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Journal Club: A Step towards Evidence Based Practice

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 JOURNAL OF THE INDIAN ASSOCIATION OF
PUBLIC HEALTH DENTISTRY Vol:2011 ISSUE:17

Journal Club: A Step towards Evidence Based Practice

Dr. Anil V Ankola1, Dr. Mamata Hebbal2, Dr. Ratika3

ABSTRACT
A Journal Club is a group of individuals who meet regularly to critically evaluate recent articles
in scientific literature. Journal clubs are usually organized around a defined subject in basic or applied
research. The general purpose of a journal club is to facilitate the review of a specific research study and
to discuss implications of the study for clinical practice. There are many advantages of participating in a
journal club, including keeping abreast of new knowledge, promoting awareness of current nursing research
findings, learning to critique and appraise research, becoming familiar with the best current clinical research,
and encouraging research utilization. Several factors are key in promoting a successful journal club,
including promoting interest, attendance, and involvement. The value of a journal club is that it can promote
a better understanding of the research process and an improved ability to critically appraise research
Key words: journal club, evidence based practice, critical appraisal

INTRODUCTION overseas news or even the crossword, you know

The volume of medical and dental literature,
even confined to one specialty area that a clinician
needs to review has exploded exponentially. Alper
et al estimated that it would take an incredible and
impossible 627.5 hours per month for a clinician
to keep up with the primary care literature. The
resident in training must not only learn a new skill
set and acquire a new knowledge base but must
also read the current literature, be familiar with
principles of evidence-based medicine (i.e.,
practice-based learning), and use the evidence to
improve practice and patient care (i.e.,
practice-based improvement).1
One method to improve the efficiency and
timeliness of reviewing the medical literature is the
traditional journal club. A journal club can be
defined as a group of interested individuals
meeting regularly to discuss the strengths,
weaknesses, and clinical application of selected
articles from the medical literature.1
which page to turn to even if there is no index.
Journals have a formal structure Cand within
journals papers have a structure too. The regular
(and busy) journal reader will find a fixed order
of events, both in journals and within research
articles, helpful. Moreover, structure provides a
template for scientists to write on.3
Some key sections commonly found in
journals are:
Original articles: a new piece of knowledge
Case report: a single event that could lead to
a new piece of knowledge
Review article: knowledge others have laid
claim to
Editorial: what the editor thinks of a piece of
knowledge that someone else is claiming
Letters to editor: what I think of the
knowledge claims in your journals.

WHAT IS A JOURNAL? WHAT IS A JOURNAL CLUB?

It is a periodical aimed at a particular
discipline. It differs from a magazine in several
ways. Journals are intended for specialists, not lay
men, and normally journal articles are written by
academicians, not journalists.2
FORMAL STRUCTURE OF A JOURNAL
Daily newspapers have a formal structure. If
you are interested in sports news, obituaries,
1
Professor and Head, 2Reader, 3P.G. Student, Dept. of Public Health Dentistry, KLE VK Institute of Dental Sciences,
Belgaum
A journal club is a group of individuals who
meet regularly to evaluate critically the clinical
application of recent articles in the medical
literature.4
HISTORY OF JOURNAL CLUB
The earliest reference to a journal club is
found in a book of memoirs and letters by the late
Sir James Paget,5 a British surgeon and one of the

