Participants conveyed many different practice virtues but no one participant conveyed all 15 virtues. As could be expected, the more experienced participants conveyed more of the virtues than the less experienced participants. This finding connects to the neo-Aristotelian framework of practice virtues constructed by MacIntyre (1981) and advocated by Carr [39]. MacIntyre suggests his approach across the peer group of practitioners rather than individual moral characters. This fits with the notion of diversity in practitioner contributions bringing a more robust set of virtues to the practice [39, 40]. The consolidated fifteen virtues we present here represent a “starter-set” of virtues for medical practice that are open for debate and challenge from others. As a non-prescriptive debating resource, this combined phronesis offers a powerful way for those in medical education and practice to debate their decision-making to serve the best interest of patients and their communities. The arts-based element of the analysis produced a seven-part video series, which is an enacted form of our participants’ ”Collective Practical Wisdom”. The videos offer a highly accessible form of moral debating resource for reflection before, during and after medical decision-making.
We present our findings as a “virtue continua” (Table 1) and as virtues per cohort (Table 2) before presenting them in text form. Due to space constraints, not all 15 virtues are presented as text. Virtues such as negotiate/or, cultural competence, seeking guidance and interpersonal communication were conveyed by a large proportion of our participants and are presented as text examples. The other virtue that is presented is Phronesis.
Virtue Continuum
The virtue continua table (Table 1) shows the virtues conveyed by our interviewees in their narratives. Each virtue extends from pole-to-pole via a mean.
Table 1: Virtue Continua
Virtue
(V.)
|
POLE1(excess)
|
MEAN
|
POLE2 (deficiency)
|
1
|
Doctor decides
|
Negotiates
|
Patient decides
|
2
|
ALL get treatment
|
Just/Fair
|
Select few get treated
|
3
|
Overly trusted
|
Trust/Integrity/
Confidentiality
|
No trust
|
4
|
Constant litigation worry
|
Lawful
|
Ignore legal constraints
|
5
|
Constantly seeks
Guidance from peers
and/or professional
bodies.
|
Making Collaborative
Decisions/ Seek guidance
|
Self –guided / Does not consult
|
6
|
Use own values
and beliefs
|
Culturally competent
|
Go with patient’s values and beliefs only
|
7
|
Too involved
Over emotional
|
Interpersonal
Communication
(including:Emotional intelligence)
|
Distant / Aloof
|
8
|
Treat at all cost
|
Recognising limits to treatments
|
Limited consideration of treatment options
|
9
|
Constant mentoring /
overly directive.
|
Approachable /
available mentor
|
No interest in mentorship
|
10
|
Trying to cater to all
aspects – Arts
/ humanities
science, spiritual
and physical.
|
Balanced approach
|
Just one approach - e.g. science/clinical only
|
11
|
Over-analytical
(Navel gazing)
|
Reflective
|
Never reflect
|
12
|
Foolhardy risk taker
|
Courage to speak out
have difficult
conversations
|
Avoids conflict
|
13
|
Thinking they are
bullet proof
|
Resilience
|
Avoidance of any stress
|
14
|
Obsessed with
finances / resources
|
Resource awareness
|
No consideration of finite resources
|
15
|
Seen it all / know it all
can deal with anything
|
Phronesis
|
Applies purely theory or just follows guidelines
|
Virtues per cohort
- The virtue per cohort table (Table 2) was produced by cross tabulating the 15 virtues by cohort in order to show whether the virtues are practiced by one, two or all cohorts. There are virtues that transcend boundaries between studentship and qualified practitioners as shown in Table 2. These virtues are: Negotiate with patients/carers while ‘doctor decides’ or ‘patient decides’ are at the polar ends (Virtue1);
- Seeks guidance/Make collaborative decisions at the mean, with ‘constantly seeks guidance from peers and/or professional bodies’ and ‘self-guided/does not consult’ are the extreme positions and hence a vice (Virtue 5);
- Culturally competent is at the mean, while ‘only using own values and beliefs’ and/or ‘only going with patient’s values and beliefs’ are the extreme positions (Virtue 6);
- Interpersonal communication/Being emotionally intelligent is at the mean, as opposed to ‘being too involved/over emotional’ or ‘being distant/aloof’ (Virtue 7).
