Medical literature is the repository of evidence to inform best practice and guideline development. The starting point for extracting this evidence is reading and critically appraising the best quality articles available in an area of practice. The solitary review of a vast array of literature is beyond the scope of a busy clinician. The barriers are greater if the clinician is in a rural setting which is distant from the activities of a larger city or hospital practice. The rural hospital may be the focus for continuous professional development for GPs and other community clinicians.
Campbelltown Hospital is a metropolitan hospital of 264 beds on the outskirts of Sydney, New South Wales, Australia. It has an innovative acute outreach service consisting of a multidisciplinary team1. The acute outreach service established a satellite facility at the 80 bed Camden Hospital in 2002. This hospital is in a semi-rural setting 16 kilometres from Campbelltown. The team developed a journal club in 2000 with the objective of continuing professional education, guideline development and facilitation of all critical appraisal skills. The session was conducted weekly, with presenters rostered to present their choice of article. The accepted practice was for the designated presenter at either site to choose a paper from a relevant recent peer-reviewed journal. The session could be cancelled if unexpected patient care needs intervene.
A video link was established in 2003 to enhance case conferencing between members of the multidisciplinary team who may have been present at either site. As a result, the existing journal club was included as a video linked activity. This session was conducted prior to the case conference session. The video link used commercially available hardware. These videoconference units were connected by ISDN telephone lines at 128 Kbit bandwidth. These units were part of the NSW Telehealth Initiative which established over 240 rural linked sites2. The authors are not aware of any of these other sites conducting regular journal clubs, although similar activities are not unusual in university videoconference networks.
The purpose of this article is to encourage the use of the video journal club as part of a professional education program. Some of the factors that have contributed to the sustainability of the present video outreach journal club are explored.
Each paper reviewed for the 2004 year (January to September) was logged and archived using a 'journal club review form' by the presenter. An audit was conducted by the authors in October. The items of interest were activity, attendance, type of journals reviewed and their relationship to change in practice.
There were 20 video outreach journal clubs conducted in the 9 month study period. This was an average of 2.2 sessions per month from a possible four per month. The attendance record was complete for all but one session. The mean total attendance was 7.9 (SD 2.1) people per session of which 2.0 (SD 0.7) per session were at the remote (Camden) site. The mean number per discipline attending were; 3 doctors, 4 nurses and 0.7 allied health personnel.
Twenty-two papers were reviewed and these consisted of 18 medical journals, one Cochrane systematic review, and 3 allied-health journals. One of the papers had been reviewed as a direct request from the department's quality meeting. The other 21 papers were selected from recently published journals with relevance to the participants' area of practice. An audit of the archived review forms attached to the papers was performed by the authors. This audit demonstrated recording recommendations in 16 of the 22 papers. It was assessed that for eight of the papers the recommendations had a high probability of, or contained documented evidence of influence on local practice.
In many ways, this dual-site journal club required similar strategies to any other journal club3. For example, it was considered important to create a non-threatening environment for presenters, to keep the session brief (30 min), to encourage a review rather than critical appraisal approach, and to allow the presenter to choose an article relevant to their practice.
It was also found helpful to establish the following procedures:
- Designate a chairman for the journal club.
- Roster presenters well in advance.
- Create a standardised review proforma for each session with attendance, citation, comments, subjects to explore, and recommendations.
- Link the journal club with an established clinical activity that also used the videoconferencing equipment.
- Archive articles and reviews for future reference.
- Ensure the chairman is technically competent to operate the video conferencing facility at both sites.
- Assist participants to claim quality or continuing medical education (CME) credits.
What did not work?
We identified a small number of problems with the outreach format. These included:
- Lack of availability of the paper under discussion at both sites.
- Stifling of discussion between sites.
- Confusion regarding the designated presenter.
- Sustainability over time due to staff changes.
How did we fix the problems?
We found these issues required only minor adaptation.
- Prior to each session the paper under discussion was faxed, emailed or internet linked for all participants.
- The chairman's skills were modified to encourage dialogue with the other site.
- The roster was made available to the distant site.
- The journal club proceedings were included in the department's procedure manual.
The journal club has continued to meet regularly for over 4 years. There have been four letters to editors of journals published from journal club activity with many more unpublished rapid responses submitted. The journal club has adapted to connect a further central and remote site. The remote site had not previously conducted a journal club. The introduction required minor changes in the existing journal club format.
The influence of journal club activity on education and change in practice is difficult to quantify. This audit has identified a link between the video outreach journal club and patient care in over one-third of the papers reviewed (8 of 22). While further research is required to determine actual impact on practice, it is contended that this finding supports the view that reading evidence-based literature can change practice. There is an opportunity for video conferencing to be used in supporting practitioners in isolated rural centres in this pursuit.
The authors would like to thank the New South Wales Department of Health Telehealth programme, and Mr Bradley Warner for Chairing and developing the work instruction for the video outreach journal club.
1. Wilson SF, Chapman M, Nancarrow L, Collins J. Macarthur Model for Ambulatory Services. Australian Health Review 2001; 24: 187-192.
2. NSW Health. Telehealth Symposium 2004. (Online) 2004. Available: http://www.health.nsw.gov.au/pmd/telehealth/ (Accessed 10 May 2005).
3. Gibbons AJ. Organising a successful Journal Club. BMJ 2002; 325: 137.