84

founders of modern pathology. He describes a
group at St. Bartholomew’s Hospital in London in
the mid-1800s with >a kind of club Y a small
room over a baker’s shop near the Hospital-gate
where we could sit and read the journals.’ It is
believed that Sir William Osler established the first
formal journal club at McGill University in
Montreal in 1875, though Osler himself might
have been aware of similar gatherings that were
taking place elsewhere 6. The purpose of Osler’s
early journal club was >for the purchase and
distribution of periodicals to which he could ill
afford to subscribe’.
AIM OF JOURNAL CLUB
The primary aim of journal club until 1980’s
was to provide its members with up to date
medical literature but quite recently it has become
a forum for teaching and learning critical appraisal
techniques and a method to promote evidence
based medicine practice.2
OBJECTIVES OF A JOURNAL CLUB1
• Acquiring, disseminating, and applying new
medical information
• Teaching and assessing critical appraisal skills
for reading and writing a scientific paper
• Promoting lifelong learning skills in
evidence-based medicine
• Improving reading habits
• Providing an interactive and social opportunity
for peer to peer learning
• Improving small group participation,
presentation, and communications skills
• Documenting practice-based learning and
• improvement in patient care
TYPES OF JOURNAL CLUBS
1. Traditional: In the traditional type of journal
club junior doctors select articles and seniors
critique their presentation. This process often
involves selecting random articles and appraising
them without the use of guidelines for validity and
clinical application. Selection of an article at
random may not be relevant to current clinical
practice, so the opportunity for developing critical
thinking in the context of clinical care may be
absent. In the traditional journal club evidence
based practice and clinical adoption are not the
true motivating factors. As they are untrained in
medical research, most trainees do not correctly
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JOURNAL OF THE INDIAN ASSOCIATION OF
PUBLIC HEALTH DENTISTRY Vol:2011 ISSUE:17
appraise the articles. Without critical appraisal the
club becomes an exercise solely for presentation
without learning.7
2. Problem and evidence based: As a first step
the trainee identifies a current clinical problem that
has created uncertainty regarding its best
management. Clinical problems are then discussed
with an appropriate mentor and then converted into
focused, answerable questions by defining the
population, intervention, possible comparison and
outcome. The identification of the problem and
formulation of the question is led by the trainee
and guided by the mentor. The second step is to
search the literature to identify the relevant
articles. This process should be structured and
conducted using keywords and search filters; an
information specialist can often help guide this
process. The potentially relevant articles are then
retrieved. The third step is a critical appraisal of
the selected articles. This must be based on
structured guidelines. It can be done either by
checklist or by computer software. The appraisal
should be reviewed by a mentor with experience
in critical appraisal. The fourth step is presentation
and discussion of the findings. The presenter
should also have the chance to reflect and receive
peer appraisal. The final version of the critical
appraisal is stored for further review and updating.
3. Methodology teaching: In this type of club
one clinical study is selected and all attendees are
provided with the selected articles and a series of
stimulus questions. The questions assess the
quality of the research, the appropriateness of the
data and methods and the validity of the
conclusions. The discussion focuses on issues
raised by the stimulus questions rather than on the
clinical aspects of the paper. This type of club
requires intensive faculty involvement and rigorous
facilitation to accomplish its goal.
4. Combined problem based with methodology
teaching: The evidence based approach is used
as before. Part of the presentation time is used to
brief attendees on the research methods used in
the presented evidence. The briefing helps increase
the knowledge of all participants about the
methodology and evidence searches.
5. Alternative journal clubs: Creativity is an
additional element in these journal clubs. These
journal clubs use varied choice of media like
videos, books and storytelling. This approach
promotes group cohesion and hence is more
impactful than traditional journal clubs.

6. Innovative journal clubs: These journal
clubs utilize “adult learning theory” with its
components of adult learning principles. They
include relating the task to immediate work
experience, use of problem solving, use of multiple
teaching formats and use of frequent constructive
formats.
USEFUL RESOURCE: THE CATmaker
CAT maker software was developed at the
Centre for Evidence Based Medicine in Oxford,
UK. It has a number of important uses with
regards to the journal club. It stores the research
question and search strategies, helps frame the
question itself, and allows appraisal, both of a
working draft (‘Kitten’) and the final form. It can
carry out important clinical calculations; including
confidence intervals, likelihood ratios, odds ratios
and numbers needed to treat, and can use an
electronic nomogram to generate post-test
probabilities. It generates files which can be
formatted, saved, stored and printed using any
word processing software. It is the electronic
offspring of a paper-based system developed by
general internal medicine fellows at McMaster
University in Canada.
CATmaker is evidence and patient based. It
promotes the acquisition and polishing of literature
searching and critical appraisal skills, as well as
the integration of evidence with clinical expertise
to form patient care decisions. A feasibility study
suggested that there was a significant increase in
reading time and knowledge of critical appraisal
when CATmaker was used in the journal club.7
HOW TO START A JOURNAL CLUB
1. Select a director: A person who is interested
and has a strong conviction that the journal clubs
play a key role expanding the knowledge base of
the participants should be chosen as director
2. Define the goals: goals of a journal club can
range from keeping abreast with the expanding
medical or dental literature, teach and learn critical
evaluation skills, to adopting findings of clinical
research in regular day to day medical or dental
practice.
3. Optimize attendance: The journal club
should stick to a fixed schedule (hour, day, week,
place etc.) and a consensus should be obtained
related to convenience of schedule
86
JOURNAL OF THE INDIAN ASSOCIATION OF
PUBLIC HEALTH DENTISTRY Vol:2011 ISSUE:17
4. Generate participant interest: there should
be a constant exchange of ideas among members
and this is facilitated by a round table or a horse
shoe pattern seating arrangement. Group should
ideally consist of 10-12 members.
5. Special preparation for journal clubs with
critical appraisal techniques: For critical
appraisal journal clubs, participants should be
oriented towards analysis of articles and should
have fundamental knowledge of epidemiology and
biostatistics.2
JOURNAL CLUB SESSION
The participants should ideally be seated in a
circle of horse shoe shape which promotes eye
contact and helps better interaction within the
group. The presenter initiates and leads the
discussion while the moderator solicits comments
from the participants to stimulate discussion when
they are not forthcoming. The director directs the
whole session and breaks the impasse when
confronted by one.2
JOURNAL CLUB PRESENTATION8
A journal club can be presented with the help
of chalk and talk, overhead projectors, power point
presentations or flash presentations. Power point
presentations are most commonly used.
The presentation should include the following
slides:
1. Title and name of the presenter
2. Aims and objectives- clinical and educational
3. Case presentation
4. Clinical question- PICO (patient/ problem,
intervention, comparison and outcome)
5. Literature search- keywords, search strategy
and healthcare databases used.
6. Papers selected B state what criteria you used
in selection process
7. Flow chart of the study
8. Details of the study- analyze tables and charts
from the study and explain their significance
9. Summary and conclusion B summarize the
findings. Should current practice be changed?
Is there lack of evidence? Is it appropriate to
consider an audit or further research?

