Formulating the Clinical Question

8/8/2019 Formulating the Clinical Question

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Formulating the Clinical Question


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External clinical evidence can inform,but can never replace,

individual clinical expertise,

and it is this expertise that decideswhether the external evidence appliesto the individual patient at all

and, if so, how it should be integratedinto a clinical decision.


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How do we actually practice EBM?

Step 1: converting the need forinformation (about prevention,

diagnosis, prognosis, therapy,causation) into an answerable question

Step 2: track down the best evidence

with which to answer that question


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Step 3:critically appraise the evidence forits validity (closeness to the truth), impact(size of its effect) and applicability(usefulness to our clinical practice)

Step 4: integrating the critical appraisal

with our clinical expertise and with ourpatients unique biology, values andcircumtances


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Step 5: evaluating our effectiveness andefficiency in executing Steps 1-4 and

seeking ways to improve them both fornext time


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Steps in Evidence Based Medicine

1. Formulating a focused clinical question2. Searching the literature for relevant

clinical articles

3. Critically appraising the evidence for itsvalidity and usefulness

4. Integrate clinical expertise, useful

findings and patients needs5. Evaluate your performance


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Asking Answerable Questions

Good Questions are the backbone of bothpracticing and teaching EBM

Patients serve as the starting point forboth

Hardest step many people face


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Almost every time we see apatient..We usually need some

information on some element abouttheir diagnosis, prognosis or

management


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What important pieces of medicalknowledge you would like to have inorder to provide better care for yourpatient?


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Well Built Clinical Question

1. Background Questions

2. Foreground Questions


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Background Questions

Asks for general knowledge about adisease

Two components:1. Aroot question (who, what, when,

where, how, why)

plus a verb2. A Disorder or the aspect of the disease


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Examples of Background Questions

What are the possible causes ofjaundice?

When do complications of untreatedhypertension usually occur?

What happens if metoprolol is

prescribed to a patient with a strongfamily history of asthma?


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Foreground Questions

Asks for a specific knowledge aboutmanaging a patient with a disease

Usually have four (or three) essentialcomponents: Patient/ or problem

Intervention Comparison intervention (if relevant)

Clinical Outcomes


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Examples of Foreground Questions

Among elderly patients with heartfailure due to isolated diastolic

dysfunction, does adding lanoxin tostandard diuretic and ace inhibitortreatment yield enough reduction in

mortality or morbidity to be worth of itsadverse effects?

Among elderly patients with heartfailure due to isolated diastolic

dysfunction, does adding lanoxin tostandard diuretic and ace inhibitortreatment yield enough reduction in

mortality or morbidity to be worth of itsadverse effects?


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Examples of Foreground Questions

In patients with Community AcquiredPneumonia, do clinical features predict

outcome well enough that low riskpatients can be treated safely at home?


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Well Built Clinical Question

1. Background Questions

Questions about background knowledge

2. Foreground Questions Arise from central issues involved in

caring for our patients


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Why bother formulating questions clearly?

Helps focus our scarce learning time onevidence that is

Directly relevant to our patients clinicalneed

Directly addresses our particularknowledge needs


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Common Problems

Tendency to ask questions about thesensitivity of our own physical

examination Example:

Among patients presenting with ________,

what is the sensitivity and specificity ofincreased vocal fremiti in the diagnosis of

________?


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Challenge

Our challenge as teachers is toidentify questions that are

patient-based arising out of the clinical problems of the

patient under the learner's care

and learner centred

targeting the learning needs of the learner


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Common Problems

Too narrow questionsAmong post-cholecystectomy patients

presenting with abdominal pain and jaundice,

what are the possible differential diagnosis?

Grrrrrrrrrrrrrr.

Too broad questionsAmong patients with non-specific abdominal

pain, what are the differential diagnosis?


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Workshop 1

Formulation of the clinicalquestion


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Objectives of Workshop 1

To formulate a focused clinical questionbased on a patients case scenario

To identify essential search terms basedon the focused clinical question


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Case Scenario

RL is a 34 year old, male, complaining of low backpain, on and off, for about 4 months. Pain wasrelieved with NSAIDS and paracetamol.

However, recurrence of symptoms brought himto your clinic. According to him, he alreadyconsulted several other doctors and alllaboratory workup revealed normal findings. Yourphysical examination was also essentially normalwith no gait or neurologic deficits observed.


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Case Scenario

Your patient is asking about theeffectiveness of alternative therapies

such as exercise programs offered insome institutions for the immediate

relief low back pain.

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Formulating the Clinical Question