- Email: [email protected]
Enhancing experiential education: Implementing and improving the journal club experience
Available online at www.sciencedirect.com
Currents in Pharmacy Teaching and Learning 7 (2015) 389–394
Opinion
http://www.pharmacyteaching.com
Enhancing experiential education: Implementing and improving the journal club experience Stephanie L. Hattoy, PharmD, BCPS, CGPa,*, Billy-Clyde Childress, PharmD, BCACP, FASCP, LDEb,c, Amanda Jett, PharmDb, Joshua Montney, PharmD, MBAb a
Department of Pharmacy Practice and Administration, University of Saint Joseph School of Pharmacy, Hartford, CT b The Center for Health & Wellness, Sullivan University College of Pharmacy, Louisville, KY c Department of Clinical and Administrative Sciences, Sullivan University College of Pharmacy, Louisville, KY
Abstract Journal club has been recognized for years as an important learning tool for student pharmacists. Literature evaluation activities consistently prove to be one of the most challenging aspects of pharmacy education for students, residents, preceptors, and even seasoned pharmacists. As clinical pharmacy practice continues to expand through innovative new health care delivery models, pharmacists and students alike have expanded opportunities to learn new skills and information through the journal club process. For pharmacy preceptors, initiating and maintaining a regular and effective journal club can be a daunting addition to other job and precepting responsibilities. This article provides resources for implementing and improving journal club in the fast-paced pharmacy practice settings of today. r 2015 Elsevier Inc. All rights reserved.
Keywords: Journal club; Journal presentation; Lead; Deliver; Present; Methods
Introduction Journal club has been broadly defined as a gathering of individuals with the purpose of discussing and evaluating current biomedical literature.1 It is a learning tool that is frequently employed throughout the medical professions, including pharmacy practice, in classrooms and practice sites. Journal clubs have repeatedly shown to promote the development of therapeutic knowledge, improve awareness of current research, and enhance critical thinking skills.1 When implemented in practice settings as a component of experiential education, journal club promotes evidence-
* Corresponding author: Stephanie L Hattoy, PharmD, BCPS, CGP, Department of Pharmacy Practice and Administration, University of Saint Joseph School of Pharmacy, 229 Trumbull Street Hartford, CT 06103. E-mail: [email protected] http://dx.doi.org/10.1016/j.cptl.2014.12.012 1877-1297/r 2015 Elsevier Inc. All rights reserved.
based pharmacotherapy and has the potential to enhance patient-centered care. As new practice models emerge with interprofessional education and interdisciplinary practice components, journal clubs need to adapt to the needs of students and practitioners. Seasoned sites may suffer from journal club fatigue, while new practitioners and practice sites may feel daunted by the thought of incorporating journal club into a busy schedule. Other barriers may stem from the lack of standardized procedures for holding journal club activities.2 This article is designed to provide the techniques, resources, and guidance to implement or enhance journal club for pharmacy students in any practice setting.
Mission drives results Journal club is more than a meeting to discuss the latest “groundbreaking” research published. Journal clubs can be
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S.L. Hattoy et al. / Currents in Pharmacy Teaching and Learning 7 (2015) 389–394
more effective as a teaching tool when discussing research that is relevant to the practice site or the interests of a particular group. Meetings should provide a forum to discuss implications of a study for clinical practice, as well as allow participants to critique research design, biostatistics, or author conclusions of a study.3–6 As pharmacy educators evaluate journal club programs or design new programs for implementation, it is vital to remember that the mission drives results. Whether starting from scratch or making improvements, educators need to assess the mission of their journal club meetings. While some might be driven to enhance student knowledge of therapeutics, others might be designed to enhance communication skills, improve presentation abilities, or foster interprofessional education.7 Properly executed journal clubs can have a major impact on helping students transition from being the “knowledge absorber” in the classroom to the “critical thinker” in the clinic.7
Choose a champion Every great cause has a champion. When the mission and purpose of journal club have been decided, it needs a champion, or facilitator, to see it through to fruition. The facilitator does not have to be a pharmacy preceptor but can be an academician, a site administrator, or a passionate provider. The journal club facilitator makes sure that all stakeholders are involved and that the mission of the meeting is achieved. Facilitators should serve as the presentation point-person, be involved in meeting planning, maintain a list of participants, ensure proper article selection, and delegate the logistical tasks prior to meetings. A complete outline of this is shown in the Table.
Define the time A vital factor to consider when planning a journal club or evaluating an existing program is the selection of a regular time and place. Interprofessional journal clubs can be difficult to maintain if a coordinated schedule is not communicated well between disciplines/departments. Meal times and periods of staffing overlap are generally ideal for a journal club, since they are less likely to interfere with patient care activities. Using a recurring schedule that is planned well into the future will also help ensure high attendance rates. Meeting or appointment e-mails should be delivered to participants who are expected to attend regularly, thus allowing the journal club facilitator to ensure that there will be sufficient space and deliverable materials (e.g., handouts and copies of the article). A convenient location—such as a central conference room or auditorium —and a consistent location encourage habit-forming behaviors for participants.
