Medicine, Health Care and Philosophy (2024) 27:165–179
https://doi.org/10.1007/s11019-024-10198-8
SCIENTIFIC CONTRIBUTION
Discovering clinical phronesis
Donald Boudreau1
· Hubert Wykretowicz2 · Elizabeth Anne Kinsella1
· Abraham Fuks3 · Michael Saraga4
Accepted: 21 January 2024 / Published online: 7 March 2024
© The Author(s) 2024
Abstract
Phronesis is often described as a ‘practical wisdom’ adapted to the matters of everyday human life. Phronesis enables
one to judge what is at stake in a situation and what means are required to bring about a good outcome. In medicine,
phronesis tends to be called upon to deal with ethical issues and to offer a critique of clinical practice as a straightforward
instrumental application of scientific knowledge. There is, however, a paucity of empirical studies of phronesis, including
in medicine. Using a hermeneutic and phenomenological approach, this inquiry explores how phronesis is manifest in
the stories of clinical practice of eleven exemplary physicians. The findings highlight five overarching themes: ethos (or
character) of the physician, clinical habitus revealed in physician know-how, encountering the patient with attentiveness,
modes of reasoning amidst complexity, and embodied perceptions (such as intuitions or gut feeling). The findings open a
discussion about the contingent nature of clinical situations, a hermeneutic mode of clinical thinking, tacit dimensions of
being and doing in clinical practice, the centrality of caring relations with patients, and the elusive quality of some aspects
of practice. This study deepens understandings of the nature of phronesis within clinical settings and proposes ‘Clinical
phronesis’ as a descriptor for its appearance and role in the daily practice of (exemplary) physicians.
Keywords Phronesis · Clinical practice · Practical wisdom · Exemplary physicians · Qualitative research · Hermeneutic
inquiry
I have to make tough decisions with little information… it’s the nature of the beast.
A quote from a physician participant.
Donald Boudreau
donald.boudreau@mcgill.ca
Introduction
Hubert Wykretowicz
hubert.wyx@gmail.com
Phronesis is a concept that can be traced to Aristotle’s
Nicomachean Ethics. In Aristotle’s view, it is a way of knowing and acting practically in the world. It is often described
as a ‘practical wisdom’ adapted to the issues of daily human
life. It is contrasted with abstract reasoning, such as pure
mathematical (episteme) or philosophical (sophia) thinking.
Phronesis relies on a capacity to navigate between general
rules and the particulars of a specific situation. A person
endowed with phronesis, the phronimos, is able to judge
what is at stake in the situation, what means are required to
bring about a good outcome and, indeed, what constitutes
a good outcome. In the Nicomachean Ethics, phronesis is
necessary to recognize and marshall a set of moral virtues,
such as bravery, generosity, truthfulness or justice, relevant
Abraham Fuks
abraham.fuks@mcgill.ca
Michael Saraga
Michael.saraga@chuv.ch
1
Faculty of Medicine and Health Sciences, Institute of Health
Sciences Education, McGill University, 1110 Pine Avenue
West, H3A 1A3 Montreal, Canada
2
Centre Hospitalier Universitaire Vaudois, Av. de Beaumont
23, 1011 Lausanne, Switzerland
3
Department of Medicine, McGill University, 3647 Peel
Street, H3A 1X1 Montreal, Canada
4
General Psychiatry, Centre Hospitalier Universitaire Vaudois,
Route de Cery 60, 1008 Prilly Lausanne, Switzerland
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to a given situation. Moreover, phronesis is a ‘know-how’,
i.e., the ability to execute the appropriate action, in an
appropriate way, and at the opportune time. Fredrik Svenaeus described the concept as follows: “Phronesis, though
not a moral virtue in itself in Aristotle’s philosophy (such as
courage or temperance), is accordingly the ability to judge
the right end of action in a particular situation and make
a wise choice.” He concluded that “Practical wisdom and
moral virtues are therefore mutually reinforcing traits.” For
Aristotle, this know-how is grounded in the dispositions of
the phronimos, nurtured and honed by experience “in concrete, practical matters of life” (Svenaeus 2022, 133–134).
Phronesis has been re-contextualized by numerous philosophers and social scientists, notably within a broader
“turn to practice” (Bondi et al. 2011; Ellett 2012; Flyvbjerg
2001; Nicolini 2013). Hans-Georg Gadamer (1977) focused
on phronesis as manifest through hermeneutic understanding
and as a foundation of moral knowledge. Dunne (1993) contrasted phronesis with other modes of intellectual endeavors,
notably techne, a reasoning aimed at a craft that results in
the fabrication of an object (e.g., a house) or the production
of a state of affairs (e.g., a safe journey). MacIntyre (1984)
conceived of phronesis as enacted and revealed through
specific practices. The conceptual landscape of phronesis
has been explored in a variety of disciplinary fields (Kinsella and Pitman 2012), including education (Kristjánsson
2007), politics (Cameron 2018), law (Longan et al. 2020),
and nursing (Jenkin et al. 2019; Flaming 2001).
Because phronesis guides decisions and behaviours in
matters of human conduct and because medical practice
requires careful and judicious conduct on the part of physicians, one would expect links to have been made between
phronesis and clinical medicine. Phronesis in medicine tends
to be invoked on the basis of two premises: that medical
practice is a moral enterprise and that reasoning in clinical
situations requires a distinct mode of rationality. Arguments
based on the former line of logic have been developed and
championed by Edmund Pellegrino and David Thomasma
(1993). They view medicine as a unique human activity, the
features of which are discoverable through its telos. In their
opinion, the knowledge and personal attributes of the physician needed to fulfill the demands of that telos aggregate
under phronesis. They consider phronesis the indispensible
intellectual virtue for medical practice, one that integrates
the moral virtues. Indeed, numerous authors have suggested
that phronesis represents a paradigmatic approach to the
understanding and teaching of clinical ethics (McGee 1996;
Carnevale 2007). The rationale underlying this proposition
may not be surprising given that Aristotle, himself the son
of a physician, used the medical analogy extensively in
developing his theory of ethics as a practical science (Jaeger
1957). A consequence of foregrounding ethical deliberation
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D. Boudreau et al.
is that the body of empirical literature on phronesis in medicine, which is relatively small, reflects a predominance of
analytic studies focused on ethical dilemmas (Paes et al.
2019; Torjuul et al. 2005; Kotzee et al. 2017; Jameel 2022).
A second justification for exploring the role of phronesis
in medicine is epistemological and is grounded in hermeneutic explorations of the illness experience, the clinical
encounter, and clinical understanding. If one considers
medical rationality as interpretive, then the pertinence of a
practical rationality, one that incorporates moral commonsense, becomes obvious. This has been advanced by GatensRobinson (1986) and Widdershoven-Heerding (1987) and
further elaborated by Montgomery (2006), Kaldjian (2014),
and Svenaeus (2022). Pellegrino and Thomasma (1993)
described how clinical judgement requires practical wisdom. Kaldjian extended that supposition by suggesting that
clinical judgement is itself constituted by practical wisdom.
