In an era of increasing complexity in health care,1 physicians often are required to solve complex problems to provide effective patient care.2,3 This form of problem solving is a key component of adaptive expertise.4,5 Adaptive expertise is characterized by an expert’s ability both to perform familiar, routine tasks using past knowledge and experience and to “break free from old routines” when necessary to address novelty and uncertainty in daily work.6 Although recent studies have begun to explore adaptive expertise in health care,7–10 a gap still exists in our understanding of the processes involved in complex problem solving and how it develops in medical trainees. This gap impedes our ability as medical educators to effectively train future adaptive experts, who represent the standard of excellence in clinical practice.10
Case formulation is a powerful example of complex problem solving and therefore provides a rich opportunity to explore adaptive expertise in daily clinical work. Case formulation has been defined as a process of providing a tentative explanation of why an individual with a certain disorder or condition comes to present in a particular way at a particular point in time.11,12 To effectively formulate cases, clinicians must consider not only the biomedical factors at play but also the dynamic psychological and sociocultural factors that influence the presentation and management of the patient.13 Therefore, each instance of case formulation is specific to the individual patient, requiring clinicians to flexibly use and potentially transform their knowledge for each case. As a result, case formulation offers a unique opportunity to explore the processes that underpin complex problem solving in clinical work. Despite the fact that case formulation is considered to be a crucial activity for many professionals, limited research has explored how clinicians formulate cases. Accordingly, the objectives of this research were (1) to understand how experienced clinicians formulate cases and (2) to use this understanding to begin to explore the broader processes involved in how clinicians solve complex problems in their daily clinical work.
We conducted a constructivist grounded theory study14,15 exploring the process of case formulation in developmental pediatrics. Case formulation is a core skill required for developmental pediatric practice16 and is a part of the daily work in this subspecialty. While clinicians must possess routine competencies to formulate many cases, frequently, they must use complex problem solving to address the unique aspects of the patient’s presentation or to manage the multiple presenting complaints that do not have a clear or simple answer. Therefore, we chose this context to explore processes in complex problem solving. The Holland Bloorview Kids Rehabilitation Hospital research ethics board approved this study, and all subjects provided written consent.
Constructivist grounded theory asserts that theories are not discovered but, rather, are constructed together by the researcher and participants. Thus, they are shaped by the researchers’ perspectives as well as by the participants’ experiences.15,17–21 Two members of the research team (A.A.K., A.O.) are developmental pediatricians familiar with the process of case formulation, and the third member (M.M.) is an education researcher whose focus is adaptive expertise. Thus, we brought both theoretical and clinical perspectives to bear on our data as we evolved our theory of case formulation as an instance of complex problem solving.
We chose to interview a purposeful criterion sample22 of physicians, in practice for more than five years, from the Division of Developmental Pediatrics at the University of Toronto, to explore their process of case formulation. By interviewing individuals who had several years of direct experience in case formulation and who have taught case formulation to others, we hoped to maximize the likelihood that participants had been involved in thinking about or discussing this process. We also interviewed a theoretical sample23 of new graduates and residents to test and develop the theory we were constructing. Theoretical sampling is conducted during data collection and analysis to expand the theory being generated through the use of purposeful sampling aimed at illuminating variations and identifying gaps that require further exploration.17 By comparing and contrasting new graduates’ and residents’ perspectives with those of the experienced clinician participants, we sought to develop a deeper understanding of case formulation in experienced clinicians rather than specifically exploring novices’ process of case formulation.
