Improving journal club presentations, or, I can
present that paper in under 10 minutes
Mark D Schwartz, Deborah Dowell, Jaclyn Aperi and Adina L Kalet Evid. Based Med.
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Do you run a journal club? A helpful insight from thisissue,itistheuseoftheABCDscore,whichtellsuswho
someone at our recently finished 3 day EBM workshop
needs urgent investigation after a transient ischaemic attack
in Oxford was that many journal clubs are boring
(TIA). The likelihood of stroke is very high in the first days
because the articles are quickly trashed as poor research and
and weeks after a TIA, and reducing risk then is vital. We
nothing changes. Since only 1 in 20 articles passes the EBM
have previously published an evaluation of the ABCD rule,
journal's validity criteria, this is likely to occur 19 out of 20
but Johnston et al have further validated the score and
times for journal articles that simply look "interesting." So for
confirmed it is highly predictive. Of course, this needs to link
journal clubs you might like to consider either articles from
to a rapid evaluation service, so you might need a little local
EBM or at least make sure that you screen articles for basic
validity before the session. In this issue there is also some good
Among the others I will try out is teaching male patients
advice from Schwartz on how to make a clear succinct
with lower urinary tract symptoms a few simple things for
presentation at journals clubs. Along with good food and
self management (Van der Muelen). The intervention has 1
coffee, we think this should be mandatory!
of our better NNTs, and is relatively simple and harmless.
We note, though, that our current criteria of requiring a
Also, although it won't directly change my practice, it's useful
randomised trial for all treatments, may have to be slightly
to know that SSRIs can start to work in depression within a
modified. One of the editors recently published an article on
week, with a close to linear build up of response over the first
when randomised trials are not needed (BMJ 2007 Feb
17;334:349–51). This was triggered by his successful use of
Unfortunately, some widely used interventions seem to
the "parent kiss" method to remove a bead lodged in a young
have small or non-existent benefits. What appears to be the
patient's nose. It seems some treatments have such a rapid
definitive trial of whether to start mammographic screening
and dramatic effect that trials are not needed to pick the
at 40 years of age or later didn't find a statistically significant
treatment signal from the prognostic noise. But currently the
reduction in breast cancer mortality (Moss). Similarly, a large
list of such dramatic treatments is pretty short.
trial of tympanostomy tubes did not show improvement inlanguage outcomes (Paradise). I am sure neither of these will
stop the arguments though.
To keep our practice up to date, it is helpful to ask with each
PAUL GLASZIOU, FOR THE EDITORS
issue of EBM what things you might start doing and what
University of Oxford
things you might stop? If I had to pick 1 change to make from
Improving journal club presentations, or, I can present that paper
in under 10 minutes
Fifteen years ago we sought to develop a method for reasonedthat,justaslearnersprogressfrommeanderingand
teaching residents how to make lean, pithy journal club
imprecise case presentations on clinical clerkships to brief,
presentations. Our aim was to help them distill an article
utilitarian sign-outs as senior residents, journal club pre-
down to its core while systematically reviewing its validity
senters can learn to efficiently convey the essence of an
and telling a compelling story. Others have created successful
journal clubs by explicitly linking the educational experience
We introduce this model of journal club presentation to
to questions raised in caring for patients.1
medical residents in a small group workshop early during
Brief article presentations are structurally similar to the
internship and then deepen residents' skills during our
brief case presentations we do all the time. On work rounds,
clinical epidemiology course in the second year.2 Residents'
morning report, or sign-out, the goal is to communicate the
skills are reinforced and refined throughout residency at a
essential information about a patient in a concise, mostly
weekly journal club attended by 10–20 residents, fellows, and
standardised format that is easily digested by the listener. We
EBM Volume 12 June 2007
We use the following 10 step guideline to help presenters
‘‘Does high dose atorvastatin for 5 years reduce the incidence of
increase efficiency in assessing a study's validity and results
stroke among patients with recent stroke or TIA and no known
and to increase confidence in limiting a presentation to the
coronary heart disease?''4
core essentials. Faculty members model the process andresidents learn through reflective practice.
4. STATE THE IMPORTANCE/RELEVANCE/CONTEXTOF THIS QUESTION
1. DESCRIBE THE CASE OR PROBLEM THAT
Following this 1 line description of the study and statement of
ATTRACTED YOU TO THIS PAPER
the question, concisely state the importance of this question.
Start your article presentation with a brief case presentation,
This information can usually be found in the author's
or briefly explain how the article is relevant to a patient or
introduction where they put their study in the context of other
problem you are considering. This helps listeners more fully
literature. This context can be described in 1–3 sentences.
engage with your presentation and makes it more of a story.
‘‘Therapy with statins reduces the risk of stroke among patients
For example, ‘‘An otherwise healthy 68 year old man came to see
with coronary heart disease and those at increased risk of
me after he suffered a transient ischaemic attack (TIA) and I
cardiovascular (CV) disease. No studies thus far, however, show
wondered if he should be on a statin even though his risk of cardiac
that statin treatment decreases the risk of recurrent stroke among
disease was low.''
otherwise healthy patients with a history of stroke or TIA.''