Finding the right articles If the mission of a journal club is to enhance therapeutic knowledge and critical thinking skills, the discussion must be evidence driven. Evidence-based medicine (EBM) has been defined as “a systematic approach to clinical problem solving which allows the integration of the best available research evidence with clinical expertise and patient values.”8 As most students enter experiential education as knowledge seekers, learning experiences must help them integrate clinical evidence with data from research to make decisions in patient care. Choosing stimulating articles can help learners understand that the answers to clinical questions are not always found in a book. An engaging journal club meeting on a regular basis can help students develop their skills to optimize health outcomes through the integration of knowledge, experience, and the best interests of the patient. Journal club facilitators should be involved in the article selection process. Ideal articles include those related to the practice site, hot topics in health care, or new therapies that may impact guidelines for patient care. Articles should reflect Patient-Oriented Evidence that Matters (POEMs), which address useful patient outcomes such as morbidity, mortality, and quality of life. POEMs should also possess valid data, free from errors or bias, which have the potential to influence practice decisions. Disease-Oriented Evidence (DOEs) includes articles describing preliminary research, pathophysiology or etiology of specific diseases.9–12 It may be worthwhile for the student to focus their efforts on identifying POEMs instead of DOEs to impart useful and practical knowledge with the potential to impact practice at their clinical site. Table Tasks for preparing a journal club presentation Responsible partya
Task
Journal club “point-person” Ensure presentation structure is maintained Lead journal club presentation discussion Delegate responsibilities to other participants Planner Select/adjust of time and/or place Create appointment/meeting reminders Create recurring events for calendar Manage participant RSVP Prepare presentation deliverables Presenter Select and receive approval for journal article Prepare discussion and evaluation of article Article and rubric distribution to participants Deliver presentation Provide follow-up to questions unanswered Other participants Read/review journal article prior to presentation Evaluate presenter using provided tool Facilitator
a Responsible parties may perform the tasks of other responsible parties (e.g., the presenter may serve as the planner and/or the facilitator).
S.L. Hattoy et al. / Currents in Pharmacy Teaching and Learning 7 (2015) 389–394
Reputable, peer-reviewed journals are suggested since experts in their content areas scrutinize the articles published for validation. While systematic reviews and metaanalyses are considered the “gold standard” for clinical evidence and application, other study types (e.g., observational or descriptive) should not be disregarded since they do contribute to the body of medical literature and can be utilized as a valuable teaching tools.12,13 Facilitators should seek input from participants and the clinicians involved to properly vet articles for presentation.
Improving the presentation Journal clubs have historically been considered time consuming, tedious, or dull by those participating in them.13 Proper planning and participation can help to reverse that stigma. It is critical to the success of the program that standards for presentations be set and well communicated to presenters ahead of time. A suggested schedule of events may include a 15-minute presentation including the study objectives, clinical question, relevant clinical practice guidelines or background research, details of the study, presenter’s critique, and conclusion.13,14 By utilizing the techniques described, journal clubs can be streamlined and focused, thus facilitating a timely discussion among participants. The key to engagement is to keep presentations focused and promote discussion and interaction regardless of the overall presentation length. As students learn to present at journal club, preceptors may best help students by providing a rubric of how the presentation will be evaluated or assessed. Using the same evaluation tool system-wide allows for consistent evaluation and familiarity for presenters and participants across disciplines (see section Assessing journal club). There are multiple techniques available to help students evaluate biomedical literature. While all of these techniques may be used to evaluate an article, journal club should respect the time of the practitioners who participate and should focus on one or two techniques. Facilitators should determine the format for a journal club and evaluation tools well in advance to promote consistency for meetings and respect the time of those who are involved. The following sections address the different techniques that can be used as part of journal club to help enhance student research and journal club experience.
391
objectives, design, methods, statistical analysis, results, and conclusions. The Strength-of-Recommendation Taxonomy (SORT) and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) schemes are common grading tools utilized by health care organizations in peerreviewed journals and clinical practice guidelines.15,16 SORT and GRADE have been used to assess the quality of evidence in a journal article and assign a letter grade to support the organization or journal’s recommendation. Students may wish to incorporate their own “grade” to the evidence, using these schemes, when presenting their conclusions. The facilitator may encourage other participants to determine their own grades in order to compare opinions and spark discussion. The PICO acronym can be used to identify and frame a clinical question, develop search terms to identify quality evidence, and set a framework to critically appraise the evidence provided. PICO describes the population related to the question or included in the clinical trial, the Intervention/exposure being evaluated versus the Comparison/Control, and the Outcomes being measured (Fig. 1).13,17 Determining if the research design is appropriate has been proposed in addition to the PICO method (PICOD) to focus more on the critical appraisal of the evidence.18 For example, the landmark Hypertension in the Very Elderly
PICO(D) and The GATE Frame
RAAMbo
P Represent?
Allocated or Adjusted? I
C
D Accounted for?
+
Prevalence O
_
Incidence
Measured? blinded or objective?
