Ben Hoban is a GP in Exeter.
Anyone intending to practise medicine must expend considerable time and effort – not to mention money – acquiring the necessary knowledge, like a prospective black cab driver learning their way around London. Most car drivers are not London cabbies, though, and lack the resources and motivation to develope such detailed familiarity with all the roads they might ever need to travel on. Instead, they get to know those which they use regularly, to the extent that they can easily travel between home and work, for example, without having to think about what they’re doing. For everything else, they turn on the sat-nav, conveniently connecting where they are and where they need to be with a clear blue line. We do the same as doctors, applying the most up-to-date guidance or referring to the relevant specialist when we find ourselves on unfamiliar streets; we even talk about clinical pathways.
Useful though the sat-nav is, it will only work properly if we enter the correct information.
Useful though the sat-nav is, it will only work properly if we enter the correct information. “That place off the Sidmouth Road where they do a massive breakfast” may be meaningful to someone who has already had the pleasure, but must be reformatted for the computer to be able to take us there. Similarly, “Victoria” would be a valid destination on every continent on earth, and more than one in outer space: we need context as well as clarity if we are to arrive at the right one. Even so, not every plottable route is a sensible one, and there are too many stories of people who drove into deserts or oceans just because they followed the blue line on their screen. In the same way, it is often difficult to know in the middle of a consultation how to bridge the gap between the abstract certainties of current best practice and the needs of our patients, which are at once more concrete, more personal, and usually harder to define. It can be hard to decide what to do.
If we cannot know everything or always rely on ready-made guidance, we need some other way of making good decisions in clinical practice. The ancient Greek philosopher Aristotle addressed this need when he wrote about phronesis: practical wisdom that enables decision-making in context; good judgement, based on an understanding of the different factors involved. Phronesis is not taught, but can be modelled; it comes with experience, but not automatically, requiring the humility and self-reflection to learn from one’s mistakes.1 It covers the ability to achieve a particular result and to discern which results are worth achieving. In this sense, phronesis is as much about values as competence.
It is not difficult to spot pairs of contrasting values in general practice once we start looking for them: access and continuity; safety and convenience; correctness and kindness; the needs of populations and individuals; the science and the story; organisational efficiency and patient care. All are important, and what we end up doing in any given instance depends on which element of each pair we prioritise. Different ethical systems can help us go about this in various ways, depending on whether we prefer to be guided by rules of conduct, virtuous motives, or simple utility, but they are all themselves value-laden, and we must still choose between them!2
The ancient Greeks were by no means the only ones to write about wisdom, of course. The Biblical book of Proverbs tells us that the point is not just to make decisions, but first of all to recognise and come to terms with the nature of reality: The fear of the Lord is the beginning of wisdom.3 Whether we consider ourselves religious or not, we all have our own internal model of reality that informs the way we live. C.S. Lewis argues that even though these models often contradict each other, there is sufficient overlap to suggest an underlying bedrock on which we all stand, a grain in the texture of the universe along which we naturally run our fingers.4 The ubiquitous cognitive-behavioural model, which links our thoughts, feelings, and behaviours with our underlying beliefs about the world, in fact encourages us to seek this out, to make decisions and weigh our values on the basis of how things are, rather than on how it suits us to see them.
We are not encouraged to think beyond what is superficial, simply to know and act: we get in the car and turn on the sat-nav.
Much of medical practice neglects this. We are not encouraged to think beyond what is superficial, simply to know and act: we get in the car and turn on the sat-nav. It is a way of reaching a particular destination that reduces the world between here and there to scenery; we arrive without having had to decide anything for ourselves, and without really understanding how we got there. Even on familiar routes, it becomes difficult not to check that we are faithfully following the blue line on the screen. It is easier to seek the reassurance of the computer than to have confidence in our own judgement.5
The reality, however, is that all medical encounters contain irreducible complexity, and therefore both uncertainty and risk. These explicitly require us to do more than just follow protocol, to find ways instead of making sense of ambiguous situations and navigating them flexibly and wisely. Any approach to clinical decision-making that disregards this will necessarily prevent genuine learning and undermine our capacity to practise in ways which are more nuanced, more real, and ultimately safer.6
There is certainly much that we need to know as doctors, but if we hope to become wise rather than merely proficient, we must also recognise the limits of knowledge and the equal importance of the values and worldviews that we and our patients hold, as well as the reality that underlies them. Driving well is not just a matter of staying on the right road, but of recognising the point at which two roads diverge from each other, having an idea of where each might lead, and deciding together with our passenger which to follow.
References
1. Jameel SY. A Critical Interpretive Literature Review of Phronesis in Medicine. J Med Philos. 2025 Mar 20;50(2):117-132. doi: 10.1093/jmp/jhae045. PMID: 39970275; PMCID: PMC11925555.
2. David Misselbrook, Thinking about Medicine: An Introduction to the Philosophy of Healthcare, CRC Press, 2024
3. Proverbs 9:10, Holy Bible, New International Version, Biblica, 2011
4. CS Lewis, The Abolition of Man, Oxford University Press, 1943
5. N Kosmyna, E Hauptmann, YT Tuan, et al. Your Brain on ChatGPT: Accumulation of Cognitive Debt when Using an AI Assistant for Essay Writing Task. arXiv 10 June 2025; 2506.08872v1 DOI: 10.48550/arXiv.2506.08872
6. Nassim Nicholas Taleb, Antifragile: Things that Gain from Disorder, Penguin, 2013
Featured Photo by Alvaro Reyes on Unsplash
