Participants conveyed many different practice virtues but no one participant conveyed all 15 virtues. The more experienced participants conveyed more of the virtues than the less experienced participants. This finding connects to the neo-Aristotelian framework of practice virtues constructed by MacIntyre  and advocated by Carr . MacIntyre suggests determining the practice virtues across a peer group of practitioners rather than individual moral characters. This fits with the notion of diversity in practitioner contributions bringing a more robust set of virtues to the practice [25, 42]. The consolidated 15 virtues we present here represent a “starter-set” of virtues for medical practice that are open for debate and challenge from others. As a non-prescriptive debating resource, this combined phronesis offers a powerful way for those in medical education and practice to debate forms of decision-making to serve the best interest of patients and their communities. The arts-based element of the analysis was used to produce a seven-part video series, which is an enacted form of our participants’ ‘collective practical wisdom’. The videos offer a highly accessible form of moral debating resource for reflection before, during and after medical decision-making (for an example see episode 3 at: https://www.youtube.com/watch?v=Azkxeddnlpg).
We present our findings as a “virtue continua” (Table 2) before presenting them in text form. The virtue continua show the virtues conveyed by our interviewees in their narratives. Each virtue extends from pole-to-pole via a mean.
Here we present four examples from Table 2, above, to demonstrate how the data supported the analysis. Additional file 1 shows all the 15 virtues gleaned from the participants’ narratives and Additional file 2 the virtues from observation data.
Many participants produced narratives about negotiating with patients and others when making decisions about treatment. Some conveyed the doctor’s role as providing suitable and relevant information to enable patients/carers to come to a decision. However, other narratives reflected that providing expert advice and guidance in the light of clinical facts was important to patients while also taking patients’ views into account. This enabled informed choice in partnership with the patient:
I guess that would be my approach, just to seek out as many facts as I possibly could on the one hand, and for more… difficult decisions, just talking to the patient and trying to get to know them a bit better and their kind of particular outlook ….. and then possibly based on that, kind of guide them to a decision that I think might suit them better. (B102).
Experienced doctors spoke about the importance of dialogue and how exchanging information resolves conflicts and enables patients to make an informed choice:
[A] a constructive conversation both ways. I’ve got something to say but let’s not jump to a decision now, because that would be wrong. (BX02).
However, decisiveness was respected both by doctors-in-training and by some patients they encountered. It was reported that some patients implicitly sought paternalistic guidance, as they may find decision-making burdensome, relying on the doctor’s expertise and knowledge to guide them:
Sometimes people do respond well actually to someone taking control of the situation, even if it’s in a way that you would think would surely be completely inappropriate, but [the patients] respond well to it. (B112).
A FY doctor reflected (in their diary) on the distress caused knowing fully well that if a surgical procedure is not conducted it would prove fatal for the patient but agreed to the request of the patient:
I felt very sorry for the patient, and a little disturbed at the idea that this was almost certainly going to kill her…… I therefore found it difficult to reconcile my wish to respect her autonomy and her decision making, and the horrific consequences of her choice. (W 108).
Sometimes, some participants said that persuading patients in their best interest is necessary because:
[A] patient doesn’t understand the severity of the decision they’re making, and perhaps only when they’ve seen people who don’t have the procedure done or don’t have an operation might they learn… the actual nature of the decision they’re making, because we see it, whereas they don’t. (WX02).
Sometimes doctors, led by patient autonomy, assume the role of information providers, enabling patients’ decisions to be implemented:
But, for me, a good decision is one where the patient is the one who essentially makes the decision, or puts forward their wishes, and we then, as the clinicians, allow that decision to come to fruition. (B107).
Collaboration (Being Collaborative/seeking guidance) (V.5)
Many participants narrated stories about the present-day clinical paradigm being where professionally isolated decision-making is often neither advisable nor possible. Seeking to involve all those entrusted with a particular patient’s care allowed holistic, tailored decisions. Counsel from multiple parties and professional guidelines was reported to be valuable. This was corroborated by our observations of different MDT meetings. When making decisions for complex cases, team members frequently found that the progressive decisions reached and displayed on the whiteboards were useful, as “they help prioritise and review decisions.” (Obs.1).
