Journal Club- The UAB Experience

Just about every internal medicine residency program has a journal club.  One could argue about the evidence behind this activity but it seems to serve its purpose if nothing else than to make housestaff read some journal articles (and not just UpToDate!). I think it does serve a purpose of encouraging critical appraisal/thinking about research publications. Doctors will always have to read new research studies. It takes time for studies to be incorporated into secondary publications like Dynamed and UpToDate. Furthermore, not everything makes it into these evidence-based resources.  Also research (published in every journal) is full of biases that lead to departure of the findings from the truth. Critical appraisal is the only way to detect them.

journal club

This is not our flier but one I found on the internet that I thought was interesting

Since 1999 or so I have been intimately involved in the journal club at UAB. At times I have run it completely but now I serve more as a guide and EBM expert for one of the chief residents who puts it all together. I think it has gotten greater buy-in from the housestaff coming from the CMR instead of me.

So I thought I would cover some of what we have done at UAB. Not that we are the world’s beacon for journal club but we have tried alot of stuff over the years. Some of it failed….some of it successful.

Time of day: we have done everything from 8am, noon, to at night at a faculty member’s house. What has gotten the best turnout is 8am before their day gets started.

Article Selection: This has been a debatable topic since day 1. We have done several things:
1) Latest articles in major journals
2) Rotating subspecialty articles (one month cardiology, one month GI, etc)
3) Article chosen by resident based on problems they saw during patient care
4) Article chosen by me to prove an EBM principle
5) Now we seem to be focusing on articles written by UAB faculty so that they can come as an expert guest.
6) We are considering using classics in medicine articles that are the foundation of what we do (eg first article on ACE inhibitors in CHF) because current residents are unlikely to ever read these articles.

Format: We seem to vary this almost yearly:
1) Faculty reviews article and asks questions of the housestaff about what various things mean
2) Teams of residents argue for or against using a drug, etc against another team of residents
3) Each individual reads the article and comes to JC not knowing what they could potentially be asked
4) A handout with Users Guides questions and a few other questions on design or applying the information is given out ahead of time but is only discussed by those willing to answer
5) Same handout given but with individual residents assigned specific questions to answer (this was the first time we could show that the residents actually read the paper ahead of time)
6) Groups of residents work on questions outside of JC on their own time (usually 3rd yr resident assigned to coordinate the group meeting) with the expectation to teach the other groups at JC. (this worked pretty good actually)
7) Last year we went to a flipped learning format where I put alot of material on that the residents were to do ahead of time (if they needed to) with assigned questions to be answered by individual residents. They felt like this was too much work to go thru all the material online.
8) This year we are to perhaps our most successful format (from resident satisfaction standpoint) where a handout of questions is answered in JC as a group project. A faculty expert gives a very short didactic talk at 2 points during JC on a very specific EBM topic related to the article (eg what is a likelihood ratio). The only expectation is that the article is read prior to JC. We still use somewhat of a flipped format where I reference a short video or 2 to watch about topics in the chosen article but its much less time intensive than last year.

I think overall what has been successful for us is when JC has the following elements:
1) Group work. Engaged learning is always desirable.
2) Clinical and EBM faculty expert present. Seems to give the article a little more value.
3) Case-based. We always solve a real world problem. I always tell the CMR making up JC to make sure the residents walk away with something they can use clinically.
4) Flipped light– giving the residents some information, but not too much, that they can review about EBM principles leads to many of them actually watching the videos or reading background papers. They come much more prepared and have a good basic knowledge that we can then build upon.

Vertical Reading Is Not Just For Clinical Reasoning

Recently I got interesting in more formalized teaching of clinical reasoning. I am currently enrolled in a Coursera ( course on clinical reasoning. My reason for taking this MOOC is that I wanted to see how others teach this material so that I could improve my teaching. A great revelation I had while reading Judith Bowen’s now classic NEJM article () and which was reenforced in the Coursera course was vertical reading. The way I summarize this is that we recognize diseases best, not by their similarities, but by their differences. With vertical reading you compare 2 or more diseases by filing out a table with epidemiology, pathophysiology, signs, symptoms, testing, etc. Instead of reading about 1 disease at a time and filling in the table horizontally you fill in the table vertically and read about each component of the table for both diseases at the same time.

The reason I bring this topic up is that I am doing journal club next week and I have asked the residents to read 2 articles on seemingly the same topic. There are nuances that make the articles different but if you read them individually and separately you likely wouldn’t pick up on these nuances. Thus, the vertical reading. I gave the residents a table to fill out comparing the 2 articles. They will read them both at the same time comparing the articles on each of the elements of the table;moving vertically down the table. They should be able to detect the nuances of each article. We will see.