Problem Statement Taufik

Problem Statement Problem Statement (Making Good Clinical (Making Good Clinical

Question)Question)

Unit Pengembangan & Evaluasi Pendidikan Unit Pengembangan & Evaluasi Pendidikan (UPEP)(UPEP)

Faculty of Medicine Faculty of Medicine University of SriwijayaUniversity of Sriwijaya

PalembangPalembang

Asking answerable clinical Asking answerable clinical questionsquestions

As we care for patients we often need As we care for patients we often need new health care knowledge to inform our new health care knowledge to inform our decisions and actions.decisions and actions.

Our knowledge needs can range from Our knowledge needs can range from simple, obvious, and readily available simple, obvious, and readily available untill complex, subtle, and much harder to untill complex, subtle, and much harder to find.find.

While many kinds of knowledge may be While many kinds of knowledge may be useful, often what we need will be useful, often what we need will be evidence derived from clinical care evidence derived from clinical care research.research.

In this chapter, we describe strategies In this chapter, we describe strategies for the first step in meeting these for the first step in meeting these evidence needs: “Asking clinical evidence needs: “Asking clinical questions that are answerable from questions that are answerable from clinical care research”.clinical care research”.

We will start with a patient encounter to We will start with a patient encounter to remind us how clinical questions arise remind us how clinical questions arise and to show how they can be used to and to show how they can be used to initiate evidence based clinical learning.initiate evidence based clinical learning.

We will also introduce some teaching We will also introduce some teaching tactics that can help us coach others to tactics that can help us coach others to develop their questioning skills. develop their questioning skills.

CLINICAL SCENARIOCLINICAL SCENARIO

You’ve just begun a month as the attending physician You’ve just begun a month as the attending physician supervising residents and students on a hospital medicine supervising residents and students on a hospital medicine inpatient service. You join the team on rounds after they’ve inpatient service. You join the team on rounds after they’ve finished admitting a patient. finished admitting a patient.

A 76-y-old woman admitted with a history of progressive A 76-y-old woman admitted with a history of progressive dyspnea and leg edema, diagnosed with congestive heart dyspnea and leg edema, diagnosed with congestive heart failure 6 mo ago, when she presented with similar complaints, failure 6 mo ago, when she presented with similar complaints, and was found on examination to have elevated neck veins, and was found on examination to have elevated neck veins, lung crackles, an S3 gallop, and pitting edema in both legs. lung crackles, an S3 gallop, and pitting edema in both legs.

On that admission, her ECG showed normal sinus rhythm and On that admission, her ECG showed normal sinus rhythm and her transthoracic echocardiogram showed systolic dysfunction, her transthoracic echocardiogram showed systolic dysfunction, with an estimated ejection fraction of 25–30%. Since then, she with an estimated ejection fraction of 25–30%. Since then, she has been treated with diuretics, ACE (angiotensin-converting has been treated with diuretics, ACE (angiotensin-converting enzyme) inhibitors, beta-blockers, digoxin, and aspirin and has enzyme) inhibitors, beta-blockers, digoxin, and aspirin and has been hospitalized twice with exacerbations of heart failure. been hospitalized twice with exacerbations of heart failure.

Now, on her third hospitalization, she is frustrated by her Now, on her third hospitalization, she is frustrated by her continued symptoms and worried about the future, given her continued symptoms and worried about the future, given her frequent exacerbations and admissions to hospital. Her frequent exacerbations and admissions to hospital. Her examination shows significant edema, neck vein distension, an examination shows significant edema, neck vein distension, an S3 gallop, and an abdominal fluid wave. Her ECG shows sinus S3 gallop, and an abdominal fluid wave. Her ECG shows sinus rhythm, and her chest radiograph shows pulmonary venous rhythm, and her chest radiograph shows pulmonary venous congestion with small bilateral effusions.congestion with small bilateral effusions.

You ask your team what questions they haveYou ask your team what questions they haveabout this patient; specifically, what important about this patient; specifically, what important pieces of medical knowledge they’d like to pieces of medical knowledge they’d like to have in order to provide better care for this have in order to provide better care for this patient. patient.

What do you expect they would ask? What do you expect they would ask? What questions occur to you about this What questions occur to you about this patient? patient?

