The Egyptian Journal of Medical Education www.EJME.

org 2019;1(1) eISSN 2090-2816 Original Article

How a Journal Club Course Changed Learners’ Approach in a Medical Doctorate

Program- an Analysis of the PhD Scholars’ Perspective.

Tania Ahmed Shakoori*1,5, Zeeshan Sarwar2, Muhammad Najam u Saqib2, Muhammad Saqib Saeed3, Usman
Mahboob4, Syed Asghar Naqi2,5, Ian Willis6, Janet Strivens6
1
Department of Biomedical Sciences, King Edward Medical University, Lahore, Pakistan.
2
Department of Surgery, King Edward Medical University, Lahore, Pakistan.
3
Department of Pulmonology, King Edward Medical University, Lahore, Pakistan.
4
Department of Medical Education, Khyber Medical University, Peshawar, Pakistan.
5
Quality Enhancement Cell, King Edward Medical University, Lahore, Pakistan.
6
Centre for Higher Education Studies, University of Liverpool, UK.

ARTICLE INFO ABSTRACT

https://doi.org/10.33328/ejme.2019.002
*Corresponding author: +923454303059;
Dept. of Biomedical Sciences, King
Edward Medical University, Nelagumbad,
Lahore 54000, Pakistan. ; study comprising of a focus group discussion, involving eight out of the
drtaniashakoori@yahoo.com,
drtaniashakoori@kemu.edu.pk
Received : 16 December, 2018
Accepted: 24 December 2018
Published : 9 January 2019
Keywords: learning, thinking, qualitative
research, focus group discussion.
This work is licensed under the Creative
Commons Attribution International License
(CC BY 4.0).
http://creativecommons.org/licenses/by/4.0/
Background/Aim: A structured journal club course that counts towards the
final assessment was introduced in a medical doctorate program course at
King Edward Medical University, Pakistan. This study aims to explore its
effects on the learning approach of PhD scholars. Methods: A qualitative
total of thirteen PhD scholars was conducted in 2017. Focus group
discussions were transcribed verbatim and codes and themes were
identified using grounded theory. The findings were triangulated with data
from teaching feedback forms of the course from all the thirteen PhD
scholars from 2015 to 2017. Results: The participants described an overall
positive effect of the course on their learning, including development of
critical and scientific thinking. They also reported improvement in their
clinical and teaching practice. They attributed these to the interactive
nature of the course, role playing as author while presenting the assigned
paper in journal club, help from the study guide, interdisciplinary peer
learning and the awareness that they were being graded on their
performance. Conclusions: A semester long structured journal club course
that contributes to the final assessment may be an effective tool to teach
medical doctorate students about the research process and critical
appraisal skills.

