“agents must in each case consider what is appropriate to the occasion as happens in medicine”—Aristotle

When is a surgeon ready for independent practice? How can we tell, and how can we facilitate that development? Despite years of deliberation and research, the answers remain elusive. Although medical knowledge and technical skills can be trained and tested, experienced surgeons know well that knowledge and technical prowess are not solely sufficient for independence. What distinguishes the genuine expert—the trusted colleague, the wise mentor, the truly noble surgeon? We believe that much of this distinction lies in the presence of a type of knowledge situated outside of our traditional sense of research and education: phronesis.

Over 2300 years ago, Aristotle proposed 3 distinct intellectual virtues or categories of knowledge: episteme, techne, and phronesis. Episteme and techne are familiar to surgeons. Episteme is knowledge which is produced over time by analytic rationality; it is context-independent scientific knowledge, known today as epistemic science.1 Episteme is well represented in surgical research; examples include basic science research investigating the effects of the microbiome, clinical research considering predictors of wound healing, and education research examining assessment validity. Techne is knowledge of art or craft; it is the application of technical expertise and skill to achieve a specific goal.1 Techne is also commonplace in surgical research as represented in development and dissemination of new technical approaches.

Phronesis has no modern-day etymological descendant but is recognized in the concepts of practical wisdom and praxis. More rigorously, phronesis can be understood as knowledge regarding context-dependent choices in situations not governed by universal rules, and how these choices interact with values.1Phronesis is a facet of knowledge necessary for a fulfilled, happy life.2 We see phronesis in those we esteem as mentors and wise masters of the craft. Phronetic knowledge is the knowledge a surgeon needs to simply exist as a virtuous surgeon: it is the ability to take the universal epistemic knowledge of the human body, combine it with the technical capacity to fix the body, and make decisions on how to do this across complex environments. It is the learned ability to make choices about one’s identity as a surgeon; and understand how one’s values relate to those of society, the hospital, and a given patient. Explicit recognition and better understanding of phronetic knowledge in surgery would facilitate development of surgeons better prepared to act and learn independently.

There is a problem with developing phronetic knowledge: it can’t be taught. Per Aristotle, it requires experience: “Although the young may be experts in geometry and mathematics, … we do not consider that a young man can have phronesis [because it] includes a knowledge of particular facts, and this is derived from experience, which a young man does not possess.“3 In this sense, phronesis is similar to tacit knowledge (ie, knowledge that can be enacted but not articulated), which is also gained by lived experience.4 In our view, tacit knowledge encompasses elements of techne and episteme that are both learned and performed without conscious thought. Phronesis, by contrast, involves correct judgments on how to apply this expertise.1 Moreover, we believe that both learning and performance of phronesis can be made more explicit. Although researchers and educators cannot guarantee that trainees recognize and learn from important experiences, we are not powerless in promoting phronesis. In particular, we can provide surgeons a foundation of awareness and tools so that when experience does come along, they recognize the moment and efficiently accrue phronetic knowledge.

Surgical episteme and teche have solid foundations, thanks to years of research. The research supporting phronesis is, by contrast, sparse. What does phronetic research look like? Since phronetic knowledge involves making choices based on personal and contextual factors in which there is not necessarily a correct answer, presenting phronetic knowledge often involves offering a framework to interpret or guide experiences. For example, a study exploring how experienced surgeons cope with intraoperative errors identified a 5-step framework (stop, talk to your team, obtain help, plan, succeed), for successful coping.5 Research in surgical shared decision-making offers another framework that highlights physician-facing factors (risk calculators and indexes, prognostic nomograms) and patient-facing decision factors (patient navigation, decision aides, values clarification).6 Conceptual frameworks originating outside surgery, such as management reasoning and the master adaptive learner, may provide additional guidance for developing phronetic research. Management reasoning highlights the dynamic, context-dependent process of negotiating a personalized patient management plan.7 Although descriptions to-date focus on office-based care, we envision that the concept of management reasoning can apply to intraoperative and perioperative decision-making as well. The master adaptive learner framework defines adaptive expertise as openness to reflecting on actions when routine practices fail, the ability to challenge assumptions, and reframe the problem.8 The master adaptive learner is, we believe, the master of (developing) phronetic knowledge.

We propose that phronesis develops at pivotal moments or ‘inflection points’ in the surgeon’s career. Some inflection points are single, memorable, powerful events such as patient conversations that go awry, intraoperative complications, and challenging team dynamics (see Table 1 for additional examples). Such experiences often emerge from situations with suboptimal outcomes, are cognitively and emotionally draining, and typically catch the unprepared surgeon off-guard. They are thus viewed as negative intrusions, and are rarely contemplated productively nor sufficiently discussed. Yet these are precisely the moments in which phronetic development can and should be encouraged. Other inflection points are individually less dramatic, but cumulatively equally or more important. These are the daily choices that define a career—acts (often recurrent) that appear mundane but have lasting effects. These include decisions about how to structure a clinical and procedural schedule or how to cultivate a mentoring relationship. Regardless of timing or intensity, inflection points are junctions from which there is no single correct direction forward. Investigating phronetic knowledge in surgery will acknowledge the universal nature of often overlooked experiences, recognize their importance, encourage reflection, and provide broader roads to professional fulfillment. Teaching at such moments will be challenging. It will require humility, patience, and acceptance of fallibility. The moments pivotal for a trainee may be mundane, repetitious, or irrelevant for the experienced surgeon. However, capitalizing on such moments—suspending ego and finding thrill in teaching—may be viewed as a moral necessity for effective teacher-learner relationships. The goal of phronetic education is not to dictate the path, but to offer a map so the lifelong-learning surgeon need not travel roads wholly unknown.