Effectiveness of Evidence Based Journal Club Conducted among Postgraduate Students by Faculty of Medical, Dental, Ayurveda Colleges Affiliated to Rajiv Gandhi University of Health Sciences in Hassan District - Karnataka, India

Introduction

A journal club is an important forum for teaching research methodology, clinical epidemiology and statistics, as well as providing opportunities for training in clinical decision making and gaining critical appraisal skills. It can be used to facilitate an evidence-based approach to problem solving, as a tool to inform the development of guidelines, and to enable sharing of ideas regarding clinical scenarios.¹

A reading club can provide a forum for discussion on current work place issues, where participants use their clinical experience to support and/or challenge the article’s content.²

Journal club (JC)is an educational intervention that improves reading habits, knowledge of clinical epidemiology and biostatistics and the use of medical literature in clinical practice for postgraduate physician in training.³ It is a group of individuals who meet periodically to evaluate critically the clinical application of recent articles in the medical literature.⁴ It also provides an opportunity for social interaction.¹ The first reported club was led by Sir James Paget in 1835 at St Bartholomew’s Hospital in London and the first known regular club was reported by Sir William Osler at McGill University in 1875. The first article examining a journal club as an educational tool was by Mattingly in 1966.^5,6

While there is considerable published literature describing journal clubs conducted in different settings and for different health consumers, there appears to be no ‘Gold Standard’ process for conducting a journal club, or to evaluate journal club effectiveness in assisting practitioners translate knowledge into practice. It is therefore an ongoing challenge for clinicians to design and maintain a stimulating, educational and sustainable journal club format that assists the participants to stay up to date with the literature and to translate journal club activities into evidence based practice.⁷ 

The journal club has becomean integral part of continuing health care and dental education. It offers the opportunities for clinical decision-making training, critical assessment skills and an evidencebased approach to the problem and provides a tool for ming the development of guidelines and exchanging ideas about clinical issues.

Materials and Methods

An observational, cross-sectional study was conducted in which structured questionnaires were randomly distributed among faculties working at Medical, Dental, Ayurveda colleges in Hassan affiliated to Rajiv Gandhi University of Health Sciences (RGUHS). Faculties fulfilling the criteria for selection and those who agreed for participation were included in the study. The study was conducted in selected hospitals and all the faculties were informed verbally about the study by the principal investigator.  

Inclusion and exclusion criteria

Faculties working for at least six months in Hassan colleges and hospitals. Faculties from all the age groups and both the sexes were included. Doctors who were working in the clinics other than those mentioned above were excluded. The research instrument was a self-administered questionnaire and was distributed to the Medical, Dental and Ayurveda faculties. 

Instrument

The research instrument was developed by the principal researcher based on reviews of similar earlier investigations.The questionnaire was divided into two parts to include attitude and practice based questions and knowledge based questions.

Data collection

Data was collected through closed ended questionnaires from January to February 2020. All the faculties were informed and given the questionnaire after obtaining consent to participate.

Data analysis

Data was analyzed using Statistical Package for Social Sciences (SPSS) version 20. The p value was considered as significant when < 0.05 (confidence interval of 95%). Descriptive statistics were carried out to calculate responses for each question. Total behaviour and performance values of each group of faculties were compared using one-way ANOVA test.

Effectiveness of evidence based journal club conducted among postgraduates by Medical, Dental, Ayurveda Faculties of RGUHS in Hassan district, Karnataka, India — Questionnaire.

1) What is a journal club?

A. A meeting where recent article is read

B. A meeting where selected articles on single theme are read

C. A group discussion to analyze latest articles

D. A group discussion where article is criticized

2) Whether you are doing evidence based journal club?

A. Always

B. Sometimes

C. Not very frequently

3) How frequently you organize journal club in department?*

A. Once in a week

B. Twice in week

C. Once in a month

D. Twice in a month

E. As and when required

4) What do you do when you can’t decide the treatment to be given from the guidelines?

A. Do as our seniors tell us to do

B. Search for articles answering the similar question, appraise and decide based on applicability

C. Search for an article in a journal and follow its conclusion

D. None of the above

5) What is the correct sequence of levels of evidences?

A. RCT > expert opinion > case control > sys review and meta-analysis

B. Expert opinion > RCT > case control > sys review and meta-analysis

C. Sys review and meta-analysis> RCT > case control> expert opinion

D. Case control > expert opinion > RCT > Systematic review and meta-analysis

6) Which part of an article is read for assessing validity of a study?

