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Asking the Clinical Question

Evidence based practice requires that clinicians make use of the best research they can find to help them in decision-making. To find that research efficiently, the clinician must ask a well-designed clinical question with all the elements that will lead to finding relevant research literature.

The first step in doing this is to determine the type of question: background or foreground. The type of question helps to determine the resource to access to answer the question.

What Is PICO?

Evidence-based practice uses the PICO model for formulating a searchable question. 

PICO is a mnemonic used to describe the four elements of a good clinical foreground question:

  • P = Population/Problem/Patient
    • How would I describe the problem or a group of patients similar to mine?
  • I = Intervention
    • What main intervention, prognostic factor or exposure am I considering?
  • C = Comparison
    • Is there an alternative to compare with the intervention?
  • O = Outcome
    • What do I hope to accomplish, measure, improve or affect?

Background vs. Foreground

Background questions ask for general knowledge about a condition or thing.

  • Broad in scope - "The Forest"
  • Provides basics for a a greater grasp of concepts
  • Typically found in textbooks, encyclopedias and reviews
  • Have two essential components: Example: What causes migraines? or How often should women over the age of 40 have a mammogram?
  • A question root (who, what, when, etc.) with a verb
  • A disorder, test, treatment, or other aspect of healthcare

The background question is usually asked because of the need for basic information. It is not normally asked because of a need to make a clinical decision about a specific patient.

Foreground questions ask for specific knowledge to inform clinical decisions or actions.

  • Focused in scope - "The Trees"
  • Requires a grasp of basic concepts to fully comprehend
  • Typically found in journals and conference proceedings
  • Have 3 or 4 essential components (see PICO below)

PICO Examples

  Patient Intervention Comparison Outcome

Describe as accurately as possible the patient or group of patients of interest

What is the main intervention or therapy you wish to consider? Include an exposure to disease, a diagnostic test, a prognostic factor, a treatment, a patient perception, a risk factor, etc.

Is there an alternative treatment to compare? Include no disease, placebo, a different prognostic factor, absence of risk factor, etc.

What is the clinical outcome, including a time horizon if relevant?

Example #1 In patients with acute bronchitis, do antibiotics   reduce sputum production, cough or days off?
Example #2 In children with cancer what are the current treatments   in the management of fever and infection?
Example #3 Among family-members of patients undergoing diagnostic procedures does standard care, listening to tranquil music, or recorded comedy routines make a difference in the reduction of reported anxiety?