Welcome back to our discussion about residency education methods. Last week, we discussed some of the philosophy of resident education, where I called for a consensus statement on best residency educational practices. By the way, as you may know, the Council on Podiatric Medical Education (CPME) is currently working on a revision to the 320 document that instructs residency programs on accreditation and “rules of the road.” I truly hope they also add instruction on best teaching methods to help all of us teach our residents more effectively. Keep in mind, though, that a rewrite of the magnitude of the 320 document is a big job by itself, and changes like what I’m suggesting often take a long time to adopt and implement.

In today’s Practice Perfect, let’s delve a little deeper into a didactic aspect of residency training, the use of the journal club. Are there “best” characteristics of journal clubs? Should our reviews contain certain content, and should these sessions be done in particular ways to maximize resident learning?

The first question we need to ask is, “Should the journal club be a mandatory part of residency education?” We are so used to having journal clubs that it seems odd to ask if we should even be doing them. Journal clubs are generally used as a means to teach critical appraisal of the research evidence (determining study validity and application to patients). Other skills that can also be taught are creating appropriate clinical questions and searching online databases for journal articles. Fundamentally, we need to determine if the way we currently run journal clubs are providing these skills in the most effective manner.

It turns out there’s very little research that demonstrates the effectiveness of journal clubs to teach residents these skills. Most of the research consists of surveys sent out to the residency community in question, determining which aspects of the journal club are considered most beneficial (usually defined based on what program directors and residents like – not translation into improved patient care). Virtually every systematic review on this topic calls for appropriately designed experimental studies to find the best evidence.

An example would be a prospective, randomized study comparing, say, a one-hour lecture versus a one-hour journal club. The primary outcome might be scores on a recall examination of specific critical analysis skills. This exam could be given immediately (to test short term recall success) and another test maybe one month later (testing longer term retention). The optimal outcome in a perfect world would be to see if patient outcomes improved. However, this measure is so difficult to study and so full of lurking variables that I don’t see the practicality in the real world. We’ll have to stay with surrogate markers for now.

With that said, Deenadayalan and colleagues performed a systematic review of this topic. They found over 80% of studies reported journal clubs were effective in improving knowledge and clinical appraisal skills¹. Similarly, Ebbert, et al found journal clubs “may improve knowledge of clinical epidemiology and biostatics, reading habits, and the use of medical literature in practice”². It must be emphasized that the vast majority of studies used subjective evaluation methods such as residency directors’ satisfaction as outcomes for effectiveness. As mentioned above, it is difficult for us to know from the current research evidence if journal clubs truly lead to improved knowledge of providers or improved patient outcomes.

Since journal clubs appear to have some educational value, the next important question is, What is the best method to deliver a high quality journal club? By “high quality”, I mean a journal club that most effectively teaches what it means to teach, leaving its attendees with improved knowledge and skills.

The research evidence consists primarily of surveys and experimental studies of variable methodological quality, so our level of evidence isn’t the highest. However, given the common outcomes among studies, we can extrapolate some recommendations.

Successful journal clubs displayed the following characteristics:^1,3,4,5

I’d also like to point out a separate research study on this topic in the podiatric education field by So, Hyer, and colleagues,⁶ which is the only study to specifically examine the podiatric journal club. This group sent out a survey to 202 residency programs and received a 47.5% response rate. They found the factors associated with successful journal clubs were: high faculty attendance, distributing articles in advance, and regularly scheduled meetings. Consistent with the nonpodiatric medical education research, this survey found implementing a “structured review instrument” was an area of potential improvement.

I’d like to end this discussion with a novel journal club idea that I came across during my research: the flipped journal club. Bounds and Boone reported on this new emergency medicine resident journal club method,⁷ which was the following. Prior to the journal club the program director and chief resident selected an important controversial clinical topic and found a landmark article on this topic. Additionally, a background recent article and a social media piece (blog or podcast) were chosen for review prior to the journal club session. Summaries of the content and discussion points were determined prior to the journal club session. During the actual session, residents were divided into groups with mixed levels of experience with each having a faculty facilitator who asked questions and provided oversight. Upon receiving a survey after the session, 95% of the residents and 100% of faculty preferred this format.

Although I don’t think the multiple small groups with multiple faculty facilitators is realistic for most podiatric residencies, I did appreciate the use of social media as part of the club. For those of you interested in trying this out, you might consider the ACFAS eLearning podcast or any of a number of online education methods such as PRESENT Podiatry’s online lectures. Clearly there are lots of good ways to go about having successful journal clubs.

Certainly, the journal club is well ensconced in training of virtually all types and levels of medical education. The one firm statement we can make is that, as in all resident education, it takes effort to create a quality experience.