Steps to improve your ability to ask and answer questions 

Become an effective computer user

One way to reduce the work of answering clinical questions is to make information easily available on a computer. Two studies have looked at physician expectations and desires for computer-based information. Woolf and Benson^[5] found that the places where information was most needed (clinic and ward) were not considered the most convenient for a terminal-based solution, suggesting that a mobile, handheld solution would be especially useful to physicians, particularly for family physicians, whose clinical questions could arise in the office, the hospital, the nursing home or extended care facility, or at home while on call.

In a survey of Michigan family physicians, 85 percent would be willing to carry a handheld computer during patient care activities.^[22] Characteristics especially valued by family physicians in decision support software included the ability to update information, a uniform interface, drug information, current treatment recommendations, and the ability to print patient educational materials. Handheld computers appear to be a promising tool for quickly answering physicians’ clinical questions at any location, because they are highly portable, turn on and off immediately, and have adequate memory and speed for the task of medical information management and reference.^[23] Eventually these units will provide inexpensive, continuous, wireless connections to the Internet and local area networks. A previous article described handheld computers and software for physicians.^[23]

Many physicians now have computers at or near the point of care. Excellent sources of evidence-based information for desktop computers include the Cochrane Library from the Cochrane Collaboration and the Best Evidence reference from the American College of Physicians and the British Medical Journal Publishing Group. Both the Cochrane Library and Best Evidence are available on CD-ROM. Useful Web sites for answering clinical questions using evidence-based information are shown in Table 2.

Create a culture of inquiry

Medical students, residents, and practitioners build an extensive database of clinical experience and medical knowledge. Like any database, though, it can grow out-of-date. Regularly reflecting on decisions and practices will stimulate clinical questions. Answering these clinical questions using valid, relevant information will keep a database up-to-date. A simple method is to keep an index card in a pocket and write down questions that cannot be answered immediately. Then, make a commitment to answer at least one or two of the most compelling questions each week.

Inquire, Don’t Advocate

Too often, physicians advocate a plan for a patient or a belief about a condition rather than inquire into the best possible approach for the patient(s). Advocacy is prefaced by such statements as “I think …,” “I believe …,” “The facts are …,” “Experience says ….,” and “My colleagues always .…” Inquiry, on the other hand, is characterized by such statements as, “What do you think?” “I wonder whether there is a better way?” “Should I keep doing this?” and “Why have I always …?” When you find yourself making advocacy statements, ask yourself whether you could instead inquire. Whereas advocacy tends to uphold the status quo, inquiry leads to new knowledge and new insights.

Feel Good About Not Knowing Everything

It is impossible for any physician, especially a primary care physician, to know everything. Family practice is a specialty defined in breadth rather than depth.^[25] Reading should therefore focus on problems common or important to your patients. When you find an article about such a problem, make sure it uses outcomes that matter to your patients, such as symptom improvement, mortality reduction, cost, or quality of life. An article that is valid and would change your practice is a POEM. Fortunately, only approximately 2 percent of the medical literature is POEMs (26), so this approach will help get rid of the stack of unread journals. Because the findings of a POEM have been shown to improve important patient outcomes and because they differ from your current practice, Shaughnessy et al^[20] argue that you are ethically obligated to know about POEMs and apply them to your practice. To learn more about POEMs and search the collected database, see the Journal of Family Practice Web site at http://www.jfponline.com or visit http://www.medicalinforetriever.com. Another excellent monthly site is Bandolier, supported by the British National Health Service.

Let Someone Else Do the Heavy Lifting

There are now several excellent sources of what is called secondary literature. Each has a group of physicians trained in critical appraisal, epidemiology, and research design who select important articles, critically appraise them for validity, and publish the results in brief synopses.

Examples include the ACP Journal Club, Journal of Family Practice POEMs feature, Evidence-Based Practice newsletter, and the journal Evidence-Based Medicine. By distilling a mountain of medical literature to the most important 10 or 20 pages every month, these resources make it possible for physicians to remain up-to-date without spending inordinate amounts of time in the library.