FORMAT RECOMMENDATIONS FOR A
SUCCESSFUL JOURNAL CLUB1
1. Mandatory attendance
2. Positive financial and philosophical support for
the journal club from the department, the
chair, and the program director
3. Designated, committed, experienced, and
skilled moderators (e.g., faculty supervisor)
4. Formal, consistent, and regular schedule and
location (e.g. monthly, same location, stable
attendance)
5. Regular provision of food and drink
6. Protected and convenient time (e.g., evening
journal club)
7. Structured checklist and explicitly defined
written goals
8. Limited number of articles but reviewed in
more depth and articles selected and
distributed with sufficient time (weeks) to read
completely
9. Emphasis on original research articles (e.g.,
clinical trials)
10. Inclusion of basic but formal epidemiology
and statistics and principles of evidence-based
medicine
11. Resident journal club independent of faculty
journal club
12. Incorporation of adult learning principles (e.g.,
rationale for study, self-directed learning,
application of reservoir of learner experiences,
task-centered approach, emphasis on practical
application of information, emphasize
problem-solving skills)
13. Reinforcement of critical information with
active instructional feedback
14. Active participation (rather than simply
attendance) with interactive, discussion format
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JOURNAL OF THE INDIAN ASSOCIATION OF
PUBLIC HEALTH DENTISTRY Vol:2011 ISSUE:17
(e.g., exchange of ideas on controversial
topics)
15. Written documentation of participation and
completion of checklist
CONCLUSION
Journal clubs can be used as a powerful tool
for promoting scientific temperament, questioning
attitude and for facilitating acquisition of new
skills. It enables critical thinking which is the need
of the hour to promote evidence based medicine
and dentistry. A journal club is an integral part of
doctors continuing medical education and an
important step towards truly evidence based
practice.
REFERENCES
1. Andrew, G. L., H. C. Boldt, et al. (2005). “Using the
Journal Club to Teach and Assess Competence in
Practice-based Learning and Improvement: A
Literature Review and Recommendation for
Implementation.” Survey of ophthalmology 50(6):
542-548.
2. Nagesh L. A handbook on journal club and critical
evaluation. Swapra Jyothi Publications.1-9.
3. David Sharp.” Formal Structure Of Scientific Journals
And Types Of Scientific Papers.@ Treballs de la
SCB. Vol. 51 (2001) 109-117
4. Milbrandt, E. and J.-L. Vincent (2004).
“Evidence-based medicine journal club.” Critical Care
8(6): 401 - 402
5. Paget S: Memoirs and Letter of Sir James Paget.
London: Longmans,Green, and Co., 1901:42.
6. Forsen JW Jr, Hartman JM, Neely JG: Tutorials in
clinical research, part VIII: creating a journal club.
Laryngoscope 2003, 113:475-483.
7. Afifi, Y., J. Davis, et al. (2006). “The journal club:
a modern model for better service and training.” The
Obstetrician and Gynaecologist 8(3): 186-189.
8. www.heftlibrary.nhs.uk/Images2/Journal%20Club%
20 Guidelines. PDF.Heft library service. Journal Club
Guidelines (2009).accessed on 31.01.2011, 12.06 p.m
 JOURNAL OF THE INDIAN ASSOCIATION OF
PUBLIC HEALTH DENTISTRY Vol:2011 ISSUE:17

Journal Club - Feedback Form

APPENDIX 1

Name of presenter: ..................................................................................................................................................

Date of presenter:......................................................................................................................................................

Name of Chair: ........................................................................................................................................................

Clinical Question/Topic: ...........................................................................................................................................

Study selected: .........................................................................................................................................................

1. Were the following slides included in the presentation?

A clear well-formulated question
Aims and objectives
A case report/context of the question
Literature search (databases/PICO/search terms)
Bibliographic details of the article selected
A flow chart of the study/details of the study
Appraisal of the study using CASP tool
A summary/conclusion
2. How do you rate the presentation on a scale of 1 to 5 (1 = str ongly disagr ee 2 = disagr ee 3 = neutr al
4 = agr ee 5 = str ongly agr ee)

Clearcommunication 1 2 3 4 5

Good use of media 1 2 3 4 5

Interactive 1 2 3 4 5

A positive response to comment/criticism 1 2 3 4 5

3. Did the presenter put enough time and effort into the presentation as a whole? On a scale of 1 to 5
(1 = str ongly disagr ee 2 = disagr ee 3 = neutr al 4 = agr ee 5 = str ongly agr ee)

1 2 3 4 5

4. Did the presenter generally demonstrate good understanding of the topic presented? On a scale of 1
to 5 (1 = str ongly disagr ee 2 = disagr ee 3 = neutr al 4 = agr ee 5 = str ongly agr ee)

1 2 3 4 5

Comments

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