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Engagement and practical wisdom in clinical practice: a phenomenological study

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Abstract

In order to understand the lived experiences of physicians in clinical practice, we interviewed eleven expert, respected clinicians using a phenomenological interpretative methodology. We identified the essence of clinical practice as engagement. Engagement accounts for the daily routine of clinical work, as well as the necessity for the clinician to sometimes trespass common boundaries or limits. Personally engaged in the clinical situation, the clinician is able to create a space/time bubble within which the clinical encounter can unfold. Engagement provides an account of clinical practice as a unitary lived experience. This stands in stark contrast to the prevailing notion, referred to as a dual discourse, that describes medicine as the addition of humanism to science. Drawing on Aristotle’s notion of phronesis and Sartre’s definition of the situation, we illustrate how this novel perspective entwines clinical practice, the person of the clinician, and the clinician’s situation.

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Notes

  1. In her study of how atherosclerosis is “enacted” in a large hospital, medical anthropologist Annemarie Mol (2002) similarly challenges the dichotomies between object and subject, between things and persons: “I privilege practices over principles … study of practices does not search for knowledge in subjects who have it in their minds … Instead, it locates knowledge primarily in activities, events, buildings, instruments, procedures, and so on” (p. 32).

  2. In German: “betroffen” could also be translated as deeply concerned, implicated or involved; these notions resonate with that of engagement.

References

  • Ackerknecht, Erwin H. 1967. Medicine at the Paris hospital, 1794–1848. Baltimore: Johns Hopkins Press.

    Google Scholar 

  • Aubenque, Pierre. 2009. La prudence chez Aristote. Paris: Presses Universitaires de France.

    Google Scholar 

  • Boudreau, J., Mary-Ellen Donald Macdonald, and Yvonne Steinert. 2014. Affirming professional identities through an apprenticeship: Insights from a four-year longitudinal case study. Academic Medicine 89: 1038–1045. https://doi.org/10.1097/ACM.0000000000000293.

    Article  Google Scholar 

  • Bynum, William F. 1994. Science and the practice of medicine in the nineteenth century. Cambridge: Cambridge University Press.

    Google Scholar 

  • Cabana, Michael D., Cynthia S. Rand, Neil R. Powe, Albert W. Wu, Modena H. Wilson, Paul-André C. Abboud, and Haya R. Rubin. 1999. Why don’t physicians follow clinical practice guidelines? A framework for improvement. Journal of the American Medical Association 282: 1458–1465. https://doi.org/10.1001/jama.282.15.1458.

    Article  Google Scholar 

  • Cassel, Eric J. 2012. The nature of healing. The modern practice of medicine. Oxford: Oxford University Press.

    Book  Google Scholar 

  • Cochrane, Lorna J., Curtis A. Olson, Suzanne Murray, Martin Dupuis, Tricia Tooman, and Sean Hayes. 2007. Gaps between knowing and doing: Understanding and assessing the barriers to optimal health care. Journal of Continuing Education in the Health Professions 27: 94–102. https://doi.org/10.1002/chp.106.

    Article  Google Scholar 

  • Desjarlais, Robert, and C. Jason Throop. 2011. Phenomenological approaches in anthropology. Annual Review of Anthropology 40: 87–102. https://doi.org/10.1146/annurev-anthro-092010-153345.

    Article  Google Scholar 

  • Dunne, Joseph. 1993. Back to the rough ground. Practical judgment and the lure of technique. Notre Dame: University of Notre Dame Presse.

    Google Scholar 

  • Engel, George L. 1976. Too little science: The paradox of modern medicine’s crisis. Pharos 39: 127–131.

    Google Scholar 

  • Engel, George L. 1977. The need for a new medical model: A challenge for biomedicine. Science 196: 129–136. https://doi.org/10.1126/science.847460.

    Article  Google Scholar 

  • Engel, George L. 1980. The clinical application of the biopsychosocial model. American Journal of Psychiatry 137: 535–544. https://doi.org/10.1176/ajp.137.5.535.

    Article  Google Scholar 

  • Feinstein, Alvan R. 1987. The intellectual crisis in clinical science: Medaled models and muddled mettle. Perspectives in Biology and Medicine 30: 215–230.

    Article  Google Scholar 

  • Feinstein, Alvan R., and Ralph I. Horwitz. 1997. Problems in the “Evidence” of “Evidence-Based Medicine.” American Journal of Medicine 103: 529–535. https://doi.org/10.1016/S0002-9343(97)00244-1.

    Article  Google Scholar 

  • Foucault, Michel. 1963. Naissance de la clinique. Une archéologie du regard médical. Paris: Presses Universitaires de France.

    Google Scholar 

  • Gadamer, Hans-Georg. 1975. Truth and method. New York: The Seabury Press.

    Google Scholar 

  • Gadamer, Hans-Georg. 2001. Gadamer in conversation: Reflections and commentary. New Haven: Yale University Press.

