by Jonathan Miller, MD1 and Jeremy Powers, MD2
1 PGY3 Resident, Virginia Commonwealth University Integrated Plastic Surgery Residency
2 PGY6 Chief Resident, Virginia Commonwealth University Integrated Plastic Surgery Residency
Presenting an article at journal club is an essential task of residency and a proxy for the critical analysis of medical literature – a crucial skill for decision making and lifelong learning as a physician. However, as a junior resident, it can be quite intimidating to comprehensively review a journal article in front of one’s peers, senior/chief residents, and faculty.
Aside from article selection, which is fundamental but not the topic of this post, the first step to consider for a successful journal club presentation is the atmosphere of the journal club itself. Journal clubs held on hospital grounds are perfectly acceptable and will facilitate efficient discussion of the selected readings. If held at a restaurant, it is important that the environment facilitate discussion (not be too loud) and be tolerant of medical/surgical photographs, as printed articles or tablet/phone screens may be seen by passersby. A corner table, or even better, private room, is ideal.
As you prepare your journal article presentation, the following principles will help you get the most out of the article and make an outstanding presentation.
Know the background material.
It cannot be stressed enough that if you are going to talk about a journal article, you should know the basic clinical information that the article addresses. For example, if you happen to be assigned an article for hand journal club that compares union rates after ulnar shortening osteotomy with transverse versus oblique pattern, you should read up on indications, patient presentation, and relevant anatomy related to these surgical techniques, not to mention the basic science of bony healing and union. If you are presenting a paper about 5th-7th nerve transfer for smile restoration, then you should know the principles of nerve anatomy/injury, the process/options for nerve regeneration/repair, and the surgical techniques/timing of facial reanimation surgery. If you are not sure where to start, your senior and chief residents are a helpful resource. After reviewing the background material, you will then have the basic foundation to understand the article and provide a critique.
Organize your thoughts and formulate your critique.
Your approach to an article should be systematic and reproducible. A journal article presentation should provide a commentary rather than regurgitate the findings or conclusions of the authors. In similar fashion to a well formulated patient presentation, you should be thorough but concise and relevant. The organization of information should be purposeful and ultimately reflect your assessment of the material.
Generally speaking, the goals of the presenter are to provide a thoughtful response to the following core questions:
What did the author(s) set out to accomplish? What is the author’s hypothesis and why did they set out to answer this question in the first place? You should inform yourself of the context in which these questions were asked and consider why they are being asked now. Examples include recent investigation into development of BIA-ALCL or safety of gluteal fat grafting. These are questions driven by both adverse clinical outcomes and increased awareness and concerns in the non-medical community. An understanding of the context in which the hypothesis was generated will later help you to interpret both the author’s findings and their relevance to clinical practice.
How did they do it?This describes the study design, variables selected, operative technique, methods of bias reduction/elimination, and analyses performed. In the context of plastic surgery journal club you should approach this question keeping in mind both your audience and the type of article you will be reviewing. Spending 10 minutes discussing bias and power for a single surgeon facelift technique review paper is a quick way to lose the attention of your colleagues and miss the point of the presentation. Clearly there are other times when a more comprehensive discussion of validity and generalizability should occur; for example, when reviewing a meta-analysis of NSAID use and postop hematoma occurrence. Single author technique papers should prompt a consideration of other common methods of performing the procedure of interest. What is your experience with this procedure and what have you seen your attendings do? This is a great opportunity for senior residents to introduce their junior counterparts to operative techniques and principles they will encounter in later years of training.
What did they find? This relates to the results and its associated figures/tables, as well as the conclusions of the paper. In a concise and straightforward manner state the authors findings. Do they mention any weaknesses or inherent biases of the study that would influence the interpretation of these results? Are the findings in line with what the authors or you expected and why or why not? Considering the population you work with at your institution, is it comparable to the patient population of interest?
Will this study change your clinical practice? This is the cornerstone of your presentation. In the most polished of article reviews, the stage should be set by the answers to the preceding three questions. Will this article change your practice, why or why not? It is also the opportunity to briefly touch on “future research,” in other words, what questions were you left with at the end of the article and if answered, would you then consider changing your practice?
Putting it all together:
‘Chekhov’s Gun’ is a literary principle from the eponymous Russian author – and physician – who stated, “If you say in the first chapter that there is a rifle hanging on the wall, in the second or third chapter it absolutely must go off.” An excellent journal article critique should only include information that contributes to your discussion and analysis. The points you make should be linear, organized, and congruous without any extraneous information.
Now review the notes you took. Consider how much time you will have to present and adjust your level of detail accordingly. Make note of specific facts or figures that will help provide visual context for your review. Drawing attention to certain figures is a helpful way to reference key content without wasting time summarizing. Your goal is to provide an engaging and succinct review, and should assume all those present have read the source material.
In order to facilitate your presentation, you may want to put together a separate outline, but depending on your level of comfort with presenting, you may not find this necessary. Junior residents may find it helpful to fill out a companion worksheet such as recommended in the Michigan Manual of Plastic Surgery, 2nd Ed (pp 632-635). Multiple readings of an article, with space between the first and second reading, can provide new perspective and insight.
In summary, preparation is key to any successful journal club. Whatever strategy you choose, be it scribbling in the margins, annotating in your PDF editor of choice, or taking notes separately, find what works for you and stick with it. With the approach we have outlined, we are confident you will be able to prepare a thorough and thoughtful article analysis and effectively communicate the key “take home points” of the article to your colleagues. Have a great journal club!