Bambang Tridjaja

deliveredbyIndahS.Widyahening

Goals
Attheendofthislecture,youwill:
Beabletocreateawellformedclinical
question
Appreciatetheimportanceofwellformed
clinicalquestionsinkeepinguptodate

Drawing conclusion
That impact on practice

Patient
Encounter

Diagnosis
Therapy
Prognosis
Etiology

Apply

Appraise

Appraising
the
Evidence

EBM

Formulating
Clinical
Question

Ask

Acquire
Hierarchy of evidence
Pre appraised resources

Searching
the
Evidence

Patient
Intervention
Comparison
Outcome

(Lang, 2000)

WhatQuestionsDoCliniciansAskatthe
Point ofCare?
RESEARCH
Physiciansreported
1question/4patients
(day)
15questions/25
patientsperday

Primarycaredoctors
2questions/3patient

Questionsrelation
33%~treatment
25%~diagnosis
15%~pharmaco
therapeutics.

2/3clinicalquestions
unanswered.
Aretheunanswered
questionsimportant?
50%oftheanswers
directimpacton
patientcare.

WHYBOTHERFORMULATINGQUESTIONS
CLEARLY?
AnswerableClinicalQuestions:
1. Helpfocusourscarcelearningtimeon
evidencethatisdirectlyrelevanttoour
patientsclinicalneeds.
2. Helpusfocusourscarcelearningtimeon
evidencethatdirectlyaddressesour
particularknowledgeneeds,orthoseofour
learners.
(Straussetal,2005)

WHYBOTHERFORMULATINGANSWERABLE
CLINICALQUESTIONS?
AnswerableClinicalQuestions:
3. Suggesthighyieldsearchstrategies
4. Suggesttheformsthatusefulanswersmight
take
5. Whensendingorreceivingapatientin
referral,theycanhelpustocommunicate
moreclearlywithourcolleagues.

(Straussetal,2005)

WHYBOTHERFORMULATINGQUESTIONS
CLEARLY?
AnswerableClinicalQuestions:
6. Whenteaching,ACQhelpourlearnersto
betterunderstandthecontentofwhatwe
teach,whilealsomodelingsomeadaptive
processesforlifelonglearning.

(Straussetal,2005)

WHYBOTHERFORMULATINGQUESTIONS
CLEARLY?
AnswerableClinicalQuestions:
7. Whenourquestionsgetanswered,our
knowledgegrows,ourcuriosityisreinforced,
ourcognitiveresonanceisrestored,andwe
canbecomebetter,faster,andhappier
clinicians.

(Straussetal,2005)

Answerable
Whydowenotanswermoreofthesequestions?
lackofconvenientaccesstoreferencematerials
timeneededtosearchforinformation

Twocharacteristicsthatpredictwhetherphysicians
willseekandfindananswertoaclinicalquestionare
theurgencyoftheproblemand
theirconfidencethattheywillfindananswer

ANSWERABLE CLINICAL QUESTIONS

Howdoyouchoosewhich
questiontoanswer?
Importanttoapatient'swellbeing(intermsof
outcomesthattheycareabout)
Feasibletoaddressinthetimeavailable(youthink
youmightbeabletofindananswer)
Likelytorecurinyourpractice(commontopractice)
Involveaninterventionthatisfeasibleandnotyour
currentpractice
Interestingtoyou
Medicolegalissue

TypeofQuestion
Evidencebasedpracticerequiresthatclinicians
makeuseofthebestresearchtheycanfindto
helpthemindecisionmaking.Tofindthat
researchefficiently,theclinicianmustaskawell
designedclinicalquestionwithalltheelements
thatwillleadtofindingrelevantresearch
literature.
Thefirststepindoingthisistodeterminethe
typeofquestion:background orforeground.The
typeofquestionhelpstodeterminetheresource
toaccesstoanswerthequestion.

TypeofQuestions
"Background"
questionsaskforgeneral
knowledgeabouta
conditionorthing.
Answeringthebackground
question.
excellentreviewarticleor
respectedevidencedbased
textbook.Wheninneedofan
overviewonclinical
presentationofadisease,
standardtherapies,diagnostic
tools,etc.,consultatextbook.

