Wisdom in rehabilitation
In May 2021, Dr Sabena Yasmin Jameel published her University of Birmingham PhD thesis on Enacting Phronesis in General Practitioners. John Launer wrote about it on November 2nd, and I saw a tweet about his article. She has studied wisdom in general practitioners, but the findings apply to all healthcare professionals. Indeed, rehabilitation professionals should find it easier to be wise, as wisdom is associated with taking a holistic perspective, as engendered by the biopsychosocial model we use. In this blog post, I will discuss aspects of wisdom in rehabilitation based on Dr Jameel’s thesis.
Acknowledgement. I acknowledge the comments made by and help given by Dr Sabena Jameel. Any remaining errors are mine. More importantly, I thank Dr Jameel for undertaking and writing such an interesting thesis which has given me much to think about. Thank you.
Table of Contents
Wisdom and phronesis
Wisdom is the quality of being wise, and to be wise is to “have or show experience, knowledge, and good judgement” [OED]. This quality is shown through decisions and actions made by the wise person.
Phronesis is well described on page 17 of the thesis:
“Aristotle stated that phronesis is underpinned by a moral orientation towards good, resulting in eudaimonia (flourishing of self and others). Eudaimonia is achieved by striving to live virtuously through developing moral and intellectual excellence. Phronesis is a metacognitive, proactive process that facilitates decision making; it integrates the moral orientation towards good, along with the appreciation of context and results in action (praxis).”
Virtue plays a vital role in guiding all decisions and actions. To be virtuous, the decision or action must lead to the flourishing of oneself and others. To achieve this, one needs a full appreciation of the context in which the decision or action is made so that the consequences of any action can be predicted and evaluated.
Rehabilitation should also be based on a full appreciation of the patient’s situation and context following a thorough assessment using the framework of the biopsychosocial model of illness. The formulation will then summarise the context, including potential actions and contingent future states, so that a suitable plan can be made.
Many decisions and plans are based on practical and short-term considerations. Wisdom in rehabilitation will be demonstrated by placing the decision in the whole context of the patient, specifically considering their situation over the rest of their life and social roles.
Establishing that someone is wise is similar to diagnosing most so-called impairments. We attribute wisdom to someone because of their behaviour, both concrete action and, more usually, their decisions. We postulate that they are wise because this label allows us to predict their future behaviour. This is the same as diagnosing someone with visuospatial neglect; that diagnosis will enable us to predict the patient is likely to wheel their wheelchair into an object on their left and not notice the person approaching from the left.
Therefore, it is unnecessary to relabel wisdom as ‘practical wisdom’ or talk about ‘enacted phronesis’ because wisdom can only be identified through practical action or enactment.
What is virtue?
There are different ethical systems, broadly divided into rule-based and virtue-based. The dominant systems within healthcare, deontology and consequentialism, are based on duties and rules (deontology) or considering the consequences of an action (consequentialism). The widely-used four-principle model of Beauchamp and Childress is another system which is often used in a rule-based way.
While any ethical framework can include reference to virtue, virtue ethics makes being virtuous the overriding factor to consider. Virtue depends upon practical wisdom, or phronesis, to prevent someone from being over-virtuous.
Conroy and colleagues studied virtue in doctors from 2015-2018. They undertook a mixed-methods study involving doctors ranging from medical students to consultants and general practitioners. They identified 15 virtues (see pages 64-65).
- Negotiates, is fair and just, has integrity and is trustworthy,
- is lawful,
- is collaborative and will seek guidance,
- is culturally competent, considering both personal and patient’s values and beliefs,
- good interpersonal communication with emotional intelligence,
- admits treatments have limits,
- is approachable and will mentor,
- takes a balanced approach,
- is appropriately reflective,
- will speak out and have difficult conversations if needed,
- is resilient,
- shows phronesis, and
- takes resources into account.
Virtue was the ethical framework for medicine for centuries, but over the last 100-200 years, the medical practice has become paternalistic. As a reaction, an explicit biomedical ethical framework developed, typified by the four principles first proposed by Beauchamp and Childress in 1977. However, people have concerns that the principles do not include morality – doing what is right. This concern reignited interest in a framework of virtue ethics first developed by Aristotle, who used the word phronesis.
The need for more emphasis on training in ethical decision-making is widely recognised. For example, in 2014, Trishia Greenhalgh and her colleagues raised concerns about the culture of following rules derived from evidence-based medicine. They proposed the change to “real evidence-based medicine”, with the ethical care of the patient being its top priority.
Phronesis – a systematic review
As a prelude to the experimental work in her thesis, Sabena Jameel undertook a systematic review of phronesis within medicine. She wished to discover what had been written, what empirical research existed, and what narrative linked phronesis to medicine. She identified a total of 65 papers and extracted 12 themes which she explored.
