Program Director Corner – February 2018
Richard J. Comi, MD
Program Director, Endocrine Fellowship
Dartmouth Hitchcock Medical Center
richard.j.comi@hitchcock.org
The Importance of Journal Club in Medical Training
Medical education is a discipline of constant evolution, keeping pace as the role of the physician in society evolves. We in medical education have the best vantage point from which to ponder the definition of “physician” because it is our charge to shape that definition. Our charge is not to shape the physician of today but the physician of today and tomorrow. To complicate this moving target, there are now more participants in health care with more varying levels of participation. Physicians no longer primarily deliver the care in a wide variety of settings – patient education, preventative medicine services, follow up care for chronic disease and even procedures are now performed by nurse practitioners , physicians assistants, pharmacists, social workers, case managers and medical assistants. As educators, we must identify the unique role of the physician in the health care landscape and emphasize it in our training programs.
One of the unique attributes of the physician in health care is the role of guiding change in clinical care by developing and incorporating the latest information, technologies and evidence base for practice. In order to do this, physician must have the deepest knowledge base of the health care team and the best skills to use that knowledge base. Starting after the first year of medical school, review of published articles is a way to exercise and sharpen the knowledge base of medicine. That knowledge base is no longer fact-based but instead principle based. Applying pathophysiologic, epidemiologic, biologic and molecular principles to published evidence practices the key skill of using knowledge based principles. It is in this arena that journal club can be an essential tool in a training program to develop the skills of critical thinking- in essence, the content of journal club is less important the process of journal club. However, if journal club is to be a key element of training, it needs to be a directed, regular exercise instead of a random casual event.
In our program, journal club is a major didactic component. We hold journal club weekly. In each journal club, one faculty member and one fellow presents a paper. To ensure that our fellows know the nature of the clinical endocrine literature, for the first half of the year the journal is assigned and those assignments are rotated from a list of 9 pertinent journals so that over 6 months each fellow has read an article in each of the major journals . We rotate the following journals:
1) Annals of Internal Medicine
2) Clinical Endocrinology
3) Diabetes Care
4) Diabetologia
5) Endocrine Practice
6) Journal of Clinical Endocrinology & Metabolism
7) Journal of Clinical Investigation
8) Lancet Endocrinology
9) New England Journal of Medicine
* We used to include Nature Medicine but found it did not lead to good discussions.
We do not assign the article, but instead for the first 6 months of the academic year the fellow and faculty member are each assigned a different journal and must select an article from its most recent issue to present. In the second half of the year we open it up to any journal of their choosing, now that they know the types of articles found in each. As one might imagine, the Journal of Clinical Investigation is considered the toughest assignment, though it is remarkable how good a job a reluctant fellow can do with this!
I strongly encourage a formatted approach emphasizing hypothesis based analysis in order to teach how to read and analyze the literature. To remain focused on data analysis, I allow no more than one or two background slides, to be taken from the paper’s introduction. The presenter must then present the hypothesis of the paper and is expected to analyze the methods and the results from the point of view- “ how does this method address the hypothesis, does this patient population represent this hypothesis, do these results pertain to the hypothesis, did the conclusion address the hypothesis.” The final slide is “will this change my practice”. In general presentations are restricted to 10 -12 slides. Discussion of every slide is encouraged, leading to a very lively conference, with comments like “ I don’t understand how this method addresses the hypothesis directly” or “this seems the wrong patient population to look at this” or “ I think these conclusions go beyond their data and hypothesis”. By providing the presenter and audience with a point of view (the hypothesis), discussion is focused and constructive. Of course, some papers do not have a clear hypothesis and this lack of a focused question becomes part of the analysis. An additional advantage of this more structured approach is that it allows evaluation of the ability to engage in critical thinking, not only of the presenter but also the participants.
My objectives with this journal club structure are to familiarize the fellows (and faculty) with the breath of the endocrine literature, to sharpen their skills of critical thinking by enabling them to use their own knowledge base to analyze data and methods. In this, study design, epidemiology and methodology are all taught in a collective experience. Journal club work practices the key skill of the modern and future clinician is to understand, analyze and assess new developments in their field for their team and for their patients. This is a unique role not shared by the other professionals within a health care team. Thus, journal club activities can be a critical training ground for future physicians.