1. بنام خدا Roxana Mansour Ghanaie Shahid Beheshti Medical University

2. طراحی سوال بالینی

3. Formulation Of Clinical Questions O Each interaction between a clinician and a patient/consumer generates several clinical questions O Sometimes the answers are known or the search for information is brief as the information is at hand

4. Formulation Of Clinical Questions O On other occasions, the information is further afield and effort is required to access it. In these cases, it is important to have well designed clinical questions in order to make the search for the information more efficient.

5. WHY do we need Clinical Questions? O Research has shown that each practitioner has about 30 needs for new information each day and that only 30% of information needs are met O Well-developed clinical questions help to focus on evidence that is relevant to the consumers and clinicians, making the searching more efficient.

6. WHY do we need Clinical Questions? O Although there may be a lot of other interesting clinical research evidence available, unless it is answering a question that clinicians, policy makers or consumers are asking it is probably not worthwhile pursuing

7. Getting the question right is not always easy

8. Questions O Question formulation also involves deciding what type of question you are asking. O Is it a question about which diagnostic test is best? O Which therapy is best? O What prognosis does the patient have? etc. O Each of these questions may be addressed by a different type of study.

9. What are the symptoms suggestive of the clinical condition? What is the prognosis for this condition? What diagnostic test/s (if any) should be arranged to confirm the diagnosis? If the diagnosis is confirmed what are the best treatment options? What other diagnostic/screening should be considered? What other treatment/s are indicated for this patient? What are the potential benefits and harms of the treatments? What are the costs of the various steps? What co-morbidities change the recommended approach?

10. Clinical Senario O Mr X, a 20year old student asks his GP to check a mole on his back that has been bleeding intermittently. O The mole is large, black and raised but has regular edges. The doctor thinks that this looks like a melanoma but possibly it is just a mole that has been repeatedly traumatised by rubbing/catching on clothing. There is no lymph node enlargement in his neck or armpits and his chest is clear.

11. O The mole is excised with wide margins and sent for analysis. The report comes back stating that it is a malignant melanoma of x mm depth, x length and x mm width and the excision is complete (the margins are clear of abnormal cells). The GP was relieved not to have missed this important diagnosis but wonders what is the diagnostic accuracy of visual inspection of moles and skin lesions?

12. O He is referred to the oncology specialist for review and advice on further treatment. Although the excision is complete and other tests have shown no spread of the cancer to other parts of the body, the specialist still advises a course of chemotherapy. Patient isn’t sure about this and seeks his GP’s advice- what are his chances of getting a recurrence of the cancer and if it does come back, is he going to die? Does he really need chemotherapy or are there other alternatives?

13. Question O Reinforcing mental and emotional responses that have been called “cognitive resonance” O “cognitive dissonance”, O turning the “negative space” of knowledge gaps into the “positive space” of well-built questions and finding answers O clinical findings, etiology, differential diagnosis, diagnostic tests, prognosis, therapy, prevention, patient experience and meaning, and self- improvement.

14. Background Questions

16. O 1. a question root with a verb (e.g. “what causes…?” or “how does…?”) O 2. some aspect of the disorder itself (e.g. cyanosis, hypoxemia). O Note also that “background” questions can cover the full range of biologic, psychological or sociologic aspects of human health and illness.

17. O Indirect O Can not be assessed

18. Forground Questions

20. O (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? O (b) In patients with community-acquired pneumonia, is the probability of Mycoplasma infection sufficiently high to warrant considering covering this organism with the initial antibiotic choice? O (c) In patients with community-acquired pneumonia, do clinical features predict outcome well enough that “low risk” patients can be treated safely at home?

21. O Notice that these questions ask for specific knowledge about how to diagnose, “prognose”, and treat patients with pneumonia, which might be called “foreground” knowledge. O When well built, such “foreground” questions usually have four components

22. O 1. The patient and/or problem of interest O 2. The main intervention (defined very broadly, including an exposure, a diagnostic test, a prognostic factor, a treatment, a patient perception, and so forth) O 3. Comparison intervention(s), if relevant O 4. The clinical outcome(s) of interest. O Just like “background” questions, “foreground” questions can cover a wide range of biologic, psychological and sociologic aspects of caring for sick persons.

23. PICO O P= population O I= Intervention O C= Comparison O O=Outcome

24. PECOT 1/Patients/consumers/participants: Which patients or participants are we interested in? How can they be best described? Are there subgroups that need to be considered? 2/ Exposure: Which intervention, treatment, factor, disease or approach are we interested in? 3/ Comparison: What is/are the main alternative/s to compare with the exposure?

