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How to Practice and Teach EBM
Asking answerable clinical questions
Reported by David Wong
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Asking answerable clinical questions
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Chapter 1 — Contents
Chapter opening Types of questions Where and how clinical questions arise Problems in posing answerable questions Questions our patients want answered Teaching the asking of answerable questions Further reading
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Need New Information
• For diagnosis, prognosis, management• ask questions and track down answers are
formidable• limited time for reading and keeping up to
date• information needs never get met
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An example
• 77/M admitted for dyspnea and fever• 4 days--low-grade fever, chills, myalgia,
rhinorrhoea, non-productive cough• 1 day ago--dyspnea on exertion, purulent
sputum, lateral chest wall pain with inspiration & shaking chill.
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An example-2
• P.H. hypertension for 12 yrs, on diuretics• P.E. RR 28, HR 108, BT 39.2’C, subtle
cyanosis, no wheezing, but bronchophonyand egophony in lt lower posterior lung field.
• Leukocytosis & hyponatremia
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Questions asked by team students
• What microbial organisms can cause community-acquired pneumonia?
• How does pneumonia cause egophony?• What do patients mean by calling
pneumonia “the old man’s friend”? What do you make of them?
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Types of questions
• “Background” questions• “Foreground” questions
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“Background” questions
Ask for general knowledge about a disorder Have two essential components:1. A question root (who, what, where, when,
how, why) with a verb2. A disorder, or an aspect of a disorder
Examples:“What causes babesiosis?”“When do complications of acute pancreatitis
usually occur?”
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“Foreground” questions
Ask for specific knowledge about managing patients with a disorder
Have four (or three) essential components:
• 1. Patient and/or problem• 2. Intervention• 3. Comparison intervention (if relevant)• 4. Clinical Outcomes
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Example
• “In older patients with heart failure from isolated diastolic dysfunction, does adding digoxin to standard diuretic and ACE inhibitor treatment yield enough reduction in morbidity and/or mortality to be worth its adverse effects?”
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Questions asked by team house officers• (a) In patients with suspected pneumonia, are any
clinical findings sufficiently powerful to confirm or exclude pneumonia all by themselves, or is a chest radiograph necessary for the diagnosis?
• (b) In patients with community-acquired pneumonia, is the probability of Legionella infection sufficiently high to warrant considering covering this organism with the initial antibiotic choice?
• (c) In patients with community-acquired pneumonia, do clinical features predict outcome well enough that “low risk” patients can be treated safely at home?
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Components of Foreground Questions
• The patient and/or problem of interest• The main intervention (defined very
broadly, including an exposure, a diagnostic test, a prognostic factor, a treatment, a patient perception, and so forth)
• Comparison intervention(s), if relevant• The clinical outcome(s) of interest.
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Reaction to knowledge demands• Cognitive resonance (認知共嗚) : background &
foreground knowledge we already possess--reinforcing mental and emotional responses and can make rapid decisions.
• Cognitive dissonance(認知 一致) : knowledge deficit, powerful motivation for learning (positive adaptive)
• Maladaptive reactions : hide knowledge deficit, overreacting emotionally
• Ignorance, not knowing when we don’t know
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Where and how clinical questions arise
• Clinical finding• Clinical manifestations
of disease• Diagnostic tests• Therapy• Experience and
meaning
• Etiology• Differential diagnosis• Prognosis• Prevention• Self-improvement
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Why bother formulating questions clearly
• Focus on patients’ clinical needs• Focus on our knowledge needs• High-yield search strategies• Useful answers might take• Communicate clearly with our colleagues• Modeling some adaptive processes for lifelong
learning• Can become better, faster and happier as clinicians
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Problems in posing answerable questions
• When we are puzzled by a patient but don’t know where to start
• When we have trouble articulating the question
• When we have more questions than time
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Which question to answer first
• Most important to patient’s well-being• Most relevant to our learners’ need• Most feasible(可行的) to answer within
the time we have available• Most interesting• Most likely to recur in our practice
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Questions our patients want answered
Asking the patient :• What do you think is the problem?• Have you any thoughts about what
treatment you need/want?• What alternatives have you heard
about/read about/considered?• What benefits do you want/need?
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Teaching the asking of answerable questions
• Good questions : backbone of both practicing and teaching EBM
• Challenge : identify questions both patient-based and learner-centered
• Teach question-asking best by example• Identifying our own knowledge gaps,
showing our learners adaptive ways to cognitive dissonance
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Role reversal for learners
• the learners must supervise our question building, thereby honing their skills further
• the learners see us admitting our own knowledge gaps and practicing what we preach
• it adds fun to rounds and sustains group morale (士氣)
• our learners begin to prepare for their later roles as clinical teachers.
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HOME WORK
•請以 PICO 方式寫出下列臨床案例的可回答問題
•A. Background question 二題
•B. Foreground question 二題
•非醫護人員可找醫護人員一同研議
•一週內交敏娟,請劉主任改卷下次簡短指正。
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Case one• A 57-yr-old female found to have a firm nodule over lt
breast in recent one week.• She was a case of breast cancer, early stage and
received right mastectomy 1 yr ago. No metastatic lesion detected at that time.
• Biopsy over lt breast also done last yr. No maligancy found at that time.
• Post operation, she received tamoxifen for hormone therapy for about 5 months, and DC tamoxifen due to elevation of SGOT and SGPT.
• A firm nodule about 1.5 cm found around the biopsy site over lt breast found recently.
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Case two• A 64 yrs old male come to your clinic with the
complaint of generalized edema and tightness over hands and feet in recent one year and no response to previous medications.
• He was a proved case of progressive systemic sclerosis (PSS) with Raynaud’s phenomenon, diffuse tightness of skin, and edematous change over hands, forearms, and lower legs. ANA 1280x (+), speckled pattern, scl-70 (+)
• plaquenil, aspirin, D-penicillamine been given for 3 months. Patient feel no definite improvement.
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•謝謝!
•該睡醒了