Teaching practical wisdom in medicine through clinical judgement, goals of care, and ethical reasoning

Abstract

Clinical decision making is a challenging task that requires practical wisdom-the practised ability to help patients choose wisely among available diagnostic and treatment options. But practical wisdom is not a concept one typically hears mentioned in medical training and practice. Instead, emphasis is placed on clinical judgement. The author draws from Aristotle and Aquinas to describe the virtue of practical wisdom and compare it with clinical judgement. From this comparison, the author suggests that a more complete understanding of clinical judgement requires its explicit integration with goals of care and ethical values. Although clinicians may be justified in assuming that goals of care and ethical values are implicit in routine decision making, it remains important for training purposes to encourage habits of clinical judgement that are consciously goal-directed and ethically informed. By connecting clinical judgement to patients' goals and values, clinical decisions are more likely to stay focused on the particular interests of individual patients. To cultivate wise clinical judgement among trainees, educational efforts should aim at the integration of clinical judgement, communication with patients about goals of care, and ethical reasoning. But ultimately, training in wise clinical judgement will take years of practice in the company of experienced clinicians who are able to demonstrate practical wisdom by example. By helping trainees develop clinical judgement that incorporates patients' goals of care and ethical reasoning, we may help lessen the risk that 'clinical judgement' will merely express 'the clinician's judgement.'

Through students' eyes: ethical and professional issues identified by third-year medical students during clerkships: Table 1

“…Without clinical mentors to teach ethics and professionalism by example, it is hard for students to learn how to act wisely in challenging situations that require the integration of clinical judgement, ethical reasoning and careful communication 22. However, students can also benefit from opportunities during clerkships that allow them to write about and discuss with faculty the challenges they encounter, thereby reflecting on the relevance of ethical and professional values in clinical practice, especially when those values may be marginalised by the hidden curriculum 23.…”

Goals of care: a concept clarification

“…). For appropriate care, Kaldjian () explains that, ‘…the selection of goals is not only based on biomedical realities and available technology, but also on beliefs about matters as fundamental as the value of prolonging life, the acceptability of suffering, the significance of a given outcome probability and the financial implications of treatment’ (p. 560). Appropriateness was the most common component found in the definition of GOC and also the most common possible treatment outcome.…”

“…The implicit goal of health care is usually cure or survival (Bern‐Klug ), so in many clinical areas, GOC are ‘reasonably taken for granted’ and not explicitly stated (Kaldjian , p. 562). This can affect quality of patient care and cost.…”

Understanding Goals of Care Statements and Preferences Among Patients and Their Surrogates in the Medical ICU

“…4 Incorporating the patient's goals of care into discussions, along with efforts to clarify the diagnosis and prognosis, allows for a reasoned and directed approach to decision making about specific interventions. 5 It also reduces the risk of inappropriately basing medical decisions on a ‘technological imperative’ 6 that assumes a treatment should be used because it is available, rather than because it is likely to help patients reach the goals of care that are most important to them. Furthermore, by incorporating the patient's goals of care in medical decision-making it becomes more apparent why a particular clinical decision is ethically justifiable.…”

“…Furthermore, by incorporating the patient's goals of care in medical decision-making it becomes more apparent why a particular clinical decision is ethically justifiable. 5 …”