T Evidence Patient Values
Clinical Considerations Policy
Appraisal techniques Journal club presenters should be familiar with commonly employed evidence appraisal techniques used in clinical practice guidelines and reviews. These techniques provide insight into the level and quality of evidence supporting key recommendations and can be used in conjunction with a review of the basic components of literature evaluation: background information, study
Fig. 1. PICO(D), the GATE frame, and RAAMbo. P ¼ population; I ¼ intervention; C ¼ comparison; O ¼ outcome; D ¼ design; T ¼ study time; GATE ¼ Graphical Appraisal Tool for Epidemiological studies; RAAMbo ¼ Representation; Allocation, Adjustment, accountability; Measured, maintained; blinded; objectives. (Adapted with permission from Jackson et al.20)
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Trial (HYVET) raises the clinical question “Which antihypertensive therapies reduce the incidence of stroke in elderly patients?”19 Using PICO(D) to identify search terms, the population (P) would include elderly patients with hypertension, the intervention (I) would include antihypertensive therapy, ideally versus placebo (C), and the outcome (O) would be a reduction in rates of stroke. Using these keywords as search terms would lead a student to finding this trial or others with similar purpose. The Graphical Appraisal Tool for Epidemiological studies, or “GATE” frame, is a pictorial appraisal method with the potential to attract visual learners. Although developed to understand the design of epidemiological studies, the GATE frame can be applied to other study designs.20 The GATE frame (Fig. 1) incorporates five sections: study participation, exposure or intervention, comparison, outcome, and study time. Study participation is represented by a triangle separated into three sections: source, eligible, and participant populations. The divided circle represents the control versus the intervention. If more interventions or comparisons are evaluated, multiple vertical lines can divide the circle. Outcomes and results are represented within a square divided into quadrants: the rows representing the intervention group and comparator, and the columns representing the absence or presence of the studied outcome. Continuous outcomes (e.g., blood pressure) may require the removal of the horizontal line. Finally, vertical and horizontal arrows represent the prevalence and the incidence, respectively. The “X” represents expert opinion and external validity or application of the study’s results into clinical practice. This may include patient preferences, clinical attributes (e.g., comorbidities) and policy considerations.20 The GATE frame also assists with calculating useful estimates like risk ratios and number needed to treat.18 The RAAMbo acronym compliments the GATE frame’s graphical representation by analyzing issues regarding study validity. Representation describes patient enrollment and recruitment. The “A” represents patient randomization and Allocation, Adjustment (stratification into subgroups), and Accountability (number of patients enrolled matching the number of outcomes evaluated). How the outcomes were Measured and how the groups were Maintained throughout the trial process should also be evaluated. Subjective or objective (o) outcomes of the trial examine how outcomes were measured and how participants were blinded (b).18,20 The PIES Method of Critique is another technique that can be utilized to evaluate a journal article.21 To aid in the efficiency of presentations, the PIES method simplifies the critique into four basic aspects: Population, Interventions, Endpoints, and Statistics. Population describes baseline characteristics, inclusion and exclusion criteria, clinical relevance, and applicability to the patient population. The Interventions component involves a review of the therapy (e.g. dose, titration, and dosing schedule). The student can also relate the interventions compared to the standard of
care supported by other well-designed studies or practice guidelines. The primary, secondary, and surrogate Endpoints include a review of subgroup analyses and study power. Finally, a review of the Statistics should be conducted. It is noteworthy that a basic understanding of statistics is necessary to critically evaluate clinical trial information. This may provoke added discussion and review of appropriate statistical tests in accordance to the data collected. Although efficient, the PIES method does not incorporate all potential trial flaws and necessitates the identification of biases or design issues.21 This may additionally provide an opportunity for valuable discussion among all journal club participants. Using the HYVET trial, an example of using PICO(D), the GATE frame, RAAMbo, and the PIES Method of Critique is demonstrated in Figure 2. Assessing journal club Assessment techniques vary and rely on the rubric or evaluation method utilized. In general, evaluations determine if the presenter included the components mentioned with a focus on the article critique and appraisal. Blommel and Abate22 described in detail the process of rubric development for journal club exercises in the classroom and on rotations at their institution. They identified critical areas to assess student performance during journal club presentations. These areas included a basic overview of the study being presented (author affiliation/study support, study design, patient/subject enrollment methods, interventions, outcomes, data handling, statistics, results, and author conclusion), study analysis and critique, the student’s conclusions and applicability to clinical practice, preparedness (knowledge of the study’s details and response to questions), and presentation skills (speaking style, timing, use of distracting mannerisms, and appropriate eye contact). These criteria are similar to the assessment and evaluation tools that are readily available for use.23–25 Prudent assessment of one’s own existing journal club should be considered to employ continuous quality improvement. Students and participants should be provided an open forum to discuss elements of the journal that worked well and what areas need improvement. An informal “post-mortem” discussion or survey could provide valid information and feedback regarding the program. It is crucial to again remember that the mission drives the results. Rubrics and evaluation forms will inevitably guide the content, format, and delivery of the journal club meetings. By defining the desired outputs first, the evaluation tools can help foster a successful program. Conclusions Journal club can be an excellent tool to develop student pharmacists, promote interprofessional education, and enhance patient care. Although journal club has developed
S.L. Hattoy et al. / Currents in Pharmacy Teaching and Learning 7 (2015) 389–394
195 centers in 13 countries 4761 eligible 3845
Indapamide +/Perindopril n=1933
Stroke
51 (12.4%)
No stroke
69 (17.7%)
randomized
Placebo n=1912
randomized, double-blind, placebo-controlled
Patients ≥ 80 years with persistent hypertension from Western/Eastern Europe, China, Australia, and North America, many healthier than expected.
