Electronic journal clubs for capacity building: A case study in psychiatry as a model for medical disciplines in developing countries

Electronic journal clubs for capacity building: A case study in psychiatry as a model for medical disciplines in developing countries

Accepted Manuscript Title: Electronic journal clubs for capacity building: A case study in psychiatry as a model for medical disciplines in developing...

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Accepted Manuscript Title: Electronic journal clubs for capacity building: A case study in psychiatry as a model for medical disciplines in developing countries Authors: Abha Thakurdesai, Abhishek Ghosh, Vikas Menon, Swapnajeet Sahoo, Adarsh Tripathi, Devavrat Harshe, Chittaranjan Andrade PII: DOI: Reference:

S1876-2018(18)30213-2 https://doi.org/10.1016/j.ajp.2018.04.026 AJP 1421

To appear in: Received date: Revised date: Accepted date:

5-3-2018 11-4-2018 12-4-2018

Please cite this article as: Thakurdesai A, Ghosh A, Menon V, Sahoo S, Tripathi A, Harshe D, Andrade C, Electronic journal clubs for capacity building: A case study in psychiatry as a model for medical disciplines in developing countries, Asian Journal of Psychiatry (2010), https://doi.org/10.1016/j.ajp.2018.04.026 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

ELECTRONIC JOURNAL CLUBS FOR CAPACITY BUILDING: A CASE STUDY IN PSYCHIATRY AS A MODEL FOR MEDICAL DISCIPLINES IN DEVELOPING COUNTRIES

Abha Thakurdesai, MD Assistant Professor, Department of Psychiatry, Lokmanya Tilak Municipal Medical College and General Hospital, Sion, Mumbai-400022, India. Email: [email protected] Phone: 91-9892152110

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Abhishek Ghosh, MD, DM (Addiction Psychiatry) Assistant Professor, Department of Psychiatry Postgraduate Institute of Medical Education & Research Chandigarh 160012, India Email: [email protected] Phone: 91-9815890436

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Running title: Electronic journal clubs for capacity building

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Vikas Menon, MD Associate Professor, Department of Psychiatry Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER) Puducherry-605006, India Email: [email protected] Phone: 91-9894410296

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Swapnajeet Sahoo, MD Senior Resident, Department of Psychiatry Postgraduate Institute of Medical Education & Research Chandigarh 160012, India Email: [email protected] Phone: 91-8872727744

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Adarsh Tripathi, MD Associate Professor, Department of Psychiatry King George's Medical University, Chowk, Lucknow 226003, India Email: [email protected] Phone: 91-9651970700 Devavrat Harshe, MD Assistant Professor, Department Of Psychiatry Dr D Y Patil Medical College Kolhapur 416006 , India Email: [email protected] Phone: 91-9167577279 *Chittaranjan Andrade, MD

Dean (Basic Sciences) Professor and Head, Department of Psychopharmacology National Institute of Mental Health and Neurosciences Bangalore 560 029, India Email: [email protected] Phone: 91-9880150971 *Correspondence

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Funding: This work was unfunded.

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Conflicts Dr Andrade is the owner and moderator of eJCIndia.The authors are all active members of eJCIndia and have no conflicts to declare with regard to the contents of the manuscript.

HIGHLIGHTS Electronic journal clubs provide a platform through internet groups for members to participate in and review journal club activities as well as journal archives in their free time. In this way, eJCs are superior to conventional journal clubs that require physical presence of the members.



We describe eJCIndia, an eJC that has been in existence for the past 3 years. eJCIndia was launched for capacity building in academic and research competence in psychiatry in India.



eJC has conducted an average of a hundred or so activities per year. These activities deal with diverse matters related to academics, critical review of journal articles, statistics and research methods, development of writing skills, and others. Participation from members has been good. About 20 articles have been published through eJCIndia collaborations, arising from eJCIndia activities.



The eJCIndia model can be replicated across medical disciplines in India and elsewhere. It may be the most efficient means for manpower development and capacity building in academic and research competence, given the inequitable geographical distribution of academic expertise in developing countries.