Write the first three of your questions in the Write the first three of your questions in the boxes below:boxes below:

    1. …………………………………………….1. …………………………………………….    2. …………………………………………….2. …………………………………………….    3. …………………………………………….3. …………………………………………….

The team’s medical students askedThe team’s medical students asked

several questions, including:several questions, including:1.1. What can precipitate an acute What can precipitate an acute

exacerbation of congestive heart exacerbation of congestive heart failure?failure?

2.2. How does congestive heart failure lead How does congestive heart failure lead to ascites?to ascites?

3.3. What did the patient mean by “If my What did the patient mean by “If my heart has failed, will I flunk, too?”heart has failed, will I flunk, too?”

The team’s house officers asked severalThe team’s house officers asked severalquestions,including:questions,including:1.1. Among patients presenting with an acute Among patients presenting with an acute

exacerbation of heart failure, how often would exacerbation of heart failure, how often would a thorough investigation uncover previously a thorough investigation uncover previously unsuspected acute ischemia as the principal (or unsuspected acute ischemia as the principal (or contributing) precipitant of the episode?contributing) precipitant of the episode?

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

3.3. In patients with recurrent exacerbations of In patients with recurrent exacerbations of heart failure, would joining a local, integrated, heart failure, would joining a local, integrated, heart failure disease management program heart failure disease management program reduce mortality, morbidity, or hospitalizations reduce mortality, morbidity, or hospitalizations enough over the next year to be worth the enough over the next year to be worth the extra time, money, or inconvenience?extra time, money, or inconvenience?

BACKGROUND AND BACKGROUND AND FOREGROUND QUESTIONSFOREGROUND QUESTIONS

Note that the students’ questions in the Note that the students’ questions in the above example concern general above example concern general knowledge that would help them knowledge that would help them understand heart failure as a disorder.understand heart failure as a disorder.

Such “background” questions can be Such “background” questions can be asked about any disorder or health state, asked about any disorder or health state, a test, a treatment or intervention, or a test, a treatment or intervention, or other aspect of health care, and can other aspect of health care, and can encompass biologic, psychologic, or encompass biologic, psychologic, or sociologic phenomena.sociologic phenomena.

When well formulated, backgroundWhen well formulated, background

questions usually have two questions usually have two components:components:

1.1. A question root (who, what, A question root (who, what, when, where, how, why) with a when, where, how, why) with a verb.verb.

2.2. An aspect of the condition or An aspect of the condition or thing of interest.thing of interest.

Well-built clinical questionsWell-built clinical questions

““Background” questions Background” questions Ask for general knowledge about a condition Ask for general knowledge about a condition

or thing or thing Have two essential components: Have two essential components:

A question root (who, what, where, when, A question root (who, what, where, when, how, why), and how, why), and A verba disorder, test, treatment, or other A verba disorder, test, treatment, or other aspect of health careaspect of health care

ExamplesExamples““How does heart failure cause ascites?”How does heart failure cause ascites?”““What causes SARS?”What causes SARS?”

““Foreground” questionsForeground” questions Ask for specific knowledge to inform clinical Ask for specific knowledge to inform clinical

decisions or actions decisions or actions Have four essential components ?Have four essential components ?

– Patient and/or problelm Patient and/or problelm – Intervention (or exposure) Intervention (or exposure) – Comparison, if relevant Comparison, if relevant – Clinical outcomes, including time if relevantClinical outcomes, including time if relevant

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

Note that the house officers’ Note that the house officers’ questions concern specific questions concern specific knowledge that could directly knowledge that could directly inform one or more “foreground” inform one or more “foreground” clinical decisions they face with clinical decisions they face with this patient, including :this patient, including :

– a broad range of biologic,a broad range of biologic,– psychologic, and psychologic, and – sociologic issues. sociologic issues.

When well constructed, such foreground When well constructed, such foreground questions usually have four components :questions usually have four components :

1.1. The patient situation, population, or problem The patient situation, population, or problem of interest.of interest.

2.2. The main intervention, defined very broadly, The main intervention, defined very broadly, including an exposure, a diagnostic test, a including an exposure, a diagnostic test, a prognostic factor, a treatment, a patient prognostic factor, a treatment, a patient perception, and so forth.perception, and so forth.

