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Learning Objectives:
- Understand the evidence-based medicine triad
- Describe the five steps to practicing EBM
- Distinguish between background vs. foreground information, and available tools for finding both
- Recognize EBM Question Types
- Become familiar with TRIP Pro database
Key Resources
Background vs Foreground
What is PICO or PICOTT?
One of the basic skills required for practicing EBP is developing a well-built clinical question. These questions need to be directly relevant to the patient or problem at hand and phrased in such a way as to facilitate the search for relevant and precise answers. PICO makes this process easier. It is an acronym/mnemonic for the important elements of a well-built clinical question. It also helps formulate the search strategy by identifying the key concepts that 
need to be in the article that can answer the question.
PICO or PICOTT:
P = PATIENT OR PROBLEM
How would you describe a group of patients similar to yours? What are the most important characteristics of the patient?
I = INTERVENTION, EXPOSURE, PROGNOSTIC FACTOR
What main intervention are you considering? What do you want to do with this patient?
C = COMPARISON
What is the main alternative being considered, if any?
O = OUTCOME
Include patient-oriented outcomes (morbidity, mortality, quality of life, etc).
T = TYPE OF QUESTION - Identify the question scenario (Therapy / Diagnosis / Etiology / Prognosis)
T = TYPE OF STUDY - Identify study design to help answer a question (Systematic review / RCT / cohort study / case controlled)
Types of Clinical Questions
PICO Elements for Therapy or Treatment Questions
Therapy questions are focused on determining the effect of interventions (i.e. treatments) on patient-important outcomes, such as symptoms, mortality, cost, and so on. Notice that the comparison can be another therapy, a placebo, or no intervention.
Guyatt, G., Rennie, D., Meade, M., & Cook, D. (Eds.). (2015). Users’ guides to the medical literature: Essentials of evidence-based clinical practice (3rd edition.). McGraw-Hill Medical.
PICO Elements for Diagnosis Questions
Diagnosis questions are focused on establishing the usefulness of a test or assessment tool to correctly identify people who have the condition or disease of interest, and correctly identify people who do not have it.
Guyatt, G., Rennie, D., Meade, M., & Cook, D. (Eds.). (2015). Users’ guides to the medical literature: Essentials of evidence-based clinical practice (3rd edition.). McGraw-Hill Medical.
PICO Elements for Prognosis Questions
Prognosis questions are focused on estimating patients' future clinical condition based on factors other than interventions (i.e. treatments). Notice that the I in PICO has been replaced by an E, for Exposure, to illustrate this.
Guyatt, G., Rennie, D., Meade, M., & Cook, D. (Eds.). (2015). Users’ guides to the medical literature: Essentials of evidence-based clinical practice (3rd edition.). McGraw-Hill Medical.
PICO Elements for Etiology or Harm Questions
Etiology questions focus on the effects of exposure to potentially harmful agents or events on patient-important outcomes. Although harmful agents can include treatments, such as chemotherapy, notice that the I in PICO has been replaced by an E, for Exposure.
Question Types
Primary Question Types
- 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.
- 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, safety, etc.
- Prognosis: how to estimate a patient's likely clinical course over time due to factors other than interventions
- Harm / Etiology: how to identify causes for disease (including its iatrogenic forms).
Other Question Types
- Clinical findings: how to properly gather and interpret findings from the history and physical examination.
- 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.
- 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.
- Prevention: how to reduce the chance of disease by identifying and modifying risk factors and how to diagnose disease early by screening.
- Qualitative: how to empathize with our patients’ situations, appreciate the meaning they find in the experience and >understand how this meaning influences their healing.
From: Straus, S. E., et al. Evidence-based medicine: how to practice and teach EBM.
The EBM Triad
The 5 A's of EBM
Evidence Pyramid
Image source: Georgetown University Medical Center
PICO(T) Tutorial
Articles and Links
Authors: Phillips R, Glasziou P.
Published in: Postgrad Med J. 2008
Abstract: This paper gives a practical account of why and how to learn to practice evidence based medicine while still in clinical training. It highlights practical benefits to learning the skills (such as passing exams, coping with information overload and helping patients), and explains how to manage each of the four essential steps (asking questions, acquiring information, appraising evidence, and applying the results). Key resources to give the trainee rapid access to evidence based answers are highlighted, as are efficient ways of keeping up to date with the emerging literature.
Resources for Evidence-Based Practice
Miner has a terrific list of resources for Evidence-Based Practice.
See the Evidence-based Practice Guide page
Videos about Evidence Based Practice
Article: Evidence changes practice
A medical histories article on evidence-based medicine, titled: "From 'trust us, we're doctors' to the rise of evidence-based medicine"