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ABSTRACT

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Background Journal clubs (JCs) teach participants how to critically read and assimilate materials published in journals. Electronic JCs (eJCs) provide a similar platform through internet groups, allowing members to participate in and review JC activities as well as JC archives in their free time.

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Methods We describe the operations and the successes of eJCIndia, to our knowledge the first eJC in India in the field of mental health. eJCIndia was started for capacity building in teaching and research competence in the field.

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Results eJC India, with >400 members comprising academic psychiatrists and postgraduate students, is now 3 years old. eJCIndia conducts about a hundred activities a year; there is active participation from the membership. Activities include posting of educational materials of interest to the group; seeking and receiving guidance on academic and practical matters of interest to the group; providing and receiving training on how to review research manuscripts submitted to journals for consideration for publication; learning how to critically review published journal articles for strengths, limitations, and applications; and learning how to design studies, analyze data, and prepare manuscripts for publication. The activities of eJCIndia have resulted in the publication of about 20 articles and in the development of several research collaborations, including one multicenter study. Conclusions

The eJCIndia model can be replicated across medical disciplines in India and elsewhere. It may be the most efficient means for manpower development and capacity building in academic and research competence, given the inequitable geographical distribution of academic expertise in developing countries.

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Key words Journal club Capacity building Statistics Research methods Psychiatry India

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Introduction In 1987, Linzer defined the now familiar term, Journal Club (JC), as a forum in which “a group of individuals meet regularly to discuss critically the clinical applicability of articles in the current medical journals (Linzer, 1987).” JCs can be traced back for at least a hundred years, when Sir William Osler was said to conduct meetings in Montreal for the purchase and distribution of periodicals to which he could ill afford to subscribe as an individual. This history has been contested and it is conjectured that Osler borrowed the concept from Germany, which was ‘the international medical leader’ at that point in time (Topf et al, 2017). It is perhaps impossible to now determine the right version of history.

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Journal clubs Regardless of origin, all journal clubs had and continue to have largely common aims (Box 1). Today, JCs are especially important because of the emphasis on the practice of evidencebased medicine; so, not just academicians but medical professionals in practice also need to have the ability to critically read journal articles and derive take-home messages therefrom. JCs, by conducting guided discussions of newly published literature, can help academicians and practitioners develop these skills as well as update themselves academically.

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In conventional JCs, medical professionals belonging to a single speciality meet at a specific time in a physical room, mostly in the academic workplace, and learning takes place through presentations and discussions (Ranmuthugala et al, 2017). In this kind of scenario, interested participants may miss sessions due to competing clinical duties or clinical rotations. A resident who is post-call may be too tired to participate meaningfully. Additionally, because such JCs are usually conducted in academic institutes, practitioners who do not work in these settings will miss the discussions. Thus, there are many barriers to the dissemination of knowledge associated with conventional JCs (Hammond and Whalen, 2006; Kuppersmith et al, 1997).

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An additional issue of concern for conventional JCs in India (and potentially other developing countries, as well) is that many medical colleges and hospitals have faculty who are competent in clinical knowledge and skills but lack the ability to critically read journal articles and thereby conduct good journal clubs. Complicating this is the shortage of medical colleges that can provide training that is sufficiently good to foster research competence; this is also an objective of a JC.

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A final limitation of conventional JCs is that discussions that take place are seldom recorded. Thus, there is no archive that can be referred to later by new participants, or participants who missed the session due to competing duties.

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Electronic Journal Clubs To circumvent the drawbacks of conventional JCs, online JCs began to surface in the late 1990s (Kuppersmith et al, 1997). Online JCs address closed communities through email lists. Additionally, with the proliferation of social media, the Twitter JC (#twitjc, @TwitJournalClub) has also come to the fore. Online JCs are not limited by barriers of time and space. Members can access the content and participate in the discussion at their own convenience and from any part of the world. In electronic journal clubs (eJCs), all questions can be asked and answered, all comments can be posted, and all clinical and research issues can be examined threadbare. This is because there

are no limitations of time. Any number of members from academic as well as non-academic settings can participate. Senior members with greater experience and expertise, who may work at academic institutes, can mentor junior members, such as postgraduate trainees, in faraway institutions. As the discussions remain on the eJC website for an indefinite period of time, they can be referred to as and when desired.