Table 2: Virtues per cohort
Cohort
|
V.1
|
V.2
|
V.3
|
V.4
|
V.5
|
V.6
|
V.7
|
V.8
|
V.9
|
V.10
|
V.11
|
V.12
|
V.13
|
V.14
|
V.15
|
2nd yr.
|
13
|
7
|
8
|
1
|
11
|
8
|
16
|
7
|
7
|
3
|
3
|
6
|
1
|
3
|
5
|
5th yr.
|
11
|
4
|
8
|
6
|
3
|
13
|
15
|
2
|
5
|
5
|
3
|
11
|
4
|
6
|
9
|
FY 1
|
11
|
5
|
4
|
5
|
17
|
8
|
12
|
8
|
7
|
6
|
10
|
5
|
3
|
3
|
7
|
FY 2
|
8
|
3
|
1
|
8
|
16
|
3
|
12
|
9
|
11
|
11
|
2
|
9
|
5
|
8
|
8
|
Exp. (includes trainees)
|
22
|
7
|
8
|
10
|
22
|
15
|
14
|
15
|
11
|
14
|
15
|
4
|
14
|
15
|
20
|
The table also shows that the virtues like lawfulness (V.4), recognising limits to treatments (V. 8), being an approachable mentor (V.9), being resource aware (V.14) and phronesis (V.15) are more common amongst foundation year and experienced doctors, with some 5th year students narrating experiences of their seniors.
Negotiate (V.1)
Many participants produced narratives about negotiating with patients and others when making decisions about treatment. The doctor’s role was conveyed as providing suitable and relevant information to enable patients/carers to come to a decision, as well as providing expert advice and guidance in the light of clinical facts, taking patients’ views into account and thereby enabling informed choice in partnership with the patient:
“I guess that would be my approach, just to seek out as many facts as I possibly could on the one hand, and for more… difficult decisions, just talking to the patient and trying to get to know them a bit better and their kind of particular outlook ….. and then possibly based on that, kind of guide them to a decision that I think might suit them better.” (B102).
Experienced doctors spoke about the importance of dialogue and how exchanging information resolves conflicts and enables patients to make an informed choice:
“a constructive conversation both ways. I’ve got something to say but let’s not jump to a decision now, because that would be wrong.” (BX02).
However, decisiveness was respected both by doctors-in-training and by some patients they encountered. It was felt that some patients implicitly sought paternalistic guidance, as they may find decision-making burdensome, relying on the doctor’s expertise and knowledge to guide them:
“Sometimes people do respond well actually to someone taking control of the situation, even if it’s in a way that you would think would surely be completely inappropriate, but [the patients] respond well to it.” (B112)
Sometimes, some participants considered that persuading patients in their best interest is necessary because:
“[A] patient doesn’t understand the severity of the decision they’re making, and perhaps only when they’ve seen people who don’t have the procedure done or don’t have an operation might they learn… the actual nature of the decision they’re making, because we see it, whereas they don’t.” (WX02).
Led by patient autonomy, sometimes doctors assume the role of information providers, enabling patients’ decisions to be implemented:
“But, for me, a good decision is one where the patient is the one who essentially makes the decision, or puts forward their wishes, and we then, as the clinicians, allow that decision to come to fruition.” (B107)
Collaborative decisions / seeking guidance (V.5)
Many participants narrated stories about the present-day clinical paradigm being where professionally isolated decision-making is often neither advisable nor possible. Seeking to involve all those entrusted with a particular patient’s care allowed holistic, tailored decisions. Counsel from multiple parties and professional guidelines was felt to be valuable. This was corroborated by the project’s observations of different MDT meetings. When making decisions for complex cases, team members found that the progressive decisions reached and displayed on the whiteboards were useful, as “they help prioritise and review decisions.” (Obs.1)
Guidelines, though useful, require contextual awareness that can be provided by those who know the patient well, such as:
“[T]he nursing staff who cared for the patient throughout, I relied on hugely because …and even the night sister … just made it more logical, and decision-making more logical. I do rely on my consultants for the ultimate decision quite a lot of the time.” (BX01)
In observation 2, the roles of the occupational therapist (OT), physiotherapist (PT) and speech therapist were seen to be central to certain patients’ treatment because they had the most up-to-date information. The registrars and consultant relied on the OT and PT to provide almost the whole information summary. These collaborative discussions become critically important when making “deprivation of liberty” decisions. This observation made it clear that:
“The lead consultant would ask questions and appeared to be kind of taking it all in, cross-referencing information he got with his records on his computer. More often than not, he would defer to the decisions of the PT and OT…..The nurse had a lot of say as well about how patients were progressing towards their goals.” (Obs. 2)
This approach was not universal. At another MDT observation (Obs. 3), the discussions were mostly contained amongst the doctors, with barely any input from other staff.