3.3. A comparison intervention or exposure, if A comparison intervention or exposure, if relevant.relevant.

4.4. The clinical outcome(s) of interest, including a The clinical outcome(s) of interest, including a time horizon if relevant.time horizon if relevant.

Return to the three questions you wrote down Return to the three questions you wrote down about the patient in the example above. about the patient in the example above.

Are they background or foreground questions? Are they background or foreground questions? Do your background questions specify 2 Do your background questions specify 2

components, and do your foreground components, and do your foreground questions contain 3 or 4 components ? questions contain 3 or 4 components ?

If not, try rewriting them to include these If not, try rewriting them to include these components, and consider whether these components, and consider whether these revised questions come closer to asking what revised questions come closer to asking what you really want to know.you really want to know.

As As CliniciansClinicians, we all have needs for both background , we all have needs for both background and foreground knowledge, in proportions that vary and foreground knowledge, in proportions that vary over time and that depend primarily on our experience over time and that depend primarily on our experience with the particular disorder at hand. with the particular disorder at hand.

When our experience with the condition is limited, at When our experience with the condition is limited, at point “A” (like a beginning student), the majority of our point “A” (like a beginning student), the majority of our questions might be about background knowledge. questions might be about background knowledge.

As we grow in clinical experience and responsibility, As we grow in clinical experience and responsibility, such as point “B” (like a house officer), we’ll have such as point “B” (like a house officer), we’ll have increasing proportions of questions about the increasing proportions of questions about the foreground of managing patients. foreground of managing patients.

Further experience with the condition puts us at point Further experience with the condition puts us at point “C” (like a consultant), where most of our questions will “C” (like a consultant), where most of our questions will be foreground. be foreground.

Note that the diagonal line is placed to show that we’re Note that the diagonal line is placed to show that we’re never too green to learn foreground knowledge, or too never too green to learn foreground knowledge, or too experienced to outlive the need for background experienced to outlive the need for background knowledge.knowledge.

OUR REACTIONS TO KNOWING OUR REACTIONS TO KNOWING AND TO NOT KNOWINGAND TO NOT KNOWING

Clinical practice demands that we use large Clinical practice demands that we use large amounts of both background and amounts of both background and foreground knowledge, whether or not we’re foreground knowledge, whether or not we’re aware of its use. aware of its use.

These demands and our awareness come in These demands and our awareness come in 3 combinations, which we will examine here. 3 combinations, which we will examine here.

FirstFirst, our patient’s predicament may call for , our patient’s predicament may call for knowledge we know we already possess, so knowledge we know we already possess, so we will experience the reinforcing mental we will experience the reinforcing mental and emotional responses termed and emotional responses termed ““Cognitive ResonanceCognitive Resonance” as we apply the ” as we apply the knowledge in clinical decisions. knowledge in clinical decisions.

SecondSecond, we may realize that our , we may realize that our patient’s illness calls for knowledge we patient’s illness calls for knowledge we don’t possess, and this awareness don’t possess, and this awareness brings the mental and emotional brings the mental and emotional responses termed “responses termed “Cognitive Cognitive DissonanceDissonance” as we confront what we ” as we confront what we don’t know, but need to know. don’t know, but need to know.

ThirdThird, our patient’s predicament might , our patient’s predicament might call upon knowledge we don’t have, yet call upon knowledge we don’t have, yet these gaps may escape our attention, so these gaps may escape our attention, so we don’t know what we don’t know and we don’t know what we don’t know and we carry on in undisturbed ignorance. we carry on in undisturbed ignorance.

Reflect for a moment on how you’ve learned to reactReflect for a moment on how you’ve learned to reactto the first two situations noted above. to the first two situations noted above. When teachers asked questions to which you knew the When teachers asked questions to which you knew the

answers, did you learn to raise your hand to be called answers, did you learn to raise your hand to be called upon to give the answers out loud? We did, as did upon to give the answers out loud? We did, as did virtually all of our learners, and in the process we’ve virtually all of our learners, and in the process we’ve learned that teachers and examinations reward us for learned that teachers and examinations reward us for knowing already. knowing already.