Introduction system. Such a course was introduced as part of the

Previous studies report the benefits of running
structured regular journal clubs [1-5]. However, in most
cases formats are not standardized [6] and there are very
few studies reporting a detailed design of their journal
clubs [2, 5, 7]. Furthermore there is no reported case of a
formal journal club course, as part of a medical PhD
curriculum, that counts towards the final assessment
Shakoori TA et al., Success of a journal club course in a medical PhD program
‘revamped’ curriculum of ‘Medical Sciences PhD Program’
at King Edward Medical University (KEMU), Lahore,
Pakistan, in 2015.
Even though research methodology and critical
appraisal workshops are offered to medical doctors in
Pakistan as part of their post graduate trainings, these are
limited in duration and the awarding of completion
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The Egyptian Journal of Medical Education
certificates is only dependent on attendance and not
assessment. This journal club course was introduced in
the PhD curriculum to train the scholars in critical
appraisal and the clinical research process. Its effects
were analyzed after 2 years of successful running of the
course.
Methods
Ethical approval was obtained from the Institutional
Review Board of KEMU (No 435/RC/KEMU). In December
2015 PhD classes commenced at KEMU under a
‘revamped curriculum’. A qualitative study was designed
to determine effects of a ’journal club course’ in this
curriculum on students’ approach to learning.
At the time of the preparation of this manuscript, this
course was successfully completed by two batches of
medical PhD scholars between 2015 and 2017 (six women
and seven men). It is pertinent to note that these scholars
included clinical as well as medical basic sciences’
professionals and had training in medical education as
most had completed certificate courses in medical
teaching or masters in medical education.
Amongst the salient features of the program was a 2.5
credit hours’ worth ‘Journal Club Course’. This course was
composed of small group discussions on critical
evaluation of published research articles, much like a
regular journal club. However, the focus was not on
keeping up to date with the latest medical advances but
on learning critical appraisal skills, research methodology,
statistical analysis and academic writing. Furthermore the
course differed from a regular clinical journal club in that
the student performance was evaluated on the basis of a
presentation they gave on their assigned research paper
and a reflective assignment. The marks obtained by the
student were given weightage in the final assessment of
the PhD program.
Each article was discussed as group and evaluated with
help of standard checklists in class. One selected student
prepared a power point presentation of the research
article as if he/she was the principal author
himself/herself, and received oral and written feedback
from the attendees [figure 1] Finally the presenting
student submitted a written reflective assignment using
Shakoori TA et al., Success of a journal club course in a medical PhD program
www.EJME.org 2019;1(1) eISSN 2090-2816 Original Article
the given checklist [figure 2] as a guide. The assignment
was graded, and detailed written feedback was provided
to the student.
Eight scholars were able to participate in the Focus
Group Discussion (FGD). A grounded theory approach was
used for analysis of transcribed data. Quotes from all the
transcripts of the FGD were regrouped as indicators for
the identified themes in a tabulated form for analysis.
These data were triangulated with the written feedback
that had been collected anonymously from all students
after each semester ended [figures 3, 4].
Results
A total of 60 codes were generated in the 1st cycle of
coding, and 14 categories in the 2nd cycle to identify the
patterns in the data. Five main themes were identified
[table 1]. These included ‘effect on learning’, ’effect on
practice’, ‘role of assessment’, ‘role of written assignment’
and ‘role of study guide’. The theme ‘effect on learning’
comprised of categories ‘inspired deep learning’, ‘critical
thinking’, ‘hands-on learning’, ‘better understanding of
research’, ‘peer learning’ and ‘lateral Integration’. The
theme ‘Effect on practice’ included the categories: effect
on teaching practice; effect on clinical practice; improved
presentation skills; improved publication track and change
in thought processes.
1. Effect on learning
The participants described how the course inspired
deep learning. The majority of the interviewees reported
that they previously only scan-read research articles but
now attempted to critically appraise them, noticed details
and tried to interpret charts and graphs.
“We used to read the abstract and conclusion of the
articles only... Journal club has equipped us to explore the
mind of the authors. We can now analyze the flaws and
gaps in his mind and see how we can fill these.”
One participant however mentioned how he still does not
read the entire article deeply, due to lack of time.
“If I think of my practices and attitudes about reading
journal articles before and now, I see no change. The
reason is that I don’t have much time.”
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Sr# THEMES CATEGORIES
1. Effect on Learning 1.Inspired deep learning
2.Change in thought
process/critical thinking
3.Hands on learning
4.Better understanding of
research
5.Peer learning
6.Lateral Integration
2. Effect on Practice 1.Effect on teaching practice
2.Effect on clinical practice
3.Improved presentation skills
4.Improved publication track
5.Change in thought
process/critical thinking
3. Role of assessment
4. Role of written assignment
5. Role of study guide
Table 1: Themes identified along with their categories (where applicable) and codes
Shakoori TA et al., Success of a journal club course in a medical PhD program
www.EJME.org 2019;1(1) eISSN 2090-2816 Original Article
CODES
1.noticing details
2.reading the whole paper
3.Importance of charts and graphs
4.Deep study of research articles
5.still not reading articles deeply due to lack of time
6.explore the mind of authors/critical reading
7.importance of critical appraisal
