Journal Club: An Approach

Choosing a paper

Choose a paper that interests you! See How to Keep Up with the Literature, for some inspiration on how to find a journal article for dissection.
Additionally consider whether the study is topical and relevant to the unit you are working in. Older studies may also not reflect current intensive care practice.

Put the study in context

Providing some background addressing why the study was performed can be helpful in justifying its place in your departmental journal club. Is there some physiological dogma that has been challenged? Is there significant practice variation amongst intensivists? Have there been previous studies with conflicting results that this study addresses?

e.g. Raised PaCO2 increases cerebral blood flow. However, whether targeting hypercapnia in patients after out-of-hospital cardiac arrest improves neurological outcomes is unknown… (TAME trial)

e.g. Previous studies have demonstrated that Selective Decontamination of the Digestive tract (SDD) reduces mortality, however despite this practice uptake has been low in the context of concerns about (i) the generalisability of previous trials to our setting and (ii) antimicrobial resistance (SuDDICU trial)

Critical Appraisal

This is what we came for! If we change our practice based only on the primary outcome of a study, we may not be doing the right thing for our patients.
Critical appraisal requires the presenter and audience to consider whether the study was valid, which can be divided up into two main questions:

1. Does the study have internal validity? That is, the extent to which the design of the study reduces bias
2. Does the study have external validity? That is, the extent to which the results of the study are generalisable

To satisfactorily answer these questions, you may need to dig around the Supplementary Information section. There are many free-to-access tools available to assist with critical appraisal (see How to Critically Appraise Critical Care Research). Further inspiration for discussion points may be found from checking out associated editorials, podcasts (e.g. Critical Care Reviews podcasts), and websites (e.g. The Bottom Line).

Will this study change my practice?

This is the most important consideration when presenting any study at a journal club. Why would we even do research if it wasn’t going to potentially change what we do (i.e. the mandate for clinical equipoise 7)?
A journal club should therefore conclude with a summary statement that addresses whether the results of the study will change practice and why or why not.
For the results of a study to change practice it needs to be both internally and externally valid. Thus, practice change statements should be informed by the critical evaluation of the study.
e.g. I will start routinely administering steroids to patients with septic shock in the ICU as this well conducted study reassures me that there are potential benefits (reduced ICU length of stay, and reduced duration of shock and mechanical ventilation) that outweigh potential harms relevant to our population (ADRENAL trial)
e.g. I will continue to administer fluid boluses to patients with sepsis, as I am not convinced that the results of this study are generalisable to our population of adult patients with a low incidence of malaria and severe anaemia (FEAST trial)
From here, inviting others to join in the discussion by asking whether the study will change their practice (and why) can help generate a conversation leading to other learning points, practice considerations, and even new hypotheses…

Presentation tips

The usual oral presentation advice also applies to journal club presentations. For example, don’t overload slides with paragraphs of tiny text and uninterpretable tables (see How to Present Your Research: Oral Presentation).

Summary

We suggest a useful journal club is one that:

• Discusses a recent study that is of interest to you and relevant to the unit in which you work
• Puts the chosen study in context by providing relevant physiological and/or historical background information
• Provides a critical appraisal of the study, assessing both its internal and external validity
• Explores a specific learning point in more depth
• Concludes with a discussion on whether the study will or will not change your practice

Finally, for those wanting to mix things up, have a look at the other resources provided below for inspiration on less traditional approaches to journal club (e.g. the “flipped” journal club)8.

References and Resources

1. Milbrandt EB, Vincent JL. Evidence-based medicine journal club (2004) Crit Care. 8(6):401-2
2. Linzer M, Brown JT, Frazier LM, DeLong ER, Siegel WC (1988) Impact of a medical journal club on house-staff reading habits, knowledge, and critical appraisal skills. A randomized control trial. JAMA 260(17):2537-41
3. Deenadayalan Y, Grimmer-Somers K, Prior M, Kumar S (2008) How to run an effective journal club: a systematic review. J Eval Clin Pract 14(5):898-911
4. Mauri L, D'Agostino RB Sr. Challenges in the Design and Interpretation of Noninferiority Trials. N Engl J Med. 2017 Oct 5;377(14):1357-1367
5. Pallmann P, Bedding AW, Choodari-Oskooei B, Dimairo M, Flight L, Hampson LV, Holmes J, Mander AP, Odondi L, Sydes MR, Villar SS, Wason JMS, Weir CJ, Wheeler GM, Yap C, Jaki T (2018) Adaptive designs in clinical trials: why use them, and how to run and report them. BMC Med 16(1):29
6. Evans S. Independent Oversight of Clinical Trials through Data and Safety Monitoring Boards. NEJM Evid 2022; 1(1)
7. London AJ. Equipoise in Research: Integrating Ethics and Science in Human Research (2017) JAMA 317(5):525-526
8. Bounds R, Boone S. The Flipped Journal Club. West J Emerg Med. 2018 Jan;19(1):23-27

Other Resources

• A-Guide-to-Leading-a-Journal-Club.pdf (monashhealth.org)
• ImprovingJournalClubPresentations.pdf (upenn.edu)
• What makes evidence-based journal clubs succeed? | BMJ Evidence-Based Medicine
• (PDF) How to prepare for and present at a journal club (researchgate.net)
• Factors That Can Affect the External Validity of Randomised Controlled Trials - PMC (nih.gov)
• Biases Archive - Catalog of Bias

Section Author

Dr Kerina Denny
Kerina is an intensive care advanced trainee with an interest in critical care research, research education, and peer support. She enjoys hanging out at the beach and exploring the Gold Coast hinterlands with her family and friends.

Reviewer

Dr Christopher Reid
Chris is a dual emergency medicine and intensive care advanced trainee (ACEM/CICM). He has an interest in evidence-based medicine and FOAMed. Originally from the UK, now enjoying life in Australia, spending time off with his kelpie, Gus, socialising with friends or playing golf.

Section Editor

Dr James Winearls
James has been an Intensivist at GCUH for over a decade. His special interests are cardiothoracic intensive care and trauma. He also dabbles a little in research. Outside of work he enjoys fanging around the waterways of the GC with his family on his boat.