Planning and executing orthopedic journal clubs

T he earliest reference to a journal club is possibly in an accepted educational paradigm in medical the biography of Sir James Paget during the period education. EBM relies on the conscientious, explicit and of 1835-1854. It was noted that a group of students judicious use of current best evidence in making decisions met in a room over a baker’s shop near St. Bartholomew’s about the care of individual patients. There are four key Hospital to read journals or play cards. However, Sir elements of EBM: question setting, literature searching, William Osler was credited to have conducted the first selecting relevant papers and critical appraisal. Historically, journal club on record in 1875 in North America. Its internal medicine training programs in Canada and the purpose was “for the purchase and distribution of United States have included the use of EBM practices. periodicals to which he (Osler) could ill afford to subscribe Recently, surgical training programs have started to include as an individual”. Osler then transferred to Johns Hopkins these principles into their curricula. Evidence-based surgery University Medical School in 1889 where he established is often poorly i corporated into orthopedic residency the Book and Journal Club. There, over dinner, the clinical training. Journal clubs can be an ideal vehicle for members recommended new books for the library and evidence-based orthopedic surgery education. reviewed the latest in medical literature. Journal clubs have now become ubiquitous in graduate medical education Several articles have studied the importance of teaching training programs, including orthopedic surgery. Greene critical appraisal skills to surgical residents. This goal surveyed 149 North American orthopedic surgery training was ranked the most important in Greene’s survey of 149 programs and found that 99% included a regularly program directors of North American orthopedic training scheduled journal club. They initially served to help programs. Other important goals identified in his study practitioners keep up to date with the latest published were instilling the habit of reading scientific journals (20% literature. More recently, however, they have been used of programs) and facilitating residents learning about to teach critical appraisal skills, research design, medical current research (9% of programs). statistics, clinical decision theory, clinical epidemiology and encourage “evidence-based” medical practices. Journal clubs in general surgery were surveyed with questionnaires filled out by program directors in American The purpose of this article is to provide organizers with institutions. A response rate of 80% from 278 programs tools to plan and execute successful journal clubs in identified that 64% of directors thought their journal club orthopedic surgery training programs. Guyatt noted that was important or very important to the educational mission not all clinicians need to appraise evidence from scratch, of their training program. Other top purposes included but all need some skills. Thus, each journal club needs to learning literature review skills (87.5% of directors), respond to the needs of its participants and thus no single providing training in research education (52.9%) and ideal format exists. research design (52.4%).

Clinical knowledge transmission was found to be a more important goal in journal clubs in orthopedic fellowship programs over residency programs. This was found in a survey of 57 hand surgery fellowship directors, where the current literature was reviewed for the fellows and faculty as a primary goal. 15 These fellowship directors felt this journal club was very important for fellowship training.
Secondary goals of journal clubs for residents include increasing reading comprehension, fostering residentfaculty relations and learning orthopedics in an alternative 4,14 manner. Dirschl, Tornetta and Bhandari published a comprehensive review of orthopedic journal clubs in 2003. 17 These authors discussed methods to design, conduct and evaluate these educational meetings with current evidence. The following discussion will address these issues.
in some countries for some specialties may include critical PLANNING AND ORGANIZATIONAL ISSUES appraisal of a paper, as seen in psychiatry. 16 Not all journal clubs are successful despite their presence The target audience must be identified, including their in the majority of the orthopedic training programs. needs and interests. This will influence the format of the Sidorov 8 defined successful journal clubs as those that meet journal club and papers chosen. Emphasis may be placed educational objectives and as those that continually on keeping up to date with recent advances in orthopedics promote and maintain resident interest. Jones et al versus the educational value of critical appraisal of papers.
suggested that all departments with a journal club should These goals are not mutually exclusive, but each requires regularly revise their selection of journals in order to significant time and organizational commitments.
increase the value of this important educational process. 18