    Google Scholar 

  • Gadamer, Hans-Georg. 2007. The Gadamer reader: A bouquet of the later writings. Evanston: Northwestern University Press.

    Google Scholar 

  • Good, Byron. 1994. Medicine, rationality and experience: An anthropological perspective. New York: Cambridge University Press.

    Google Scholar 

  • Good, Byron, and Mary-Jo DelVecchio Good. 1993. Learning medicine: The constructing of medical knowledge at Harvard Medical School. In Knowledge, power and practice: The anthropology of medicine and everyday life, eds. Shirley Lindenbaum, and Margaret M. Lock, 81–107. Berkeley: University of California Press.

    Google Scholar 

  • Graham, Ian D., Jo Logan, Margaret B. Harrison, Sharon E. Straus, Jacqueline Tetroe, Wenda Caswell, and Nicole Robinson. 2006. Lost in knowledge translation: Time for a map? Journal of Continuing Education in the Health Professions 26: 13–24. https://doi.org/10.1002/chp.47.

    Article  Google Scholar 

  • Hirsh, David A., S. Eric, Holmboe, and Olle ten Cate. 2014. Time to trust: Longitudinal integrated clerkships and entrustable professional activities. Academic Medicine 89: 201–204. https://doi.org/10.1097/ACM.0000000000000111.

    Article  Google Scholar 

  • Jonson Albert R., and Stephen Toulmin. 1988. The abuse of casuistry: A history of moral reasoning. Berkeley: University of California Press.

    Google Scholar 

  • Keel, Othmar. 2001. L’avènement de la médecine clinique moderne en Europe: 1750–1815. Politiques, institutions et savoirs. Montréal: Les Presses de l’Université.

    Google Scholar 

  • Kinsella, Elizabeth A., and Allan Pitman, eds. 2012. Phronesis as professional knowledge: Practical wisdom in the professions. Rotterdam: Sense Publishing.

    Google Scholar 

  • Lave, J., and E. Wenger. 1991. Situated learning: Legitimate peripheral participation. Cambridge: Cambridge University Press.

    Book  Google Scholar 

  • Leif, Harold I., and Renée C. Fox. 1963. Training for ‘Detached concern’ in medical students. In The psychological basis of medical practice, eds. Harold I. Lief, Victor F. Lief and Nina R. Lief, 12–35. New York: Harper and Row.

    Google Scholar 

  • Leucht, Stefan. 2007. Psychiatric treatment guidelines: Doctors’ non-compliance or insufficient evidence? Acta Psychiatrica Scandinavica 115: 417–419. https://doi.org/10.1111/j.1600-0447.2007.01030.x.

    Article  Google Scholar 

  • Lugtenberg, Marjolein, Judith M. Zegers-van Schaick, Gert P. Westert, and Jako S. Burgers. 2009. Why don’t physicians adhere to guideline recommendations in practice? An analysis of barriers among Dutch general practitioners. Implementation Science 4: 54. https://doi.org/10.1186/1748-5908-4-54.

    Article  Google Scholar 

  • MacIntyre, Alasdair. 1981. After virtue. Notre Dame: Notre Dame Universty Press.

    Google Scholar 

  • Marcum, James A. 2008. An introductory philosophy of medicine: Humanizing modern medicine. Berlin: Springer.

    Google Scholar 

  • Merleau-Ponty, Maurice. 1967. L’œil et l’esprit. Paris: Gallimard.

    Google Scholar 

  • Mol, Annemarie. 2002. The body multiple: Ontology in medical practice. Durham: Duke University Press.

    Book  Google Scholar 

  • Mol, Annemarie. 2008. The logic of care: Health and the problem of patient choice. London: Routledge.

    Book  Google Scholar 

  • Morse, Janice M. 2004. Purposive sampling. In The SAGE encyclopedia of social science research methods, eds. Michael S. Lewis-Beck, Alan Bryman, and Tim Futing Liao, 885. Thousand Oaks: SAGE Publications.

    Google Scholar 

  • Nicolini, Davide. 2012. Practice theory, work, and organization: An introduction. Oxford: Oxford University Press.

    Google Scholar 

  • Nigam, Amit. 2012. Changing health care quality paradigms: The rise of clinical guidelines and quality measures in American medicine. Social Science and Medicine 75: 1933–1937. https://doi.org/10.1016/j.socscimed.2012.07.038.

    Article  Google Scholar 

  • Olmsted, James M.D. 1935. The influence of Claude Bernard on medicine in the United States and England: Part I. California and Western Medicine 42: 111–113.

    Google Scholar 

  • Peabody, Francis W. 1927. The care of the patient. Journal of the American Medical Association 88: 877–882. https://doi.org/10.1001/jama.1927.02680380001001.

    Article  Google Scholar 

  • Pellegrino, Edmund D., and David C. Thomasma. 1993. The virtues in medical practice. Oxford: Oxford University.

    Google Scholar 

  • Reading, Anthony. 1977. Illness and disease. Medical Clinics of North America 61: 703–710.