Most medical students were of the view that it is far better for “not-so-experienced doctors” to defer to people with more experience:
“[Y]ou know, bigger decisions, you’re not going to want to take that onto yourself, you’re going to defer to people that have got the experience.” (W203)
Newly trained doctors find it easier (and safer) to seek guidance from, and feel reassured by, more experienced doctors. This was observed (Obs. 3) in an Emergency Department environment, when the junior doctor requested a consultant to discuss “an older patient with complex health and social problems”:
“…. they’ve probably made that before and they can tell you with experience the outcome and why. And they might come up with ideas as to why your idea might not be the best for that patient.” (W101)
Experienced doctors also seek guidance in challenging cases. This reduces the cognitive load and help make better decisions:
“…sometimes that consensus is really useful because you’re basically going through the arguments … and again clarifying some of the aspects of it, I think.” (BX11)
Some participants referred to guidelines being interpreted contextually. This could result in referring to more experienced doctors to gain insights into wider interpretation of the guidelines:
“…so we’ve got an SHO ….[with] very good book knowledge, he’s very academic, [and] knows the guidelines for everything off by heart but he doesn’t really have a grasp of the fact that not every patient can be treated as per guidelines. And we’ve been trying to explain to him that a guideline is just that, it’s a guideline, it’s not rigid; it’s meant to guide your practice….. he’s had real issues with not calling for senior support because he feels that he’s got a guideline to follow and that he follows it..” (WX05)
Culturally competent (V.6)
Some stories conveyed that respecting patients’ values and beliefs is important. Many of the participants said that they consult their colleagues to understand cultural issues. However, some participants narrated experiences where the doctor chose to follow their own beliefs and values, rather than their patients’. One doctor experienced a situation where a doctor refused an intervention that challenged their personal beliefs leading to treatment delay. They felt:
“it is important to park your own values. You should not allow those values to affect the decision.” (BX04)
A 5th Year medical student told of a consultation in a sexual health clinic, where the doctor seemed judgemental towards a patient:
“ he said something like, ‘Are you gay or straight?’ or something. Just, like, which is incorrectly phrased? There’s far more, like, tactful ways to do it. But he, kind of, shouted at them, so, ‘Are you gay?’ kind of thing.” (B501)
Cross-cultural sensitivity was seen important in building trust. Rehabilitation, for example, is seen to follow a “white Anglo-Saxon” model. An experienced doctor explained:
“The Muslim perspective is a more vitalist perspective in terms of – you can have everything that’s possible. Whereas I think there’s – generally there’s mistrust of the NHS that we pull out too soon, and we don’t do everything that’s possible,…………. don’t do everything we should be doing.. but that’s compounded by.. a cultural view of life I think….. there is a cultural clash, so there is mistrust that can be on both sides. The only way to get around that is to recognise that there is a difference in view and maintain open dialogue.” (BX05)
Interpersonal communication / Emotional Intelligence (V.7)
Good interpersonal communication was conveyed as commendable by our participants. For example:
“you can be the greatest doctor in the world but if you can’t communicate, nobody will do what you say, will they?” (BX103).
