title: Integrating competencies: exploring complex problem solving through case formulation in developmental pediatrics.
abstract: OBJECTIVE
  To understand how experienced clinicians formulate cases and to use this understanding to explore the broader processes involved in how clinicians solve complex problems in their daily work. Case formulation is a process that allows clinicians to provide a tentative explanation for why a patient with a certain condition presents in a particular way at a particular time.
  
  
  METHODS
  In this constructivist grounded theory study, the authors conducted semistructured interviews with 12 physicians (9 experienced clinicians, 3 new graduates and residents) from the University of Toronto Division of Developmental Pediatrics between July and December 2012. They used a constant comparative analysis to identify themes and iteratively developed a thematic structure, which one researcher applied to the entire data set. They maintained a detailed audit trail throughout the process.
  
  
  RESULTS
  Experienced clinician participants articulated three interconnected themes that characterize their complex problem solving during case formulation: (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.
  
  
  CONCLUSIONS
  Findings suggest that these interpretive, strategic, and longitudinal processes appear to be central to the complex problem solving of experienced clinicians engaged in case formulation. They illuminate how clinicians integrate multiple competencies when they solve complex problems in their daily work. Exploring this integration of competencies has broader implications for understanding expertise and expert development and may inform pedagogical practices that promote the development of complex problem solving in trainees.
authors.affiliation: Dr. Kawamura is assistant professor, Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada. Dr. Orsino is assistant professor, Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada. Dr. Mylopoulos is assistant professor, University of Toronto, Faculty of Medicine, and education researcher, Learning Institute, Hospital for Sick Children, Toronto, Ontario, Canada.
authors.forename: Anne A
authors.initials: AA
authors.lastname: Kawamura
authors.forename: Angela
authors.initials: A
authors.lastname: Orsino
authors.forename: Maria
authors.initials: M
authors.lastname: Mylopoulos
mesh_terms: D019090:Case Management; D002648:Child; D002657:Child Development / Q000502:physiology; D002983:Clinical Competence; D003430:Cross-Sectional Studies; D005260:Female; D006801:Humans; D007396:Internship and Residency / Q000706:statistics & numerical data; D007407:Interviews as Topic; D008297:Male; D008505:Medical Staff, Hospital / Q000706:statistics & numerical data; D009864:Ontario; D005791:Patient Care / Q000379:methods*; D010372:Pediatrics / Q000193:education*; D011340:Problem Solving