Svenaeus (2022) explored the nature of good medical practice, focusing on differences between understanding and
explanation. The former is described as follows: “To understand in medicine from the doctor’s point of view implies
to be understanding, which means attempting to put oneself
in the patient’s situation. This bridging takes place through
empathy, guiding and assisting clinical understanding, but
the empathy does not exclude a critical, productive distance,
since the doctor’s understanding belongs to a professional
horizon manifesting a specific kind of medical interpretation” (Svenaeus 2022, 160).
The body of literature on phronesis is overwhelmingly
theoretical in nature. Phronesis, as enacted in medical practice (and, for that matter, in other domains) has only recently
been examined on the basis of empirical data and as noted
above, primarily with a focus on moral adjudication. We cite
four research programs that have resonance with the aims
of our inquiry. A cross sectional study by Jameel (2022)
explored how phronesis was manifested in the family medicine practices of 16 exemplary physicians. Jameel conceived
of phronesis as a constellation of 34 constitutive elements,
using a school of fish as a visual metaphor to represent
the concept. The result is intricate and somewhat abstract.
Another exploration of practical wisdom was undertaken
by a research group at the University of Birmingham. The
motivations, rationales, findings, and outcomes of this multiphased program are summarized in a final report (Conroy
et al. 2018). This work was part of a broader program of
research (Kotzee et al. 2017; Malik et al. 2020) focused on a
‘deliberative’ interpretation of phronesis, namely the structure of ethically wise decision making. The research was
conducted with a deductive approach to analysis, based on
the ‘goals of medicine and goals of care’ framework proposed by Kaldjian (2010). A third study, this time with a
social constructivist frame and an inductive approach, with
Discovering clinical phronesis
similar goals of understanding decision making in the face
of ethical dilemmas, was conducted by Paes and colleagues
(2019). A fourth paper, recently published by Lauris Kaldjian and colleagues (2023), investigated practical wisdom in
medicine as understood by medical students and physicians.
Using a highly structured study design, incorporating both
inductive and deductive approaches, they found that participants conceived of phronesis as a virtue that is “deliberative, goal-directed, context-sensitive, integrated with ethics
and marked by integrity and the motivation to act.”
The research we present below differs from these previous inquiries in two respects. First, we privileged in-depth
interviews with an iterative inductive approach to analysis.
Second, we focused on physicians’ usual practices rather
than decision making confined to ethically challenging clinical situations.
We set out to explore the nature of phronesis in quotidian
clinical practice. We did so by examining empirical material
gathered from exemplary and experienced clinicians who
discussed their work in interviews intended to understand
their medical work. We searched for instances of phronesis
in order to describe its dimensions and importance in clinical medicine.
Methodology
This paper stems from a re-analysis of a series of eleven sets
of transcripts of semi-structured interviews of physicians,
respected by their peers for their clinical excellence, and
involved in teaching medical students and residents (Saraga
et al. 2019). The participants included four women and seven
men, with a range of 13 to 40 years of post-residency clinical
experience, from the specialties of general surgery, pediatric surgery, emergency medicine, family medicine, cardiology, nephrology, obstetrics-gynecology, general internal
medicine, and psychiatry. The initial study used interpretive
phenomenological analysis and found that clinical practice
as a lived experience can be broadly described as ‘engagement’ in the clinical situation. Furthermore, we noted that
the findings pointed to phronesis as a central dimension of
the practice of these exemplary physicians. Therefore, the
research team undertook a secondary analysis of the data,
this time focused on phronesis. The aim was to elucidate the
nature of clinical phronesis and its place in medical practice.
We used a hermeneutic and phenomenological framework
for the secondary analysis (Gadamer 1977, 1996a, 1996b;
Heiddeger 1962; Jardine 1992; Kinsella 2006; Moules et al.
2015; Ricoeur 1991).
Our approach is phenomenological and oriented toward
a rich description of the human lived experience we wish
to elucidate, in this case, the lifeworld of medical practice,
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gleaned from the points of view of the physicians’ verbal
renditions. It is also hermeneutical because, as Ricoeur suggests, accessing the meaning of lived experience requires
mediation. For Ricoeur, mediation requires interpretation
of works of culture; in our case, these works of culture are
the physicians’ own narratives. In most instances, the transcripts disclose actual encounters and verbal engagements
with patients while others are stories of physicians’ actions
on behalf of patients under their direct care.
The hermeneutical approach (Gadamer 1977, 1996a;
Ricoeur 1991) assumes working within an epistemological
circle, that is, starting with a pre-understanding of what is at
stake and putting it to work when confronting the research
material. At the same time, avoiding a self-fulfilling outcome requires at least two steps. First, it involves an explicit
starting point in the tradition (Gadamer 1977); in our case,
in the works of Aristotle and Aristotelean scholars. From
a hermeneutical perspective, this pre-understanding is not
a bias, but rather a means to explore the narratives of the
physicians. Second, it depends on attending to the ‘things
themselves’, listening to what the physicians themselves
say, instead of discovering what we may already know.
We consider the concept of hermeneutics in three different though related senses. The first is the epistemological meaning of an interpretive analysis of a text — in our
case, the transcripts of the interviews that constitute our
primary research data. The second refers to an understanding of clinical medicine as a form of dialogical hermeneutic
practice. We were conscious that the testimonies of some
of our physician participants, when they gave accounts of
patient’s words, signs, and behaviours, could be construed
as, “meeting between two persons [physician and patient]
and an interpretation of the ill person’s being-in-the-world,
with the aim of restoring a life that has turned unhomelike”
(Svenaeus 2022, 91). Third, we turn to a deeper meaning
of hermeneutics, as described by Heidegger and Gadamer.
Their ontological framing of hermeneutics provides an
entry for considering the being-in-the-world of physicians.
What is underlined is the nature of the “world”, that is, the
clinician’s world, comprised of clinical situations. Clinical practice is a “being-in-the-clinical-situation”, of which
the patient is a focal point, but whose horizon encompasses
much more. In other words, the object of medicine as a hermeneutic endeavor encompasses the whole of the clinical
situation. While there is substantial literature on the lifeworld of patients, there is much less on the lifeworld of physician practitioners — the focus of our research.
We bring pre-understandings and situated experiences as
academics, theorists, and practitioners with a scholarly interest in phronesis, into conversation with physicians’ accounts
of their clinical practices. The research team brought disciplinary perspectives from medical education, internal
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medicine, psychiatry, philosophy, philosophy of education,
and philosophy of medicine. Our team has scholarly expertise with phronesis, having published manuscripts, book
chapters, and books focused on various aspects of phronesis
and professional practice (Boudreau et al. 2018); (Boudreau
and Cassell 2021); (Fuks et al. 2012); (Kinsella and Pitman
2012); (Saraga 2019); (Wykretowicz 2011).
At the outset, the research team met on three occasions
to discuss pre-understandings and interpretations of phronesis. Our work began with conversations about the scholarly
literature on phronesis and readings from influential thinkers. The team members discussed how they ‘came to’ phronesis in their scholarly work. We then engaged in dialogue
regarding the analytic focus and the research question of
the inquiry. After several iterations, the following question
emerged: How is ‘phronesis’ manifest in exemplary physicians’ stories of clinical practice?
