Transcript Preceptor Skills: Journal Club

Evan Williams, PharmD, BCPS
Assistant Professor of Pharmacy Practice
Husson University School of Pharmacy
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Why literature evaluation is important and
why people hate it
How to make literature less terrible for
students and preceptors
What parts of the study are important and
what is beyond essential
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Students should focus on the
statistical methods used as it relates
to internal validity of the findings
more so than the external validity of
the study when discussing journal
articles.
True or False
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Journal Article Presentations should
a) Focus on an area of practice relevant to the
practice site
b) Tie into some other project or problem at the
practice site
c) Be flexible enough to fit into the amount of
time a practice site or preceptor can devote to
the assignment
d) All of the above
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The following study for gorillastatin produced the
following results after 5 years of follow up. Based
on the results in the table, about how many
patients do I need to treat with gorillastatin for 5
years to prevent one CAD event?
a) 5
b) 8
c) 12
d) 16
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Discuss reasons literature evaluation is an
essential skill for all pharmacists
Identify components of a quality “journal
club” format
Describe ways to make student literature
review useful to your practice
Briefly distinguish between useful and
confounding statistical methods and
demonstrate ability to calculate NNT and NNH
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Essential skill for any clinician
Everyone wants to follow “evidence-based
medicine”
◦ How do you know if recommended treatment is
evidence based?
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Needed to keep up with emerging therapies
◦ New drugs
◦ New guidelines
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If you don’t do this, the next generation of
pharmacists will be followers instead of
leaders regarding drug therapy
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Dry, boring reading
◦ 50 Shades of Primary Literature?
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Time considerations
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Perceived lack of utility
◦ This is all summarized in Pharmacists’ Letter
anyway
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Fear of statistics
◦ What the devil is the difference between a t-test, ftest, and a z-test, anyway?
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There is nothing “clubby” about it
◦ We force them to present some random article and
belittle them for not knowing stuff we never taught
them
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It is detached from other learning outcomes
◦ “Pick a recent article that has something to do with
your internal medicine rotation.”
◦ They pick terrible articles because of this
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They lack good examples of what we are
expecting
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Decide what the desired learning outcome is
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Presentation skills?
A refined, grammatically perfect handout?
Identify all of the trial’s strengths and weaknesses?
Distinguish important clinical implications of the
trial presented?
Once the outcome is identified, make sure
this is communicated to the student
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Selection of Articles
◦ Student vs. Preceptor Selection
◦ Ensure that the article relates to something
happening on rotation!
 This will make it relevant and useful
◦ Type of Article
 Original Research
 Review Article
 Guideline Evaluation
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Selection of Articles
◦ Good vs. Bad Articles
 Clinical vs. Surrogate Outcomes
 Sketchy statistics
 Primary outcomes vs. Secondary outcomes
◦ New vs. Old
 Older articles aren’t bad or irrelevant!!
 If the student doesn’t know it, it is a learning
opportunity
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Identify what you’d like the student to
present
◦ Background
 Do you need this?
 Needs to be quick
◦ Methods
 Brief
 These are fairly standard
 Breeze through the stats
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Identify what you’d like the student to
present
◦ Results
 Best presented in a table format
 Identify primary vs secondary outcomes
 Distinguish between clinical and statistical significance
 Does power matter?
 Calculate NNT and NNH
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Identify what you’d like the student to
present
◦ Discussion should take the most time
 Is the outcome valid based on the test used?
 Confounders
 Are they looking at the right groups of patients?
 Influence of uncontrolled variables?
 Statistical vs. clinical significance?
 Does this change my practice?
◦ Conclusions
 Do you agree with the author’s conclusion?
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Presentation Setting
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Big time presentation and roast?
Conversational?
Panel Discussion?
CE style?
Do what makes sense for your practice site!
◦ Make this useful to you
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Give students enough time
◦ Check in to make sure progress is being made
◦ Suggest addressing questions prior to the
presentation to improve the quality of the
presentation
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Read the article!
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Show the student a clear example of a good
handout to follow
◦ Many are available, so pick one that you like
 Students tend to do better with bullet points
 Make them create their own tables
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In order to properly evaluate the student’s
critique, you need to have identified the key
points that should have pointed out
◦ What are the results?
◦ Are the results valid?
◦ How can I use the results in my practice?
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Any statistically significant differences?
◦ p-value vs confidence intervals
 Little p-values don’t make results more significant
 Confidence intervals can give an impression of how
precise the results are
 Confidence intervals that cross unity are not significant
◦ Clinical significance?
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Number Needed to Treat
◦ Good way to quantify clinical significance
◦ 1/difference in the event rate between groups
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25 of 500 people in the placebo group died - (5%)
10 of 550 people in the drug group died – (1.8%)
The difference between the groups is 3.2%, or 0.032
1/0.032 = 31.25 ~ 31
If I treat 31 people with the drug, I will prevent one
death
◦ Compare this to the Number Needed to Harm
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Number Needed to Harm
◦ Same calculation, but for adverse events
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10 of 500 people had major bleeding in the placebo group – (2%)
22 of 550 people had major bleeding in the drug group – (4%)
The difference between the groups is 2%, or 0.02
1/0.02 = 50
If I give 50 people the drug, I will cause 1 major bleed
◦ Does the risk vs benefit ratio seem reasonable?
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Was the primary endpoint clearly stated and
reported?
◦ Was it relevant?
◦ Surrogate vs clinical endpoints
◦ Composite endpoints
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Was the designed to reveal the primary
endpoint?
◦ Powered enough to detect a difference if one wasn’t
found?
◦ Does the discussion focus on subgroup analyses?
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Where the right people included?
◦ Intent to Treat (ITT) or Per Protocol Analysis?
◦ Inclusion and exclusion criteria
 Do they control for confounders?
 Do they limit external validity?
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Was bias effectively dealt with?
◦ Blinding
◦ Valid control groups
 Placebo vs active control?
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NNT vs NNH
Are the patients studied similar to my
patients?
How does this evidence jive with other
studies regarding the same subject?
Is this study important enough to shift
clinical practice?
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New Drugs
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New Guidelines
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Things you don’t know/always get questions
about
◦ What studies got this approved?
◦ Who was looked at?
◦ Side effect profiles?
◦ Check the references
◦ Things that have strong/low evidence
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When is aspirin indicated?
Evidence that vaccines don’t cause autism?
Does LDL really correlate with MI?
Why do we still use warfarin?
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Pharmacists need to be able to evaluate literature
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We should be showing students why this is important
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Make sure journal article presentations focus on
preparing pharmacists that can critically evaluate
literature
◦ Presentation style, format, handouts, length can all vary
and should be adapted to the practice site
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Focus on the key issues within the studies presented
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Make the exercise beneficial for you and the student
◦ Don’t get bogged down in statistics
◦ Consider the clinical impact


Students should focus on the
statistical methods used as it relates
to internal validity of the findings
more so than the external validity of
the study when discussing journal
articles.
True or False

Journal Article Presentations should
a) Focus on an area of practice relevant to the
practice site
b) Tie into some other project or problem at the
practice site
c) Be flexible enough to fit into the amount of
time a practice site or preceptor can devote to
the assignment
d) All of the above

The following study for gorillastatin produced the
following results after 5 years of follow up. Based
on the results in the table, about how many
patients do I need to treat with gorillastatin for 5
years to prevent one CAD event?
a) 5
b) 8
c) 12
d) 16
Questions?
Thank you!