UVA School of Medicine (SOM) students will have weekly opportunities to present self-directed learning (SDL) presentations to their small groups in the Foundations of Clinical Medicine course.

The SDLs should be guided by the 5A Framework in order to:

• Form good patient-oriented questions using PICO on a topic either assigned by their coach or generated from a previous FCM encounter.
• Build literature search strategies to efficiently find relevant answers to appraise and apply back to the patient scenario in a PowerPoint presentation to their small group

The SDL will include a 10-minute PowerPoint presentation that includes a screen shot of their final database (Ovid MEDLINE, PubMed, etc.) search strategy with search terms and results. 

One primary journal article (no review articles) will be selected from the search results to be read and evaluated as to it's relevance for answering the PICO question.  The citation reference should be included as a footnote and/or on a final Bibliography slide..

We will assume in FCM that the first "A" for "ASSESS" is coming from a patient case you may have seen in class or perhaps from a patient seen in a hospital visit.

The student assigned to give the SDL Lecture the following week should briefly discuss a plan and draft a key clinical question (see Step 2: How to Ask a Clinical Question) with their Coach.

Using the 5A Framework will provide a nice formula to follow in completing this assignment. 

We use an acronym called PICO to be sure we have included all important factors to consider when forming a good searchable clinical question.  PICO is a tool that clarifies and focuses questions that arise during a patient assessment, and helps to identify and organize the key aspects of a complex patient presentation.

Those key components include:

• P = Patient or Population
• I = Intervention (Are you looking to diagnose? Treat? Learn about a prognosis?)
• C = Comparison or Control - this is not part of all questions (Is there a control? Placebo? Gold Standard?)
• O = Outcome (What do you hope to accomplish? Better treatment? Decreased mortality?)

PICO Examples:

Example 1:
In ventilated patients (P), does the head of the bed elevation of 45 degrees (I) compared to 20 degrees (C) reduce the incidence of ventilated associated pneumonia (O)?

Example 2:
In an 86-year old man with coronary artery disease (P), is aspirin (C) a more effective agent than heparin (I) in reducing stroke risk (O)?

SEARCHING MEDLINE
Students may use the MEDLINE Database (through Ovid or PubMed) to acquire the journal literature needed to answer their clinical questions.  In addition to MEDLINE, there are links to other databases such as the Web of Science available from the Medical Student Library Portal.

SEARCHING THE LITERATURE
Having the clinical question in PICO format and knowing what TYPE of question it is, will help before developing the MEDLINE (or other database) search strategy.

Before beginning to search, ask yourself "What type of question is this?" because it will possibly impact your choice of Medical Subject Headings (MeSH), Subheadings, and Limits.  There are 4 common types of clinical questions:

1. Therapy - determining the effect of interventions on patient-oriented outcomes
2. Diagnosis - establishing the power of a test to differentiate between those with and without a condition or disease
3. Etiology/Harm - ascertaining the effects of potentially harmful agents on patient-oriented outcomes
4. Prognosis - estimating a patient's future course

There are "BEST" (i.e. strongest) Study Designs for each type of question:

• Therapy - Randomized Control Trial (RCT) > Cohort Study
• Diagnosis - Prospective Study or Blind Comparison to a Gold Standard
• Etiology/Harm - RCT > Retrospective Cohort > Case Control > Case Series
• Prognosis - Cohort Study > Case Control > Case Series