Refreshing a Resident-Run Journal Club: A Focus on Article Selection

To the editor:

Residency journal clubs frequently suffer from low attendance, limited reading of the primary article, and poor resident engagement. At the Massachusetts General Hospital/McLean Hospital (MGH/McLean) adult psychiatry residency program, journal club has been a required component of the curriculum for many years; however, attendance and interest have historically been poor. We have undertaken a critical review of our current journal club and altered the article selection process to rekindle interest.

The authors (J.C. and P.C.) were tasked with facilitating the residency journal club for the MGH/McLean residency for the 2018-2019 year. The MGH/McLean residency has 64 residents (16 per year) and about 1000 faculty (approximately 450 part-time and 550 full time) across two campuses. Prior to the 2018-2019 academic year, each journal club consisted of two post-graduate year two (PGY-2) residents presenting any article of their choosing. Each PGY-2 pair was asked to identify an expert discussant to address specific topics and help answer questions. The PGY-2 presenters would use the first half hour to review the paper and the latter half for a question and answer session with the discussant. A PGY-3 resident, chosen by the program director, helped to schedule and oversee the journal club sessions, but was not involved in article selection. In preparation for journal club, PGY-1 residents attend a didactic series on “Reading the Literature,” which covers major large-scale clinical trials in psychiatry.

This format had several key strengths. Residents had the autonomy to identify any article of importance and focus on a topic of interest. This potentially led to increased buy-in for an otherwise mandatory presentation and allowed residents to practice teaching their co-residents about a topic that was meaningful to them. Having a PGY-3 organizer was useful in keeping the sessions focused, assisting in discussant choice, and setting presentation dates. This format also involved the utilization of a faculty discussant, who brought an expert viewpoint to each discussion.

However, the older model had several significant problems. For one, unrestricted article selection led to inappropriate articles being chosen. Some articles were of poor research quality, too long to be reasonably read by a large group, or not applicable to residents. Article selection may be challenging for more junior residents, especially those without research experience. Attendance was also sporadic, even with lunch offered, especially among senior residents. Of the residents who attended, a minority read the assigned article ahead of time.

As the PGY-3 journal club facilitators for the 2018-2019 year, the authors aimed to improve journal club in a systematic way and, in doing so, created a structure upon which other residencies might improve their journal clubs. Based on an informal needs assessment of the residents, the most challenging portion of journal club was determined to be article selection. Residents had difficulty identifying which articles might be relevant or interesting, and attendance was particularly poor when the article chosen was clinically irrelevant, very long, or unlikely to change clinical practice.

Options for journal club reform included having a facilitator select the article and discussant for each pair of presenting residents, which would likely improve article quality and reduce work for the presenting residents; however, that approach would also increase the burden on journal club facilitators and would not allow residents to choose a topic of interest. Requiring reading of the paper by attendees prior to journal club presentation was considered; however, it was felt that this might represent a barrier to attending journal club. Mandatory attendance was felt to be detrimental to the discussion if residents viewed the activity as burdensome. Opening up journal club attendance up to faculty in addition to residents was considered; however, this might reduce residents’ comfort in asking questions.

We observed that the most meaningful journal club presentations were those which presented research that was innovative, impactful and relevant for clinical practice. To that end, we identified faculty members with prominent roles in teaching, clinical work, administration, or research. We asked them to identify 1-5 papers published within the past two years that were “important” or “innovative”. While there are some curated lists of important psychiatric articles available online [1], we created our own list in order to prioritize recent, empirical research articles specifically tailored to topics valued by our program. We focused on research articles to promote discussion of research design and critique, and because other venues existed to expose residents to classic non-research articles. The journal club facilitators screened each paper to evaluate its likely interest to a resident and ensure that it represented a primary research paper published within the last two years. Efforts were also made to limit articles to 10 pages, include some flawed studies in order to teach study design, and ensure a variety of research approaches, including randomized controlled trials, open label and cohort studies.

While no formal feedback was collected, this simple intervention related to article selection led to greater attendance at journal club. Residents appeared to be more engaged and asked more questions of the presenters and discussant. There was benefit, too, for the journal club facilitators, who had increased interactions with department leadership, increased reading of the literature to help identify suitable articles, and management experience in working with junior residents.

While the changes in journal club format had a number of advantages, the new format has some potential drawbacks. As more interesting and relevant papers were chosen, more questions were asked throughout the presentation, leaving less time for discussion. However, this likely signals a higher degree of engagement amongst audience members. Journal clubs may teach residents to identify important or interesting papers for themselves, whereas our residents chose from a pre-curated list. Nevertheless, using the provided list may help residents better recognize examples of well-chosen papers, and we allowed flexibility for ambitious resident pairings to choose their own articles, which were then vetted by facilitators. Our new format also increased the burden on facilitators and faculty advisors; however, this felt manageable given the relatively limited number of sessions. Finally, anecdotally, there continued to be low rates of reading the article prior to attending. Increasing article readership is an opportunity for further improvement.

Engaging faculty in paper selection appeared to improve the journal club experience for presenters, attendees, and facilitators. Minor modifications to this model could allow for implementation in diverse training programs. For example, a smaller program could combine with other residencies via videoconference. A program with limited faculty discussants could identify a champion generalist with a research background who could serve as a consistent discussant. A program with lower research literacy could institute a didactic seminar early in residency to teach foundational research skills.

As noted above, increasing attendance and encouraging reading the article prior to journal club continue to be areas for potential improvement. Increasing the motivation of residents, for example, by providing “boards style” questions regarding the paper, might increase readership. Finally, given that there is still significant variation in the presentation style at journal club, a standardized approach, such as the patient/problem/population-intervention-compairson/control-outcome (PICO) framework [2], could be considered.