1. Formulating Clinical Questions Fall Semester David Keahey, PA-C, MSPH Connie Goldgar, PA-C, MS Sackett DL, Richardson WS, Rosenberg W, and Haynes RB: Evidence-based Medicine: How to Practice and Teach EBM, Churchill Livingstone, New York, 2000.

2. Focused Questions - Why Bother ? As students, you are already asking questions overtly and subconsciously scores of times each day Formalizing the process helps to sharpen your focus and make your search for answers fruitful “Mindfulness”

3. Background Questions: 2 Components The question root (who, what, when, where, why) with a verb a disorder, or an aspect of a disorder

4. Foreground Questions: 4 Components The P atient or problem being addressed The I ntervention or exposure being considered The C omparison intervention or exposure, when relevant The clinical O utcomes of interest. “PICO”

5. Four Elements of Well Built Clinical Questions “P” “I” “C” “O” How would I WhichWhich What do describe a intervention amalternative I want to group of I considering?will I use? accomplish? patients similar to mine?

6. Origins of Clinical Questions Clinical Findings Differential Diagnosis Etiology Clinical Epidemiology of Disease Diagnostic Tests Therapy Prognosis Prevention & Education Experience and Meaning Self Improvement

7. Matching Question Types to Ideal Study Designs Diagnosis: prospective cohort/RCT; quality validation with “gold standard”. Prognosis: prospective cohort Therapy/prevention: prospective RCT Harm/etiology: RCT, cohort or case- control Economic: analysis of costs/benefits based on evidence

8. Central Activities of Clinical Work Clinical Findings How to properly gather and interpret findings from the history and physical examination.

9. Central Activities of Clinical Work Differential Diagnosis When considering the possible causes of our patient’s clinical problem, how to select those that are likely, serious, and responsive to treatment.

10. Central Activities of Clinical Work Etiology How to identify causes for disease (including iatrogenic).

11. Central Activities of Clinical Work Clinical Epidemiology of Disease Knowing how often and when a disease causes its clinical manifestations and how to use this knowledge in classifying our patient’s illness.

12. Central Activities of Clinical Work Diagnostic Tests How to select and interpret diagnostic tests in order to confirm or exclude a diagnosis based on considering their precision, accuracy, acceptability, expense and safety.

13. Central Activities of Clinical Work Therapy How to select treatments to offer our patients that do more good than harm and that are worth the efforts and costs of using them.

14. Central Activities of Clinical Work Prognosis How to estimate our patients’ likely clinical course over time and anticipate likely complications of the disorder and our treatments.

15. Central Activities of Clinical Work Prevention & Education How to reduce the chance of disease by identifying and modifying risk factors and how to diagnose disease early in screening.

16. Central Activities of Clinical Work Experience and Meaning How to empathize with our patient’s situations, appreciate the meaning they find in the experience and understand how this meaning influences their healing.

17. Central Activities of Clinical Work Self-improvement How to keep up to date, improve our clinical and other skills and run a better, more efficient clinical practice.

18. “PICO” Pay careful attention to the questions that spontaneously occur to you. Listen for the question behind the question: What antihypertensive medication is best for diabetics?

19. “PICO” Pay careful attention to the questions that spontaneously occur to you. Listen for the question behind the question: What antihypertensive medication is best for diabetics? In diabetics with HTN, how do ARBs compare with ACEIs in reducing the progression of DM-related renal disease?