1. What is a journal club? Anthea Colledge Dept of Primary Care and Social Medicine

2. © Imperial College LondonPage 2 Journal Club basics First recorded JC is 1875, organised by Osler. Definition of a traditional JC is “a group of individuals who meet regularly to evaluate critically the clinical application of recent articles in the medical literature” (Milbrandt & Vincent, 2004) May also be online and in other disciplines.

3. © Imperial College LondonPage 3 Evidence based health care (EBHC) JCs have a long history, but have become identified with evidence based healthcare and problem/practice based learning. EBHC means using best available evidence to guide health care decisions, to improve quality and/or (cost) effectiveness. Cycle of ‘getting evidence/research into practice’.

4. © Imperial College LondonPage 4 Getting research into practice Finding the evidence Checking the validity of the evidence Applying the evidence

5. © Imperial College LondonPage 5 Aims of the Journal Club JCs can add value at each stage of the cycle. Commonest reported aims of JCs: 1.To teach/develop critical appraisal skills 2.To increase awareness of the current literature in a specialty. 3.To influence clinical practice. (Ebbert et al., 2001 ) Focus on 1).

6. © Imperial College LondonPage 6 Critical appraisal (checking the validity of the evidence) Tries to answer the questions: 1.Is this study valid? 2.What are the results? 3.Are the results clinically useful? Considers specifics of the research (e.g. methods, results) plus wider questions (e.g. is it important, will it change practice). Various tools are available e.g. CONSORT statement (RCTs), CASP checklists (all research types), PICO (defining a search strategy or framework for appraisal).

7. © Imperial College LondonPage 7 Objectives - how the aims are achieved Monthly small group meeting. Presentation of a topic or paper/s. Discussion. Discussion may be written up (and published). See example by Kind et al (2004). The organiser does not have to do the presentation. Journals have published guidelines for successful JCs. (e.g. Gibbons, 2002)

8. © Imperial College LondonPage 8 Tips for success Organisation  Publish a timetable of dates and presentations.  Ensure a senior clinician is present to chair and/or provide a summary at the end.  Food? Presenting  Keep in mind the aim (usually developing appraisal skills) and try to answer the 3 critical appraisal questions.  Present for approximately 10 minutes per paper.  Use appropriate guidelines for appraising papers.  Don’t take criticism personally. (Gibbons 2002, Atzema 2004)

9. © Imperial College LondonPage 9 Evidence base for journal clubs 1 Most research on JCs has studied their effects in postgraduate medical education. 5 relevant systematic reviews (Alguire, 1998; Norman & Shannon, 1998; Green, 1999; Ebbert et al, 2001; Coomerasamy et al, 2003) 4 systematic reviews (including one using Cochrane methodology) have consistent conclusions:  JCs can improve: reading habits, knowledge of clinical epidemiology and biostatistics, use of medical literature in practice. Strongest evidence is for increased knowledge.  JCs have not yet been shown to improve critical appraisal skills.

10. © Imperial College LondonPage 10 Evidence base for journal clubs 2 1 systematic review (Green, 1999) did conclude critical appraisal skills could be improved. Discrepancy due to papers excluded from other reviews. Lack of evidence re critical appraisal could be due to lack of effect, inadequate measurement, or lack of power. JCs could also be effective on outcomes not considered in studies/reviews.

11. © Imperial College LondonPage 11 Benefits of journal clubs Increase knowledge about statistics and clinical epidemiology (Ebbert, 2001; Coomarasamy, 2003) May improve reading habits and use of medical literature (Ebbert, 2001; & e.g. Goodfellow, 2004) Other reported benefits include:  Increased interest in research and generation of research ideas  Increased awareness of own research and appraisal skills (Atzema, 2004)  Improved presentation skills (Gibbons, 2002)

12. © Imperial College LondonPage 12 References Critical appraisal skills programme (CASP) http://www.phru.nhs.uk/casp/critical_appraisal_tools.htm Alguire, P. C. 1998, "A review of journal clubs in postgraduate medical education", Journal of General Internal Medicine, vol. 13, no. 5, pp. 347-353. Atzema, C. 2004, "Presenting at journal club: A guide", Annals of Emergency Medicine, vol. 44, no. 2, pp. 169-174. Coomarasamy, A., Taylor, R., & Khan, K. S. 2003, "A systematic review of postgraduate teaching in evidence-based medicine and critical appraisal", Medical Teacher, vol. 25, no. 1, pp. 77-81. Ebbert, J. O., Montori, V. M., & Schultz, H. J. 2001, "The journal club in postgraduate medical education: a systematic review", Medical Teacher, vol. 23, no. 5, pp. 455-461. Goodfellow, L. M. 2004, "Can a journal club bridge the gap between research and practice?", Nurse Educator, vol. 29, no. 3, pp. 107-110.

13. © Imperial College LondonPage 13 References Green, M. L. 1999, "Graduate medical education training in clinical epidemiology, critical appraisal, and evidence- based medicine: A critical review of curricula", Academic Medicine, vol. 74, no. 6, pp. 686-694. Kind, T., Simon, A. E., Everett, P., & Cabana, M. D. 2004, "Can an information prescription change parental attitudes and behaviors related to using the internet for health information resources?", Archives of Pediatrics & Adolescent Medicine, vol. 158, no. 9, pp. 864-866. Milbrandt, E. B. & Vincent, J. L. 2004, "Evidence-based medicine journal club", Critical Care, vol. 8, no. 6, pp. 401- 402. Norman, G. R. & Shannon, S. I. 1998, "Effectiveness of instruction in critical appraisal (evidence-based medicine) skills: a critical appraisal", Canadian Medical Association Journal, vol. 158, no. 2, pp. 177-181.

14. © Imperial College LondonPage 14 Discussion following the presentation Clarification re the systematic reviews –Due to time constraints the presentation was based mainly on 5 identified systematic reviews. Of these 5 systematic reviews only 1 found that JCs improved critical appraisal skills. This finding was based on a small number of studies excluded from the other 4 systematic reviews. Clarification re publishing journal club discussions –More likely to publish a letter than a paper. Most JCs are longer than the one here.

15. © Imperial College LondonPage 15 Discussion following the presentation How to move from a broad topic to a focused presentation AC’s strategy (when little/no background knowledge) is: 1.Use Medline, Cochrane database, web of knowledge etc to identify relevant papers, especially systematic reviews. 2.Use systematic reviews and abstracts to get an idea of the scope of the field and construct possible outline headings for the presentation. 3.Focused reading of papers to fill in the outline.

16. © Imperial College LondonPage 16 Discussion following presentation How are papers selected for presentation? –Literature suggests the presenter and a senior clinician should jointly choose the paper. –Papers should be relatively recent, relevant to members, and suitable for critical appraisal. –Relevance to clinical practice is especially important. It was suggested that suitable papers might be about new guidelines, or common issues in general practice, especially those faced by F2s/new GPs.