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Understanding electronic journal clubs using a case study : eJCIndia eJCIndia is an example of an online JC which operates through a closed email community. The membership is predominantly comprised of psychiatrists. eJCIndia was launched on 9th March, 2015, in order to create an internet-based learning platform that would help in developing academic and research competence in India in the field of mental health and the allied neurosciences. Whereas eJCIndia was started by the Task Force of the Indian Psychiatric Society on Psychopharmacology, along with the Task Force of the Indian Psychiatric Society on Workshops and Training, and with the support of the Department of Psychopharmacology at the National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, India (Rao and Andrade, 2015), it is presently operated and moderated only by the Department of Psychopharmacology, NIMHANS.

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As with traditional JCs and eJCs, eJCIndia provides an e-platform for discussing and imparting training in academic and research-related issues. It aims to develop member skills in critically reading a research paper, to clarify issues related to research methodology (ranging from study design through choice of appropriate research instruments for use in specific contexts to methods of statistical analysis of data) and to improve member skills in scientific writing. The most important mission of eJCIndia is to train trainees and their trainers; that is, to strengthen academic and research capacities in departments of psychiatry across the country so that future generations are benefited. Instructions provided to eJCIndia members at the time of joining, and periodically, as reminders to the group, are presented in Box 2.

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eJCIndia: Members and their contributions No strictures are placed on applications for and approval of eJCIndia memberships. eJCIndia currently has 426 members (as on April 08, 2018), almost all of whom are based in India, and almost all of whom belong to the field of psychiatry. Most of the members are postgraduate students, some are recently graduated psychiatrists, and a sizeable number are psychiatrists who are academic faculty in teaching institutions. eJCIndia has only a small representation from among psychiatrists who are solely in practice.

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The representation of members in eJCIndia is diverse in terms of age, gender, years of experience, areas of interest, and geographical locations. The senior members of the group, usually the moderator, from the Department of Psychopharmacology, NIMHANS, periodically initiate and moderate discussions (described as ‘Activities’); sometimes, discussions are also initiated by junior members. Members participate in or merely follow the activities and discussions at their own convenience. About 1-3 activities are conducted each week. eJCIndia: Educational alerts as spontaneous activities There are many posts to eJCIndia that require no discussion. Examples of such posts include links to important, recently-published articles; links to important websites (such as a website that teaches visitors how to read magnetic resonance imaging scans, or websites for online data analysis); a link to a tutorial on how to efficiently use PubMed to search the medical

research literature; or even merely an article on how to do a Boolean search for online resource materials. The purpose of such posts is to improve the general knowledge base of the members of the group, to improve knowledge about the availability of online resources, and to improve specific academic skills.

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eJC India: Questions and discussions as spontaneous activities eJCIndia members are encouraged to ask questions and seek clarifications about doubts that they may have on any matter that lies within the purview of the group (Box 2). Common themes relate to instruments that may be used for a particular research purpose and methods that may be used to analyze data that have been collected. Other discussions include, for example, matters related to publication ethics as well as practical problems that members face in their research and manuscript submission experiences. Several psychiatrists who work in academic setups and who conduct research use this forum to clarify dilemmas on matters such as the best instrument for the study of a particular variable or the best statistical test in a given scenario. The solutions offered lead to an improvement in the quality of studies designed and papers written by members. Thus, ideas can be shared and expanded upon with knowledge pooling by members who have expertise in different fields of psychiatry.

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Sometimes, a random query can trigger a discussion with many offshoots, and may culminate in something transformative. For instance, a query on the right choice of instrument to measure stress in individuals led to a wide-ranging discussion on the pros and cons of the different instruments available, and eventually in the initiation of a multicenter collaborative study.

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eJC India: Reviewer training as a planned activity As part of capacity building, it is important for psychiatrists in academia to learn how to review manuscripts that are submitted to journals for consideration for publication. Such learning empowers participants to more efficiently deliver reviewer services to the scientific community as well as helps them understand how reviewers perceive research that they may conduct and manuscripts that they may submit. Thus, practical experience is provided on matters regarding designing and conducting studies, analyzing data, and preparing manuscripts for publication.

