Far transfer through music? This longitudinal study suggests it works!

A post on the potential “far transfer” of music education – ie the longer term impact on cognitive ability. I like the way that Pedro restrains his enthusiasm here! “Far transfer” is tricky to study, but also is a factor in education that needs to be considered when subjects/disciplines are accused of lacking “relevance”

From experience to meaning...

I’m a musician as some of you might know and very much in favor of music and music lessons, but I’m a bit hesitant about this new study. It sounds like great news: cognitive skills developed from music lessons appear to transfer to unrelated subjects, leading to improved academic performance.

Why I’m not so sure? Well, this kind of far transfer is not something easy to achieve and I don’t want to get my hopes up too high. So, let’s have a look at the press release:

Structured music lessons significantly enhance children’s cognitive abilities — including language-based reasoning, short-term memory, planning and inhibition — which lead to improved academic performance. Published in Frontiers in Neuroscience, the research is the first large-scale, longitudinal study to be adapted into the regular school curriculum. Visual arts lessons were also found to significantly improve children’s visual and spatial memory.

Music education has…

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Stephen Westaby, “community focus”, and medical education

Not so long ago, surgery and (internal) medicine were the pinnacles of medical school, the final subjects before graduation. Surgery in particular possessed a dark, elitist glamour, its notoriously long hours and intensity attracting rather than repelling many. Of course, being attracted by a perceived mystique is different from having a sustainable career (and life)

In recent years, medical curricula have been reshaped by many factors, including the realisation that most doctors will practice not as surgeons but as general practitioners, and that the bulk of healthcare need is perhaps more mundane than what goes on in the operating theatre. While there is justice to this “community orientation” of medical education, there is also a certain sense of taking the surgeons and physicians down a peg or twenty. Perhaps there is also a certain anti-intellectualism at work – focusing on the behavioural acts that a doctor performs, rather than the academic disciplines (which include clinical disciplines)

Recently I have been reading Simon Westaby’s memoir of his surgical career, Fragile Lives: A Heart Surgeon’s Stories of Life and Death on the Operating Table. Indeed, the above paragraphs are taken from a first draft of my review (both paragraphs cut for reasons of space and general narrative flow of the review). Westaby’s book is a good read (there, that’s the review bit out of the way) and full of exciting surgical action, described deftly but dramatically. It is also something of an elegy for a certain time of medical and surgical training – an era of overwork and monomaniacal dedication, but also one of intellectual and moral curiosity and rigour, often absent from a modern practice subservient to bureaucratic imperatives. I have already blogged about Westaby’s thoughts (and research) on the impact of league tables on surgical practice. I do wonder whether, for all its manifold faults, “traditional” medical education created a breed of doctor with an espirit de corps to whom a resistance to bureaucratic imperatives came easier?

 

 

#revScreen – Cochrane Crowd Challenges on home visiting and medical education

Previously I blogged about the addictive nature of EMBASE Screening. This is now rebranded as Cochrane Crowd, but the overall approach is unchanged – the user assesses abtracts to see if they are RCTs/CCTs or not. It it surprisingly addictive.

 

Anyhow, there are two new Cochrane tasks – screening for RCTs for two specific reviews Home visiting for socially disadvantaged mothers, and  Interventions for improving medical students’ interpersonal communication in medical consultation. 

If any readers are interested in these areas, the Cochrane Crowd process exposes one to a wide range of (at times rather tenuously related) studies and papers on the topic… I tend to get sidetracked easily.

Anyhow, here is the email:

Dear all,

 

We need your help!

 

When you next log into Cochrane Crowd you will be able to see two new ‘tasks’ in your dashboard area. One is for an update of a review entitled: Home visiting for socially disadvantaged mothers, and the other is for a new review, called: Interventions for improving medical students’ interpersonal communication in medical consultations.

 

The searches for each of these reviews has identified between 3000-5000 records. The core author team for each review has come toCochrane Crowd asking if this community can help. I think we can.

 

Before you dive in, here are some questions you might have:

 

What do I need to do that is different from the usual RCT screening task?

Absolutely nothing. The task is exactly the same making you very well qualified to help! We want all the randomized or quasi-randomized trials to be identified even if the trial has nothing to do with the topic of the review.

 

What’s in it for me?

For those who screen 250 or more records, your contribution will be acknowledged in the review for which you contributed. In addition, on one of the reviews, the home visiting review, the review team will reward authorship to the top screener. This will be based not just on the amount you screen but the accuracy of your screening.

 

How long will these tasks be posted for?

We’ve set the deadline for 31^st March. It would be fantastic to have both sets of records screened by that date.

 

Who can I contact if I have any questions or queries?

You can either contact me, Anna, (anna.noel-storr@rdm.ox.ac.uk) or my brilliant colleague, Emily (crowd@cochrane.org) and we’ll try and get back to you as quickly as possible.

 

Do I need to let anyone know if I plan to contribute or not?

No, you don’t need to let us know either way. If you want to contribute to either or both reviews, just log into Crowd and get cracking! We’ll know who has taken part. Likewise, if this just isn’t for you or you don’t think you’ll have the time, that’s absolutely fine; you don’t need to let us know.

 

When can I start?

Right now! Go and make a nice cup of tea and hop over to Cochrane Crowd (http://crowd.cochrane.org). Log in as usual and you should see the two new tasks. I think I’ll head there now myself.

