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Jarrod Shapiro, DPM
Practice Perfect Editor
Assistant Professor,
Dept. of Podiatric Medicine,
Surgery & Biomechanics
College of Podiatric Medicine
Western University of
Health Sciences,
St. Pomona, CA |
Who has time today to read journals? We have busy schedules. We work long hours and have little enough time to see our families, much less read a journal article.
Yet we physicians are supposed to be lifelong learners, part of which is staying current with the literature. I'll avoid the subject of how much reading a practicing podiatric physician should do. Instead, I'll answer my original question: who has time today to read journals?
The answer, of course, is residents.
A fundamental academic activity for the vast majority of residency programs, podiatric or otherwise, is the journal club. The journal club has been in existence for quite some time, the earliest mention of it in North American medical history dating back to 1875, when Doctor William Osler was working at McGill University in Montreal, Canada1 (before he revolutionized the American medical education system). However, the journal club's existence likely dates back yet further with a possible  origin in Germany (at the time, the world powerhouse of medicine). Even as early as 1835 in London, Sir James Paget (of Paget's disease fame and one of the founders of pathology as a science) described some of his students having met regularly in a room over a baker's shop to read journals and play cards.1 It appears the original journal clubs used the medical literature as a sort of doorway leading to a discussion of general medical issues.
Clearly, with the advent of the science of statistics and the application of the randomized controlled trial to medicine around the 1940's, medical literature has changed significantly. Add to that the evidence-based medicine movement, and today we have a journal club that would likely not be recognizable to Dr. Paget's students...
Or would it?
In my personal experience journal clubs in the allopathic and osteopathic realms have always been highly systematic and analytical. But in podiatric medicine, I've either personally experienced or heard from various students and residents that our journal clubs tend to be along the same lines as the clubs from 100 years ago. That is, a broad, noncritical review of the literature with a focus on individual experience. Is this where our journal clubs should be?
Its one thing to criticize our podiatric literature, which I have done previously (we have too many low level retrospective case studies), but what about our residency journal clubs?
I've seen too many discussions about the literature in which the discussion is simply a summarization of the article – a book report – that then devolves into a "this works in my hands" conversation. Where is the analysis? Do we just implicitly believe everything that's written as valid because it was published in one of our journals? Just because something is written on paper doesn't mean it's valid. Yet, that's the direction too many of our journal club discussions seem to point. If your residency journal club simply does a summary of a number of journal articles, then you're doing it wrong.
A Better Way
"Ok, smarty pants," you say. "If you're so high and mighty with your journal club, then what's the correct way?" Funny you should ask. There is, in fact, a better way. Here are some suggestions to help.
First, plan some extra time at first. Schedule a two hour period at least once per month if not more often at first. As your group becomes more comfortable with critical analysis, you'll eventually be able to get through the articles more quickly.
Second, analyze no more than 2 articles at a time.
Third, if you have access to a biostatistician or someone with solid research experience, then have them join you. They'll be invaluable since most of us (myself included) do not have statistics and research training.
Fourth, eliminate the summary and replace it with analysis. If everyone in the club has read the articles beforehand then they should all know what it says. Why tell me that there were 56 patients in X study when I already read it? Redundancy is a waste of time. We don't want a book report; we want analysis. Instead you might discuss the significance of a study group size of 56 patients, and if that strengthens or weakens the particular study.
Fifth, use a systematic approach to your analysis. This one's up to you, and there are many methods available. For example, the Center for Evidence Based Medicine (CEBM) has free resources to download. Also, an excellent series of articles was published in the Journal of the American Medical Association, titled Users Guides to the Medical Literature, which is highly useful and relatively interesting to read, with a clear and easy method applicable to clinical situations.2 At Western University, we use a highly detailed method for critical analysis created by one of my partners, Jacqueline Truong, DPM, MPH, one the most knowledgeable people I've met when it comes to this subject. Click here for a copy. Not everyone can work with this method (it's highly detail oriented), but it might provide some ideas to help get you started.
Sixth, consider choosing topics that relate to patient questions that have arisen over the course of the month. What questions have been generated by your students and residents? How did they pick the best evidence to answer their questions? A common method to generate clinical questions is the PICO method (Patient, Intervention, Comparison treatment, Outcomes). Say, for example, you've been seeing a patient with adult acquired flatfoot, and you're planning surgery. Which is the best procedure? Using the PICO method, you might phrase your search question as follows: In patients with adult acquired flatfoot (Patient), is a medial displacement calcaneal osteotomy (Intervention) superior to the Evan's procedure(Comparison Treatment) in reducing pain(Patient)? Your residents would then use this question to search for appropriate articles. By making the discussion patient-centered, the conversation will be both more interesting and more applicable to the real world.
At your next journal club, do your own little experiment. Have one resident present the old-fashioned way with the summary. Have your discussion, and then have a different resident present the next article using whatever standardized analytical method you like. See which one leads to the best result. Try my "better way" and see how it goes. Good luck with your next journal club.
Best wishes.
Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]
References:
- Linzer M. The journal club and medical education: over one hundred years of unrecorded history. Postgraduate Medical Journal 1987; 63: 475-478.
- Oxman A, et al. Users Guides to the Medical Literature: I. How to Get Started. JAMA Nov 1993; 270(17): 2093-2095.
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