    Article  Google Scholar 

  • Roper, William L., William Winkenwerder, M. Glenn, Hackbarth, and Henry Krakauer. 1988. Effectiveness in health care. An initiative to evaluate and improve medical practice. New England Journal of Medicine 319: 1197–1202. https://doi.org/10.1056/NEJM198811033191805.

    Article  Google Scholar 

  • Rosenberg, Charles E. 2007. Our present complaint: American medicine, then and now. Baltimore: Johns Hopkins University Press.

    Google Scholar 

  • Royal College of Physicians and Surgeons of Canada. 2014. Competence by design (CBD): Moving towards competency-based medical education. http://www.royalcollege.ca/portal/page/portal/rc/resources/cbme. Accessed 22 Mar 2018.

  • Ryle, Gilbert. 1945. Knowing how and knowing that: The presidential address. Proceedings of the Aristotelian Society 46: 1–16.

    Article  Google Scholar 

  • Saraga, Michael, Régis Marion-Veyron, Frederic Stiefel, and Céline Bourquin. 2016. Trois aspects de l’éthos médical. Revue Médicale Suisse 12: 296–298.

    Google Scholar 

  • Saraga, Michael, Abraham Fuks, and J. Donald Boudreau. 2014. George Engel’s epistemology of clinical practice. Perspectives in Biology and Medicine 57: 482–494. https://doi.org/10.1353/pbm.2014.0038.

    Article  Google Scholar 

  • Sartre, Jean-Paul. 1943. L’être et le néant. Essai d’ontologie phénoménologique. Paris: Gallimard.

    Google Scholar 

  • Schultz, Dawson S., and Franco A. Carnevale. 1996. Engagement and suffering in responsible caregiving: On overcoming maleficience in health care. Theoretical Medicine 17: 189–207. https://doi.org/10.1007/BF00489445.

    Article  Google Scholar 

  • Smith, Jonathan A., Paul Flowers, and Michael Larkin. 2009. Interpretative phenomenological analysis: Theory, method and research. London: SAGE Publications.

    Google Scholar 

  • Svenaeus, Frederik. 2003. Hermeneutics of medicine in the wake of Gadamer: The issue of phronesis. Theoretical Medicine 24: 407–431. https://doi.org/10.1023/B:META.0000006935.10835.b2.

    Google Scholar 

  • Svenaeus, Frederik. 2014. Empathy as a necessary condition of phronesis: A line of thought for medical ethics. Medicine, Health Care and Philosophy 17: 293–299. https://doi.org/10.1007/s11019-013-9487-z.

    Article  Google Scholar 

  • Weatherall, Mark W. 1996. Making medicine scientific: Empiricism, rationality, and quackery in mid-Victorian Britain. Social History of Medicine 9: 175–194. https://doi.org/10.1093/shm/9.2.175.

    Article  Google Scholar 

  • Weinmann, Stefan, Markus Koesters, and Thomas Becker. 2007. Effects of implementation of psychiatric guidelines on provider performance and patient outcome: Systematic review. Acta Psychiatrica Scandinavica 115: 420–433. https://doi.org/10.1111/j.1600-0447.2007.01016.x.

    Article  Google Scholar 

  • Weisz, George, Alberto Cambrosio, Peter Keating, Loes Knaapen, Thomas Schlich, and Virginie J. Tournay. 2007. The emergence of clinical practice guidelines. Milbank Quarterly 85: 691–727. https://doi.org/10.1111/j.1468-0009.2007.00505.x.

    Article  Google Scholar 

  • Whitehead, Cynthia R., Brian D. Hodges, and Zubin Austin. 2013. Dissecting the doctor: From character to characteristics in North American medical education. Advances in Health Sciences Education 18: 687–699. https://doi.org/10.1007/s10459-012-9409-5.

    Article  Google Scholar 

  • Wiener, Carolyn L. 2000. The elusive quest: Accountability in hospitals. New York: Aldine de Gruyter.

    Google Scholar 

  • Zwolsman, Sandra, Ellen te Pas, Lotty Hooft, Margreet Wieringa-de Waard, and Nynke van Dijk. 2012. Barriers to GPs’ use of evidence-based medicine: A systematic review. British Journal of General Practice 62: e511–e521. https://doi.org/10.3399/bjgp12X652382.

    Article  Google Scholar 

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Authors and Affiliations

  1. Centre Hospitalier Universitaire Vaudois, Liaison Psychiatry, Av. de Beaumont 23, 1011, Lausanne, Switzerland

    Michael Saraga

  2. Faculty of Medicine, Center for Medical Education, McGill University, Montreal, Canada

    Donald Boudreau

  3. Department of Medicine, McGill University, Montreal, Canada

    Abraham Fuks

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  1. Michael Saraga
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Correspondence to Michael Saraga.

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Saraga, M., Boudreau, D. & Fuks, A. Engagement and practical wisdom in clinical practice: a phenomenological study. Med Health Care and Philos 22, 41–52 (2019). https://doi.org/10.1007/s11019-018-9838-x

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