Students’ perception of implementing journal clubs in an undergraduate medical curriculum

1Department of Pathology, College of Medicine and Health Sciences, The National University of Science and Technology, Sohar, Sultanate of Oman 2Department of Anatomy, College of Medicine and Health Sciences, The National University of Science and Technology, Sohar, Sultanate of Oman 3Department of Epidemiology, Public health and Biostatistics, College of Medicine and Health Sciences, The National University of Science and Technology. Sohar, Sultanate of Oman


Original Research
performance, particularly in lower-achieving students, improved students' research paper presentations 4 . Implementing and conducting successful journal clubs for undergraduates is a challenging task. One of the common concerns is that the use of higher-level language in research literature can hinder students' understanding and applying knowledge beyond traditional textbooks. Many residents feel that presenting in journal clubs is an intimidating process and is one of the reasons for unsuccessful journal clubs. 5 Therefore, it is important to overcome the pitfalls of the implementation of journal clubs for undergraduate medical students. Efforts should be made to present innovative journal clubs that can create interest in students, build foundational knowledge and enhance critical appraisal thinking.
The aim of the study • To know whether students are aware of the concept of journal club. • To assess students' willingness to implement journal clubs in their undergraduate medical curriculum.

Methodology
This is a cross-sectional study conducted among undergraduate medical students at the College of Medicine and Health Sciences, The National University of Science and Technology, in February 2019. This study was conducted to understand the perception of students around the implementation of journal club in an undergraduate curriculum. Convenience sampling was conducted. All medical students were sent invitations and consent forms to their group emails to participate in the survey.
• Inclusion criteria-All students who gave consent to participate. • Exclusion criteria -Premedical students; students who did not give consent. A survey was conducted among 161 students undergraduate preclinical and clinical year students. The purpose of the study was explained and instructions for filling out the survey forms were given. A questionnaire containing 8 items was administered using Google Forms to students' emails. Students were given sufficient time to answer all questions.
A survey-based questionnaire was developed after several literature reviews. This questionnaire was created to address the knowledge, attitudes, and perceptions towards the implementation of a journal club in the undergraduate curriculum among undergraduate students. An attempt was made to identify questions that were appropriate for the pre-selected domains. Five questions addressed knowledge and perceptions of journal club and three questions addressed attitudes towards the implementation of journal club. The questionnaire was evaluated for relevance, clarity, grammar /spelling, ambiguity, and sentence structure by four subject experts at the university for content and face validity. The four experts were preclinical faculty who had sufficient experience in conducting journal clubs for postgraduates in medical colleges. They were given a cover letter that explained the purpose of the study, the reasons for selecting the content expert, a description of the questionnaire, and an explanation of the content evaluation procedure. The experts scored each question as follows: Strongly agree-5, Agree-4, Neutral-3, Disagree-2, and Strongly disagree-1. The experts were asked to provide suggestions for revision or deletion of the questions to which they gave a lower score (1 or 2). For questions in need of revision, the experts were requested to comment on the clarity and to provide a suitable option of addressing the relevance of the question. The Item-Content Validity Index (I-CVI) estimations for the 8 KAP items that ranged between 0.78 and 1.00 were retained after the evaluation of the panelists, indicating that these items were considered clear, understandable, and relevant to the questionnaire. The modified Kappa (K*) values for all items were excellent (> 0.75), illuminating that the agreement between experts was not due to chance. The Scale Content Validity Index (S-CVI/Ave) was 0.90, confirming the content validity of the scale.
The internal consistency reliability, Cronbach's alpha, was measured to be 0.782. The questionnaire was reviewed and approved by the Research and Ethics Committee. (Reg.no -CMHS/REC/016/18/C).
Data were analyzed using SPSS version 22. Descriptive statistics (The frequency with percentages for categorical variables) were used for the study variables, and chi-square (X 2 ) test was applied to establish statistical significance.

