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Problem Statement

(Making Good Clinical


Question)

Unit Pengembangan & Evaluasi Pendidikan


(UPEP)
Faculty of Medicine
University of Sriwijaya
Palembang

Asking answerable clinical


questions

As we care for patients we often need new


health care knowledge to inform our
decisions and actions.
Our knowledge needs can range from
simple, obvious, and readily available untill
complex, subtle, and much harder to find.
While many kinds of knowledge may be
useful, often what we need will be
evidence derived from clinical care
research.

In this chapter, we describe strategies for


the first step in meeting these evidence
needs: Asking clinical questions that are
answerable from clinical care research.
We will start with a patient encounter to
remind us how clinical questions arise
and to show how they can be used to
initiate evidence based clinical learning.
We will also introduce some teaching
tactics that can help us coach others to
develop their questioning skills.

CLINICAL SCENARIO

Youve just begun a month as the attending physician


supervising residents and students on a hospital medicine
inpatient service. You join the team on rounds after theyve
finished admitting a patient.
A 76-y-old woman admitted with a history of progressive
dyspnea and leg edema, diagnosed with congestive heart failure
6 mo ago, when she presented with similar complaints, and was
found on examination to have elevated neck veins, lung
crackles, an S3 gallop, and pitting edema in both legs.
On that admission, her ECG showed normal sinus rhythm and
her transthoracic echocardiogram showed systolic dysfunction,
with an estimated ejection fraction of 2530%. Since then, she
has been treated with diuretics, ACE (angiotensin-converting
enzyme) inhibitors, beta-blockers, digoxin, and aspirin and has
been hospitalized twice with exacerbations of heart failure.
Now, on her third hospitalization, she is frustrated by her
continued symptoms and worried about the future, given her
frequent exacerbations and admissions to hospital. Her
examination shows significant edema, neck vein distension, an
S3 gallop, and an abdominal fluid wave. Her ECG shows sinus
rhythm, and her chest radiograph shows pulmonary venous
congestion with small bilateral effusions.

You ask your team what questions they have


about this patient; specifically, what important
pieces of medical knowledge theyd like to have
in order to provide better care for this patient.
What do you expect they would ask?
What questions occur to you about this patient?
Write the first three of your questions in the
boxes below:
1. .
2. .
3. .

The teams medical students asked


several questions, including:
1.

2.

3.

What can precipitate an acute


exacerbation of congestive heart failure?
How does congestive heart failure lead
to ascites?
What did the patient mean by If my
heart has failed, will I flunk, too?

The teams house officers asked several


questions,including:
1.
Among patients presenting with an acute
exacerbation of heart failure, how often would a
thorough investigation uncover previously
unsuspected acute ischemia as the principal (or
contributing) precipitant of the episode?
2.
In adults with heart failure who are in sinus
rhythm, would adding warfarin to standard
therapy reduce morbidity or mortality from
thromboembolism enough over 35 years to be
worth the harmful effects and inconveniences of
warfarin?
3.
In patients with recurrent exacerbations of
heart failure, would joining a local, integrated,
heart failure disease management program
reduce mortality, morbidity, or hospitalizations
enough over the next year to be worth the extra

BACKGROUND AND
FOREGROUND QUESTIONS

Note that the students questions in the


above example concern general
knowledge that would help them
understand heart failure as a disorder.
Such background questions can be
asked about any disorder or health state,
a test, a treatment or intervention, or
other aspect of health care, and can
encompass biologic, psychologic, or
sociologic phenomena.

When well formulated, background


questions usually have two
components:
1. A question root (who, what, when,
where, how, why) with a verb.
2. An aspect of the condition or
thing of interest.

Well-built clinical questions


Background questions

Ask for general knowledge about a condition or


thing

Have two essential components:


A question root (who, what, where, when, how,
why), and
A verba disorder, test, treatment, or other
aspect of health care
Examples
How does heart failure cause ascites?
What causes SARS?