• Baseline characteristics Table 1 of HYVET; groups well matched • Inclusion and exclusion criteria appropriate and applicable to the population studied
Exclusion criteria met, run-in period with placebo, patients were randomized to intervention or placebo.
• Indapamide SR (thiazidelike diuretic) allows for good BP control and well tolerated • Perindopril with indapamide shown in previous studies to have benefit in prevention of stroke (PROGRESS trial)
Figure 1 in HYVET publication, 55% and 53% of patients did not complete trial in treatment versus placebo group, respectively 1882
Fatal or non-fatal stroke
O 1843
Mean duration of follow up 1.8 years
Diuretics + ACE-I reduce risk of stroke Consider comorbidities, Patient values drug interactions, extended lifespan cost of medications, etc. No relevant policy considerations
l Double-blind trial; although investigator aware of BP. Objective measure of determining if patient had fatal or non-fatal stroke (TIA not considered); predefined definition of endpoints in study protocol. Designed to detect 35% reduction in stroke with 90% power assuming an event rate of 40 per 1000 patientyears; 10,500 patient-years follow-up required. Trial terminated due to benefit discovered in treatment arm.
393
• Endpoints represent study purpose • Primary and secondary endpoints are clinically significant in elderly population • No surrogate endpoints • Data assessed includes nominal data (stroke vs. no stroke) Cox and logrank • Continuous data using ztest, proportions using chisquare, incidence using log-rank (all appropriate) • Intention-to-treat and perprotocol analysis • Kaplan-Meier for determining survival (appropriate) • Sample size adequate • NNT = 94 (high, limited clinical significance); 40 (to prevent 1 death in 2 years; clinically significant) although difficult to extrapolate in frail elderly
Fig. 2. PICO(D), the GATE frame, RAAMbo, PIES, and HYVET example. P ¼ population; I ¼ intervention; C ¼ comparison; O ¼ outcome; D ¼ design; T ¼ study time; GATE ¼ Graphical Appraisal Tool for Epidemiological studies; RAAMbo ¼ Representation; Allocation, adjustment, accountability; Measured, maintained; blinded; objectives; PIES ¼ Patient population; Intervention; Endpoints; Statistics; HYVET ¼ Hypertension in the Very Elderly Trial; ACE-I ¼ angiotensin-converting enzyme inhibitor; BP ¼ blood pressure; TIA ¼ transient ischemic attack; SR ¼ sustained release; PROGRESS ¼ perindopril protection against recurrent stoke study; NNT ¼ number needed to treat.
a reputation for being tedious and time consuming, the techniques presented here can make these events more interactive and engaging experiences. Whether trying to revamp a dying journal club or start up a new one at a practice site, these techniques can help ensure success. References 1. Kleinpell RM. Rediscovering the value of the journal club. Am J Crit Care. 2002;11(5):412–414. 2. Zarghi N, Mazlom SR, Rahban M. Challenges of e-journal club: a case study. Creat Educ. 2012;3(6):708–711. 3. Dwarakanath LS, Khan KS. Modernizing the journal club. Hosp Med. 2000;16(6):425–427.
4. Sidorov J. How are internal medicine residency journal clubs organized, and what makes them successful? Arch Intern Med. 1995;155(11):1193–1197. 5. Brown University. Biophysics journal club. 〈http://www.brown. edu/research/labs/tang-biophysics/biophysics-journal-club〉; Accessed February 19, 2015. 6. Shearer J. The Nursing Research Journal Club: an ongoing program to promote nursing research in a community hospital. J Nurs Staff Dev. 1995;11(2):104–105. 7. Accreditation Council for Pharmacy Education. Accreditation Council for Pharmacy Education accreditation standards and guidelines for the professional program in pharmacy leading to the Doctor of Pharmacy degree, v2.0. Chicago. 〈https://www. acpe-accredit.org/pdf/FinalS2007Guidelines2.0.pdf〉; 2011 Accessed February 19, 2015.
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8. Sackett DL, Strauss SE, Richardson WS, Rosenberg W, Haynes RB. Evidence-Based Medicine: How to Practice and Teach EBM. London: Churchill-Livingstone; 2000. 9. Slawson DC, Shaughnessy AF, Bennet JH. Becoming a medical information master: feeling good about not knowing everything. J Fam Pract. 1994;38(5):505–513. 10. Bennett JH, Shaughnessy AF, Slawson DC. Becoming an information master: a guidebook to the medical information jungle. J Fam Pract. 1994;39(5):489–499. 11. Slawson DC, Shaugnessy AF. Becoming an information master: using POEMs to change practice with confidence. J Fam Pract. 2000;49(1):63–67. 12. Akobeng AK. Understanding randomized controlled trials. Arch Dis Child. 2005;90(8):840–844. 13. Schwartz MD, Dowell D, Aperi J, Kalet AL. Improving journal club presentations, or, I can present that paper in under 10 minutes. Evid Based Med. 2007;12(3):66–68. 14. Phillips RS, Glasziou P. What makes evidence-based journal clubs succeed? ACP J Club. 2004;140(3):A11–A12. 15. Ebell MH, Siwek J, Weiss BD, et al. Strength of Recommendation Taxonomy (SORT): a patient-centered approach to grading evidence in the medical literature. Am Fam Physician. 2004;69(3):548–556. 16. Guyatt GH, Oxman AD, Vist GE, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. Br Med J. 2008;336(7650):924–926. 17. Friends of the Children of Great Ormand Street Library. UCL critical appraisal of a journal club. 〈http://www.ucl.ac.uk/ich/
18.
