ASKING ANSWERABLE CLINICAL QUESTION Akbar soltani. MD, MSc Tehran University of Medical Sciences (TUMS) Endocrine and Metabolism Research Center (EMRC) Evidence-Based Medicine research Center (EBMRC) Shariati Hospital

Outline Background and foreground question Asking question and research methodology What is PICO? What is educational prescription?

دکارت از میان اشیاء عالم ، عقل بهتر از هر چیز دیگری ، برابر تقسیم شده است. زیرا هر کسی بهره خویش را از عقل ، آنچنان تمام میداند که حتی کسانی که د رهمه چیز از همه دشوار پسند ترند معمولا بیش از آنچه هم اکنون از آن دارند آرزو نمی کنند.

مونتنی در میان همه مواهبی که طبیعت به انسان داده ، قوه قضاوت ( حس تشخیص ) عادلانه تر از هر چیز قسمت شده است، زیرا هیچ کس از بهره خویش ناخوشنود نیست.

Background Q: is about general knowledge not specific cases –Back ground Q is related to disease not patients? K: answer is not important, what is the kind of answer is more important Questions 1.analytic 2.empirical 3.normative So, for every types we have specific type of answer

Which answer is appropriate for different types of questions? Analytic: answers are based on definitions, tautologies, A priori,… Empirical: answers are based on experiments Normative: based on metaethics?

A five-step process for using an evidence-based approach in general practice (1)Define the problem (2)Track down the information sources you need (3)Critically appraise the information (4)Apply the information with your patients (5)Evaluate how effective the application of information is

The First Step in EBM Develop a well-built, structured, answerable clinical question

Answerable Question ANSWERABLE: means not subjective and …. Because if you ask a subjective question from your colleagues s/he would answer because s/he catch the question but databases do not catch as they are not human! So you should ask an answerable questions Principally subjective / vague,… could not be understand definitely so could not be answered correctly

Gaps in our medical knowledge: a source of our clinical questions Range from miniscule to complete lack of familiarity with the patient’s need. Negative response –Anxiety, shame, burnout Positive response “Embrace our opportunity to learn” –Asking questions –Searching for answers –Channeling nervous energy into useful work

Where do the clinical questions come from? 1.Therapy 2.Diagnostic Test 3.Clinical Findings 4.Etiology 5.Differential Diagnosis 6.Prognosis 7.Prevention 8.Self-improvement

A clinical scenario The patient is a 77-year-old man admitted for dyspnea and fever. He fell ill 4 days ago with low-grade fever, chills, myalgias, rhinorrhoea and a non-productive cough. One day ago he developed dyspnea on exertion, purulent sputum, lateral chest wall pain with inspiration and a shaking chill. His general health is fairly good; He has had essential hypertension for 12 years, well controlled on diuretic therapy. He has not smoked.

On examination, his respiratory rate is 28, his heart rate is 108 and his temperature is 39.2°C. He have subtle cyanosis His chest expands symmetrically He has no wheezing There is bronchophony and egophony in the left lower posterior lung field. A clinical scenario (cont.)

Initial blood tests show leukocytosis and hyponatremia. A clinical scenario (cont.) The team suspects acute community-acquired pneumonia with hypoxemia, and plans chest radiographs, sputum studies, supplemental oxygen and antimicrobial therapy

what are your questions about this case?

A medical student’s questions: 1.What microbial organisms can cause community- acquired pneumonia? 2.How does pneumonia cause egophony? 3.What is the incidence of community-acquired pneumonia?

Background question Notice that the student’s questions ask for general or “background” knowledge about pneumonia, the disorder that explains much of this patient’s acute illness. Epidemiology, Prevalence, Incidence, Pathophysiology, … (as in the first parts of textbooks)

Background questions Ask for general knowledge about a disorder Two essential components: 1) A question root (who, what, where, when, how) 2) A disorder, or an aspect of a disorder

A practitioner’s questions: 1.In this patient, are clinical findings sufficiently powerful to rule in or rule out pneumonia?(Dx) 2.In this patient, is a Chest X-Ray necessary for the diagnosis?(Dx) 3.In this patient, is the probability of Legionella infection sufficiently high to warrant considering coverage of this organism using initial antibiotic choice? (Tx) 4.In this patient, do clinical features predict outcome well enough that as a “low risk” patient, he can be treated safely at home?