Foreground questions
Ask for specific knowledge to inform clinical
decisions or actions
Have four essential components ?

Patient and/or problelm


Intervention (or exposure)
Comparison, if relevant
Clinical outcomes, including time if relevant

Example
In adults with heart failure who are in sinus
rhythm, would adding warfarin to standard
therapy reduce morbidity or mortality from
thromboembolism enough over 3-5 years to be
worth warfarins harmful effects and
inconveniences?

Note that the house officers


questions concern specific
knowledge that could directly
inform one or more foreground
clinical decisions they face with
this patient, including :

a broad range of biologic,


psychologic, and
sociologic issues.

1.
2.

3.
4.

When well constructed, such foreground


questions usually have four components :
The patient situation, population, or problem of
interest.
The main intervention, defined very broadly,
including an exposure, a diagnostic test, a
prognostic factor, a treatment, a patient
perception, and so forth.
A comparison intervention or exposure, if
relevant.
The clinical outcome(s) of interest, including a
time horizon if relevant.

Return to the three questions you wrote down


about the patient in the example above.
Are they background or foreground questions?
Do your background questions specify 2
components, and do your foreground questions
contain 3 or 4 components ?
If not, try rewriting them to include these
components, and consider whether these
revised questions come closer to asking what
you really want to know.

As Clinicians, we all have needs for both background and


foreground knowledge, in proportions that vary over time
and that depend primarily on our experience with the
particular disorder at hand.
When our experience with the condition is limited, at point
A (like a beginning student), the majority of our
questions might be about background knowledge.
As we grow in clinical experience and responsibility, such
as point B (like a house officer), well have increasing
proportions of questions about the foreground of
managing patients.
Further experience with the condition puts us at point C
(like a consultant), where most of our questions will be
foreground.
Note that the diagonal line is placed to show that were
never too green to learn foreground knowledge, or too
experienced to outlive the need for background
knowledge.

OUR REACTIONS TO KNOWING


AND TO NOT KNOWING

Clinical practice demands that we use large


amounts of both background and foreground
knowledge, whether or not were aware of
its use.
These demands and our awareness come in
3 combinations, which we will examine here.
First, our patients predicament may call for
knowledge we know we already possess, so
we will experience the reinforcing mental
and emotional responses termed
Cognitive Resonance as we apply the
knowledge in clinical decisions.

Second, we may realize that our


patients illness calls for knowledge we
dont possess, and this awareness brings
the mental and emotional responses
termed Cognitive Dissonance as we
confront what we dont know, but need to
know.
Third, our patients predicament might
call upon knowledge we dont have, yet
these gaps may escape our attention, so
we dont know what we dont know and
we carry on in undisturbed ignorance.

Reflect for a moment on how youve learned to react


to the first two situations noted above.
When teachers asked questions to which you knew the
answers, did you learn to raise your hand to be called
upon to give the answers out loud? We did, as did virtually
all of our learners, and in the process weve learned that
teachers and examinations reward us for knowing already.
When teachers asked questions to which you didnt know
the answers, did you learn to raise your hand to be called
upon and say I dont know this, but I can see how useful
it would be to know and Im ready to learn it today?
Didnt think so, and neither did we or our learners, so in
the process weve all learned that teachers and
examinations do not reward us for showing our ignorance
and being ready and willing to learn.

Situations of Cognitive Dissonance (we know that


we dont know) can become powerful motivators for
learning, if handled well, such as by celebrating the
finding of knowledge needs and by turning the
negative space of knowledge gaps into the positive
space of well-built clinical questions and learning how
to find the answers.
Unfortunately, if handled less well, it might lead us to
less adaptive behaviors, such as trying to hide our
deficits, or by reacting with anger, fear, or shame.
By developing awareness of our knowing and thinking,
we can recognize our cognitive dissonance when it
occurs, recognize when the knowledge we need would
come from clinical care research, and articulate the
background or foreground questions we can use to
find the answers.