In summary, she found phronesis was conceptually vague, with different people interpreting it differently. However, it was agreed to be a process focused on the salient moral aspects of a problem using “perspectival, context-sensitive metacognitions to integrate, guide and synthesise moral virtues”. She highlighted that the “moral compass” depended primarily on the character of the professional person and that, consequently, some people concluded that phronesis could not be taught. Sabena Jameel is a medical educator; she questioned this conclusion which will be discussed later.
The search also revealed little empirical research into phronesis. She noted that no one questioned whether phronesis was good, even though there was no evidence.
Sabena Jameel asserts, with evidence, that a defining characteristic of any professional is that they can make a judgement in uncertain circumstances. She suggests this professional behaviour arises from cognitive, reflective, and affective elements. She highlights the importance of reflective practice to match possible courses of action against moral values.
Her study, which aimed to discover what features characterised family doctors who enacted phronesis, depended upon measuring wisdom, which has been researched for at least 40 years. Her review of wisdom concluded, as one would expect, that wisdom is a nebulous concept with at least four groups of characteristic traits. She gave four examples of measures of wisdom.
For her study of general practitioners, Dr Jameel chose a measure developed by Monika Ardelt in 2003, the three-dimensional wisdom scale, abbreviated to 3-DWS. The three dimensions (scales) are cognition, affect, and reflection and the separate scales have 14, 13, and 12 items, respectively. The subject reads each statement and indicates their agreement using a Likert scale, from strongly agree to strongly disagree (or a similar verb depending on the statement). There is reasonable evidence supporting its validity and repeatability.
The study involved general practitioners who were also educational trainers. Two hundred and eleven completed the three-dimensional wisdom scale. From this 211, 20 of the highest-scoring doctors were selected for an interview because they would likely be exemplars, and five of the lowest were chosen as a contrast. Of those selected, 16/20 and 2/5 agreed to be interviewed.
She chose to analyse the narrative data using a Biographic Narrative Interpretive Method. To learn more about this, you will need to read the thesis. [Chapter 6, from page 166, with the analytic method described from page 182]
Dr Jameel used a corpus linguistic frequency analysis method to analyse the transcripts from the two doctors with lower scores. Ten themes emerged, shown in this Mind Map. (Also shown below.) She then worked the ten themes into a model (Also shown below.) showing how they interrelate to influence decision-making.
These themes were then applied to the 16 high-scoring doctors. Finally, the two groups (16 high-scoring and two low-scoring doctors) were compared. From this analysis, Dr Jameel derived 34 constituents of ‘enacted phronesis’, features that characterised the doctors with the most wisdom.
The following Mind Map (Also shown below)shows the 34 characteristics that typified the 16 wisest doctors studied.
The Fish School Theory of practical wisdom.
Sabena Jameel presented an original way to represent her findings, named “The Fish School Theory of practical wisdom”, which, as far as I can discover, is only published within her thesis. This theory neatly ties modern empirical research back to Aristotle, who first linked phronesis with medical practice. Aristotle spent many years studying fish in their natural environment, where many form fish schools (large groups of fish who swim together, for readers unfamiliar with the collective name of a group of fish).
It is arguable whether this is truly a theory because it is not testable, but it is certainly a good metaphor, a good way to conceptualise her idea. It is illustrated on page 286 (figure 8.4b) of her thesis.
She observes that a school of fish move as one entity, with all the individual fish swimming in the same direction. She suggests practical wisdom is similar in that all 34 individual components act in the same conceptual approach.
Just as in a school of fish, some individual fish will be bigger or smaller than average, and some individual fish will be swimming a few degrees off the main direction, so in individual people, components will differ a bit in strength and quality. Nevertheless, the combined effect in a person of all 34 features is wisdom, making wise decisions, just as a school of fish can look like an individual organism with a behaviour.
To quote her description of the Fish School Theory given alongside the illustration:
- “The whole school I greater than the sum of the constituents when working synergistically.
- Together, as a school, the phi [the Greek letter representing the 34 elements] have a purposeful direction (towards good) in which the move (telos to praxis) [Greek: telos – the aim or goal; praxis = an idea translated into action (hence dyspraxia, when an intended movement is not enacted correctly)]
- They are protected and nourished in this community (flourishing = eudaimonia) [Greek: state or condition of ‘good spirit’]
- The process is the intellectual virtue known as practical wisdom (phronesis)
- Achieving phronesis through the constituents functioning in this way is actualising personal potential.”
Although not stated in the thesis, these 34 elements do not only apply to an individual professional making a clinical decision about a patient or any other matter. The ideas apply equally to organisations. At present, economic and financial considerations dominate hospitals; they forget that money is not an end in itself; it is the means to an end, the delivery of good healthcare.
The importance of embedding virtuous decision-making processes in hospitals and other healthcare organisations cannot be overstated. Without organisational support, the best intentions of professionals will have little impact. An example of this comes from patient-centred care, an aspiration of most healthcare providers. Unless the organisation signs up to a patient-centred culture, care will remain low quality.
