Abstract
The practice of medicine is a complex endeavor requiring high levels of knowledge and technical capability, and the capacity to apply the skills and knowledge to do the right thing in the right way, for the right reason, in a particular context. The orchestration of the virtues, managing uncertainty, applying knowledge and technical skills to a particular individual in a particular circumstance, and exercising the virtues in challenging circumstances, are the tasks of practical wisdom. Centuries ago, Aristotle suggested that capacities for wise action are developed through practice, experience, and reflection. Neuroscience and cognitive psychology are now beginning to contribute to our understanding of the complex interplay between emotion, cognition, and behavior that is necessary for wise action, and how this capacity for wise action can be developed. In this paper, I propose that wisdom offers an appropriate true north for medical education. Wisdom shifts the focus beyond the simple acquisition of knowledge and technical skills and integrates essential virtues like compassion, trustworthiness, humility, and the balancing of the virtues, into the professional formation for medical students. Informed by the humanities, the neurosciences, and the social sciences, we must now integrate the skills and practices necessary to the development of practical wisdom into medical education at all levels.
I. INTRODUCTION
Medicine is hard. The knowledge and procedural skills required are vast and can be overwhelming. Even harder is applying the knowledge and skills in the right way for a particular person or in a particular context. Medicine is full of ambiguity and uncertainty, and often the right thing to do is not at all clear at the moment. Medicine also involves highly challenging circumstances, with high stakes, high emotions, less-than-ideal circumstances, and urgency. So even when a physician knows the right thing to do, doing it and doing it well is often highly challenging. In addition, medicine requires an effective therapeutic relationship, with individuals, communities, and the public, to achieve its goals. In fact, of all the tools a physician has, the therapeutic relationship is arguably the most essential. For example, although we may develop effective vaccines to prevent serious diseases, without a therapeutic relationship with both individual patients and the public at large, doctors will not be able fully to utilize those vaccines to save lives. Or a patient in dire need of a medical procedure may decline because they do not trust the person doing that procedure. Medicine, therefore, demands more than knowing, or doing. Good medicine necessarily involves virtues, including compassion, prudence, trustworthiness, discernment, humility, patience, courage, honesty, integrity, and excellence (Kaldjian, 2010; Kinghorn, 2010; Kotzee, 2017; Bain, 2018). Good medicine demands “being” (Cruess, Cruess, and Steinart, 2016).
Although most would agree that being a good doctor involves virtues, modern medical education has struggled to embrace fully the task of developing these virtues in students and trainees. The challenges of defining, identifying, and measuring wisdom, for example, have made it difficult for those proponents of the importance of the virtues in medicine, like wisdom, to plead their case. As scientific knowledge in certain domains advanced, the science that could inform our understanding of the virtues essential to medical practice, the neurosciences, lagged. The social scientific and neurobiological understanding of human perception, cognition, emotion, and behavior, of the virtues such as compassion, patience, kindness, trustworthiness, and quite recently, wisdom, is just now beginning to emerge. Measurement as presented should not be underestimated. For decades, it has been much easier to measure knowledge than, for example, compassion or wisdom. In medical education, what cannot be measured tends to be de-emphasized. Until quite recently, there were no good, functional, self-reporting, or observational scales, and certainly no biomarkers, for things like compassion, love, forgiveness, or wisdom. Not surprisingly, then, the “true north” of medical training became the technical knowledge and procedural skills involved in medical practice. This was understandable, but it has ultimately limited the development of the profession and left it wide open for the gradual devaluing of certain components of medical practice. Even patients began excusing a lack of bedside manner, accepting that perhaps one could still be a good doctor without the skills of compassion, empathy, and relationality. However, we are now at a point of general dissatisfaction with medical care. Patients and clinicians alike are unhappy and beginning to complain loudly about what is missing. Society is questioning what parts of medicine can be done just as well by a robot. But it turns out that the human side of medicine, which has been difficult to define, measure, and teach, is being recognized as an essential part of medicine. Patients actually do want a doctor who cares about them, and who can walk the confusing, ambiguous, and risky diagnostic and therapeutic journey with them, with compassion, trustworthiness, and wisdom. The good news is that with the information emerging from the social sciences and the neurosciences about the virtues, their impact on our behavior, and neurobiology, we have an exciting opportunity to understand concepts like compassion and wisdom through a scientific lens, giving us new tools to understand them, new avenues for exploring how to mentor them and new ways to demonstrate their true value. We have also begun to develop psychological and sociological measures for the virtues that are increasingly reliable and integrated. It is therefore time for a new paradigm in medicine and medical training; it is time for wisdom.
