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Group Writing of Letters to the Editor as the Goal of Journal Club
To the Editor: A traditional journal club consisting of reiterating study results or generating lists of criticisms may enhance exposure to the medical literature, but its effectiveness in advancing critical appraisal skills has been questioned.1 Because fellows and faculty had found the journal club experience unfocused, unproductive, and difficult to sustain, we altered it to add a concrete goal: composing, editing, and submitting a letter to the editor, with the intention of improving skills in critical analysis and scientific writing.
Methods
The VA Outcomes Group journal club at the Department of Veterans Affairs Hospital in White River Junction, VT, includes approximately 12 faculty and fellows from 7 specialties and subspecialties. It receives no financial support, does not provide meals, and members are not relieved of other commitments. Meetings are scheduled at lunchtime or late afternoon when most members are available.
Article Selection. Journal club articles are nominated by group members. Each month 1 article, recent enough so that the letter to the editor can be submitted within 4 weeks of publication, is chosen by the fellows, and is provided to members 1 week before the meeting. The article is considered over 2 consecutive meetings 1 week apart, each lasting 1 to 2 hours, facilitated by the most senior faculty member.
Critical Evaluation. The first meeting focuses on methodical evaluation and begins with an effort to sketch out (on a dry erase board) exactly what the authors did in conducting their study and whether their conclusions were supported by the data. We then solicit comments from the most junior members of the group. Then, all members are invited to raise concerns, and after discussion we reach consensus about the article's primary strengths and weaknesses. Based on the importance of the identified threats to validity, we decide whether a letter to the editor is warranted. If so, the letter is outlined, and a member (usually a fellow) is asked to write a first draft.
Synthesis and Writing. In the second meeting, the group edits the draft, using a computer and projecting the text. We confirm consensus regarding the major points and decide whether other points need to be included with the intention of not only identifying criticisms but suggesting constructive approaches to address them. We then focus on the organization of the letter and the clarity of the writing sentence by sentence. When the second meeting is adjourned, the letter is ready for submission.
Submission and Follow-up. Following submission, the author communicates with the journal and, if needed, makes revisions. We track the progress of each letter; at subsequent meetings we review all letters published in response to the original article to see if similar points were made and if additional points were raised that we missed.
Consent to report these results was waived by the Institutional Review Board.
Results
From May 2005 to June 2006, we applied this process to 9 articles. Our first letter addressed a discrepancy in results based on self-reported vs objective exposure measures2 (Table). Other issues have included residual confounding, problematic disease definitions, inappropriate use of 5-year survival statistics, failure to report absolute risks, use of a noncomparable control group, and work-up bias in diagnostic test evaluation. For 1 article, no letter was submitted because we were unable to offer constructive approaches to address our criticisms. Eight letters were submitted: 3 were published,2-4 1 is under review, 3 were rejected outright, and 1 was rejected after a request for revision. For 1 of the rejected letters, another letter raising a similar point was published; we are not aware of the reasons the other 3 were rejected.
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Table. Summary of Published Letters and Related Articles, May 2005-June 2006
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Attendance at each session has been approximately 75% for faculty and 100% for fellows. Although we have not formally evaluated changes in critical evaluation or writing skills, participants believe that these goals are being met.
Comment
Others have reported letter writing as part of their journal clubs (for medical students5 and public health practitioners6). However, we are not aware of others engaging in a group writing exercise, or using computer-facilitated real-time editing, a process that allows for immediate feedback and is much more efficient than circulating drafts among multiple members.
We note that the process is time consuming and may be difficult for some groups to sustain. Furthermore, the success of this process may be dependent on the individuals involved and the group dynamic. If there is a hierarchical structure, comments from more experienced participants may carry more weight. We have tried to avoid such dominance by soliciting comments from junior members first, and by inviting them to write the first drafts.
In conclusion, we believe our new process enhances the educational value of journal club.
Author Contributions: Dr Kallen had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Kallen, Russell, Larson, Davies, Sirovich, Schwartz, Woloshin, Welch.
Acquisition of data: Kallen, Russell, Larson, Davies, Schwartz, Woloshin, Welch.
Analysis and interpretation of data: Kallen, Wilson, Davies, Larson, Schwartz, Woloshin, Welch.
Drafting of the manuscript: Kallen, Russell, Wilson, Larson, Davies, Schwartz, Woloshin, Welch.
Critical revision of the manuscript for important intellectual content: Kallen, Wilson, Larson, Sirovich, Schwartz, Woloshin, Welch.
Statistical analysis: Russell, Larson, Davies.
Obtained funding: Schwartz, Woloshin, Welch.
Administrative, technical, or material support: Kallen, Larson, Davies, Schwartz.
Study supervision: Schwartz, Davies, Larson, Welch.
Financial Disclosures: None reported.
Funding/Support: This project was supported in part by grant 09-098, a Research Enhancement Award, from the Department of Veterans Affairs.
Role of the Sponsor: The sponsor had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; or preparation, review, or approval of the manuscript.
Disclaimer: The views expressed herein do not necessarily represent the views of the Department of Veterans Affairs, or the United States government.
Alexander J. Kallen, MD, MPH;
Chad T. Wilson, MD, MPH;
Michelle A. Russell, MD;
Robin J. Larson, MD, MPH;
Louise Davies, MD, MS;
Brenda E. Sirovich, MD, MS;
Lisa M. Schwartz, MD, MS;
Steven Woloshin, MD, MS
steven.woloshin{at}dartmouth.edu
H. Gilbert Welch, MD, MPH
VA Outcomes Group
White River, Vt
1. Ebbert JO, Montori VM, Schultz HJ. Journal club in postgraduate medicine: a systematic review. Med Teach. 2001;23:455-461.
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2. Welch HG. Statins and the risk of colorectal cancer [comment]. N Engl J Med. 2005;353:953.3. Wilson CT. Basal cell and squamous cell carcinoma in persons younger than 40 years [comment]. JAMA. 2006;295:278.
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4. Wilson CT. NMP22 and surveillance for recurrent bladder cancer [comment]. JAMA. 2006;296:44-45.
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5. Edwards R, White M, Gray J, Fischbacher C. Use of journal club and letter-writing exercise to teach critical appraisal to medical undergraduates. Med Educ. 2001;35:691-694.
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6. Sandifer QD, Lo SV, Crompton PG. Evaluation of a journal club as a forum to practise critical appraisal skills. J R Coll Physicians Lond. 1996;30:520-522.
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JAMA. 2006;296:1053-1054.
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