The wisdom of entrustability: A critically conscious approach to practical wisdom

Derived from the Aristotelian observation of the human capacity to reason and act accordingly, practical wisdom has gained rapid traction in health professions education literature because of its ability to bridge the problem of a knowledge – action divide associated with the realities of clinical practice. 1 Through coordination of the right character trait expression practiced in real time, practical wisdom offers an attractive framework for operationalising clinical judgement. 2 As practical wisdom supports righteous decision making in ethically complex, context-specific situations, a strong case can be made for its explicit curricular integration in clinical training and active cultivation by medical students and trainees as part of professional development. 1,2 In their latest paper, Kaldjian and colleagues consider how to make practical wisdom a ‘ meaningful and teachable concept in medicine ’ , focusing on clarifying the dimensions of practical wisdom as perceived by physicians and medical students. 3 In doing so, they uncover heterogeneity in how practical wisdom is understood and applied in terms of associated virtues, noting that practical wisdom is ‘ developed through cultivating other virtues ’ that mirror the traits empirically associated with professional judgement and good medical practice. 3 However, mindful of the global trend towards inclusivity and decolonisation in health professions education, these findings suggest a need to examine the role of culture in mediating how virtues are conceptualised and a deeper understanding of how they are expressed and experienced by diverse groups of people.

Derived from the Aristotelian observation of the human capacity to reason and act accordingly, practical wisdom has gained rapid traction in health professions education literature because of its ability to bridge the problem of a knowledge-action divide associated with the realities of clinical practice. 1Through coordination of the right character trait expression practiced in real time, practical wisdom offers an attractive framework for operationalising clinical judgement. 2As practical wisdom supports righteous decision making in ethically complex, context-specific situations, a strong case can be made for its explicit curricular integration in clinical training and active cultivation by medical students and trainees as part of professional development. 1,2 their latest paper, Kaldjian and colleagues consider how to make practical wisdom a 'meaningful and teachable concept in medicine', focusing on clarifying the dimensions of practical wisdom as perceived by physicians and medical students. 3In doing so, they uncover heterogeneity in how practical wisdom is understood and applied in terms of associated virtues, noting that practical wisdom is 'developed through cultivating other virtues' that mirror the traits empirically associated with professional judgement and good medical practice. 3However, mindful of the global trend towards inclusivity and decolonisation in health professions education, these findings suggest a need to examine the role of culture in mediating how virtues are conceptualised and a deeper understanding of how they are expressed and experienced by diverse groups of people.
These findings suggest a need to examine the role of culture in mediating how virtues are conceptualised.
'Critical consciousness' is the application of social justice principles alongside introspection and the recognition of personal bias to understand marginalised perspectives. 4When applied to practical wisdom frameworks, two inherent tensions are revealed.The first is the modelling of practical wisdom acquisition as a process shaped by virtue narratives from 'wiser' clinicians that excludes the perspectives from other groups: when virtuosity is demonstrated through acting for the good of patients, 1-3 how patients, relatives, colleagues and others, perceive and understand the applied virtues becomes a valuable source of reflection to guide the application of future practical wisdom.This becomes even more evident when considering those from non-Western backgrounds, where the conceptualisation and clustering of virtues may be different, propagating specific and distinct cultural norms that can inform clinical practice.Arising from Japanese culture, for example, is 'Bushido', a personal code of conduct and virtue-based value system for the samurai class and a forerunner of modern Japanese professionalism. 5Nishigori and colleagues have shown that while the seven virtues of Bushido have elements in common with Western professionalism constructs, they are unique constructs and themselves worthy of study. 5Further empirical evidence comes from Shikama et al., 6 who identified culturally unique character traits similar to Western constructions of altruism but closer to the virtues expressed in Bushido in the interaction of non-medical professionals with medical students; these virtues facilitated culturally congruent professional identity formation and the internalisation of cultural working norms. 6Therefore, Kaldjian and colleagues' case for practical wisdom as a vehicle for patient-centredness can be more fully realised by applying a critically conscious lens to identified virtues to understand their cultural construction.

The conceptualisation and clustering of virtues may be different, propagating specific and distinct cultural norms that can inform clinical practice.
The second tension arises when integrating practical wisdom frameworks with the practicalities of competence-based training, given the agent-centred locus of the former and the act-centred focus of the latter.Kaldjian and colleagues discuss how trainees and students may not be considered 'wise' under Aristotle's definition because of their lack of experience but highlight how they can effectively engage with the dimensions of practical wisdom. 3This makes facilitation of practical wisdom in the curriculum not only desirable but also necessary to enable professional development that leads to students 'thriving' as physicians.However, the practical wisdom to accomplish this is currently lacking.

Tension arises when integrating practical wisdom frameworks with the practicalities of competence-based training.
A new direction to overcome these tensions may lie in reframing practical wisdom through the lens of entrustability during training.
Entrustability is traditionally understood in health professions education in terms of entrustable professional activities (EPAs), which are widely accepted as 'units of professional practice', comprising tasks or responsibilities that trainees undertake independently after demonstrating the required proficiency. 7Designed to bridge a theory-practice divide, EPAs facilitate the translation of professional standards and qualities to real practice, 7 akin to how practical wisdom facilitates the translation of goal-directive ethical reasoning to realtime action.Further similarities arise as both are activities confined to qualified persons; require the application of knowledge, skills and attitudes that are acquired through training; have a distinct beginning and outcome, are context-specific and goal-oriented; and involve the integration of multiple competency domains. 2,8It is through these similarities that practical wisdom could meaningfully enter training through actualising goal-directed ethical reasoning in a supported progressive manner, in the same way EPAs actualise competency frameworks.
A new direction to overcome these tensions may lie in reframing practical wisdom through the lens of entrustability.
Moreover, modelling practical wisdom as an entrustable concept may help trainees to consolidate their understanding of practical wisdom and its dimensions through its transformation from an unconscious act to a supervised learning event.Entrustment gives trainees ownership, enabling them to seek out culturally diverse learning experiences to better inform their construction and use of practical wisdom and its associated virtues.
Entrustment gives trainees ownership, enabling them to seek out culturally diverse learning experiences to better inform their construction of practical wisdom.
In conclusion, practical wisdom is essential for wise decision making.There is a strong impetus for meaningful curricular integration and improved teaching.Tensions arising through a lack of diversity in supporting virtuous professional development, and the challenges of curricular integration, may be overcome through a critically conscious approach and transformation of practical wisdom via the lens of entrustment.Such integration into clinical training marks the next stage in building inclusive empirical frameworks for practical wisdom, with practical wisdom supporting EPAs as the original entrustable professional virtue.

AUTHOR CONTRIBUTIONS
Maham Stanyon conceptualised, drafted and reviewed all versions of this manuscript.