Between July and December 2012, we conducted 45-minute semistructured interviews with participants, using a semistructured interview guide to explore participants’ views on case formulation. Participants were asked for a definition of case formulation, how they formulate cases, how the process compared and contrasted with that of a differential diagnosis, and how it linked to case management. The interviews were audiotaped and transcribed. During data collection, we concurrently analyzed the interview transcripts using a constant comparative approach.24 New transcripts were iteratively compared with themes identified in previous transcripts. We also revised the interview guide during data collection to expand and refine newly identified themes. In subsequent interviews, we purposefully explored examples from the data that did not support or that contradicted our emergent themes.25 We continued to interview participants until no new themes were identified.24
We entered our data into a qualitative data analysis software program (NVivo 10; Doncaster, Australia) to facilitate collaboration and organization of the data. Interview transcripts were reviewed independently by each team member and then together by the whole team. Consistent with a constructivist grounded theory approach,14,15 the analysis was both inductive and deductive. Using constant comparative analysis, each team member explored the data inductively for emergent themes; we each also used our experiences and existing theories and literature on case formulation, complex problem solving, and adaptive expertise as lenses to deductively explore the data. We discussed preliminary themes at group meetings until we agreed on a stable thematic structure. The thematic structure then was applied to the entire data set by one researcher (A.A.K.). In NVivo10, we maintained a detailed audit trail26 consisting of notes from team meetings, codes from various stages in data analysis, and serial versions of the data coded.
We interviewed 12 participants—9 experienced clinicians and 3 novices (new graduates and residents). Experienced clinician participants defined case formulation as a clinical reasoning27 process that focuses on the patient’s problem. Information is comprehensively and systematically collected, then integrated and synthesized into a succinct explanation of why the patient is presenting with this problem. Participants articulated three interconnected themes that underpin 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.
Theme 1: Interpreting individual patient factors in the context of medical and clinical knowledge
Experienced clinician participants described the importance of linking their medical and clinical knowledge with the individual patient’s story. The details of each patient’s presentation vary, and, as these are incorporated, they make the formulation unique to each patient assessed. One participant commented:
You can use the common path of physiology and anatomy to make a fairly educated guess as to what kinds of problems they may have, but each individual has specific unique features with respect to their development and their function.
In developmental pediatrics, information is rarely collected directly from the patient. Individual patient details often are gathered from the perspective of another person (e.g., a parent, a teacher, a therapist). The information gathered is not “black or white” but is colored by the individual presenting it. The clinician then must interpret this information with what he or she observes independently as well as what he or she knows clinically. Another experienced clinician participant commented:
In developmental pediatrics, a lot of it’s subjective, so observations of behavior, history of developmental milestones, and parents’ perceptions of behavior and teachers’ perceptions of behavior, which is all fairly gray, right?
Resident and new graduate participants did not mention the importance of integrating and interpreting individual patient details in the context of their clinical knowledge to arrive at a formulation that best explains the patient’s presentation. However, experienced clinician participants recognized that these aspects are key in the co-construction and communication of the case formulation as the formulation must be shared with others, in particular, with the child’s family who may or may not share the same understanding of the child’s problems.
Theme 2: Strategically co-constructing the case formulation with parents and team members
Experienced clinician participants described a constant checking back and forth between what they were thinking and what the parents and other team members thought. This reciprocal process of exploring others’ views allows the clinician to co-construct the case formulation with the parents and other team members, thereby negotiating a shared understanding of the child. This process starts, as one participant explained, by exploring the concerns of everyone involved in the child’s care.
So, formulation isn’t just a differential diagnosis and showing it back to people. It’s saying, okay, how does the formulation that you make explain what the parent’s and the school’s and the doctor’s concerns were when they arrived at your front doorstep.
Novice participants, however, discussed formulation as a way of developing an impression that was heavily focused on making a diagnosis. They did not describe formulation as being strategically co-constructed through exploring the perspectives of others involved in the care of the child, but rather, they saw it as a means of convincing others to see their point of view by providing enough evidence.
You’re trying to explain it, either verbally or in a letter, in a way that leads parents, health care professionals, and other people to see how you came to that diagnosis, so that they understand your thinking and hopefully, believe it by the time that they get there.