Some participants also conveyed that having the clinical knowledge regarding the disease at hand is also essential:
“you can be a very compassionate person, but a useless doctor if you don’t know what you’re doing.” (W207),
Some participants narrated experiences where an apparent lack of interpersonal communication skills was displayed by a doctor:
“…the clinician who saw her [the patient] wasn’t very communicative and reassuring in his approach to the patient… [the patient] was having a miscarriage, [the clinician] left it at that; left the room, and I was standing there with a very distraught couple… I told the clinician and he said, ‘Oh they’ll probably figure it out some way along the line’. And wasn’t very keen on going back and telling the patient – reassuring them.” (W502).
Some conveyed how empathic communication made patients amenable to discussion:
“I think you have to, I suppose, temper your objective, rational facts for your decision-making process in a way that comes across as empathetic and sympathetic and looking at a bigger picture view beyond the current situation; and also to help parents to think about things from their baby's view.” (BX12).
Phronesis (V.15)
The development of practical wisdom was conveyed by most interviewees as sequentially experiential. One medical student termed it “learned experience” (N203), while a foundation year doctor spoke of it as a “mix of nurture and nature” (B104, Follow-up). For one experienced doctor:
“…some people are inherently wiser, they are really wise people…now, whether that wisdom is inherent or … is simply because that person has walked past that journey ahead of me.” (NX05)
Experience can, however, lead to an assumption about personal knowledge. A foundation year doctor recounted a difficult birth where no pain relief was given to the mother, and the consultant seemed to show a lack of compassion for the mother and focussed on getting the baby out alive:
“… experience makes you better at making clinical decisions… but not necessarily in terms of ethical decisions… a lot of people get stuck in their ways.” (B504)
Assuming that they “know it all” and following a textbook approach can cause a doctor to be caught out:
“You can’t make a decision based on what the textbooks say… because if the textbooks say it, you can only say that that’s right 99% of the time. There will always be the one case that will catch you out if you treat everybody the same… there’s things that are really rare, but they still happen.” (WX02)
An experienced doctor highlighted another risk that arises with experience and seniority and was “arrogant or foolhardy.” (BX04).
Similarly, another experienced doctor reflected on a senior consultant who regularly over-ruled on the basis of experience rather than book knowledge:
“Because evidence-based medicine tells you something else, but the experience of this doctor was something different, so there is, kind of, a clash between the two, rather than both going forward in a symbiotic relationship…. Which is why I'm wary of saying that wisdom is the most important thing.” (NX04)
Phronesis was variously described as the collation of holistic information, both clinical and social, from different sources, as well as being able to weigh that up against protocols, guidelines, various situations encountered in the past and then getting other “opinions, other approval, putting the situation to a new pair of eyes, and saying okay this is what I have got here.” (B106).
But for some medical students, phronesis seemed to be narrowly defined as diagnostic skills (i.e. techne) as opposed to the broader process of a holistic decision-making (as described by foundation and experienced doctors):
“You know you learn by example, by following what someone else is doing… the art and the science of medicine… you need the clinical knowledge and then you need the experience to know how to apply it and when to apply it.” (W207)
Another medical student also spoke of consultants with a “repertoire of patterns” (W209). However, experience and “time served” were not enough to guarantee wise decision-making, and certain other virtues were seen as key to phronetic decisions. For instance, being reflective, “open to insight” (WX04) and being consultative: “it is always questioning what the right thing to do is.” (B110). There were those who considered it as intuition, “a sixth sense” (NX02).
Phronetic decisions were often seen as the avoidance of the rigid application of rules and guidelines, what was termed by one experienced doctor as the “protocolisation of medicine” (WX03). In medicine “it is this difficulty of managing an illness rather than treatment of an illness which is the more difficult bit and there are never going to be mathematically accurate answers.” (WX06)
A foundation year doctor described a consultant’s decision to not “red-card” a drug user found injecting heroin in the hospital toilets, who was due a life-saving operation that day:
“the rules were applied but also there was some practical wisdom applied” (B104).
Phronetic decisions were often seen as practical and experiential:
“… where wisdom comes from, it’s a lot of thinking back to your past experiences and what you did badly, what you did well and trying to apply that… You’ve just got to think about in an ideal world what you want to do, and then think how you could possibly get as close to that with what you’ve got.” (B110 FP)