Journal Club – Oct 2014Managing Expectations of Antibiotics for Upper Respiratory Tract Infections: A Qualitative Study

What is Journal Club?

“A group of individuals who meet regularly to critically discuss applicability of current articles found in medical journals”

Kleinpell, RM, Rediscovering the value of the journal club, Am J Crit Care, 2002;11:412-4

History of Journal ClubJournal club was first mentioned in London between 1835 – 1854 in the memoirs of Sir James Paget describing the situation in St Bartholomew’s Hospital as: “Some of the pupils, making themselves into a sort of club, had a small room over the baker’s shop near the Hospital Gate where we could sit and read the journals and where some, in the evening, played cards” (quoted by Linzer, 1987)

Source: Cave MT, Clandinin J. Revisiting the journal club, Med Teach 2007; 29:365-370

Goals of Journal Club• Keeping up to date with the literature• Promoting evidence-based practice• Teaching research methodology, clinical

epidemiology, and statistics• Providing opportunities for training in

clinical decision making/gaining critical appraisal skills• Informing guidelines development• Fulfilling a social role of having regular

contacts with colleagues and have social interaction

Traditional Journal Club• Randomly selecting articles• Random articles may not be relevant to

current clinical practice• Evaluation without using any tools to assess

validity and applicability

Problem and Evidence-based JC• Identification of a current clinical problem• discuss with a senior staff or among trainees• convert into focused and answerable

question• Searching of literature to find relevant

articles • Critical evaluation of selected articles w/

checklist• Presentation and discussion of the

findings

CATMaker Software• Stores research question and search

strategies• Helps frame the question, allows

appraisal• Clinical calculations including confidence

intervals, ratios, numbers needed to treat• Generates files which can be formatted,

saved, sorted and printed

Conclusion Journal Club• A journal club• is an integral part of doctors’ CME• is a step forward in evidence-based practice• uses surveys to assess goals and monitor

satisfaction

Journal Club – Oct. 2014

Journal Club – Oct. 2014• This study uses qualitative methods to

try to tap into the wisdom of experienced family physicians for their strategies to reduce inappropriate antibiotic prescribing by managing expectations. The article presents an opportunity to develop subtlety in practice.

What question is asked by this study and why does it matter? • Communication experts: ask patients

directly whether they expect to receive antibiotics• Aim of study: • explore views/experiences of family

physicians about asking patients directly whether they expect abx• address problem of eliciting expectations of

antibiotics as a possible treatment for URTIs• Importance: • Guidelines are good – but could/should they

be implemented in everyday clinical life practice?

How does this study advance beyond previous research and clinical practice on this topic? • What is known:

• audiotaped consultations for URTI symptoms cite lack of patient centeredness, possible explanation for clinicians overprescribing antibiotics• advocate direct elicitation of expectations

(hypothetical)• What is new:

• look at the actual views of family physicians, revealing they do not like to elicit directly because it could be negatively perceived• prefer to ask open questions to identify concerns

and expectations of patients or parents

How strong is the study design for answering the question? • Study design• qualitative research methods

• Rationale• to explore in depth the perspectives of family

physicians from their own point of view• Answering the question• good study design • the aim was not to quantify preexisting

categories that we already knew about but to explore what clinicians actually do

To what degree can the findings be accounted for by the following:• How participants were selected? (Did the

authors achieve saturation? That is, did they sample until the point at which no new information was obtained from further sampling?) • Yes, saturation was achieved after 17

interviews• To assure complete saturation, 3 more

interviews with family doctors were conducted

To what degree can the findings be accounted for by the following:• How the data were collected?• Data collection via in-depth, semistructured

interviews with 20 family physicians in South Wales (United Kingdom) • Primary author conducted a single face-to-

face interview with each of the 20 participants between October 2010 and April 2011 • Semistructured interview schedule that

included open questions about general opinions on the URTI consultation

To what degree can the findings be accounted for by the following:• Preconceptions on the part of the

investigators?• Well handled• began with confirmation that it was not a test

of knowledge or an audit to assess whether they were adherent to the latest guidelines • the aim was not to quantify preexisting

categories that we already knew about but to explore what clinicians actually do

To what degree can the findings be accounted for by the following:• How the findings were analyzed and

interpreted?• Data were analyzed using thematic analysis

after completion of data collection• Line-byline reading of transcripts →

identification, annotation of numerous interpretations → codes• Relationships between the codes, grouping

them into coherent concepts• The final level of analysis grouped the

concepts into major categories

To what degree can the findings be accounted for by the following:• The theoretical framework used to guide

the investigation?• Semistructured interview schedule that

included open questions about general opinions on the URTI consultation

What are the main study findings?• Family physicians• assumed most patients/parents wanted abx • assumed most patients wanted to be

“checked out” to make sure the illness was “nothing serious.” • did not ask direct questions about

expectations• preferred to elicit expectations for abx

indirectly • reported findings of exam as a “running

commentary”

How relevant is the study sample to you and your practice?• Does it matter that the physicians are not

a representative sample? What is your judgment about the transferability of the findings to your setting? • Probably representative of that area in

South-Wales• Transferrable to Kurdistan? Possibly –

discuss.

What contextual factors are important for interpreting the findings?

How might this study change your practice? Policy? Education? Research? • What do you do different this week what

you did not do last week?• Improve patient-doctor communication• Elicit expectations of abx

Who are the constituencies for the findings?• How they might be engaged in

interpreting or using the findings?

What are the next steps in interpreting or applying the findings? • Think outside the box, outside traditional

norms and preconceptions, i.e. • Just do it even if it is not expected of you

What researchable questions remain? • Are the results applicable to Duhok?• What are the patient expectations of

abx?• What is the level of patient satisfaction

with the new approach of patient management