A note of caution is appropriate here. As with any domain, whether it be neuroscience, the social sciences, history, philosophy, or sociology, the lens through which we examine events and circumstances, through which we make sense of data, influences our interpretation of those data. In the thought-provoking book Biopolitics After Neuroscience, the authors caution against falling too hard into the trap of thinking that the neuroscience of virtues is somehow more reliable and less prone to the influences of our political, economic, and social context than other domains like philosophy, and caution us against thinking that somehow the neurosciences are both more “objective” or more important contributors to our understanding of the virtues and their importance to medicine (Bishop, Lysaught, and Michel, 2022). I must say that as a physician I am keenly aware of the failings of science, frequently changing course on recommendations for patients based on different evidence coming forth. One has only to recall how badly wrong medical “science” got things, and how influenced it was by the political and social context during the eugenics period. Researchers looking for an explanation for and a defense of slavery were deeply involved in substantiating the practice through “scientific findings.” (You find what you are seeking.) One of the saving graces to wisdom as a true north is that a fundamental tenant of wisdom is humility—that constant awareness of how one might be wrong and the vigorous imperative to seek out those ways in which our perspective might lead us astray.
A second cautionary note is the imperative to guard against any reductionist approach to a concept like wisdom, or the analysis of wise action. Bishop et al. note “moral philosophy saw behaviors, capacities, and characteristics as products of social formation, habituation and will, and contemporary neuroscience straightforwardly locates morality in the brain.” What I argue in this paper is that this is not an either/or endeavor, it is both/and. When integrating science into our exploration, or explanation, of wisdom, it is tempting to reduce wisdom to a brain function or, in the case of psychology, for example, into a measurable set of behaviors or answers on a questionnaire. Although I agree that these additions are helpful, they are not sufficient, and our goal right now is to utilize all of the information that we can gain to become better. Therefore, taking the lead from Jeste’s exploratory integration of new neuroscience into the philosophical and psychological concepts of wisdom, I explore how this integration can shape a practical wisdom framework for medical training and practice (Meeks and Jeste, 2009; Jeste et al., 2019; Jeste and Lee, 2019). As Jeste’s approach suggests, this paper assumes that the neuroscience of wisdom “is not the destiny or an obstacle, but an opportunity; by securing more of an understanding of the physiology underpinning wise behavior, novel wisdom enhancing interventions might be developed, increasing such capacities for all of us.” Thus, learnings from neuroscience, psychology, sociology, and human performance studies are seen as additive to the centuries of contributions of philosophy, religion, sociology, and most recently psychology, to our understanding of wisdom, how wisdom is developed, and how it may be taught and mentored. Being able, as a doctor, to act wisely in the challenging circumstances that physicians have to manage every day is a complex, lifelong endeavor. It takes every insight we can get into how human beings function, how we make decisions, how we make choices, and how we can best interact with one another, to help us become wiser doctors as we gain experience. Articulating wisdom as the true north of medical formation, and then fully integrating all of the ways that we know so far to foster wisdom in medical training, is a worthy endeavor.
Wisdom has been conceptualized in numerous ways (Baltes and Staudinger, 2000; Ardelt, 2004; Glück, Bluck, and Westrate, 2018). It is a concept that is big and complex and difficult to describe, although we know it when we see it. Wisdom researchers in psychology and sociology have begun to establish some consensus around the definition of wisdom, and the defining characteristics of wise people (Baltes and Staudinger, 2000; Ardelt, 2004; Glück, Bluck, and Westrate, 2018). For the purposes of this paper, I rely heavily on Ardelt’s wisdom model (Ardelt, 2004), and its application to medical practice and medical education. Ardelt’s model of wisdom has three dimensions: reflective, cognitive, and affective (Ardelt, 2004). The reflective dimension is characterized by the capacity to reflect on one’s own thoughts and behaviors, and the ability to see events and circumstances from multiple perspectives. The cognitive dimension is characterized by the capacity to manage ambiguity and uncertainty, by an awareness of the limits of one’s knowing, and by a capacity to see the bigger picture and the deeper meaning in events and circumstances. The affective dimension of wisdom is characterized by compassion.
How does this model apply to medicine? Good medicine requires both the ability to reflect on one’s own thoughts, decisions, and behaviors, as well as the ability to see things from the perspective of the patient and of society. Clinical interviewing and clinical diagnosis are both iterative processes, requiring constant metacognition and reflection. Good medicine always requires the capacity to see things from the perspective of our patients, eliciting their understanding, their hopes, and their goals, in order to create an appropriate therapeutic plan for each individual. In the cognitive domain, medicine is filled with ambiguity and uncertainty, and managing this is essential to making good medical decisions. The rightness or wrongness of a diagnosis, for example, tends to be revealed over time, presenting a highly challenging situation for the clinician and the patient. Premature closure is a common rookie mistake (Graber, Franklin, and Gordon, 2005). A wise physician must strike the balance between over-confident knowing and paralyzing doubt (Meachum, 1990). Making good decisions requires the capacity to see the bigger picture so that the proper goals can be used to guide decisions. In the affective domain, a wise clinician must have the capacity to be compassionate, even when it is hard. Treating a patient with compassion, despite the patient’s anger or impatience, is an attribute of a good doctor.
