#5 Let’s go (Journal) Clubbing

January 11, 2022 | By Molly Heublein

Summary

Curbsiders own literature appraisal expert, Dr Rahul Ganatra @rbganatra, shares tips and tricks for running a journal club.  We will talk you through the basics of selecting an article, preparing ahead of time, engaging learners during the session, and finding key take away points.  Make journal club at your institution fun and successful!

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Credits

• Host/Editors: Era Kryzhanovskaya MD, Molly Heublein MD
• Writer/Guest: Rahul Ganatra MD
• Infographic, Cover Art: Andrew DeLaat
• CME Questions: John Ong DO
• Editor (audio): Clair Morgan of Nodderly

CME Partner: VCU Health CE

The Curbsiders are partnering with VCU Health Continuing Education to offer FREE continuing education credits for physicians and other healthcare professionals. Visit curbsiders.vcuhealth.org and search for this episode to claim credit. See info sheet for further directions. Note: A free VCU Health CloudCME account is required in order to seek credit.

Show Segments

• Intro, disclaimer
• Picks of the Week
• Case from Kashlak
• Challenges of Journal Club
• Goals/Objectives
• Practical first steps
• Adult learning theory framework applied to choosing an article
• Building a common basic understanding
• Taking it to the next level
• Encouraging engagement
• Wrapping up Journal Club
• Take home points
• Outro

Let’s go (Journal) Clubbing Pearls

1. A great journal club can’t happen without preparation: facilitators need to be ready and participants need to read the article ahead of time
2. A successful journal club really delivers! Staying current with new literature, practicing critical appraisal skills, having a lively discussion with colleagues, and/or writing letters to the editor or tweetorials helps with engagement and increases buy-in.
3. Choose articles that are relevant to clinical issues often seen.
4. Push learners to take the next step in appraisal- in what direction do chance or bias push the results and does this change the final outcome?
5. End with a clinically applicable summary- How does this article impact our practice?

Let’s Go (Journal) Clubbing Show Notes 

Challenges of Journal Club

• Lacking guidance on article selection and on the “how to’s” of critically appraising literature
• Low expectations that teachers are prepared ahead of time or that learners will read beforehand

HOWEVER….Journal Club can be Awesome because: 

• There’s nowhere to go but up!
• It can be done successfully in a way analogous to clinical reasoning–where we are very used to handling uncertainty, working in teams to get to an answer, and making our best guess at the truth.

Goals/Objectives of Journal Club

Tailor to your learners- what is the composition of your journal club?  Define the goals broadly for your group and get buy-in. Examples of goals/objectives include:

• Staying current with new literature
• Reading “classic” literature
• Practicing critical appraisal skills
• Having a lively discussion with colleagues

• Writing letters to the editor or tweetorials 
• Independently deciding whether a new study should or should not change practice before professional society guidelines are available

Practical Tips to Ensure a Successful Journal Club

• Set high expectations while creating a safe space to learn
• Send the paper out ahead of time and communicate the expectation that everyone reads it
• Model successful handling of scientific uncertainty
• Make journal clubs fun and useful

Framework for Adult Learning Applied to Choosing an Article

Dr Ganatra uses a theoretical framework for choosing an article for Journal Club based on Malcolm Knowles’ 4 principles of andragogy (meaning adult learning, as opposed to “pedagogy”):

1. Adults need to be involved in the planning of their learning.  You need learner buy-in!
2. Experience (including mistakes) provides the basis for learning.   Choose a paper addressing something your learners have experience with! The common things (HF, AKI, CAP, HTN, DM2) – think about the times you legitimately didn’t know what to do in order to identify clinical questions
3. Adults are most interested in learning things with immediate and direct relevance to their job/life → choose a paper relevant to a clinical decision your learners actually have to make
4. Adult learning is often problem-oriented rather than content-oriented → always connect your discussion of a paper back to a concrete action: “given this information, what should we do for the patient in front of us?”

Do articles need to be Peer-Reviewed for us to trust the findings?  How do we determine trustworthiness?

• No features of a paper or journal make them inherently trustworthy. We have to balance objective skepticism with the need to actually do something at the end of the day.
• Peer review is important but has limitations and isn’t the solution to guarantee high-quality research.  Dr Ganatra points out that the 3 most highly cited retracted papers of all time were published in NEJM, Lancet, and Science!
• The discussion that comes out of journal club can help us work toward an understanding of credibility

Three Questions to Build a Basic Discussion

The first step for the facilitator is to identify the minimum information everyone needs to be on the same page in order to participate in the discussion. Establish this in the first few minutes. This is usually some version of:

• What was the basic scientific question that the study sought to answer?
• If there was a comparison,  how were the comparison groups defined?
• What were the main findings?

PICO– population, intervention, comparison, outcome- is another framework which can work well (Brown 2020).

