ASKING QUESTIONS: BACKGROUND VS. FOREGROUND

(Alex Montero, MD)

• Background Questions

– Medical student/textbook type questions

• Physiology, pathophysiology

• Available diagnostic tests general prognosis

• Available management options

• Consider consult

• Foreground Questions

• How to interpret a specific diagnostic test

• The prognosis of this particular patient

• Benefits/Harms of a particular management option

FRAMING THE QUESTION

• Population

– Who are the relevant patients?

• Interventions or exposures

– Therapy/Prevention (drugs/ surgery/ foods)

– Harm (environmental toxins, medicine)

– Prognosis (time)

– Diagnosis (diagnostic tests)

– Control/Comparison (for Therapy/Harm/Diagnosis)

• Outcomes

– PATIENT-RELEVANT consequences

– Society level consequences (cost/ resource use)

DETERMINING QUESTION TYPE

• Therapy

– Determining the effect of different treatments on patient functioning or avoiding adverse events

• Harm

– Determining the effects of potentially harmful agents on patient function, morbidity, and mortality

• Prognosis

– Estimating the future course of a patient’s disease

• Diagnosis

– Establishing the power of an intervention to differentiate between those with and without a target condition or disease

• Differential Diagnosis

– In patients with a particular presentation, establishing the frequency of the underlying disorders

SYSTEMS RESOURCES
Evidence Based Medicine Guidelines	http://ebmg.wiley.com/ebmg/ltk.koti
PIER (ACP)	http://pier.acponline.org/index.html
Clinical Evidence (BMJ)	http://clinicalevidence.bmj.com/ceweb/index.jsp http://library.cpmc.columbia.edu/hsl/
DynaMed	http://www.ebscohost.com/dynamed/logIn.php
UpToDate	http://www.utdol.com/online/index.do

PRE-APPRAISED RESOURCES (SYNOPSES)
ACP Journal Club	http://www.acpjc.org/index.html Or Click E-Resources / Databases / Medline-Ovid / “EBM Reviews – ACP Journal Club” from CUMC Library Home Page: http://library.cpmc.columbia.edu/hsl/
NY Academy of Med	http://ebmny.org/journal.html
Bandolier	http://www.medicine.ox.ac.uk/bandolier/index.html

SYSTEMATIC REVIEWS AND GUIDELINES (SUMMARIES)
Cochrane	http://www3.interscience.wiley.com/cgi-bin/mrwhome/106568753/HOME Or Click E-Resources / Databases / Cochrane from CUMC Library Home Page: http://library.cpmc.columbia.edu/hsl/
DARE	http://www.crd.york.ac.uk/crdweb/
AHRQ – National Guideline Clearinghouse	http://www.guidelines.gov/

ORIGINAL/PRIMARY STUDIES (STUDIES)
MEDLINE	http://library.cpmc.columbia.edu/hsl/
PUBMED – Clinical Queries	http://www.ncbi.nlm.nih.gov/corehtml/query/static/clinical.shtml
CCRCT	http://www.mrw.interscience.wiley.com/cochrane/cochrane_clcentral_articles_fs.html

OTHERS (?THE FUTURE?)
Google	http://www.google.com
Google Scholar	http://www.scholar.google.com
Sumsearch	http://www.sumsearch.uthscsa.edu