WHERE AND HOW CLINICAL


QUESTIONS ARISE

As you might expect, over the years weve found that


most of our foreground questions arise around the central
issues involved in caring for patients.
These groupings are neither jointly exhaustive (other
worthwhile questions can be asked), nor mutually
exclusive (some questions are hybrids, asking about both
prognosis and therapy for example).
Still, we find it useful to anticipate that many of our
questions will arise from common locations on this map:
clinical findings, etiology, differential diagnosis, diagnostic
tests, prognosis, therapy, prevention, patient experience
and meaning, and self-improvement.
We keep this list handy and use it to help locate the
source of our knowledge deficits when we recognize the
stuck feelings of our cognitive dissonance.
Once weve recognized our knowledge gaps, articulating
the questions can be done quickly, usually in 30 seconds
or less.

Over the years weve found that many of our knowledge


needs occur around, or even during, our clinical encounters
with patients.
While often they arise first in our heads, just as often they are
voiced at least in part by our patients themselves. For
instance, when a patient asks What is the matter? this
relates to questions about diagnosis that arise in our minds.
Similarly, What will this mean for me? conjures both
prognosis, and experience and meaning questions, while
What should be done? brings up issues of treatment and
prevention.
No matter who initiates the questions, we consider finding
relevant answers as one of the ways we serve our patients,
and to indicate this responsibility we call these questions ours.
When we can manage to do so, we find it helpful to negotiate
explicitly with our patients about which questions should be
addressed, in what order, and by when. And, increasingly
often were discovering that patients want to work on
answering some of these questions with us.

Central issues in clinical work, where clinical questions often


arise
1.
Clinical findings: how to properly gather and interpret
findings from the history and physical examination.
2.
Etiology: how to identify causes or risk factors for disease
(including latrogenic harms).
3.
Clinical manifestations of disease : knowing how often
and when a disease causes its clinical manifestations and
how to use this knowledge in classifying our patients
illnesses.
4.
Differential diagnosis: when considering the possible
causes of our patients clinical problems, how to select
those that are likely, serious, and responsive to treatment.
5.
Diagnostic tests: how to select and interpret diagnostic
tests, in order to confirm or exclude a diagnosis, based on
considering their precision, accuracy, acceptability, safety,
expense, etc.

Central issues in clinical work


(lanjutan)
6.

Prognosis: how to estimate our patients likely


clinical course over time and anticipate likely
complications of the disorder.
7. Therapy: how to select treatments to offer our
patients that dio more good thatn harm and that are
worth the efforts and costs of using them.
8. Prevention: how to reduce the chance of disease
by identifying and modifying risk factors and how to
diagnose disease early by screening.
9. Experience and meaning: how to empathize with
our patients situations, appreciate the meaning
they find in the experience, and understand how
this meaning influences their healing.
10. Improvement: how to keep up-to-date, improve
our clinical and other skills, and run a better, more
efficient, clinical care system.

SELECTING, SCHEDULING, AND


SAVING QUESTIONS TO
ANSWER

Since our patients illness burdens


are large and our available time is
small, we find that we usually
have many more questions than
time in which to answer them.
For this circumstance, we
recommend 3 strategies:
Selecting, Scheduling, and Saving.

Selecting

We mean deciding which one or few of the


many questions we asked should be pursued.
This decision requires judgment and wed
suggest you consider the nature of the
patients illness, the nature of your knowledge
needs, the specific clinical decisions in which
youll use the knowledge, and your role in that
decision process.

Then, try this sequence of filters:


1.
Which question is most important to the patients wellbeing, whether biologic, psychologic, or sociologic?
2.
Which question is most relevant to your/your learners
knowledge needs?
3.
Which question is most feasible to answer within the
time you have available?
4.
Which question is most interesting to you, your learners,
or your patient?
5.
Which question is most likely to recur in your practice?
With a moment of reflection, you can usually select one or
two
questions that best pass these tests and will best inform the
decisions at hand.