When teachers asked questions to which you didn’t know When teachers asked questions to which you didn’t know the answers, did you learn to raise your hand to be called the answers, did you learn to raise your hand to be called upon and say “I don’t know this, but I can see how useful upon and say “I don’t know this, but I can see how useful it would be to know and I’m ready to learn it today”? it would be to know and I’m ready to learn it today”?

Didn’t think so, and neither did we or our learners, so in Didn’t think so, and neither did we or our learners, so in the process we’ve all learned that teachers and the process we’ve all learned that teachers and examinations do not reward us for showing our ignorance examinations do not reward us for showing our ignorance and being ready and willing to learn.and being ready and willing to learn.

Situations of Situations of Cognitive DissonanceCognitive Dissonance (we know that (we know that we don’t know) can become powerful motivators for we don’t know) can become powerful motivators for learning, if handled well, such as by celebrating the learning, if handled well, such as by celebrating the finding of knowledge needs and by turning the finding of knowledge needs and by turning the “negative space” of knowledge gaps into the “negative space” of knowledge gaps into the “positive space” of well-built clinical questions and “positive space” of well-built clinical questions and learning how to find the answers. learning how to find the answers.

Unfortunately, if handled less well, it might lead us Unfortunately, if handled less well, it might lead us to less adaptive behaviors, such as trying to hide our to less adaptive behaviors, such as trying to hide our deficits, or by reacting with anger, fear, or shame. deficits, or by reacting with anger, fear, or shame.

By developing awareness of our knowing and By developing awareness of our knowing and thinking, we can recognize our cognitive dissonance thinking, we can recognize our cognitive dissonance when it occurs, recognize when the knowledge we when it occurs, recognize when the knowledge we need would come from clinical care research, and need would come from clinical care research, and articulate the background or foreground questions articulate the background or foreground questions we can use to find the answers.we can use to find the answers.

WHERE AND HOW CLINICAL WHERE AND HOW CLINICAL QUESTIONS ARISEQUESTIONS ARISE

As you might expect, over the years we’ve found that As you might expect, over the years we’ve found that most of our foreground questions arise around the most of our foreground questions arise around the central issues involved in caring for patients. central issues involved in caring for patients.

These groupings are neither jointly exhaustive (other These groupings are neither jointly exhaustive (other worthwhile questions can be asked), nor mutually worthwhile questions can be asked), nor mutually exclusive (some questions are hybrids, asking about both exclusive (some questions are hybrids, asking about both prognosis and therapy for example). prognosis and therapy for example).

Still, we find it useful to anticipate that many of our Still, we find it useful to anticipate that many of our questions will arise from common locations on this questions will arise from common locations on this “map”: clinical findings, etiology, differential diagnosis, “map”: clinical findings, etiology, differential diagnosis, diagnostic tests, prognosis, therapy, prevention, patient diagnostic tests, prognosis, therapy, prevention, patient experience and meaning, and self-improvement.experience and meaning, and self-improvement.

We keep this list handy and use it to help locate the We keep this list handy and use it to help locate the source of our knowledge deficits when we recognize the source of our knowledge deficits when we recognize the “stuck” feelings of our cognitive dissonance. “stuck” feelings of our cognitive dissonance.

Once we’ve recognized our knowledge gaps, articulating Once we’ve recognized our knowledge gaps, articulating the questions can be done quickly, usually in 30 seconds the questions can be done quickly, usually in 30 seconds or less.or less.

Over the years we’ve found that many of our knowledge Over the years we’ve found that many of our knowledge needs occur around, or even during, our clinical encounters needs occur around, or even during, our clinical encounters with patients. with patients.

While often they arise first in our heads, just as often they While often they arise first in our heads, just as often they are voiced at least in part by our patients themselves. For are voiced at least in part by our patients themselves. For instance, when a patient asks instance, when a patient asks “What is the matter?”“What is the matter?” this this relates to questions about diagnosis that arise in our minds. relates to questions about diagnosis that arise in our minds.

Similarly, Similarly, “What will this mean for me?”“What will this mean for me?” conjures both conjures both prognosis, and experience and meaning questions, while prognosis, and experience and meaning questions, while “What should be done?” brings up issues of treatment and “What should be done?” brings up issues of treatment and prevention. prevention.

