Surgical wisdom as phronesis: An evidence-based hypothesis about "understanding… the great gray that exists in the field"

Abstract

Background: Surgeons make vital decisions in the face of uncertainty, yet, the development of surgical wisdom necessary to make these choices prudently remains understudied and undefined. On the basis of previous commentary, we asked whether phronesis, the ability to combine epistemic knowledge and technical skill and choose the best action from many possible right actions, provides a useful conceptual framework to explicate the notion of surgical wisdom.

Methods: We conducted a thematic analysis. One-hour in-depth semistructured interviews were conducted with a convenience sample of faculty surgeons from 2 hospitals. Participants described experiences observing, acting with, and teaching surgical wisdom. We interpreted our findings through our proposed lens of phronesis. We applied deductive and inductive thematic coding, with deductive codes based on previously established definitions and components of phronesis and inductive codes aimed to capture additional aspects of surgical wisdom. Authors read interview transcripts, applied codes, synthesized findings into main themes and subthemes by group consensus.

Results: Thirty-one surgeons participated. Surgeon participant comments provided empirical support for understanding surgical wisdom as phronesis, a capacity distinct from medical knowledge and technical skill that allows one to understand and competently make choices in situations characterized by competing values, ill-defined rules, and unique circumstances. Comments supported previously proposed functions of phronesis (constitutive, integrative, blueprint, emotional regulative). Novel themes emerged related to the building blocks necessary for the development of surgical wisdom: variety of experience, failure, openness to change/growth mindset, and challenging situations.

Conclusion: Phronetic knowledge and its associated functions and building blocks provide new concepts to help refine, restructure, and reconceptualize how surgeons view their developmental trajectory and the path to surgical wisdom. This research offers a vision of practice that can help redefine professional goals and our understanding of success as a surgeon.