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Because the review of manuscripts is a confidential assignment, reviewer training activities are conducted as a very small group activity limited to a maximum of 2-3 eJCIndia member participants who are interested and competent in the field of the manuscript. Senior members in eJCIndia who receive manuscripts for review invite interested members in the group through a general announcement, and further activity takes place in small, completely private email exchanges amongst the participants. Essentially, after the confidentiality of the exercise is stressed, the manuscript is circulated amongst the 2-3 selected participants, they submit their reviews, their submissions are discussed, and the moderator of the activity provides final clarifications as well as his/her own review that will be submitted at the journal website. Thus, in an internship-like process, the trainee reviewers gain valuable hands-on experience on manuscript review processes from the time of receipt of the manuscript to the preparation of the review in a journal-ready format. Reviewers commonly take assistance from colleagues for aspects of manuscripts that lie outside their sphere of competence, and the small group discussion that takes place actually results in an improved quality of review, so, whereas we accept that this could be a gray area, we think that it is reasonable to consider that reviewing ethics have not been breached even

though formal permission from journal editors has not been taken for such a collaborative review.

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eJCIndia: Journal article discussions as the most frequent planned activity There is an extraordinarily large number of print and open access journals in medicine, in medical specialties, and in medical subspecialties. A psychiatrist would be expected to keep in touch with developments in medicine, in general. S/he would be expected to read journals in general psychiatry; in psychiatric subspecialties such as schizophrenia, mood disorders, and psychosomatic medicine; and in treatments such as psychopharmacology and brain stimulation. There are hundreds of journals, several dozens of which are important to the field. It is impossible to keep abreast of current medical literature and to understand critical developments in the field without the help of journal clubs that bring articles to the attention of members and teach members how to critically evaluate the content of these articles.

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Journal article discussions are the primary focus of eJCIndia. Activities are initiated by a senior member of the group and start with the posting of the article that is to be discussed. Specific questions are proposed by the member initiating the activity. These questions are constructed so as to help members view the article from a critical perspective. Often, the questions point members’ attention towards the identification of shortcomings in the study methods or the data analysis or the interpretation of the findings. Members are invited to respond to the questions. The questions may sometimes be narrow, inviting members to view a table or figure and identify a flaw therein. The activities do not focus on small imperfections or trivia; rather, they deal with what, in eJCIndia parlance, are described as elephants. Elephants are substantial errors that were not spotted during the review process.

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Involvement in elephant-identification activities is enthusiastic, with junior as well as senior members of eJCIndia participating in the discussions. The elephant is often but not always spotted; the moderator provides clues or, after a reasonable period of time, such as 2 days, provides the answer.

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These activities can be basic and are addressed, for example, to first-year postgraduate students, or may be advanced and are addressed to senior members in the group. Because the activities identify serious flaws in very recently published literature, members of eJCIndia who identified or came close to identifying the flaws are encouraged to prepare a letter or commentary that is then submitted to the journal that published the paper under discussion. Impressively, such activities have led to the preparation of about 20 articles in 3 years, almost all of which have been published or accepted for publication.

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eJCIndia: Training in manuscript preparation as an evolved activity Once an elephant has been identified, as discussed in the previous section, the moderator invites 4-5 members who contributed meaningfully to its identification to prepare a manuscript for submission to the journal that published the paper containing the elephant. One member, usually a junior member, is assigned the role of lead and corresponding author. This member drafts the manuscript with inputs from the other invited members. When a final version is ready, the moderator provides inputs to correct and improve the manuscript and to bring it up to journal standards. Effectively, this provides an internship for hands-on training in manuscript preparation. The junior member is then guided in the process of manuscript submission.

As an example, in August, 2017, the PACECAR study (Rao et al, 2017), which addressed compliance and cost efficacy of antidepressants in a rural setting, was circulated for review to members of eJCIndia. The members identified limitations in the methods and analysis of the study. The discussion of these limitations was moderated for scientific accuracy and participants were taught to weigh the importance of various points. Members who participated in drafting a response to the PACECAR study were given inputs on improving their writing style. These discussions helped the participants improve analytical as well as writing skills. The discussion eventually led to publication of a letter to the editor, summarizing the online discussion (Thakurdesai et al, 2017a).