No matter who initiates the questions, we consider finding No matter who initiates the questions, we consider finding relevant answers as one of the ways we serve our patients, relevant answers as one of the ways we serve our patients, and to indicate this responsibility we call these questions and to indicate this responsibility we call these questions ours. ours.

When we can manage to do so, we find it helpful to When we can manage to do so, we find it helpful to negotiate explicitly with our patients about which questions negotiate explicitly with our patients about which questions should be addressed, in what order, and by when. And, should be addressed, in what order, and by when. And, increasingly often we’re discovering that patients want to increasingly often we’re discovering that patients want to work on answering some of these questions with us.work on answering some of these questions with us.

Central issues in clinical work, where clinical questions often Central issues in clinical work, where clinical questions often arise arise

1.1. Clinical findingsClinical findings: how to properly gather and interpret : how to properly gather and interpret findings from the history and physical examination.findings from the history and physical examination.

2.2. EtiologyEtiology: how to identify causes or risk factors for : how to identify causes or risk factors for disease (including latrogenic harms).disease (including latrogenic harms).

3.3. Clinical manifestations of diseaseClinical manifestations of disease: knowing how : knowing how often and when a disease causes its clinical often and when a disease causes its clinical manifestations and how to use this knowledge in manifestations and how to use this knowledge in classifying our patients’ illnesses.classifying our patients’ illnesses.

4.4. Differential diagnosisDifferential diagnosis: when considering the possible : when considering the possible causes of our patient’s clinical problems, how to select causes of our patient’s clinical problems, how to select those that are likely, serious, and responsive to those that are likely, serious, and responsive to treatment.treatment.

5.5. Diagnostic testsDiagnostic tests: how to select and interpret : how to select and interpret diagnostic tests, in order to confirm or exclude a diagnostic tests, in order to confirm or exclude a diagnosis, based on considering their precision, diagnosis, based on considering their precision, accuracy, acceptability, safety, expense, etc.accuracy, acceptability, safety, expense, etc.

Central issues in clinical work Central issues in clinical work ((lanjutanlanjutan))

6. 6. PrognosisPrognosis: how to estimate our patient’s likely : how to estimate our patient’s likely clinical course over time and anticipate likely clinical course over time and anticipate likely complications of the disorder.complications of the disorder.

7.7. TherapyTherapy: how to select treatments to offer our : how to select treatments to offer our patients that dio more good thatn harm and that are patients that dio more good thatn harm and that are worth the efforts and costs of using them.worth the efforts and costs of using them.

8.8. PreventionPrevention: how to reduce the chance of disease : how to reduce the chance of disease by identifying and modifying risk factors and how to by identifying and modifying risk factors and how to diagnose disease early by screening.diagnose disease early by screening.

9.9. Experience and meaningExperience and meaning: how to empathize with : how to empathize with our patients’ situations, appreciate the meaning our patients’ situations, appreciate the meaning they find in the experience, and understand how they find in the experience, and understand how this meaning influences their healing.this meaning influences their healing.

10.10. ImprovementImprovement: how to keep up-to-date, improve : how to keep up-to-date, improve our clinical and other skills, and run a better, more our clinical and other skills, and run a better, more efficient, clinical care system.efficient, clinical care system.

SELECTING, SCHEDULING, AND SELECTING, SCHEDULING, AND SAVING QUESTIONS TO SAVING QUESTIONS TO ANSWERANSWER

Since our Since our patients’ illness burdens patients’ illness burdens are large and our available time is are large and our available time is smallsmall, we find that we usually , we find that we usually have many more questions than have many more questions than time in which to answer them. time in which to answer them.

For this circumstance, we For this circumstance, we recommend 3 strategies: recommend 3 strategies: Selecting, Scheduling, and Saving.Selecting, Scheduling, and Saving.

SelectingSelecting

We mean deciding which one or few of theWe mean deciding which one or few of the

many questions we asked should be pursued.many questions we asked should be pursued. This decision requires judgment and we’dThis decision requires judgment and we’d

suggest you consider the nature of the suggest you consider the nature of the patient’s illness, the nature of your knowledge patient’s illness, the nature of your knowledge needs, the specific clinical decisions in which needs, the specific clinical decisions in which you’ll use the knowledge, and your role in you’ll use the knowledge, and your role in that decision process. that decision process.