Scheduling

We mean deciding by when we need to have our


questions answered, paying particular attention
to when the resulting decisions need to be made.
While integrated clinical care and information
systems may improve to the point at which our
questions will be answerable at the time they
arise, for most of us this is not yet the case, and
we need to be realistic in planning our time.
With a moment of reflection, you can usually
discern the few questions that demand
immediate answers from the majority that can be
answered later that day or at the next scheduled
appointment.

Saving

The third strategy involves saving our questions.


Since it seems obvious that unsaved questions become
unanswered questions, it follows that we need practical
methods to rapidly record questions for later retrieval
and searching.
Having just encouraged you to articulate your questions
fully, it may surprise you that we recommend using very
brief notations when recording questions on the run,
using shorthand that makes sense to you.
For instance, when we jot down wt loss CMD
depression, we mean Among adults confirmed to have
major depressive disorder who undergo thorough
evaluation, what proportion will have unexplained weight
loss as their principal presenting problem? (a question
of the frequency of clinical manifestations of disease,
hence CMD).

But how best to record these questions? Over the years,


weve tried, or heard of others trying, several solutions:
1. Jotting brief notes on a page with four columns drawn,
one for each of the elements of foreground questions.
2. Keying brief notes into a similarly arrayed electronic file
on a desktop computer.
3. Dictating questions into a pocket-sized recording device.
4. Jotting concise questions onto actual prescription blanks
(and remembering not to give them to the patient
instead of their actual prescriptions!).
5. Jotting shorthand notes onto 35 cards kept in a handy
pocket.
6. Turning on a PDA and tapping in similar shorthand notes.
Whenever weve timed ourselves, we find it takes us about
15 seconds to record the gist of our questions.

WHY BOTHER FORMULATING


QUESTIONS CLEARLY?
Experiences suggest that well-formulated questions can help
in 7 ways:
1. They help us focus our scarce learning time on evidence
that is directly relevant to our patients clinical needs.
2. They help us focus our scarce learning time on evidence
that directly addresses our particular knowledge needs, or
those of our learners.
3. They can suggest high-yield search strategies.
4. They suggest the forms that useful answers might take.
5. When sending or receiving a patient in referral, they can
help us to communicate more clearly with our colleagues.
6. When teaching, they can help our learners to better
understand the content of what we teach, while also
modeling some adaptive processes for lifelong learning.
7. When our questions get answered, our knowledge grows,
our curiosity is reinforced, our cognitive resonance is
restored, and we can become better, faster, and happier
clinicians.

In addition, the research weve seen so far


suggests that clinicians who are taught this
structured approach will :

ask more specific questions,


undertake more searches for evidence,
use more detailed search methods and find more
precise answers.

Also, if when family doctors curbside consult


their specialty colleagues they include a clinical
question that is clearly articulated along these
lines, they are more likely to receive an answer.
Some groups have begun to implement and
evaluate question-answering services for their
clinicians, with similarly promising initial results.

There are 4 main steps how to ask good


questions.
If we are to recognize potential questions in
learners cases, help them select the best
question to focus on, guide them in building
that question well, and assess their questionbuilding performance and skill, we need to be
proficient at building questions ourselves.
Moreover, we need several attributes of good
clinical teaching, such as good listening skills,
enthusiasm, and a willingness to help learners
develop to their full potential.
It helps to be able to spot signs of our learners
cognitive dissonance, to know when and what
theyre ready to learn.

Key steps in teaching how to ask questions for EBM


Recognize: how to identify combinations of a
patients needs and a learners needs that
represent opportunities for the learner to build
good questions.
Select: how to select from the recognized
opportunities the one (or few) that best fits the
needs of the patient and the learner at that
clinical moment.
Guide: how to guide the learner in transforming
knowledge gaps into well built clinical
questions.
Assess: how to assess the learners performance
and skill at asking pertinent, answerable
clinical questions for practicing EBM.

TERIMA KASIH

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