Foreground Questions

Back to Physician's Core Toolkit

Clinical questions can be divided into roughly two types: background and foreground questions. Determining the type of question will help you to select the best resource to consult for your answer.

Foreground questions ask specific clinical questions that try to find relationships between a patient and their condition, an exposure (therapeutic, diagnostic), and an outcome. They are generally very detailed questions that can best be answered with the information contained in published research studies.

Examples are:

“What is the most effective dose of prednisone used to treat temporal arteritis?”

“Is glucophage combined with a low carbohydrate diet more effective than insulin alone at achieving good glycemic control for type II diabetics?”

Treatment information, which is constantly changing, is a foreground question that can best be located in systematic reviews and other research databases.

The anatomy of a good clinical question can often be broken down into a PICO(M) structure.

Question Structure

The structure of a question might contain five components. Practitioners of Evidence-Based Practice (EBP) often use the following framework to outline a question.

1. P = for Patient, Population/Demographics, or Problem/Disease
How would you describe patients similar to your own – what are their most important characteristics? This can include the primary disease, co-existing conditions, gender, age, or race of the patient.

2. I = Intervention, Risk Factor, or Exposure
Which intervention, risk factor, or exposure is being considered – what will you be doing for the patient? This can include treatments or diagnostic procedures. Was the patient exposed to something environmental or occupational? Are there factors that could affect treatment outcomes, such as age or co-morbid conditions?

3. C = Comparison or Control
Is there a “gold standard” or an alternative to compare to your intervention? (A “good” clinical question does not always need a comparison or control to be valid.)

4. O = Outcome(s)
What do you want to happen or what are you trying to do for the patient? Often, thinking about the desired outcome is the best place to start when formulating a question.

Sometimes, question anatomy will include:

5. (M) = Method(s)
What types of studies will yield the most useful and relevant information?

An Example of How to Use PICO

Start out with a good clinical question and then use the PICO framework to break it down into its components.

Our question:

“Do ACE inhibitors improve rates of mortality and myocardial infarction in elderly male patients with hypertension, compared with thiazide diuretics?”

The PICO framework can be filled in as follows:

P elderly males with hypertension
I ACE inhibitors
C thiazide diuretics
O improved rates of mortality & myocardial infarction