PREVALENCE AND CHARACTERISTICS OF ORTHOPEDIC LEADERSHIP JOURNAL CLUBS
The responsibility of running the journal club by a There are only two known published papers regarding designated individual or group of individuals is important. orthopedic journal clubs. In 2000, Greene was the first to Effective journal clubs are correlated with having a survey 161 North American orthopedic training program designated leader. 5 An interest in medical education and a One hundred and forty-nine programs (93%) belief that the journal club is important are essential responded. Regularly scheduled journal clubs were part attributes of the leader and facilitators. This person or of the educational program in 99% of the orthopedic persons would be responsible for the organization, residency training programs. Seventy-eight per cent met execution and evaluation of the club. In addition, having once per month and 9% met twice per month. Papers from residents actively involved in planning and operating the more than one scientific journal were reviewed in 82% of club has been found to be important. 19,20 Having a skilled clubs. Half of the meetings (50%) restricted discussion to moderator, whether resident or faculty member, is scientific studies only. A minority of clubs discussed case important to the value and attendance of the club. 17 reports or review articles. The average number of assigned papers to each resident was 2.6 (range: [1][2][3][4][5][6][7][8]. A designated Part of the success of any journal club is the organization faculty member (38%) or the chairman of the orthopedic within which it is run. If the orthopedic division or program (17%) moderated the discussion, whereas 32% department supports this activity, then it is more likely to chairmen. 4 were moderated by rotating faculty and 13% by chief residents. Half of the meetings were held at the departmental office, 31% met at the home of a faculty member and 18% met at a restaurant. The meetings were held in the evening (68%) or at the start of the work day (29%). All journal clubs met for a period of one to two hours. Attendance by the residents at the club was rated as 80% to 100% by 59% of programs, 60% to 80% by 36% of programs and 40% to 60% by 4% of programs. A full meal was provided at 50% of the meetings or a light snack provided at 37%, mostly funded by departmental funds. The top three goals of these clubs were: teaching residents how to evaluate scientific articles, instilling a habit of reading scientific journals and facilitating residents be successful.

LEARNING OBJECTIVES
Although many studies state educational goals for the journal club, many programs do not have formal written learning objectives. This was demonstrated in a survey of emergency medicine program directors, where 42% of programs had not established objectives. 19 These objectives are important to formalize as they articulate and communicate the goals of the club. Parameters of the meeting can be defined regarding the content, number of papers to be reviewed, which journals' papers should be obtained from, the format and setting. The effectiveness of the club can then be   8,20 Having a trainee as a club leader may make the fellow trainees feel less intimidated in asking questions. Senior trainees, rather than the faculty, may be more attuned to the needs of their junior colleagues.

FREQUENCY
Monthly journal clubs are the norm for the majority of postgraduate training programs. 4,22 More frequent meetings may be difficult, especially if residents are expected to review numerous papers for each club or if a detailed critical attendees and the room should be comfortable. By appraisal is required. maintaining clear boundaries, group theory suggests that the environment allows a sense of security and thus allows TIME creative thinking. 16 Residents and faculty are busy attending to clinical duties Audience participation is crucial to the success of journal during daytime working hours in the majority of clubs, unlike traditional teaching conferences. It has been orthopaedic training programs. Thus having journal clubs shown that interventions involving only didactic sessions early in the morning before the work day or in the do not change physician behavior. 21 The educational value evenings is more convenient for all involved. 17 In contrast, of the meeting is optimized by the interactions of the midday meetings may be more convenient in nonsurgical attendees and the dynamic exchange of opinions and training programs.

FOOD
Mandatory attendance has been found to be important 8 with respect to high attendance rates and longevity of The regular provision of food has been associated with journal clubs. Continuity is promoted by having a regular successful journal clubs . 4,22 In orthopedics, 87% of meetings group of attendees. On the other hand, trainees may feel provide some sort of food. 4 Longevity and high attendance attendance is imposed on them rather than viewing the rates are correlated with the provision of food. 8 club as an educational opportunity. This may be addressed journal club meals may be provided by individual faculty by allowing residents to set their own rules such as journal or by divisional or departmental support. There have been club presenter opportunities and participating in choosing recent strict North American guidelines on industry funding papers to discuss.
of medical educational events. This same issue has been discussed in the United Kingdom. 39 The venue should suit the group. It should facilitate relaxation and conversation. Promoting eye contact and NUMBER OF PAPERS TO REVIEW encouraging active participation are facilitated by seating individuals in a circle or a horseshoe. 16,17 Options for There is significant variability in the number of papers to meeting locations include departmental offices or review in journal clubs. 15,23,24 A range of three to 10 papers conference rooms, faculty homes or restaurants. 4 seems to be a reasonable trade-off between having too ideas. 17

Funding
Restaurants or pubs may be distracting if there is significant ambient noise or music drowning out the discussion of papers.
Optimal discussion groups are composed of 10 to 12 members. 17 Thus in large journal clubs, it may be necessary to divide attendees into these smaller groups to facilitate participation and discussion amongst all members.

MODERATORS
Faculty support with independent running of the journal club (by a senior trainee) was shown to lead to high many articles (limiting valuable discussion) and too few articles (limiting the breadth of information). 17 The number of papers and depth of review should be individualized by each training program.

