EBM

(Evidence-based Medicine)
Asking Answerable
Clinical Questions
dr. Isti Ilmiati Fujiati, MSc.CM-FM, MPd.Ked.

What is EBM?

Evidence-based medicine (EBM) requires

the integration of the best research
evidence with our clinical expertise and our
patients unique values and circumstances

Best research evidence means valid and

clinically relevant research
Clinical expertise means ability to use our
clinical skills and past experience to rapidly
identify each patients unique health state and
diagnosis
Patient values means the unique preferences,
concerns and expectations each patiens brigs to
a clinical encounter and which must be integrated
into clinical decisions if they are to serve the
patient
Patient's circumstances means their individual
clinical state and clinical setting

How do we actually practice EBM?

Step-1: converting the need of information

(about prevention, diagnosis, prognosis,
therapy, causation, etc.) into an answerable
questions
Step-2: tracking down the best evidence
with which to answer that question
Step-3: critically appraising that evidence
for its validity, impact and applicability

How do we actually practice EBM?...

Step-4: integrating the critical appraisal with

our clinical expertise and with our patients
unique biology, values, and circumstances
Step-5: evaluating our effectiveness and
efficiency in executing steps 1-4 and
seeking ways to improve them both for next
time

Scenario

A pediatrician was called to the hospital to attend

the delivery of a new born. The mother, a 28 year
old primigravida, had experienced elevated blood
pressure during an otherwise uncomplicated
pregnancy. The labor was induced because the
pregnancy had continued 2 weeks past the
expected date of delivery. During labor, evidence
of fetal distress occurred. When the membranes
ruptured, the obstetrician noted thick greenish
containing meconium.

At the time of delivery

the male newborn was limp and cyanotic, and had
no spontaneous respiratory effort and a heart rate
only 50 beats/ min. When meconium was
suctioned from his mouth and nose, the baby did
not grimace, cough, or sneeze.
Vigorous effort at resuscitation were initiated,
including bag-and-mask ventilation with 100%
oxygen and chest compressions, but the Apgar
Score at 1 min. of life was 1. Despite continuing
resuscitation, the 5 min. Apgar score improved
only to 2, with a heart rate of 110 beats/ min.

The 10 min. Apgar score remained depressed

at 3, and the neonate was transferred to the
Newborn Intensive Care Unit. With
aggressive medical management, the 3100
gram neonate continued to improve without
evidence of acute neurologic complications.
He was discharged from the hospital on the
twelfth day of life.

Apgar Score for Evaluation of

Neonatal Asphyxia
Score
0

Sign
Heart Rate (x/ min)
Respiration
Muscle Tone
Color

(-)
(-)
Limp
Blue, pale

Reflex response to None

catheter in nostril

< 100
Slow, irregular
Slow flexion
Body pink,
extremities blue
Grimace

>100
Regular, crying
Active motor
Completely pink
Cough, sneeze

Questions
What are the complications of Low APGAR
SCORE?
How does the Low APGAR SCORE lead to
neurological complications?
What did the patient mean by if my baby
can not cry immediately, will he be fine?

Questions

Among patients presenting Low APGAR

SCORE, how often would develop
neurological complications?
In babies with Low APGAR SCORE, would
joining an integrated self care parents
management program reduce morbidity
from abnormal mental capacity over 5-7
years?

Background and Foreground

Questions
Background questions
Ask for general knowledge about a
condition or thing
Have two essential components:
1. A question root (who, what, where, when,
how, why) and a verb
2. A disorder, test, treatment or other aspect
of health care

Background and Foreground

Questions
Foreground questions
Ask for specific knowledge to inform clinical
decisions or actions
Have four essential components:
1. Patient and/ or problem
2. Intervention or exposure
3. Comparison, if relevant
4. Clinical outcomes including time if relevant

(P)
(I)
(C)
(O)

Learn to Ask a Focused Clinical Question Foreground

Patient
Problem /
Population

Description of the group to which your patient

belongs, (age, gender, race, ethnicity, and
stage of disease). The description should be
specific enough to be helpful, but not overly
specific.

Intervention

description of the test or treatment that you

are considering

Be specific!

what you plan to do for that

patient

Comparison

the alternative. Not all questions need a

comparison,
the main alternative you are considering

Outcome

something that not only matters to you, but

matters to the patient. Be specific!
what is the main concern?

Be specific!

The components: P

Think about who / what you wish to apply this

evidence to e.g.

People with a particular disorder?

People in a particular care setting?

e.g. community

Particular groups of people

e.g chronic recurrent cystitis

e.g. sexually active young women?

the elderly?
children?

How would you describe your clients / setting?

The components: I
The

intervention / topic of interest (e.g.

cause, change in practice etc.) e.g.
Use of guava juice (as a drink)
Might want to specify how much / how often
For complex interventions may need to give
specific detail / consideration to the
description

What

exactly am I considering?

The components: C
The

comparison or alternative
applicable to all questions) e.g.

(not

Anti-biotic therapy?
Nothing?
Fluids alone?

What

alternatives actions might I try?

The components: O

The outcome e.g.

Cure
Duration of disease
Prevention
Death
Side effects
Pain (reduced)
Wellbeing

What am I hoping to accomplish

(what outcomes might reasonably
be affected...)?

Foreground

Background

Experience with Condition

A = limited experience with the condition

B = as we grow in clinical experience and
responsibility
C = further experience with the conditions
Diagonal line shows were never too green
to learn foreground knowledge or too
experience to outlive the need for
background knowledge

Our reactions to knowing and

to not knowing

Clinical practice demands that we use large

amounts of both background and foreground
knowledge, whether or not were aware of its use.
Combinations of practice demands and our
awareness:
1st our patients predicament may call for
knowledge that we already possess, so we will
experience the reinforcing mental and emotional
responses termed Cognitive Resonance

Our reactions to knowing and

to not knowing

2nd we may realize that our patients illness calls

for knowledge that we dont possess, and this
awareness brings mental and emotional
responses termed Cognitive Dissonance need
to know
3rd - our patients predicament might call upon
knowledge that we dont have, yet these gaps
may escape our attention, so we dont know what
we dont know and we carry on undisturbed
ignorance.

Unfortunately
if handled less well, our cognitive
dissonance might lead us to less adaptive
behaviors such as trying to hide our
deficits, or by reacting with anger, fear, or
shame

By developing awareness of our knowing

and thinking, we can recognized our
cognitive dissonance when it occurs,
recognized when the knowledge we need
would come from clinical care research,
and articulate background and foreground
questions we can use to find the answers.

Central issues in clinical work where

clinical questions often arise

Clinical findings how to properly gather and

interpret findings from the history and physical
examination

Etiology how to identify causes or risk factors

(including iatrogenic harms)

Clinical manifestation of disease knowing

how often and when a disease causes its clinical
manifestations and how to use this knowledge in
classifying our patient's illnesses

Central issues in clinical work where

clinical questions often arise

Differential diagnosis
Diagnostic tests
Prognosis
Therapy
Prevention
Experience and meaning
Improvement how to keep up-to-date

For you to have the skills in

questioning

Make an answerable clinical questions

(background or foreground question)
Use your knowledge in semester 1, 2, 3,
and/ or 4 to make the question.
You can choose the scenario from one of
the triggers in Tutorial to help you formulate
the questions
You have 7 minutes to do this exercise

 Well

done
keeping practice!