A. Abstract

B. Methodology

C. Results

D. Discussion

7) Which of the following is not the part of a good evidence? *

A. Large case series.

B. Study with minimal risk of bias

C. Study with large sample size

D. Has minimal lost to follow up

8) Only studies with positive results being accepted by journals leads to

A. Selection bias

B. Publication bias

C. Recall bias

D. No bias

9) What are the components of evidence based medicine?

A. Following results from journal articles

B. Following results obtained from critical evaluation of a review article

C. Following results obtained from critical appraisal of best available evidence

D. Following results obtained from critical appraisal of best available evidence tied with clinical expertise and patient values

10) What does p – value < 0.05 mean?

A. Probability that the result is seen by chance is < 5%

B. Probability that the result is seen by chance is > 5%

C. No information obtained regarding significance of the result

D. The null hypothesis can be accepted

11) Which is not a characteristic of a randomized control trial?

A. Random selection of cases and controls

B. Randomized allocation of participants and concealment

C. Same baseline characteristics of the two groups

D. Same treatment to the two groups apart from the treatment being studied

12) Which of the following is true about confidence interval?

A. It gives information about whole population

B. p – value gives more information

C. Crosses line of null effect if the result is significant

D. Wider the CI, more precise is the result

13) In which of the following article will you see a forest plot?

A. RCT

B. Systematic review

C. Meta-analysis

D. Prospective cohort study

14) What do horizontal lines on a forest plot represent?

A. P – values of different studies

B. Confidence intervals of different studies

C. Relative risk of different studies

D. Odds ratios in different studies

15) Which of the following is a character of an applicable article?

A. PICO matched between clinical query and study question

B. Statistically significant results, not clinically significant

C. Clinically significant results, not statistically significant

D. at and b E. at and c

16) Do you think that following evidence based journal club will aid in decision making?

A. Yes

B. No

C. Can’t say

Results

In the present study, a total of 405 faculties participated, among which 60 were from Dental, 270 were from Medical and Ayurveda faculties were 75 (Figure 1). Five percent dropouts were noted during the analysis of study. Total attitude and practice scores and knowledge scores between each group of faculties were compared using one-way ANOVA test (Table 1 and Figure 2 & 3). The mean knowledge score for dental faculties was 7.3±2.3, for medical faculties was 6.9±1.8 and for Ayurveda faculties was 7.0±2.0. Total attitude and practice score for dental faculties was 5.5±2.1, for Ayurveda faculties was 5.9±1.8 and for medical faculties was 5.3±1.9. 

Pair wise comparison was done using Scheffe post hoc test (Table 2). There was no statistical significant difference in mean attitude and practice scores between medical and dental (i.e., p=0.852) and between dental and Ayurveda (i.e., p=0.447). Attitude and practice scores between medical and Ayurveda (i.e., p=0.072). Pair wise comparison for total knowledge was also done by Scheffe post hoc test. There was no statistical significant difference observed in between faculties.

In the present study, correlation between knowledge and attitude + practice was done using Pearson correlation. There was a weak positive correlation between knowledge and attitude + practice (i.e., r=0.041) and the correlation was found to be statistically not significant (i.e., p=0.641).

In the study, group wise comparison of each question was done using Chi-square test(Table 3).For the question ‘what is journal club?’, correct answer was provided by 86.6% dental faculties, 90.4% medical faculties and 85.3% Ayurveda faculties;there was no statistical significant difference noted. For the question ‘whether they were doing evidence based journal club’, 53.3% of dental, 59.6% medical and 57.3% Ayurveda faculties responded as ‘sometimes’. Statistical significance was noted for the data obtained with a p value of 0.001.

Regarding the frequency of organizing journal club in the departments, 21% of dental faculties, 29.6% of medical faculty and 24.0% of Ayurveda faculties responded as once in a week. There was no statistical difference between the groups (p=0.96).

For the question,‘What they will do when they can’t decide the treatment to be given from the guidelines’, 80% of dental faculties, 66.7% of medical faculties and 86.7% of Ayurveda faculties provided the correct answer as they search for an article in a journal and follow its conclusion. Statistical significance was noted with a p value of 0.001.

