Asking an answerable question By

definition, the question generated within an "evidence-based prescription" is derived from a patient encounter. For example, a woman aged 32 years with facial acne may want to know whether it is safe to take a combined anti-androgen/oestrogen pill, as opposed to continuing on prolonged oral antibiotics. Further discussion may reveal that she is mainly concerned about deep vein thrombosis as she has a family history of this. The structured evidence-based question emanating from this discussion would then be, "What is the increased risk for a woman in her thirties to suffer a deep vein thrombosis when taking the combined anti-androgen/oestrogen pill for her acne when compared with taking an oral antibiotic?". This will, of course, depend on other factors such as whether she is a smoker, her weight, exercise profile etc. but it nevertheless illustrates how an evidence-based question needs to be tailored in a structured way around a particular individual.

2. Searching for relevant information. This may at first seem to be the domain of the dermatologist, yet the advent of the internet and many high-quality skin information websites has transformed this. Many patients now come to their first dermatology consultation armed with pages printed out from the internet. They may sometimes correctly self-diagnose conditions such as "cold urticaria" when even their family doctor was unsure. Whilst it is true that much of the information on the internet is of dubious value as a result of various vested interests and the lack of explicit criteria used to develop it, the internet can be a useful source of information for many rare and common skin diseases. In this sense, the "consumer" can play a useful role by helping their dermatologist to search for information that may be relevant to the evidence-based question.

3. Appraising the quality of the data. Again, although it might seem that only the dermatologist can appraise the validity of the data by checking for things such as adequacy of concealment of the randomisation schedule, and issues of blinding and intention-to-treat analysis, such an assessment is of little value if the dermatologist examines reported outcomes in a trial that means little to the patient. Consumers are ideally placed to help inform dermatologists about which aspect of the disease is important to them. For example, in patients with atopic eczema, is it short-term control of itching, duration or frequency of remissions, healing painful cracks in the fingers, coping skills, or ability to take part in sport and social activities?

4. Applying the information back to the patient. An "evidence-based prescription" is useless if that information is not then presented back to the patient who generated it. Patients are the only people who can ultimately decide if the treatment options they are offered fit in with their expectation for improvement, willingness to be inconvenienced by side-effects and frequent visits, and so on.

Thus it can be seen that the consumer has a central role in driving and informing the process of evidence-based dermatology in that the important questions begin and end with the patient. The dermatologist is seen as the patient's advocate, guiding and interpreting the evidence and applying it to the patient's unique circumstances through a caring and trusting partnership.

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