To create a shared understanding of the child with the family or team member, experienced clinician participants also used a number of strategies to communicate the formulation. One participant commented on an approach used when sharing a diagnosis of autism with parents. This clinician establishes that the parents also see that lack of pointing and decreased eye contact are important features in an autism diagnosis to help the parents understand and agree with the diagnosis.
So, if I’m explaining that I see their child doing something, like not always using pointing, or not always using eye contact, then I ask them is this something that you see with your son or daughter at home and that helps too and then we can kind of be on the same page about some of the things.
Another experienced clinician participant commented on the constant adjustments that are made in communicating the formulation based on the reactions observed in the parents.
So you really have to look at both parents’ faces, both parents’ reactions. Are they with you, are they not with you. Are they so anxious that they’re not listening or can you get them kind of to the point of being with you in terms of saying, yeah, we saw that, you saw that, this is what this means, that’s what that means.
In this way, physicians attempt to bridge their clinical impression with the thoughts and views of the parent. At times, however, clinicians also acknowledge that a shared understanding cannot be achieved and therefore accommodate to maintain the relationship.
The other key thing I’ve learned, especially in rehab, is that although you may have a specific goal in mind when it comes to intervention, the individual and their family may not see that as a key component. Although you may still keep that in your records as a potential area of intervention and something to be addressed in future, if they’re not accepting of it, it’s not going to move anywhere.
Maintaining the relationship between clinician and patient is important when working with children with disabilities because of the chronic nature of the issues being addressed. It allows the physician to continue collaborating with the family and team over time.
Theme 3: Refining the case formulation over time
Experienced clinician participants commented that case formulation is a longitudinal process requiring iterative review and integration of new information. When caring for individuals with chronic conditions, the patient’s disease may progress or his or her disorder may evolve, resulting in the development of new problems that require a revision of the formulation.
It’s almost like you have a separate formulation for why the child was the way they were at different times in life.
Participants also commented that the case formulation may change in response to new information. By maintaining the relationship, the physician uncovers information that was not accessible in previous meetings. One participant explained:
Sometimes you find out after the fact that parents were taking drugs, or there was some environmental disruption, like some family crisis that you didn’t actually know about at the time, so you didn’t include that in your formulation and you find out about it six months, a year later. And, of course that explains why there was a particular problem at that time. So, it may completely change your formulation.
With this new information in hand, the formulation is iteratively reviewed and generates a greater understanding of the patient’s presentation that is built on previous interpretations. As one participant described:
We understand more about an individual as time goes by, you’re collecting more data all the time, you can build on what the previous person did, and there may be new evidence that comes to light.
Novice participants did not comment on these longitudinal and dynamic aspects of case formulation. Although they reported using case formulation each time they see a patient, they did not specify that the formulation may change over time. By observing and reflecting on these changes, the physician builds his or her knowledge of clinical outcomes and care management strategies.
Experienced clinician participants commented on time being an important factor in their learning.
Actually following them over time, because often our patients are the best teachers because they show you, over time, what the problem is, what the reason is, and what the solution’s going to be.
In this way, the longitudinal refinement of the case formulation allows the clinician to further develop his or her understanding of the patient, as well as to expand his or her own learning and experience over time.
Case formulation is a skill that involves clinical reasoning at its core; however, our results suggest important interpretive, strategic, and longitudinal processes that enable clinicians to bridge their internal thought processes with the perspectives of the patient and the team with whom they interact. Clinicians interpret the case formulation within the individual patient’s story, strategically co-construct it with others, and refine it over time. This fluidity is important in determining how clinicians will use case formulation in their daily clinical work and seems as crucial as the clinical reasoning skills used to develop the case formulation itself. We have argued that case formulation can be understood as an instance of complex problem solving, a process at the core of adaptive expert practice. Thus, our results can be seen as an elaboration of how the processes that underpin adaptive expertise are used in daily clinical work. In particular, our findings point to the integrated competencies that clinicians use as they solve complex problems.