The team met every 3 to 4 weeks over the course of a
year to discuss the transcripts; each team member read all
transcripts in depth. Throughout the process, researchers
created mind maps of key aspects of phronesis revealed in
the texts, noted excerpts from the transcripts that ‘showed’
phronesis, dissected clinical stories that revealed phronesis, and reflected on what ‘hit a chord’ during engagement
with and close reading of the texts. The initial notes from
the mind maps of each team member were collated, and
reviewed iteratively, by two subgroups, and then collectively by the whole team.
The overarching themes we identified were: ethos, clinical habitus, encountering the patient, reasoning amidst complexity, and embodied perceptions. Each of the transcripts
was revisited and coded for these themes by a research
assistant. The coded data were extracted from each transcript according to each theme. A data set of 12–20 pages
for each of the five themes was compiled from the coded
data. This served as the basis for the verbatim citations that
are presented in the findings section of this manuscript.
Our study received continuing review and approval from
the Institutional Review Board of the Faculty of Medicine
and Health Sciences of McGill University on April 18, 2021
under the IRB Study Number A04-E18-21 A (21-04-045).
D. Boudreau et al.
present the thick descriptions from the raw data in this section and follow with a detailed analysis in the discussion.
In addition, at the end of each of the thematic subsections
we provide a link between our empirical findings and philosophical concepts, notably hermeneutics and phenomenology. Finally, while the themes are presented separately, it
is important to note that this is an instrumental disentanglement, as much of the data could be placed in more than one
thematic category. The dimensions of phronesis that we
discerned in our analysis of practitioners’ accounts of their
clinical practice are inevitably intertwined.
Ethos
The physicians offered detailed descriptions of clinical
practice that revealed aspects of character, that is, what they
value, who they are as persons, and who they have become
as physicians — their ethos.
The sources shaping character were a recurrent topic of
conversation. Early experiences and role models, both parents and clinical teachers, were described. A psychiatrist
stated:
People who are good clinicians – that resonated with
me. And what went into my development so that the
role models that I had were able to impact on me. You
know it probably had as much to do with my family
and my parents as it had to with my role model physicians. (P-2).1
The same participant recalled how, when he was a teenager,
his physician was “a warm compassionate human being”
and how that was formative (P-2). Another participant discussed how lived experiences become “embedded… in your
character, in your being” (FU P-4). Similarly, a family physician stated, “Why did I end up the way I am? I guess I
blame my family, my parents, my upbringing” (P-8). And,
an emergency room physician reflected on experience and
character:
I believe this comes, again, from a cumulative experience of how you were taught to see the world by – as a
child…the people you’ve met over the course of your
lifetime who have influenced you, the books you’ve
read, you know, your humanity, your interest in other
people. (FU P-9).
Findings
Below we present the themes drawing on descriptions of
phronesis identified through sustained deep engagement
with the physicians’ accounts of practice. Our aim is to
‘show’ the data, rather than to ‘tell’ what was found, so that
readers can bring their own interpretations to the extracts
from the transcripts and see the basis of our interpretation.
As is common in qualitative research of this nature we
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Participants underscored moral dispositions as important
to good practice. For instance, clinical humility, along with
1
The interview transcripts are coded from P-1 to P-11 indicating the
initial hour-long interviews. A follow up second interview transcript is
coded FU P-1 to FU P-11.
Discovering clinical phronesis
qualities such as “understanding your own limitations,” “not
being so egotistical,” and “always trying to learn” (P-1). One
physician referred to himself as “an everyman” articulating
his ethos to “work hard” and take his job “seriously” (FU
P-2). Humility was also linked to truthfulness. A pediatric
surgeon explained, “by sense of humility, I mean to admit
your mistakes, to admit that things could have been done
better” (P-4). An internist highlighted humility as linked to
“an honest practice” stating “if I make a mistake or an error
I will admit it; if I forget to do something, I will tell them
I forgot,” and reflecting further, “and if I don’t do it, I feel
bad about myself…I hear my mother’s voice in my head
and things like that” (P-10). For some, humility was linked
to “putting the needs of the system before yours” and to
“accountability” (P-7). This was echoed by a surgeon who
described a “personal sense of accountability to people.”
With respect to its origin, she added that it “was something
I learned very early on” (P-1).
A commonly expressed element of character was a capacity for hope and optimism, which at times edged into faith.
An emergency room physician shared that “you want to
always have people around you that have hope. And in most
cases, hope is appropriate. It’s a rare case where there is no
hope” (P-9). A surgeon, dealing with a difficult operation,
explained that “it was really an act of faith. You know, just
hoping and praying that I am wrong and that, despite all my
medical knowledge, that this will still turn around” (P-4).
Others invoked the metaphor of a glass half-full: “I love
what I do; I’m enthusiastic…I think I’m a positive person”
(P-6); “if you want to look at that [glass] half empty, then
you look about all the things that haven’t worked and how
frustrating it is, but that’s not my personality” (FU P-7);
and “People say you’re always happy, you are always smiling, you always put a positive spin on everything. I really
love what I do, and I try to model that behaviour for other
people” (P-8).
The disposition of being available and responsive was
common:
If they ever called me with a problem, I was quick to
respond and maybe did a good job. …My colleagues
still, if they have a family member, a patient in distress, I will respond the same day. (P-7).
Seeing one’s work as a vocation rather than a job and wanting to make a difference was noted frequently:
These kinds of people who just see it more as a vocation than a job, which I think is what it should be,
frankly, given what we deal with on a day-to-day
basis…in the vocation, there’s a certain passion and
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intensity that allows you to extend beyond the rules.
(P-7).
A surgeon described this disposition as “a desire to be significant” (FU P-4) and an emergency medicine doctor as “I
have the opportunity to make a difference for many more
people and that’s personally rewarding for me” (P-9).
Several participants referred to conscientiousness and
attention to details, at times bordering on compulsiveness.
A nephrologist linked this characteristic to a “fear of missing something and doing something wrong” (P-3). A general
internist noted, “I guess I’m sort of a tidy person…It means
I’ve checked off my list of things to be done” (P-11), and
“I’m kind of a systematic and organized person…that sort
of helps me in taking care of patients” (FU P-11). The conclusion of this physician was, “that’s just part of the way I
was born” (P-11).
That there is a set of personal characteristics deemed to
be suited to the practice of medicine is hardly a novel proposition. Innumerable commentaries are premised on the idea
that moral dispositions are at the heart of medicine (Bryan
2009; Pellegrino 1993; Walker 2005). It is well aligned with
classical Aristotelian views of moral virtues as grounded in
the individual’s character — moralis in Latin or ethos in
Greek (MacIntyre 1984, 38). In contrast, and regrettably, the
notion of character has been supplanted by related notions
such as personality, professional duties, or the unfortunate
and incongruous entity ‘behavioural competencies’. There
is, however, general agreement on the desired personal attributes or ‘excellences’ fitted to doctoring (Boudreau et al.
