While most trainees understand the importance of keeping up with the medical literature, many do not recognize that published studies often lack the rigor or the power required to redefine various aspects of clinical practice. Despite every medical educator's best effort to instill the art of critical reading and analytical thinking into all trainees, educators likely have encountered trainees who would quote 1 newly released study, and then vigorously insist on changing an age-old practice. Medical education programs hold regular journal clubs to teach trainees to read beyond the conclusions, yet the value of the journal club has not been examined systematically. Based on our experience as educators for more than 20 years, journal clubs are often perceived by trainees as a required “chore” with minimal interest and questionable learning value. However, we stumbled upon a fun and interactive format for a journal club that has stopped our trainees from casually elevating conclusions from recently published trials to the new “gold standard.”
It all started with the case of a patient who presented with severe kidney injury, frank hemoptysis, and respiratory failure requiring mechanical ventilation. A swift multi-team evaluation uncovered the diagnosis of granulomatosis with polyangiitis, involving both the lungs and kidneys. Nephrology was consulted to comanage the patient with the intensive care and rheumatology services. While the nephrology attending recommended the use of a standard older drug, a young, bright, and well-read nephrology fellow suggested a trial of a new medication after quoting treatment success in the new Rituximab Versus Cyclophosphamide for ANCA-Associated Vasculitis (“RAVE”) trial.1 Despite resistance on the part of the attending, the fellow continued, day after day, to ask about the new treatment.
It then occurred to the attending that perhaps the fellow did not fully appreciate the clinical implications of the study, and thus “Kidney Court” at the Olive View–University of California, Los Angeles Nephrology Fellowship Program was born. The fellow was assigned the task of presenting the RAVE trial and picking a cofellow to be on his “defense” team, while allowing his other 2 cofellows to serve on the “prosecuting” team. The goal of the “trial” was to determine if RAVE provided sufficient data to support the use of the new drug for the patient in question. A staff attending was assigned to be the “judge.” All other faculty members had the option to chime in at any time, and the freedom to join the team with the highest likelihood of winning. This was the perk of being a faculty member.
Next came the RAVE trial's day in “court.” Surprisingly, everyone in the room had read and closely analyzed the article. Fellows and attendings came to court with handwritten notes to either praise or criticize the article. Court was “called to order,” and the session began. The study was presented, and RAVE was placed on trial. There was laughter, humorous collegial bickering, and highly thoughtful comments between the 2 sides, which included every fellow and faculty member. After much discussion about the study, it became obvious to the fellow that RAVE excluded patients similar to his patient. After the trial ended, the fellows independently and unanimously selected the most appropriate treatment: in this case, the older drug. The daily requests for the use of the new medication came to a complete halt.
The attending-fellow “deliberation” brought to Kidney Court turned out to be the most engaging journal club ever witnessed by everyone in attendance. After the prosecution and defense both rested, the judge (attending) rendered the decision to permanently replace the mundane monthly journal clubs with the more enjoyable Kidney Court.
Almost 3 years have passed since the first Kidney Court session. Our fellows continue to enjoy this format of journal club and actually look forward to the next “court date.” Senior fellows remind their junior teammates to study upcoming articles so they can win in court. At the end of each Kidney Court, the entire team grades the quality of the study and decides whether any change should be made in the routine practice of nephrology. This format of journal club not only teaches fellows to critically analyze a study, but also provides fellows the opportunity to work as a team to formulate necessary changes in clinical practice that would improve patient care.
Graduate medical education programs are required to hold journal clubs to teach critical analysis of peer-reviewed research articles. The traditional format typically involves 1 trainee reading, presenting, and interpreting an article. Everyone else in the room acts interested and tries to make some form of insightful comments; that is, if he or she has not succumbed to total boredom or daydreaming. The Kidney Court format is a fun educational tool that eliminates listening to possibly boring presentations while teaching trainees to dissect clinical trials as defense or prosecuting “attorneys.” For larger groups of trainees, jurors may be assigned to assure everyone's involvement.
Since the birth of Kidney Court, our fellows have been observed criticizing new clinical studies among themselves without faculty involvement. This is the best learning outcome that any program director could hope to achieve from holding journal club.
Whether it be Kidney Court, Bone Court, ENT Court, Judge Judy, or Judge “Attending Name,” it is time to introduce fun into our medical education system, and transform the journal club travail into a journal club trial.
References
Author notes
The authors would like to thank Pamela Dyne, MD, Designated Institutional Officer and Chair of Graduate Medical Education Committee, Olive View–UCLA Medical Center, and Jeffrey Burnett Kopp, MD, FACP, FASN, Section Chief, Kidney Disease Section, National Institute of Diabetes and Digestive and Kidney Diseases, for their encouragement in sharing our educational tool with the academic medical community.