Results
A total of 161 (N = 161) students from preclinical and clinical years participated in the survey. In all, 112 (69.4%) students were from preclinical years and 49 (30.6%) were from clinical years. About 90% (n = 145) of the students were female and 10% (n = 16) were male.
Majority of the students from preclinical years (70.5%; n = 79) did not know what a journal club was but many students (59.1%; n = 29) from the clinical years knew about journal club. The difference between preclinical and clinical years regarding knowledge of journal club was statistically significant as shown in Table 1 (significance: P<0.05).
Regarding the source of information about journal club, majority of the students came to know about journal club through friends/seniors (40.9%), followed by the internet (36.4%), through attending journal club (10.2%), and 17% of the students learned about journal club through literature. Students were able to select multiple responses.
The overall percentage of students asked for the role of the journal club in improving knowledge and skills choosing "yes" was 65.2% (n = 105) shows that it certainly improves the medical knowledge /clinical skills. In addition, 26.2% (n = 42) chose "yes, but not now. " 7.5% (n = 12) did not agree ( Table 2).
An important aspect of journal club is that journal club helps update knowledge of current medical literature. Majority of the students from both clinical and preclinical years (71.4%; n = 115) agreed; only 5.6% (n = 9) did not agree. However, 21% (n = 34) were not sure whether journal clubs help in updating knowledge. These results are shown in Table 3.
When questioned about the fact that the journal clubs play a major role in motivating research activities, 49.0% of students overall chose "yes", 12.4% chose "no, " and 36.6% said they were not sure.
Almost half of the students (46.1%; n = 74) said they would like to have journal clubs incorporated in their curriculum, while 30.4% (n = 49) of students said it would not make a difference and 22.3% (n = 36) of students did not want it to be included in their curriculum.
Among the five reasons for journal clubs to be included in the curriculum, the option chosen most often (30.8%) was to help them gain confidence to present cases in the clinics and exams. Next highest was 21.2 % for the option to create awareness about current research updates, then 19.9 % for helping gain a deeper understanding of the subject, 18.6% for motivating self-learning, and 9.6% for giving the opportunity to learn biostatistics ( Figure 1).
Of the five reasons for a journal club not to be included in the curriculum, the results are as follows in descending order: 92 students felt JC required a lot of time to prepare; lack of sufficient resources (n = 25); stage fright (n = 14); difficulty in understanding statistics (n = 12); JC would not help much at (n = 10). Students were encouraged to choose multiple options ( Figure 2).