2. EXPLAIN HOW YOU CAME ACROSS THIS ARTICLE
5. DESCRIBE THE METHODS BY GIVING MORE
Very briefly describe the search strategy you used to track
DETAIL ON THE QUESTION COMPONENTS
down this particular article.
Following this brief background, 1 way of briefly describing
‘‘I found this paper by searching Medline using the terms
the methods is to give a bit more detail on the Patients,
Intervention, Comparison, and Outcomes (PICO) related to
inhibitors, and the Clinical Query for therapy (maximising
specificity) which identified 9 articles.''
P—‘‘The study included 4371 patients, 60% men with an average
age of 63 years and mean LDL cholesterol of 133 mg/dl. All patientshad a recent stroke (69%) or TIA (31%). Those with atrial
3A. DESCRIBE THE STUDY …
fibrillation, embolism from other cardiac sources, and subarachnoid
In a case presentation we start with some standard descriptors
haemorrhage were excluded.''
of the patient followed by the chief complaint or STATEMENT
IC—‘‘Atorvastatin 80 mg daily or identical placebo.''
OF THE CLINICAL PROBLEM. For example:
O—‘‘After a median of 4.9 years of follow up, the primary
outcome was incidence of fatal or non-fatal stroke, and all cause
This is a 55 year old male smoker from Bangladesh who
death. Secondary end points include a composite end point of stroke or
presented with 2 hours of burning chest pain and is
TIA, major coronary event, major CV event, acute coronary event, any
ADMITTED AS A RULE OUT.
coronary event, revascularisation, and any CV event.''
When presenting an article, we can think of some standard
descriptors. For example:
6. STATE YOUR ANSWERS TO THE CRITICALAPPRAISAL QUESTIONS ON VALIDITY
N What type of question was asked—for example, diagnos-
Next, briefly answer the appropriate critical appraisal questions
tic, therapeutic, prognostic, aetiologic, or economic?
on validity using the JAMA users' guides to the medical literature5
N What type of study (method) was used—for example,
and elaborate with some explanation, questions, or concerns if
randomised controlled trial, retrospective cohort, case
needed. Although it is a bit formulaic to go through each
control, meta-analysis, cross-sectional, descriptive, deci-
question, it is a good habit to develop, and use of the GATE
sion analytic, or cost effectiveness?
frame makes it easier.6 Remember, if you suspect bias, consider
N Where was the study done (if relevant)—for example,
not only its possible presence, but also its direction, magnitude,
multicentre, veteran affairs centre, population based,
and impact on the study's conclusions; not all flaws are fatal. Be
Antarctica, New York City, academic medical centre, or
cautious to not get lost in the statistics/analysis section.
Remember, ‘‘Statistics are a tool while study methods rule!''
N Any other outstanding features—for example, well known
For a study of the efficacy of therapy, these questions apply:
author or first study of its kind.
N Did the experimental and control groups start out with a
So we might start by saying, ‘‘This was a multinational,
randomised, controlled trial of therapy, and the first study designed to
– Were patients randomized? YES.
answer the question .''
– Was randomisation concealed? YES.
3B … AND THE RESEARCH QUESTION:
– Were patients analysed in the groups to which they
were randomised? YES—intention to treat analysis.
The chief complaint of an article is the research questionor hypothesis to be tested. A well built research question
– Were groups similar re known prognostic factors?
has 4 basic components (PICO—see section 5 below):3
YES—see table 1.
Population—who was studied?
Did the experimental and control groups retain a similar
prognosis after the study started?
Intervention or exposure—what therapy, risk factor, tests,etc.?
– Were patients, clinicians, and outcome assessors aware
N Comparison or control–what alternative to intervention or
of group allocation? NO—all were blinded to random
N Outcome—clinical, functional, economic, etc.?
– Was follow up complete? YES and similar in each group.
EBM Volume 12 June 2007
‘‘Atorvastatin may modestly reduce the risk of recurrent
Remember, ‘‘The conclusions givith but the methods taketh
cerebrovascular events in patients with recent ischaemic cere-
away! Caveat lector—reader beware!''
brovascular accident or TIA. I will offer this medication to suchpatients but will still focus more on those at higher risk of cardiacevents.''
