8/2/2019 Well Built Question

1/2

Module Reading

Angkor Hospital for ChildrenFaculty Development Course

TheWell-builtClinicalQuestion:AKeytoEvidence-basedDecisionsRichardson,W.ScottMD;Wilson,MarkC.MD,MPH;Nishikawa,JimMD;Hayward,RobertS.A.MD,MPH

ACPJournalClub,Vol123Nov-Dec1995ppA-12

Considerthefollowingclinicalsituations:

A19-year-oldwomancomeshomefromcollegewithanacutemaxillarysinusitis.Youjustheardabouttreating

thiswithashorter3-daycourseofantibioticsratherthantheusual10daysofprescribedtreatment.Youwonder

whetheryoushouldtrytheshortercoursewiththispatient.

A44-year-oldwomanwithrecentlydiagnosedovariancancerpresentstotheemergencyroomwithdyspnea

andinspiratorychestdiscomfort.Theventilation-perfusionscanisreadas'indeterminate.'Theemergencyroom

doctorasksyouradvice'nowthatembolismhasbeenruledout.'

A69-year-oldretiredteacherreturnsforfollow-upofcongestiveheartfailurethatfirstpresented1month

before.Afteryoureviewherprogress,sheasksyouaboutherprognosis.

Whatdothesescenarioshaveincommon?Amongotherthings,theyareallopportunitiestomakeexplicit

andsystematicuseofthebestavailableevidencewhenteachingandpracticingclinicalmedicine.Inother

words,theyaremomentsofopportunityforevidence-basedmedicine(1,2).Manyreadersof ACPJournalClub

arealreadyrecognizingandcapitalizingonthesemomentsintheirdailywork.Insodoing,thesecliniciansare

usingtheirsearchingskillstotrackdownpublishedevidence;theyareusingtheircriticalappraisalskillsto

judgethescientificvalidityandclinicalusefulnessofthatevidence;andtheyareusingtheirclinicaljudgmentto

decidewiththeirpatientshowbesttoputtheevidenceintopractice.Forthesestepstobeefficientand

effective,theymuststartbyusinganadditionalfundamentalskillforevidence-basedmedicine:askingwell-

builtclinicalquestions.

Whatmakesaclinicalquestionwellbuilt?First,thequestionshouldbedirectlyrelevanttotheproblemat

hand.Next,thequestionshouldbephrasedtofacilitatesearchingforapreciseanswer.Toachievetheseaims,

thequestionmustbefocusedandwellarticulatedforall4partsofits'anatomy'(3):

1. P- thepatientorproblembeingaddressed;2. I- theinterventionorexposurebeingconsidered;3. C- thecomparisoninterventionorexposure,whenrelevant;4. O- theclinicaloutcomesofinterest.

Forexample,fortheclinicalscenarioswebeganwith,thefollowingquestionscouldbeasked:

Inadultswithacutemaxillarysinusitis,doesa3-daycourseoftrimethoprim-sulfamethoxazoleyieldthesame

cureratesasa10-daycourse,withfeweradverseeffectsandcosts?-aquestionoftherapy(4).

Whencomparedwithpulmonaryangiography,howwelldoesanindeterminateresultofaventilation-perfusion

scanruleoutpulmonaryembolisminapatientwithahighpretestprobability?-aquestionofdiagnosis(5).

Whatistheaveragesurvivalafteronsetinpatientswithcongestiveheartfailure,andwhatclinicalfeatures,ifany,identifypatientslikelytosurvivelongerorshorterthanaverage?-aquestionofprognosis(6).

Howoftendocliniciansaskquestionsabouttheirpatients?Investigatorshaveobservedandinterviewed

doctorswhiletheypractice,countingthequestions.Therateofquestionaskinginthesestudiesrangedwidely,

fromasfewas1questionevery15patientsinoutpatientfamilypractices(7),to1questionevery1or2

patientsinmixedspecialtyoffices(8,9),andupto5questionsperpatientonaninpatientteachingservice(10).

Butcancliniciansactuallyaskfocused,4-componentquestions?Webelieveso,but,aswithmanyclinical

skills,ittakespractice.Doingitwellrequiresthatyouhaveinsightintowhatyoudonotknow,coupledwith

curiosityandawillingnesstolearn.Also,knowinghowquestionsarise,wheretheycomefrom,andhowto

recognizeandarticulatethemcanhelpyourefineyourskills.

Howdoclinicalquestionsarise?Duringapatientencounter,theclinicianmaybeuncomfortablemakingadecisionuntilmoreisknown.Findingthese'knowledgegaps'cancausethecliniciantoreactinseveralways,

someaffective,suchaswithanxietyorguilt,andsomecognitive,suchasaskingquestionsandsearchingfor

answers.Althoughnotalwayspossible,werecommendquietingyouremotionswhileturningyourimplicit

knowledgegapsintoexplicitquestions.