8.Developed scientific approach
9.Critical thinking not due to JC but part of natural progression as a clinician
10.Learned not follow books blindly
11.Change as a person/critical thinking
12.hands on
13.Not hands on
14.Putting yourself in researcher’s shoes
15.Practical rather than theoretical understanding
16.journal club better than lectures
17.Better understanding of research methodology
18.didn’t know research before
19.Practical rather than theoretical understanding
20.Research seems doable now
21.More Confident about conducting research
22.peer learning
23.multidisciplinary/interdisciplinary learning
24.Coming together of all PhD subjects
25.replication of teaching style in their own practice
26Initiated JOURNAL CLUB in their programs
27.improved their own JCs
28.effect of role modeling to change teaching practice
29.Which teaching style would they use?
30.Better supervisor
31.critically evaluate research synopses
32.gives advice on publication
33.spends more time in giving feedback
34.Effect on clinical practice/change as a clinician
35.Adopted evidence based approached
36.Applying scientific thought
37.No effect on clinical practice
38.Practice for conference presentations
39.defending research at a conference
40.more confident in conference presentations
41.More publications after journal club course
42.Improved scientific paper writing
43.Helps fulfill research requirements of TTS (tenure track system)
44.importance of critical appraisal
45.Developed scientific approach
46.Critical thinking not due to JC but part of natural progression as a clinician
47.Learned not follow books blindly
48.Change as a person/critical thinking
49.Took more seriously
50.Aware of assessment
51.Additional motivation
52.useful since assessed
53.facilitates deeper reflection
54.not useful
55.complements presentation
56.better understanding by writing
57.helped organize thoughts
58.helps remember things
59.passed on to own trainees
60.should stay
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The interviewees also commented on a change in their
thought process and how they viewed knowledge. They
described how they realized that textbooks cannot be
considered exclusive and irrefutable sources of
knowledge, that evidence comes from research articles
and even that can only be accepted after critical
evaluation.
“Previously, we used to study books first then see the
patients. Now we have this new understanding that
diseases don’t study books. Exceptions are there and we
need to see them and keep our eyes and minds open”.
One participant described development of scientific/
critical thinking through an anecdote:
“. .. I advised my colleague who was prescribing the new
drug, not to blindly follow American guidelines regarding
this drug. I suggested that we design a study and see if
our local patients treated with the drug suffered from
decompensated liver failure .. .and only then decide if we
should prescribe this medication.”
Two participants were however skeptical about the
perception that the critical appraisal exercises of journal
club had a role in the development of this scientific
thinking. One argued that this improvement was part of
the natural evolution of a clinician as they do through
their training and gain more experience.
“With every passing moment, our acumen to treat the
patient improves. It’s a natural phenomenon. This could
be the reason of change in our thought process as well.
How can you know if this improvement in thought process
occurred due to clinical practice or critical appraisal
exercises in journal club?”
The PhD scholars also talked about how they have a
better understanding of the research process after
attending the journal club course, even though they had
attended many didactic lectures and workshops on
research methodology as part of their respective post
graduate trainings.
“We got a better understanding of study designs. ..plus I
got a better understanding of biostatistics through this
journal club.”
Shakoori TA et al., Success of a journal club course in a medical PhD program
www.EJME.org 2019;1(1) eISSN 2090-2816 Original Article
They attributed the clarity of concepts gained from the
course to the format which required them to defend the
research in presentations as if they were the authors.
“The role given to us was that we are authors. That made
a difference. We had to defend it (the research paper)
and we had to own it. It was presented as our own project;
that was the major difference.”
The participants discussed in detail how going through
actual research articles gave them better understanding
of concepts like study design and statistical tests as
compared to lectures on the same topics.
“The more exposure we had to journal club the more
clarity we got about research. Instead of spending our
time on theoretical discussion of ‘how to conduct a case-
control study’, we practically applied it in journal club and
studied different scenarios.”
The participants appreciated the fact that there was a
successful collaborative learning atmosphere despite the
fact that the students ranged from senior professors to
junior assistant professors and belonged to different
specialties.
“For PhD, I actually prefer an interdisciplinary class. The
good thing about all participants was that they took off
their caps (of professorial cadre) and participated in the
classroom as colleagues.”
2. Effect on Practice
All the PhD scholars in the cohort were involved in
classroom and bedside teaching. They commented on
how they had implemented some of the teaching
techniques they experienced as students of the course
into their own respective teaching practices. Those who
did not have a journal club in their wards previously felt
motivated to start one or had already started one.
“In our clinical wards, we didn’t have a journal club due to
other commitments, but now we have added this to our
teaching program.”
Some of participants were already running Journal Clubs
in their department. They described how they had
improved the format after exposure to this course.
“..We have made it interactive now.”
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The Egyptian Journal of Medical Education www.EJME.org 2019;1(1) eISSN 2090-2816 Original Article

