Friday, November 6, 2009

Where and How Clinical Questions Arise

In the practice of evidence-based chiropractic, there is a significant amount of attention paid to developing good clinical questions. Part of the approach used to teach EBP is to focus on the development of a so-called PICO question; that is, a question that asks us to determine what the population of interest is (for example, middle-aged women), what the intervention of interest is (for example, adjustment), what a comparison intervention might be (for example, exercise or physical therapy) and what the outcomes of interest are (for example, decreased pain and disability). As you can see, this is all contextualized around the patient, not around formal content.

Sackett and colleagues (1) note that it is their experience, not based on data from clinical trials, that it is helpful to formulate clinical questions clearly, because in their experience it helps find evidence faster, finds better evidence, and is used more wisely in clinical care. The find that well-formulated question help then in the following ways:

1. It helps them focus their scare time resources on evidence directly related to patient need.

2. It helps focus on evidence that addresses the knowledge needs of their learners and of themselves.

3. It can help develop better search strategies.

4. It helps suggest the form that useful answers might take.

5. It can help with better communication between colleagues if referral is needed.

6. It can help model appropriate learning behaviors and adaptive processers among learners.

7. Answering questions is itself something that helps reinforce our own curiosity, restores our cognitive resonance and makes us happier as clinicians and/or teachers.

Thus, the context for teaching EBP should center around the patient. This may seem a challenge if you are someone teaching a first or second trimester course, but you can always set up scenarios that involve a simulated patient to drive home a learning lesson about a basic science topic. As students progress through the DC program, more and more of their time ends up focused on clinical training specifically. It is likely, therefore, that we as teachers and educators could anticipate that many questions will now arise related to clinical issues: clinical findings, etiology and prognosis, differential diagnosis, diagnostic tests, therapy, prevention, and patient experience and meaning. A later blog will probe these issues.

(Note: I am posting this today rather than on Monday, November 9, as I will then be attending the annual conference of the American Public Health Association. The next post will occur on November 16.)

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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