December 16, 2011

Breaking down the primary literature: the role of the journal club

by Emily C. Pherson, Pharm.D., PGY1 Pharmacotherapy Residency, the Johns Hopkins Hospital 

As pharmacy students, we have courses where we are instructed on the key elements of a research study and we are tasked with trying out our literature evaluation skills by writing evaluations of major drug trials. As pharmacy residents, we are faced with reviewing multiple pieces of primary literature nearly every day in order to find the best data we can to inform the drug treatment decisions we are making for our patients. Leading journal clubs has helped me develop the skills I need to break down the primary literature.

As a pharmacy resident at Johns Hopkins, I was excited to discover that the first record of a medical journal club was one founded in 1875 by Sir William Osler, a renowned physician with Hopkins roots. He originally described the journal club as facilitating the distribution of unaffordable periodicals, and later evolved it into a book and journal club that met over dinner to discuss the latest in medical research.1 

A journal club is a teaching tool that helped me digest large amounts of information in limited amounts of time. When I started to think more about how I could conquer breaking down the necessary information in a journal article for a journal club, I realized that an easy way to do this would be to apply Gagne’s 9 events of learning, one of the many educational strategies we have been exploring in the Educational Theory and Practice Course.

To really engage participants in a journal club, you need to gain their attention. I find that applying the journal article to a patient case is a good way to get participants to relate to the content. It is also important to emphasize that at the end of the journal club, all attendees should understand the clinical implications of the data presented. This is always a recurring key objective for a journal club. It also important to give a bit of background on the disease state or therapy being addressed in the article as a way to stimulate recall of prior learning and help the attendees draw on information they already know about the topic. As far as presenting the content, a 2004 overview in the American Journal of Health-System Pharmacy points out three key steps to providing adequate discussion about an article.2 First, the presenter must determine the relevance of the study (something I accomplish by laying out my objectives). Next, the validity of the trial must be determined. This is where the patient population, the study design and how the study was conducted are all evaluated. Lastly, the results must be evaluated. Askew suggestions that you list all of the efficacy endpoints of the study and then calculate the relative risk reduction and the absolute risk reduction.2 Other important things to look at include the statistical analyses. It may be helpful to calculate the number needed to treatment (NNT) and/or the number needed to harm (NNH). It is also important to consider if the study was adequately powered to assess the defined outcomes.2 

In order to provide learning guidance and engage learners, its helpful to prepare some discussion questions to get the conversation started. These questions should be focused on the application of key study findings. If you started the journal article with a patient case, this can be a good time to bring the case back into discussion.

Its also important to have an evaluation tool available to assess the learners performance and provide feedback on the presentation. A 2007 article in the American Journal of Pharmaceutical Education provides an extensive evaluation rubric that was piloted with pharmacy students. In addition to the rubric, the students were also provided with an outline of important considerations for each section of the study. The authors provide a truly comprehensive tool that’s very useful for providing feedback to learners.3 

The last event that Gagne proposes is that we must enhance retention and transfer knowledge. At the conclusion of every journal club, its important to summarize the discussion and talk about how the information can be applied in practice.  Some days later, I invariably find myself applying what I’ve learned during a journal club to specific patient cases I see on my rotations.  I encourage participants to think about when they might use the information in the journal article again.

I would challenge any educator who is faced with the task of discussing the primary literature with learners, to considering using a journal club format and applying Gagne’s 9 events of learning when conducting them. 

1. Greene WB. The role of journal clubs in orthopaedic surgery residency programs. Clin Orthop. 2000;373:304–310.
2.  Askew JP. Journal club 101 for the new practitioner: Evaluation of a clinical trial. Am J Health-Syst Pharm. 2004;61:1885-1887. 
3.  Blommel ML and Abate MA. A rubric to assess critical literature evaluation skills. Am J Pharm Educ. 2007;71:1-8.

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