Practical wisdom has been characterized as the capacity to choose when and how to apply knowledge, technical expertise, and virtues like compassion and trustworthiness, in a particular circumstance for a particular good, in other words, doing the right thing, in the right way, at the right time, for the right reason (Schwartz and Sharpe, 2010). It has been characterized as the “conductor” virtue—orchestrating the application of knowledge, expertise, and virtues in a particular context. To dissect this process of acting wisely, we must discern the capacities, virtues, habits, and skills required. Jeste suggests that wisdom includes specific components: social decision-making, emotional regulation, and prosocial behavior, guided by capacities such as compassion, self-reflection, acceptance of uncertainty, decisiveness, and spirituality (Jeste et al., 2019).
In the past, attempts to improve wise action (ethical action) in medicine have fallen short. This is at least in part because wise reasoning in medicine is particularly difficult. It is infused with high degrees of uncertainty and particularity, with virtues or goals at times in conflict, or at least requiring a balancing, making rules not easily applied or useful in the everyday decisions and actions of a physician. For example, a physician must balance the virtues of compassion with steadfastness when dealing with a patient who refuses measles vaccination for their child, or balance compassion with justice or equity when interacting with a patient who refuses to be cared for by the surgeon whose skin is black. As Kinghorn states “. . . in marked contrast to technē, the action consistent with moral excellence in any particular situation cannot be specified with any precision prior to the deliberation of the practically wise person . . . Although generalized theoretical knowledge is important for phronesis, it is never sufficient: moral excellence is discovered only as it is exercised, as the phronimos engages particular situations in a morally excellent way” (Kinghorn, 2010, 101). He goes on to say that there is little value in giving lists of professional precepts to medical students and expecting them to apply them in the context of complex medical practice.
Unless these physicians are the sorts of persons who through a lifetime of practice and habituation have cultivated the excellence of practical wisdom by formation in particular types of moral communities, the precepts will probably be useless; and furthermore, if practical wisdom is present, the precepts will probably be unnecessary. The practically wise person does not need general guidelines about how to act morally; the practically unwise person cannot successfully and consistently apply such guidelines when they are given, and might not even try. (Kinghorn, 2010, 101)
Acting wisely involves much more than wise reasoning. Physicians must exercise compassion when patients are angry and abusive toward them, or when the physician is on hour 30 of a 30-h shift. As Kinghorn suggests, Aristotle has some strong guidance here: “an Aristotelian approach would emphasize that moral excellence in clinical practice is much less about discursive rationality than about the character that displays itself most readily in clinical situations—the middle of the night, while fatigued, under duress—in which rational analysis is most unlikely” (Kinghorn, 2010, 99).
So how do we develop the capacity for wise action in medicine? Indeed, Aristotle suggests, “The virtues we acquire by having put them into action . . . we become just through the practice of just actions, self-controlled by exercising self-control, and courageous by performing acts of courage” (2009, 1103a31–1103b1). Knowing what to do is only half the equation. Being able to do it is the other half. Can the science of human performance (human factors engineering and psychology) and the emerging understanding of human thought, emotion, and behavior through the neurosciences help guide us? Are there ways that we can help doctors to act wisely?
In the early days of the patient safety movement, when we first became aware of the shockingly common nature of medical errors (Institute of Medicine, 2000), a common assumption was that clinicians who make mistakes were lacking in will. If a doctor only tried harder, then these mistakes would not happen. Although the will or intention to do the right thing is clearly important, we now know that despite the best intention and strength of will, mistakes still happen, and that understanding how the human brain functions puts us at risk for mistakes in perception and judgment can add important ways of mitigating disastrous errors. To use a simple example, if my son keeps losing his keys to the car, despite my repeated admonitions to care more about his car, and to pay more attention to keep track of his keys, taking into account our understanding of the human brain and how it works, in addition to encouraging his will to do better, I might suggest that he develop a practice of always putting his keys in the same place. The science of human performance (human factors) and how to reduce errors by adapting processes, equipment, and practices, had made vast improvements in nuclear power plant safety and airline safety. So patient safety experts then turned to the science of human performance to help improve the safety of health care. Research on human cognition and perception demonstrated ways to make it easier to perform tasks in medicine reliably, like washing hands, dispensing medications to the correct patient, operating on the correct limb, to keeping patients safe, despite highly complex, challenging circumstances (Institute of Medicine, 2000 report). Some worried that this focus on creating safer systems would somehow diminish the focus on individual responsibility, and would diminish the focus on the “will” to do the right thing. On the contrary, however, taking responsibility for understanding and then using those processes and practices that help us to function at the highest level of safety seems the most individually responsible thing we can do.