Foreground question These questions ask for specific knowledge about diagnosis, prognosis, and treatment of patients with pneumonia, which might be called “foreground” knowledge. Due to high turnover of foreground Q, always we have foreground Q and we should search in opposite to background Q

Foreground 1.The patient and/or the problem 2.The main intervention (defined very broadly, including an exposure, a diagnostic test, a prognostic factor, a treatment, a patient perception,…) 3.Comparison intervention 4.The clinical outcome.

Foreground Questions Background Questions Experience

Questions: – When did you publish your last paper? – When did you begin your study? – When was you paper accepted? – When was the new textbook renewed? –So, text books are not perfect resource to find foreground Q

Hallmarks of a good question: Relevant - Will the answer matter? Answerable - Can the question be answered by research data? Clear – unambiguous, definite, objective Worthy - Is the answer worth the work?

This skill can be improved by: Breaking the question down into its component parts Classifying the question into a specific domain –t–therapy, diagnosis, prognosis, harm… Formulating a clinical question

Using the question to guide searching Scenario - You are interested in checking the hearing of elderly patients, and have heard that the ‘whispered voice test’ is good. Question –Population – in elderly patients does –Indicator – a ‘poor’ whispered voice test –Comparator – a ‘normal’ whispered voice test –Outcome – predict abnormal audiogram 1. Underline the key terms 2. Number the order of importance from Think of alternate spellings, synonyms, & truncations Paul Glasziou

Using the question to guide searching Scenario - You are interested in checking the hearing of elderly patients, and have heard that the ‘whispered voice test’ is good. Question –Population – in elderly patients does –Indicator – a ‘poor’ whispered voice test –Comparator – a ‘normal’ whispered voice test –Outcome – predict poor hearing (audiogram) 1. Underline the (root of the) key terms 2. Number the order of importance from Think of alternate spellings, synonyms, & truncations Paul Glasziou

* Means any other letters AND means both terms required Check the question type Check the emphasis Paul Glasziou

Stepwise searching Search with #1 PICO item –Whisper* Then go to “Clinical Queries”: diagnosis –Whisper* (again) Add #2 PICO item –whisper AND (hear* OR audiogram) Paul Glasziou

Combining terms with Boolean operators – AND chitosan weight weight AND chitosan - has both terms IN CAPITALS Paul Glasziou

Combining terms with Boolean operators – OR chitosan weight weight OR chitosan - has either term Paul Glasziou

Your tasks Search for the best single article (systematic review or trial) for –Your question from notes –Your own question(s) When you are finished –Print just the abstract for each –Write your search strategy on the page Paul Glasziou

Boo-le-ans* AND = both terms OR = either term NOT = not this term (ADJacent, NEAR, … = AND + close) * George Boole (a man) is claimed to have invented “logic” Paul Glasziou

Where to the brackets go? If you want –cheese AND fruit Which do you ask for? –cheese AND (apple OR pear OR melon) –(cheese AND apple) OR pear OR melon What does PubMed do with if AND and OR? –Cheese AND apple OR pear –(Look at DETAILS tab) Paul Glasziou

General structure of search (Population OR synonym 1 OR …) AND (Intervention OR synonym 1 OR …) AND (Comparator OR synonym 1 OR …) AND (Outcome OR synonym 1 OR …) AND FILTER (for best study type) Paul Glasziou

* Means any other letters AND means both terms required Check the question type Check the emphasis

Your tasks Search for the best single article (systematic review or trial) for –Your question from notes –Your own question(s) When you are finished –Print just the abstract for each –Look at methodology –Write your search strategy on the page Paul Glasziou

Common types of questions and related evidence Causation / Etiology Cohort > Case Control > Case series > Case reports Diagnosis Cross-sectional > and/or cohort > case controls

Common types of questions and related evidence (cont.) Therapy Systematic review of RCTs > RCT > Cohort, Case-control > Expert Opinion Prognosis Cohort > Case-control, …

Risk Factors Cause(s) Symptoms Signs, Tests Prognosis Treatment Effect Past current future Types of question: stroke Frequency Cohort Study Survey Inception Cohort Study Treatments Randomised Trial

Types of Evidence Question Types Type of QuestionBest Evidence Health care interventions: treatment, prevention Quantitative: Systematic Review of RCTs or RCT Harm or EtiologyQuantitative: Observational Study - Cohort or Case Control PrognosisQuantitative: Observational Study - Cohort, Case Control Diagnosis or AssessmentQuantitative: Comparison to Gold Standard EconomicsQuantitative: Cost-effectiveness Study MeaningQualitative: case study, ethnography, grounded theory, phenomenologic approach

Question components : PICO What types of P articipants? What types of I nterventions? What types of C omparison? What types of O utcomes?

