Chapter 4: What Is the Question?

Three Ways to Use the Medical Literature

Consider a medical student, early in her training, seeing a patient with newly diagnosed type 2 diabetes mellitus. She will ask questions such as the following: “What is type 2 diabetes mellitus?” “Why does this patient have polyuria?” “Why does this patient have numbness and pain in his legs?” “What treatment options are available?” These questions address normal human physiology and the pathophysiology associated with a medical condition.

Traditional medical textbooks, whether in print or online, that describe underlying pathophysiology or epidemiology of a disorder provide an excellent resource for addressing these background questions. In contrast, the sorts of foreground questions that experienced clinicians usually ask require different resources. Formulating a question is a critical and generally unappreciated skill for evidence-based practice. The following ways to use the medical literature provide opportunities to practice that skill.

Staying Alert to Important New Evidence

A general internist is checking e-mails on a smartphone while riding public transit to work. While screening a weekly e-mail alert from EvidenceUpdates (http://plus.mcmaster.ca/EvidenceUpdates, Figure 4-1), the internist sees an article titled, Cardiovascular Effects of Intensive Lifestyle Intervention in Type 2 Diabetes,¹ recently published and rated by internist colleagues as newsworthy and highly relevant for practice.

This internist is in the process of addressing a question that clinicians at all stages of training and career development are constantly posing: “What important new evidence should I know to optimally treat patients?” Clinicians traditionally addressed this question by attending rounds and conferences and by subscribing to target medical journals in which articles relevant to their practice appear. They kept up-to-date by skimming the table of contents and reading relevant articles.

This traditional approach to what we might call the browsing mode of using the medical literature has major limitations of inefficiency and its resulting frustration. Many screened articles may prove of little relevance or newsworthiness or fail to meet the critical appraisal criteria that are presented in this book. To make matters worse, the volume of research is markedly increasing,² and relevant studies appear in a large variety of journals.³ Evidence-based medicine offers solutions to these problems.

The most efficient strategy for ensuring you are aware of recent developments relevant to your practice is to subscribe to e-mail alerting systems, such as EvidenceUpdates, used by the internist in this example. This free service has research staff screening approximately 45000 articles per year in more than 125 clinical journals for methodologic quality and a worldwide panel of practicing physicians rating them for clinical relevance and newsworthiness.⁴ You can tailor alerting systems to your information needs (clinical disciplines and frequency of alerts) and identify the 20 to ...