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Allopathic Medicine: NSU MD Library Guide: Evidence Based Medicine

An instructional pathfinder to researching for Dr. Kiran C. Patel College of Allopathic Medicine

Background vs. Foreground Questions

What is the difference between a background and a foreground questions?

Background questions are more general ones that begin with how, what, why, when, or where and ask about some aspect of patient care: How do you diagnose...?  How do you treat...? What are the risk factors for…? What is the prognosis for…? With questions like this, you are not asking about specific tests, treatments, risk or prognostic factors but are more generally asking about the best among all possibilities. You are often acknowledging that you may not know a lot about a particular subject and need some general background information to get started. These are questions most appropriately answered by textbooks or online references like UpToDate or Harrison’s or the expert opinion found in general review articles. They are too general for the primary research literature to address and so aren’t good questions for a MEDLINE search.

Foreground questions, on the other hand, are more specific questions defined by the 4-part PICO acronym. They require a specific named intervention and comparison, which makes them good questions for MEDLINE and the research literature. They cover the same 4 content areas as background questions – diagnosis, treatment, etiology, and prognosis – and are the only types of questions we deal with in evidence-based medicine.

As people move through their careers, they tend to ask fewer background questions, having already acquired much of this information, and more foreground questions, which will advances their knowledge of current research in their specialty areas. 

Looking for background of foreground information?

Background questions ask for general knowledge about a condition or thing.

Foreground questions ask for specific knowledge to inform clinical decisions or actions. 

Background Questions

  • Asks for general knowledge about a disease or disease process
  • Have two essential components:
    • A question root (who, what, when, etc.) with a verb
    • A disorder, test, treatment, or other aspect of healthcare
    • Example: What causes migraines? or How often should women over the age of 40 have a mammogram?

The background question is usually asked because of the need for basic information. It is not normally asked because of a need to make a clinical decision about a specific patient.

Foreground questions

  • Ask for specific knowledge about managing patients with a disease
  • Have 3 or 4 essential components (see next tab)

Asking the Clinical Question: Asking Background Questions

Background questions usually concern conditions, and consist of two parts:

  1. The root question (W5H) + verb, eg. what causes ...? [W5H = who, what, when, where, why, how]
  2. Problem, eg. influenza

Early in training, a medical student on seeing a patient with newly diagnosed diabetes mellitus, may ask questions such as:

  • What is type 2 diabetes mellitus?
  • Why does this patient have polyuria?
  • Why does this patient have numbness and pain in his/her legs?
  • What treatment options are available?

These background questions address normal human physiology and the pathophysiology associated with a medical condition.

Most background questions can be answered by standard textbooks, such as Harrison's Principles of Internal Medicine (Harrison's Online), Rudolph's Pediatrics, Williams Gynecology, Williams Obstetrics, and Current Diagnosis & Treatment: Surgery or Pathophysiology of Disease: an Introduction to Clinical Medicine

Innovative evidence-based resources, such as UptoDate or First Consult (log on to ClinicalKey, search for a term or diabetes, then select First Consult [FC] articles) also provide answers to some background questions. To provide faster searching, various publishers may group collections of textbooks together to be searched at the same time. Major collections of such textbooks at HPD Library are found at ClinicalKey and AccessMedicine. These collections can also include various other resources besides textbooks.provide answers to some background questions. To provide faster searching, various publishers may group collections of textbooks together to be searched at the same time. Major collections of such textbooks at  These collections can also include various other resources besides textbooks.

Such e-textbooks are usually easy to search. A single term (such as a disease) can be searched and will lead to further categories or chapters.

Asking the Clinical Question: Asking Foreground Questions

Foreground questions usually concern choices, are specific to decision-making, and are asked by more experienced clinicians who are able to use the specialized knowledge typical of experts in the subject field. Different resources to those used to answer background questions are often used to answer such foreground questions.

You can search for synopses of the literature in evidence-based resources such as EssentialEvidencePlus (EE+).  EE+ carries both evidence summaries (POEMs) as well as research summaries, and can also be searched under broad subject "topics", such as Infectious Diseases or Pregnancy and Childbirth. First Consult (a database within in ClinicalKey) also offers evidence-based literature. Additionally, Best Practice offers synopses of various conditions, and is useful for evidence-based practice. 

PubMed can be searched for summaries and the primary literature, and use of the Clinical Queries option in PubMed can be helpful, as it offers the ability to search using evidence-based filters such as diagnosis or prognosis (see Clinical Queries on PubMed in the  guide).