Discussion
Medical education in the new era has made it essential for teachers to deliver the curriculum in a planned manner to keep pace with modern educational developments. Several innovative teaching methods, such as PBL, TBL, integrated teaching and evidence-based learning, are being investigated and practiced for a better understanding of these subjects.
Journal clubs can also be used as a teaching-learning method that promotes understanding, attitudes, motivation, and competencies essential for practicing evidence-based care. Journal clubs are usually implemented for different purposes in different settings, such as journal clubs for health professionals to improve clinical practice, apply research into practice or develop their skills in setting clinical questions, discussing, evaluating, and updating scientific knowledge. 6 Journal clubs are important forums for keeping upto-date knowledge with the latest research happening worldwide. Critical analysis of the research studies helps in self-appraisal and improves skills associated with evidence-based medicine. Journal club remains one of the most essential parts of the postgraduate curriculum, but it is usually not included in the undergraduate medical curriculum. Majority of our students did not know about journal club. Most students learned about it through friends or seniors or the internet. Only a few students had attended journal clubs conducted in college for faculties.
Regular didactic lectures, seminars, and formal assessments are not sufficient in modern medicine. There is a need for competency in seeking knowledge, clinical skills, and evidence-based practice 7 . Journal clubs not only improve knowledge and reading habits but also help in keeping the momentum of medical knowledge and creating enthusiasm for conducting research. A discussion of research articles will benefit the participants by increasing the depth of their knowledge. 8 A previous study reported that participation in an active learningbased undergraduate journal club improved student performance in research paper presentations (science communication), particularly in lower-achieving students. 4 Majority of our students agreed with the fact that the journal club helps improve medical knowledge, clinical skills, and update knowledge of current medical literature. Similar results were seen in a study conducted for nursing students where most (75%) of the students reported that their competency to search, evaluate and report scientific knowledge had improved. 7 Reading the primary literature is the best way, apart from doing research, to learn how research is performed and presented. 9 Undergraduate students require confidence in their capacity to read such specialized writing so that they can effectively contribute to journal club. Some of the students (26.2%) in our study felt that although journal club would help update their knowledge, it will be more helpful only at later date and not at the present time.
About half of the students (49%) agreed that journal clubs would motivate them to undertake research. Since many of the students did not know what journal clubs were, they either had a neutral opinion or they disagreed. An intervention study conducted by Sandeufer with university students found that all the students who participated in the study were so motivated that they were interested in research-based graduation studies in the future. 10 Journal clubs as evidence-based teaching have many advantages. They help in a deeper understanding of the subject, give the opportunity to learn biostatics and create awareness about current research updates. A 2001 systematic review found that journal clubs can improve reading practices, knowledge of clinical epidemiology and biostatistics, and the use of medical literature for residents and registrars. 11 Mark et al introduced several ten-step guidelines in their journal club program for medical residents at the New York University School of Medicine to help presenters increase efficiency in assessing a study's validity and results. As a result, residents improved both their presentation and critical appraisal skills, which in turn helps them in patient case presentations in clinics and exams. 12 Most of our students wanted journal clubs in their curriculum for the same reason.
Adult Learning Theory is intended to promote students towards self-directed learning. Several kinds of literature have come up with studies that focus on teaching selfdirected learning (Green & Ellis 1997;Hartzell 2007). 13,14 Self-learning gives residents personal responsibility for their education. More importantly, it teaches a set of skills that they will be able to use throughout their career after residency which will give them confidence and independence in their future practice. Identifying specific models to practice these skills is essential if programs expect graduating residents to be confident and successful in using these after their training is completed. Zoshua et al. reported that a journal club model developed for residents helped them use the skills learned in journal club for their patient care. It also increased their confidence level in evaluating medical literature and contributed to an improved sense of independence as a physician. 15 Around 18.6% of our students in our survey felt that journal clubs would motivate self directed learning.
Journal clubs are not an integral part of the undergraduate curriculum; hence, it becomes critical to select the most crucial articles for presentation for successful journal clubs. The topics selected from the curriculum should be beneficial and interesting to the students. Supportive mentorship and guidance from a   Reasons for not incorporating Journal clubs in Curriculum devoted faculty member also ensures the maintenance of the structure and systematic presentation, which will help residents be creative and innovative in their presentations. 16 One of the limitations for implementing journal clubs is participation from the students. Majority of our students (64.3%) did not want journal clubs to be incorporated into their curriculum since they require a great deal of time to prepare. Some students say they have stage fright, and some do not feel they understand the statistics sufficiently to be able to present a paper.
Many residents felt that presenting journal club would be an intimidating process for several reasons, including the fact that they are already burdened with many subject lectures, assessments, and assignments. Inadequate infrastructure, faculty, high-speed internet, etc., may also be factors weighing against inculcating journal club into the curriculum. 17 Around 17.5% of our students did not want journal club because they felt there were not sufficient resources to support it.
To summarize, some students in our study were aware of journal club through friends, the internet, and the literature. Majority of the students would like to have journal clubs as they think it would give them confidence in presenting cases, especially during their OSCE exams. Journal clubs are time-consuming and hence some students may not like to have journal clubs to be implemented in the curriculum. However, efforts could be made to see that journal clubs do not affect regular curricular activities and that the topics selected would be from the curriculum so that students would not have the burden of spending time on unrelated topics. Journal clubs should not be a "fall-flat" session but a lively discussion that not only brings research into practice but also gives undergraduates lifelong learning skills that will continue to be useful throughout their career.

Conclusion
Incorporating a journal club in an undergraduate curriculum will help students gain a deeper understanding of the subject, help them to analyze, familiarize them with biostatics, and inspire them to conduct research in the future. Majority of our students showed a willingness towards the implementation of journal clubs. Hence it is necessary to motivate and help them realize that journal club is a teaching-learning methodology which can immensely improve their presentation skills which are analogous to their case presentations in clinics or exams. Journal clubs, when initiated at the undergraduate level, can help students develop into a great researcher, presenter, and investigator.
The most common concern for the implementation of journal clubs is the time factor. Students think it requires a lot of time which may hinder their performance in major subjects. Therefore, journal clubs for students should be scheduled in such a way that it should not affect their regular academic commitments and should be tightly entwined with the curriculum to provide greater depth and learning.

Ethical approval
Reviewed and approved by Research and Ethics committee of College of Medicine and Health Sciences, National University of Science and Technology, Oman. Reg.no -CMHS/REC/016/18/C.