​PHRONESIS PROJECT

Most agree that traditional medical training is insufficient to meet our nation’s current and predicted healthcare needs. [1-5] The 2010 Carnegie Foundation call for reform found that “medical training is inflexible, overly long, and not learner-centered.”[1] Medical students will need to be better trained to provide high value activities such as behavior change, in order to influence the health of their patients. They will need to form close relationships with patients in order to authentically and effectively explore wise choices in health care that meet the deeper goals of their patients. Medical students, previously trained primarily in the hospital setting, need to begin early in their training to see the world of health care with a different lens, starting with the patient in their community. In the world of population-based health care, the doctor’s job is no longer to treat only the patient who comes into the clinic or the hospital, but also overseeing the health of their population, whether the patients present to a clinic or not. Training students to see themselves as integral members of a health care team, to form effective relationships with patients, and to deliver high value care, requires a new way of seeing themselves and their patients, a completely new formation process for young physicians. This kind of training requires a dramatic shift in their clinical experiences from their first day in training. To that end, we began the Phronesis Project, a longitudinal formation curriculum in which the students are critical members of the accountable care organization health care team, taking on developmentally appropriate responsibility for their patients throughout their training.

 

Why wisdom?

 

The calls for change in our health care systems have strikingly similar themes: they call for a culture of compassion; other-centeredness and self-awareness; relationships and collaboration; teamwork; embracing complexity; applying knowledge to discern the right action; and a re-focusing on the greater good. Consider for a moment the characteristics generally associated with wise persons: understanding the deeper meaning of things, knowing the limits of knowledge, tolerating ambiguity, engaging in reflective and self-reflective thinking, showing compassion and sympathy toward others, and the capacity to be other-centered. It is interesting that the ABIM chose to name their campaign to reduce unnecessary testing and treatment the “Choosing Wisely” campaign. It takes wisdom to provide truly high value care. A clinician must be able to understand and respect the deeper goals in the patient’s life. In order to reduce unnecessary testing and treatment, the clinician must be continuously aware of the limitations of medical knowledge and be able to accept (and help their patients accept) the uncertainties and ambiguities in life. To help patients with behavior change, they must be able to see and foster the best in their patients. In helping patients through the most difficult experiences of their lives, clinicians must be able to guide their patients with compassion. As William Branch suggests, “wisdom is what we should be striving for in our development as clinicians” and “seeking wisdom should be embedded in our culture.” It is fitting that wisdom development should be the formation framework for students embarking on professions that require exceptional knowledge and skill; the capacity to apply that knowledge and skill in the best possible way; and to display the most profound trustworthiness, other-centeredness, and devotion to the greater good.  

 

We have designed our curriculum to reflect Monika Ardelt's three-dimensional framework to describe and measure wisdom. Below, we list Ardelt’s definitions and the key concepts that students will practice during their Phronesis experience. 

 

Reflective. A perception of phenomena and events from multiple perspectives. Requires self-examination, self-awareness, and self-insight.

 

Key concepts in medicine:

• mindful medical practice including awareness of interpersonal dynamics to improve relationship skills and skills in behavior change;

• self-awareness in clinical decision-making to reduce errors;

• situational awareness in critical situations;

• awareness of human factors, how they contribute to errors and how to mitigate their effects to improve safety.
   

Cognitive. Ability to apply knowledge and skill to right action, understanding the deeper meaning of things, awareness of the inherent limits of knowledge, and an awareness of the unpredictability, ambiguity and uncertainty in life.

 

Key concepts in medicine:

• understanding complexity;

• avoiding inappropriate simplification in clinical decision-making;

• probing meaning and life goals with patients in shared decision-making;

• understanding and awareness of the limits of knowledge; awareness of the possibility of mistakes;

• ability to honestly evaluate, disclose and learn from these mistake; 

• learning to work in teams to reduce errors due to human fallibility.

 

Compassionate. Compassion and a desire to foster the well being of all, requires the transcendence of self-centeredness.

 

Key concepts in medicine:

• compassion is a fundamental necessary capacity for all health professionals;

• fostering compassion involves fostering an environment of compassion;

• understanding the challenges to compassionate care;

• fostering meaning in their work;

• finding the best in one another and fostering positive emotion.