1 November 2001
PROJ01\HABROWN.MS--
1,350 words

How to research the medical literature:

Framing specific foreground and background questions in an evidence-based way

NEW YORK -- The most important part about searching the medical literature is framing the right question. And nowadays the question is framed and the literature is critically appraised within the structure of evidence-based medicine.

That's the advice of helen-ann brown, MLS, MS, Librarian on the Information Services Team, Weill Cornell Medical Library, New York NY, who teaches medical students, residents, and faculty how to research the literature. (brown spells her name in lower case.)

Evidence-based medicine (EBM)

Definition. Gurus of EBM, David L. Sackett, W. Scott Richardson and R. Brian Haynes, define Evidence-Based Medicine as "the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients." ( Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS Evidence based medicine: what it is and what it isn't. BMJ 1996 Jan 13;312(7023):71-2 )

Evidence-based medicine asks 2 questions about the literature, said brown:

Are the results of this study valid? and
How does this study relate to my patient?

The Process. The EBM process begins with a health care scenario. The scenario may center on a question of treating, diagnosing, finding the cause (etiology) or following the course of a disease. Brown suggests the following scenario:

middle-aged African-American woman

slightly obese

moderate hypertension

What weight loss plan would be beneficial

"You look at the elements of the scenario and formulate background and foreground questions," says brown.

Background questions

Background questions "fill in the gaps of your knowledge base," said brown. In the above scenario, sample background questions are:

What's hypertension?
What's moderate hypertension?
How overweight is a woman to be considered slightly obese?

Answers to background questions are found in books, literature from professional organizations or journal review articles. "MEDLINE would not be your first choice for background questions," said brown.

Textbooks such as Harrison's Principles of Internal Medicine are available in print and online versions. MD Consult is a commercial resource of about forty online versions of specialty textbooks. One free on-line textbook for background information, which is being marketed heavily, is Emedicine .

For links to free peer-reviewed textbooks on the Internet, see MedicalStudent.com , MEDLINEPlus from the National Library of Medicine, or Medical Matrix .

Professional organizations. brown also suggests going to a professional organization's web site. A list can be found on the Virtual Hospital .

Search engines. To search the Internet, brown recommends Google as a single search engine and Ixquick as a metasearch engine.

Ixquick eliminates duplicates, and awards each site one star for each search engine that placed it in its top ten for your search, clearly indicating the quality of the result.

Review articles published in journals, such as the New England Journal of Medicine , are another good source to answer background questions. "I would not make a habit of going to the New England Journal of Medicine first," said brown. "I would look at everything that was available." To retrieve review articles, most online searching systems like PubMed , Ovid or SilverPlatter will let you limit your search to review articles.

Foreground questions

Foreground questions are "patient-centered" or "patient-focused," said brown. The PICO method , established by W. Scott Richardson MD and Mark Wilson MD, two leading EBM educators, helps dissect a scenario and frame foreground questions.

"P" stands for patient, problem or population.: In this example, the patient is a middle-aged African-American woman, slightly obese with moderate hypertension.
"I" stands for intervention.: The intervention may be therapy, diagnosis, etiology or prognosis. You decide whether you're going to treat, diagnose, find the cause or follow the natural course of the disease. Most foreground questions are about therapy or diagnosis. In this example, Mrs. R.'s blood pressure and obesity will be treated with a diet plan.
"C" stands for comparison.: There may be a benchmark or gold standard to compare your planned treatment or diagnosis. You may be treating or diagnosing for the first time; therefore there is no comparison. In this example, you want compare the DASH diet to another weight reduction plan or compare Mrs. R. not being on a diet before and now being placed on one.
"O" stands for outcome.: What results are you looking for, physically, socially or economically? In this example, the outcome is for Mrs. R. to lose weight and reduce blood pressure for a better quality of life.

"After you fill out the PICO, the foreground questions just jump out," said brown. In the scenario about Mrs. R one foreground question may be, "In this middle-aged African-American woman whose is slightly obese with moderate hypertension (the P), would treating her (the I) with a weight loss plan (the C) be beneficial to reduce her blood pressure (the O)?"

When you finish PICO, "You have the basic elements and you can put them into an online literature searching system," said brown.

You can search PubMed , Ovid, Silver Platter, Medscape , SumSearch or others. PubMed and SumSearch are available to all with an internet connection at no charge.

Cochrane Library. "For foreground questions especially about therapy, people turn now to the Cochrane Library , for a systematic review of the literature," said brown. "At the moment they are the most sought-after kind of literature to answer a foreground question," she said. The reviews are written in a systematic way, indicating search strategy, kinds of studies to be included, kinds of studies to be excluded and how conclusions are reached. Cochrane systematic reviews are indexed in PubMed, but the complete review is available on CD or through online searching systems, such as Ovid Technologies .

PubMed , especially the Clinical Queries section, is another place to find answers to foreground questions, recommends brown. Clinical Queries is a choice under PubMed Services, located on the blue bar on the left side of the web site. The articles in Clinical Queries have been pre-filtered in an evidence-based way, so you retrieve randomized controlled studies, double-blind studies, or placebo-controlled studies to answer therapy questions.

For this example, on the Clinical Queries page you would leave the default buttons selected at "therapy" and "specificity," and type in the search box "weight reduction AND hypertension" or "diet plans AND blood pressure", brown explained. (PubMed requires the searching operators, AND and OR, be entered in capital letters.)

Further information

To learn more about Evidence-Based Medicine, brown suggests the following:

Books

Sackett, David L. Evidence-Based Medicine: How to Practice and Teach EBM. 2nd edition New York: Churchill Livingstone, 2000

McKibbon, Ann. PDQ: Evidence-Based Principles and Practice, Hamilton, Ontario: BC Decker, Inc., 1999.

Greenhalgh, Trisha. How to Read a Paper: The Basics of Evidence Based Medicine. London: BMJ, 2001.

Guyatt, Gordon. User's Guides to the Medical Literature: A Manual for Evidence-based Clinical Practice, Chicago, IL: AMA Press 2002

Web Sites

British Medical Journal, Collections of BMJ Articles by Specialty and Topic , How to Read a Paper Greenhalgh's book on-line, free.

Evidence-based Medicine Resource Center at the New York Academy of Medicine

Health Information Research Unit-McMaster University

Duke University EBM Subject Guide

Thomas Jefferson University EBM Tutorials

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