Next Questions:

Once everyone is on the same page with the basics (the dough of the pizza) then you can move on to more detailed discussion (the pizza toppings).

• Who was included in the study? Who was excluded? 
• Specific intricacies or unique aspects to the methods?
• What are sources of chance (random variation, lack of precision) or bias (source of error in a specific direction)? 

The goal is to get people to think about “in what ways could these results be wrong, and which direction are they more likely to be wrong in?”

This builds a strong conversation that can dive deep into how the findings may be impacted by these details- in which direction do the sources of chance and bias you identify push the results- does this underestimate the findings or overestimate the findings and does this impact the final outcomes of the trial?  Try to turn this into a comprehensive assessment or narrative just as we would in clinical medicine.

Tips for Facilitation 

 A good “road map” is to go through all of the figures and tables and make sure learners can say, outloud, without jargon what each of them shows. The facilitator should have discussion questions prepared for each of them. 

• Questions can be as simple as, “Can someone say, in plain language, what this figure shows?” or, more complex, like for an RCT CONSORT diagram, “Based on how patients were enrolled, can anyone talk about the potential for selection bias in this trial?”
• Avoid temptation to show off or hide behind unnecessarily technical descriptions of things. 

It is OK if the discussion meanders! A lively, meandering discussion is kind of the goal – you can always bring it back at the end. 

If you’re having trouble getting people to participate/stay engaged, what are some good questions to ask?

Have discussion questions ready ahead of time! Prepare your own answers and what direction do you expect the discussion to go.  

• Discussions on generalizability are a great place to start and can get people engaged even if they haven’t thought critically about the study.
• Ethics of performing a randomized controlled trial is another easy, low bar question that can encourage discussion.

Once a participant has highlighted a criticism, push them to identify how this may impact the findings, what direction would it push the findings?  Will this impact the likelihood that the findings are real?

Wrapping up a Journal Club

Plan how the journal club will end – for example, asking learners, “Will this change your practice? How?”

Use this time to model uncertainty– avoid premature closure on a conclusion if the data have not answered your question.  How good does the evidence need to be to change your practice? Another key pearl: End on time!

Take Home Points

• When you are preparing a journal club, think about the audience and objectives–how do you get buy-in from the learners.  Set expectations that some pre-work will be required.
• Choose papers that are relevant and applicable to decisions learners actually make in practice
• Get everyone on the same page from the beginning with a few basic questions.
• Job of the facilitator is to guide learners through the discussion to identify chance and bias and to push learners to describe what direction these might impact the findings.
• Wrap up the Journal Club with a discussion on if or how this study will change practice!

Links*

1. Rahul’s pick of the week: Critical Care the Game created by Lakshman Swamy, MD, MBA
2. Era’s pick of the week: podcast Alie Ward the Ologies especially the episode on happiness
3. Molly’s pick of the week: The Daily Podcast’s Sunday Read, Weird Al Yankovic’s Weirdly Enduring Appeal  
4. Article discussed: Essien UR, Kim N, Hausmann LRM, Mor MK, Good CB, Magnani JW, Litam TMA, Gellad WF, Fine MJ. Disparities in Anticoagulant Therapy Initiation for Incident Atrial Fibrillation by Race/Ethnicity Among Patients in the Veterans Health Administration System. JAMA Netw Open. 2021 Jul 1;4(7):e2114234. doi: 10.1001/jamanetworkopen.2021.14234. PMID: 34319358; PMCID: PMC8319757.
5. SALT-ED trial: ​​Self WH, Semler MW, Wanderer JP, Wang L, Byrne DW, Collins SP, Slovis CM, Lindsell CJ, Ehrenfeld JM, Siew ED, Shaw AD, Bernard GR, Rice TW; SALT-ED Investigators. Balanced Crystalloids versus Saline in Noncritically Ill Adults. N Engl J Med. 2018 Mar 1;378(9):819-828. doi: 10.1056/NEJMoa1711586. Epub 2018 Feb 27. PMID: 29485926; PMCID: PMC5846618.
6. Rahul’s plug: The Freakonomics MD podcast hosted by Anupam “Bapu” Jena MD, PhD

*The Curbsiders participates in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising commissions by linking to Amazon. Simply put, if you click on our Amazon.com links and buy something we earn a (very) small commission, yet you don’t pay any extra.

Goals

Listeners will become familiar with critically appraising the literature for clinical questions and the steps to running an effective journal club. 

Learning objectives

After listening to this episode, listeners will be able to…

1. List the steps in approaching appraisal of literature.
2. Identify ways to improve the journal club experience 
3. Cultivate a growth mindset when approaching reviewing articles

Disclosures

Dr Ganatra reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures. 

Citation

Ganatra R,  Kryzhanovskaya E, Heublein, M. “Let’s go (Journal) Clubbing”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/teach.  January 11, 2022.