25. PECOT O 4/ Outcome: O What is really important to the patient/consumer? What does this exposure affect? Which outcomes should be considered? - intermediate or short term measures O (eg lowering in cholesterol levels), mortality, morbidity and treatment complications, O rates of relapse, late morbidity and readmission, return to work and physical and O social functioning and other measures such as quality of life, general health status. O Cost to the consumer is another outcome that should be considered. O 5/ Time: O Over what time frame is it reasonable to expect an effect? Time frame for outcomes should be considered in all cases.

26. O It can be difficult to translate information needs into questions that can be answered by the literature. O At each step of a typical clinical scenario, key questions arise and need to be addressed in a logical sequence.

27. تعیین نوع سوال بالینی O انواع سوال بالینی foreground: O 1/ درمان O 2/ تشخیص O 3/ اتیولوژی / harm O 4/ پروگنوز O 5/ پیشگیری

29. O 1. They help us focus our scarce learning time on evidence that is directly relevant to our patients’ clinical needs. O 2. They help us focus our scarce learning time on evidence that directly addresses our particular knowledge needs, or those of our learners. O 3. They can suggest high-yield search strategies O 4. They suggest the forms that useful answers might take

30. O 5. When sending or receiving a patient in referral, they can help us to communicate clearly with our colleagues. O 6. When teaching, they can help our learners to better understand the content of what we teach, while also modeling some adaptive processes for lifelong learning. O 7. When we answer our questions, our curiosity is reinforced, our cognitive resonance is restored, and we can become better, faster and happier as clinicians.

31. Problems in posing answerable questions O When we’re puzzled by a patient but don’t know where to start. When we’re stuck but we’re not sure where, and ask ourselves, for each of the ten clinical issues, whether we have any cognitive dissonance or uncertainty. If we can’t confidently and quickly answer “No!”, we’ve just found a knowledge gap.

32. O When we have more questions than time. This will almost always be the case, so we need to develop a strategy for deciding where to begin O Which question is most important to the patient’s well-being? O Which question is most relevant to our learners’ needs? O Which question is most feasible to answer within the time we have available? O Which question is most interesting? O Which question is most likely to recur in our practice?

33. O From this scenario 3 major questions arise: O Diagnosis Question: What is the diagnostic accuracy of visual inspection of moles and skin lesions? O Prognosis Question: What are his chances of getting a recurrence of the cancer and if it does come back, what is the likely prognosis? O Therapy Question: Does he really need chemotherapy or are there other alternatives?

34. Clinical Senario O Mr X, a 20year old student asks his GP to check a mole on his back that has been bleeding intermittently. O The mole is large, black and raised but has regular edges. The doctor thinks that this looks like a melanoma but possibly it is just a mole that has been repeatedly traumatised by rubbing/catching on clothing. There is no lymph node enlargement in his neck or armpits and his chest is clear.

35. O The mole is excised with wide margins and sent for analysis. The report comes back stating that it is a malignant melanoma of x mm depth, x length and x mm width and the excision is complete (the margins are clear of abnormal cells). The GP was relieved not to have missed this important diagnosis but wonders what is the diagnostic accuracy of visual inspection of moles and skin lesions?

36. O He is referred to the oncology specialist for review and advice on further treatment. Although the excision is complete and other tests have shown no spread of the cancer to other parts of the body, the specialist still advises a course of chemotherapy. Patient isn’t sure about this and seeks his GP’s advice- what are his chances of getting a recurrence of the cancer and if it does come back, is he going to die? Does he really need chemotherapy or are there other alternatives?

37. PopulationExposureComparisonOutcomeTime In young male adults (aged 18-30 years) with a mole or skin lesion visual inspection and clinical examination Gold standard(Bio psy) Accuracy of diagnosis One point in time

38. PopulationExposureComparisonOutcomeTime In young adults (aged 18-30 years) with a malignant melanoma Does size, depth, central body location, clear tissue margins, no evidence of secondary spread Different size, depth, location or spread Influence the likelihood of recurrence or survival Over 5 years

39. PopulationExposureComparisonOutcomeTime In young adults (aged 18-30 years) with a malignant melanoma that is fully excised with no evidence of metastatic disease Chemotherapy Drug X (dose and duration)OR Drugs X, Y and Z OR combination of drugs OR alternative therapies eg. homoeopathy, naturopathy using A, B or C No chemotherap y OR alternative therapies using A, B or C OR single drug therapy SurvivalOver 5 years

40. سوالا ت بالینی PIC نوع سوال Phrase of Recommendation کد مقاله پشتیبان پرسش 1 G1 G2 G3 تحلیل توصیه های بالینی راهنماهای مورد مطالعه