2018). Our physician participants make mention of compassion, humility, truthfulness, and conscientiousness — these
often appear on lists of characteristics of the ‘good doctor’.
They also insisted on a capacity for hope; it is an aspect of
the medical ethos that is less salient in the academic literature, though perhaps not in the lay press.
Clinical habitus
Our participants described particular ways of how they go
about getting things done in their clinical practice.
A general internist underlined the importance of not
interrupting the patient prematurely: “Every visit, I try to
give [patients] a little forum at the beginning to make sure
I know what they want to talk about and try not to interrupt too soon… I make a conscious effort to do that” (P-10).
This ‘know-how’ was linked to the notion of holding off
on judgements: “You are there not to judge them…you are
there to help them with their health issues…I want people
to trust me” (P-10). A psychiatrist expressed something
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similar: “in establishing trust with patients…I take a nonjudgmental stance…I’m understanding it without judging
it” (P-7).
A family doctor conceived of his clinical work as one
of offering guidance: “My job is to be more of a guide and
a resource…to be there for them if they need me, to help
them and give them some direction, but not necessarily tell
them what to do” (P-8). Another participant expressed what
it means to ‘be there’ for patients as follows: “I’ll be there
for them…if someone is not happy about something then
I’d like to fix it. You know if someone feels like they’re in
crisis, we’re there to help [them] through it” (P-3).
Helping patients getting through clinical visits at times
required forethought and meticulous groundwork. As an
illustration, a nephrologist, anticipating a need for dialysis in the future, introduced that possibility gradually over
many prior months so that her patients “are ready by the
time they need to do this treatment.” She added that “the
manner in which it’s accepted by the person is part of your
treatment, you know” (FU P-3). This physician explains
to patients, “we need to prepare you…and we’re gonna do
things a little bit at a time” (FU P-3).
Another ‘trick of the trade’ was revealed through the
complex maneuvers sometimes necessary to make patient
visits possible. “I don’t think he ever realized to what extent
I had squeezed him into clinics that had no space, saw him
on days that I had no clinic… and if he didn’t show up to
an appointment, remade the appointment for him” (P-3).
These kinds of adaptations were described as a response to
a system that may seem broken, “things that we try to do to
accommodate for a system that doesn’t change, for things
that get lost” (P-3).
Knowing how to do things may involve setting the tone
for the clinical environment, as was vividly described by a
surgeon talking about the operating room and his role as a
“tone-setter”:
There are times in the operating room where a fatality
feeling starts to set in – that we’re going to lose this
patient, and it becomes a self-fulfilling prophecy…
I often find myself the re-setter for peoples’ tone…
Let’s focus on this…that’s one of the things I think
I do well. I don’t get all anxious and start just sort
of panicking…once a tone of panic sets in, it’s amazing how infectious it becomes…the next thing you
know…the whole team is no longer communicating;
everybody’s just in panic mode. (P-4).
One participant discussed clinical know-how as “streetsmarts”: “that’s streets-marts, right – someone who knows
– who recognizes something bad when it’s bad; something
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D. Boudreau et al.
good when it’s good; how to get out of trouble; how to not
get into trouble, you know. This exists in medicine” (P-9).
These dispositions, which we have designated clinical
habitus, are a facet of practical wisdom. The findings underscore the importance of experience in their development.
The cumulative experience shapes a set of dispositions of a
pragmatic nature that allow the physician to be “completely
geared to the demands of the situation” (Dreyfus 2014, 81)
This is a major aspect of the practical wisdom which consists of “the process of bringing a thing or situation from
unintelligibility to understanding” (Svenaeus 2022, 107).
A focus on clinical habitus reminds us that “medical practice is to be understood as a special form of understanding,
which is identical with neither explanation in science nor
interpretation in the humanities” (Svenaeus 2022, 108).
Encountering the patient
A theme, overlapping with ethos and habitus and with striking salience in our data, was the attentiveness of physicians
to the unique needs and situations of individual patients.
Participants frequently viewed patients as family and cared
for patients as they would wish a member of their own
family to be treated. As one surgeon explained, “there’s no
checkbox saying, ‘would you let this person operate on your
daughter?’ which is the bottom line, because this is what the
patients want to know when they come in at the end of the
day” (P-1). She elaborated, “I think that is often the thing
that runs through my head, ‘if it was my mother, father, husband I would want the best person possible for them’” (P-1).
“I approach patients as if they’re family members, so…if I
operated on them and they’re in the hospital, I’m not going
to let someone else look after them while they are in the
hospital; it would be me that sees them” (P-1).
The patient’s perspective and experience are at the centre of care. One physician stated, it is “the patient who has
the illness; you know, the person – the persons’ history, and
their perspective and their experience, their subjectivity.”
He went on to discuss a clinical situation where this “was
real; it wasn’t like lip service” and where patient experience
was built into “the fabric of what we did” (FU P-2).
A cocooning aspect to the clinical dyad was frequently
noted, described as “being-in-the-moment” or offering
“undivided attention.” One participant used the metaphor of
“being in a bubble,” to describe a role-model physician who
“was able to focus – have the patient focus on him, on the
process…just that attentive, active listening and questioning in a busy place, but they somehow…seemed like they
were alone” (FU P-10). This “implies that their attention
is dedicated to the person in front of them…they are able
to clear their mind and their duties for that brief period…
able to focus” (P-10). He noted this bubble of undivided
Discovering clinical phronesis
attention could occur “anywhere.” “They were able to do
it anywhere. Bedside, stretcher in the hallway…it’s not the
most private place in a busy emergency hallway but they
were able to do it there, at the bedside, in a lounge chair in
the solarium or whatever” (P-10). An emergency physician
described something similar:
You have to make sure that the patient gets the feeling that you are in that minute…you have to give the
impression that [you are] in the moment……I don’t
mean just look them in the eye……but I mean absorb
the moment that you’re with them. (P-9 and FU P-9).
Several physicians talked about “giving their all” to patients.
A cardiologist stated: “I’m your doctor, you put your trust,
your faith in me, and I’m gonna do everything I can for you,
no matter who you are”. He went on to say, “I try to give my
100%, and no matter if it’s a follow up for ten minutes, or if
it’s a new consultation, or if it’s someone – a VIP or whatever – I treat everybody the same…so it’s not very complicated, and I just give my all” (P-6).
Relatedly, the physicians’ stories offered illustrations of
respectful behaviour, such as self-introduction and referring
to the patient by name rather than disease category or hospital room number:
I made sure that every room we go in, I introduce
myself and the student and what he is here for…no
matter how busy you are, you need to introduce yourself to the patient and tell them who is in the room…I
mean, these are all very basic things, but often they’re
left undone. (P-4).
The imperative of listening to patients was a prominent
topic of discussion. One physician estimated that 75% of
patients were helped “just by listening to them”. He stated,
“you don’t actually offer any solutions. You just listen and
they say ‘thank you’ (laughs) and they go away happy. I
used to be a bit puzzled and…I didn’t solve their problem…
it might have just been that someone actually listened” (FU
P-11). “…the effort is listening – I think it’s the active listening side and finding something to latch onto in the patient’s
story… you do have to make the initial effort” (FU P-10).