What Types of P articipants? (Patient / Population) Disease or condition of interest Potential co-morbidity Setting Demographic factors

First component Think about who / what you wish to apply this evidence to… e.g. –People with a particular disorder? e.g chronic recurrent cystitis –People in a particular care setting? e.g. community –particular groups of people e.g. sexually active young women? the elderly? children? How would you describe your clients / setting?

What Types of I ntervention? Type of treatment Type of diagnostic test Type of causative agent Type of prognostic factor

Second component The intervention / topic of interest (e.g. cause, change in practice etc.) e.g. –Use of cranberry juice (as a drink) –Might want to specify how much / how often –For complex interventions may need to give specific detail / consideration to the description… What exactly am I considering…?

Third component The comparison or alternative (not applicable to all questions) e.g. –Anti-biotic therapy? –Nothing? –Fluids alone? What alternatives actions might I try?

Fourth component The outcome… e.g. –Cure –Duration of disease –prevention –Death –Side effects –Pain (reduced) –Wellbeing What am I hoping to accomplish (what outcomes might reasonably be affected…)?

Patient oriented outcomes Mortality/Survival Disease free period Quality of life Work absenteeism Disability/ Duration and severity of illness Pain

For treatment, treatment, it includes all outcomes that are important to people, and lead to make decisions to define success of therapy For prognosis prognosis, outcome is the chosen endpoint of the disease (Mortality, Morbidity, Quality of life: Disease-free period, admission period, pain, work absence,…) Outcomes:Outcomes: a)Patient oriented b)Disease oriented What Types of O utcome?

O: Outcomes POEM: Patient Oriented Evidence that Matters (Foreground) DOE: Disease Oriented Evidence (Background)

Examples of Hypothetical DOE and POEM studies Drug A lowers cholesterol Drug A lowers cardiovascular mortality Drug A decreases overall mortality Fouride increase osteoblast ic activity Fuoride increse BMDFluoride increase fracture Tight control of type 1 diabetes mellitus keeps FBS<140mg/dl Tight control of type 1 Diabetes decreases Microvascular complications Tight control of type 1 Diabetes decreases mortality and improves quality of life DOEPOEM

Patient oriented outcomes Mortality/Survival Disease free period Quality of life Work absenteeism Disability/ Duration and severity of illness Pain

Common Types of Questions 1) Diagnosis 2) Therapy 3) Prognosis 4) Causation / Etiology

Treatment P – In a child with frequent febrile seizures I – would anticonvulsant therapy C – compared to no treatment O – result in seizure reduction?

Diagnosis P – In an otherwise healthy 7-year-old boy with sore throat, I - how does the clinical exam C – compare to throat culture O – in diagnosing Streptococcal infection?

Diagnosis P – In a 15 month old child with FTT I – is IgA antigliadin antibodies C – comparable to biopsy O – in diagnosing celiac disease?

Example A TV programme has highlighted a hospital in Suffolk in which a stroke unit has been set up that specialises in the treatment of patients who have suffered strokes. The hospital trust wants to know about the effectiveness of stroke units in terms of lives saved before deciding whether to invest in one.

Patient Or Problem InterventionComparisonOutcomes

Patient Or Problem InterventionComparisonOutcomes Patients who have suffered strokes

Patient Or Problem InterventionComparisonOutcomes Patients who have suffered strokes Stroke units

Patient Or Problem InterventionComparisonOutcomes Patients who have suffered strokes Stroke unitsNormal hospital care

Patient Or Problem InterventionComparisonOutcomes Patients who have suffered strokes Stroke unitsNormal hospital care Lives saved

Or Do stroke units save lives ?

Example A acute cough is a common reason for patients to consult their GP. The causes of acute cough varies a lot. In GP the treatment often includes antibiotics. The effectiveness of Abx is questionable and there has been a great deal of concern about bacterial resistance from over- prescribing.

