Clinical Inquiry and Uncertainty in Generating Clinical Questions

Where clinical questions come from (i.e., their origin) is an important consideration. On a daily basis, most clinicians encounter situations for which they do not have all the information they need (i.e., uncertainty) to care for their patients as they would like (Ely et al., 2002; Scott et al., 2008). The role of uncertainty is to spawn clinical inquiry. Clinical inquiry can be defined as a process in which clinicians gather data together using narrowly defined clinical parameters to Melnyk_Chap02.indd 28 3/3/2010 12:47:08 PM Asking Compelling, Clinical Questions chapter 2 29 appraise the available choices of treatment for the purpose of finding the most appropriate choice of action (Horowitz, Singer, Makuch, et al., 1996). Clinical inquiry must be cultivated in the work environment. To foster clinical inquiry, a level of comfort must be had with uncertainty. Scott et al. (2008) define uncertainty as the inability to predict what an experience will mean or what outcome will occur. Lindstrom and Rosyik (2003) state that uncertainty is a sequela of ambiguity. Clinicians live in a rather ambiguous world. What works for one patient may not work for another patient. The latest product on the market claims that it is the solution to wound healing, but is it? Collaborating partners in caring for complex patients have “their” way of providing care. Formulating clinical questions in a structured, specific way, such as with PICOT formatting (discussed later in this chapter), assists the clinician in finding the right evidence to answer those questions and to decrease uncertainty. This approach to asking clinical questions facilitates a well-constructed search. Schardt et al. (2007) found that that using PICOT templates improved clinicians’ skills to search PubMed for answers to burning clinical questions. These successes then foster further clinical inquiry. Clinical circumstances, such as interpretation of patient assessment data (e.g., clinical findings from a physical examination or laboratory data), a desire to determine the most likely cause of the patient’s problem among the many it could be (i.e., differential diagnosis), or simply wanting to improve one’s clinical skills in a specific area, can prompt five types of questions. These five types of foreground questions are (a) intervention questions that ask what intervention most effectively leads to an outcome; (b) prognosis/prediction questions that ask what indicators are most predictive of or carry the most associated risk for an outcome; (c) diagnosis questions that ask what mechanism or test most accurately diagnoses an outcome; (d) etiology questions that ask to what extent a factor, process, or condition is highly associated with an outcome, usually an undesirable outcome; or (e) meaning questions that ask how an experience influences an outcome, the scope of a phenomenon, or perhaps the influence of culture on healthcare. Whatever the reason for the question, the components of the question need to be considered and formulated carefully to efficiently find relevant evidence to answer the question.

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