harden – A Medical Education

THE SOPHISTS AND THE PROFESSIONALISATION OF MEDICAL EDUCATION

One of the direct ways in which the Sophists are relevant to today is that they were the first to put a monetary value on education; they were the first professional educators. In Plato’s Hippias Major Socrates remarks that Gorgias ‘by giving exhibitions and associating with the young, he earned and received a great deal of money from the city’ and that Prodicus ‘in his private capacity, by giving exhibitions and associating with the young … received a marvellous sum of money.’

The Sophists’ innovation of seeking payment for tuition is the first appearance of an idea now all pervasive. Today it is taken almost entirely for granted that teachers require payment, and with it in the modern age come sick leave, maternity leave, pensions and other payments.

The professionalisation of education in general is therefore a legacy of the Sophists. The whole apparatus of modern university teaching, for good and ill, has its root in this idea. Despite a long gestation, it is only in recent years that a professionalisation of medical education has taken root, and it still faces cynicism and opposition today even in recent times (Peterson 1999). There has been concern at the standard of clinical teaching in medicine internationally for a number of years (Wall and McAleer 2000). In the United Kingdom, partly under the influence of the National Committee of Inquiry into Higher Education (Dearing 1997), in the number of departments of medical education attached to medical schools has grown, and a proliferation of masters level programmes and postgraduate certificates in medical education (Pugsley et al. 2008). The whole apparatus of modern academic discourse — peer-reviewed journals, associations, national and international conferences and other scholarly paraphernalia — has grown up around the subject. The subtitle of Peterson’s article cited above — Tomorrow’s doctors need informed educators not amateur tutors — gives a flavour of this new emphasis on professionalisation in medical education.

THE SOPHISTS AND TEACHING VIRTUE

The second great sense in which the Sophists are still relevant is their case that virtue was not inborn or innate, but could be taught. Their ‘most revolutionary innovation was, precisely, that, faced with nature, they set up teaching to counteract it and considered that virtue could be learned by attending their classes’ (de Romilly 2002), and the problem of nature versus nurture, as it is invariably dubbed today, is a very old one that troubled the Athenians with a peculiar intensity. We see it in Thucydides, in the comparison between the courage of the Athenians — described by the historian as deriving from reason, from expertise and from experience — and that of the Spartans, portrayed as ‘natural’ and traditional. We see it in Euripides’ play, Hecabe, when Hecabe (wife of King Priam of Troy) learns of the slaughter of her daughter. After a few rather perfunctory expressions of grief she launches into a meditation on this very question:

How strange, that bad soil, if the gods send rain and sun,

Bear a rich crop, while good soil, starved of what it needs,

Is barren, but man’s nature is ingrained—the bad

Is never anything but bad, and the good man

Is good: misfortune cannot warp his character,

His goodness will endure.

Where lies the difference?

In heredity or upbringing? Being nobly bred

At least instructs a child in goodness; and this lesson,

If well learnt, shows him by that measure what evil is.

(Vellacott 1963, lines 593–603)

Plato’s dialogue Protagoras is devoted to the dispute between Socrates and Protagoras on this particular issue, the teaching of virtue. Although both agree that virtue can be taught, Socrates doubts Protagoras’ self-confidence on the issue. This is an issue that has huge implications not only for education but also for wider political economy. Improved knowledge of genetics in the last hundred years has given the problem a new acuity. Nevertheless, in this as in many fields one can get the impression from contemporary media coverage that all this is a new problem, which only our time has had to face. Nothing could be further from the truth, as the example of the Sophists illustrates.

Whatever ones own beliefs on the issue of nature-nurture, and whatever science may or may not tell us about it, one must concede that the Sophists have, from a practical point of view, won the argument. That education should be available for all is such a commonplace in Western society that to suggest otherwise would be social and (for an elected official) political suicide. Prior to the Sophists, the idea that arete was inborn and therefore unteachable was widely held. Therefore aristocratic birth alone qualified one for rule. If Protagoras’ self-confidence in his ability to teach virtue seemed dubious to Socrates, who was after all sympathetic to the essential point, imagine how shocking it must have been to Athenians more in thrall to notions of aristocratic virtue.

This parallels the reaction medical educators often receive from colleagues. While it is often not directly articulated, the claim that communication skills, for instance, or attitudinal aspects of medical practice, cannot be taught but are innate is frequently encountered. With the exception of ethics teaching (discussed below), medical educators may not consider themselves as teaching ‘virtue’, per se, but overall professionalism and attitudinal aspects of medical practice are explicitly incorporated into curricular design and structure. For instance Harden et al. (1999) describe a concentric circle model of learning outcomes, with an inner core of task focused outcomes defining the technical competency of a doctor, a middle section of ‘approach to practice’ outcomes defining understanding of the context of illness and evidence-based and ethics-based approaches to clinical work, and finally an outer circle of outcomes focused on the overall role of the doctor and ongoing personal development. The term ‘personal development’ itself implies that character can be changed by training.