19.
20.
21. 22. 23.
24.
25.
services/library/training_material/critical-appraisal〉; 2011 Accessed February 19, 2015. Daly A, Raza A Journal Club Handbook. Birmingham: Birmingham Women Great Ormand Street Library. 〈http:// www.bwnft.nhs.uk/professionals/library-home/journal-club-hand book/〉; 2012 Accessed February 19, 2015. Beckett NS, Peters R, Flecther AE, et al. Treatment of hypertension in patients 80 years of age or older. N Engl J Med. 2008;358(18):1887–1898. Jackson R, Ameratunga, Broad J, et al. The GATE frame: critical appraisal with pictures. Evid Based Med. 2006;11(2): 35–38. Baroletti S, Szumita PM. PIES method of critique. Crit Pathw Cardiol. 2004;3(4):205–208. Blommel ML, Abate MA. A rubric to assess critical literature evaluation skills. Am J Pharm Educ. 2007;71(4): Article 63. University of Texas at Austin. Journal club presentation evaluation form. 〈http://www.utexas.edu/pharmacy/general/ experiential/practitioner/journal.pdf〉; Accessed February 19, 2015. Pharmacist’s Letter Preceptor Toolbox. Journal club evaluation criteria. 〈http://pharmacistsletter.therapeuticresearch.com/ ptrn/downloaditem.aspx?cs=&s=PL&id=466〉; Accessed February 19, 2015. Pharmacist’s Letter Preceptor Toolbox. Journal club assessment form. 〈http://pharmacistsletter.therapeuticresearch.com/ ptrn/downloaditem.aspx?cs=&s=PL&id=467〉; Accessed February 19, 2015.
Currents in Pharmacy Teaching and Learning 7 (2015) 389–394
Opinion
http://www.pharmacyteaching.com
Enhancing experiential education: Implementing and improving the journal club experience Stephanie L. Hattoy, PharmD, BCPS, CGPa,*, Billy-Clyde Childress, PharmD, BCACP, FASCP, LDEb,c, Amanda Jett, PharmDb, Joshua Montney, PharmD, MBAb a
Department of Pharmacy Practice and Administration, University of Saint Joseph School of Pharmacy, Hartford, CT b The Center for Health & Wellness, Sullivan University College of Pharmacy, Louisville, KY c Department of Clinical and Administrative Sciences, Sullivan University College of Pharmacy, Louisville, KY
Abstract Journal club has been recognized for years as an important learning tool for student pharmacists. Literature evaluation activities consistently prove to be one of the most challenging aspects of pharmacy education for students, residents, preceptors, and even seasoned pharmacists. As clinical pharmacy practice continues to expand through innovative new health care delivery models, pharmacists and students alike have expanded opportunities to learn new skills and information through the journal club process. For pharmacy preceptors, initiating and maintaining a regular and effective journal club can be a daunting addition to other job and precepting responsibilities. This article provides resources for implementing and improving journal club in the fast-paced pharmacy practice settings of today. r 2015 Elsevier Inc. All rights reserved.
Keywords: Journal club; Journal presentation; Lead; Deliver; Present; Methods
Introduction Journal club has been broadly defined as a gathering of individuals with the purpose of discussing and evaluating current biomedical literature.1 It is a learning tool that is frequently employed throughout the medical professions, including pharmacy practice, in classrooms and practice sites. Journal clubs have repeatedly shown to promote the development of therapeutic knowledge, improve awareness of current research, and enhance critical thinking skills.1 When implemented in practice settings as a component of experiential education, journal club promotes evidence-
* Corresponding author: Stephanie L Hattoy, PharmD, BCPS, CGP, Department of Pharmacy Practice and Administration, University of Saint Joseph School of Pharmacy, 229 Trumbull Street Hartford, CT 06103. E-mail: [email protected] http://dx.doi.org/10.1016/j.cptl.2014.12.012 1877-1297/r 2015 Elsevier Inc. All rights reserved.
based pharmacotherapy and has the potential to enhance patient-centered care. As new practice models emerge with interprofessional education and interdisciplinary practice components, journal clubs need to adapt to the needs of students and practitioners. Seasoned sites may suffer from journal club fatigue, while new practitioners and practice sites may feel daunted by the thought of incorporating journal club into a busy schedule. Other barriers may stem from the lack of standardized procedures for holding journal club activities.2 This article is designed to provide the techniques, resources, and guidance to implement or enhance journal club for pharmacy students in any practice setting.
