Operationalizing Clinical Competence among Occupational Physicians: Three Domains and Five Cross-Cutting Processes Identified by Reflexive Thematic Analysis.

Introduction: Occupational physicians (OPs) in Japan share a common medical foundation with other clinicians, but they primarily work in advisory and preventive settings. How this medical foundation is recontextualized and operationalized as clinical competence in everyday occupational practice remains underexplored. Clarifying this process may help to better understand how biomedical reasoning is applied to workplace decision-making beyond diagnosis and treatment. Methods: We conducted a qualitative study using reflexive thematic analysis (RTA) of semi-structured interviews with 12 OPs in Japan. Braun and Clarke's six-phase framework guided iterative coding, theme development, and interpretive synthesis. Credibility was enhanced through reflexive, iterative analytic procedures. Results: Analysis identified three interrelated practice domains: (1) statutory occupational health duties, including fitness-for-work and return-to-work judgment, (2) advice and negotiation with stakeholders, and (3) individualized support and follow-up, and five cross-cutting processes: role adaptation, reinterpretation of prior clinical expertise, responsiveness to legal and organizational contexts, collaborative negotiation, and reflective learning. Across these domains, OPs selectively mobilized clinical knowledge to address often undifferentiated health concerns, translating biomedical reasoning into context-sensitive judgments, advice, and coordination under workplace constraints. Despite substantial variability in how clinical competence was understood, recurring operational patterns were observed across participants' accounts. Conclusions: Clinical competence in occupational medicine was not defined by fixed standards or uniformly shared expectations. Nevertheless, practice remained operationally coherent through recurring patterns across three domains and five processes, through which OPs selectively mobilized and translated clinical reasoning in response to role-related, organizational, and regulatory demands. Rather than prescribing a single competence standard, these findings provide an empirical basis for understanding how general medical training is adapted for preventive and advisory practice in occupational health, and may inform reflective, case-based learning in heterogeneous training settings.