“…the things that I think I attach particular importance to
are that I listen to the patients that are there. I respect them,
respect what they have to say and the manner in which they
would like to be treated” (P-3). And, “[what] I strive to do
is to be respectful to the patients, to listen to them, to treat
them as human beings, to be a nice person, to make them
feel comfortable about coming to the doctor” (FU P-6).
The act of listening was of pragmatic value: “number one
reason I made that diagnosis is because I listened” (P-9).
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Furthermore, “in that clinical bubble, you’re trying to get
at an underlying disease…[a] goal that’s very clear – and
listening for clues…is obviously the ultimate goal…” (FU
P-10).
One participant summed up his views quite simply as:
“When you’re one-on-one with your patient, you should
give them the time; listen to them; be careful not to hurt
them, not to harm them; make sure you don’t make mistakes. If you make a mistake, you tell the patient, ‘I’m sorry
I made a mistake,’ and discuss it with them” (FU P-6).
The importance of the encounter between physician and
patient is woven throughout the interview material and
represents a major feature of medicine as a hermeneutic
endeavor. Marianne Paget, in a phenomenological interpretation of clinical work, describes it as: “a practice of
responding to the experience of illness. As such, its context
is a relational encounter between persons about the afflictions of the human body and the human spirit. It is grounded
here in this relational encounter from which it typically
departs and to which it typically returns” (Paget 1988, 21).
Reasoning amidst complexity
All participants reflected on the complexity of thinking and
decision making amidst the uncertainties and contingencies
inherent in the practice of medicine. For instance, an emergency physician stated: “I have to make tough decisions
with little information with severe consequences, but you
have to make the decision…it’s the nature of the beast” (FU
P-9). A pediatric surgeon discussed the unpredictability of
clinical contexts by highlighting the absence of fixed and
immutable anchors: “one thing I know in medicine is that
there is no zero and there is no hundred – those numbers
don’t exist” (P-4). Another surgeon alluded to the “betwixt
& between” feel of practice, where clinical goals are
subject to change: “‘Get better’ is a moving target… and if
we teach our older students [that] you’re trying to restore
health, it doesn’t necessarily mean they [the patients] don’t
have an illness” (P-1).
A psychiatrist noted that his clinical reasoning was influenced by a recognition of the limitless range of patient characteristics and the incompleteness of what can be known
about patients: “You know people are complicated. There’s
lots going on. We see little bits of it. We need to know that
we’re only seeing little bits and understanding little bits and
try to understand more” (P-2).
Another psychiatrist described taking various contingencies into account in her deliberations on prioritizing admissions: “I have almost a dilemma between the patient in front
of me and the general picture of all the people waiting for
care” (P-7). She described weighing “pertinent factors” to
guide her actions:
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We kinda feel – a young person who’s never been
hospitalized, where someone who has been hospitalized ten times – if they’re equal, then the person who’s
never been hospitalized should have a chance. That
kind of decision, you know – ethical like. There are
issues like school. If they don’t get in, in June, then
they won’t get out to go back to school; so that’s a factor that gets entered in. (P-7).
Those two quotes, by psychiatrists, illustrate how clinical
thinking involved polarities. They refer to ‘lots’ vs. ‘little
bits’ and the ‘general picture’ vs. ‘pertinent factors.’ There
were multiple expressions of that nature in the accounts. A
pediatric surgeon stated: “I think it is part of our training
that we don’t just think in one arena; we look at the global
picture…Whereas, people who are just focused on their one
task, they just stay on their one task until they succeed or
fail” (P-4).
One participant discussed how she holds the big picture
of a patient’s prognosis while attending to current issues:
I always have kind of a big picture whenever I see
somebody – I have sort of an idea of what the next
weeks will be like, and what the next months will be
like, and what the next years will be like…then I kind
of whittle it down into little parts of digestible segments. (P-3).
An emergency room physician described how a student
reasoned toward a faulty diagnosis by attributing too much
weight to a few symptoms, thereby missing the forest for
the trees:
I was talking with a medical student yesterday how in
the case she saw with me – someone who was anxious,
shortness of breath and palpitations – and she thought
for sure she had a pulmonary embolism because these
are three symptoms you can get, when it was completely evident to me that she was just very anxious.
And I spoke to her that she’s seeing the individual
trees but not the big forest that made up a person, that
made up someone that is anxious. (P-9).
One participant highlighted the risk of drowning in details,
and how wise physicians mitigate information overload by
foregrounding the most salient aspects of a situation:
Sometimes patients are…very complex. They have
fifteen different issues going on and you might get
put on the list, and sometimes people just drown in
the details – and then some people have the ability to
say, ‘Okay, this fits with this, and this doesn’t fit with
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this, and this is the most important thing, and this is
the second thing’, so they can take all this morass of
detail and structure it in a way that makes the patient
manageable. (P-11).
The choreography involved in thinking about the general
aspects and the particularities of a case came to the fore
when clinicians discussed their use of algorithms. For example, a cardiologist, giving an account of his reasoning about
a patient suffering from coronary artery disease, stated:
He’s diabetic; he’s got three-vessel coronary disease.
According to the guidelines, this patient should go for
surgery. But, having seen everything that happened
with other surgeries – he’s infected everything that’s
ever been put in – and with this whole prosthesis and
all that stuff, the thought of this guy having a bypass
operation and somehow getting through it without
being put on long-term dialysis therapy…I basically
discussed with him and I said, ‘Listen, I could send
you to surgery. My feeling is that you wouldn’t be better after it.’ (P-6).
Clinical practice often proceeds in the midst of uncertainty,
complexity, epistemological confusion, and emotional
upheaval. The cardiologist’s use of the phrase “my feeling”
is revealing, undergirds the idea that clinical rationality is
more than ratiocination, is highly complex, and difficult to
characterize. Kathryn Montgomery has described medicine
as “an acquired rationality — culturally engendered, communally reinforced, interpretive, situationally sensitive and
therefore dialogic and aphoristic in character” (Montgomery 2006, 165). Clinical judgement may be conceived as
grounded in an experienced knowing and understanding; as
Gadamer contends, it is precisely an intelligence of the situation that in turn leads to wise judgement (Gadamer 1991,
36). Gadamer’s assertion that “the Aristotelian virtue of
wisdom—phronesis—is the basic hermeneutic virtue itself”
(Svenaeus 2022, p 132) could readily be applied to our
understanding of the nature of physicians’ reasoning amidst
the complexity of medical practice.
