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Focusing Questions with PICO

The PICO mnemonic helps define questions to address specific clinical issues and aids in finding relevant evidence in the literature. Create your own PICO questions with this PICO worksheet.

Patient or Problem

How would I describe a group of patients similar to mine?

Intervention, Exposure, or Prognostic Factor

What is the main intervention, exposure, or prognosis being considered?

Comparison

What is the main alternative being considered, if any?

Outcome

What can I hope to accomplish, measure, improve, affect?

More on Asking Questions

Types of Questions

Therapy
How to select treatments to offer our patients that do more good than harm

Diagnostic Test
How to select and interpret diagnostic tests in order to confirm or exclude a diagnosis

Prognosis
How to estimate a patient's likely clinical course over time due to factors other than interventions

Harm/Etiology
How to identify causes for disease

Prevention
How to reduce the chance of disease by identifying and modifying risk factors; how to diagnose disease early by screening

Qualitative
How to empathize with our patients’ situations, appreciate the meaning they find in the experience and understand how this meaning influences their healing

Appropriate Study Design by Question Type

Question Type	Appropriate Study Design
Therapy	Randomized controlled trial
Diagnostic Test	Independent, blind comparison to the gold standard
Prognosis	Cohort study > case-control study > case series
Harm/Etiology	Randomized controlled trial > cohort study > case-control study > case series
Prevention	Randomized controlled trial > cohort study > case-control study > case series

For each of the question types above, a systematic review or meta-analysis is better than an individual study. A systematic review will compare several approximately designed studies and aggregate the results.

Background vs. Foreground Questions

Background Questions
Background questions are more general questions that often begin with what, when, where, why, or how. Some examples include:

• How do you diagnose...?
• How do you treat...?
• What are the risk factors for…?
• What is the prognosis for…?

With questions like this, you are not asking about specific tests, treatments, risk or prognostic factors but are more generally asking about the best among all possibilities. You are often acknowledging that you may not know a lot about a particular subject and need some general background information to get started. These are questions most appropriately answered by textbooks or online references like DynaMed Plus or UpToDate. They are too general for the primary research literature to address and therefore aren’t good questions for searching databases like PubMed or Ovid Medline.

Foreground Questions
Foreground questions are more specific questions often defined by the PICO mnemonic. They require a specific named intervention and comparison, which makes them good questions for the searching the primary research literature using databases such as PubMed or Ovid Medline. Foreground questions are also referred to as clinical questions.