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It's iterative and personal
Integrating Competencies: Exploring Complex Problem Solving through Case Formulation in Developmental Pediatrics Kawamura AA et al. Academic Medicine 2104 89:11

Reviewed by Michelle Haight

What was the study question?
How do experienced clinicians formulate cases to solve complex problems in their clinical work?

How was the study done?
Three researchers conducted 45 minute, semi-structured interviews with 12 participants: 9 experienced clinicians (≥ 5 years in practice) and 3 new graduates/residents (novices) in the Division of Developmental Pediatrics at the University of Toronto. Data were collected, coded, analyzed and interpreted using a constant comparative analysis model to identify emergent themes and develop a global thematic structure. The "novice" group data was used as a "theoretical" sample in order to deepen the understanding of case formulation in experienced physicians.

What were the results?
Three themes emerged: 1) interpreting individual patient factors in the context of medical and clinical knowledge, 2) strategically co-constructing the case formulation with parents and team members, and 3) refining the case formulation over time. Experienced clinicians defined case formulation as a "clinical reasoning" process which is focused on the patient's problem. Experienced clinicians emphasized the need to connect clinical and medical knowledge to the patient's story. They likewise commented on the necessity to create a "shared understanding" of the patient with the family and underscored the dynamic nature of case formulation through "iterative review and integration of new information" across time. Novices spoke about case formulation as a more routine process to make a diagnosis and provide a global impression rather than a flexible, iterative, longitudinal process. Novices did not comment on the significance of acknowledging and integrating individual patient details (context specificity) to arrive at an optimal case formulation.

What are the Implications of these findings?
Integrating multiple competencies creates the foundation to developing effective case formulations and clinical reasoning skills. These competencies include: collecting and interpreting information from multiple sources (patient care), integrating this information into clinical acumen (knowledge for practice) and strategically communicating this information to parents and patients (interpersonal and communication skills).

Editors' note: This well done study provides causes one to think about ways to make clinical reasoning more explicit to our trainees. We should, for instance, explicitly mention and demonstrate the iterative nature of arriving at a correct diagnosis (SLB).

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