"Foreground"
questionsaskforspecific
knowledgetoinformclinical
decisionsoractions.
Answeringtheforeground
question.
Primarysource:journal
Secondarysource:Cochrane

BackgroundQuestions
Askforgeneralknowledgeaboutadiseaseordisease
process
Havetwoessentialcomponents:
Aquestionroot(who,what,when,etc.)withaverb
Adisorder,test,treatment,orotheraspectofhealthcare
Example:Whatcausesmigraines? orHowoftenshould
womenovertheageof40haveamammogram?

Thebackgroundquestionisusuallyaskedbecauseof
theneedforbasicinformation.Itisnotnormallyasked
becauseofaneedtomakeaclinicaldecisionabouta
specificpatient.

Foregroundquestions
Askforspecificknowledgeaboutmanaging
patientswithadisease
Have3or4essentialcomponents
Patientand/orproblem
Indicator/Intervention
Comparativeintervention(optional,includeif
relevant)
Clinicaloutcome

Inyoungchildrenwithacuteotitis media,is
shorttermantibiotictherapyaseffectiveaslong
termantibiotictherapy?

Type of question depend

on the clinical experience
SPECIFIC KNOWLEDGE
Question
type
GENERAL KNOWLEDGE

Clinical experience

PICO
PICOisamnemonicusedtodescribethefour
elementsofagoodclinicalforeground
question.
PPatient
IIndicator/Intervention
CComparison
OOutcome

P=Population/Patient/Problem
Howwouldyoudescribeagroupofpatients
similartoyours?
Whatarethemostimportantcharacteristics
ofthepatient?
Thismayincludetheprimaryproblem,
disease,orcoexistingconditions.
Sometimesthesex,ageorraceofapatient
mightberelevanttothediagnosisor
treatmentofadisease.

I=Indicator/Intervention;E=Exposure
Whichmainintervention,prognosticfactor,or
exposureareyouconsidering?
Whatdoyouwanttodoforthepatient?
Prescribeadrug?
Orderatest?Ordersurgery?
Whatfactormayinfluencetheprognosisofthe
patient?Age?Coexistingproblems?
Whatwasthepatientexposedto?Asbestos?
Cigarettesmoke?

Comparison
Whatisthemainalternativetocomparewith
theintervention?
Areyoutryingtodecidebetweentwodrugs,a
drugandnomedicationorplacebo,ortwo
diagnostictests?
Yourclinicalquestiondoesnotalwaysneeda
specificcomparison.

Outcome
Whatcanyouhopetoaccomplish,measure,
improveoraffect?
Whatareyoutryingtodoforthepatient?
Relieveoreliminatethesymptoms?
Reducethenumberofadverseevents?
Improvefunctionortestscores?

QUESTIONCATEGORIES

QuestionCategories
Diagnosis Howtoselectadiagnostictestorhow
tointerprettheresultsofaparticulartest.
TherapyWhichtreatmentisthemosteffective,
orwhatisaneffectivetreatmentgivena
particularcondition.
HarmorEtiologyArethereharmfuleffectsofa
particulartreatmentorexposureorriskfactor
Prognosis Whatisthepatient'slikelycourseof
diseasegiventhecharacteristic

Exercise
Inpatientswithsuspecteddepressionwhatisthe
Inpatientswithacutebronchitis,doantibiotics
accuracyofatwoquestioncasefinding
reducesputumproduction,coughordaysoff
instrumentfordepressioncomparedwithsix
work?
previouslyvalidatedinstruments?
Inwomentakingoralcontraceptives,istherean
associationbetweentheiruseandcardiovascular
disease?

EXERCISE
Inpatientswithsuspecteddepressionwhatisthe
accuracyofatwoquestioncasefinding
instrumentfordepressioncomparedwithsix
previouslyvalidatedinstruments?

P=
I=
C=
O=

EXERCISE
Inwomentakingoralcontraceptives,istherean
associationbetweentheiruseandcardiovascular
disease?