Mission drives results Journal club is more than a meeting to discuss the latest “groundbreaking” research published. Journal clubs can be
390
S.L. Hattoy et al. / Currents in Pharmacy Teaching and Learning 7 (2015) 389–394
more effective as a teaching tool when discussing research that is relevant to the practice site or the interests of a particular group. Meetings should provide a forum to discuss implications of a study for clinical practice, as well as allow participants to critique research design, biostatistics, or author conclusions of a study.3–6 As pharmacy educators evaluate journal club programs or design new programs for implementation, it is vital to remember that the mission drives results. Whether starting from scratch or making improvements, educators need to assess the mission of their journal club meetings. While some might be driven to enhance student knowledge of therapeutics, others might be designed to enhance communication skills, improve presentation abilities, or foster interprofessional education.7 Properly executed journal clubs can have a major impact on helping students transition from being the “knowledge absorber” in the classroom to the “critical thinker” in the clinic.7
Choose a champion Every great cause has a champion. When the mission and purpose of journal club have been decided, it needs a champion, or facilitator, to see it through to fruition. The facilitator does not have to be a pharmacy preceptor but can be an academician, a site administrator, or a passionate provider. The journal club facilitator makes sure that all stakeholders are involved and that the mission of the meeting is achieved. Facilitators should serve as the presentation point-person, be involved in meeting planning, maintain a list of participants, ensure proper article selection, and delegate the logistical tasks prior to meetings. A complete outline of this is shown in the Table.
Define the time A vital factor to consider when planning a journal club or evaluating an existing program is the selection of a regular time and place. Interprofessional journal clubs can be difficult to maintain if a coordinated schedule is not communicated well between disciplines/departments. Meal times and periods of staffing overlap are generally ideal for a journal club, since they are less likely to interfere with patient care activities. Using a recurring schedule that is planned well into the future will also help ensure high attendance rates. Meeting or appointment e-mails should be delivered to participants who are expected to attend regularly, thus allowing the journal club facilitator to ensure that there will be sufficient space and deliverable materials (e.g., handouts and copies of the article). A convenient location—such as a central conference room or auditorium —and a consistent location encourage habit-forming behaviors for participants.
Finding the right articles If the mission of a journal club is to enhance therapeutic knowledge and critical thinking skills, the discussion must be evidence driven. Evidence-based medicine (EBM) has been defined as “a systematic approach to clinical problem solving which allows the integration of the best available research evidence with clinical expertise and patient values.”8 As most students enter experiential education as knowledge seekers, learning experiences must help them integrate clinical evidence with data from research to make decisions in patient care. Choosing stimulating articles can help learners understand that the answers to clinical questions are not always found in a book. An engaging journal club meeting on a regular basis can help students develop their skills to optimize health outcomes through the integration of knowledge, experience, and the best interests of the patient. Journal club facilitators should be involved in the article selection process. Ideal articles include those related to the practice site, hot topics in health care, or new therapies that may impact guidelines for patient care. Articles should reflect Patient-Oriented Evidence that Matters (POEMs), which address useful patient outcomes such as morbidity, mortality, and quality of life. POEMs should also possess valid data, free from errors or bias, which have the potential to influence practice decisions. Disease-Oriented Evidence (DOEs) includes articles describing preliminary research, pathophysiology or etiology of specific diseases.9–12 It may be worthwhile for the student to focus their efforts on identifying POEMs instead of DOEs to impart useful and practical knowledge with the potential to impact practice at their clinical site. Table Tasks for preparing a journal club presentation Responsible partya
Task
Journal club “point-person” Ensure presentation structure is maintained Lead journal club presentation discussion Delegate responsibilities to other participants Planner Select/adjust of time and/or place Create appointment/meeting reminders Create recurring events for calendar Manage participant RSVP Prepare presentation deliverables Presenter Select and receive approval for journal article Prepare discussion and evaluation of article Article and rubric distribution to participants Deliver presentation Provide follow-up to questions unanswered Other participants Read/review journal article prior to presentation Evaluate presenter using provided tool Facilitator
a Responsible parties may perform the tasks of other responsible parties (e.g., the presenter may serve as the planner and/or the facilitator).
S.L. Hattoy et al. / Currents in Pharmacy Teaching and Learning 7 (2015) 389–394
Reputable, peer-reviewed journals are suggested since experts in their content areas scrutinize the articles published for validation. While systematic reviews and metaanalyses are considered the “gold standard” for clinical evidence and application, other study types (e.g., observational or descriptive) should not be disregarded since they do contribute to the body of medical literature and can be utilized as a valuable teaching tools.12,13 Facilitators should seek input from participants and the clinicians involved to properly vet articles for presentation.
Improving the presentation Journal clubs have historically been considered time consuming, tedious, or dull by those participating in them.13 Proper planning and participation can help to reverse that stigma. It is critical to the success of the program that standards for presentations be set and well communicated to presenters ahead of time. A suggested schedule of events may include a 15-minute presentation including the study objectives, clinical question, relevant clinical practice guidelines or background research, details of the study, presenter’s critique, and conclusion.13,14 By utilizing the techniques described, journal clubs can be streamlined and focused, thus facilitating a timely discussion among participants. The key to engagement is to keep presentations focused and promote discussion and interaction regardless of the overall presentation length. As students learn to present at journal club, preceptors may best help students by providing a rubric of how the presentation will be evaluated or assessed. Using the same evaluation tool system-wide allows for consistent evaluation and familiarity for presenters and participants across disciplines (see section Assessing journal club). There are multiple techniques available to help students evaluate biomedical literature. While all of these techniques may be used to evaluate an article, journal club should respect the time of the practitioners who participate and should focus on one or two techniques. Facilitators should determine the format for a journal club and evaluation tools well in advance to promote consistency for meetings and respect the time of those who are involved. The following sections address the different techniques that can be used as part of journal club to help enhance student research and journal club experience.