Embodied perceptions
As highlighted in the last quote, certain clinical decisions can be based on embodied perceptions, sometimes
described as “gut feelings”. A cardiologist explained: “following these gut feelings where you just feel it’s the right
way…like you’re being pushed in a certain way, that you
just need to kind of be like a leaf in the wind, and just…go
where you’re being kind of guided” (FU P-6). A surgeon
noted: “some of your movements come from a gut feeling
Discovering clinical phronesis
that is the right thing to do; some of your movements do
come from experience that ‘I’ve done this before – I’ve had
a patient bleeding from the spleen or bleeding from a large
blood vessel before’” (P-4). He described how his “gut feeling” shaped a particular case:
I did what my experience tells me to do, which is
pack that pack…yes, this is the way we do it…but in
this particular case, we need to do [something else],
we packed just enough to let the sponges absorb the
blood…to get as much of the blood out, [then] took
that out and found the vessel…and that actually
worked. (P-4).
Several participants referred to ‘instincts’ or ‘intuitions.’ A
psychiatrist stated: “I go up to see her during rounds, and
I have… you know the instinct of a physician where you
think the patient’s gonna die any second?” (P-7). Similarly, in describing a 57-year old man, a family physician
explained:
[He] met the criteria for major depressive episode
[but there was] no past psychiatric history, no family
history…no alcoholism…it didn’t fit my typical pattern…When I went through it in my mind… there was
just something inside of me that said…I call it intuition, I said deep down, there’s something wrong with
this story. (P-8).
Such a feeling can be elusive: “Sometimes …you just get
worried…he didn’t look really well…And it’s hard to actually put a finger on exactly what it is, but it’s quite striking”
(P-11).
Some participants referred to intuitive clinical impressions, for instance as being able to see the shape of a
patient’s illness or prognosis, almost as a ‘gestalt’:
I looked at her…she had a massive pulmonary embolism, and like I just saw it in her, right away. I’ve seen
that in other cases…I’m seeing the disease as a physical manifestation…I felt so much like this guy who
says he didn’t see the numbers; he saw a shape – this
was a shape I was seeing that was the shape of pulmonary embolism. (FU P-9).
Impressions of this nature were sometimes at odds with
standardized guidelines:
There are patients that may be along the algorithm
now where surgery would be recommended, that I
don’t send for surgery…because I’ve got this feeling
that they’re gonna be dead – they’re not gonna make
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it through …on paper, you’d think that that was the
right thing to do, but it’s like somehow…I just feel
that they’re not gonna make it. (P-6).
One participant commented on these types of impressions
as related to a certain clinical sense, noting that it may be
absent for some physicians:
You know, you can look at diagnostic studies…there’s
still a certain clinical sense that will never be really
quantified…there are some people…who don’t have
any clinical sense at all, who purely go by objective
data; and there are people…who just come close to a
patient’s bedside, look in their eyes, and say, ‘I think
they’ve got this’ (laughs). (FU P-4).
A number of participants described complex and ineffable
situations where, in addition to relying on gut feelings,
instincts, or intuitions, they enlisted prayers when considering what may be a desirable clinical course of action: “It’s
when we go off the algorithms that it’s a little bit more complex…and we have to rely on our better clinical judgement
or what we think is right, and you hope is right, and sometimes it’s a little bit of prayers involved” (P-6).
The recurrent comments regarding clinical sense and a
need to reconsider algorithms speaks to a form of attunement
of an experienced physician to the large array of elements
in the clinical situation, some of them not readily reducible
to objective data. As we noted before, when speaking of the
clinical habitus, clinical practice is a hermeneutic, endeavour which is so deeply embodied that its mastery is more of
a “skillful coping” than a rule-governed judgement. Dreyfus
illustrates this as follows: “when I enter a room I normally
cope with whatever is there. What enables me to do this
is not a set of beliefs about rooms, nor a rule for dealing
with rooms in general and what they contain; it is a sense of
how rooms normally behave, a skill for dealing with them,
that I have developed by crawling and walking around many
rooms” (Dreyfus 2014, 89). These observations are not tantamount to considering scientific explanatory reasoning as
irrelevant but rather to realizing that practical wisdom goes
beyond scientific reasoning. As Ricoeur would suggest, science can explain more so as to understand better (Turoldo
2018).
Discussion
Contemporary discourse on phronesis in the health professions has generally been tethered to its philosophical
underpinnings in the Aristotelian tradition and centred on
ethical decision-making. There have been few empirical
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explorations of phronesis and its enactment in the actual
lifeworld of medical practice. Our study’s intention was
to reveal and understand how phronesis is manifest in the
experiential accounts of expert physicians. Our analysis
brought to light the following elements of phronesis: ethos,
clinical habitus, encountering the patient, reasoning amidst
complexity, and embodied perceptions.
In this section we engage in further reflection on our
findings in order to elucidate the phenomenology of clinical
practice. Our study is based on the idea that a hermeneutic phenomenological lens to examine phronesis in practice
can contribute to a richer understanding of the being-in theworld of physicians. Indeed, their accounts revealed the
nature of the challenges and predicaments they face — in
particular the complexity and contingency of clinical work
— and how a prudent savoir faire helps physicians fulfill
their duties and responsibilities.
Our discussion highlights how the initial theoretical
framing of classical phronesis places the empirical findings into relief, namely: the contingent nature of the clinical
situation, a hermeneutic perspective on clinical thinking, the
tacit dimensions of practice as revealed through practical
know-how, the centrality of caring clinical responses, and a
certain “je-ne-sais-quoi” or intuitive and less tangible quality of practice. Each of these are discussed below, linking
back to the theoretical foundation and supported by numerous citations to the empirical data.
The contingent nature of the clinical situation
The clinical situations described by our participants are
characterized as complex. Complex situations in the data
were linked to “little information” (P-9), the “morass of
details” (P-11), “moving targets” (P-1), “complicated people” (P-10), “dilemmas” (P-2), and the “many arenas” (P-4)
pointing to the contingent nature of clinical practice. In
Aristotelian terms, this “contingent world” represents that
part of reality that “could be otherwise” (Aristotle 1999, 89
[1140a]). Phronesis is the mode of thinking and acting with
regard to the contingent world. Indeed, a central feature of
phronesis for Aristotle is that it is oriented toward decisions
and actions. This contrasts with the “necessary world,” i.e.,
the part of reality that must, of necessity, be as it is, therefore not requiring deliberation. Practical understanding and
action take place in the contingent world, whereas theoretical thinking deals with universal and necessary rules, for
example, mathematical propositions. Since, in our view,
clinical practice is made up of a series of clinical situations,
it is important to clarify what we mean by a ‘situation.’