Patient Or Problem InterventionComparisonOutcomes

Patient Or Problem InterventionComparisonOutcomes Acute Cough in primary care setting

Patient Or Problem InterventionComparisonOutcomes Acute Cough in primary care setting Antibiotics

Patient Or Problem InterventionComparisonOutcomes Acute Cough in primary care setting AntibioticsNo antibiotics

Patient Or Problem InterventionComparisonOutcomes Acute Cough in primary care setting AntibioticsNo antibiotics Duration and severity of illness

Prognosis P - In children with Down syndrome, I - is IQ an important prognostic factor C – O – in predicting Alzheimer’s later in life?

Prognosis P – In a 14 year old teen with a low grade frontal oligodendroglioma, who is symptom free I – receiving standard therapy, C – O – what is life expectancy?

Etiology/Harm P – Controlling for confounding factors, do otherwise healthy children I - exposed in utero to cocaine, C – compared to children not exposed O – have increased incidence of learning disabilities at age six years?

Etiology/Harm P – Does a newborn I – given vitamin K at birth C – compared to no vitamin K O – have an increase in cancer later in life?

Is PICO effective? Use of PICO-structured forms resulted in more complex search strategies (P = 0.002) Clinical requests handled by PICO-structured form resulted in fewer items retrieved (P = 0.028) [i.e. more specific searches]. Librarians preferred minimally structured forms to PICO- structured forms in every dimension except informativeness. (Booth A, et al. Structuring the pre-search reference interview: a useful technique for handling clinical questions. Bull Med Libr Assoc Jul;88(3):239-46)

Only 20% of questions the intervention and the control groups were properly specified from at baseline. 7/14 questions previously mis-specified in the intervention group were properly specified at follow-up (P = 0.008). Control group showed no changes from baseline. Intervention group more likely to explicitly describe patients (P = 0.028), comparisons (P = 0.014), and outcomes (P = 0.008). (Villanueva EV, et al. Improving question formulation for use in evidence appraisal in a tertiary care setting: a randomised controlled trial. BMC Med Inform Decis Mak. 2001;1(1):4. Epub 2001 Nov 08.) Is PICO effective?

Should I ask a colleague? 12 occupational therapy questions –E.g., Is a 38-year old sewage worker subject to a higher risk of contracting Hepatitis A as a result of occupational exposure? (No) Obtain advice from 2 professionals on 3 cases each. 37% wrong answers –17% wrong if based on literature –65% wrong if not Schaafsma BMC Health Services Research 2005

Impact of searching on correctness of answers to clinical questions Right to Right Wrong to Right Right to Wrong Wrong to Wrong McKibbon (GP or IM) 28%13%11%48%

Impact of searching on correctness of answers to clinical questions Right to Right Wrong to Right Right to Wrong Wrong to Wrong McKibbon (GP or IM) 28%13%11%48% Quick Clinical (GPs) 21%32%7%40% Hersh (Med students) 20%31%12%36% Hersh (Nursing) 18%17%14%52%

Deciding which question to answer first 1. What is the most important issue for this patient now? 2. Which question, when answered, will help me most? (Has direct and significant impacts on decision-making) 3. Most likely recur in my practice?

Example A acute cough is a common reason for patients to consult their doctors. The causes of acute cough varies a lot. the treatment often includes antibiotics. The effectiveness of Abx is questionable and there has been a great deal of concern about bacterial resistance from over- prescribing.  Convert the problem to an answerable question (30 seconds)

Example Patient: Acute Cough in primary care setting Intervention: Antibiotics Comparison: No antibiotics Outcomes: Duration and severity of illness

My 1 yr old just had a febrile seizure - what will happen to her in future? Patient: In children 6mo-6yrs who have had febrile seizure Intervention: (Exposure): a first febrile seizure Comparison: No febrile seizure Outcomes: the likelihood of recurrent febrile seizures; epilepsy; neurologic damage?

A 44-year-old woman with recently diagnosed ovarian cancer presents to the emergency room with dyspnea and inspiratory chest discomfort. The ventilation-perfusion scan is read as “indeterminate.” The emergency room doctor asks your advice. Scenario

When compared with pulmonary angiography, how well does an indeterminate result of a ventilation- perfusion scan rule out pulmonary embolism in a patient with a high pretest probability? Convert the problem to an answerable question (15 seconds)  Convert the problem to an answerable question (15 seconds) Scenario

Patient: Woman with Ovarian cancer, dyspnea Intervention: Ventilation-Perfusion scan Comparison: Pulmonary Angiography Outcomes: Pulmonary Embolism Scenario

Broad or narrow questions? BroadBroad –Do drug X reduce mortality and morbidity in people with severe malaria? NarrowNarrow –Do drug X suppositories reduce mortality in children with cerebral malaria?

