REVIEW ARTICLE

Pdf version

Evidence Based Medicine Series

ASKING FOCUSED ANSWERABLE CLINICAL QUESTIONS

NM Lai, MRCP, MRCPCH Department of Paediatrics, School of Medicine and Health Sciences, Monash University Malaysia.

Address for correspondence: Dr Lai Nai Ming, Senior Lecturer in Paediatrics, School of Medicine and Health Sciences, Monash University Malaysia, JKR 1235, Bukit Azah, 80100 Johor Bahru, Johor, Malaysia. Tel: +607 2190600, Fax : +607 2190601, Email: lainm123@yahoo.co.uk

Lai NM. Evidence Based Medicine Series. Part 2. Asking focused answerable clinical questions. Malaysian Family Physician. 2009; 4(1):23-25.

Identifying the need for new information from important and relevant issues in patient care in the face of clinical uncertainties, and converting this need into answerable questions is the first step of Evidence Based Medicine (EBM).¹ Different types of questions come up in our minds during the bedside rounds or clinic consults. Some are questions that concern general knowledge, the answers of which are readily available in the standard texts. For example:

What causes Hand Foot Mouth Disease?
What should we use to treat migraine?
How common is hip pain in the elderly?
When (at what age) should we start screening for breast cancer?
How does liver become enlarged with heart failure?

These are “Background questions”, with two major components: A question root (what, why, when, where, how) linking with a disorder, test, treatment or health care issue2. Most background questions have answers that increase knowledge and the amount of information that we can share with patients, but they generally do not help directly in improving patient care. Other background questions are unanswerable, for example question no 2, because whatever answer to these questions will amount to inappropriate generalization, as the questions do not consider specific patient characteristics and outcomes of interest, which are essential elements to consider in deciding whether certain treatment should be used in different clinical circumstances.

With some “touch-ups”, background questions can be converted to specific questions with direct bearing on clinical decisions - the “foreground questions”.  For example:

1. In children with Hand Foot Mouth Disease, does treatment with antiviral compared to no antiviral result in faster resolution of lesions?
   (Question on THERAPY)
2. In adult patients with heart failure, does the presence of ascites increase the risk of mortality? (in 1 year/3 years/5 years etc)
   (Question on PROGNOSIS)

There are four components in the foreground questions, as shown below:

The PICO framework encompasses the important elements of a focused, answerable question, which are the predominant questions we should be asking in our day-to-day patient encounters. The answers to these questions may not be readily available from the standard text. Even if they are, they may no longer be accurate when we find them. The best answers to these questions reside within the sea of up-to-date clinical literature, waiting for us to gather using a set of skills that our next article in the series will elaborate.

Why PICO?

There are several advantages when we formulate questions using the PICO framework:²

• It is a convenient way of helping us focus on the clinical needs of our patients as well as our learning needs, especially when our times are limited.
• It helps identify the types of research that can best answer our questions, provides us important keywords in our search, and appears to improve search precision.³
• Communication between colleagues making use these four elements, for example, during referral, helps in putting across a clear picture of our patients.
• This framework presents a systematic and easy-to-follow method of acquiring retainable clinical knowledge from patient encounters.
• It makes teaching (bedside or classroom teaching like Problem Based Learning) more efficient and focused.

Issues in patient care leading to questions1
These are broadly categorised into the issues relating to:

• Diagnosis: the diagnostic accuracy of a test, including clinical symptoms or signs.
• Therapy: the effectiveness of a treatment (medication, surgery or other therapeutic regimes) in improving or preventing certain outcomes. The safety/harm of a treatment.
• Prognosis: whether certain patient or disease characteristics predicts certain outcomes/ complication.
• Other issues (health care related or personal) like cost and efficiency of care, self-improvement in clinical skills and knowledge

Prioritizing questions to be answered
Among the many questions that might surface during our practice, we may not have enough time or memory with the pressure of work to remember them all, let alone finding answers for them. The following is a rough guide on how to choose questions to answer (these are not in the order of importance):1

• Choose the most immediately relevant : the one that concerns the most urgent decisions we have to make on the patient
• Choose the one that we would like to know most
• Choose the one that our patient asks
• Choose the one we know is most likely to have answers, for example, common issues
• Choose the one that is most likely to recur in our practice

WORKSHEET FOR CLINICAL QUESTIONS

References

1. Richardson WS, Wilson MC, Nishikawa J, et al. The well-built clinical question: a key to evidence-based decisions. ACP J Club. 1995;123(3):A12-3 [PubMed]
2. Straus SE, Richardson WS, Glasziou P, et al. Evidence-Based Medicine. How To Practice And Teach EBM. 3rd ed.: Edinburgh: Churchill Livingston. 2005:13-30
3. Schardt C, Adams MB, Owens T, et al. Utilization of the PICO framework to improve searching PubMed for clinical questions. BMC Med Inform Decis Mak. 2007;7:16 [PubMed] [Full text]