This debate is particularly relevant to ethics training. A tension has been described (Eckles et al. 2005) between proponents of the view that ethics training should be aimed at the formation of virtuous physicians (for instance, Pellegrino and Thomasina,1993) while others have argued that the moral character of medical students is formed at arrival in medical school (Glick1994). This latter viewpoint is expressed as a belief that the goal of ethics training is to impart of body of ethical knowledge and provide a set of skills for application by medical graduates, whose underlying virtue has been established prior to admission to medical school. Eckles et al. identify this dichotomy as making it ‘difficult to find a consensus regarding the goals of medical ethics education’ and suggest that further theoretical work is needed to delineate the core content, processes and skills relevant to the ethical practice of medicine. The antiquity of this debate is not acknowledged.

INTERLUDE – PROTAGORAS AND EDUCATION

A theme of this article is that what the Sophists really thought, and what their influence on Western thought really was, is very different from the broad caricature often presented. Before discussing the final trend in medical education which is prefigured in Sophist thought, I wish to examine the thought of a specific Sophist figure and link with modern medical education theory. The thought of Protagoras (circa 490-420 BC) described as ‘the first and greatest of the Sophists’ (Waterfield2000) is known from a seven fragments and the reports of others, especially his appearance in the Platonic dialogue Protagoras. Both Socrates and Protagoras believe that virtue can be taught, although to differing degrees (and Plato will later have Socrates definitively oppose this view in the dialogue Meno), but Socrates is sceptical of Protagoras’ confidence on this issue.

The surviving fragments of Protagoras’ thought indicates the seriousness with which he thought about education (Lavery2008). The most famous, ‘man is the measure of all things’, is often cited as a key motif of relativist thought. Debate continues as to whether this was an example of ‘strong’ or ‘weak’ relativism – in other words whether this is a general statement about humanity or is about the individual human being’s ability to accurate perceive the world. However the underlying relativist thrust of this aphorism is not in doubt. Constructivist theories of learning, which are influential in medical education today, are clearly influenced by this approach.

Other Protagorian mottos directly related to education are ‘teaching needs endowment and practice. Learning must begin in youth’ (cited as Fragment 2 in Lavery, 2008). ‘Art without practice, and practice without art, are nothing’ (Fragment in Lavery,2008) and ‘education does not take root in the soul unless one goes deep’ (Fragment 8 in Lavery, 2008). All of these are relevant to medical education – the emphasis on practice and on deep learning, and on lasting attitudinal and behavioural change particularly so. As can be seen, these aphorisms are far in spirit from the caricature of the Sophists as promoting a superficial, purely rhetorical education.

THE SOPHISTS AND BEST EVIDENCE MEDICAL EDUCATION

Another characteristic of contemporary medical education theory prefigured in the thought of the Sophists is an evidence-based approach. The Sophists championed empirical knowledge and direct enquiry, which as well as marking them out as early pioneers of the scientific method, also suggests their place as exemplars of evidence-based practice.

The pre-Socratic philosophers of the centuries before both Socrates and the Sophists are often called both the first philosophers and the first scientists. This, of course, is due to their inquiring minds, and readiness to challenge explanations that depended solely on divine action — thus we have the atomic theory of Democritus, or the postulate of Thales that all matter is water (Waterfield 2000). Nevertheless, a modern reader often finds the Sophists more familiarly ‘scientific’ than the pre-Socratics. This is due to the pre-Socratics’ tendency to expand speculation into explanation, and to engage in metaphysics. The Sophists are more recognisable ancestors of modern scientific method because of their scepticism, their refusal to accept simple explanations, and their pragmatic bent. Defining the scientific method is a hugely problematic enterprise, but an attempt at the unprejudiced search for alternative explanations for any given event or observation is one of its cardinal features.

‘Making the weaker argument the stronger’, a taunt of Aristophanes in The Clouds, is one of the phrases with which the Sophists were most often abused. At first glance, it suggests a sort of confidence trick, a justification for wrongdoing. Yet on reflection, ‘the weaker argument’ may conceal the best answer. The querying approach of the Sophists forces one to examine apparently sound arguments and justifications, and thereby perhaps discover their soundness to be illusory. Richard Feynman described the scientific method as ‘a kind of scientific integrity, a principle of scientific thought that corresponds to a kind of utter honesty–a kind of leaning over backwards. For example, if you’re doing an experiment, you should report everything that you think might make it invalid—not only what you think is right about it: other causes that could possibly explain your results; and things you thought of that you’ve eliminated by some other experiment, and how they worked—to make sure the other fellow can tell they have been eliminated’ (Feynman 1974). So openness to alternative explanations, and a willingness to accept that the ‘weaker argument’ (or initially less persuasive or attractive hypothesis) may be closer to the truth, is a characteristic not of rhetorical chicanery, but of any empirical approach to knowledge and practice.

Best evidence medical education enshrines this empirical approach. Mirroring definitions of evidence-based medical practice, it is defined by Harden and Lilly (2000) as the implementation, by teachers in their practice, of methods and approaches to education based on the best evidence available. This means integrating individual educational expertise with the best available external and internal evidence from systematic research. Best evidence medical education approaches mean that the assumptions of medical educationalists are themselves open to question. Our fondness for a particular innovative means of teaching should be as suspect as the stubborn retention of every aspect of traditional teaching. In Western thought, the Sophists were the great intellectual gadflies, the questioners – pointing out social assumptions and prejudices for what they were. Medical educators owe a debt to these intellectual precursors.

Declaration of interest: The author reports no conflicts of interest. The author alone is responsible for the content and writing of the article.

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