LINKING JOURNAL CLUB TO THE CURRICULUM
As mentioned earlier, journal clubs can be a venue to teach critical appraisal skills to residents, either as formal sessions or through discussion of the chosen papers. Supplemental formal lectures on this topic could also be provided in the core curriculum of training programs. This has been an important stated goal of orthopedic program directors.  Alguire et al 22 published a packaged critical appraisal Many authors have studied the educational effects of curriculum that included reading guides and other teaching journal clubs in residency training programs. In one study, materials. residents whose meetings focused on epidemiology and biostatistics thought they read with more attention to the The use of a reading checklist was evaluated in an study design and methodology, in self-assessment, than emergency medicine training program. 25 the control group of residents in a traditional journal club. 20 the structured review instrument was associated with higher In this randomized study, there were no significant overall satisfaction with the journal club format and a differences between the two groups of residents in objective perceived improvement in clinical education. Improvement testing of knowledge of epidemiology, biostatistics, nor in critical appraisal skills was not tested. The residents did critical evaluation.
not perceive an increased workload, nor did attendance rates decrease. In a similar study of emergency medicine residents with a prospective, case-controlled design, the study group Thus the use of a structured review instrument is an effective (journal club with emphasis on epidemiology principles) adjunct to the journal club for teaching and applying critical and control group (traditional journal club) of residents appraisal. This tool may be used for resident evaluation of improved their performance over the one-year period. 25 knowledge acquisition and the impact of the meeting on No difference was shown between groups with objective the overall educational training program. pre-testing and post-testing in gaining knowledge in clinical epidemiology principles. This similar result was found in TYPES OF JOURNAL CLUBS another study of two pediatric training programs, whose only difference was that one program had two introductory Many types of journal clubs exist. No one type is superior lectures on epidemiology principles. 26 to the others. This allows organizers to tailor the club to their educational objectives. An individual residency IMPACTS OF JOURNAL CLUB ON READING HABITS, training program may choose to adopt more than one type, KNOWLEDGE AND SKILLS as each one may not address all goals and objectives desired. Innovative types of journal clubs used elsewhere Parkes et al revealed a small evidence base that journal may generate ideas for local use.
Resident use of clubs probably do improve knowledge in biostatistics and clinical epidemiology in a Cochrane review. 27 Conflicting evidence exists on whether they enhance critical appraisal skills. Self-assessment shows more improvement than objective measurement of skills. 22 The impact of journal clubs on patient outcomes has not yet been investigated in a well-designed trial, as there is difficulty in measuring this process.

STRUCTURED REVIEW INSTRUMENTS
Prepared checklists exist to review papers in a structured format. These can be found in reading guides such as the Users' Guide to Medical and Surgical Literature series of articles in the Journal of Bone and Joint Surgery, 28   Most EBM occurs in a journal club format. 11 Training programs may offer a seminar series, where residents present cases, generate questions and critically appraise the literature. Simpler concepts of EBM may be assigned to junior level residents, such as therapy and diagnosis. More complex topics, such as meta-analysis, decision analysis and economic analysis, may be assigned to senior level residents. research methods and statistics are the focus.
It should be noted that not all residents or faculty are There are several possible formats to run the EBM journal interested in attaining an advanced level of EBM skills. 9 club. One session may focus on question setting and Thus other sources of papers may include the use of identifying the most relevant papers. The next session can evidence-based summaries written by others, such as the appraise them. Secondly, attendees can prepare the first evidence-based orthopedics section of the Journal of Bone three steps in advance, leaving the club's time for critical and Joint Surgery. Learning a basic subset of skills will appraisal. Lastly, a question could be posed for a debate help in training the next generation of orthopedic surgeons between two teams. A chairperson could mediate to be up-to-date practitioners, who are referred to as arguments from each side.
evidence-based users.
An evidence-based journal club has been designed for JOURNAL CLUBS BASED ON CRITICAL APPRAISAL faculty interested in medical education, which can be applied to almost any clinical topic or specialty area. 8 Here, To reiterate, critical appraisal is the systematic weighing unread journals relating to a specific topic area are brought up of evidence. The principles of research methods and to the conference. The attendees read the titles of the papers statistics are the focus of this format. A structured review out loud in small groups and ask three questions to evaluate instrument is used. Up to five papers are reviewed at each if specific papers achieve relevancy criteria: 1. Does the meeting. Classic papers may be reviewed, which are article have an impact on the topic? 2. Does the article frequently referred to in the literature. Attendees can then focus on a common issue? 3. Will the article change assess the validity of the conclusions drawn. practice? The article is tagged for critical review if the answer is yes to all three questions. It is then assigned to By dividing attendees into small groups of 10 to 12 two attendees for review and discussion at the next meeting.
members, more audience participation may occur. 12,17 Each Challenging the participants to think critically about which group is assigned critical appraisal questions after the article to read was linked to high satisfaction levels.
presenter briefly introduces the paper. The session is completed with a general group discussion of the correct In an obstetrics and gynecology program, a very structured answers. The Pocket Guide to Critical Appraisal 32 may aid 12-month evidence-based curriculum has been designed in selecting appropriate questions. to cover 24 topics in epidemiology, biostatistics and experimental design. 31 The journal club met monthly for two hours and two sets of papers were distributed for each session. The first set consisted of literature on topics in epidemiology, biostatistics and experimental design, with two to six papers distributed for each session. The second set of papers consisted of articles for critical review, selected from all medical specialties to illustrate the concepts learned from the first set of papers for each session. It was reported as well received by the residents, although a great deal of preparation was necessary. The residents commented that they would have preferred all of the papers to have come from the obstetrical and gynecological literature instead of from general medicine. The full list of papers can be One disadvantage of this format is that attendees, including faculty members, may feel intimidated to participate if they don't feel confident with their critical appraisal skills.
Inviting a statistician to the journal club will aid in understanding statistical issues. 16 An article from internal medicine 33 reported such a format. One resident volunteers to select and present one clinical study for the journal club. All residents are provided with the paper two weeks before the meeting. At the same time, the resident and a faculty mentor devise and provide a series of questions to all participants regarding the quality of the research, appropriateness of the data and methods and the validity of the conclusions. At the journal club, discussion focuses on answering the questions rather than the clinical aspects of the paper. A great deal of faculty involvement and facilitation is required to succeed in this format.