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eJCIndia: Research collaborations The aim of eJCIndia at the time of inception, which was to build capacity in research competence, would be truly realised if the group members could design and conduct studies that are of relevance and impact. In 2017, during a discussion on instruments to measure stress, the Presumptive Stressful Life Events Scale (PSLES) by Gurmeet Singh et al was considered (Singh et al, 1984). After its drawbacks were pointed out, it was realised that the scale requires revision to make it more relevant. Eventually, the discussion concluded in a proposal that sought to modify the widely quoted PSLES which was felt to have limited generalizability.

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Members of eJCIndia enthusiastically participated in the activity. Fourteen members working in academic institutions in different parts of the country volunteered to be a part of a multicenter project that would be conducted in several phases. The project protocol has been designed and is currently being reviewed and revised by the members before its submission to respective Institutional Ethics Committees for approval.

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eJCIndia: Successes The fact that eJCIndia is 3 years old and still active and growing is itself an index of its success. There have been about a hundred major activities each year and many minor ones; participation in these activities has been good, with a total of 3193 conversations recorded as of April 08, 2018. About 20 publications in indexed journals have arisen through eJCIndia activities.

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As an example, in July 2017, a study (Rao et al, 2017) published in the Indian Journal of Psychiatry evaluating compliance with treatment in patients suffering from psychosis was presented for discussion. eJCIndia members raised several relevant points ranging from whether the method used to assess compliance was valid to whether the analysis and presentation of data were appropriate. Eventually, three teams were formed, and these teams presented their critiques in 3 separate letters addressed to the editor of the journal. All 3 letters were accepted for publication (Pinto et al, 2017; Thakurdesai et al, 2017b; Ghosh et al, 2017). The prospect of writing a letter which may be published encourages members to participate in the group activities. Publications are a personal success for each participant in the discussion as well as a success for eJCIndia as a whole. eJCIndia: Challenges The existence of eJCIndia has been brought to the notice of the academic fraternity through editorials in the Indian Journal of Psychiatry (Rao and Andrade, 2015a and b), through announcements in the official e-group of the Indian Psychiatric Society, and through word of

mouth announcements at over a hundred major academic events, across the country, that were attended by teaching faculty and postgraduate students, themselves. Despite these efforts, the penetration has been disappointing. In 2015, there were 267 members recruited; these numbers were 51 in 2016, 47 in 2017, and 61, so far, in 2018. The total membership, as on February 16, 2018, stands at 426. It is possible that academic motivation is not as good as one would like it to be.

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One way of looking at it is that if capacity building is the most important goal of eJCIndia, then it suffices if persons with motivation and talent join, for it is they who will lead the field in future years. However, if the goal is to produce widespread improvement in journal reading and comprehension capacity for the better practice of evidence-based medicine, then certainly all postgraduate students and academic psychiatrists, and even all psychiatrists, including those solely in practice, should join. For the moment, attempts are being made to involve academic departments in institutions that offer postgraduation in psychiatry.

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Limitations We do not know how many of the members actually follow and benefit from the activities and discussions. However, as with any other academic program, such as a lecture or a conference presentation, head counts are all that is possible. Just as there is no way of knowing whether physical attendance is associated with attention and learning, there is no way of knowing whether membership in the group is actually benefiting everybody. However, efforts are continuing, participation is good, and indices of success, such as participation, collaborations, and publications, suggest that the initiative enjoys reasonable success. At a future point in time, we plan to obtain formal feedback and suggestions from the membership of the group.

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Recommendations Capacity building in medical research is an important long-term goal for India and other developing countries. We believe that the successes of eJCIndia can be replicated in other medical disciplines in the country and suggest our effort as a model on which other initiatives in our and other medical disciplines can be launched at state, zonal, and even national levels in the country. The experiences and successes of eJCIndia can also be replicated in other developing countries for more efficient manpower development and capacity building in academic medicine. The availability of active, committed, competent, and experienced senior members for the provision of guidance, and a competent and efficient moderator, is a key to success.