Education – encouraging wisdom.
Dr Jameel is an educator and emphasises that her theory or metaphor can lead to practical suggestions for improving the performance of individuals and, potentially, organisations. I will summarise some of her ideas.
Healthcare professionals can use the elements as they reflect on and assess their professional performance, promoting attention to values and healthcare goals. Organisations such as rehabilitation services or hospitals can also use the elements when assessing their performance, perhaps especially when performance is shown to be poor.
Using the 34 elements as a framework will increase the profile of soft metacognitive skills because they are demonstrably linked to best clinical practice. It will encourage the development of underappreciated skills, such as valuing different perspectives and maintaining boundaries, benefiting individual practitioners and whole organisations.
Trainees and trainers can use them to structure any discussion of professionalism and how to make good decisions in complex cases. It offers a more positive approach to education, contrasting with the emphasis on achieving minimal levels of competence and safe practice.
Fortunately, there are now published strategies on how to develop virtue. Michael Lamb and colleagues from Oxford have proposed seven strategies in a recent paper. The seven methods are summarised on a Wake Forest University website page, which says they are used regularly in their university.
Seven character-building strategies
The seven strategies are based on the seven Aristotelian character development strategies, considering more recent theoretical and empirical research. They are:
- Habituation through practice. This will be very familiar to anyone studying rehabilitation and most people. “Practice makes perfect.” It is a well-known saying, with the additional benefit of being true. However, in contrast to many practical skills, one is not aiming to make the skill automatic and not requiring cognitive effort; one specifically needs to think.
- Reflection on personal experience. The crucial role of reflective practice in maintaining good professional practice is widely recognised and supported, for example, by the General Medical Council and the Academy of Medical Royal Colleges. Other professional bodies also have much guidance on reflection by professionals.
- Engagement with virtuous exemplars. Learning from and aspiring to emulate people with virtue is a long-standing practice. This includes much more than finding someone locally, which may be challenging. One can read about other people, past and present, and, more importantly, study people with virtue in different fields and literature. The importance of studying humanities must not be underestimated.
- Dialogue that increases virtue literacy. Discussing virtue as an equal part of any clinical discussion will help normalise and embed virtuous thinking. It would be especially appropriate when discussing any very complex or challenging situation, such as reviewing a case after a less promising outcome. Still, it must not be reserved only for exceptional circumstances.
- Awareness of situational variables. This means paying attention not simply to the central facts of a case, but the many social, economic, and cultural influences on and consequences of a decision. This should be familiar to people in rehabilitation who use the biopsychosocial model. Still, in practice, these factors probably get little attention, and we should make a conscious effort always to consider broader influences and consequences.
- Moral reminders. Many organisations now publish their values; some regularly mention their values in formal meetings, such as executive committee meetings, but I wonder how many hospital trusts demonstrate commitment to their published values in their daily decisions. It is good to have agreed values, but they have no purpose or meaning if they are not used.
- Friendships of mutual accountability. Aristotle recognised that our local culture and community have a vital influence on character development, and he felt that developing and maintaining mutually-accountable friendships contributed to establishing virtue. However, it is also evident that friendship needs to be “with noble people” and that being friends with people will not necessarily increase integrity.
Wisdom in Rehabilitation.
Wisdom is a crucial characteristic needed by an expert in rehabilitation. One of the seven entrustable Capabilities in Practice in rehabilitation (or eight, in the medical curriculum) is “Able to recognise, accept, explain and manage the uncertainty present in all aspects of rehabilitation, helping all people involved to understand and work with the patient despite the uncertainty.”. This capability tests a professional’s wisdom in a rehabilitation context.
However, wisdom should be used in all situations. Each patient is of equal importance, has a complex problem (multi-factorial and endowed with uncertainty), and has their own social, cultural, and economic background. Practical wisdom, phronesis, is a process for making a good decision, and all decisions should be as good as possible.
Rehabilitation professionals, and professionals in other specialities, such as palliative care, general practice, and psychiatry, have an advantage over other healthcare professionals because they use the biopsychosocial model of illness when assessing a patient and formulating a case – or they should.
We could move one step further and include an open discussion of virtues and values in our daily conversations about patients, service standards, and processes. We need to understand and act on the principles set out above, aiming for all professionals to acquire some wisdom rather than hoping that a few notable people do, with most not having any. Practical wisdom is a culture in which some people become exemplars.
Wisdom could become a specific area of expertise within rehabilitation, helping us become indispensable within healthcare. We are well-placed for this because our training and practice already involved understanding patients in their context and managing uncertainty. Sabena Jameel’s thesis provides a framework work developing phronesis, and Michael Lamb et al. have set out how we can change and improve rehabilitation culture to achieve this. The need for more training in professionalism has been