Engagement and practical wisdom in clinical practice: a phenomenological study

  • Michael SaragaEmail author
  • Donald Boudreau
  • Abraham Fuks
Scientific Contribution


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.


Clinical practice Health care professionals Hermeneutic phenomenology Qualitative research Phronesis 


Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.


  1. Ackerknecht, Erwin H. 1967. Medicine at the Paris hospital, 1794–1848. Baltimore: Johns Hopkins Press.Google Scholar
  2. Aubenque, Pierre. 2009. La prudence chez Aristote. Paris: Presses Universitaires de France.Google Scholar
  3. Boudreau, J., Mary-Ellen Donald Macdonald, and Yvonne Steinert. 2014. Affirming professional identities through an apprenticeship: Insights from a four-year longitudinal case study. Academic Medicine 89: 1038–1045. Scholar
  4. Bynum, William F. 1994. Science and the practice of medicine in the nineteenth century. Cambridge: Cambridge University Press.Google Scholar
  5. Cabana, Michael D., Cynthia S. Rand, Neil R. Powe, Albert W. Wu, Modena H. Wilson, Paul-André C. Abboud, and Haya R. Rubin. 1999. Why don’t physicians follow clinical practice guidelines? A framework for improvement. Journal of the American Medical Association 282: 1458–1465. Scholar
  6. Cassel, Eric J. 2012. The nature of healing. The modern practice of medicine. Oxford: Oxford University Press.CrossRefGoogle Scholar
  7. Cochrane, Lorna J., Curtis A. Olson, Suzanne Murray, Martin Dupuis, Tricia Tooman, and Sean Hayes. 2007. Gaps between knowing and doing: Understanding and assessing the barriers to optimal health care. Journal of Continuing Education in the Health Professions 27: 94–102. Scholar
  8. Desjarlais, Robert, and C. Jason Throop. 2011. Phenomenological approaches in anthropology. Annual Review of Anthropology 40: 87–102. Scholar
  9. Dunne, Joseph. 1993. Back to the rough ground. Practical judgment and the lure of technique. Notre Dame: University of Notre Dame Presse.Google Scholar
  10. Engel, George L. 1976. Too little science: The paradox of modern medicine’s crisis. Pharos 39: 127–131.Google Scholar
  11. Engel, George L. 1977. The need for a new medical model: A challenge for biomedicine. Science 196: 129–136. Scholar
  12. Engel, George L. 1980. The clinical application of the biopsychosocial model. American Journal of Psychiatry 137: 535–544. Scholar
  13. Feinstein, Alvan R. 1987. The intellectual crisis in clinical science: Medaled models and muddled mettle. Perspectives in Biology and Medicine 30: 215–230.CrossRefGoogle Scholar
  14. Feinstein, Alvan R., and Ralph I. Horwitz. 1997. Problems in the “Evidence” of “Evidence-Based Medicine.” American Journal of Medicine 103: 529–535. Scholar
  15. Foucault, Michel. 1963. Naissance de la clinique. Une archéologie du regard médical. Paris: Presses Universitaires de France.Google Scholar
  16. Gadamer, Hans-Georg. 1975. Truth and method. New York: The Seabury Press.Google Scholar
  17. Gadamer, Hans-Georg. 2001. Gadamer in conversation: Reflections and commentary. New Haven: Yale University Press.Google Scholar
  18. Gadamer, Hans-Georg. 2007. The Gadamer reader: A bouquet of the later writings. Evanston: Northwestern University Press.Google Scholar
  19. Good, Byron. 1994. Medicine, rationality and experience: An anthropological perspective. New York: Cambridge University Press.Google Scholar
