In the world of the blogosphere I sometimes wonder whether the concept of Journal Clubs is a bit risky. There is much talk out there at the moment about how useless journals are and how their days are numbered. If you don’t believe the concerns then hop over to the Guardian and have a wander through their excellent series on scientific publication, or even better read Richard Smith’s book on the trouble with medical journals for an insiders account of what’s gone wrong.
Anyway, we should not confuse the terminal diagnosis for medical journals from the need to ensure that critical appraisal is done well. Arguably the demise of journals means that the ability to critically appraise is even more essential as a core skill for emergency physicians. At least the journals tried to peer review and quality control what was published….in the blogosphere you can publish pretty much anything. In the world of the internet it is reader beware, or rather it should be reader ‘prepare’.
We’ve published a fair bit on critical appraisal in the past and of course we hacve both the bestbets site and our MSc in Emerg Med which contain modules on how to read the literature, but there is also a place for the practical tips of how top set up and run a JC for the ED.
So, how do we prepare and practice our abilities to seek, sift, appraise and share the evidence that is out there? We call it a journal club which seems a little historical, but we are British and we have a history so we like it. So this is what we would recommend for a successful journal club.
- 1. Great leadership. You need someone who is really motivated, enthusiastic and talented to keep the energy and enthusiasm in your JC. It does not have to be a senior doc (but it helps – see 3. below, though I should mention @thegreathornero for doing a fab job recently). There is admin involved in a good JC, from keeping the rota up to date, to explaining to new members of staff what it’s about, to helping people when they first present, to finding papers, to emailing them out, to photocopying…..the list goes on. It’s easy to be enthusiastic for a few weeks but can you maintain it? Do you need a helper? Do have a succession strategy for when you get bored of organising it (Emergency physicians are not noted for their long term engagement with anything!).
- 2. Link to clinical practice. What’s the point of a journal club if it does not change practice on the shop floor. An hour spent discussing things that are irrelevant to you is a waste of your valuable time. Make sure that there is a link between what you discuss and what you will then do. Think about how you disseminate what you find. Maybe you should start a blog (like this one) or use your JC to formulate new protocols. We use BestBets of course which links in perfectly with the Journal Club and also leads on to the CTRs (clinical topic reviews) needed for FCEM.
- 3. Senior ‘buy in’. Like it or not you need your senior clinicians to be engaged in the journal club. If they are not there, if they don’t read the papers and if they are not helping the group learn through critical appraisal then it will be difficult to achieve point 2 – the link to clinical practice. Ask them (and yourself) whether they are evidence based emergency physicians? If they are not coming to JC then how are they keeping up to date?
- 4. Structure. Some JCs are anything goes affairs, but that’s not helpful when you have a group of clinicians who change through rotation, nights, holidays etc. Some form of structure is helpful (particularly for newcomers) to orientate them to how the JC works and to help them when it is their turn to present. We think the following are essential structural foundations for your JC.
- 5. Teaching and learning for everyone. If you are reading this then you are probably the nerdy geek kid who loves IT, reading journals and generally sounding cleverer than your friends. Well that’s great. here you are in great company, but……my friend, you may be the exception and not the rule. Do not assume that all your colleagues (young and old) will share the delight of discussing the differential benefits of minimisation vs stratification in RCTs (arguably a poor example as a fascinating topic – Ed). There will be a range of abilities, enthusiasm and engagement and you just have to manage this. Teach, question and do your best to enthuse your colleagues about reading papers. Give top tips, direct to helpful websites, lend books, basically whatever it takes to support all people who have taken the time to come.
- Share. Now this is a new one as in the past we were fixed to a weekly slot for journal club. If you were there then fantastic, if not then you missed out. You need some mechanism to share the learning for those people on nights, holiday or just seeing the patients who are still in the ED! We started off sharing by email, then by a private discussion board and now we are sharing on this blog and through our Twitter feeds. Find something that works for you but remember that in a 24/7 speciality we need to engage everyone in the process.
So, those are overarching principles for a sustainable, accessible and friendly JC. We hope that you share them, but what about the practicalities? What are you going to discuss and how?
Let’s start with how. You can, and I’ve seen it done, just chat about a paper in a fairly unstructured way. This can work amongst experienced readers but it’s not so good in a mixed group and is not the best way to help people learn. We strongly advocate the use of checklists for critical appraisal and (no surprise) we use the BestBets ones we designed.
What then to discuss? The only key message here is that papers at JC should meet three criteria. They must be A – interesting AND, B – of decent quality AND, C- of relevance to practice. Life is too short and too busy to read uninteresting, irrelevant rubbish. Again there are options and these can broadly be described as either reactive or proactive.
- Reactive. Papers are selected by the presenter on the basis of what is hot/topical/of interest/exciting. This has some advantages as it means that the presenter will be keen and motivated and the relevance question is almost always answered. The downside is that it can end up with a JC that is themed around your comfort zones. It’s a bit like practicing a musical instrument – if you only the practice the elements of a piece of music you know then you don’t really get any better overall. It’s the same with EBM. I know quite a lot already about X already so I need JC to make me look at Y as well.
- Proactive. The second approach is to use JC as a collective way to scan, review and share papers from a range of journals and sources. In this model there is a plan that allocates a journal and a presenter to each week’s slot. The presenter is responsible for scanning the last x month’s worth of issues of that journal to look for something interesting, relevant and of decent quality. The advantage here is that collectively the group effectively looks at every EM journal every year. Try doing that on your own (Cliff Reid is the only man I know can do this and he is superhuman). The downside is that when it is your turn to present you might get a topic you’re not interested in.
So, ultimately you need to find your own way, your own system and your own structure, but should you wish to copy any of our ideas having run a successful journal club for over 10 years then please go right ahead.
Here is a typical list of journals together with their sample frequency.
|Emergency Medicine Journal (EMJ)||6|
|Academic Emergency Medicine||4|
|American Journal of Emergency Medicine||4|
|Annals of Emergency Medicine||4|
|Archives of diseases in childhood / Pediatric Emergency Care||3|
|New England Journal of Medicine||3|
|Journal of Trauma and Critical Care||2|
|European Journal of Emergency Medicine||2|
|Hong Kong J Emergency MedicineJournal of Emergency Nursing||1|
|Canadian Journal of Emergency Medicine||1|
|AnaesthesiaBritish Journal of AnaesthesiaCritical Care Medicine
Intensive Care Medicine
|Total||48 (approx 4 lost to holidays/year)|