JOURNAL CLUBS BASED ON KNOWLEDGE TRANSMISSION
Moro JK, et al.: Orthopaedic Journal Clubs particular journal to review. The residents in each year divide the articles in their assigned journal and each resident prepares written reviews of the article(s), usually one to five papers per month. Each resident then submits their review(s) via e-mail to all residents and faculty in the department. Thus a complete review of the current month's otolaryngology literature is provided. The best four to 10 articles are then selected to discuss at that month's journal club. These monthly reviews are archived on a server, This may be the most popular form of journal club in most which are accessible from the departmental website to all training programs. Despite many formats that exist, the residents and faculty. It can also be searched by title, date, main goal is to provide a brief overview of new journal and thread. developments in a topic area or subspecialty.

EVALUATION OF THE JOURNAL CLUB
A survey of orthopedic hand surgery fellowship programs revealed that as many as 12 papers are discussed in a one-hour conference. 15

THE NO PREPARATION JOURNAL CLUB
Periodically asking the attendees about their satisfaction with the club is one way to modify the meeting if needed. Anonymous feedback from the residents may alert In this unique format, the paper(s) for discussion is not distributed to the attendees prior to the journal club. 24 Here, organizers about strengths and weaknesses and potentials for improvement. 17 The residents could also be asked to a resident chooses a paper and then discusses it at the self-assess their clinical reading habits and critical appraisal meeting with the aid of a faculty moderator. The attendees skills. Objective measures of understanding critical appraisal do not read the paper beforehand. A brief presentation of skills could be performed to document knowledge gain in the research question of the selected study begins the epidemiologic principles, with a pre-test and post-test meeting. The participants are then asked to suggest format 24 or by the evaluation of a factitious standardized appropriate study designs to address the research question, article. 23,25 These periodic evaluation methods will aid in followed by the author's chosen study method. The improving the educational experience of the journal club, attendees are then asked to assume the author's chosen regardless of its format. study design and suggest and discuss additional details of study methodology. This process continues until all relevant CATALOGUING CRITICALLY APPRAISED ARTICLES aspects of the study methodology are discussed. The results have developed and conclusions are then reviewed. It was reported in this article that more positive discussion of methodological issues occurred rather than participants being hypercritical, which occurs when papers are reviewed before the journal club meeting. As well, resident workloads were decreased by not having to prepare in advance of the meeting, attendance rates were higher and residents gained a greater appreciation of the author's design choices.

INTERNET-BASED JOURNAL CLUBS
An otolaryngology residency program reported on a journal club employing e-mail and the internet to archive current literature reviews in otolaryngology. 34 Each training year in the residency program (PGY2, PGY3), was assigned a FROM JOURNAL CLUB Critically appraised topics (CATs) is a term regarding a document one creates for themselves in response to a clinical question. It summarizes an individual item of evidence one has found and presents the results in an easily readable format. General internal medicine fellows at McMaster University invented CATs as a means to sharpen their critical appraisal skills and improve their abilities as bedside teachers of evidence-based medicine. Several medical training programs maintain internetbased logs of papers that have met predetermined criteria for validity on various topics. Thus a database is created of current evidence for access by residents, fellows and faculty.

JOURNAL CLUBS AND ADULT LEARNING
Educational research has identified several unique characteristics of adult learners. These principles include: relate the task to personal goals or to the immediate environment, present learning objectives as clinical problems, use problem-solving strategies, vary teaching approaches to suit different learning styles, use active learner participation and provide frequent constructive feedback. 16 It may be that instruction that incorporates