Sabena Jameel, a GP and Associate Dean for GP Education based in Birmingham, talks about her current PhD studies looking at the intellectual virtue of Phronesis (Practical Wisdom) as it relates to medical education and work as a GP.
Wednesday evening, and I am sitting on the side-lines of the dojo watching ‘the Master’ sow seeds of wisdom to my six year old son. The Tae-kwondo teacher is speaking about the belts he has to progress through in order to attain mastery.
“These mark your wisdom” he says, “treat them with respect”.
Fast forward to my other world (GP Education) and I saw a connection; Competence, Capability and Phronesis are like belts. Completing speciality training is not the end of learning journey, in fact it is probably just the beginning.
To me, the ultimate CPD is to seek what it means to be a wise doctor. To do the right thing, at the right time for the right person, whilst keeping societal flourishing in mind and attending to one’s own well-being (Eudaimonia). This concept is described as Phronesis (Practical Wisdom) by Aristotle. Yes, that’s right Aristotle, the son of a physician from 2500 years ago!
Phronesis is an intellectual virtue that adjudicates moral virtues. It has an executive function when moral virtues conflict e.g. honesty versus compassion. It lends itself to situations which are unpredictable and ambiguous. Phronesis seems particularly suited to the work of the General Practitioner, where uncertainty prevails. The dominant positivist approach to the practice of medicine operates on a level of predictive probability guiding the clinician’s knowledge. We know that the rules don’t always fit and the guidelines are often step removed from the real world. General Practice defines itself in terms of relationships, where knowledge is co-constructed and is specific to the circumstances at hand. Alasdair MacIntyre developed these ideas further in his work “After Virtue”, he speaks of Phronesis as a broader concept in holistic professional development.
Phronesis is rooted in Virtue Ethics, an undervalued moral framework in Healthcare education. The moral frameworks that dominate medical education and healthcare are rules-based code ethics (Deontology, Consequentialism and more recently Libertarianism). The code-rules based ethics have no doubt revolutionised medicine (EBM, Quality standards etc.) but I believe it can only get you so far, and we end up with reductionist targets and hidden curriculums as unintended outcomes, sometimes with deleterious consequences.
Phronesis captures not only the essential, well-emphasised cognitive aspects of professional practice, but it highlights the importance of the agent’s affective (character) and reflective abilities. These three elements have been repeatedly emphasised in more general literature on wisdom development and attainment.
“There are three ways in which we learn wisdom, the first is by reflection which is the noblest, the second is by imitation which is the easiest, and the third is by experience which is the bitterest” Confucius
So, the cynics will now be thinking “character education?”, “Professional virtues?” How is it possible to educate for this with so much moral pluralism in society? Agreed, but we are talking professional virtues and we already have set standards in good medical practice. I think the key here is to nurture a growth mind-set (Dweck) in learners, moving away from the fixed mind-set that plagues competitive courses and careers. We need to talk about professional virtues, benchmarking against each other in supportive environments.
How do we know what a Phronimos looks like? Rodger Neighbour suggests, “We will know it when we see it” (The Inner Physician). Aristotle defines them as attaining the golden mean, which is a path of moderation between two extremes (e.g. Sentimentality…..COMPASSION…..Detachment).
We face huge challenges, but not insurmountable. We know how important it is to be a reflective practitioner, but the wielding axe of legalism comes in, and doctors are scared to reflect candidly in their learning portfolios in fear of being sued. We are time-starved, with stress levels hitting an all-time high for many. To me these are indicators that we need to do something, we need a paradigm shift.
The bottom line is that there are so many unanswered questions, and the only way we will come closer to understanding and maybe even achieving a ‘Phronesis belt in Medical Practice’, is if we take the concept seriously and study it. That is why my PhD aims to look at enacted Phronesis in General Practitioners.
“The best doctor is also a philosopher” Galen.
About Dr Sabena Jameel
Dr Sabena Jameel BMBS, BMedSci, M.MedEd, FRCGP is a General Practitioner in Aston, Birmingham and Associate Dean for GP Education (Health Education England West Midlands). She is also a GP Appraiser for NHS England. She is a third year PhD Candidate at the Jubilee Centre for Character and Virtues, part of Birmingham University School of Education. She is committed to highlighting the importance of the meta-cognitive aspects of learning and developing empirical research that enables professional virtues and values to be developed in Medical Education.
Online module on Character in Medicine:
US Undergraduate Phronesis project: