ASSESS THE PATIENT
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.

ASK A QUESTION
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 - not part of all questions. (Is there a control? Placebo? Gold standard?)
• O = Outcome (What do you hope to accomplish? Better treatment? Decreased mortality?)

EXAMPLES:
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)?

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)?

Adding Type of Question and Type of Study to the PICO framework reminds you that different types of study designs are used to answer different types of questions. Evidence exists in hierarchies based upon the strength of the study design and type of question being asked. These considerations will, in turn, guide the development of your MEDLINE search strategy.

So I recommend in addition to PICO, consider adding the following 3 Ts to your clinical question:

• T = Time factors
  Would the desired outcome be within a month? A week? While hospitalized?
• T = Type of question
• Therapy
• Diagnosis
• Etiology
• Harm
• Prognosis
• ​Prevention
• T = Type of study sought to answer the question
  Randomized Controlled Trial, Systematic Review, Cohort Study, etc.

EXAMPLE:
In surgical patients (P), does chlorexidine (I) compared to povidone-iodine (C) reduce surgical site infections (O) during hospitalization? (T)  Time Factor added

Two of the three "Ts" in PICOTTT are for the "Type of Question" (therapy, diagnosis, prognosis, etiology, prevention & control) and the "Type of Study" (randomized controlled trial, meta-analysis, etc.).

These two items are directly related in that the question type guides you in selecting the best study design that will yield the highest level of evidence. This image will help in understanding this relationship [permission to use this image granted by Dahlgren Memorial Library]:

Evidence hierarchies provide a short-cut to help you filter your searches to the most likely best evidence for the kind of question you are asking.

For prevention and treatment questions, start by searching for evidence at the top of the list, systematic reviews of randomized trials. Consider the publication date in the selection process. If the systematic review you find was published a number of years ago and found inconclusive evidence, then look for newer randomized trials as your next step. If no evidence is found at the top levels, move down the list looking for systematic reviews and then single studies of first cohort studies and then case-series or case-control studies.

Remember that all evidence must be critically appraised. A poorly conducted or reported randomized trial does not provide stronger evidence than the results of a well conducted cohort study.