  20. Good, Byron, and Mary-Jo DelVecchio Good. 1993. Learning medicine: The constructing of medical knowledge at Harvard Medical School. In Knowledge, power and practice: The anthropology of medicine and everyday life, eds. Shirley Lindenbaum, and Margaret M. Lock, 81–107. Berkeley: University of California Press.Google Scholar
  21. Graham, Ian D., Jo Logan, Margaret B. Harrison, Sharon E. Straus, Jacqueline Tetroe, Wenda Caswell, and Nicole Robinson. 2006. Lost in knowledge translation: Time for a map? Journal of Continuing Education in the Health Professions 26: 13–24. Scholar
  22. Hirsh, David A., S. Eric, Holmboe, and Olle ten Cate. 2014. Time to trust: Longitudinal integrated clerkships and entrustable professional activities. Academic Medicine 89: 201–204. Scholar
  23. Jonson Albert R., and Stephen Toulmin. 1988. The abuse of casuistry: A history of moral reasoning. Berkeley: University of California Press.Google Scholar
  24. Keel, Othmar. 2001. L’avènement de la médecine clinique moderne en Europe: 1750–1815. Politiques, institutions et savoirs. Montréal: Les Presses de l’Université.Google Scholar
  25. Kinsella, Elizabeth A., and Allan Pitman, eds. 2012. Phronesis as professional knowledge: Practical wisdom in the professions. Rotterdam: Sense Publishing.Google Scholar
  26. Lave, J., and E. Wenger. 1991. Situated learning: Legitimate peripheral participation. Cambridge: Cambridge University Press.CrossRefGoogle Scholar
  27. Leif, Harold I., and Renée C. Fox. 1963. Training for ‘Detached concern’ in medical students. In The psychological basis of medical practice, eds. Harold I. Lief, Victor F. Lief and Nina R. Lief, 12–35. New York: Harper and Row.Google Scholar
  28. Leucht, Stefan. 2007. Psychiatric treatment guidelines: Doctors’ non-compliance or insufficient evidence? Acta Psychiatrica Scandinavica 115: 417–419. Scholar
  29. Lugtenberg, Marjolein, Judith M. Zegers-van Schaick, Gert P. Westert, and Jako S. Burgers. 2009. Why don’t physicians adhere to guideline recommendations in practice? An analysis of barriers among Dutch general practitioners. Implementation Science 4: 54. Scholar
  30. MacIntyre, Alasdair. 1981. After virtue. Notre Dame: Notre Dame Universty Press.Google Scholar
  31. Marcum, James A. 2008. An introductory philosophy of medicine: Humanizing modern medicine. Berlin: Springer.Google Scholar
  32. Merleau-Ponty, Maurice. 1967. L’œil et l’esprit. Paris: Gallimard.Google Scholar
  33. Mol, Annemarie. 2002. The body multiple: Ontology in medical practice. Durham: Duke University Press.CrossRefGoogle Scholar
  34. Mol, Annemarie. 2008. The logic of care: Health and the problem of patient choice. London: Routledge.Google Scholar
  35. Morse, Janice M. 2004. Purposive sampling. In The SAGE encyclopedia of social science research methods, eds. Michael S. Lewis-Beck, Alan Bryman, and Tim Futing Liao, 885. Thousand Oaks: SAGE Publications.Google Scholar
  36. Nicolini, Davide. 2012. Practice theory, work, and organization: An introduction. Oxford: Oxford University Press.Google Scholar
  37. Nigam, Amit. 2012. Changing health care quality paradigms: The rise of clinical guidelines and quality measures in American medicine. Social Science and Medicine 75: 1933–1937. Scholar
  38. Olmsted, James M.D. 1935. The influence of Claude Bernard on medicine in the United States and England: Part I. California and Western Medicine 42: 111–113.Google Scholar
  39. Peabody, Francis W. 1927. The care of the patient. Journal of the American Medical Association 88: 877–882. Scholar
  40. Pellegrino, Edmund D., and David C. Thomasma. 1993. The virtues in medical practice. Oxford: Oxford University.Google Scholar
