Seeking medical wisdom: Development of a physician-defined practical model of wise competence

Abstract

Purpose: Medical practice is complex, ambiguous and dynamic. It requires more than technical knowledge; it necessitates the application of wisdom. Unfortunately, integration of the wisdom construct into established U.S. medical competency frameworks has been difficult. This study explored this interdisciplinary problem by investigating how academic physicians define medical wisdom (MW) and discern barriers and facilitators to such integration.

Method: Investigators conducted in-depth, semi-structured interviews with 19 faculty physicians at 3 U.S. academic medical centres. They probed physicians' definitions of MW and perceived barriers and facilitators to the development of MW. Interview data were analysed using thematic analysis (TA). TA results and insights from non-medical models of wisdom and complex problem-solving supported the creation of a model of MW. Polarity mapping of the moral economies of medical wisdom and medical science was utilized to clarify the challenges and opportunities of integrating these two philosophically distinct paradigms.

Results: TA of transcripts suggests physicians understand MW as consisting of interactions between 3 core components: adaptive capacity, values and technical knowledge. This finding and insights on their integration derived from non-medical models of wisdom supported the creation of a tripartite model of medical wisdom (TMMW) with features of complex adaptive systems (CAS). Polarity mapping of the moral economies of medical wisdom and medical science highlighted differences in assumptions, values and practices between the two paradigms. Barriers and facilitators identified through TA reinforced the relevance of these differences to difficulties in incorporating wisdom into established medical competency frameworks.

Conclusions: Wise competence is the ability to integrate medical knowledge with clinical context and patient wishes to deliver patient-centered care. The TMMW offers a mental model of such integration with features of CAS and a critical role for metacognition. Introduction of MW models into established competency frameworks may benefit from explicit acknowledgement of each paradigm's underlying moral economies.

FIGURE 1

The tripartite model of medical wisdom (TMMW) depicts wisdom as a complex construct representing the integration of three core components: knowledge, values and adaptive capacity. Themes from the TA are grouped with each component (see inset for adaptive capacity). Three established structural models of wisdom and complex problem‐solving share homology in content and organization with the TMMW strengthening support for the TMMW and offering insights on the adaptive and integrated nature of medical wisdom., , [Color figure can be viewed at wileyonlinelibrary.com]

FIGURE 2

Differences in imperatives between the moral economies of medical science and medical wisdom offer philosophical resistance to the conception of “wise competence” (upper half of figure). Barriers and facilitators to the conception of “wise competence” identified by TA correspond to tensions between these two moral economies. The traditional ACGME competency framework organizes clinical competencies in a manner that supports the analytic and predictive imperatives of medical science (lower left). The integrated TMMW framework nests the ACGME competencies into a structure that better supports the holistic and adaptive imperatives of wisdom (lower right). Abbreviation: ACGME, Accreditation Council for Graduate Medical Education. [Color figure can be viewed at wileyonlinelibrary.com]