Navigating Challenging Conversations: The Interplay Between Inquiry and Knowledge Drives Preparation for Future Learning.

Introduction: While some physicians hone their skills through informal learning in clinical practice, others do not. There is a lack of understanding of why some physicians seek improvement and how they use the workplace context to build their capabilities. Because physicians rarely pursue formal professional development activities to improve communication skills, examining physician-patient communication offers a powerful opportunity to illuminate important aspects of preparation for future learning in the workplace. Methods: This qualitative observational study involved over 100 hours of observation of eight pediatric rehabilitation physicians as they interacted with patients and families at an academic teaching hospital in 2018-2020. Detailed field notes of observations, post-observation interviews, and exit interviews were the data sources. Data collection and analysis using a constructivist grounded theory approach occurred iteratively, and themes were identified through constant comparative analysis. Results: Through their daily work, experienced physicians employ 'habits of inquiry' by constantly seeking a better understanding of how to navigate challenging conversations in practice through monitoring and attuning to situational and contextual cues, taking risks and navigating uncertainty while exploring new and varied ways of practicing, and seeking why their strategies are successful or not. Discussion: Engaging in communication challenges drives physician learning through an interplay between habits of inquiry and knowledge: inquiry into how to improve their communication supported by existing conceptual knowledge to generate new strategies. These 'habits of inquiry' prompt continual reinvestment in problem solving to refine existing knowledge and to build new skills for navigating communication challenges in practice.

Examining the Impact of Dialogic Learning on Critically Reflective Practice.

PURPOSE: While research is beginning to reveal the potential of dialogue in sparking critical reflection (critically reflective ways of seeing), additional research is needed to guide the teaching of critical reflection toward enabling critically reflective practice (critically reflective ways of seeing and doing). An experimental study was conducted to investigate the impact of dialogic learning on critically reflective practice, compared to discussion-based learning. The dialogic intervention integrated the theory of Mikhail Bakhtin with the theory of critical reflection and critical disability studies. METHOD: In interprofessional groups of 4, medical, occupational therapy, and speech-language pathology students were randomly assigned to a learning condition that used a reflective discussion or critically reflective dialogue about a pediatric patient case. All participants were then randomly assigned a clinical report for a novel pediatric patient and asked to write a hypothetical clinical letter to the child's school. Hierarchical logistic regression models were constructed to estimate the probabilities of sentences and letters being critically reflective. RESULTS: The probability of sentences being critically reflective was significantly higher for the dialogue condition (0.26, 95% CI [0.2, 0.33]), compared to the discussion condition (0.11, 95% CI [0.07, 0.15]). Likewise, the probability of letters being critically reflective was significantly higher for the dialogue condition (0.26, 95% CI [0.15, 0.4]), compared to the discussion condition (0.04, 95% CI [0.01, 0.16]). In both conditions, the probability of a letter being critically reflective was positively associated with the proportion of critically reflective sentences. CONCLUSIONS: The results demonstrate dialogic learning prepared students to enact critically reflective practice when writing mock clinical letters. Students who participated in a dialogue engaged in a collaborative process of critical reflection and subsequently applied that way of seeing in the individual act of writing a letter. This study highlights how Bakhtin's theory of dialogue can advance critical pedagogy.

Integrating competencies: exploring complex problem solving through case formulation in developmental pediatrics.

PURPOSE: 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. METHOD: 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.