  41. Reading, Anthony. 1977. Illness and disease. Medical Clinics of North America 61: 703–710.CrossRefGoogle Scholar
  42. Roper, William L., William Winkenwerder, M. Glenn, Hackbarth, and Henry Krakauer. 1988. Effectiveness in health care. An initiative to evaluate and improve medical practice. New England Journal of Medicine 319: 1197–1202. Scholar
  43. Rosenberg, Charles E. 2007. Our present complaint: American medicine, then and now. Baltimore: Johns Hopkins University Press.Google Scholar
  44. Royal College of Physicians and Surgeons of Canada. 2014. Competence by design (CBD): Moving towards competency-based medical education. Accessed 22 Mar 2018.
  45. Ryle, Gilbert. 1945. Knowing how and knowing that: The presidential address. Proceedings of the Aristotelian Society 46: 1–16.CrossRefGoogle Scholar
  46. Saraga, Michael, Régis Marion-Veyron, Frederic Stiefel, and Céline Bourquin. 2016. Trois aspects de l’éthos médical. Revue Médicale Suisse 12: 296–298.Google Scholar
  47. Saraga, Michael, Abraham Fuks, and J. Donald Boudreau. 2014. George Engel’s epistemology of clinical practice. Perspectives in Biology and Medicine 57: 482–494. Scholar
  48. Sartre, Jean-Paul. 1943. L’être et le néant. Essai d’ontologie phénoménologique. Paris: Gallimard.Google Scholar
  49. Schultz, Dawson S., and Franco A. Carnevale. 1996. Engagement and suffering in responsible caregiving: On overcoming maleficience in health care. Theoretical Medicine 17: 189–207. Scholar
  50. Smith, Jonathan A., Paul Flowers, and Michael Larkin. 2009. Interpretative phenomenological analysis: Theory, method and research. London: SAGE Publications.Google Scholar
  51. Svenaeus, Frederik. 2003. Hermeneutics of medicine in the wake of Gadamer: The issue of phronesis. Theoretical Medicine 24: 407–431. Scholar
  52. Svenaeus, Frederik. 2014. Empathy as a necessary condition of phronesis: A line of thought for medical ethics. Medicine, Health Care and Philosophy 17: 293–299. Scholar
  53. Weatherall, Mark W. 1996. Making medicine scientific: Empiricism, rationality, and quackery in mid-Victorian Britain. Social History of Medicine 9: 175–194. Scholar
  54. Weinmann, Stefan, Markus Koesters, and Thomas Becker. 2007. Effects of implementation of psychiatric guidelines on provider performance and patient outcome: Systematic review. Acta Psychiatrica Scandinavica 115: 420–433. Scholar
  55. Weisz, George, Alberto Cambrosio, Peter Keating, Loes Knaapen, Thomas Schlich, and Virginie J. Tournay. 2007. The emergence of clinical practice guidelines. Milbank Quarterly 85: 691–727. Scholar
  56. Whitehead, Cynthia R., Brian D. Hodges, and Zubin Austin. 2013. Dissecting the doctor: From character to characteristics in North American medical education. Advances in Health Sciences Education 18: 687–699. Scholar
  57. Wiener, Carolyn L. 2000. The elusive quest: Accountability in hospitals. New York: Aldine de Gruyter.Google Scholar
  58. Zwolsman, Sandra, Ellen te Pas, Lotty Hooft, Margreet Wieringa-de Waard, and Nynke van Dijk. 2012. Barriers to GPs’ use of evidence-based medicine: A systematic review. British Journal of General Practice 62: e511–e521. Scholar

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© Springer Science+Business Media B.V., part of Springer Nature 2018

Authors and Affiliations

  1. 1.Centre Hospitalier Universitaire VaudoisLausanneSwitzerland
  2. 2.Faculty of Medicine, Center for Medical EducationMcGill UniversityMontrealCanada
  3. 3.Department of MedicineMcGill UniversityMontrealCanada

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