The importance of integrating competencies during clinical practice increasingly has been recognized.3 In studies of expert practice, research has shown that renowned physicians’ perception of diagnostic expertise also requires an integration of multiple competencies involving more than just the medical expert or knowledge for practice role.8 Moreover, the communication of clinical reasoning has been described as a complex, dynamic, and fluid process that requires the clinician to employ skills, such as active listening, thoughtful framing, and presenting of the message, to match the needs of the co-communicator.28 Thus, communication increasingly is being understood as “an inherent part of reasoning.”28
In our research, we moved beyond an articulation of the importance of the integration of competencies and elaborated the ways in which clinicians perceive and describe this form of integration as they solve complex problems. In case formulation, clinicians bring together multiple sources of knowledge to construct an understanding of their patient’s problem: their medical and clinical knowledge, interpretations of the patient’s story, and iterative reflections over time. To gather and strategically combine these potentially diverse sources of knowledge, our findings suggest that clinicians must integrate multiple competencies to negotiate the development of the case formulation with numerous audiences. Specifically, our participants described case formulation as a process of collecting and interpreting information from various sources (patient care, interprofessional collaboration), which is integrated with clinical knowledge (knowledge for practice) and is communicated strategically with the patient and parents (interpersonal and communication skills).29 Understanding the processes of complex problem solving and articulating them within the existing competency frameworks provides an opportunity for educators to more effectively identify, foster, and assess this form of integration.
One of the key features of case formulation that makes it an instance of complex problem solving is the variability between patients: Each case is unique in its features and context and therefore requires flexibility and innovation. This form of variability can be interpreted as context specificity in clinical reasoning30—the understanding that physician, patient, and encounter-specific factors interact to influence the clinical outcome. Whereas context specificity can explain how the case formulation varies with each patient and the specifics related to that situation, our results demonstrate that experienced clinicians consciously use integrative processes to navigate through context. In particular, the description of “checking back and forth” between the clinicians’ cognitive representations of the case and those of the other participants requires the use of integrated competencies to strategically co-construct the case formulation within the unique context of that patient, family, and team.
Importantly, novices seem to struggle in learning and mastering case formulation.31 In our study, new graduates and residents discussed case formulation as a more routine process, focused on making a diagnosis and providing a global impression, rather than as a flexible process requiring the use of multiple, integrated competencies. Further exploration of case formulation in novices is necessary to fully understand the development of complex problem solving; however, the importance of integrating competencies may not be explicitly addressed in our teaching. As educators, we will need to find ways to teach and promote the development of integrated Accreditation Council for Graduate Medical Education competencies in our trainees.3
We may meet this challenge both by broadening the discussion of complex problem solving in medicine to involve not only clinical reasoning but also the diversity of perspectives that must be gathered and strategically negotiated with real patients in real practice and by exploring the integration of competencies that underpins these processes. Studies investigating how students develop these integrated competencies and the teaching methods that are effective in achieving this mastery will inform and improve current curricula.
There are limitations to this study. We included a small sample of clinicians from a single discipline at a single institution. A larger study involving multiple professionals who use case formulation (e.g., psychiatrists, clinical psychologists) working in other institutions will provide a broader perspective on the processes involved. In addition, we focused on participants’ perspectives on case formulation. Future studies using direct observation of clinicians in clinics and on the wards may further advance our understanding of how these processes are enacted in real practice. Finally, we could not fully explore the development of complex problem solving in novices in our small theoretical sample of new graduates and residents in developmental pediatrics.
In conclusion, studying case formulation, a daily clinical activity, allows us to examine the processes involved in complex problem solving—in particular, the ways in which clinicians integrate multiple competencies. Further exploration of how medical students and residents develop complex problem-solving abilities and the pedagogical methods that promote the integration of the competencies necessary for clinical practice may be valuable in helping medical educators point trainees toward adaptive expertise.
Acknowledgments: The authors wish to thank Dr. Ilene Harris for her valuable input on earlier drafts of the manuscript.
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