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How Do I . . . ?
EBM - Question Formulation


In the literature on EBM, clinical questions are referred to as background or foreground questions. Background questions ask for definitions and other general information to help fill in your basic level of knowledge. Typically this information is found in dictionaries and textbooks. Foreground questions are narrowly focussed and patient-centred. Typically this information is found by formulating answerable questions using PICO and developing a strategy for searching databases of medical research literature.

EBM always begins and ends with the patient. To begin this process, consider the following clinical scenario:

Pauline is a new patient and she came for a routine physical exam today. Pauline is in good health although she has had hypertension for many years. You note that there is a family history of stroke. She is 76 years old and walks 3-4 miles several times a week. Pauline's hypertension has been successfully controlled by Beta-blockers and she expressed satisfaction with this therapy. However, Pauline's son, has recently been diagnosed with hypertension and was given Captopril. Pauline's son asked her to ask you whether or not Captopril would be a better medication for her.

Anatomy of a good clinical question - PICO method

  1. Patient or problem
    How would you describe a group of patients similar to yours? What are the most important characteristics of the patient? This may include the primary problem, disease, or co-existing conditions. Sometimes the sex, age or race of a patient might be relevant to the diagnosis or treatment of a disease.
  2. Intervention, prognostic factor, or exposure
    Which main intervention, prognostic factor, or exposure are you considering? What do you want to do for the patient? Prescribe a drug? Order a test? Order surgery? What factor may influence the prognosis of the patient? Age? Co-existing problems? What was the patient exposed to?
  3. Comparison
    What is the main alternative to compare with the intervention? Are you trying to decide between two drugs, a drug and no medication or placebo, or two diagnostic tests? Your clinical question does not always need a specific comparison.
  4. Outcomes
    What can you hope to accomplish, measure, improve or affect? What are you trying to do for the patient? Relieve or eliminate the symptoms? Reduce the number of adverse events? Improve function or test scores?
Patient/Problem high blood pressure, elderly
Intervention beta-blockers
Comparison ACE inhibitors
Outcome reduce blood pressure, minimize adverse effects

As a result, the clinical question might be:
In elderly patients, are ACE inhibitors more effective than beta-blockers in controlling high blood pressure and minimizing adverse effects?