Virtue ethics suggests that doing the right thing in medicine involves more than knowing what the right thing to do is (Kinghorn, 2010; Kotzee, 2017; Bain, 2018; Lamb et al., 2021). However, it does not yet help us to know what skills and practices are needed to be able to exercise the virtues in highly challenging circumstances, or how to develop the virtues reliably in the profession. We could simply select students for the virtues, but we know now that how we currently train affects the virtues in students, probably both negatively and positively (Smith, 2017). Finally, just as with patient safety, there are undoubtedly systemic issues currently influencing the practice of medicine (constraints and incentives) that diminish the clinician’s ability to act wisely and work against any emerging attempts to exercise the virtues effectively in medicine (Pelligrino, 1999). If our educational attempts are to be successful, these constraints must be addressed.
In this paper, I argue that with the emerging behavioral and neurosciences integrated with the humanities, we have a new opportunity in medical education to embrace, as true north, a concept large enough to bring together all of the components necessary to lay the foundation for good doctoring, and that is wisdom. I demonstrate that practical wisdom, being the orchestrator of the virtues, and of the right application of knowledge and procedural expertise in a particular circumstance, is an appropriate “true north” for medical training. We have an opportunity to integrate the science of human performance, the emerging neuroscience of emotion, reasoning, perception, and behavior, with the foundational principles and insights of the humanities, to explore ways to help physicians to think and act wisely, to be good doctors. Neuroscience is beginning to provide evidence that the virtues have physiologic, measurable impacts on us, that they can be developed, and that developing the virtues requires practice. The sciences give us new insights into how best to teach and mentor toward wisdom. I argue that capacities for practical wisdom can be developed in the course of medical training and suggest a roadmap and key elements to explore.
II. A ROADMAP TO EDUCATING FOR PRACTICAL WISDOM IN MEDICAL TRAINING (Fig.1)
Roadmap Element 1: Close Observation Using the Lens of Wisdom to Identify, Name, and Dissect Examples of Practical Wisdom in Medical Practice
Classically, the first step in examining a concept in science is observation. In order to identify practical wisdom in action and understand its importance, we can first observe, name, and dissect the wisdom work in exemplary case studies. We can also teach students to note this wisdom work as they watch mentors in real-time. As an example, in the following case study, I take note of the wisdom work, of how knowledge, skills, and various virtues were orchestrated in the context of exemplary clinical care. On the face of it, this encounter was fairly straightforward. Once the lens of wisdom is applied, it becomes more clear exactly what knowledge, skills, and virtues were orchestrated to produce the best possible outcome. It is hoped that this case study serves as an example of practical wisdom’s orchestrating function in what might appear to be a simple medical encounter but which is an illustration of exemplary medical practice.
A suggested roadmap toward wisdom in medical practice with key elements.
Case study: the patient (a pediatrician) and his wife (an internist) arrive, along with their twenty-something son who has travelled down from New York, in the waiting room of the neuromuscular clinic for a consultation with a neurologist at the major medical center where they both work, following an extensive work-up for progressive weakness and fasciculations in the left hand. With other possibilities at this point almost excluded, anxiety that this might be Amyotrophic Lateral Sclerosis (ALS-a rapidly progressive, universally fatal disease) was high. This visit was the last stop on the journey to a final diagnosis. Almost immediately, a forty-something doctor comes to the waiting area to greet them and guide them to the exam room. Finding comfortable places for each to sit, the physician settles in, unhurried, kind, showing interest in the particulars of the son’s travels and career intentions. After a bit of polite conversation, the neurologist turns to the patient . . . “So, tell me the story . . . how did this all begin?”
This might seem like a simple straightforward process with a few pleasantries. Where is the practical wisdom in this encounter so far? What knowledge was needed, what virtues were exercised, and what skills were required? Broad knowledge of patient–doctor relationship building, history taking, and the perils and pitfalls of caring for a fellow physician were necessary. The virtues exercised include compassion, trustworthiness, perspective-taking, timing, and generosity. The skills needed to exercise properly these virtues are first applied behind the scenes. To exercise compassion and trustworthiness, when being tasked with taking care of two physician colleagues, the neurologist has to be aware of and able to regulate his own emotions. The emotion generated by caring for “one of your own” can easily overwhelm the ability to maintain a functional balance between empathy and detachment. That is partly why it is so difficult to be a doctor’s doctor. To do this, the neurologist takes a slow deep breath to calm and focus, and checks in with his own emotions, so that he can be fully present from the moment he walks out to greet the family. Second, perspective-taking and timing are crucial to establishing trustworthiness. Through perspective-taking, the neurologist is aware of how vulnerable this family is feeling, and how important it is for him to establish a sense of safety and trust. So he extends himself, going to the waiting room himself to greet them. Although the patient and wife are his colleagues, the neurologist had yet to meet the son. To bridge that gap, he spends a bit more time getting to know him. Third, he knows how to time the transition to history. An abrupt transition would be jarring, threatening the sense of safety. A delayed transition (i.e., too much banter) would make light of what is a highly charged, serious, and vulnerable situation. Finally, he chooses a skilled way to enter into the history that gives the patient control over the story and that communicates that he wants to hear everything the patient thinks is important to relay: “So, tell me the story. How did this all begin?”
