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The primary purpose of dental education is to ensure that dentists improve and hone their clinical skills, expand their knowledge base, and increase clinical competence. Competence is the ability of clinicians to use that knowledge, execute the psychomotor skills, and apply professional attitudes to provide high-quality care in a safe environment.
Knowledge, craft, and character are the three foundation pillars that collectively ensure clinical excellence. Knowledge is concerned with how much the clinician knows, and theoretical understanding (head), craft is concerned with the clinician’s dexterity and manual proficiency (hands), and character is about empathy, ethical conduct, and exercising compassion (heart). This is one application of the 3 H model developed by Leonard Orr in 1992. It offers a holistic approach to education and training and aims to produce competent and caring dental professionals who provide high-quality, patient-centred care.
In his work Nicomachean Ethics (written circa 240BC) Aristotle identified three types of knowledge: episteme, techné, and phronesis. Each knowledge type serves a different purpose.
Episteme, or scientific knowledge, refers to professional knowledge. It is largely theoretical and is derived from research. It underpins the undergraduate, taught curriculum and includes anatomy, physiology, pathology, dental materials science, and the procedural elements of clinical practice. Techné (craft knowledge) is the practical skill or craft of dentistry. It requires the application of theoretical knowledge which allows dentists to treat their patients by undertaking the wide range of clinical procedures available today.
Phronesis refers to practical wisdom or prudence, which involves the ability to make sound decisions and judgments. It reduces clinical error and litigation by enhancing clinicians' ability to make wise, ethical decisions in complex situations, thereby improving patient care, preventing mistakes, and reducing the likelihood of legal disputes through thoughtful and prudent judgment.
Aristotle believed that both craft knowledge and practical wisdom are types of practical knowledge, in contrast to scientific knowledge which is largely theoretical. Each category of knowledge progresses from the preceding one: episteme establishes a theoretical groundwork, techne develops practical skills, and phronesis informs ethical and practical decision-making and guides us through the complexities of commercial conflicts where self-serving bias no longer puts the patient’s interests first. Contrary to how it is often presented, this is not a modern-day challenge. Over 2,000 years ago, Thrasymachus, a character in Plato's Republic, posed a provocative question about the role of doctors, when he asked: ‘Is the physician, taken in that strict sense of which you are speaking, a healer of the sick or a maker of money.’ It is a subject that continues to generate much discussion in the profession.
So, what is wisdom? It is a cognitive process which relies on reflective practice. It is the ability to make sound decisions and take appropriate actions based on experiential knowledge, context, and situational awareness.
I am reminded of a quote attributed to Miles Kington: “Knowledge is knowing that a tomato is a fruit, wisdom is knowing not to put tomatoes in a fruit salad.”
Wisdom flows from the accumulated experience gathered over many years, Leonardo Da Vinci described it as the “daughter of experience”. experience of clinical practice does not guarantee the development of practical wisdom. It emerges from repeated refinement of a clinician’s performance.
Aristotle believed that practical wisdom was the highest intellectual virtue. It has been described as an ‘executive virtue‘ as distinct from run-of-the-mill virtues like compassion, kindness, integrity, empathy, and humility – subjects for discussion in a future editorial.
According to Plews-Ogan and Sharpe ”there has been a focus on the technical knowledge of medicine, but a failure to develop the phronesis or practical wisdom necessary to do medicine in the best way possible”. The same can be said of dentistry and I believe there is a strong case for a reorientation towards phronesis.
The University of Queensland-Ochsner Clinical School focuses on the development of virtues and character necessary to practise safely as a clinician. The students’ feedback on this curricular innovation has been overwhelmingly positive and many report not only has it changed the way they practise, but they also experience a greater sense of well-being and fulfilment in their professional and personal lives. Wiser dentists it can be said are also happier dentists.
A person with phronesis can evaluate concerns raised by patients, determine the appropriate actions or responses needed to address them effectively, and discern what constitutes a satisfactory resolution. Practical wisdom cannot be taught but can be fostered through mentorship from experienced colleagues, storytelling and reflective practice. It is one reason why we share cases from our files; phronesis can be acquired vicariously by learning from the experience and insights of others. It is difficult to measure but, like charisma, is easily recognisable through a person’s actions ad behaviour.