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Edward G. Miner Library

Med Students: Phase 1: Session 1: Ask

This guide will serve as an information resource for first year medical students at the University of Rochester School of Medicine and Dentistry

Ask

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

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)

      

PICO Template

For an intervention/therapy: 

In _______(P), what is the effect of _______(I) on ______(O) compared with _______(C) within ________ (T)? 

 

 

For etiology: 

Are ____ (P) who have _______ (I) at ___ (Increased/decreased) risk for/of_______ (O) compared with ______ (P) with/without ______ (C) over _____ (T)? 

 

 

Diagnosis or diagnostic test: 

Are (is) _________ (I) more accurate in diagnosing ________ (P) compared with ______ (C) for _______ (O)? 

 

 

Prevention: 

For ________ (P) does the use of ______ (I) reduce the future risk of ________ (O) compared with _________ (C)? 

 

 

Prognosis/Predictions:

Does __________ (I) influence ________ (O) in patients who have _______ (P) over ______ (T)? 

 

 

Meaning:

How do ________ (P) diagnosed with _______ (I) perceive ______ (O) during _____ (T)? 

 

 

Melnyk B., & Fineout-Overholt E. (2010). Evidence-based practice in nursing & healthcare. New York: Lippincott Williams & Wilkins.

PICO(T) Tutorial

Types of Clinical Questions

Depiction of PICO elements for therapy or treatment 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.

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.

Background vs Foreground

Two column table explaining where to find background and foreground information.

The EBM Triad

EBP is the conscientious and judicious use of:

  • The best research evidence (found in health sciences literature)
  • Clinical expertise (what the provider knows)
  • Patient values and expectations (what the patient believes and wants)

The 5 A's of EBM

Steps of Evidence-Based Practice:

  1. ASK patient-oriented, relevant, answerable questions about the health status and context of patients or populations
  2. ACQUIRE the best available evidence to answer the question
  3. APPRAISE the evidence critically for validity and applicability to the problem at hand
  4. APPLY the evidence by engaging in collaborative health decision-making with the patient(s) or population(s)
  5. ASSESS not just the patient outcome, but your performance in this process.  How can you improve?

Evidence Pyramid

Image source: Georgetown University Medical Center

Articles and Links

Evidence based practice: The practicalities of keeping abreast of clinical evidence while in training. 

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

Viva la Evidence

Studies that I Like to Quote

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"