The concept of the jigsaw puzzle emerged from discussions between a small group of family physicians with an interest in respiratory care. To test and refine it as a diagnostic clinical practice and teaching concept, a multidisciplinary group of 20 primary care asthma experts from 14 countries was convened. The group included family physicians, a nurse, two pharmacists and adult and paediatric asthma specialists (Table 1). An in-person facilitated workshop was held over 2 days during the world conference of the International Primary Care Respiratory Group, followed by online consultations.

A three-round modified nominal group technique was used during the workshops12, conducted in English. This used an adapted teaching method also known as the jigsaw teaching method (Fig. 1)13 to facilitate collaboration and consensus building. Drawing on international expertise enabled content to reflect asthma diagnosis in a variety of settings, envisaging adaptation of the teaching concept across different language and resource contexts.

The asthma diagnosis, jigsaw puzzle development process.

Prior to the workshop, the faculty categorised the asthma diagnostic process into four domains: presenting symptoms, physical examination and investigations, predisposing factors and precipitating factors, informed by case formulation used in biopsychosocial approaches14. Participants were advised that the goal was to build an asthma jigsaw puzzle. For Assignment 1, participants were allocated to one of the domain groups based on role, country and area of expertise. Each domain group was invited by the facilitators to discuss and agree on the most important factors—jigsaw pieces—in their domain which were described using the ‘why/how/when/who’ framework to justify inclusion (Box 1).

During the workshop, the original terms “predisposing factors” and “precipitating factors” (i.e. what prompted the presentation) were revised following vigorous debate. The final categorisation of domains was clarified as follows: Presentation, history, symptoms and physical examination and objective tests, to ease understanding of the multi-national primary care audience.

In Assignment 2, participants were each asked to move to a different table so that all four domains were represented at each table. Participants advocated for their jigsaw pieces, duplicates were prioritised and by consensus placed in the most relevant domain.

For Assignment 3, participants came together as a whole group, presenting and agreeing the final puzzle pieces required to construct a complete jigsaw puzzle. This final stage was led by two facilitators, one ensuring that all groups had the opportunity to speak, the other ensuring clarity and accuracy of language for each item of content and related descriptors.

A video summary of these stages can be seen here.

Following the in-person workshops, expert participants were invited to form a writing group. This group met three times. There was consensus that the metaphor of a jigsaw puzzle would be a helpful educational and teaching concept. The group decided that key outputs from the workshop should be a desktop helper, a practical two-page guide for global primary care and at least one peer-reviewed publication that explained the process. A sub-group finalised the desktop helper and, after trial and error, chose a famous image to illustrate the jigsaw puzzle metaphor as shown in Fig. 2.

Using a jigsaw puzzle metaphor to facilitate the diagnosis of asthma in primary care.

Descriptor

Descriptor details

‘Occupation’ as an example jigsaw puzzle piece

Why

Why is the content/piece of information important for decision making?

1 in 6 cases of new onset asthma are caused by work exposure16

How

How could the content/piece of information be obtained? For example: by questioning, observation, examination, or requesting an investigation.

Ask nature of work, appreciate high risk jobs; are symptoms work related and/or better on days off or on holiday?

When

When might this content/piece of information be sought? For example: at the first consultation, at all consultations, at the annual review, at exacerbations.

At every visit and/or if change in work circumstances.

Who

Who or from whom, would this content/piece of information be sought? For example: from the patient themselves, from the parents or carer of the patient, from previous medical records.

From all of working age (16+ years)