Posing a Learning Question

CanMEDS Scholar

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Posing a Learning Question

Hay Kranen, 2006

Types of Questions

Learning how to ask critical questions is an important skill to learn.[1] It will help you get relevant answers.

Many questions about patient care are general questions about a clinical problem or disease process. An example of such a question is: “What are the risk factors for pulmonary embolism?”. Such questions are known as “background questions” and are best answered by referring to a textbook or review article.

Complex questions that address specific patient problems and ask for specific knowledge to inform clinical decisions and actions are known as “foreground questions”. These questions often relate to risk-benefit assessment, or likelihood of a given outcome, and are best answered by referring to studies in the literature. An example of such a questions is: “In a patient without lung pathology in whom a pulmonary embolism is suspected, is a V/Q scan a better first test than CT pulmonary angiogram to diagnose a pulmonary embolism?”

The PICO method

Asking the right question is fundamental to the evidence-based decision making process. The PICO method [2][3] was developed to help create well-formulated questions. PICO is a method of putting together a search strategy that allows you take a more evidence based approach to your literature searching when you are searching bibliographic databases like Medline (OVID), PubMed and Embase.

PICO stands for:

Patient/Population - Who or What?

Intervention – What is the medication/investigation/treatment being investigated?

Comparison - What is the main alternative?

Outcome - What are you trying to accomplish, measure, improve?

A well-built question should include four key parts that encompass PICO.

Patient/Population

The first step in developing a question is to identify the patient problem or population. Ask yourself: “What are the important characteristics of this patient?” and “How would I describe the patient to a colleague?” Identify the main problem of the patient or population that you are investigating.

Using our example, the Patient is “a patient without lung pathology in whom a pulmonary embolism is suspected”.

Intervention

Identify what aspect of the patient or population’s care you are investigating. This may include administration of a medication, diagnostic test or other treatment. Ask yourself: “What do I plan to do for this patient?”

Using our example, the Intervention is “V/Q scan”.

Comparison

Determine what you are comparing your intervention to. Ask yourself: “What is the main alternative?” It should be specific in order to facilitate an effective search.

Note that this component of PICO is the only optional component of the PICO question. It is possible to look at the Intervention without comparing to an alternative, and at times, an alternative may not be available.

In our case, the Comparison is “CT pulmonary angiogram”

Outcome

Specify the results you are trying to measure. Ask yourself: “What are you trying to accomplish, measure, or improve?” It is important to be specific as this will yield better search results.

In the above example, the Outcome is “diagnosing pulmonary embolism”.

Practicing PICO

Example: You are seeing a healthy child in your practice for his 18 month MMR vaccine. His mother has been reading that the MMR vaccine can increase the risk of her child developing autism and she is concerned about getting her child vaccinated. She asks you about the risk of the MMR vaccine causing autism in her child.

You decide to perform a literature search to answer this question. An appropriate PICO question might be: In a healthy18 month old, is the risk of developing autism higher with administration of the MMR than without vaccination?

Patient: healthy 18 month old

Intervention: MMR vaccine

Comparison: no MMR vaccine

Outcome: risk of developing autism

Try the following exercise to practice your PICO skills:

Generate a PICO questions for each of the following scenarios

1.	Mr. J is a 78 year old man with osteoarthritis of the knees, obesity and hypertension. He takes ibuprofen for his osteoarthritis pain. He comes to your clinic for his yearly physical exam. You are concerned about the potential risk of GI bleeding associated with chronic use of NSAIDS and wonder whether starting a proton-pump inhibitor would reduce his risk of a GI bleed.

Mr. S. is a 57 year old man with mild COPD who has tried, unsuccessfully, to quit smoking. He knows that tobacco smoke is linked to a number of health problems and has tried quitting “cold-turkey”, using a nicotine patch and using nicotine gum, but has still not be able to quit. He has heard of the anti-depressant agent nupropion and wonders if this might help him quit if used in conjunction with his nicotine patch.

3.	Mr.W is a 23 year old, previously healthy man presenting to the Emergency Room is his first episode of abdominal pain that started in peri-umbilical region and has moved to the right lower quadrant. You suspect that he may have acute appendicitis and you wonder whether an ultrasound or a CT scan would be the best imaging option.

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