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Microsoft word - pico handout.doc

PICO and Formulating the Clinical Question: A Guided Exercise

Background & Foreground Questions
Many questions arise during patient care. Some are general questions about a clinical problem or a disease process, e.g.
What is the overall best approach to trauma?” These are called Background Questions and are best answered by
going to an excellent review article or respected evidenced-based textbook. When in need of an overview on clinical
presentation of a disease, standard therapies, diagnostic tools, etc., consult a textbook.
Complex clinical questions are best answered by going to the primary or pre-assessed studies in the literature these are
called Foreground Questions. These patient-centered problematic questions, involve interpretation and consideration of
the risks vs. benefits for a patient or group of like patients. This can be approached efficiently and effectively if you start by
first systematically clarifying the question (PICO M), understanding what type of clinical question it is and what type of
study design is appropriate before searching the literature. Using the PICO acronym will help you organize your query into
a searchable foreground question.

Question Categories: Identify the question type to consider appropriate studies and data sets.

Exercise 1
After careful consideration of the clinical manifestations, you suspect that your patient has acute cholecystitis. In order to
confirm a Dx you plan to order a test. You know that cholescintigraphy / HIDA (radionuclide) scan has been shown to
have the highest sensitivity and specificity. However, the attending tells you to order an ultrasound because “it is the best
first test.” Seeking further evidence you decide to consult the literature and then frame the question,
“In patients with suspected acute cholecystitis, without previous gallbladder disease, is ultrasound a better first test than
cholescintigraphy or hida / radionuclide scan?” -- A Question of Diagnostic Test
[A background question would be: “What is the differential diagnosis for acute upper right quadrant pain?”]

Exercise 2
As a resident you have just seen a 58-year old patient with type 2 diabetes with normal blood pressure. You consider
treating this patient with ace inhibitors because the attending said treatment could delay progression to diabetic

Ehrman Medical Library | 550 First Avenue, New York, NY 10016 | Phone: (212) 263-8483 | Exercise 3
For this exercise you will work together in small groups on either one of cases below. You will be assigned a
case and source to search. After 15 minutes we will review your search history and examine your results. Use the
Evidence-Based Health Care Worksheet
to develop your strategy and to indicate your findings.
Case 1
There has been a special clinical conference to discuss the use of macrodantin vs. bactrim in treating young teen-age
girls with UTI. Bellevue Hospital recommends bactrim, Tisch Hospital recommends macrodantin. You must come up with
an evidence-based recommendation for what the hospitals should use. You are to retrieve the “strongest” evidence from
either a primary or evidence-based secondary resource.
In adolescent girls, is macrodantin more effective than bactrim in treating UTI?
Bonus Search Challenge

Case 2

Tobacco smoke has been linked to a number of health problems. There has been much discussion of the efficacy of
therapies for smoking cessation. Various forms of nicotine replacement are used as a therapeutic intervention with varying
results. It has been suggested that greater efficacy can be achieved by combining nicotine replacement therapy with anti-
depressive agents such as Bupropion.
Is the combination of anti-depressive agents such as Bupropion with nicotine replacement more successful in achieving
smoking cessation than nicotine replacement alone?

Æ Resources and Further Reading

Ehrman Medical Library Assistance: email:
Telephone 212-263-8483
EBM Toolkit (
A collection of Web resources for learning about, teaching, and practicing EBM
Patient Management Toolkit (
A broader collection of Web resources for patient management information
PDA Toolkit (
Useful links for EBM calculators for the personal digital assistant
Search the Ehrman Medical Library online Catalog MEDCat
Search by Subject: Evidence based medicine
Users Guide to the Medical Literature Series—JAMA (
A definitive guide to the practice of EBM
McMaster (
Workshop on how to teach Evidence Based Clinical Practice
Ehrman Medical Library | 550 First Avenue, New York, NY 10016 | Phone: (212) 263-8483 |


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