P=
I=
C=
O=

EXERCISE
Inpatientswithacutebronchitis,doantibiotics
reducesputumproduction,coughordaysoff
work?

P=
I=
C=
O=

PICO&Applicability

Adaptedfrom:Sackettetal.sEvidenceBasedMedicine:HowtoPracticeandTeachEBM

PICO&Applicability

InformationPyramid

GUIDETOPICOAPPLICABILITY
PATIENT/PROBLEM

INDICATOR

PICO:
TypeofQuestion:
Typeofstudy/methodology:

COMPARISON

OUTCOME

Case#1
Yournextpatientisa72yearoldwomanwith
osteoarthritisofthekneesandmoderate
hypertension,accompaniedbyherdaughter,a
labtechfromthehospital.Thedaughter
wantsyoutogivehermotheraprescription
foroneofthenewCOX2inhibitors.Shehas
heardthattheycauselessGIbleeding.

FILLINTHECOLUMN
PATIENT/PROBLEM

INTERVENTION

PICO:
TypeofQuestion:
Typeofstudy/methodology:

COMPARISON

OUTCOME

Case#1
PATIENT/PROBLEM

INTERVENTION

72yearoldwoman COX2Inhibitor
withosteoarthritis
ofthekneeand
moderate
hypertension

COMPARISON
otherNSAIDS

OUTCOME
lessGIbleeding

PICO:
Ina72yearoldwomanwithosteoarthritisoftheknee,canCOX2Inhibitoruse
decreasetheriskofGIbleedingcomparedwithotherNSAIDs?

TypeofQuestion:
Therapy/Treatment

Typeofstudy/methodology:
SystematicReview/MetaAnalysisofDoubleBlindRandomizedControlledTrials

Case#2
Youseea70yearoldmaninyouroutpatient
clinic3monthsafterhewasdischargedfrom
yourservicewithanischemicstroke.Heisin
sinusrhythm,hasmildresidualleftsided
weaknessbutisotherwisewell.Hisonly
medicationisASAandhehasnoallergies.He
recentlysawanarticleontheBMJwebsite
describingtheriskofseizureafterastrokeand
isconcernedthatthiswillhappentohim.

FILLINTHECOLUMN
PATIENT/PROBLEM

INTERVENTION

PICO:
TypeofQuestion:
Typeofstudy/methodology:

COMPARISON

OUTCOME

Case#2
PATIENT/PROBLEM
70yearoldman

INTERVENTION
Stroke

COMPARISON

OUTCOME
Seizure

PICO:
Ina70yearoldmandoesahistoryofstrokeincreasehisriskforseizure?

TypeofQuestion:
Prognosis

Typeofstudy/methodology:
Cohortstudies

Case#3
Youadmita75yearoldwomanwithcommunity
acquiredpneumonia.Sherespondsnicelyto
appropriateantibioticsbutherhemoglobinremainsat
10g/dlwithanMCVof80.Herperipheralbloodsmear
showshypochromia,sheisotherwisewellandisonno
incriminatingmedications.Youcontactherfamily
physicianandfindoutthatherHgb was10,5g/dl
about6monthsago.Shehasneverbeeninvestigated
foranaemia.Aferritin hasbeenorderedandcomes
backat10mmol/l.Youadmittoyourselfthatyou're
unsurehowtointerpretaferritin resultandaren'tsure
howpreciseandaccurateitis.

FILLINTHECOLUMN
PATIENT/PROBLEM

INTERVENTION

PICO:
TypeofQuestion:
Typeofstudy/methodology:

COMPARISON

OUTCOME

Case#2
PATIENT/PROBLEM

INTERVENTION

Elderlywomanwith Ferritin
anaemia

COMPARISON

OUTCOME
Irondeficiency
anaemia

PICO:
Inanelderlywomanwithhypochromic,microcytic anaemia,canalowferritin
diagnoseirondeficiencyanaemia?

TypeofQuestion:
Diagnosis

Typeofstudy/methodology:
ControlledStudies;SystematicReview/MetaAnalysisofControlledStudies