Ask a Silly Question…
Many of us will have had the experience, at some point in our lives, of sitting in a doctor's office feeling bewildered and, quite possibly, scared. We've come to the doctor in need of answers. "Am I ill? How sure are you of what I have? How would it affect me if we left it untreated? What can you do about it, and how will that treatment affect me? Will I have to change my lifestyle, will the treatment change my schedule or have side effects which might?" In some parts of the world, I might also be asking how much the treatment would cost me, and whether it would be value for money.
What may surprise you is that the doctor sitting with you might have all kinds of questions buzzing through their brain as well. Will this person need diagnostic tests to confirm? How soon can we do those? How will various tests distinguish from the many possible causes of that pain she has? How likely are complications? From the illness, or the treatment I'm going to prescribe? Will the illness shorten this person's life? Is it worth telling them to stop smoking/drinking/eating cake? Are some treatments for this person opposite me right now more suitable than others? So many questions.
When I was at school, my computing teacher used to have a catchphrase: "You put garbage in, you get garbage out". What he meant was, you can't expect to get helpful information from a program if you haven't put any quality stuff in there in the first place. This phrase has been surprisingly useful ever since in my every day life, from watching patterns of voting in general elections to the alarming contents of my young son's nappy when he once ate a bag of Licorice Allsorts.
When we try to look at the effectiveness of health treatments, and ask questions of what may help a particular patient, much the same principle applies. You ask a silly question and you'll get a silly answer. If you're vague and unfocussed about who your patient is, what outcome you hope for from a treatment, or what kinds of health intervention you're trying to focus on then you'll get search results as vague and woolly as a politician under scrutiny on TV.
Evidence Based Medicine is a discipline remarkably fond of acronyms, and in order to try and focus questions they've come up with a cracker. We use PICO to try and figure out what we actually want to discover from searching the literature. When a patient is sitting in front of them, or they're trying to work out a new treatment policy, health care workers need first to be willing to admit that there are big gaps in their knowledge, then be willing to fill them with the right questions.
Who is the person or group you're trying to help? Sometimes knowing their gender, age or race might be important to you, other times these may be beside the point. What are their key symptoms? This may seem an obvious question, but people are complicated and they don't necessarily have just the one condition you're treating. Someone has diabetes and high blood pressure, will the drugs you prescribe for each interfere with each other? Which is the most acute aspect that needs to be treated as a priority? Maybe your population is "men in their 50s with type 2 diabetes", maybe it's "women in their early 40s with a first time pregnancy", maybe it's "otherwise healthy middle aged women diagnosed with high blood pressure","young children aged between 3 and 5 with occasional severe abdominal pain"... Take your pick. What are the possibly important factors about the person sitting in front of you needing treatment?
So here is your patient, sitting in front of you and waiting for you to come up with a solution for their ailment. Take a moment to think about what it is you're considering. Are you going to prescribe them some tablets? Order a test or recommend surgery? Send them to a consultant that might know more about the problem than you? In terms of mental health, would you maybe recommend CBT, medication or counselling?
Once you have a vague idea, you might want to consider what else might influence the treatment. The patient's age? Any other health issues they have, and how they're being treated already for those? The patient's lifestyle or if they have any disabilities that may affect how well they can carry out your recommendations? If the problem has been caused by an exposure in their lifestyle such as cigarette smoke, can you remove them from the exposure?
So you've defined the important stuff about your patient and you have a pretty good idea of the best way to tackle their issue. So what should be stopping you from just going ahead?
The idea that something out there might possibly be better.
Are you wondering whether this new drug you've heard about might be better than the one you've been using since leaving medical school? Are you thinking that maybe your depressed patient is suffering from bereavement, and that talking things through would be better than medication? Are you wondering if chemotherapy would be a better option than surgery for an elderly patient with an early stage tumour? Or if either of those would lose too much quality of life in their final years, and they're best left alone?
While your question does not always need a comparison between treatments it can be helpful, and such small increments and comparisons are in reality how modern medicine improves all the time.
What do you actually want to achieve for this patient? It may seem like an obvious question, you want them to "get better". But in reality the answer to this question might be far more complicated. The main problem might be a side effect, for instance, and another drug might have less side effects but also be less effective. Say you're taking a drug that keeps your blood pressure down but has you needing the toilet every hour through the night. There's another drug that is less effective at keeping your blood pressure down but hasn't the exhausting, sleepless side effect. How do you weigh up what you want the most?
Do you want to lower someone's blood pressure or blood sugar levels, even if it means the quality of their life might lessen in their perception? Do you want to reduce adverse effects even if that means a drug less effective at controlling the actual symptoms? Is your aim to get them off drugs altogether and replace it with another treatment, such as counselling or regular exercise, or stopping smoking? Of course, your patient may have different expectations and ideas of what would be a "success". All of these things need to be considered as part of your clinical question, before you start searching for answers.
Asking the right questions, and using PICO to help us do that, is the vital first step in Evidence Based Medicine. Yet asking any questions, yet alone the right ones, is difficult for some because it involves admitting we have huge gaps in our knowledge. Think about it. When was the last time you saw someone rewarded for admitting that they don't know something, but would be willing to learn? Yet we're rewarded for knowing stuff from our earliest years. Health care workers, like all of us, are in danger of seeking out knowledge that seems to confirm what they already think they know, and we need to be aware of that.
If handled well, the cognitive dissonance that comes from admitting "I don't know the answer to that, but I'd be interested in finding out" is incredibly rewarding. And in the case of finding medical evidence, it may not only be rewarding for the person asking the question, but for the patient on the other side of the desk.