Practical wisdom in complex medical practices: a critical proposal

In recent times, daily, ordinary medical practices have incontrovertibly been developing under the condition of complexity. Complexity jeopardizes the moral core of practicing medicine: helping people, with their illnesses and suffering, in a medically competent way. Practical wisdom (a modification of the Aristotelian phronèsis) has been proposed as part of the solution to navigate complexity, aiming at the provision of morally good care. Practical wisdom should help practitioners to maneuver in complexity, where the presupposed linear ways of operating prove to be insufficient. However, this solution is unsatisfactory, because the proposed versions of practical wisdom are too individualistic of nature, while physicians are continuously operating in varying teams, and dealing with complicated technologies and pressing structures. A second point of critique is, that these versions are theory based, and thus insufficiently attuned to the actual context of everyday medical practices. Now, our proposal is to use an approach of practical wisdom that enables medical practices to counter the complexity issue and to re-invent the moral core of medical practicing as well. This implies a practice oriented approach, as thematized by practice theory, qualitative empirical research from the inside, and abduction from actual performed practical wisdom towards an apt understanding of phronèsis.

     

Practical wisdom in health and social care: teaching for professional phronesis

The purpose of teaching ethics to nurses and other health and social care practitioners is not always clear. At the extremes of the continuum of aims sit (i) the teaching of ethics as a subject just like any other subject; and (ii) the teaching of ethics as a form of moral education. In this article, I outline the pedagogic tension this uncertainty creates before offering some insights into the educational implications of teaching ethics from the perspective of the ethics of Aristotle. In this conception, ethics is the pursuit of character development and specifically the development of practical wisdom, or what I have termed professional phronesis . I argue that while learning to approximate practical wisdom for nursing is possible, from the perspective of the ethics of Aristotle it is problematic for higher education. An Aristotelian approach has the potential to undermine the demarcation of teacher role as this is usually understood in higher education at the present time because, as I suggest, the best teachers of professional phronesis may turn out to be those practitioners (including practitioners of teaching) who exemplify the professional phronimos (or professionally wise practitioner).     

Pearls of the plain film

Three case presentations from a general rheumatologic practice show the importance of the plain x-ray in making the diagnosis of arthritis. Clinical history, physical examination, and the plain x-ray are likely to provide the diagnosis most often over laboratory and more technologically advanced imaging studies for arthritis.     

Detecting trends in noisy data series: application to biomarker series

It is common to define a change in health status or in a disease state on the basis of a sustained rise (or decline) in a biomarker over time. However, such observations are often subject to important variability unrelated to the underlying biologic process. The authors propose a method to evaluate rules that define an event on the basis of consecutive increases (or decreases) in the observations, given the presence of random variation. They examine how well these rules correctly identify a truly rising biomarker trajectory and, conversely, how often they can recognize a truly stable series or a slowly rising series. The method relies on simulation of realistic, sophisticated data sets that accurately reflect the systematic and random variations observed in marker series. These flexible, empirically based simulations enable estimation of the sensitivity and specificity of rules of consecutive rises as a function of the underlying trend, amount of random variation, and schedule of measurements (frequency and duration of follow-up). The authors illustrate the approach with postradiotherapy series of prostate-specific antigen, where three consecutive rises in prostate-specific antigen indicate treatment failure; the data are described by using a Bayesian hierarchical changepoint model. The method is particularly flexible and could be applied to evaluate other rules that purport to accurately detect upturns (downturns) in other noisy data series, including other medical data or other application areas.     

Practical measurement of affordability: an application to medicines

Objective

To develop two practical methods for measuring the affordability of medicines in developing countries.

Methods

The proposed methods – catastrophic and impoverishment methods – rely on easily accessible aggregated expenditure data and take into account a country’s income distribution and absolute level of income. The catastrophic method quantifies the proportion of the population whose resources would be catastrophically reduced by spending on a given medicine; the impoverishment method estimates the proportion of the population that would be pushed below the poverty line by procuring a given medicine. These methods are illustrated by calculating the affordability of glibenclamide, an antidiabetic drug, in India and Indonesia. The results were validated by comparing them with the results obtained by using household micro data for India and Indonesia.

Findings

When accurate aggregate data are available, the proposed methods offer a practical way to obtain informative and accurate estimates of affordability. Their results are very similar to those obtained with household micro data analysis and are easily compared across countries.

Conclusion

The catastrophic and impoverishment methods, based on macro data, can provide a suitable estimate of medicine affordability when the household level micro data needed to carry out more sophisticated studies are not available. Their usefulness depends on the availability of accurate aggregated data.     

Modeling the wisdom of journeying together: parish nursing and chaplaincy

We describe how a chaplain and a parish nurse built an interprofessional group within a hospital and used the process to increase attention to spiritual care within a hospital. We identify organizational and system characteristics that support this effort, in particular the importance of administrative support and the willingness of hospital staff to value their own spirituality as a resource for patients and family members.