Asking clinical question

10th Evidence based medicine workshop

Prince Sultan Military Medical CityDepartment of post Graduate Medical education

EBM committee

Asking Answerable Clinical Question

Dr. Faisal Al HaddadDr. Faisal Al Haddad

Consultant of Family Medicine & Occupational HealthConsultant of Family Medicine & Occupational HealthIncharge of Occupational Health in PSMMCIncharge of Occupational Health in PSMMC



EBM committee

The Five steps (5A) of EBM

• Asking an answerable question

• Acquiring the “best” evidence

• Appraising the evidence

• Applying the acquired and critically appraised evidence to your pt.

• Assessing your performance and hoping to do better next time!



EBM committee

Where and how clinical questions arise?• Most common setting is patients’ care setting

• They are mostly about issues related to:Etiology Diagnosis Prognosis Therapy Prevention



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Types of questions

Background (general knowledge): Question root: who, what, where, when…etc An aspect of the disorder Example: what causes lower limb swelling?

Foreground questions Ask for a specific aspect of the patient’s illness Example: what is the accuracy of V/Q scan in this patient with lung infiltrate on chest-x rays compared to pulmonary arteriogram



EBM committee

Background vs. Foreground Questions



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Foreground questions

Four components: PICO• Patient/Population• Intervention• Comparison• Outcome

Example: In patients with incidentally discovered atrial fibrillation, does anticoagulation compared to no intervention Improve the long-term mortality and morbidity?



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Reactions to knowledge deficit

A clinical question arises

You know the answer

Cognitive Resonance

You do not know the answer

Cognitive Dissonance

Adaptive Response Maladaptive Response



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Why bother to formulate answerable questions?

• They help focusing our scarce time on evidence:- That is directly relevant to our patients’ needs- That addresses particular knowledge needs

• Help following a highly productive search strategy

• May suggest the forms that useful answers may take



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Why bother to formulate answerable questions?

• Can help us communicating clearly with other colleagues

• Help make teaching understandable

• Help improving our learning process



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Problems in formulating an answerable questions

• Inability to clearly define the problem

• Inability to articulate the question

• Many questions, scarce time



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Factors deciding priority questions• Which question is most important to the patient’s well-being?

• Which question is most relevant to the learner’s need?

• Which question is most feasible to answer?

• Which question is most interesting?

• Which question is most frequent in our practice?



EBM committee



EBM committee

What is an Educational Prescription?

• It specifies the clinical problem that generated the question. • It states the question, in all of its key elements.

• It specifies who is responsible for answering it. • It reminds everyone of the deadline for answering it (taking into

account the urgency of the clinical problem that generated it).

• Finally, it reminds everyone of the steps of searching, critically appraising and relating the answer back to the patient



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Case # 1

• 75-year-old man known case of DM since 30 yrsadmitted with shortness of breath, fever, and cough,and right lower limb swelling for 1 wk.

• On Physical Examination:T=38.5, pulse=110 min regular, O2 Sat 88%Chest: bilateral crackles on the basesChest x-rays: bilateral lower lobe infiltratesRight lower limb swelling



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Answer #1

In patients suspected to have PE and have CXRchanges, what is the diagnostic accuracy of V/Q scancompared to pulmonary angiography in diagnosingPE?



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Case #2

• You saw a 70-year-old man for palpitations with no other complaint

• Physical Examination Findings: opulse is 88/min irregularoRest of exam: unremarkableo ECG: atrial fibrillation with a rate of 90/mino Echo: normal valves and Ejection fraction



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Answer # 2

In elderly patients with lone AF what is the benefits oflong-term anticoagulation compared to noanticoagulation in decreasing the risk of embolicstroke?



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Case # 3

• You have seen a 40-year-old man for general check-up• Has no complaint• Physical examination: unremarkable• Labs: all normal except FBS of 118 mg/dl



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Answer # 3

In middle aged men with impaired FBS, does life stylemodification compared to no intervention decreasethe risk of development of DM?



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Any Question?

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Asking clinical question