This document discusses how to formulate clinical questions to guide searches of the medical literature. It introduces the PICO framework for structuring questions around patients, interventions, comparisons, and outcomes. Five common types of clinical questions are identified: therapy, harm, differential diagnosis, diagnosis, and prognosis. Each question type lends itself to different study designs that provide the best evidence. Examples are provided to demonstrate how unstructured questions can be clarified using PICO. The goal is to construct answerable clinical questions that facilitate efficient literature searches.

1. What Is the Question?
Ch. 3
EBM/ EBP
Dr. Emad Abu Al Rub MD PhD Dr. Sundus Shalabi MD PhD
Textbook page 25
https://jamaevidence.mhmedical.com/
1

2. Objectives:
In This Chapter
 Three Ways to Use the Medical Literature
• Staying Alert to Important New Evidence
• Problem Solving
• Asking Background and Foreground Questions
 Clarifying Your Question
• The Structure: Patients, Exposures, Outcome
• Five Types of Foreground Clinical Questions
• Finding a Suitably Designed Study for Your Question Type
 Three Examples of Question Clarification
• Example 1: Diabetes and Target Blood Pressure
• Example 2: Transient Loss of Consciousness
• Example 3: Squamous Cell Carcinoma
 Conclusion: Defining the Question Textbook page 25
2

3. Asking answerable clinical questions
“What important new evidence should I know to optimally treat patients?”
Formulating a question is a critical and generally unappreciated skill for evidence-based practice.
The following ways to use the medical literature provide opportunities to practice
that skill.
Staying Alert to Important New Evidence
Traditional approach
 By attending rounds and conferences
 By subscribing to target medical journals in which articles relevant to your practice
appear
negatives
Browsing mode has major limitations .. resulting frustration.. little relevance.. critical appraisal criteria failure,
huge volume of research yearly …. large variety of journals
THREE WAYS TO USE THE MEDICAL
LITERATURE
3

4. Efficient approach
The most efficient strategy/ approach for ensuring you are aware of
recent developments relevant to your practice is to
subscribe to e-mail alerting systems, such as EvidenceUpdates
positives:
• methodologic quality and
• a worldwide panel of practicing physicians rating them for clinical relevance
and newsworthiness.
Example: keeping up todate
General internist is checking e-mails on a smartphone
while riding public transit to work.
While screening a weekly e-mail alert from EvidenceUpdates
(http://plus.mcmaster.ca/ EvidenceUpdates, Figure 3-1)
4

5. Free, subscription-based alerting systems are available
to keep up-to-date
• wide scope of disciplines: eg, NEJM Journal Watch, http://www.jwatch.org
• specific subspecialties: eg, OrthoEvidence, http://www.myorthoevidence.com
Other than alerting system
• Secondary evidence based journals: e.g, ACP Journal Club(http://acpjc.acponline.org)
• New York Academy (http://www.nyam.org/fellows-members/ebhc/eb_publications.html).
Some specialties (cardiology already has specialty-devoted secondary journals; others do not.
5

6.  Problem Solving
Experienced clinicians define specific questions raised in caring for patients and then consulting the
literature to resolve these questions related to the condition.
e.g, DM type 2
• Q1“In patients with new onset type 2 diabetes mellitus, which clinical features or test
results predict the development of diabetic complications?”
• Q2 “In patients with type 2 diabetes mellitus requiring drug therapy, does starting with metformin
treatment yield improved diabetes control and reduce long-term complications better than
other initial treatments?”
6

7.  Asking Background and Foreground Questions
Clinical questions can be categorized as either background or foreground.
Determining the type of question will help you to select the best resource to consult for your answer.
 Background questions ask for general knowledge about a condition, test or treatment. These
types of questions typically ask who, what, where, when, how & why about things like a disorder, test, or
treatment, or other aspect of healthcare.
For example:
- What is type 2 diabetes mellitus?
- Why does this patient have polyuria?
- Why does this patient have numbness and pain in his legs?
- What treatment options are available?
- What are the clinical manifestations of menopause?
- What causes migraines?
- What are COX-2 inhibitors?
Traditional medical textbooks, whether in print or online,
that describe underlying pathophysiology or epidemiology of
a disorder provide an excellent resource for addressing these
background questions.
7

8. Foreground questions ask for specific knowledge to inform clinical decisions.
* These questions typically concern a specific patient or particular population.
* They tend to be more specific and complex than background questions.
* Quite often, foreground questions investigate comparisons, such as two drugs, or two treatments.
For example:
* Is Crixivan effective in slowing the rate of functional impairment in a 45 year old male patient with
Lou Gehrig's Disease?
* In patients with osteoarthritis of the hip, is water therapy more effective than land-based exercise in
restoring range-of-motion?
* What are the effects of prolonged bed rest on patients with severe scoliosis after lumbar surgery?
* Are mobile devices an effective tool to manage workflow in an emergency department?
* What are the determinants of transitions to palliative care in acute care patients under the age of 35?
8