Our data align with a phenomenological view that situations have three important characteristics (Heiddeger
1962; Sartre 2003). First, a situation is always more than
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an example of a generic category; rather, it is a singular set
of contingent elements facing an individual. For example,
the situation of the diabetic patient with three-vessel coronary disease extends well beyond coronary morphology
and guidelines on how to manage similar cases. Second,
the situation is not given as such to the clinician; rather, the
clinician helps shape and sharpen a reality that is blurred at
first, transforming it into a meaningful and actionable situation, what one participant alluded to as a “big picture….
an idea of what the next weeks (and) months will be like”
(P-3). Thus, the situation is not an objective given, a picture passively laid out in front. We can see it emerge from
the dynamic interplay between the clinician and the environment and its many actors. The situation is construed as
a field of affordances and hindrances; it triggers the clinician’s predispositions, disclosing possibilities, and requires
an understanding of what is at stake as well as a capacity for
taking appropriate actions (Gibson 1986; Noë 2004). Third,
clinicians envisage situations as a complex web of heterogeneous and intertwined concerns, not limited to strictly biomedical issues, but including the broader medical and social
issues at stake: the patient, most certainly, but also the family, the nurse on call, the overworked radiologist, the recalcitrant spleen, the new practice guidelines, the crowd in the
waiting room, the pressure of time, etc. These varied and
relevant aspects of medical practice have been described in
a variety of contexts. This perspective corresponds with an
understanding of practice as described by Joseph Dunne; in
contrasting the rationality of practice with technical rationality he points out that the latter pays insufficient attention
to the “socio-political, institutional, and historical matricies
within which individuals themselves are located” (Dunne
2005, 382). Similarly, Svenaeus noted that “Phronesis is not
devoid of feelings, it is rather based in feelings that help the
morally wise person to see and judge what is at stake in the
situation” (Svenaeus 2022, 135). In sum, a situation is at the
same time: (1) contingent (Aristotle) (2) emergent from a
dynamic engagement of the clinician with the total clinical
environment (Sartre 2003) and, (3) heterogeneous and complex in nature (Ingold 2021). Thus, it is not surprising that
clinical phronesis was revealed when physicians confronted
and responded to murky and challenging clinical situations.
A hermeneutic perspective on clinical thinking
Our results indicate that the clinical thinking of the phronimos is distinct from a traditional view of rationality, one
that subsumes the particular case under general laws. To go
back to the example of the diabetic patient, the cardiologist
does not simply categorize the patient as “having a threevessel disease” (P-6) and then applies the guideline of recommending surgery. Rather, what this participant describes
Discovering clinical phronesis
is a hermeneutic engagement in the situation. Clinicians
must gain an understanding of what is to be done through a
number of interpretations, whose objects include inter alia:
the patients, their past history, their environment, the clinicians’ environment, and the guidelines themselves. Such a
perspective raises a number of issues. For example, there
are limitations and constraints. Clinicians’ understandings
are always partial and there is a risk of missing something
important. As one participant said, “we only see little bits”
(P-2). It is the case that clinicians are never able to obtain
a God’s eye view—what Nagel (1986) refers to as a “view
from nowhere”—even though anonymous algorithms might
appear to provide complete clarity. Therefore, interpretive,
albeit constrained, engagement is the only way to gain an
understanding of what is at stake. In this view, subjectivity
is not a ‘bias’ that should be corrected, as a strict cognitivist
would have physicians do (Kahneman et al. 2021). Our findings suggest that the physicians’ interpretive engagement in
the multidimensional clinical situation allows them to make
sense of a messy reality: “they can take this morass of detail
and structure it in a way that makes the patient manageable”
(P-11).
Clinical thinking is not simply rational decision-making
but rather a mode of orienting oneself in the practical world,
such as resetting the “tone” of the operating room and getting everyone to focus on the task at hand. This involves
a hermeneutic back and forth between the general and the
particular. In our data, indeed, we find many different kinds
of ‘generals’ and ‘particulars’: patients and their illnesses,
the body and its parts, foreground and background, big picture and focal point, long-term and short-term, principles of
medicine and individual cases, guidelines and the demands
of the situation, best practices and systemic constraints.
Medical education can provide a series of orientation maps,
notably in the form of clinical practice guidelines and protocols. These are essential signposts for novices. In contrast,
our participants, masters of the clinical craft with a “fund
of experience in the culture” (Dreyfus 2014, 199), often
alluded to gestalts, for example, the physician who recognized “the shape” of a pulmonary embolism. Thus, this
mode of thinking is more than a form of reasoning—it is a
way of being in the world. It is a form of understanding that
flows from the physician’s attunement and an empathetic
grasp of the numerous dimensions of health, illness, and
clinical environments.
Tacit dimensions of being and doing in clinical
practice
Phronesis is not purely cognitive; rather, it is a know-how,
a mode of grasping a situation that depends essentially on
who one is (Gadamer 1971). The wise judgment, the good
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decision, and the right action are grounded in a tacit background of ingrained dispositions that are both practical and
moral. In the findings, we used clinical habitus to designate
the practical dispositions, or ‘know how’ of the clinician,
whereas ‘ethos’ referred to the physician’s personal characteristics. This distinction is somewhat arbitrary, as dispositions are themselves manifestations of the clinician’s
character. Indeed, ‘habitus’ is the Latin translation of the
Greek ‘ethos’. However, we found the distinction useful to
organize our results and for the purpose of the discussion.
Practical dispositions are capabilities that enable clinicians to grasp situations in a quasi-automatic mode and to
perceive affordances for actions. In other words, habitus
enables one to discern what is at stake and what is to be
done. In our data, the ‘what’ went beyond strict biomedical
or techno-scientific issues. To discern the ‘what’ of the situation, its crucial elements, the clinician may, for example,
invoke a “magic bubble” (P-10), pushing back on intrusive
aspects of the environment; or, rely on “street-smarts….
(to) get out of trouble” (P-9); or, parse out the situation
in smaller “digestible bits” (P-3). Such dispositions seem
to be, to a large extent, tacit and only partially conscious.
Physicians frequently talked about “gut feelings” (P-6),
“instinct” (P-7) or, “intuition” (P-7, P-8) as informing their
clinical decisions. This aligns with literature that describes
how physicians use reasoning that is automatic and that
draws on experiential inductive reasoning—in addition to
more analytic hypothetico-deductive modes of reasoning—
to inform decision making (Croskerry 2009a, 2009b; Adler
2022). According to Hubert Dreyfus and Stuart Dreyfus,
practitioners’ intuition is indicative of accumulated know
how and tacit knowledge that an expert acquires by “dealing
with, and seeing the outcome of, a large number of concrete
situations” (Dreyfus 2014, 199).
Ethos refers to the virtues of the individual, in an Aristotelian sense (Collins 1999; Deslauriers 2002; Jimenez
2016), that is, character shaped by an education embedded within a set of shared norms, beliefs and values that is
conducive to a good life. Our participants discussed several
‘clinical virtues’: humility, responsibility, a willingness to
act, and being meticulous, available, and responsive. The
good life in medicine entails good clinical practice: it may
be precisely because clinicians have developed an appropriate ethos and clinical habitus that they are able to provide
excellent care. In the material, ethos seems to be shaped by
experiences, clinical role models, and values instilled across
the life span, including parental influences and early childhood upbringing: “if I don’t do it, I feel bad about myself…I
hear my mother’s voice in my head” (P-4). Such experiences appear to become integrated and embodied in the physician’s character and dispositions.
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The connection between ethos and habitus is also manifest in the idea that medicine is more a vocation than a
job. Vocation is grounded in the physician’s character and
enacted in practical modes in the clinic: “there’s a certain
passion and intensity that allows you to extend beyond
the rules” (P-7). The participants’ embodied the values of
medicine rooted in a clinical tradition and modelled by their
teachers. The ethos is acquired through a process of socialization, in which the apprentice is willing to be transformed
by the practice, and will, in turn, transform the practice of a
clinician and teacher.
