professionals

 

In 2004, Trisha Torrey discovered a golf-ball sized lump on her torso.  There was no  pain associated with the lump.  Trisha contacted her doctor and ultimately several tests were performed.  The tests revealed a devastating diagnosis, a rare form of lymphoma that is nearly always fatal.  She was told to begin chemotherapy immediately.

Trisha felt something was not right.  She did all her Internet research and discovered that she had no other significant symptoms associated with this type of lymphoma.  It just did not add up.

Through a friend, she found a new doctor for a second opinion.  Then came the shocking (but happy!) news.  Trisha did not have cancer!  She would have gone through chemotherapy for nothing!  (Chemotherapeutic agents are toxic. It would have been devastating to go through this treatment and not actually need it!)

For Trisha, this was a life altering time for many reasons.  From that moment, she became a patient advocate to help others through the healthcare maze. Today, Trisha is the About.com expert on the topic of patient empowerment.  She recently posed a question to her readers, “What Should Medical Students Learn?”  These are some the responses that you will find helpful:

•  Do not “give/write orders.” Medicine is not a military command. The patient makes the final decisions. You are there to offer expertise on diagnosis and treatment options. Take the time to make certain that patients understand clearly what options are available to them and the pros/cons/costs of all the options.
• If you want patients who have money / insurance, you will have to accommodate some aspects of customer service in the medical care regimen. Treat patients, not disease.

• Treat every patient with dignity and respect, imagining that each patient was your own loved one: parent, grandparent, child, brother, sister, or spouse.

• For some patients, gender matters, especially with intimate procedures and exams. Some women would prefer female caregivers, some men would prefer male caregivers. Medical staff should not assume just because a patient doesn’t discuss their preferences, that everything is just fine.

• Never forget that your world, the world of the hospital, is not the real world. It’s not where most of us live. Explain things. Talk. Communicate. Don’t assume too much about what patients already know, want to know, or value personally. Ask.

 Trisha’s first book, You Bet Your Life! The Ten Mistakes Every Patient Makes, was published in 2010. You can contact Trisha through her personal website:  www.EveryPatientsAdvocate.com

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Edward Leigh, MA, is the Founder and Director of the Center for Healthcare Communication.  The Center focuses on increasing patient satisfaction and decreasing the risk of medical errors. We offer high-impact training, consulting and one-on-one coaching. Contact us today!
http://www.CommunicatingWithPatients.com or 1-800-677-3256

My Mother’s Recent Hospitalization Experiences: The Good, the Bad and the Ugly!

About a month ago, my mother was crossing the street with her friend. Just as she stepped on the sidewalk she started feeling faint and began to feel sick.  An ambulance was immediately contacted and my mother was taken to the ER.  My mother’s friend accompanied her to the hospital — she called us from the hospital and told us to come right over.

My brother and I entered the hospital’s ER to find my Mom awake and alert. An ER nurse told us that my mother’s EKG was abnormal and that she had a condition known as Atrial Fibrillation and would need to take the medication, Coumadin.

A few hours later, my mother was admitted to the hospital.  The physician on the unit determined the underlying medical issue, dehydration.  We thought my mother was drinking enough fluids — obviously not.  My mother was in the hospital for four days.  Upon proper hydration, she was feeling fine and looking forward to returning home.

These are my observations regarding my mother’s recent hospitalization.  I base the observations on my PIE Model of Patient Communication.
P  Psychosocial (providing emotional support)
I  Interviewing (getting information)
E  Educating (giving information)

Psychosocial Dimension

Everyone was very friendly and kind.  I found the healthcare professionals to be very caring and treated my mother quite well.  However, what I did not find was any direct empathic responses.  I was waiting for someone to make a statement such as, “I know this must be difficult for you.”  Every medical center and practice always mention that empathy is an important component of their work.  In reality, empathy is rarely displayed.  This is due to the fact that healthcare professionals are not educated on how to convey empathy.

Interviewing Dimension

The questioning techniques employed were sufficient to gather information from my mother and I.  There was the usual issue of asking too many closed questions in succession and not allowing the patient sufficient time to discuss their medical issues.

The biggest issue was closing the interview with this question, “Do you have any questions?”  That is a closed question.  To encourage patients to ask questions, we should rephrase the question as an open question, “What questions do you have?”

Educational Dimension

Brace yourself and fasten your seat belt!  This was by far the weakest area.  Upon discharge, the unit nurse reviewed the discharge instructions, which were disjointed at best.  There were so many issues, I almost did not know where to begin my evaluation.  These are the problem areas and suggestions for improvement:

Excessive use of medical jargon:  The discharge instructions used the terms presyncope and mixed hyperlipidemia.  I am in the healthcare field and know what the terms mean, but what if I wasn’t in the field and didn’t know what the words meant?  Use patient-friendly language.

Ultimate diagnosis not mentioned. My mother initially fainted, but was ultimately diagnosed with dehydration by the attending physician.  Dehydration was never mentioned in the discharge report. This is a perfect of example of how poor handoffs lead to medical errors. At the time of discharge, I asked about the dehydration and how much fluid my mother should consume.  The nurse said, “About 3-4 glasses a day, I guess.” (Having a solid healthcare background, I researched the topic and developed a daily fluid intake plan for my mother.)
Vague comments. The discharge form states, “Will order Influenza vaccine.” Was it ever administered to my mother?  I called the hospital and was first sent to the Medical Records Department — they had no idea.  The Medical Records Department sent me to the unit, who also had no idea.  The unit nurse did say this, “Your Mom most likely did get the flu shot.  We usually give it to people 50 or over.”  Why didn’t the report state, “Patient was given a flu shot?”

No educational materials / resources.  In spite of the fact my mother was diagnosed with dehydration, no information was provided.  A brochure, website or organization to contact would have been helpful.

Overall, the healthcare professionals who took care of my mother were kind and skilled at their jobs.  There were some issues with the interviewing questions and empathic responding, however the biggest concern was the poor patient education component.  If patients do not comprehend their medical situation, they are at risk.

I signed the form for my mother (I have Power of Attorney).  By signing the form, I indicated I understand the discharge papers.  I actually did understand them — I have been in healthcare over 20 years.  My biggest concern is that most people will sign the form stating they understand, but they really do not.

Hospitals need to do a better job at educating patients.

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Edward Leigh, MA, is the Founder and Director of the Center for Healthcare Communication.  To book one of his high-content credit-hour-approved keynote speeches or training programs, visit or call: http://www.CommunicatingWithPatients.com / 1-800-677-3256

New “Readability Toolkit” Helps Develop Understandable Patients Forms and Educational Materials

The Group Health Center for Health Studies recently created an excellent report, the “Readability Toolkit.”  The Toolkit is designed to show research teams how to create consent forms and other participant materials in plain language.  Overall, the Toolkit has excellent information to create patient-friendly forms and educational literature.

The Toolkit contains these sections:

What You Should Know Before Using this Toolkit – Background information on health literacy, plain language, and why both are important in the research context.

The Principles of Plain Language – An explanation of the components of plain language, as well as concrete strategies that support plain language writing.

How to Determine Reading Level – Information and advice about using readability formulas to rate the approximate reading level of your materials.

Quick Reference Guide for Improving Readability – An at-a-glance summary of plain language principles and strategies, plus other formatting, editing, and proofreading tips.

Editing Checklist for Participant Materials – A companion to the Quick Reference Guide that guides users through a systematic process to improve readability, identify unclear concepts, and eliminate proofreading errors.

Resources for Informed Consent Documents – Readability advice and resources specifically for consent forms, including a list of common pitfalls, links to helpful consent templates and guidelines, and a selection of easy-to-read template language for common consent topics, such as randomization and voluntary participation.

Resources for HIPAA Authorization Documents – Links to helpful HIPAA templates and guidelines, along with a brief selection of easy-to-read HIPAA language.

Alternative wording suggestions – A list of plain language alternatives for hundreds of words typically used in medical and research settings and links to online resources that define medical and research jargon.

Examples of improved readability– Before and after “snapshots” of plain language revisions to original text taken from actual participant materials.

Examples of improved formatting – Techniques for improving readability through
formatting changes are illustrated with three before and after examples: an advance letter, a consent form, and a study information sheet. While the focus is on improved formatting, all three examples also illustrate other plain language techniques.

Repository of readability resources and references – A clearinghouse of Web-based resources focused on health literacy, readability, plain language, and informed consent, plus a short bibliography of articles related to literacy and readability in health research.

Download the complimentary Toolkit here:  http://www.centerforhealthstudies.org/capabilities/readability/ghchs_readability_toolkit.pdf

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Edward Leigh, MA, is the Founder and Director of the Center for Healthcare Communication.  To book one of his high-content credit-hour-approved keynote speeches or training programs, visit or call: http://www.CommunicatingWithPatients.com or call 1-800-677-3256