What is the Best Treatment for Zoster? What is the most cost-effective treatment for zoster if we consider pain reduction, quality of life and prevention of post-herpetic neuralgia? Is famciclovir effective at preventing postherpetic neuralgia (defined as pain 3 months after rash healing) in otherwise healthy patients aged who present within 48 hours of zoster rash, compared with placebo?

You admit a 65 year old man with a stroke. On examination you find that he has mild weakness of the right arm and right leg and bilateral carotid bruits. You send the patient for carotid doppler ultrasonography and subsequently receive the report that he has moderate stenosis (50-69% by NASCET criteria) of the ipsilateral carotid artery. You've noticed in the pile of journals that is accumulating in your office that there has been some recent literature addressing surgical versus medical (ASA=acetylsalicylic acid=Aspirin) therapy for patients with symptomatic carotid stenosis but you are unsure what the results of these studies indicate. A clinician could ask the following questions: 1. Can ASA (acetylsalicylic acid, Aspirin) decrease the risk of stroke? 2. Does a carotid bruit predict significant carotid stenosis? 3. How effective is a carotid endarterectomy in someone with moderate carotid stenosis? How can we make well-built clinical questions from these clinical dilemmas? Example 1

Example 1. Prevention Patient or Problem 65 year old man with a stroke and moderate carotid stenosis InterventionASA Comparisonplacebo Outcomestroke Question In a 65 year old man with a stroke and moderate carotid stenosis, can ASA decrease the risk of another stroke compared with no treatment?

Example 1. Diagnosis Patient or Problem 65 year old man with a stroke Interventioncarotid bruit Comparisondoppler ultrasonography Outcomecarotid stenosis Question In a 65 year old man with a stroke, how precise and accurate is the presence of an ipsilateral carotid bruit for diagnosing significant carotid stenosis compared with doppler ultrasonography?

Example 1. Therapy Patient or Problem 65 year old man with a stroke and moderate carotid stenosis Interventioncarotid endarterectomy ComparisonASA Outcomestroke Question In a 65 year old man with stroke and moderate carotid stenosis, can carotid endarterectomy decrease the risk of stroke compared with medical therapy?

You admit a 75 year old man with a stroke (left sided weakness) who is having trouble ambulating, feeding, bathing and dressing himself. He has hypertension but it is well controlled with a diuretic. He is otherwise well and now that he is medically stable you decide after discussion with him to transfer him to a stroke unit. His family asks to see you because they are concerned about this transfer. They live very close to the acute care hospital and wonder why he can't stay on the general medical ward where he currently is. You arrange to meet with him and his family to discuss their concerns. In the meantime, you decide to review the evidence for the use of stroke units. What clinical questions could you ask? Example 2

Patient or Problem 75 year old man with a stroke and residual weakness Interventionadmission to a stroke unit Comparisongeneral care Outcomefunctional status Question In an elderly man with a stroke, does admission to a stroke unit decrease the risk of death and dependency?

You are a GP. Your middle-aged patient comes to see you because of painful, weak, and stiff left shoulder. A few days ago, while lifting some heavy furniture, he felt a pop in the shoulder. You suspect a rotator cuff tear and send him to an orthopedic specialist. Your patient returns after a couple of days, angry because the doctor at the hospital first ordered an MRI, but since the machine was not operational he used the ultrasound, ensuring your patient that “it’s all the same”. Your patient doesn’t believe this to be a valid diagnosis. Can you, by reviewing evidence of diagnostic procedures in such cases, persuade him to see the specialist again? What clinical questions could you ask? Example 3

Patient or Problem middle-aged man with a rotator cuff tear Interventionultrasound ComparisonMRI Outcomediagnosis QuestionIs diagnostic ultrasound imaging as accurate as MRI in detecting partial thickness rotator cuff tear in middle age? Example 3

