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Evidence Based Practice

This tutorial was developed by staff at Duke University Medical Center Library and the Health Sciences Library at the University of North Carolina at Chapel Hill. It is used with permission by Saint Louis University Medical Center Library.

The Well Built Clinical Question

Asking the Well Built Clinical Question

 

ASSESS
the patient

1. Start with the patient -- a clinical problem or question arises from the care of the patient

ASK
the question

2. Construct a well built clinical question derived from the case 

 

OUR CASE EXAMPLE:

The patient is a 65 year old male with a long history of type 2 diabetes and obesity.  Otherwise his medical history is unremarkable.  He does not smoke.  He had knee surgery 10 years ago but otherwise has had no other major medical problems. Over the years he has tried numerous diets and exercise programs to reduce his weight but has not been very successful. His granddaughter just started high school and he wants to see her graduate and go on to college.  He understands that his diabetes puts him at a high risk for heart disease and is frustrated that he cannot lose the necessary weight.  His neighbor told him about a colleague at work who had his stomach stapled and as a result not only lost over 100 lbs. but also "cured" his diabetes.  He wants to know if this procedure really works.

 

The next step in this process is to take the identified concern or problem and construct a question that is relevant to the case and is phrased in such a way as to facilitate finding an answer.

Anatomy of a good clinical question: PICO(T)

PICO is a mnemonic that helps one remember the key components of a well focused question.  The question needs to identify the key problem of the patient, what treatment or tests you are considering for the patient, what alternative treatment or tests are being considered (if any) and what is the desired outcome to promote or avoid.

P= Patient Problem:

How would you describe a group of patients similar to yours? What are the most important characteristics of the patient? This may include the primary problem, disease, or co-existing conditions. Sometimes the gender, age or race of a patient might be relevant to the diagnosis or treatment of a disease.

I= Intervention, prognostic factor or exposure: 

Which main intervention, prognostic factor, or exposure are you considering? What do you want to do for the patient? Prescribe a drug? Order a test? Order surgery? Or what factor may influence the prognosis of the patient - age, co-existing problems, or previous exposure? 

C= Comparison: 

What is the main alternative to compare with the intervention? Are you trying to decide between two drugs, a drug and no medication or placebo, or two diagnostic tests? Your clinical question may not always have a specific comparison.

O= Outcome: 

What can you hope to accomplish, measure, improve or affect? What are you trying to do for the patient? Relieve or eliminate the symptoms? Reduce the number of adverse events? Improve function or test scores?

T = Time:

This is the time it will take for the procedure/outcome

 

OUR CASE:

Patient Problem

obese, diabetes type 2, male

Intervention

stomach stapling (gastric bypass surgery; bariatric surgery)

Comparison

standard medical care

Outcome

remission of diabetes; weight loss; mortality

For our patient, the clinical question might be: In patients with type 2 diabetes and obesity, is bariatric surgery more effective than standard medical therapy at increasing the probability of remission of diabetes?

Two additional elements of the well-built clinical question are the type of question and the type of study. This information can be helpful in focusing the question and determining the most appropriate type of evidence or study.