Guidelines, though useful, require contextual awareness that can be provided by those who know the patient well, such as:
[T]he nursing staff who cared for the patient throughout, I relied on hugely …and even the night sister … just made it more logical, and decision-making more logical. I do rely on my consultants for the ultimate decision quite a lot of the time. (BX01).
In observation 2, the roles of the occupational therapist (OT), physiotherapist (PT) and speech therapist were seen to be central to certain patients’ treatment because they had the most up-to-date information. The Registrars and Consultant relied on the OT and PT to provide almost the whole information summary. These collaborative discussions become critically important when making “deprivation of liberty” decisions. This observation made it clear that:
The lead consultant would ask questions and appeared to be kind of taking it all in, cross-referencing information he got with his records on his computer. More often than not, he would defer to the decisions of the PT and OT…..The nurse had a lot of say as well about how patients were progressing towards their goals. (Obs. 2).
This approach was not universal, though. At another MDT observation (Obs. 3), the discussions were mostly contained amongst the doctors, with barely any input from other staff.
Most medical students were of the view that it is far better for “not-so-experienced doctors” to defer to people with more experience:
[Y]ou know, bigger decisions, you’re not going to want to take that onto yourself, you’re going to defer to people that have got the experience. (W203)
Several newly trained doctors conveyed that they appreciated the opportunities to seek guidance from, and feel reassured by, more experienced doctors. This was observed (Obs. 3) in an Emergency Department environment, when the junior doctor requested the Consultant to discuss “an older patient with complex health and social problems”, because:
…. they’ve probably made that [decision] before and they can tell you with experience the outcome and why. And they might come up with ideas as to why your idea might not be the best for that patient. (W101).
Experienced doctors also conveyed that they seek guidance in challenging cases as it helps them clarify the situation and make better decisions:
…sometimes that consensus is really useful because you’re basically going through the arguments … and again clarifying some of the aspects of it, I think. (BX11)
Some participants referred to guidelines being interpreted contextually. This could result in referring to more experienced doctors to gain insights into wider interpretations of the guidelines:
…so we’ve got an SHO ….[with] very good book knowledge, he’s very academic, [and] knows the guidelines for everything off by heart but he doesn’t really have a grasp of the fact that not every patient can be treated as per guidelines. And we’ve been trying to explain to him that a guideline is just that, it’s a guideline, it’s not rigid; it’s meant to guide your practice….. he’s had real issues with not calling for senior support because he feels that he’s got a guideline to follow and that he follows it.. (WX05).
Cultural competence (V.6)
Some stories conveyed that respecting patients’ values and beliefs is important. Many of the participants said that they consult their colleagues to understand cultural issues. However, some participants narrated experiences where the doctor chose to follow their own beliefs and values, rather than the patients’. One doctor experienced a situation where a doctor refused an intervention that challenged their personal beliefs leading to treatment delay. They said:
[I]t is important to park your own values. You should not allow those values to affect the decision. (BX04).
Similarly, reflecting in their diary a FY doctor wrote:
However, one point I am completely certain of is the importance of professionalism. I feel one should never impose their views on to a patient (W103).
A 5th Year medical student told of a consultation in a sexual health clinic, where the doctor seemed judgemental towards a patient:
[H]e said something like, ‘Are you gay or straight?’ or something. Just, like, which is incorrectly phrased? There’s far more, like, tactful ways to do it. But he, kind of, shouted at them, so, ‘Are you gay?’ kind of thing. (B501).
Cross-cultural sensitivity was stated to be important in building trust. Rehabilitation, for example, is conveyed as following a “white Anglo-Saxon” model. An experienced doctor explained:
I think there’s – generally there’s mistrust of the NHS that we pull out too soon, and we don’t do everything that’s possible,…………. don’t do everything we should be doing.. but that’s compounded by a cultural view of life I think….. there is[at times] a cultural clash, so there is mistrust that can be on both sides. The only way to get around that is to recognise that there is a difference in view and maintain open dialogue. (BX05).
Emotional Intelligence (including Interpersonal communication) (V.7)
Good interpersonal communication was conveyed as commendable by our participants, because:
[Y]ou can be the greatest doctor in the world but if you can’t communicate, nobody will do what you say, will they? (BX103).
However, some conveyed that having the clinical knowledge regarding the disease is also essential:
[Y]ou can be a very compassionate person, but a useless doctor if you don’t know what you’re doing. (W207),
Some participants narrated experiences where an apparent lack of interpersonal communication skills was displayed by a doctor:
…the clinician who saw her [the patient] wasn’t very communicative and reassuring in his approach to the patient… [the patient] was having a miscarriage, [the clinician] left it at that; left the room, and I was standing there with a very distraught couple… I told the clinician and he said, ‘Oh they’ll probably figure it out some way along the line’. And wasn’t very keen on going back and telling the patient – reassuring them. (W502).
Others conveyed how empathic communication made patients amenable to discussion:
I think you have to, I suppose, temper your objective, rational facts for your decision-making process in a way that comes across as empathetic and sympathetic and looking at a bigger picture beyond the current situation; and also to help parents to think about things from their baby's view. (BX12).
The development of practical wisdom was conveyed by most interviewees as sequentially experiential. One medical student termed it “learned experience” (N203), while a FY doctor spoke of it as a “mix of nurture and nature” (B104, Follow-up). For one experienced doctor:
…some people are inherently wiser, they are really wise people…now, whether that wisdom is inherent or … is simply because that person has walked past that journey ahead of me. (NX05).
Experience can, however, lead to an assumption about personal knowledge. Another FY doctor recounted how the Consultant seemed to show a lack of compassion and so:
“… experience makes you better at making clinical decisions… but not necessarily in terms of ethical decisions… a lot of people get stuck in their ways. (B504)
Assuming that they “know it all” and following a textbook approach can, according to another participant, cause a doctor to be caught out:
You can’t make a decision based on what the textbooks say… because if the textbooks say it, you can only say that that’s right 99% of the time. There will always be the one case that will catch you out if you treat everybody the same… there’s things that are really rare, but they still happen. (WX02).
An experienced doctor reported another risk that arises with experience and seniority as being “arrogant or foolhardy.” (BX04). Similarly, another experienced doctor reported on a senior consultant who regularly over-ruled based on experience rather than book knowledge:
Because evidence-based medicine tells you something else, but the experience of this doctor was something different, so there is, kind of, a clash between the two, rather than both going forward in a symbiotic relationship…. Which is why I'm wary of saying that wisdom is the most important thing. (NX04).
Phronesis was variously described as the collation of holistic information, both clinical and social, from different sources, as well as being able to weigh that up against protocols, guidelines, various situations encountered in the past and then getting other “opinions, other approval, putting the situation to a new pair of eyes, and saying okay this is what I have got here.” (B106).
But for some medical students, phronesis seemed to be narrowly defined as diagnostic skills (i.e. techne) as opposed to the broader process of a holistic decision-making (as described by FY and experienced doctors):
You know you learn by example, by following what someone else is doing… the art and the science of medicine… you need the clinical knowledge and then you need the experience to know how to apply it and when to apply it. (W207).
Another medical student spoke of consultants with a “repertoire of patterns” (W209). However, experience and “time served” were not enough to guarantee wise decision-making, and certain other virtues were seen as key to phronetic decisions. For instance, being reflective, “open to insight” (WX04) and being consultative: “ always questioning what the right thing to do is.” (B110). There were those who considered it as intuition, “a sixth sense” (NX02).
Phronetic decisions were often seen as the avoidance of the rigid application of rules and guidelines, what was termed by one experienced doctor as the “protocolisation of medicine” (WX03). In medicine “it is this difficulty of managing an illness rather than treatment of an illness which is the more difficult bit and there are never going to be mathematically accurate answers.” (WX06).
Phronetic decisions were often conveyed as practical and experiential:
… where wisdom comes from, it’s a lot of thinking back to your past experiences and what you did badly, what you did well and trying to apply that… You’ve just got to think about in an ideal world what you want to do, and then think how you could possibly get as close to that with what you’ve got. (B110 FP).