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objectives, design, methods, statistical analysis, results, and conclusions. The Strength-of-Recommendation Taxonomy (SORT) and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) schemes are common grading tools utilized by health care organizations in peerreviewed journals and clinical practice guidelines.15,16 SORT and GRADE have been used to assess the quality of evidence in a journal article and assign a letter grade to support the organization or journal’s recommendation. Students may wish to incorporate their own “grade” to the evidence, using these schemes, when presenting their conclusions. The facilitator may encourage other participants to determine their own grades in order to compare opinions and spark discussion. The PICO acronym can be used to identify and frame a clinical question, develop search terms to identify quality evidence, and set a framework to critically appraise the evidence provided. PICO describes the population related to the question or included in the clinical trial, the Intervention/exposure being evaluated versus the Comparison/Control, and the Outcomes being measured (Fig. 1).13,17 Determining if the research design is appropriate has been proposed in addition to the PICO method (PICOD) to focus more on the critical appraisal of the evidence.18 For example, the landmark Hypertension in the Very Elderly
PICO(D) and The GATE Frame
RAAMbo
P Represent?
Allocated or Adjusted? I
C
D Accounted for?
+
Prevalence O
_
Incidence
Measured? blinded or objective?
T Evidence Patient Values
Clinical Considerations Policy
Appraisal techniques Journal club presenters should be familiar with commonly employed evidence appraisal techniques used in clinical practice guidelines and reviews. These techniques provide insight into the level and quality of evidence supporting key recommendations and can be used in conjunction with a review of the basic components of literature evaluation: background information, study
Fig. 1. PICO(D), the GATE frame, and RAAMbo. P ¼ population; I ¼ intervention; C ¼ comparison; O ¼ outcome; D ¼ design; T ¼ study time; GATE ¼ Graphical Appraisal Tool for Epidemiological studies; RAAMbo ¼ Representation; Allocation, Adjustment, accountability; Measured, maintained; blinded; objectives. (Adapted with permission from Jackson et al.20)
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Trial (HYVET) raises the clinical question “Which antihypertensive therapies reduce the incidence of stroke in elderly patients?”19 Using PICO(D) to identify search terms, the population (P) would include elderly patients with hypertension, the intervention (I) would include antihypertensive therapy, ideally versus placebo (C), and the outcome (O) would be a reduction in rates of stroke. Using these keywords as search terms would lead a student to finding this trial or others with similar purpose. The Graphical Appraisal Tool for Epidemiological studies, or “GATE” frame, is a pictorial appraisal method with the potential to attract visual learners. Although developed to understand the design of epidemiological studies, the GATE frame can be applied to other study designs.20 The GATE frame (Fig. 1) incorporates five sections: study participation, exposure or intervention, comparison, outcome, and study time. Study participation is represented by a triangle separated into three sections: source, eligible, and participant populations. The divided circle represents the control versus the intervention. If more interventions or comparisons are evaluated, multiple vertical lines can divide the circle. Outcomes and results are represented within a square divided into quadrants: the rows representing the intervention group and comparator, and the columns representing the absence or presence of the studied outcome. Continuous outcomes (e.g., blood pressure) may require the removal of the horizontal line. Finally, vertical and horizontal arrows represent the prevalence and the incidence, respectively. The “X” represents expert opinion and external validity or application of the study’s results into clinical practice. This may include patient preferences, clinical attributes (e.g., comorbidities) and policy considerations.20 The GATE frame also assists with calculating useful estimates like risk ratios and number needed to treat.18 The RAAMbo acronym compliments the GATE frame’s graphical representation by analyzing issues regarding study validity. Representation describes patient enrollment and recruitment. The “A” represents patient randomization and Allocation, Adjustment (stratification into subgroups), and Accountability (number of patients enrolled matching the number of outcomes evaluated). How the outcomes were Measured and how the groups were Maintained throughout the trial process should also be evaluated. Subjective or objective (o) outcomes of the trial examine how outcomes were measured and how participants were blinded (b).18,20 The PIES Method of Critique is another technique that can be utilized to evaluate a journal article.21 To aid in the efficiency of presentations, the PIES method simplifies the critique into four basic aspects: Population, Interventions, Endpoints, and Statistics. Population describes baseline characteristics, inclusion and exclusion criteria, clinical relevance, and applicability to the patient population. The Interventions component involves a review of the therapy (e.g. dose, titration, and dosing schedule). The student can also relate the interventions compared to the standard of
