FCM: Using the 5A Framework

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. 

Karen Knight, the Medical Education Librarian is available to provide assistance with forming the clinical question and conducting the literature search.

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

CRITICAL APPRAISAL
Articles are not necessarily reporting well done research and findings just because they are found through a literature search or appear in a prestigious journal. Articles need to be evaluated for their RELEVANCE to your question and the VALIDITY of the methodology and findings.  

Learning how to critically appraise journal articles is a challenging and often time-consuming task.  The appraisal piece for FCM is less ambitious than for a full Journal Club presentation, but provides a chance to learn and practice these important skills.The SDL Examples in the introduction above provide two examples of what is expected. 

Appraisal Checklists can be useful. Once you know the type of article you are reviewing, consider using an appropriate checklist. Here is a link to some free downloadable checklists from CASP. 

Here is another quick list - "Critical Appraisal: A Checklist" from a blog post by Robert Will:

Critical Appraisal of ... the Introduction

• Does the article attempt to answer the same question as your clinical question?
• Is the article recently published (within 5 years) or is it seminal (i.e. an earlier article but which has strongly influenced later developments)?
• Is the journal peer-reviewd?
• Do the authors present a hypothesis?

Critical Appraisal of ... the Methods

• Is the study design valid for your question?
• Are both inclusion and exclusion criteria described?
• Is there an attempt to limit bias in the selection of the participant groups?
• Are there methodological protocols (i.e. blinding) used to limit other possible bias?
• Do the research methods limit the influence of confounding variables?
• Are the outcome measures valid for the health condition you are researching?

Critical Appraisal of ... the Results

• Is there a table (usually Table 1) that describes the subject demographics?
• Are the baseline demographics between groups similar?
• Are the subjects generalizable to your patient?
• Are the statistical tests appropriate for the study design and clinical question?
• Are the results presented within the paper?
• Are the results statistically significant and how large is the difference between groups?

Critical Appraisal of ... the Discussion/Conclusion

• Do the authors attempt to contextualize non-significant data in an attempt to portray significance?
• Do the authors acknowledge limitations in the article?
• Are there any conflicts of interest noted?

APPLY TO YOUR PATIENT

Your last SDL slide should discuss how you would apply (or not apply) the article's findings to your patient or specific clinical question.  It is important to take patient preferences into consideration when applying research findings.

SEARCH QUESTION:  In an adult hypertensive male (P), does a low salt diet (I) reduce hypertension (O)?

This is a THERAPY question so I would really like to find a well-done Randomized Controlled Trial (RCT).  Better yet - a Systematic Review or Meta-Analysis of multiple RCTs would provide even stronger evidence for answering my question.

1. Search for "HYPERTENSION"
2. Maps to the Medical Subject Heading (MeSH) term = HYPERTENSION
3. You can apply SUBHEADINGS to your MeSH term to get at the TYPE OF QUESTION,  as there are Subheadings for diagnosis, etiology, therapy, prevention & control, and more.
4. This question is a THERAPY question, so I apply the "diet therapy" and "therapy" subheadings to the HYPERTENSION MeSH term
5. Search "LOW SODIUM DIET"
6. Maps to the Medical Subject Heading (MeSH) term = DIET, SODIUM-RESTRICTED
7. In this case, I select BOTH the MeSH term and the Keyword option below it - combined with an "OR"
8. The Keyword option looks for a match on exactly what you type in article TITLES and ABSTRACTS.  You can tell it is a Keyword search by the ".mp." after the term.  *Most MEDLINE searches will be a combination of MeSH and KEYWORD searching*
9. COMBINE the two search sets together with an "AND"
10. As a last step, apply appropriate LIMITS, such as:
    • ​​MALE
    • ENGLISH LANGUAGE
    • PUBLICATION TYPES
    • Many Publication Types are included as LIMITS.  However, they do NOT include - Case-Control Studies and Cohort Studies - these two must be searched as MeSH terms and added to your other search terms during your search
    • I would select RANDOMIZED CONTROLLED TRIAL for this search as it is a strong study design for therapy questions
    • But there are other study designs to select from, such as SYSTEMATIC REVIEW and META-ANALYSIS

This is what your Ovid MEDLINE SEARCH STRATEGY will look like for such a search:

[Right mouse click to open Image in new tab for a larger view]