McKibbon A, Wyer P, Jaeschke R, Hunt D. Finding the evidence. Ch. 4. In: Guyatt G, Rennie D, Meade MO, Cook DJ, eds. Users’ Guides to the Medical Literature: A Manual for Evidence-Based Clinical Practice. 2nd ed. New York: McGraw-Hill; 2008. Available: [Accessed 26.07.2012]

EBM Resources

EBM Mobile Resources


Websites and You Tube:

TRIP Database

CEBM Channel

Evidenced-Based Medicine Toolbox

Evidence-Based Medicine Instructional Guides from University of Illinois

What is Evidence Based Medicine?

                                                                                                                                          Best Research evidence, clinical expertise, and patient values make up EBM.

Evidence-Based Medicine (EBM): Evidence-based medicine is the judicious use of the best research evidence (found in health sciences literature), clinical expertise (what the health care provider knows) and patient values (what the patient wants and believes) to create a plan of action regarding patient care.

The 5 A's of the Evidence Cycle: The 5 A's are a good system for remembering the steps needed to practice evidence-based medicine.

Ask - Develop a searchable question. PICO is a helpful format for ensuring that a clinical question includes four essential elements: patient, intervention, comparison, and outcome. 

Acquire - Once a searchable question is developed, EBM resources are used to locate a high quality information source to answer that question.

Appraise - Use critical appraisal to ensure that the information being used is high quality, authoritative, and relevant to the patient.

Apply - Combine the best research evidence, clinical expertise and patient values to determine a course of action and apply the it to the patient. 

Analyze - Reflect on the course of action taken, and seek ways to improve. 

Where to Look

EBM Pyramid with Mapped Resources

Study Types

Types of Clinical Questions

Recognizing your clinical question's domain is an important part of the Evidence-Based Practice (EBP) process. Establishing the question type allows you to:

  • Identify the research methodology that provides the best evidence to answer the question.  Note that the hierarchy of evidence (covered in 1.3 Hierarchy of Evidence) will differ according to question type.
  • Select the best EBP Tools to search for the evidence. The Cochrane Database of Systematic Reviews, for example, only addresses treatment and prevention questions.  Other databases address questions of treatment and prevention, diagnosis, prognosis, etiology, quality improvement, and health economics, among others.
  • Select evidence filters in PubMed / CINAHL and other databases that will help narrow your search to papers using appropriate research methods.

Identifying your question type will also assist you in critically appraising the evidence based on the appropriateness and rigor of the research methods described in a paper.

Common Types of Clinical Questions

Study Designs

These are a few of the publication types associated with evidence-based practice taken from the Glossary of EBM Terms from the Centre for Evidence-Based Medicine Toronto, Accessing Preappraised Evidence: Fine Tuning the 5S Model into a 6S Model, and from the MeSH Database

Systems: An electronic medical record that is able to link updated, evidence-based information related to a patient's clinical information. Also known as an integrated computerized decision support system. Very few exist at this time.

Summary: These include topic summaries and clinical practice guidelines that integrate evidence-based information about specific clinical problems with regular updating.

Synopses of Syntheses: A synthesis would be a systematic review (defined below). A synopsis of that synthesis would be an expert/authoritative appraisal or critique of a high quality systematic review that provides sufficient information to support clinical action.

Syntheses: A summary of the medical literature that uses explicit methods to perform a comprehensive literature search and critical appraisal of individual studies. There are two categories of synthesis.

  • Systematic Reviews: A qualitative integration or description of individual studies.
  • Meta-analysis: A quantitative integration of data from individual studies using statistical techniques.

Synopses of Single Studies: An expert/authoritative appraisal or critique of an individual study that provides sufficient information to support clinical action.

Randomized Controlled Trial: A study in which participants are randomly allocated into an experimental group or control group and followed over time for the variables/outcomes of interest.

Cohort Studies: Studies in which subsets of a defined population are identified. These groups may or may not be exposed to factors hypothesized to influence the probability of the occurrence of a particular disease or other outcome. A cohort study will have a control group that represents the unexposed population.

Case Controlled Studies: A study which involves identifying patients who have the outcome of interest (cases) and patients without the same outcome (controls), and looking back to see if they had the exposure of interest.

Case Series/Reports: A report on a series of patients or single patient with an outcome of interest. No control group is involved.



Video on Background and Foreground Information:

For more information, watch this video: Search for Evidence Based Information, by Lynne Fox at the University of Colorado Health Sciences Library, which will go into more detail about background and foreground questions.

Video from WHO on formulating the PICO Question:

This video Formulating Questions and Choosing Patient Important Outcomes from the World Health Organization and McMaster University, is part of the series The Grade Approach--Online Learning Modules for Guideline Development at WHO. The video will advance on it's own, but you may want to watch specific sections again by clicking on the table of contents on the left.