7. SUMMARISE THE PRIMARY RESULTSAt last, the results. Some like to present the bottom line result
10. FINALLY, PREPARE A 1 PAGE SUMMARY OF THE
up front in their presentation titles, similar to the format in
OUTLINE ABOVE AS A HANDOUT
ACP Journal Club and Evidence-Based Medicine. Alternatively,
The summary will serve as your notes for the presentation
you can report the results after the descriptors and research
and will help guide the group's attention. It also provides a
question. We find that when browsing a journal our eyes go
storable record of the article, similar to Critically Appraised
from the title (if it sounds interesting) to the conclusions in the
abstract. The inner question is, ‘‘If this is true (valid) would it be
Believe it or not, you can do all this in 10 minutes easy, 5
interesting or important to me?'' Or, if you prefer to keep people
minutes with very tight editing, and 2–3 minutes hitting just
in suspense, save the bottom line answer for the results:
‘‘Atorvastatin reduced the rate of fatal and non-fatal stroke from
These guidelines have dramatically improved the enthu-
13.1% on placebo to 11.2%, a statistically significant 16% relative
siasm for, quality of, and attendance at our journal clubs,
reduction in risk over 5 years. There was no difference in overall
which have now been running continuously for more than 15
years. Residents are expected to present the paper in 10
Limit your summary of the results to the primary question
minutes, provide a concise 1 page summary using the outline
and only present secondary results if they are relevant. It is
above, and lead a 20 minute discussion on the clinical and
helpful to bring your listeners' eyes to a particular row on a
methodological issues. As a result, residents have improved
table or a bar on a graph to illustrate your point. You will not
both their presentation and critical appraisal skills. In our
insult anyone by taking them by the hand and leading them
experience, this approach, familiar to residents because they
through the paper. And feel free to play with the numbers.
are parallel to patient case presentations, is easily learned and
‘‘As you can see under secondary outcomes in table 2, major
portable. Developed for a smaller group of primary care
coronary events were reduced by 35% from 5.1% to 3.4%. The
residents, the model is now used for all medical residents
primary result suggests an absolute reduction of 2% in fatal and non-
and fellows. Slides from these workshops are available at
fatal stroke so that we would need to treat 50 patients with 80 mg of
www.evidence-basedmedicine.com/. We believe this model has
atorvastatin for 5 years to prevent 1 event, a modest impact.''
contributed to the long running success of our journal club and
8. DESCRIBE WHY YOU THINK THE RESULTS CAN OR
made it a lively, relevant, and fun way to simultaneously
CANNOT BE APPLIED TO YOUR PATIENTS/
explore methods and medicine.
MARK D SCHWARTZ, MD
Finish with your assessment of the study's external validity—
DEBORAH DOWELL, MD
can you apply these results to your patients? Or better, are the
ADINA L KALET, MD, MPH
patients or setting so different from your own so as to make
New York University School of Medicine
these findings useless to you? How much might you have to
New York, New York, USA
adjust the study findings due to differences between the
1 Phillips RP, Glasziou P. What makes evidence-based journal clubs succeed?
study's patients or setting and your own?
Evid Based Med 2004;9:36–37.
2 Meserve C, Kalet A, Hanley K, et al. Clever nihilism: Do cynics
‘‘Would the efficacy be larger or smaller in older patients? In
learn in an evidence based medicine course? Medical Education Online
addition, the authors excluded patients at higher risk of haemor-
rhagic stroke and, in fact, atorvastatin may have increased the risk of
3 Richardson WS, Wilson MC, Nishikawa J, et al. The well-built clinical
question: a key to evidence-based decisions [editorial]. ACP J Club
haemorrhagic stroke in this study.''
4 Amarenco P, Bogousslavsky J, Callahan A, et al. High-dose
9. CONCLUDE WITH YOUR OWN DECISION ABOUT THE
atorvastatin after stroke or transient ischemic attack. New Engl J Med
UTILITY OF THE STUDY IN YOUR PRACTICE—RESOLVE THE
5 The Evidence-Based Medicine Working Group. Users' guides to the medical
CASE OR QUESTION WITH WHICH YOU BEGAN
literature: a manual for evidence-based clinical practice. Chicago: AMA Press,
If you started your presentation with a case, be sure to leave
time to come back to the case at the end and try to apply the
6 Jackson R, Ameratunga S, Broad J, et al. The GATE frame: critical appraisal
with pictures. Evid Based Med 2006;11:35–8.
study's findings to your patient or problem. Give the listeners
7 Centre for Evidence-Based Medicine. www.cebm.net/cats.asp (accessed 20
a sense of closure:
13th Oxford Workshop on Teaching Evidence-Based Practice
10th – 14th September 2007; Oxford, UK.
Chair for this workshop:
Prof. Paul Glasziou
Director, Centre for Evidence-Based Medicine;
University of Oxford.
The workshop is aimed at clinicians and other healthcare professionals, including those involved in mental health, who already
have some knowledge of critical appraisal and experience in the practice of evidence-based health care and who want to explore
issues around teaching evidence-based medicine.
Further details can be obtained at www.cebm.net/ or by emailing [email protected]
EBM Volume 12 June 2007
Vormals NVersZ V Info-Letter ersicherungs- und Haftungsrecht In Zusammenarbeit mit der Neuen Juristischen Wochenschrift Nr. 15 · 14. August 2003 Schriftleiter: Rechtsanwalt Dr. Theo Langheid, Köln Editorial Aktuelles Thema BB – oder: die Macht der Rating - Agenturen RA Dr. Henning Seel:
Published May 3, 1999 Inhibition of T Cell Proliferation by MacrophageTryptophan Catabolism By David H. Munn,*‡ Ebrahim Shafizadeh,* John T. Attwood,*Igor Bondarev,* Achal Pashine,* and Andrew L. Mellor* From the *Institute of Molecular Medicine and Genetics and the ‡Department of Pediatrics, Medical College of Georgia, Augusta, Georgia 30912