2.

Asking a Good
Clinical Question

Mark H. Ebell, M.D., M.S.
Deputy Editor, American Family Physician
Associate Professor
Dept of Family Practice, MSU

Objectives
! Understand the importance of clinical
questions to learning
! Be able to apply the PICO framework to
your clinical questions
! Practice asking better clinical questions

Adult learning
! Children
" Told what, when, and where to learn
" Lecture and practice without application

! Adults
" Decide what they have to learn
" Learning is focused on solving problem and
dressing their learning needs

they’re important: " Only 30% pursued. " 75% of those are answered " Of those not pursued. half were important .Information about clinical questions ! They’re common: " Direct observation: about 1 question for every 1- 2 patient encounters in primary care " Many are suppressed due to lack of time or resources ! Nevertheless.

Physicians are adults! ! The problems that physicians have to solve are the clinical questions that arise during patient care ! Traditional continuing medical education can highlight advances. make us aware of deficits. ! Answering clinical questions and applying them to our patients is how we learn . and teach skills – but little real learning takes place in the lecture hall.

The Information Pathway ! Unrecognized information need – “you don’t know that you don’t know” ! Recognized information need – a question is asked ! Pursued information need – you try to find the answer ! Satisified information need – the question is answered ! Implimented information need – you apply the answer to your patient and future patients .

The Information Pathway: an endless cycle " Questions arise " They are answered and applied " New questions arise .

The Information Pathway Satisfied need .

doesn’t know that uncomplicated corneal abrasions don’t require patching Recognized .wonders if you really have to patch corneal abrasions Pursued .finds a POEM at the JFP Web site after searching on the phrase “corneal abrasion” that answers the question Implemented .does not patch the next patient’s eye .looks for an RCT comparing patch to no patch in corneal abrasion Satisfied .does not patch this patient’s eye Maintained .Information Pathway: An Example Unrecognized .

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Overcoming Barriers on the Information Pathway ! Cultural " Encourage reflection " Question authority and conventional wisdom " Value questions and learn to enjoy healthy debate " Record questions for later answering if appropriate .

evidence-based point of care resources available ! Computers ! PDA ! Web " Buildtime in each week to answer important questions .Overcoming Barriers on the Information Pathway ! Environmental " Make high quality.

Overcoming Barriers on the Information Pathway ! Skills " Learn the language and skills of evidence- based practice " Learn how to ask good questions (later in this presentation) " Learn how to use Medline as a clinician " Become familiar with PDA resources .

the question requires that you know the patient and the particulars of their case.Asking a Good Clinical Question ! Too often clinical questions are couched in terms specific to a particular patient: " “What test should I order for this 28-year-old woman with chest pain?” ! As phrased. ! This may be appropriate when talking to a human consultant but not when searching a medical reference. .

the question on the previous slide could be rephrased as: " “What is the best test to rule out myocardial infarction in this person with chest pain and a low likelihood of disease?” . ! For example.Make Questions Generalizable ! You are much more likely to get a helpful answer from a medical reference or a medical librarian if you ask a well-formed. more generalizable question.

PICO ! “PICO” is a useful acronym that describes the elements of a well-formed clinical question about therapy: "Population "Intervention "Comparison "Outcome .

Population ! Description of the group to which your patient belongs. You are unlikely to find studies of “Asian 63 year old women” (too specific). and may include: " Age and gender " Race or ethnicity " Stage of disease ! The description should be specific enough to be helpful. describing the population as “Post- menopausal women” is much more likely to be helpful. but not overly specific. .

Intervention ! This is a description of the test or treatment that you are considering that might include information on the: " Dose " Intensity " Duration .

Comparison ! Comparison is the alternative to the treatment. ! For example. if the intervention is “Drug A” for someone with pulmonary embolism. the alternative could be: " Drug B " Drug A + Drug B " Surgery " Counseling " Doing nothing .

but matters to the patient (“patient oriented outcomes”) ! You may want to involve the patient in defining the outcome. .Outcome ! The outcome should generally be something that not only matters to you.

Example: ! Population " “Among otherwise healthy adults with cough and no fever…” ! Intervention " “…does a macrolide antibiotic…” ! Comparison " “…when compared with placebo…” ! Outcome(s) " “…reduce symptoms and speed return to usual activities?” .

you are preparing to write a prescription for a serotonin specific reuptake inhibitor (SSRI). She denies any suicidal ideation. and has a normal history and physical examination. what about St. John’s Wort a reasonable choice for this patient?” . John’s Wort? ! You wonder: “Is St. ! After diagnosing her with minor depression.Case #1 ! Jean Birkenstock presents with a complaint of fatigue and loss of interest in her usual activities. Your patient asks.

PICO format for this question ! Population: Adults with minor depression ! Intervention: St. John’s Wort ! Comparison: An SSRI ! Outcome: relief of symptoms .

John’s Wort or an SSRI more effective at relieving symptoms?” .Putting it all together… ! “In adults with minor depression. is St.

The diphenhydramine he has used in the past now makes him tired.Case #2 ! Jimmy Coryza is a 14 year old with seasonal allergies. He presents in April with his usual symptoms. ! You wonder: should you prescribe a nasal corticosteroid or a non-sedating anti- histamine? .

but don’t box yourself in at the outset) ! Intervention: nasal corticosteroid ! Comparison: non-sedating antihistamine ! Outcome: relief of symptoms (other important outcomes could include sedation and cost.PICO format for this question ! Population: Patients with seasonal allergies (if you find data for adolescents or children.) . for example. so much the better. or you could look at the symptom that is most troublesome to the patient. Coryza.

is an inhaled corticosteroid or a non-sedating antihistamine better at relieving coryza?” .Putting it all together… ! “In patients with seasonal allergies.

Case #3 ! Hack Fredrickson has been coughing for 6 weeks. ! You wonder: Given his history. should you skip the chest x-ray and go straight to a CT scan? . and you are concerned about malignancy. He is a heavy smoker.

PICO format for this question ! Population: Patients with cough ! Intervention: chest x-ray ! Comparison: chest CT ! Outcome: positive and negative predictive value .

Putting it all together… ! “In patients with cough. does chest x-ray or chest CT have a better positive and negative predictive value?” .

.In summary ! Be curious ! Remember PICO ! Learn to use resources and make them convenient to use ! Lifelong learning means learning in small increments over a long period of time ! Attempts to do it all at once are both impossible and bound to frustrate.