Focusing the Question

Key Points

• Identify the existence of a knowledge gap.

• Determine the information source most likely to answer the type of question.

• Develop a focused question consisting of four parts: patient's problem, intervention, comparison intervention, and outcome of interest.

Many studies have documented that important clinical questions arise during the day-to-day care of patients (Dee and Blazek, 1993). The number and types of questions depend on the clinical setting and the experience of the physician. The most common generic questions involve choosing which drugs to prescribe, determining the cause of a condition, and deciding what diagnostic study to order (Ely et al., 2000). Studies also show that answers are not sought for most questions that arise, but that physicians who seek answers are usually successful in finding them (Ely et al., 1999). Previous studies that documented little dependence on computerized resources for finding answers may reflect that the studies were conducted when computers were not extensively used in the course of routine patient care (Covell et al., 1985; Osheroff and Bankowitz, 1993).

After identifying a knowledge gap relevant to making a clinical decision, the next step is finding the information necessary to close the gap. To find the necessary information, an answerable question must be developed. There are two general types of clinical questions: background and foreground. Background questions are the "who, what, why, and how" questions usually answered in textbooks and asked by medical students; for example, What oral drugs are used in the treatment of diabetes? Foreground questions focus on the specifics surrounding care of a patient; for example, Which is more effective in reducing fasting blood sugar level in an obese patient with type 2 diabetes—metformin or glyburide? It is unlikely that a textbook could adequately answer this second question.

Being able to identify the type of question helps direct the physician to the best source of information for answers.

Most of the questions that arise out of patient care can be categorized as foreground questions, because they are specific to a particular patient's case. Although unlikely to be found in textbooks, the ability to answer these questions at the point of care is essential to providing the best care in a timely manner. A focused clinical question must be developed to find the information efficiently (Richardson et al., 1995). Unfortunately, this critical step is often overlooked, causing needless frustration when searching for answers among thousands of hits in a search engine. Sackett and colleagues (2000) propose that "educational prescriptions" be used to teach this important skill to physicians in training.

The four components of a focused clinical question are (1) the patient's problem, (2) the intervention, (3) the comparison intervention, and (4) the outcome of interest. Patient-oriented outcomes are always better than disease-oriented outcomes because they are direct measures rather than secondary markers. For example, a study documenting that a new drug reduces total cholesterol by 20% (secondary marker) is important, but not as persuasive as a study documenting a decrease in cardiovascular death (direct measure).

Whether Mrs. Smith should remain on estrogen therapy is a complex question. You know that the WHI study assessed multiple outcomes of importance for this patient population, including the impact of hormones on heart disease, fracture rates, venous thromboembolism, colon cancer, and breast cancer. The question of whether Mrs. Smith should keep taking estrogen cannot be answered without weighing the risks and benefits of the therapy and the importance of each of these outcomes to the patient. Mrs. Smith's primary concern is the prevention of osteoporosis because her mother had severe osteoporosis with multiple fractures during her life. This additional information helps to guide the development of a relevant, focused clinical question for Mrs. Smith: In postmenopausal women at risk for osteoporosis (i.e., the patient's problem), is continuation of estrogen replacement therapy (i.e., the intervention) better than changing to bisphosphonate therapy (i.e., the comparison intervention) for prevention of osteoporotic fractures (i.e., the outcome of interest)?

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