You admitted 4 year old boy with the diagnosis of bacterial meningitis. Blood tests revealed existence of IgM-class antibodies reactive to antigens from H. influenzae. You wondered how sure can you only by this test confirm the diagnosis, but despite that questions, soon after taking blood sample for hemoculture, you introduced therapy with antibiotics. You are familiar with the fact that 20% of cases of meningitis caused by H. influenzae result in complete or partial hearing loss. You also remember that you read somewhere that risk of this sequel may be lowered by application of dexamethasone. Ask clinical question, search the literarture, and appraise the results? Example:

Asking clinical question Patient or Problem 4 year old man with H. influenzae meningitis Interventionantibiotics+dexamethasone Comparisonantibiotics only Outcomehearing losss Question In a 4 year old boy with H. influenzae meningitis, does application of dexamethasone decreases the risk of partial or complete hearing loss?

Educational Prescription Date and place to be filled___________ Educational tasks to be completed before session Learner:_________ Task:___________ ___________ Presentations will cover: –How you found what you found –What you found –The validity and applicability of your find –How it will alter your management –How well you think you did

Advantages of the educational prescription 1.It specifies the clinical problem that generated the question. 2.It states the question, in all of its key elements. 3.It specifies who is responsible for answering it. 4.It reminds everyone of the deadline for answering it (taking into account the urgency of the clinical problem that generated it). 5.Finally, it reminds everyone of the steps of searching, critically appraising and relating the answer back to the patient.

One tactic we use is to make specifying clinical questions an integral part of presenting a new patient to the group. For example, we ask learners on our general medicine in-patient clinical teams, when presenting new patients, to tell us “33 things in 3 minutes” about each admission.

the final element of their presentations is the specification of an important question to which they need to know the answer and don’t. If the answer is vital to the immediate care of the patient, it can be provided at once by another member of the clinical team Most of the time the answer can wait a few hours or days, so the question can serve as the start of an educational prescription.

A patient presentation 1.The patient’s surname. 2.The patient’s age. 3.The patient’s gender. 4.When the patient was admitted. 5.The chief complaint(s) that led to admission. For each complaint, mention the following: 6.Where in the body it is located. 7.Its quality. 8.Its quantity, intensity and degree of impairment.

A patient presentation 9.Its chronology: when it began, constant/episodic, progressive. 10.Its setting: under what circumstances did/does it occur. 11.Any aggravating or alleviating factors. 12.Any associated symptoms. 13.Whether a similar complaint had happened previously. If so: 14.How it was investigated. 15.What the patient was told about its cause. 16.How the patient had been treated for it.

A patient presentation 17.Pertinent past history of other conditions that are either of prognostic significance or would affect the evaluation or treatment of the chief complaint. 18.And how those other conditions have been treated. 19.Family history, if pertinent to chief complaint or hospital care. 20.Social history, if pertinent to chief complaint or hospital care.

A patient presentation 21.Their: –(a) Ideas (what they think is wrong with them) –(b) Concerns (about their illness, and other issues) –(c) Expectations (of what’s going to happen to and for them). 22.Their condition on admission: –(a) acutely and/or chronically ill –(b) severity –(c) requesting what sort of help. 23.The pertinent physical findings on admission. 24.The pertinent diagnostic test results.

A patient presentation 25.Your concise, one-sentence problem synthesis. 26.What you think the most likely diagnosis is. 27.And the other items in your differential diagnosis. 28.Any further diagnostic studies you plan to carry out. 29.Your estimate of the patient’s prognosis. 30.Your treatment plans.

A patient presentation 31.How you will monitor the treatment. 32.And what you will do if the patient doesn’t respond to the treatment. 33.The educational prescription you would like to write for yourself in order to better understand the patient’s disorder (“background” knowledge) or how to care for the patient (“foreground” knowledge) in order to become a better clinician.

Self-evaluation Answerable Questions Are you asking any questions at all? Are you  Asking 4 part questions?  Using education prescriptions?  Asking “what’s your evidence for that?” Is your success rate of asking answerable questions rising? Do your questions compare with those of respected colleagues?

Critically Appraised Topic Declarative title Question Name of paper Search terms Design Setting Patients Intervention Outcome Measures Results Conclusion Commentary

Summary Questions are design specific Answerable question, PICO (DOE, POEM) Background Vs Foreground questions Textbooks are more useful for background Qs Broad Vs Narrow Qs CAT

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