Figure 1: Checklist used to

grade the Students research
paper presentation.

“Yes, there was a journal club before … but it was just for
the sake of doing it. .. Now, ..focus is also on study design,
no. of participants, its flaws etc.”
Most of the enrolled clinical scholars were active clinical
researchers. They mentioned how defending the research
papers of other authors during the journal club trained
them in better conducting and presenting their own work
at different clinical forums and conferences.
“We learnt from our journal club presentations, how to
present in a conference in the form of power point slides
and how to present in front of a learned audience.”
3. Role of study guide
The participants talked about how they referred to the
study guide while preparing their journal presentations
and assignments and even when teaching the research
process to their own trainees.
“The study guide given to us at the start was like a
measuring tool and using it we were able to organize our
thoughts in better way.”
4. Role of written assignment
There was difference in agreement with regards to the
importance of the written assignment. Most thought it
added to their learning.
“While writing the assignment, I read the paper in greater
depth... So this written assignment was complementary to
the oral presentation and the class discussion in
enhancing my understanding.”

Shakoori TA et al., Success of a journal club course in a medical PhD program 5

The Egyptian Journal of Medical Education www.EJME.org 2019;1(1) eISSN 2090-2816 Original Article

Figure 2: A page from the

study guide for the journal
club course showing
assessment criteria for the
written assignment.

One participant had a contrasting opinion about the utility
of the assignment.
“For me the written assignment was not very useful
because for me it was simply writing down what I learnt
here… I would rather not do it.”
5. Role of assessment
The participants also commented that they
concentrated more and worked harder because it was
part of their summative assessment.
“… We had to present like an author and we were being
assessed on it and were also defending it that’s why we
studied in depth.”

Shakoori TA et al., Success of a journal club course in a medical PhD program 6

The Egyptian Journal of Medical Education
Results of Surveys
As can be seen in figure 4, the students’ response was
overwhelmingly positive. The feedback for all questions
asked in survey was either ‘excellent’ or ‘good’.
Discussion
It has been suggested that a regular, structured journal
club with mandatory attendance best achieves its learning
objectives [1, 4, 8, 9]. These features were a part of our
journal club course and likely contributed to its success. In
addition to adopting the best practices suggested in
literature for running a successful journal club, the course
contributed to the final assessment of the PhD program.
There is substantial evidence that assessment and testing
enhances memory retention and factual recall which is
independent of the act of repeatedly going over the
material as part of test preparation [10]. It has further
been demonstrated that learning motivation of students
increases as the weightage of the subject within the
assessment system increases [11]. We argue that testing
can also facilitate deep learning and reflection if the
system of assessment was designed accordingly. The
Shakoori TA et al., Success of a journal club course in a medical PhD program
www.EJME.org 2019;1(1) eISSN 2090-2816 Original Article
assessment of the journal club course was based largely
on a reflective assignment which was graded on the basis
of criteria that had already been provided to the students
in their ‘study guide’. The criteria gave more weight to
evidence of reflection [figure 2]. Furthermore the course
had significant weight (11.1%) in the calculation of the
Figure 3: Evaluation of
teaching in Journal Club
course by the students.
final Cumulative Grade Point Average (CGPA) of the PhD
scholars. The PhD scholars were very aware of this fact
and this added to their motivation in learning. They ‘were
being assessed on it’ so they ‘studied in depth’. Our
findings thus further validate the concept that if the
system rewards deep learning, critical thinking and
reasoning, then the successful learner will aim for that [12,
13] .
One feature of the journal club the students
appreciated was presenting the papers as authors. They
described how ‘putting themselves in the researcher’s
shoes’ not only motivated them to study the article
deeply, but also encouraged them to consider all the
practical and logistic aspects of the research project as
well. Thus this role-playing as the ‘author presenting
his/her work’ forced them to look at the research and its
clinical application from all angles. This is in line with
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The Egyptian Journal of Medical Education www.EJME.org 2019;1(1) eISSN 2090-2816 Original Article

published research which describes how role playing can
help students make clearer connections between
different concepts, and give them the ability to apply that
information in different contexts [14]. Thus we saw many
of the students from the cohort make research proposals,
based on the questions that were raised during the
discussion of their assigned journal club papers in class.
feel that the interactive discussion of the journal club,
facilitated by an approachable facilitator in a comfortable
learning environment, provided fertile ground for the
learners to pass through the learning phases of
‘dissonance’, ‘refinement’ and ‘organization’. There was
adequate time to discuss and reflect on the concepts
during discussions. Furthermore the checklists provided in

Figure 4: Feedback of PhD Batches 2015-2018 and 2016-2019 on Teaching in Journal Club
Course

Motivates to publish your research findings in an…

Teacher helps in topic / research material search
Refers to recent and current developments in…
Instructor displays professional behavior
Evaluation is fair, feedback is timely
Learning environment is comfortable
Maintains a friendly respectful atmosphere
Maintains student interest and attention
Plans student assignments/Quizzes
Displays evidence of preparation
Has a positive attitude
Provides motivation and leadership
Encourages student participation
Uses of audio visuals resources/innovations
Has good grasp of the subject
-1 1 3 5 7 9 11 13

