Lecturer's Précis - Sackett et al (2000; Chapter 1)
"Evidence-Based Medicine: How to Practice and Teach EBM"
Chapter 1 - Asking Answerable Clinical Questions
Copyright Notice: This material was written and published in Wales by Derek J. Smith (Chartered Engineer). It forms part of a multifile e-learning resource, and subject only to acknowledging Derek J. Smith's rights under international copyright law to be identified as author may be freely downloaded and printed off in single complete copies solely for the purposes of private study and/or review. Commercial exploitation rights are reserved. The remote hyperlinks have been selected for the academic appropriacy of their contents; they were free of offensive and litigious content when selected, and will be periodically checked to have remained so. Copyright © 2010, High Tower Consultants Limited.
First published online 09:00 BST 22nd June 2004, Copyright Derek J. Smith (Chartered Engineer). This version [HT.1 - transfer of copyright] dated 18:00 14th January 2010
Although this paper is reasonably self-contained, it is primarily designed to be read as a subordinate file to our e-paper on "Experiential Learning: The Knowledge Structures and the Cognitive Processes".
1 - Effective Clinical Questioning
"What's the bleeding time?" (Sir Lancelot Spratt).
Arguably the most valuable practical educational skill of all is that of asking questions capable of helping to consolidate a learning experience into usable knowledge. Sackett et al (2000) suggest the following guidelines for "asking answerable clinical questions". Firstly, they distinguish carefully between "background" and "foreground" questions. The background questions are typically "who/what/where" one-liners, designed to probe a student's general knowledge about a disorder, whilst the foreground questions probe specific points of knowledge about the management of that disorder, and will generally focus on the patient and/or the problem, the interventions, and the possible clinical outcomes. Here are some examples of each .....
Examples of Background Questions:
"Who popularised the concept of the 'cell assembly' as a physiological explanation of memory?" [answer]
"What type of speech was preserved in Broca's patient Leborgne?"
"What is the seventh task in Shallice and Burgess's (1991) Multiple Errands Test?" [answer]
Examples of Foreground Questions:
"In assessing the effectiveness of advance organisers as aids to the effectiveness of adult reading, what are the drawbacks of relying on simple tests of knowledge retention?" [answer]
Sackett et al point out that both types of knowledge are needed, but that the relative proportion of each will change over time as the mental knowledge network knits together to support ever more sophisticated and abstract interrogation. Gradually, the relative proportion of background knowledge will decrease, and the body of foreground knowledge will evolve into an evidence-base fit to deliver clinical competence in the field. Here is Sackett et al's list of the ten areas of clinical work where questioning is likely to be most productive .....
(1) Clinical Findings: Questions under this heading should address the gathering and interpreting of data from patient history and examination.
(2) Aetiology: Questions under this heading should address the various causes of the condition in question, "including its iatrogenic [ie. "physician-induced"] forms" (p19).
(3) Clinical Manifestations: Questions under this heading should address "how often and when the disease causes its clinical manifestations" (p19).
(4) Differential Diagnosis: Questions under this heading should address how to use known key observations to suggest "possible causes of our patient's problem" and to select "those that are likely, serious, and responsive to treatment" (p19).
(5) Diagnostic Tests: Questions under this heading should address the selection and interpretation of diagnostic tests, "their precision, accuracy, acceptability, expense, safety, etc." (p19). [This is therefore where the full impact of the formal theory of medical decision making is going to be felt, not least such critical concepts as "sensitivity" [glossary], "specificity" [glossary], and "predictive value" [glossary].]
(6) Prognosis: Questions under this heading should address the likely clinical course of the condition, and note in advance any complications likely to arise.
(7) Therapy: Questions under this heading should address the selection of treatments, mindful of those which might do more harm than good.
(8) Prevention: Questions under this heading should address how a disease might be avoided by identifying risk factors and screening programmes.
(9) Experience and Meaning: Questions under this heading should address how "to empathise with our patient's situations, appreciate the meaning they find in the experience, and understand how this meaning influences their healing" (p19).
(10) Self-Improvement: Questions under this heading should address the student's awareness of how best to keep up-to-date in an area.
Example: "If you could afford to go to only one conference this year, what might be the best one in order to monitor progress in [state specific field]?"
2 - References