care supported by other well-designed studies or practice guidelines. The primary, secondary, and surrogate Endpoints include a review of subgroup analyses and study power. Finally, a review of the Statistics should be conducted. It is noteworthy that a basic understanding of statistics is necessary to critically evaluate clinical trial information. This may provoke added discussion and review of appropriate statistical tests in accordance to the data collected. Although efficient, the PIES method does not incorporate all potential trial flaws and necessitates the identification of biases or design issues.21 This may additionally provide an opportunity for valuable discussion among all journal club participants. Using the HYVET trial, an example of using PICO(D), the GATE frame, RAAMbo, and the PIES Method of Critique is demonstrated in Figure 2. Assessing journal club Assessment techniques vary and rely on the rubric or evaluation method utilized. In general, evaluations determine if the presenter included the components mentioned with a focus on the article critique and appraisal. Blommel and Abate22 described in detail the process of rubric development for journal club exercises in the classroom and on rotations at their institution. They identified critical areas to assess student performance during journal club presentations. These areas included a basic overview of the study being presented (author affiliation/study support, study design, patient/subject enrollment methods, interventions, outcomes, data handling, statistics, results, and author conclusion), study analysis and critique, the student’s conclusions and applicability to clinical practice, preparedness (knowledge of the study’s details and response to questions), and presentation skills (speaking style, timing, use of distracting mannerisms, and appropriate eye contact). These criteria are similar to the assessment and evaluation tools that are readily available for use.23–25 Prudent assessment of one’s own existing journal club should be considered to employ continuous quality improvement. Students and participants should be provided an open forum to discuss elements of the journal that worked well and what areas need improvement. An informal “post-mortem” discussion or survey could provide valid information and feedback regarding the program. It is crucial to again remember that the mission drives the results. Rubrics and evaluation forms will inevitably guide the content, format, and delivery of the journal club meetings. By defining the desired outputs first, the evaluation tools can help foster a successful program. Conclusions Journal club can be an excellent tool to develop student pharmacists, promote interprofessional education, and enhance patient care. Although journal club has developed
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195 centers in 13 countries 4761 eligible 3845
Indapamide +/Perindopril n=1933
Stroke
51 (12.4%)
No stroke
69 (17.7%)
randomized
Placebo n=1912
randomized, double-blind, placebo-controlled
Patients ≥ 80 years with persistent hypertension from Western/Eastern Europe, China, Australia, and North America, many healthier than expected.
• Baseline characteristics Table 1 of HYVET; groups well matched • Inclusion and exclusion criteria appropriate and applicable to the population studied
Exclusion criteria met, run-in period with placebo, patients were randomized to intervention or placebo.
• Indapamide SR (thiazidelike diuretic) allows for good BP control and well tolerated • Perindopril with indapamide shown in previous studies to have benefit in prevention of stroke (PROGRESS trial)
Figure 1 in HYVET publication, 55% and 53% of patients did not complete trial in treatment versus placebo group, respectively 1882
Fatal or non-fatal stroke
O 1843
Mean duration of follow up 1.8 years
Diuretics + ACE-I reduce risk of stroke Consider comorbidities, Patient values drug interactions, extended lifespan cost of medications, etc. No relevant policy considerations
l Double-blind trial; although investigator aware of BP. Objective measure of determining if patient had fatal or non-fatal stroke (TIA not considered); predefined definition of endpoints in study protocol. Designed to detect 35% reduction in stroke with 90% power assuming an event rate of 40 per 1000 patientyears; 10,500 patient-years follow-up required. Trial terminated due to benefit discovered in treatment arm.
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• Endpoints represent study purpose • Primary and secondary endpoints are clinically significant in elderly population • No surrogate endpoints • Data assessed includes nominal data (stroke vs. no stroke) Cox and logrank • Continuous data using ztest, proportions using chisquare, incidence using log-rank (all appropriate) • Intention-to-treat and perprotocol analysis • Kaplan-Meier for determining survival (appropriate) • Sample size adequate • NNT = 94 (high, limited clinical significance); 40 (to prevent 1 death in 2 years; clinically significant) although difficult to extrapolate in frail elderly
Fig. 2. PICO(D), the GATE frame, RAAMbo, PIES, and HYVET example. P ¼ population; I ¼ intervention; C ¼ comparison; O ¼ outcome; D ¼ design; T ¼ study time; GATE ¼ Graphical Appraisal Tool for Epidemiological studies; RAAMbo ¼ Representation; Allocation, adjustment, accountability; Measured, maintained; blinded; objectives; PIES ¼ Patient population; Intervention; Endpoints; Statistics; HYVET ¼ Hypertension in the Very Elderly Trial; ACE-I ¼ angiotensin-converting enzyme inhibitor; BP ¼ blood pressure; TIA ¼ transient ischemic attack; SR ¼ sustained release; PROGRESS ¼ perindopril protection against recurrent stoke study; NNT ¼ number needed to treat.
a reputation for being tedious and time consuming, the techniques presented here can make these events more interactive and engaging experiences. Whether trying to revamp a dying journal club or start up a new one at a practice site, these techniques can help ensure success. References 1. Kleinpell RM. Rediscovering the value of the journal club. Am J Crit Care. 2002;11(5):412–414. 2. Zarghi N, Mazlom SR, Rahban M. Challenges of e-journal club: a case study. Creat Educ. 2012;3(6):708–711. 3. Dwarakanath LS, Khan KS. Modernizing the journal club. Hosp Med. 2000;16(6):425–427.
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