Monday, November 16, 2009

Clinical Questions Continued

Sackett and colleagues provide a set of 10 central issues in clinical work that lead to clinical questions. This information can be found in a table on page 19 of their small text (1). Among them are:

1. Clinical findings: this refers to the need to gather information about a patient and then be able to understand and interpret the information, which comes from the physical examination and the patient history.

2. Etiology: this refers to the need to understand the cause of disease.

3. Clinical manifestation of disease: this refers to knowing about how a disease causes the clinical manifestations seen in the patient and how a clinician can use that information to help classify the patient’s illness.

4. Differential diagnosis: after a patient has arrived for examination and treatment, how do we work through the list of possible diagnoses that may be present and decide which among them are most likely?

5. Diagnostic tests: what tests should we use for a given patient? How do we interpret the results that we receive? What do we know about the precision of the test, its sensitivity and specificity, and how do we come up with a pre-test probability for the presence of a disease in order to use a likelihood ratio to find the post-test probability?

6. Prognosis: how well can we predict the course of care and patient response to our treatment? How well can we predict the complications that might occur?

7. Therapy: How do we know which treatment to offer the patient, so that we help them rather than harm them? How do we know whether the costs justify offering a given treatment?

8. Prevention: Can we identify risk factors for a given disease? Can we create interventions to help reduce those risk factors? Can we find valid and effective screening procedures?

9. Experience and meaning: How well can we understand what our patients are experiencing as they progress through the course of their illness? Can we empathize with them as they do so? Can we appreciate the meaning the find in what they undergo? Can we understand how that meaning may help or hinder their response to our care?

10. Self-improvement: how can we use the cases we see to help keep us up-to-date and to help improve our clinical skills?

As you can see, a doctor-patient interaction creates fertile ground for the generation of clinical questions which can help drive an evidence-based practice. In terms of chiropractic education, this helps create an environment where every patient is a potential source of learning beyond the singular treatment of that patient. Our education is geared toward the time our students enter clinic; once in clinic, their patients should drive their education. This model helps do just that.

1. Sackett D, Straus SE, Richardson WS, Rosenberg W, Haynes RB. Evidence-based medicine: how to practice and teach EBM. New York, NY; Churchill Livingstone, 2000:19

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