The history. In a well-done history, symptoms over time become a story of the illness. The neurologist sits quietly as the patient tells the story. He jots notes occasionally, pausing the story only briefly for clarification, then gently summarizing, inviting any corrections or additions, the storyline revealing both pieces that fall together and pieces that stand alone, stubbornly outside of a perfect fit. Clarifying questions are asked gently. Seeming contradictions in the story are resolved together until all are satisfied that the neurologist has the story right. Only after the story is complete does the neurologist ask a set of more focused questions, like “So I didn’t hear anything about numbness. Have you had any numbness?”
The wisdom work here includes applying extensive knowledge of neuromuscular diseases and their clinical presentation to this particular patient’s presentation and applying that knowledge to take a detailed neurologic history to elicit all of the pertinent information, creating and modifying a differential diagnosis for complex neurologic presentations as the history unfolds. Practical wisdom here involves orchestrating the virtues of patience, tolerance for ambiguity, kindness, and humility. It takes patience to allow the story to be told without interruption. Data suggests that a physician interrupts a patient after, on average, 11 s, despite the fact that allowing the patient to tell their story uninterrupted is the most efficient approach to obtaining accurate and complete information (Ospina et al., 2019). The neurologist exhibited a critical tolerance for ambiguity as the history came forward, carefully holding those pieces that did not fit with a particular pattern, and resisting the temptation of premature closure (the most common cause of diagnostic error; Graber, Franklin, and Gordon, 2005). ALS is a challenging diagnosis to make, and because it is universally fatal, the stakes are high. Humility is essential. Finally, the neurologist used the skills of both pattern recognition and the more laborious “type 2” thinking (Kahnemann, 2013) to hone the differential, and used the skills of active listening, summarizing, and silence expertly to elicit the most accurate and complete information.
The exam: A quiet, slow, carefully orchestrated, detailed examination of the neuromuscular system. The neurologist takes long, silent pauses to watch muscle groups for subtle fasciculations, uses a gentle tapping to elicit the hyper-excitable reflexes. The exam culminates with the most detailed exam focused on the most severely affected muscles of the left hand—muscles that courageously struggle to perform the basic function of extending the fingers. At the conclusion of a comprehensive, thorough exam, a gentle, knowing glance is exchanged between doctors.
The practical wisdom work here involves applying detailed knowledge of the neurologic exam to this particular patient’s presentation, exercising the virtues of patience, temperance, preciseness, compassion, discernment, and humility. Using expert skills in performing the neurologic exam, and in differential diagnosis, the neurologist methodically gathers information designed to either confirm or eliminate diagnoses on the differential. This careful building of the differential diagnosis requires intellectual humility and cognitive flexibility. His exam vastly expands in detail where more information is needed, informed by the particulars of the patient’s presentation, something that routinely confounds the novice who approaches the neurologic exam as a standard format. Students must learn the practical wisdom to expand and contract the neurological exam based on the patient’s story and the patient’s differential. Students must practice holding uncertainty and learn carefully to explore alternative explanations as they move through the diagnostic process. All of this is done mindfully, compassionately, and respectfully. For example, knowing that in this particular patient, the reflexes are likely to be hyperactive, the neurologist taps ever so gently, giving a warning to the patient before doing so. A mindless, generic tap would have elicited a startling, uncontrolled, generalized spasm that is disquieting both physically and emotionally—an unnecessary, mindless, and even disrespectful act.
The Electromyography (EMG): Done expertly, the EMG is an example of the virtue of prudence and procedural excellence. In good hands, it is a procedure shaped by the particulars of the patient’s presentation, giving just the information needed to help make a difficult diagnosis. This prudence saves pain, suffering (the EMG is a painful test), time, and resources. Unnecessarily testing every nerve and muscle creates needless suffering, but leaving out an essential area to test would miss important information.
