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
- 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.
- 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?
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.
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?
||high blood pressure, elderly
||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?