Practical wisdom and the integration of science and humanism in medicine

Early in my training as a physician, I noticed that some physicians are much more capable than others in caring for patients. In time, I realised why. While most physicians are really smart (they have a large fund of knowledge) and many also demonstrate good clinical judgement (they can apply knowledge to achieve desired outcomes), only some physicians integrated knowledge and good judgement with an ethical perspective. This moral vision allowed them to see patients not as problems to be solved or cases managed but as persons requiring care within the particularity of their physical, psychological, social and spiritual needs. In short, I learned to recognise the difference between knowledge, problem solving and a virtue-based understanding of practical wisdom in medicine. In doing so, I came to appreciate the truth of Edmund Pellegrino's pronouncement that ‘Medicine is the most humane of sciences, the most empiric of arts, and the most scientific of humanities’.¹ Science, practicality and humanism: these three dimensions combined explain excellence in patient-centred care.

This multidimensionality is reflected in the virtue of practical wisdom, a telos-guided capacity to know and pursue the best means to achieve good ends.² In the virtue traditions associated with Aristotle and Aquinas, practical wisdom is understood as goal-oriented, context-sensitive, ethically integrated, deliberative, motivated and guided by reason-informed emotion.^3-5 Practical wisdom in medicine reflects a capacity for patient-centred deliberation directed toward the goals of health and flourishing; it accurately perceives context and circumstances, integrates moral virtues and principles, harmonises reason and emotion and is motivated to act to promote the patient's good.⁶ Practical wisdom can be described as a master virtue, or meta-virtue, because it orchestrates other virtues that need to be integrated, prioritised and balanced.⁵ Anchored in virtue ethics,⁷ practical wisdom in medicine is part of the character of a physician who treats patients as persons, holistically, recognising the biological nature of disease and the human experience of illness. It responds to the needs, preferences and goals relevant to the health, flourishing and dignity of a particular patient in a particular context at a particular time.

In this issue, the study by Millhollin et al.⁸ is an interesting effort to explore and model medical wisdom through a blend of qualitative research and conceptual theorising. It also endeavours to relate medical wisdom to the ACGME core competencies⁹ in medical education. The qualitative portion of their study comprised thematic analyses of interviews with 19 internal medicine physicians to elicit their definitions of medical wisdom and situations that require it. Their study design and model development were guided by existing models of wisdom, psychological theories emphasising metacognition and insights from complex adaptive systems. They also sought to compare the value sets (moral economies) of medical wisdom and medical science. The general domains of their proposed model of wisdom (technical knowledge, adaptive capacity and values), would appear to parallel Pellegrino's dimensions of science, practicality and humanism.

The work of Millhollin et al. reminds us of the need, in medical education, to integrate multiple dimensions of meaning and practice. In encouraging consideration of practical wisdom and virtue ethics in relation to psychology and complex adaptive systems, important epistemological and normative questions arise. Such interdisciplinary intersections shine light on contrasting conceptual frameworks, as seen, for example, in the comparison of neo-Aristotelian and psychological concepts of wisdom.^{10, 11}

Questions can also be raised in relation to the authors' remarks about the incommensurability between the values of medical science (analytic, predictive, knowledge-oriented and integration resisting) and the values of medical wisdom (holistic, adaptive, patient-centred and integration-promoting). Against the background of this dichotomy, the authors express concern about ‘the reductionist structure of prevailing medical education competency frameworks’ and seem to suggest that the ACGME core competencies adhere to the values of medical science (‘when structured as individual competencies linked to specific and measurable behavioral anchors’).⁸ This is a notable claim. But is it fair to classify all the ACGME competencies under medical science? Or, would it be more fitting to classify them within the broader category of ‘medicine’ and thereby communicate a broader, more inclusive scope of concern that integrates (rather than opposes) the values the authors assign to medical science and medical wisdom? An answer to this question comes by examining the substance of the ACGME competencies, which to my review imply an integrated view of science and humanism in medicine (even if the competencies, when operationalised in educational measurement and assessment, could perhaps be construed as scientifically reductionistic).

To illustrate, consider the following selected contents from the six ACGME competencies: (1) Professionalism (commitment to professionalism, adherence to ethical principles, compassion, integrity, respect for others, responsiveness to patient needs that supersedes self-interest, cultural humility, respect for patient privacy and autonomy, accountability, respect for diverse patient populations and addressing conflict of interest), (2) Patient Care and Procedural Skills (care that is patient- and family-centred, compassionate, equitable, appropriate and effective), (3) Medical Knowledge (application of biomedical, clinical, epidemiological and social-behavioural knowledge to patient care), (4) Practice-Based Learning and Improvement (assimilating evidence from scientific studies related to patients' health problems), (5) Interpersonal and Communication Skills (communicating effectively across a broad range of socioeconomic circumstances, cultural backgrounds and language capabilities, including end-of-life and other care goals) and (6) Systems-Based Practice (responsiveness to the larger context and system of health care, including the statement that ‘every patient deserves to be treated as a whole person’).⁹

The breadth and depth of these contents from the ACGME competencies exemplify an appreciation for the multidimensional reality of patients as persons who need medical care that is genuinely holistic, grounded in ethical values and guided by the integration of science, practicality and humanism. This suggests that the ACGME core competencies manifest integration rather than resist it and that they are compatible with the dimensions of practical wisdom.

Though it can be challenging to achieve in practice, I think there is broad formal agreement in medical education about the need for scientific–humanistic integration in medicine.¹² The question is not whether the promoters of ACGME core competencies or EPAs (entrustable professional activities) appreciate the need for such integration but rather how we can ensure (as clinicians, teachers and mentors) that these different dimensions of scientific–humanistic care are kept together. The need for this integration is profound, even in intense moments when it may be tempting to try to rationalise reductionistic practices that rely heavily on technologies, interventions and the physical aspects of treatment. Consider, for instance, the challenge of evaluating and managing a trauma patient and the scientific–humanistic ability a surgery resident needs while ruling out intra-abdominal bleeding so she can perceive and respond to a terrified patient. While following life-saving checklists and procedures, she also needs the ability to remember what care really means—to realise the value of taking a well-timed moment to hold her patient's hand, look into his frightened eyes and speak words of comfort, courage and hope.

Practical wisdom perceives and responds to such need—integrating science and humanism by combining technical skill and compassionate care. Experience tells me that the need for this integration is widely understood and endorsed among physicians. The challenge is not so much a matter of knowing that this integration is needed but of becoming and being the kind of people who are committed to doing it.