Caring clinical responses
We have discussed that phronesis deals with practical situations and outlined their characteristics. We now wish to
further describe the specific clinical nature of the situations
the participants shared with us—situations that have the
patient as a focal point. This was made visible by an array
of caring responses described by the participants. Here, we
refer to their dedication and concern for the patient and their
emotional involvement. Participants spoke of their careful
listening to the patient, thereby avoiding early interruption.
They devised creative workarounds to circumvent systemic
and institutional constraints and to deliver the quality of
care they deemed appropriate and necessary. They demonstrated an intense dedication to their patients, with accounts
that brimmed with tenderness and were often moving. Most
expressed a profound regard for patients and their life experiences. A recurring notion was that of treating patients as if
they were family members, which implied a deep personal
commitment—as stated by one participant, “I have them
and they have me” (P-9). This engaged and caring attitude is
not consistently associated with phronesis in the literature.
Notwithstanding, it is worth noting that Svenaeus (2022)
argued that phronesis incorporates a feeling component
and that this feeling component is empathy, where empathy is considered a kind of discernment — a way of seeing
the world we share with others. Hubert Dreyfus and Stuart Dreyfus, for their part, have defended that phronesis is
predicated on a capacity for a “caring response to the unique
situation” (Dreyfus and Dreyfus 2014, 199). We suspect,
indeed, that clinical phronesis is distinct from phronesis in
other contexts because it includes such a caring response
oriented toward the patient.
Je-ne-sais-quoi
One finding in the material which we grappled to understand were statements with an elusive quality. Participants
used expressions such as “hearing little voices” (P-10),
following a “sixth sense” (P-5) or a“certain sense” (P-9),
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“feeling the wind” (P-6), and “praying” (P-4). Perhaps such
statements can be related to two distinct but interconnected
aspects of clinical practice. First, as we discuss above, phronesis involves a tacit know-how; this know-how is difficult
to express in words and tends to be evoked using metaphors and approximations. Second, these statements speak
to the impossibility of a complete mastery of the clinical
situation, which is messy, heterogeneous, indeterminate,
and dynamic. In contrast to the chess master, who is able
to grasp the totality of the chess board, the expert clinician
is working within contingent situations. In the ambiguities
of practice, physicians are looking for ways to orient themselves, a path to follow, strategies to navigate the unpredictable, and resources to deal with inevitable limitations. This
may account, in part, for their occasional references to hope,
faith, and prayer.
Conclusion
This empirical study has permitted us to develop detailed
observations of how phronesis is manifest in (exemplary)
physicians’ stories of clinical practice. We offer the term
‘clinical phronesis’ as a descriptor for the appearance and
role of phronesis in daily medical practice. This term was
previously alluded to in a perspective piece, written by
Schultz and Carnevale (1996), on responsible caregiving.
Their commentary was focused on ethics. They proposed
clinical phronesis as a specific kind of virtue ethics. Our
empirical study broadens the phenomenological understanding of the nature of phronesis within clinical settings.
It also complements the contributions of scholars who have
examined various features of clinical practice from the theoretical perspective of phenomenology (Baron 1990; Cooper
1994; Leder 1990; Svenaeus 2014).
The picture of clinical work that emerges is at odds with
a portrayal of medicine that presents a detached physician,
equipped with the knowledge of bioscience and trained in
pre-defined competencies, who arrives at a diagnosis and
selects therapies following algorithmic practice guidelines.
We learned that exemplary clinical care is grounded in a
particular ethos. A physician with a refined clinical habitus,
shaped by accumulated experience, can grasp and make
sense of a specific situation. Wise practice is pragmatic,
intersubjective, and personal in being tailored to the individual as well as relational and caring in its enactment. The
mode of reasoning, developed through years of practice, is
hermeneutic and often tacit and intuitive.
The clinical situation comprises both patient and physician and is shaped by them jointly, against a backdrop of
a myriad of contextual factors. These elements are encompassed within the clinical situation with the patient as the
Discovering clinical phronesis
focal point of care. A physician with a fine grained and culturally engendered clinical habitus can grasp, elaborate, and
organize a difficult and often messy clinical situation. Such
a phronimos accompanies the patient through a thicket of
choices in an environment laden with contingencies. It is our
hope that this picture of ‘clinical phronesis’, grounded in the
accounts of exceptional physicians, makes the concept more
tangible and accessible and offers insight into how it may
serve as a ‘guiding light’ for practice (Flaming 2001) and a
‘guiding logic’ for medical education (Kinghorn 2010).
Acknowledgements We are grateful to Stephanie Leblanc Olmstead
for her dedicated and exceptional work as a research assistant on this
project and to McGill’s Institute of Health Sciences Education for support of this work.
Author contributions All five authors contributed to the study conception, design, and write-up. Data collection was performed by M.S.
Reading of all interview transcripts and coding were performed by all
five authors. Data analysis proceeded in several phases. In an initial
phase, mind maps and codes were reviewed by two subgroups: one
team (in Montreal) was comprised of D.B., E.A.K. and A.F., and another team (in Lausanne) was comprised of M.S. and H.W. In subsequent phases, in a series of online meetings, all 5 authors contributed
to data analysis. All five authors contributed written sections to the
first draft of the manuscript. Subsequent versions, including the final,
were written by all five authors. All authors read and approved the final
manuscript.
Funding The authors received financial support for a research assistant through the ‘Newell Trust in Research in Health Sciences Education’ fund at the Institute of Health Sciences Education (IHSE) at
McGill University. No other funds, grants or support was received to
conduct this study. Two authors, Michael Saraga and Hubert Wykretowicz, received generous support from the ‘Dr. Menard M and Anna
Gertler Visiting Scholars Program’ fund at the IHSE to visit McGill
during preparation of the final version of the manuscript.
Declarations
Ethical approval This research was conducted according to McGill
University’s ethical requirements as well as the 1964 Helsinki Declaration and the ethical principles stated in the amended Declaration of
Helsinki (2013). The study received continuing review and approval
from the Institutional Review Board of the Faculty of Medicine and
Health Sciences of McGill University on April 18, 2021 under the IRB
Study Number A04-E18-21 A (21-04-045).
Consent to participate Informed consent was obtained from all individual participants included in the study.
Open Access This article is licensed under a Creative Commons
Attribution 4.0 International License, which permits use, sharing,
adaptation, distribution and reproduction in any medium or format,
as long as you give appropriate credit to the original author(s) and the
source, provide a link to the Creative Commons licence, and indicate
if changes were made. The images or other third party material in this
article are included in the article’s Creative Commons licence, unless
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included in the article’s Creative Commons licence and your intended
use is not permitted by statutory regulation or exceeds the permitted
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use, you will need to obtain permission directly from the copyright
holder. To view a copy of this licence, visit http://creativecommons.
org/licenses/by/4.0/.
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