References : Ghosh A, Suhas S, Solanki C, Dave M, Tharayil HM, Damodharan D, Andrade C., 2017. From compliance to adherence: changing views, changing concepts. Indian J Psychiatry. 59: 399-400. Hammond J, Whalen T., 2006. The electronic journal club: an asynchronous problem-based learning technique within work-hour constraints. Curr Surg. 63(6):441-443.

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Kuppersmith RB, Stewart MG, Ohlms LA, Coker NJ., 1997. Use of an Internet-based journal club. Otolaryngol Head Neck Surg. 116(4):497–498.

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Linzer M., 1987. The journal club and medical education: over one hundred years of unrecorded history. Postgraduate Medical Journal. 63(740):475-478.

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Pinto E, Sahoo S, Deshmukh D, Vadlamani N, Dhingra I, Karia S, Andrade C., 2017. Treatment compliance and noncompliance in psychosis: methodological issues. Indian J Psychiatry. 59: 401-402.

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Ranmuthugala G, Plumb JJ, Cunningham FC, Georgiou A, Westbrook JI, Braithwaite J., 2011. How and why are communities of practice established in the healthcare sector? A systematic review of the literature. BMC Health Serv Res. 11(1):273.

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Rao KN, George J, Sudarshan CY, Begum S., 2017. Treatment compliance and noncompliance in psychoses. Indian J Psychiatry. 59:69-76.

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Rao T S, Manohar J S, Raman R, Darshan M S, Tandon A, Karthik K N, Saraswathi N, Das K, Harsha G T, Kunkeri SP, Andrade C., 2017. The prospective, 24-week assessment of costefficacy of and compliance to antidepressant medications in a rural setting (PACECAR) study. Indian J Psychiatry. 59:157-163.

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Sathyanarayana Rao T S, Andrade C., 2015. Ethical issues in research: study design and publicationworthiness as a case in point. Indian J Psychiatry. 57:1-3.

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Sathyanarayana Rao T S, Andrade C., 2015. Initiative for capacity building in academic psychiatry in India: The E-Journal Club of the Indian Psychiatric Society. Indian J Psychiatry. 57:115-116.

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Singh G, Kaur D, Kaur H., 1984. Presumptive stressful life events scale (PSLES) - A new stressful life events scale for use in India. Indian J Psychiatry. 26(2):107-114. Thakurdesai A, Karia S, Satish S, Harshe D, Tripathi A., 2017a. Antidepressant compliance in a rural setting. Indian J Psychiatry. 59:519. Thakurdesai A, Menon V, Lakdawala B, Soni AB, Krishnamurthy K, Andrade C., 2017b. The importance of using a valid method to assess medication compliance in psychosis. Indian J Psychiatry. 59: 400-401.

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Topf JM, Sparks MA, Phelan PJ, Shah N, Lerma EV, Graham-Brown MPM et al., 2017. The evolution of the Journal Club: From Osler to Twitter. Am J Kidney Dis. 69:827-836.

Box 1: Common aims of journal clubs

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1. To help participating members understand the theoretical and practical relevance of a research paper. 2. To help participating members develop an ability to critically read a scientific paper and understand its strengths and limitations. 3. To help participating members learn how to express scientific views verbally and in writing.

Box 2: Guidance provided to eJC members

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1. eJCIndia [e-Journal Club, India] is a platform for members to learn how to critically read a journal article, understand its relevance to the field, and understand its strengths and limitations. Other, important, objectives include helping members develop knowledge and skills in statistics and research methods, improving member skills in academic manuscript preparation, and promoting member learning in the field of mental health and the related behavioral, neurological, and medical sciences. eJCIndia primarily addresses the needs of postgraduate students in psychiatry and those in academic psychiatry; however, anybody with an interest in the objectives of the group is welcome to join the group and participate in the discussions. 2. Any member of eJCIndia can post to the group. Messages are not moderated. However, messages are required to be restricted to those related to the objectives of the group. 3. Members of the group are welcome to use the forum to ask academic questions or to teach each other. In this context, members are welcome to ask questions and share knowledge regardless of their level of seniority. 4. A specific instruction to members: If your name does not show in your email address, please sign off with your name so that we know who is writing to us. If you are not well known in the group, it could help if you also mentioned your designation and place of work, though this is not mandatory.