Then, try this sequence of filters:Then, try this sequence of filters:1.1. Which question is most important to the patient’s well-Which question is most important to the patient’s well-

being, whether biologic, psychologic, or sociologic?being, whether biologic, psychologic, or sociologic?2.2. Which question is most relevant to your/your learners’ Which question is most relevant to your/your learners’

knowledge needs?knowledge needs?3.3. Which question is most feasible to answer within the Which question is most feasible to answer within the

time you have available?time you have available?4.4. Which question is most interesting to you, your Which question is most interesting to you, your

learners, or your patient?learners, or your patient?5.5. Which question is most likely to recur in your practice?Which question is most likely to recur in your practice?

With a moment of reflection, you can usually select one or With a moment of reflection, you can usually select one or twotwo

questions that best pass these tests and will best inform thequestions that best pass these tests and will best inform thedecisions at hand.decisions at hand.

SchedulingScheduling

We mean deciding by when we need to have We mean deciding by when we need to have our questions answered, paying particular our questions answered, paying particular attention to when the resulting decisions need attention to when the resulting decisions need to be made.to be made.

While integrated clinical care and information While integrated clinical care and information systems may improve to the point at which our systems may improve to the point at which our questions will be answerable at the time they questions will be answerable at the time they arise, for most of us this is not yet the case, and arise, for most of us this is not yet the case, and we need to be realistic in planning our time. we need to be realistic in planning our time.

With a moment of reflection, you can usually With a moment of reflection, you can usually discern the few questions that demand discern the few questions that demand immediate answers from the majority that can immediate answers from the majority that can be answered later that day or at the next be answered later that day or at the next scheduled appointment.scheduled appointment.

SavingSaving

The third strategy involves “saving” our questions. The third strategy involves “saving” our questions. Since it seems obvious that unsaved questions become Since it seems obvious that unsaved questions become

unanswered questions, it follows that we need practical unanswered questions, it follows that we need practical methods to rapidly record questions for later retrieval methods to rapidly record questions for later retrieval and searching. and searching.

Having just encouraged you to articulate your Having just encouraged you to articulate your questions fully, it may surprise you that we recommend questions fully, it may surprise you that we recommend using very brief notations when recording questions on using very brief notations when recording questions on the run, using shorthand that makes sense to you. the run, using shorthand that makes sense to you.

For instance, when we jot down “wt loss CMD For instance, when we jot down “wt loss CMD depression,” we mean “Among adults confirmed to depression,” we mean “Among adults confirmed to have major depressive disorder who undergo thorough have major depressive disorder who undergo thorough evaluation, what proportion will have unexplained evaluation, what proportion will have unexplained weight loss as their principal presenting problem?” (a weight loss as their principal presenting problem?” (a question of the frequency of question of the frequency of clinical manifestations of clinical manifestations of disease, hence “CMDdisease, hence “CMD”).”).

But how best to record these questions? Over the years, But how best to record these questions? Over the years, we’ve tried, or heard of others trying, several solutions:we’ve tried, or heard of others trying, several solutions:

1.1. Jotting brief notes on a page with four columns drawn, Jotting brief notes on a page with four columns drawn, one for each of the elements of foreground questions.one for each of the elements of foreground questions.

2.2. Keying brief notes into a similarly arrayed electronic file Keying brief notes into a similarly arrayed electronic file on a desktop computer.on a desktop computer.

3.3. Dictating questions into a pocket-sized recording device.Dictating questions into a pocket-sized recording device.4.4. Jotting concise questions onto actual prescription blanks Jotting concise questions onto actual prescription blanks

(and remembering not to give them to the patient (and remembering not to give them to the patient instead of their actual prescriptions!).instead of their actual prescriptions!).

5.5. Jotting shorthand notes onto 3×5 cards kept in a handy Jotting shorthand notes onto 3×5 cards kept in a handy pocket.pocket.

6.6. Turning on a PDA and tapping in similar shorthand notes.Turning on a PDA and tapping in similar shorthand notes.

Whenever we’ve timed ourselves, we find it takes us about Whenever we’ve timed ourselves, we find it takes us about 15 seconds to record the gist of our questions.15 seconds to record the gist of our questions.