Diagnosis and treatment plan: Leading a difficult conversation. When the neurologist returns to the room, he begins with phrases that prepare the listeners, gently summarizing his findings. He uses medical terms that are familiar to the patient and his physician wife, but he then turns to the non-physician son and interprets what he is saying in a way that meets him respectfully, exactly where he is in his understanding. The neurologist has prepped the room with Kleenex and prepped his schedule with ample time. He allows for silence. He pauses with a poise that offers dignity to his listeners. He uses familiar phrases as a way to signal the bad news ahead: “This is not what we were hoping for . . .”. He finds a way to give the diagnosis with kindness, “Based on all that we know at this time, I believe that you have ALS.” The neurologist sits quietly as the patient and family process the news. He holds a presence that allows for all quietly and gently to move on towards a discussion of treatment and clinical course. He checks for understanding. He gives time. He has recommendations for treatment. He finds ways to offer hope.
Here we see the virtues of excellence, compassion, trustworthiness, kindness, discernment, and humility applied expertly through the skills of balancing honesty with hope, perspective taking, clear and compassionate communication, managing strong emotion, balancing the need to give information with the readiness to receive it, and managing uncertainty while conveying trustworthiness and expertise, emotion awareness and emotion regulation and balancing time needed with time available.
The case illustrates wisdom as the virtue which orchestrates the exercise of many other virtues and applies knowledge and skill to the right action for a particular patient in a highly charged, high-stakes circumstance.
Closely observing this medical encounter through the lens of practical wisdom, we are able to identify, name, and examine the practical wisdom at work.
Now that we have done this close observation we can ask how the neurosciences, psychology, sociology, and human performance research help us to understand how this all happens in the human being, and how through awareness, practices, skills, and processes, we might be able to foster wise action in medicine. By integrating new knowledge about human performance, neuroscience, and psychology, we can establish practices and teach skills that will make it more likely that an individual can act wisely, even in challenging circumstances. We might also be able to mitigate the ways in which human perception and bias can lead our decision-making astray and negatively influence our behaviors.
Roadmap Element 2: Establish a Platform of Positive Emotion
We have evidence that certain positive emotions and virtues have a relationship with wisdom. The relationship between forgiveness and wisdom is positive and fairly strong (Taylor, Bates, and Webster, 2011). Gratitude and wisdom have also been found to have a similarly positive relationship. Konig and Glück (2014) found that participants with higher scores on a wisdom measure tended to score higher on three gratitude measures than those with lower wisdom scores. The directionality of this relationship is not entirely clear. Plews-Ogan, Owens, and Ardelt (2019) found a likely reciprocal positive relationship between gratitude, forgiveness, spirituality, and wisdom. We have some evidence that positive emotion can predispose us to wise action (conflict studies). Gratitude can lead to prosocial behavior. Curiosity leads to the expansion of choice and is essentially a practice in perspective-taking. Assuming positive intent reduces the possibility of a fundamental attribution error, increases unconditional positive regard, and can lead to better outcomes (Kabota et al., 2014). Humility, engaged through the practice of asking “how might I be wrong” before a decision is made, can lead to better decisions (Johnson, Murphy, and Messer, 2016; Porter et al., 2022).
If the neurosciences suggest a relationship between positive emotion and wisdom, how do we enhance these capacities, and does that change the fundamental experience? There is evidence that, at baseline, the human brain has a negativity bias (Haizlip et al., 2012). Although at times that bias may be useful, in general, an unconscious bias leads to unconscious reaction, rather than conscious choice. Understanding the negativity bias helps us to counter that bias in important ways to enhance wise action. There is good evidence that through practice we can build a platform of positive emotion. Examples include gratitude practices (Wood, 2010) and compassion training (Klimecki, 2014). Building this platform might not only expand our capacity for these positive emotions even in challenging situations, but they also change our perceptions prospectively, such that situations may not even be perceived in a way that is threatening or challenging. For example, if through the practice of assuming positive intent, I can create the default of perceiving another person as good, I may promote a positive interaction (Osgood, 2021).
Roadmap Element 3: Identify Skills and Practices That Help to Act Wisely in a Reliable Way
Cognitive flexibility and intellectual humility
Clinical decision-making is complex and prey to bias (Croskerry, Singhal, and Mamede, 2013; Saposnik et al., 2016; Plews-Ogan et al., 2020). Diagnostic error is common, with proximate causes, including premature closure (prematurely settling on a diagnosis that in the end turns out to be wrong), and confirmation bias (looking only for data that confirm our diagnosis and ignoring data that would challenge or that do not “fit”), both default strategies not unique to doctors. Once a diagnosis is reached, doctors often fall prey to anchoring bias (anchoring onto that premature diagnosis despite evolving patient data that would suggest a different diagnosis). As Porter and Schumann suggest, “Even when a person desires to be intellectually humble, recognizing the limits of one’s knowledge requires overcoming metacognitive limitations that distort self-appraisal”(2018, 528). Science is emerging that can help us with this problem. Intellectual humility is a virtue that can serve as a defense against diagnostic errors, among other things. Research into intellectual humility suggests that there are practices that may increase this virtue (Porter and Schumann, 2018; Porter et al., 2022), as well as help to exercise this virtue in challenging situations. Simply being aware of intellectual humility (i.e., identifying the virtue and its benefits) improved self-reported humility (Porter and Schumann, 2018). Deliberate reflection on decisions can improve medical decision-making (Mamede, 2008; Stanovich, 2011). Self-distancing is a strategy that can improve decision-making (Grossmann and Kross, 2014; Grossman and Dorfman, 2019; Grossmann et al., 2021), as can counterfactuals (Galinsky and Moskowitz, 2000), and simply trying to explain one’s thought process can improve awareness of the limits of one’s knowledge (Johnson, 2016). Practices that focus on perspective-taking can build cognitive flexibility and are critical for making good decisions in medicine, which must always account for the perspective of the patient (Gill, 2007; Houser, 2018). Bias awareness and de-biasing techniques can become a part of the Morbidity and Mortality review teaching conferences (Abraham et al., 2021).
