When a question or problem arises from a clinical scenario some of the first questions asked may be background questions. Such background questions will provide important general knowledge about a disorder or health state, a test, a treatment or intervention, or some other aspect of health care including the pathophysiology, epidemiology, or the natural history of disease. They usually begin with how, what, why, when, or where. Some examples include:
Resources for Background Questions
These types of questions are best answered with textbooks like Harrison's, online references like UpToDate, or expert opinion found in general review articles. They are too general to be found in primary research articles, and so a Medline search is not usually appropriate as you will likely end up overwhelmed with way too many articles that are much too specific for this information need.
Background questions can usually be answered with:
Textbooks/Reference Books
Medical textbooks in basic and clinical sciences including Harrison’s Principles of Internal Medicine.
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Also includes multimedia, Diagnosaurus differential diagnosis tool, practice guidelines, diagnostic tests, evidence-based outlines of conditions and disorders, self-assessment, patient education, integrated drug database, photos and illustrations, and cases.
Drug Directories
Guidelines
Most guidelines from societies are published in journals and are available in PubMed/Medline by using the article type filter for "Guideline."
Point of Care Tools
Or reliable online health information sources such as MedlinePlus or the NIH.
Foreground questions are much more specific and require different resources to answer. If a background questions asks, "what is that," a foreground question asks, "what is the most effective intervention for that?"
Foreground questions have 3 or 4 essential components: patient/problem, intervention, comparison (if relevant), and clinical outcomes.
Ex.: In obese patients with newly diagnosed type 2 diabetes, does a low-carbohydrate diet compared to a traditional low-fat diet lead to greater weight loss?
PICO and other question frameworks can help clinicians construct a focused question that will also facilitate the information search process. The PICO framework helps to organize key aspects of a complex patient presentation.
PICO or PICOTT
| P | Patient, population or problem | How would you describe a patient similar to yours? What are the most important characteristics? |
| I | Intervention, exposure, or prognostic factor | What main intervention, exposure, or prognostic factor are you considering? What do you want to do with this patient? |
| C | Control or comparison (optional) | What is the main alternative being considered, if there is one? |
| O | Outcomes | What are you trying to accomplish, measure, improve, or affect? |
| T | Type of question | Therapy, diagnosis, harm, prognosis, prevention |
| T | Type of study | Systematic review, RCT, cohort study, case-control |
Most foreground questions fall into one of these primary question types:
The type of question will often dictate the best study design to address the question.
| Type of Question | Type of Study |
| Intervention/Therapy |
Systematic Review; Randomized Controlled Trial (RCT) |
| Prognosis |
Cohort Study > Case-Control Study > Case Series |
| Harm/Etiology |
RCT* > Cohort Study > Case-Control Study > Case Series |
| Diagnostic Testing or Screening |
Prospective, blind comparison to a gold/reference standard |
*Harm data may be included in the results of an RCT as adverse effects of a treatment. However, depending on the intervention, it may be unethical to deliberately expose patients to harm.
Because the category of question may at times determine the type of study needed, using the following template may help you formulate your PICO question.
| Question Type | PICO Template |
| Intervention/Therapy | In ___________ (P), how does _________ (I) compared with _________ (C) affect ________ (O) within ________ (T)? |
| Prognosis | In _________ (P), how does _________ (I) compared with _________ (C), influence _________ (O) over _________ (T)? |
| Harm/Etiology | Are __________ (P) who have __________ (I), compared with those without ________ (C), at _____ risk for _________ (O) over ___________ (T)? |
| Diagnostic testing or screening | In ___________ (P), are/is _________ (I) compared with __________ (C) more accurate in diagnosing ________ (O)? |
Based on: Melnyk, B. M., & Fineout-Overholt, E. (2011). Evidence-based practice in nursing & healthcare: A guide to best practice. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins.