Discovering clinical phronesis.

Phronesis is often described as a 'practical wisdom' adapted to the matters of everyday human life. Phronesis enables one to judge what is at stake in a situation and what means are required to bring about a good outcome. In medicine, phronesis tends to be called upon to deal with ethical issues and to offer a critique of clinical practice as a straightforward instrumental application of scientific knowledge. There is, however, a paucity of empirical studies of phronesis, including in medicine. Using a hermeneutic and phenomenological approach, this inquiry explores how phronesis is manifest in the stories of clinical practice of eleven exemplary physicians. The findings highlight five overarching themes: ethos (or character) of the physician, clinical habitus revealed in physician know-how, encountering the patient with attentiveness, modes of reasoning amidst complexity, and embodied perceptions (such as intuitions or gut feeling). The findings open a discussion about the contingent nature of clinical situations, a hermeneutic mode of clinical thinking, tacit dimensions of being and doing in clinical practice, the centrality of caring relations with patients, and the elusive quality of some aspects of practice. This study deepens understandings of the nature of phronesis within clinical settings and proposes 'Clinical phronesis' as a descriptor for its appearance and role in the daily practice of (exemplary) physicians.

An empirical and philosophical exploration of clinical practice.

BACKGROUND: Previous empirical work among physicians has led us to propose that clinical practice is experienced by clinicians as an engagement-in-the-clinical-situation. In this study, we pursue our exploration of clinical practice 'on its own terms' by turning to the experience of patients. METHODS: Phenomenological analysis of in-depth individual interviews with 8 patients. RESULTS: We describe the patient experience as a set of three motifs: the shock on the realization of the illness, the chaos of the health care environment, and the anchor point provided by an engaged physician. We draw on Heidegger's notion of solicitude to show that patients are actively ascertaining the physician's engagement in their care. CONCLUSIONS: These findings lead us to question the classical "dual discourse" of medicine that offers a dichotomous account of clinical practice as the addition of care to cure, art to science, humanism to technique, and person to medical case. We found no such distinctions in our empirical investigation of clinical practice. Rather, in our synthesis, practice appears as a unitary experience. The physician's solicitude for the patient entrains engagement in the clinical situation. Moreover, the solicitous, engaged physician constitutes an anchor point for the patient.

Engagement and practical wisdom in clinical practice: a phenomenological study.

In order to understand the lived experiences of physicians in clinical practice, we interviewed eleven expert, respected clinicians using a phenomenological interpretative methodology. We identified the essence of clinical practice as engagement. Engagement accounts for the daily routine of clinical work, as well as the necessity for the clinician to sometimes trespass common boundaries or limits. Personally engaged in the clinical situation, the clinician is able to create a space/time bubble within which the clinical encounter can unfold. Engagement provides an account of clinical practice as a unitary lived experience. This stands in stark contrast to the prevailing notion, referred to as a dual discourse, that describes medicine as the addition of humanism to science. Drawing on Aristotle's notion of phronesis and Sartre's definition of the situation, we illustrate how this novel perspective entwines clinical practice, the person of the clinician, and the clinician's situation.

Twelve tips for conducting a medical education journal club.

BACKGROUND: Journal clubs are active at many universities and they involve many specialties and subspecialties. There is a surprising dearth of journal clubs which deal with articles related to the science of medical education. AIMS: In an effort to expose medical educators to the outstanding benefits of medical education journal clubs we have devised a set of twelve tips to success for such clubs. METHODS: We conducted a survey of journal club directors at the nine Canadian medical schools known to conduct education journal clubs. We also conducted interviews with all members of the McGill University Centre for Medical Education. RESULTS: Combining the results from these two information sources allowed us to develop an approach to assuring success in medical education journal clubs.

Aortic rhythmic wrinkling in youth: the PDAY study.

Transverse, white-streak 'wrinkles' in the aorta were first described as Querlinien (cross lines) or Wellenlinien (wave lines) in the German literature in the early 20th century. These rhythmic structures were previously thought to be artifacts of stretching and shrinkage of the aorta. Not until the 1970s was it proposed that the areas of rhythmic wrinkling (RW) might be part of the process of atherosclerosis. We analyzed 2,650 aortas from the Pathobiological Determinants of Atherosclerosis in Youth (PDAY) study for prevalence, extent, and topographical distribution of these areas of RW. Furthermore, we investigated the possible relationship of RW to atherosclerotic sudanophilic stained 'fatty streaks' and elevated intimal lesions called 'raised lesions' (RL). This study provides evidence that (1) the prevalence of RW is fairly high in the aorta and occurs in a specific distribution in both the thoracic and abdominal aorta; (2) RW seems to precede the development of RL, with RL occurring in the same topographical areas as RW; and (3) RW may be associated with the subsequent development of advanced atherosclerosis, particularly raised lesions.

Adipose tissue triglyceride fatty acids and atherosclerosis in Alaska Natives and non-Natives.

Essential polyunsaturated fatty acids (PUFA) of the omega-3 family are believed to protect against cardiovascular disease. A rich source of omega-3 PUFA is found in fish and marine mammals (seal, walrus, whale), which are a large part of the traditional diet of Alaska Natives (Eskimo, American Indians, Aleuts), a group that has been reported to have a lower mortality rate from cardiovascular disease than non-Natives. An autopsy study using standardized methods to evaluate the extent of atherosclerosis and its risk factors, and analyses of stored triglyceride fatty acids was conducted in a sample of Alaska Native subjects and non-Native subjects living in Alaska. Findings indicate that Alaska Natives had less advanced atherosclerosis in coronary arteries, along with higher proportions of omega-3 and lower proportions of omega-6 PUFA in adipose tissue, than did non-Natives. We conclude that high dietary intake of omega-3 PUFA may account for the lower extent of coronary artery atherosclerosis, contributing to the reported lower heart disease mortality among Alaska Natives.

ACE insert/delete polymorphism and atherosclerosis.

We report on the results of a large autopsy study focusing upon the hypothesis that deletion of the Alu insert in the angiotensin converting enzyme (ACE) gene is associated with: (a) greater prevalence or extent of atherosclerosis in the aorta and coronary arteries; and (b) microscopic qualities of established atherosclerotic plaques in the coronary arteries. This study was conducted in young US black (n=290) and white (n=379) males using available materials and data from the Pathobiological Determinants of Atherosclerosis in Youth (PDAY) study, a multi-center cooperative autopsy study organized in 1985 to explore the relationships of known cardiovascular risk factors to atherosclerosis in victims of accidents, homicides, or suicides in the age range of 15-34 years. The results provide strong evidence that ACE genotype may not be a predictor of either the prevalence or the extent of the lesions of atherosclerosis in the right coronary artery or the aorta of young adults, an observation that confirms previous studies that estimated the prevalence and extent of atherosclerosis using coronary angiography. In addition, the results suggest that ACE genotype does not contribute to the formation of atherosclerotic lesions that have the characteristics of vulnerable plaques in the left anterior descending coronary artery of young adults.

The ATM gene is a target for epigenetic silencing in locally advanced breast cancer.

Several epidemiological studies on ataxia-telangiectasia families indicate that obligate ATM heterozygotes display an elevated risk for developing breast cancer. However, a molecular basis for a potential link between diminished ATM function and sporadic breast malignancy remains elusive. Here, we show that 78% (18 out of a panel of 23) of surgically removed breast tumors (stage II or greater) displayed aberrant methylation of the ATM proximal promoter region as judged by methylation-specific PCR. Aberrant methylation of the ATM promoter was independently confirmed in several tumors by bisulfite sequencing. Moreover, bisulfite sequencing indicated that this region of the genome is subject to dense methylation. Further, we found a highly significant correlation (P = 0.0006) between reduced ATM mRNA abundance, as measured by real-time RT-PCR, and aberrant methylation of the ATM gene promoter. These findings indicate that epigenetic silencing of ATM expression occurs in locally advanced breast tumors, and establish a link at the molecular level between reduced ATM function and sporadic breast malignancy.

Atherosclerosis in coronary arteries and aorta among Greenlanders: an autopsy study.

In a cross-sectional autopsy study of 107 Inuit in Greenland, the extent of arterial surface involvement with atherosclerosis was evaluated in the presence of known or estimated environmental risk factors for coronary heart disease (CHD): age, gender, obesity, serum lipids, smoking, and hypertension. Mean, median, and range values for all of the risk factor variables and for the extent of atherosclerosis in the thoracic aorta, abdominal aorta, right coronary artery, and left anterior descending coronary artery are reported by age strata, along with the results of covariant analysis of the dependence of the extent of atherosclerosis upon the risk factors. No significant differences between females and males were found in either the risk factors or prevalence and extent of atherosclerosis in the aorta and in the coronary arteries. It appears that the extent of advanced atherosclerotic lesions in Greenlanders appears to be the same as that previously reported in a similar study in Alaska Natives.

Integration of a statewide public hospital laboratory system.

Louisiana operates one of the largest public hospital and clinic systems in the nation, consisting of nine geographically dispersed hospitals, providing a full range of medical care to approximately 1 million low-income and indigent citizens. For many years, these hospitals were under the auspices of the State Department of Hospitals. In 1997, just at the end of a multi-million-dollar procurement project to install laboratory information systems at several of the sites, governance of the nine hospitals was transferred formally to Louisiana State University (LSU) under a new branch, the LSU Health Care Services Division. As a result of Y2K issues at several sites not originally included in the procurement, the LIS installation had to be expanded while facing a very critical implementation deadline. This article describes the procedural and organizational strategies used to successfully accomplish a major project of reorganization and systemic integration of nine geographically distant and disparate public hospital laboratories while simultaneously installing a new networked LIS at all sites within a relatively short span of 3 years.