Self-regulation and metacognition
Self-regulation and metacognition can be critical for making good decisions in highly complex critical situations (Wilkowski, Robinson, and Troop-Gordon, 2010; Burgess, Beach, and Saha, 2017; Helion and Ochsner, 2018). Mindfulness practice can reduce activity in the amygdala and increase activity in the areas of the brain associated with reasoning and re-appraisal. S.T.O.P. and other pause techniques are self-regulatory skills and practices that allow a space to open between event and reaction, giving time to engage the reasoning brain in a conscious response.
Compassion versus empathy
One excellent example of how emerging neuroscience can inform the training and practice of medicine is the neuroscience of empathy and compassion. Empathy is feeling what another person is feeling. Compassion involves empathy, but in addition includes the active desire to relieve the suffering of another. Understanding the differences between empathy and compassion in the neuro-circuitry has important implications for training and practice. In a 2014 study, Klimecki et al. found that “in response to videos depicting human suffering, empathy training, but not memory training (control group), increased negative affect and brain activations in brain regions previously associated with empathy for pain. In contrast, subsequent compassion training reversed the increase in negative affect and augmented self-reports of positive affect. In addition, compassion training increased activations in a nonoverlapping brain network spanning ventral striatum, pregenual anterior cingulate cortex and medial orbitofrontal cortex” (2014, 873). Based on early evidence, it is possible that our previous attempts to “teach empathy” might backfire in clinicians, actually increasing negative affect in these clinicians, by engaging the empathy circuit without engaging the step of helping, a step that is essential to moving this experience from the pain circuitry to the reward circuitry. This is one example of how neuroscience can properly focus our efforts to enhance virtue and virtuous behavior in medicine.
Element 4: Mentor and Provide Opportunities for Exploratory Processing of Critical Incidents
Wisdom has an important relationship with the experience of adversity. Although not thought to be a necessary condition of wisdom gained, it is arguably the most likely stimulus to wisdom-generating growth (Plews-Ogan, 2013; Jayawickreme, 2017; Westrate and Glück, 2017). Clearly, not everybody gains wisdom from their challenging experiences. What makes the difference? Is it what we bring to the experience? Is it how we process and are supported through the experience? It is likely a little bit of both.
There are predispositions (capacities, ways of seeing events) that predispose us to wisdom formation through experience (openness to experience, positive emotion, gratitude, forgiveness) (Plews-Ogan, 2019). One might consider this the platform or foundation that we stand on as we go through our experiences. There are also ways of reflecting on/processing experiences that are associated with wisdom gained. Westrate and Glück (2017) delineated the difference between processing that leads to adaptation, and processing that leads to wisdom gained. The kind of exploratory processing that leads to wisdom gained is effortful and can be mentored.
We actually know something about what it looks like to learn and grow in the wake of challenging experiences in medicine (Plews-Ogan, Owens, and May, 2013). Building on the understanding of post-traumatic growth (Tedeschi and Calhoun, 2004), the Wisdom in Medicine study, we investigated how physicians coped with a serious adverse outcome in their care of a patient, a ubiquitous experience for doctors. This experience can lead to serious negative consequences (quitting medicine, defensive or negative coping behaviors, even suicide) or it can result in deep learning and growth. Figure 2 shows the important elements identified by those who moved through challenging circumstances of a serious adverse event with wisdom gained.
Path elements and subthemes for the path through adversity.
This process was not linear and could take years. The wisdom-generating response began with a clear-eyed acceptance of the situation and an active stepping into (rather than avoiding) the hard parts. It was a long process of integrating that experience into their understanding of themselves and the world—often a significant expansion or revamping of their self-concept (the imperfect but good doctor). It took exploration of what that means in real terms—how has this changed how I do things? Finally, the wisdom gained could be used to change a system or to help others.
