Unanswered Questions, part 2

The second research article is part of series published by Ely et al.:

Ely JW; Osheroff JA; Maviglia SM; Rosenbaum ME: Patient-care questions that physicians are unable to answer. J Am Med Inform Assoc 2007 Jul-Aug;14(4):407-14. Epub 2007 Apr 25 . PMID 17460122

This is a follow-up to a previous study in which the investigators had observed primary care physicians and recorded questions that arose during patient care. In the current study, the investigators worked with the questions for which physicians had pursued answers, but were unable to find them.

In the current study, the investigators analyze a portion of the unanswerable questions, categorize them, and try to find answers using a select list of resources that were “clinically oriented, generally available, and commonly used in practice.” I found the resource set interesting: UpToDate, Micromedex, Medline (actually PubMed, from the URL), National Guideline Clearinghouse, Harrison’s Principles of Internal Medicine, Nelson Textbook of Pediatrics, the Sanford Guide to Antimicrobial Therapy, the Red Book, eMedicine, and Google (!!). Three of the investigators report a current or past association with Thomson, which produces Micromedex.

The investigators were able to find answers to 70% of the questions studied in at least one of the 10 resources. They point out that they performed a “leisurely” search averaging 3.8 minutes per resource per question (up to 10 resources each), while the physicians who could not find the answers may at most have had a couple of minutes between patients. (Anyone who can get something useful from Google in 3.8 minutes is a more focussed searcher than I! I get distracted following interesting links.)

The authors reported their findings as an unanswered question taxonomy, recommendations for physicians, and recommendations for authors. I was most interested in their advice for physician/answer seekers.

The authors take issue with the PICO search strategy format, citing a poor phrasing of the question as one reason that physicians are unable to find an answer. While the PICO strategy is likely to find evidence-based answers, they contend, the answers don’t necessarily match the physician’s original question.

Their recommendations for physicians, to be more effective in finding answers, include selecting the most appropriate resource (handbooks and clinically oriented reviews rather than comprehensive textbooks); rephrasing questions to better match the type of information found in clinical resources (women with “fibrocystic disease” rather than “previous benign breast biopsies”); and using more effective search terms (treatment for “triglycerides” rather than for “very-low-density-lipoprotein cholesterol”).

I find PICO useful in reference interviews, myself. I may not structure my search strategy around the PICO format, but it helps me to ask the right questions, so that I know the patron asking for “pressure ulcers and surgery” wants to prevent skin ulcers in postop patients rather than to treat skin ulcers with surgery.

It seems to me that learning to break a question into component parts (which the article does touch on) and put it back together in a way that makes sense for the resource at hand would be a valuable skill for any searcher. The PICO format is one way, but not the only way, to do that. It also helps to know the resources well, know how to use the controlled vocabulary when it’s available, understand Boolean search logic … Searching 101.

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