Complex decision making in medical training: key internal and external influences in developing practical wisdom

Abstract

Context Good judgement and the ability to make complex decisions are key attributes of a skilled professional. There has been limited study of doctors and their decision making, particularly in relation to making complex decisions. The study aims were to understand how trainee doctors develop practical wisdom through investigating their approach to difficult decision making, understanding the influences on the development of practical wisdom, and identifying potential interventions that may help develop this further. Methods Constructing an understanding of the process of developing practical wisdom was analysed within a social constructivist frame. The study investigated trainee doctors at different stages of their careers. Qualitative semi‐structured interviews were used to explore the approaches doctors take to difficult decision making, as well as the key training influences in learning these skills. Constant comparative analysis was carried out within a grounded theory approach. Results Key elements emerged from the data regarding the doctors themselves and the environments they worked in that assisted in developing decision making. This led to the construction of a conceptual model setting out the development of practical wisdom among trainee doctors. The model describes a process of gaining experience in decision making, moderated by key external and internal influences. The important roles of self‐efficacy and agency (relational) are highlighted as key enablers of the process. Discussion The implications of this model are considered in relation to postgraduate training of doctors. The importance of training doctors to be self‐regulated learners in learning environments that support their development is highlighted. Aspects of the clinical learning environment (structure) such as rotation structures, the culture, supervision and feedback can all be enhanced. Self‐efficacy and relational agency, alongside other internal influences, are key factors in accelerating development of practical wisdom. Other studies have shown that these factors can be improved with targeted interventions.

Aynı Üniversite Kliniğinden Mezun Olan Göğüs Hastalıkları Uzmanlarının Bronkoskopi Yetkinlikleri

“…The competency based education is student oriented, and based on learning by doing process and ensures that those who complete the process graduate with minimum necessary knowledge and skills (7). At the core of competency-based medical education is the requirement that learners demonstrate competence in the application of their learning to patient care (8). Interventional competencies include clinical knowledge, complex cognitive decision making (diagnosis, treatment planning), psychomotor skills (technical/practical skills) and post-operative (postoperative) care (6).…”

“…Key attributes of a professional skill are good judgement and the ability to make complex decisions. The doctors gaining experience in decision making moderated by external and internal factors where they worked in (8). The trainings on bronchoscopy competence should be organized on learner oriented approach.…”

The development of clinical thinking in trainee physicians: the educator perspective

“…Other research on context has sought to capture the medical trainees’ viewpoint in this regard [e.g. [ 16 – 18 ]. However, the focus of our work was on gaining the educator perspective since they, as noted above, are largely responsible for, and well placed to understand and comment on, the development of clinical thinking in trainee physicians.…”

Practical wisdom, a dormant character in medical education?

“…Deciding on the correct course of action to achieve good relies on knowing the situation, and vice versa. It also requires deliberation, reflection and judgement of what to do in different situations …”

“…It also requires deliberation, reflection and judgement of what to do in different situations. 9 Practical wisdom therefore brings together theory and practice; it cannot exist without both…”