Now what helped? The participants reported that talking about it, learning from it making positive change, forgiveness, and teaching about it, were all things that helped them to move through the challenging experience with wisdom gained (Plews-Ogan et al., 2016; Westrate and Glück, 2017).
Figure 3 is a proposed schematic of the entire process of wisdom through the experience of critical events, including those things that are identified as helping people to cope positively, gaining wisdom through the experience. One can also see that wisdom gained leads to helping behaviors and increased positive emotion, which then becomes a virtuous cycle.
Summary of possible pathways in the wake of a challenging event.
Element 5: Create a Wisdom Atmosphere in Healthcare Training
Wisdom researcher Jack Meacham talks about wisdom being fostered in a specific kind of learning community, a “wisdom atmosphere” in which people are free to question, to work in the space between too confident knowing and paralyzing doubt (Meacham, 1990). Intellectual humility is fostered in an atmosphere in which potential failures are sought out prospectively: “how might I be wrong?” (Porter et al., 2022). One example of building intellectual humility into the culture of medicine is collaborative cross-checking during a handoff. When one physician hands off care of the patient to another physician, a process of collaborative cross-checking creates the expectation that the receiving physician reviews the clinical decision-making and asks important clarifying questions designed to cross-check the work of the retiring team.
One critical component of the “wisdom atmosphere” in mentoring phronesis is continuity (Plews-Ogan and Sharpe, 2022). Wisdom development over time can be best situated in longitudinal relationships where this integration of experience occurs over time. This longitudinal relationship can be the crucible in which to hone the skills of practical wisdom.
Element 6: Systemic Change to Promote Wise Practice
Change to the system of training and clinical care requires a clear-eyed defense of the components necessary to practice wisely. Recognizing and naming wise actions is the first step in valuing them. Unless we can delineate these invaluable actions and the practices and skills needed to develop them, they will go unacknowledged, un-supported, and eventually eliminated from our work (Pelligrino, 1999). But we must also begin to identify those things in the system that are anti-wisdom. Again, the science can help us here. There is evidence from human factors performance studies to suggest that there are specific factors that reliably increase the risk of human error. For example, the risk of error in the performance of a task is increased by the following factors: being unfamiliar with the task (17-fold risk of error), time pressure (11-fold risk), information overload (six-fold risk), misperception of risk (four-fold risk), and inadequate checking (three-fold risk) (Institute for Electronics and Electronics Engineers, 1988). Now think about the work situation of an intern in medicine. They are new to their tasks, pressured for time by covering too many patients with simultaneous serious needs, asked to work 30 h at a stretch, and flooded with information too vast for any individual to absorb. Or consider the work of a primary care physician, whose time with a patient has been reduced to 15 min, with tasks of elucidating, diagnosing, and treating, for example, two new symptoms, managing eight medications to treat six chronic illnesses, and finally discerning and responding appropriately to the emotions and priorities of the patient. Given what we know so far from psychology and human factors engineering, it is not surprising that we have doctors who come to medicine with high ideals and deep commitment to providing excellent, compassionate care, yet who are disillusioned, and who describe both burnout and moral injury because of their work. So, these “anti-wisdom” factors must be changed.
The current system will not be supportive initially. As we move this forward, the practical wisdom we develop in our students and trainees is likely to create some impatience with our current system of care, its priorities, and the resultant constraints . . . but impatience is better than learned helplessness, or ignorance, or adaptation. Impatience implies a sense of empowerment, and a clear sense of what we are striving toward that will help our students to separate fact from fiction and become change agents.
Can we foster wisdom in medicine? Yes. Integrating what we know from neuroscience, psychology, sociology, and human factors engineering sciences along with the foundational work of the humanities, we can begin to build a different training paradigm, one that establishes a solid platform of wisdom practices, a “wisdom atmosphere” to reflect on experience in a wisdom-generating way, and longitudinal mentorship focused on the development of practical wisdom as the “true north” of medical education. One such experiment is the phronesis project at the University of Virginia School of Medicine (Kobert, 2016). The anatomy of the redesign included the mentoring of wisdom practices, including mindfulness, gratitude practice, emotion awareness, and self-regulation, structured reflection on critical incidents, and a complete re-structuring to create a 4-year-long, structured, patient-student-mentor longitudinal relationship that was the crucible of the learning. This pilot program was so successful that it has now been expanded to include the entire student body.
Medical education must change the paradigm—from the simple acquisition of knowledge and technical skills to the development of practical wisdom. Although wisdom development is a lifelong endeavor, the fundamentals can be acquired in medical school, such that experiences thereafter can lead to growth. This process begins with the articulation of practical wisdom as the true north of education in medicine, the development of detailed observations of what wise action in medical practice looks like, the identification of the virtues essential to good medical practice, and the integration of the skills and practices necessary to the development of practical wisdom into medical education at all levels.