9.  CLARIFYING YOUR QUESTION
PICO Framework
Without a well-focused question, it can be very difficult
and time consuming to identify appropriate resources and
search for relevant evidence.
Practitioners of Evidence-Based Practice (EBP) often use
a specialized framework, called PICO, to form the
question and facilitate the literature search.
PICO stands for:
Patient Problem, (or Population)
Intervention,
Comparison or Control, and
Outcome
The question needs to be:
* Directly relevant to the identified problem
* Constructed in a way that facilitates
searching for a precise answer.
9

10. 10

11. When forming your question using PICO, keep the following points in
mind:
 Your Patient is a member of a population as well as a person with (or at risk of) a health
problem. So, in addition to age and gender, you may also need to consider ethnicity,
socioeconomic status or other demographic variables.
 A Comparison is not always present in a PICO analysis.
 Outcomes should be measurable as the best evidence comes from rigorous studies with
statistically significant findings.
 An Outcome ideally measures clinical wellbeing or quality of life, and not alternates
such as laboratory test results.
11

12. PICO Elements Change According to Question Type (Domain)
When forming your question using the PICO framework it is useful to think about what type of question it is you are
asking, (therapy, prevention, diagnosis, prognosis, etiology).
The following below illustrates ways in which Problems, Interventions, Comparisons and Outcomes vary according to
the type (domain) of your question.
Five Types of Foreground Clinical Questions
There are 5 fundamental types of clinical questions:
1. Therapy: determining the effect of interventions on patient important
outcomes (symptoms, function, morbidity, mortality, and costs)
2. Harm: ascertaining the effects of potentially harmful agents
(including therapies from the first type of question) on patient-important outcomes
3. Differential diagnosis: in patients with a particular clinical
presentation, establishing the frequency of the underlying disorders
4. Diagnosis: establishing the power of a test to differentiate between those with and without a target
condition or disease
5. Prognosis: estimating a patient’s future course
Randomized Controlled Trial (RCT)
RCT or Cohort Study
Cohort Study and/or Case-Control Series
cohort or case-control studies
RCT or Cohort Study
Types of evidence to answer the question
12

13. Finding a Suitably Designed Study
for Your Question Type
Recognizing your clinical question's domain is an important part of the Evidence-Based Practice (EBP)
process.
Establishing the question type allows you to:
 Identify the research methodology that provides the best evidence to answer the question. Note that the
hierarchy of evidence will differ according to question type.
 Select the best EBP Tools to search for the evidence. The Cochrane Database of Systematic Reviews, for
example, only addresses treatment and prevention questions. Other databases address questions of
treatment and prevention, diagnosis, prognosis, etiology, quality improvement, and health economics,
among others.
 Select evidence filters in PubMed / CINAHL and other databases that will help narrow your search to
papers using appropriate research methods.
 Identifying your question type will also assist you in critically appraising the evidence based on the
appropriateness and rigor of the research methods described in a paper.
13

14. 14

15. 15

16. 16

17. Three Examples of Question Clarification
We will now provide examples of the transformation of unstructured clinical questions into the structured
questions that facilitate the use of the medical literature.
Bear in mind that how specific you are will affect the outcome
of your search: general terms (such as ‘heart failure’) will give you a
broad search, while more specific terms (for example, ‘congestive
heart failure’) will narrow the search.
17

18. 18

19. Please refer to
textbook page 36
for the details
19

20. Please refer to
textbook page 37
for the details
20

21. 21
Please refer to
textbook page 39
for the details

22. Exercise 1
1. Go back to the above mentioned 3 examples of clinical
questions. Decide whether each of these is a properly focused
question in terms of
(a) the patient or problem;
(b) the manoeuvre (intervention, prognostic marker, exposure);
(c) the comparison manoeuvre, if appropriate;
(d) the clinical outcome.
2. Now try the following:
(a) A 5-year-old child has been on high-dose topical steroids for severe
eczema since the age of 20 months. The mother believes that the
steroids are stunting the child’s growth, and wishes to change to
homeopathic treatment. What information does the dermatologist
need to decide (i) whether she is right about the topical steroids and
(ii) whether homeopathic treatment will help this child?
22

23. (b) A 48-year-old man presents to a private physician complaining of low
back pain. The physician administers an injection of corticosteroid.
Sadly, the man develops fungal meningitis and dies. What information
is needed to determine both the benefits and the potential harms of
steroid injections in low back pain, in order to advise patients on the
risk–benefit balance?
23

24.  CONCLUSION: DEFINING THE QUESTION
Constructing a searchable and answerable question that allows
you to use the medical literature to solve problems is no simple
matter.
Bearing the structure of the question
in mind—patient or population, intervention or exposure,
outcome, and, for therapy or harm questions, comparison—is
helpful in arriving at an answerable question.
Identifying the
type of questions—therapy, harm, differential diagnosis, diagnosis,
and prognosis—will not only ensure you choose the right
question structure but also ensure that you are looking for a
study with an appropriate design.
24

25. At the end of the lecture, you should be able to:
•Formulate a clinical question using the PICO framework;
•Identify five common categories of clinical questions;
•Identify which research methodologies provide the best evidence for
your question type;
25

26. Thank you!
26