How to Practice and Teach EBM

Asking answerable clinical questions

Reported by David Wong

Asking answerable clinical questions

Chapter 1 — Contents

Chapter opening Types of questions Where and how clinical questions arise Problems in posing answerable questions Questions our patients want answered Teaching the asking of answerable questions Further reading

Need New Information

• For diagnosis, prognosis, management• ask questions and track down answers are

formidable• limited time for reading and keeping up to

date• information needs never get met

An example

• 77/M admitted for dyspnea and fever• 4 days--low-grade fever, chills, myalgia,

rhinorrhoea, non-productive cough• 1 day ago--dyspnea on exertion, purulent

sputum, lateral chest wall pain with inspiration & shaking chill.

An example-2

• P.H. hypertension for 12 yrs, on diuretics• P.E. RR 28, HR 108, BT 39.2’C, subtle

cyanosis, no wheezing, but bronchophonyand egophony in lt lower posterior lung field.

• Leukocytosis & hyponatremia

Questions asked by team students

• What microbial organisms can cause community-acquired pneumonia?

• How does pneumonia cause egophony?• What do patients mean by calling

pneumonia “the old man’s friend”? What do you make of them?

Types of questions

• “Background” questions• “Foreground” questions

“Background” questions

Ask for general knowledge about a disorder Have two essential components:1. A question root (who, what, where, when,

how, why) with a verb2. A disorder, or an aspect of a disorder

Examples:“What causes babesiosis?”“When do complications of acute pancreatitis

usually occur?”

“Foreground” questions

Ask for specific knowledge about managing patients with a disorder

Have four (or three) essential components:

• 1. Patient and/or problem• 2. Intervention• 3. Comparison intervention (if relevant)• 4. Clinical Outcomes

Example

• “In older patients with heart failure from isolated diastolic dysfunction, does adding digoxin to standard diuretic and ACE inhibitor treatment yield enough reduction in morbidity and/or mortality to be worth its adverse effects?”

Questions asked by team house officers• (a) In patients with suspected pneumonia, are any

clinical findings sufficiently powerful to confirm or exclude pneumonia all by themselves, or is a chest radiograph necessary for the diagnosis?

• (b) In patients with community-acquired pneumonia, is the probability of Legionella infection sufficiently high to warrant considering covering this organism with the initial antibiotic choice?

• (c) In patients with community-acquired pneumonia, do clinical features predict outcome well enough that “low risk” patients can be treated safely at home?

Components of Foreground Questions

• The patient and/or problem of interest• The main intervention (defined very

broadly, including an exposure, a diagnostic test, a prognostic factor, a treatment, a patient perception, and so forth)

• Comparison intervention(s), if relevant• The clinical outcome(s) of interest.

Reaction to knowledge demands• Cognitive resonance (認知共嗚) : background &

foreground knowledge we already possess--reinforcing mental and emotional responses and can make rapid decisions.

• Cognitive dissonance(認知　一致) : knowledge deficit, powerful motivation for learning (positive adaptive)

• Maladaptive reactions : hide knowledge deficit, overreacting emotionally

• Ignorance, not knowing when we don’t know

Where and how clinical questions arise

• Clinical finding• Clinical manifestations

of disease• Diagnostic tests• Therapy• Experience and

meaning

• Etiology• Differential diagnosis• Prognosis• Prevention• Self-improvement

Why bother formulating questions clearly

• Focus on patients’ clinical needs• Focus on our knowledge needs• High-yield search strategies• Useful answers might take• Communicate clearly with our colleagues• Modeling some adaptive processes for lifelong

learning• Can become better, faster and happier as clinicians

Problems in posing answerable questions

• When we are puzzled by a patient but don’t know where to start

• When we have trouble articulating the question

• When we have more questions than time

Which question to answer first

• Most important to patient’s well-being• Most relevant to our learners’ need• Most feasible（可行的） to answer within

the time we have available• Most interesting• Most likely to recur in our practice

Questions our patients want answered

Asking the patient :• What do you think is the problem?• Have you any thoughts about what

treatment you need/want?• What alternatives have you heard

about/read about/considered?• What benefits do you want/need?

Teaching the asking of answerable questions

• Good questions : backbone of both practicing and teaching EBM

• Challenge : identify questions both patient-based and learner-centered

• Teach question-asking best by example• Identifying our own knowledge gaps,

showing our learners adaptive ways to cognitive dissonance

Role reversal for learners

• the learners must supervise our question building, thereby honing their skills further

• the learners see us admitting our own knowledge gaps and practicing what we preach

• it adds fun to rounds and sustains group morale (士氣）

• our learners begin to prepare for their later roles as clinical teachers.

HOME WORK

•請以 PICO 方式寫出下列臨床案例的可回答問題

•A. Background question 二題

•B. Foreground question 二題

•非醫護人員可找醫護人員一同研議

•一週內交敏娟，請劉主任改卷下次簡短指正。

Case one• A 57-yr-old female found to have a firm nodule over lt

breast in recent one week.• She was a case of breast cancer, early stage and

received right mastectomy 1 yr ago. No metastatic lesion detected at that time.

• Biopsy over lt breast also done last yr. No maligancy found at that time.

• Post operation, she received tamoxifen for hormone therapy for about 5 months, and DC tamoxifen due to elevation of SGOT and SGPT.

• A firm nodule about 1.5 cm found around the biopsy site over lt breast found recently.

Case two• A 64 yrs old male come to your clinic with the

complaint of generalized edema and tightness over hands and feet in recent one year and no response to previous medications.

• He was a proved case of progressive systemic sclerosis (PSS) with Raynaud’s phenomenon, diffuse tightness of skin, and edematous change over hands, forearms, and lower legs. ANA 1280x (+), speckled pattern, scl-70 (+)

• plaquenil, aspirin, D-penicillamine been given for 3 months. Patient feel no definite improvement.

•謝謝！

•該睡醒了