For the correct sequence of levels of evidence i.e systematic reviews and meta-analysis >RCT > case control study > expert opinion, 71.1% of dental faculties, 50% of medical faculties and 53.3% of Ayurveda faculties provided correct answer with a statistical significance (p=0.010). For the question, ‘which part of an article is read for assessing the validity of a study?’, 63.3% of dental faculties, 43.3% medical faculties and 38.7% of Ayurveda faculties responded with the right answer as abstract, and there was a statistical significant difference observed (0.008).

For the question pertaining to the meaning of p value, 45.0% of dental faculties, 60.4% medical faculties and 45.3% of Ayurveda faculties gave the correct answer (p= 0.015).

For the question ‘what do the horizontal lines on a forest plot represent?’, 38.3% of dental faculties, 23.3% of medical faculties and 68% Ayurveda faculties provided the correct answer as the confidence intervals of different studies, and a statistical significant difference was observed (p<0.001). In the scatter plot (Figure 4) showing the correlation between the total attitude+ practice and total knowledge showed a weak positive correlation was observed.

Discussion

A survey instrument containing 16 questions was used to evaluate the attitudes and knowledge of participants and the perceived impact of JC on professional practice.The survey included specific questions to evaluate participants’ attitude plus knowledge and practice. Journal clubs are well-known approaches that are used by different Health Care Professionals (HCP) to critique and be up to date with relevant health literature.⁸ The main aim of JCs is typically to bring a group of HCPs together who share the same interests, to engage in a discussion of selected articles related to their field and clinical practice.⁹ 

About 53.3% of dental professionals and 59.6% medical professionals are doing evidence based journal clubs ‘sometimes’ and 41.3% Ayurveda faculties always conduct evidence based journal clubs. The frequency of conducting journal club twice a week is only 13.3% in dental, 26.3% in medical and 21.3% in Ayurveda. It should be increased to enhance knowledge and practice in future professionals. Journal clubs conducted once in a month was observed in case of dental professionals, but medical and Ayurveda professionals reported it as once in a week.

By encouraging discussion among journal club participants, JCs enhance their critical appraisal skills. This enhancement of critical appraisal skills leads to development of knowledge about evidence based practice (EBP). Development of knowledge about EBP impacts participants’ clinical practices.⁸

According to Dirschl et al.,⁶ although many examples of different format of journal clubs exist, all share a common goal of transmitting to participants a superficial knowledge of new developments in a particular topic or subspecialty area. Journal clubs are for transmission of clinical information to medical professionals for their better practice and knowledge.

Lizarondo et al., (2009) stated that JCs create a supportive environment among participants to discuss research articles. This can be enhanced by a moderator who encourages journal club members to read articles, facilitates questions, engages in discussion, and ensures equal contribution by all journal club members.¹⁰

Selection of articles forthe journal club that are of interest to graduates or, even better, allowing them to participate in the selection of articles, also is an important means to generate postgraduate participation.¹¹According to Fleenor, Sharma, Hirschmann, and Swarts (2018), “critical appraisal is defined as those skills that enable practitioners to apply laws of logic to published clinical data so they may estimate the validity, reliability, and utility of the information presented in the article.”¹² Journal club attendance enhances HCPs’ knowledge of evidence based practice. Journal clubs increase knowledge of research in general, which consequently promotes knowledge of EBP principles.¹³

This study is in correlation with the findings of Tan, Hatah, and Tan (2017)¹⁴ who reported a positive association between involvement in JCs and research utilization practice. In the present study, a positive correlation was found between attitude plus knowledge and practice.

The internet-based journal club is also encouraged now a days. It is likely that consultants are confidant in voicing their opinions and have a greater interest in exchanging ideas on a global scale.¹⁵ 

Conclusion

The main purpose of journal club is to translate knowledge into practice and guide the clinician in critical appraisal skills regarding evidence based practice in medical profession. This awareness about journal clubs is essential in understanding the facilitators and barriers in the implementation of JCs, satisfaction with JCs, and the impact of JCs in practice.

By encouraging discussion among journal club participants, JCs enhance their critical appraisal skills. This enhancement of critical appraisal skills leads to development of knowledge about evidence based practice. Development of knowledge about EBP impacts participants’ clinical practices to a great extent. Journal clubs help participants update themselves with current relevant research. Discussion of this research encourages the incorporation of new knowledge into practice. A positive attitude towards journal clubs is essential for proper knowledge and the implementation of this knowledge into practice.