Formulating the Clinical Question

External clinical evidence can inform,

but can never replace,
individual clinical expertise,
and it is this expertise that decides
whether the external evidence applies
to the individual patient at all
and, if so, how it should be integrated
into a clinical decision.
 How do we actually practice EBM?

Step 1: converting the need for

information (about prevention,
diagnosis, prognosis, therapy,
causation) into an answerable question

Step 2: track down the best evidence
with which to answer that question
 How do we actually practice EBM?

Step 3:critically appraise the evidence for

its 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 our
patients unique biology, values and
circumtances
 How do we actually practice EBM?

Step 5: evaluating our effectiveness and

efficiency in executing Steps 1-4 and
seeking ways to improve them both for
next time
 Steps in Evidence Based Medicine
1. Formulating a focused clinical question
2. Searching the literature for relevant
clinical articles
3. Critically appraising the evidence for its
validity and usefulness
4. Integrate clinical expertise, useful
findings and patients needs
5. Evaluate your performance
 Asking Answerable Questions

Good Questions are the backbone of both

practicing and teaching EBM

Patients serve as the starting point for
both

Hardest step many people face
Asking Answerable Questions

“Almost every time we see a

patient…..We usually need some
information on some element about
their diagnosis, prognosis or
management”
Asking Answerable Questions

“What important pieces of medical

knowledge you would like to have in
order to provide better care for your
patient?”
 Well Built Clinical Question

1. “Background” Questions
2. “Foreground” Questions
 “Background” Questions

Asks for general knowledge about a
disease

Two components:
1. A root question (who, what, when,
where, how, why)

plus a verb
2. A Disorder or the aspect of the disease
 Examples of “Background” Questions

What are the possible causes of

jaundice?

When do complications of untreated
hypertension usually occur?

What happens if metoprolol is
prescribed to a patient with a strong
family history of asthma?
 “Foreground” Questions

Asks for a specific knowledge about
managing a patient with a disease

Usually have four (or three) essential
components:

Patient/ or problem

Intervention

Comparison intervention (if relevant)

Clinical Outcomes
 Examples of “Foreground” Questions

“Among elderly patients with heart

failure due to isolated diastolic
dysfunction, does adding lanoxin to
standard diuretic and ace inhibitor
treatment yield enough reduction in
mortality or morbidity to be worth of its
adverse effects?
 Examples of “Foreground” Questions

In patients with Community Acquired

Pneumonia, do clinical features predict
outcome well enough that low risk
patients can be treated safely at home?
 Well Built Clinical Question

1. “Background” Questions

Questions about background knowledge
2. “Foreground” Questions

Arise from central issues involved in
caring for our patients
 Why bother formulating questions clearly?

Helps focus our scarce learning time on

evidence that is

Directly relevant to our patients clinical
need

Directly addresses our particular
knowledge needs
Why bother formulating questions clearly?

Can suggest high yield search strategies

Suggest the forms that useful answers
might take

When we teach, they can help our
learners to better understand the
context of what we teach

When we answer our questions, our
curiosity are reinforced
 Common Problems

Tendency to ask questions about the
sensitivity of our own physical
examination

Example:

Among patients presenting with ________,
what is the sensitivity and specificity of
increased vocal fremiti in the diagnosis of
________?
 Challenge

Our challenge as teachers is to
identify 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
 Common Problems

Too narrow questions

Among post-cholecystectomy patients
presenting with abdominal pain and jaundice,
what are the possible differential diagnosis?

Grrrrrrrrrrrrrr……….

Too broad questions

Among patients with non-specific abdominal
pain, what are the differential diagnosis?
 Workshop 1
Formulation of the clinical
question
 Objectives of Workshop 1

To formulate a focused clinical question
based on a patients’ case scenario

To identify essential search terms based
on the focused clinical question
 Case Scenario
RL is a 34 year old, male, complaining of low back
pain, on and off, for about 4 months. Pain was
relieved with NSAIDS and paracetamol.
However, recurrence of symptoms brought him
to your clinic. According to him, he already
consulted several other doctors and all
laboratory workup revealed normal findings. Your
physical examination was also essentially normal
with no gait or neurologic deficits observed.
 Case Scenario

Your patient is asking about the

effectiveness of alternative therapies
such as exercise programs offered in
some institutions for the immediate
relief low back pain.