8/2/2019 Well Built Question

2/2

Module Reading

Angkor Hospital for ChildrenFaculty Development Course

Wheredothesequestionscomefrom?Theycanarisefromvirtuallyanypointintheclinician'sworkwith

patients.Afteryearsofbeingaskedquestions,aswellasaskingourown,wehavefoundthatmostofour

questionsarisefromthefollowing6aspectsofclinicalwork:

1.Clinicalevidence:howtogatherclinicalfindingsproperlyandinterpretthemsoundly.

2.Diagnosis:howtoselectandinterpretdiagnostictests.

3.Prognosis:howtoanticipatethepatient'slikelycourse.

4.Therapy:howtoselecttreatmentsthatdomoregoodthanharm.

5.Prevention:howtoscreenandreducetheriskfordisease.

6.Education:howtoteachyourself,thepatient,andthefamilywhatisneeded.

Wekeepthislisthandyanduseitto'map'whereclinicalquestionscomefrom.

Howcanyourecognizeandformulateclinicalquestionsastheyoccur?Herearesometacticsthatwehave

founduseful.First,paycarefulattentiontothequestionsthatspontaneouslyoccurtoyou.Alsolistenforthe

'questionbehindthequestion';thus,'shouldIincreasethispatient'sdiureticdosebeyondtherecommended

dailymaximum?'mightbecome'inthispatientwithuncontrolledheartfailuredespitefulldosesofdiureticand

anangiotensin-convertingenzymeinhibitor,shouldIadddigoxintoreducecongestionandimproveexercise

tolerance?'

Next,trysayingyourquestionsoutloudorwritingthemdownwithall4componentsincluded.Ifyouare

stuck,usethemapabovetolocatewhereyouarestuck.Thenbuildyourquestionin2steps,startingwiththe

'location,'suchas'myquestionisabouttherapy,'thenfillinginall4componentsexplicitly,suchas'dopersons

withinsulin-dependentdiabeteswhoaretreatedwithanintensiveinsulinregimenhavefewerlong-term

complicationsoralowermortalityratethanthosetreatedwithatraditionalinsulinregimen?'

Whatiftoomanyquestionsarise?Forpatientswhohavemorethan1activeproblem,andwithpossible

questionsaboutdiagnosis,prognosis,therapyforeachproblem,yourquestionsmaybetoonumeroustoeven

ask,letaloneanswer.Inthispredicament,westillrecommendbuildinggoodquestions,thenselectingfromthe

manythefewquestionsthataremostimportanttoanswerrightaway.Ifyouarestuckonthisselection,trythis

sequenceofqueries:Whatisthemostimportantissueforthispatientnow?WhatissueshouldIaddressfirst?

Whichquestion,whenanswered,willhelpmemost?

Aftersomepractice,youshouldbeabletorecognizekeyclinicalquestionsreadilyandbuildthemwellto

helpyoufindtheanswers.Weinvitecorrespondencefromthosewhowanttobecomebetterquestion-askers

onthewaytobecomingbetterclinicians.

References

1. Evidence-BasedMedicineWorkingGroup .Evidence-basedmedicine:anewapproachtoteachingthepracticeofmedicine.JAMA.1992;268:2420-5.

2. RosenbergW,DonaldA. Evidence-basedmedicine:anapproachtoclinicalproblem-solving.BMJ.1995;310:1122-6.

3. OxmanAD,SackettDL,GuyattGH,fortheEvidence-BasedMedicineWorkingGroup .Users'guidestothemedicalliterature:I.howtogetstarted.JAMA.1993;270:2093-5.[MedlineLink]4. WilliamsJW,HollemanDR,SamsaGP,SimelDL.Randomizedcontrolledtrialof3vs.10daysoftrimethoprim/sulfamethoxazoleforacutemaxillarysinusitis.JAMA.1995;273:1015-21.

5. ThePIOPEDInvestigators .Valueofventilation/perfusionscaninacutepulmonaryembolism:resultsoftheProspectiveInvestigationofPulmonaryEmbolismDiagnosis(PIOPED).JAMA.1990;263:2753-9.

6. HoKK,AndersonKM,KannelWB,GrossmanW,LevyD. SurvivalaftertheonsetofcongestiveheartfailureinFraminghamHeartStudysubjects.Circulation.1993;88:107-15.

7. ElyJW,BurchRJ,VinsonDC. Theinformationneedsoffamilyphysicians:case-specificclinicalquestions.JFamPract.1992;35:265-9.

8. CovellDG,UmanGC,ManningPR.Informationneedsinofficepractice:aretheybeingmet?AnnInternMed.1985;103:96-9.

9. GormanPN,HelfandM.Informationseekinginprimarycare:howphysicianschoosewhichclinicalquestionstopursueandwhichtoleaveunanswered.MedDecisMaking.1995;15:113-9.

10.OsheroffJA,ForsytheDE,BuchananBG,BankowitzRA,BlumenfeldBH,MillerRA .Physicians'informationneeds:analysisofquestionsposedduringclinicalteaching.AnnInternMed.1991;114:576-

81.