Unsatisfactory Satisfactory Good Excellent

We believe that the kind of reflection, which role-playing the study guide were frequently referred to during
as an author triggered, could not have happened discussions and acted as ‘scaffolding’ to support
otherwise. formation of ideas in the ‘organization phase’ of learning.
The ‘feedback phase’ corresponded to the feedback given
The format of the course complements the five stages
in the presentation and written assignment stages of the
of learning proposed by Taylor and Hamdy in their multi-
journal club course. Finally as the presenter prepared
theories model of adult learning [15]. According to this
his/her reflective assignment, he/she continued with
model learning begins with a ‘dissonance phase’ when the
further organization of his/her thoughts based on
‘learner’s existing knowledge is challenged and found to
feedback he/she received during the presentation stage
be incomplete’. During the ‘refinement phase’, the learner
and further reflected, all the time motivated by a desire
refines the new information into a series of new concepts.
to get good grades. Arguably these stages were most
This is followed by the ‘organization phase’ where the
intense for the learner who was assigned the article and
learner restructures their ideas into schemata which
was being assessed, however the learning experience of
make sense. ‘Reflection in action’ is key in this stage. We
Shakoori TA et al., Success of a journal club course in a medical PhD program 8
The Egyptian Journal of Medical Education
the rest of the class cannot be underestimated. Knowing
that they would go through the same cycle when their
turn came, the rest of learners were highly motivated and
engaged in discussions in all stages of each session. The
last phase of the learning cycle or ‘consolidation’
inevitably continued as each student witnessed the next
learner make his/her presentation and received feedback
on it. It is also reasonable to extrapolate that this
‘reflection on action’ continued as the PhD scholar started
working on the research synopsis for his/her PhD thesis
and also as they guided their own research students as
supervisors.
There is some evidence from the data that the course
challenged if not changed some of the students’
epistemological beliefs related to medical evidence and
research. This was an unexpected finding as it was not
one of the original objectives when the course was first
designed and executed. As an example, the students
described how they changed their views on books as
irrefutable sources of knowledge. According to literature,
restricting to textbooks as the only sources of learning
may stifle the development of scientific thinking and the
critical appraisal skills [16]. It is interesting how when this
cohort developed these skills they arrived at this same
conclusion. The students narrated incidents from their
previous educational experiences in post graduate
training where they were discouraged from questioning in
general and referring to anything beyond their medical
textbooks. One participant captured this traditional
learning atmosphere with the following verses of a
famous poem by poet and philosopher Dr. Muhammad
Iqbal
“In their hearts no desire (to reflect) ever arises;
when it does by chance, it dies young”[17]
The students further commented how they now truly
understand that ‘diseases don’t read books’ so they have
to think of exceptions when making diagnoses. One
student commented that after learning to critically
evaluate research articles she understood that she could
not ‘trust journal articles blindly’ or apply the findings to
her patients automatically. The participants described
how they try to pass this belief on to their own trainees
by saying to them “do not follow books. Books are only
Shakoori TA et al., Success of a journal club course in a medical PhD program
www.EJME.org 2019;1(1) eISSN 2090-2816 Original Article
guidelines. If your minds are working, explore new things.’
Previous studies have shown that educational
interventions may lead to domain specific epistemic
changes in university students from diverse disciplines
[18-20]. It was interesting to see the same phenomenon
in our cohort of full time clinical professionals enrolled in
a PhD program.
With such changes in learning behavior and thinking
process, change in practice was inevitable. The students
described how they had self reportedly improved as
clinical supervisors and even clinicians. They reported
how they now reviewed research proposals, papers and
theses more critically and confidently. They also reported
replicating the journal club in the teaching program of
their clinical trainees. Some of the participants (physicians)
in the cohort reported improved clinical reasoning and
attributed it to the training in critical appraisal and
scientific thinking received in the course. Two surgeons
disagreed and proposed that the improved clinical
reasoning and application of scientific thought to patent
care may be part of natural evolution of a practicing
clinician. The difference in the two perceptions may be
attributed to factors related to the individuals learning
styles and factors specific to their specializations.
Conclusions
A semester long structured journal club course that
contributed to the final assessment may be an effective
tool to teach medical doctorate students about the
research process and critical appraisal skills. In light of our
findings it is recommended that such a course should
made an essential part of PhD curriculum for doctors.
Acknowledgements
Prof. Dr. Shakila Zaman whose teaching style inspired the
format of the course.
Prof Dr. Faisal Masud, Ex VC KEMU for supporting
development of this non-traditional course.
Disclaimer
The article has not been previously presented or
published, and is not part of a PhD or thesis project.
9
The Egyptian Journal of Medical Education
Conflict of Interest
There are no financial, personal, or professional conflicts
of interest to declare.
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