WHY BOTHER FORMULATING WHY BOTHER FORMULATING QUESTIONS CLEARLY?QUESTIONS CLEARLY?

Experiences suggest that well-formulated questions can help Experiences suggest that well-formulated questions can help in 7 ways:in 7 ways:

1.1. They help us focus our scarce learning time on evidence They help us focus our scarce learning time on evidence that is directly relevant to our patients’ clinical needs.that is directly relevant to our patients’ clinical needs.

2.2. They help us focus our scarce learning time on evidence They help us focus our scarce learning time on evidence that directly addresses our particular knowledge needs, or that directly addresses our particular knowledge needs, or those of our learners.those of our learners.

3.3. They can suggest high-yield search strategies.They can suggest high-yield search strategies.4.4. They suggest the forms that useful answers might take.They suggest the forms that useful answers might take.5.5. When sending or receiving a patient in referral, they can When sending or receiving a patient in referral, they can

help us to communicate more clearly with our colleagues.help us to communicate more clearly with our colleagues.6.6. When teaching, they can help our learners to better When teaching, they can help our learners to better

understand the content of what we teach, while also understand the content of what we teach, while also modeling some adaptive processes for lifelong learning.modeling some adaptive processes for lifelong learning.

7.7. When our questions get answered, our knowledge grows, When our questions get answered, our knowledge grows, our curiosity is reinforced, our cognitive resonance is our curiosity is reinforced, our cognitive resonance is restored, and we can become better, faster, and happier restored, and we can become better, faster, and happier clinicians.clinicians.

In addition, the research we’ve seen so far In addition, the research we’ve seen so far suggests that clinicians who are taught this suggests that clinicians who are taught this structured approach will :structured approach will :– ask more specific questions,ask more specific questions,– undertake more searches for evidence,undertake more searches for evidence,– use more detailed search methods and find more use more detailed search methods and find more

precise answers.precise answers. Also, if when family doctors “curbside consult” Also, if when family doctors “curbside consult”

their specialty colleagues they include a clinical their specialty colleagues they include a clinical question that is clearly articulated along these question that is clearly articulated along these lines, they are more likely to receive an answer.lines, they are more likely to receive an answer.

Some groups have begun to implement and Some groups have begun to implement and evaluate question-answering services for their evaluate question-answering services for their clinicians, with similarly promising initial results.clinicians, with similarly promising initial results.

There are 4 main steps how to ask good There are 4 main steps how to ask good questions.questions.

If we are to recognize potential questions in If we are to recognize potential questions in learners’ cases, help them select the “best” learners’ cases, help them select the “best” question to focus on, guide them in building question to focus on, guide them in building that question well, and assess their question-that question well, and assess their question-building performance and skill, we need to be building performance and skill, we need to be proficient at building questions ourselves. proficient at building questions ourselves.

Moreover, we need several attributes of good Moreover, we need several attributes of good clinical teaching, such as good listening skills, clinical teaching, such as good listening skills, enthusiasm, and a willingness to help learners enthusiasm, and a willingness to help learners develop to their full potential. develop to their full potential.

It helps to be able to spot signs of our It helps to be able to spot signs of our learners’ cognitive dissonance, to know when learners’ cognitive dissonance, to know when and what they’re ready to learn.and what they’re ready to learn.

Key steps in teaching how to ask questions for Key steps in teaching how to ask questions for EBM EBM

RecognizeRecognize: how to identify combinations of a : how to identify combinations of a patient’s needs and a learner’s needs that patient’s needs and a learner’s needs that represent opportunities for the learner to build represent opportunities for the learner to build good questions.good questions.

SelectSelect: how to select from the recognized : how to select from the recognized opportunities the one (or few) that best fits opportunities the one (or few) that best fits the needs of the patient and the learner at the needs of the patient and the learner at that clinical moment.that clinical moment.

GuideGuide: how to guide the learner in transforming : how to guide the learner in transforming knowledge gaps into well built clinical knowledge gaps into well built clinical questions.questions.

AssessAssess: how to assess the learner’s performance : how to assess the learner’s performance and skill at asking pertinent, answerable and skill at asking pertinent, answerable clinical questions for practicing EBM.clinical questions for practicing EBM.

TERIMA KASIHTERIMA KASIH