If you’re a twitterer, we’ll be using #RevScreen for these two exciting pilots!

 

With best wishes to all and happy citation screening,

 

 

Anna and Emily

 

Cochrane Crowd

 

The imperative voice in medical journal editorials

I’ve long wanted to do a little study – though in my experience no study is ever “little” – which is available to anyone in the entire world to do if they have the time and inclination (and resources)

Essentially I wished take a year or so of editorials from various medical journals and assess how much imperative language used. The seemingly endless “musts” and “shoulds” and “needs” that tend to be as inescapable a feature as the words “more research is needed.” I would like to assess exactly who “must” do this-or-that, and what the this-or-that tends to be. Often the subjects of this imperative language are those old standbys “stakeholders” or “policymakers”, adding to their holding of stakes and making of policy duties. Often it is rather specific bodies, often it is more generalised groups (“doctors”, “consultants”, “junior doctors”) It would be interesting to have the benefit of some kind of empirical study of this phenomenon.

For all the status of the medical profession, doctors do not seem to be a terribly happy bunch.   In the piece I just linked to I originally had a section in the opening paragraphs more explicitly exploring how much of this was contextual – related to working patterns, social attitudes, etc. – and how much was something inherent in the profession of medicine itself, either in the practitioners or in the practice. As I wrote in that review:

Lewis Terman’s classic study of “gifted” individuals, published in 1954, found that physicians tended to feel inferior relative to those of comparable attainment in other fields, and the Grant Study, George Vaillant’s epic survey of adult development, following the Harvard Class of 1944, identified self-doubt as the feature distinguishing physicians from control subjects.

In Myers and Gabbard’s highly readable The Physician as Patient we read of the physicians ultimate impotence in the face of death and much disease, and discussion of the defence mechanisms used to manage this. There is also a tendency to conscientiousness that can easily tip over into obsessionality.

Of course, there are non-conscientious doctors, and no doubt plenty of very happy doctors, and doctors who lack of the feelings of inferiority identified by Terman and Valliant (although Myers and Gabbard write that to a certain degree the oft-purported medical narcissism is a defence against the unknown and uncontrollable)

The essential point remains however. It has always struck me that – admirable as it is – the culture of audit and of quality improvement can all too easily tip into a kind of self-flagellation. There is no end to the potential improvements would could  make to one’s own practice. It can be difficult to separate out the individual from the role, especially the role of the individual within a system, and to over-personalise the findings of an audit.

I wonder too about the endless imperative language of editorials feeding into this tendency. With a certain amount of irony, a recent Lancet editorial “When the doctor is sick too” illustrates the style perfectly in its closing paragraph:

The Academy, the RCP, NHS England, NHS Employers, and Health Education England need to work together to provide solutions without stifling individual actions. Junior doctors need to lead on actions, supported by their organisations. But overall, family structures and small groups work better than huge multidisciplinary teams in supporting the health of junior doctors. Consultants and managers, please take note.

I am not disputing anything that is being said – indeed (perhaps more than most editorials) I would fully support what is being said, especially about the relative benefit of “family structures and small groups.” Yet it is more the tone of the imperative language used that struck me as typical of a certain kind of editorial.
It can be easy to spot the point in an editorial where the author switches from descriptive or evaluative language into something-must-be-done mode.

I find the issue most acute in papers with an educational bent. Surveys of the degree to which topic A is taught in medical schools will almost always find that topic A isn’t taught enough, or taught properly, or taught in a way that students feel emboldened to fill out a Likert scale self-assessing their competence with “Very Competent.” Topic A therefore needs to be, must be, or should be more integrated or even included in the curriculum. In papers on medical education published outside the specialist medical educational literature, rarely if ever is there much discussion beyond a few cursory words on that fact that curricula are already quite overloaded as it is, and while Topic A is no doubt wonderful if not life-saving, not all goods are reconcilable.

Engaging clinicians and the evidence for informatics innovations

A few weeks ago Richard Gibson from Gartner spoke to members of the CCIO group. It was a fascinating, wide-ranging talk – managing the time effectively was a challenge. Dr Gibson talked about the implications for acute care and long term care of technological innovations – as might be obvious from my previous post here, I have a concern that much of the focus on empowerment via wearables and consumer technology misses the point that the vast bulk of healthcare is acute care and long term care. As Dr Gibson pointed out, at the rate things are going healthcare will be the only economic, social, indeed human activity in years to go

One long term concern I have about connected health approaches is engaging the wide group of clinicians. Groups like the CCIO do a good job (in my experience!) of engaging the already interested, more than likely unabashedly enthusiastic. At the other extreme, there always going to be some resistance to innovation almost on principle. In between, there is a larger group interested but perhaps sceptical.

One occasional response from peers to what I will call “informatics innovations” (to emphasise that this not about ICT but also about care planning and various other approaches that do not depend on “tech” for implementation) is to ask “where is the evidence?” And often this is not a call for empirical studies as such, but for an impossible standard – RCTs!

Now, I advocate for empirical studies of any innovation, and a willingness to admit when things are going wrong based on actual experience rather than theoretical evidence. In education, I strongly support the concept of Best Evidence Medical Education and indeed in following public debates and media coverage about education I personally find it frustrating that there is a sense that educational practice is purely opinion-based.

With innovation, the demand for the kind of RCT based evidence is something of a category error. There is also a wider issue of how “evidence-based” has migrated from healthcare to politics. In Helen Pearson’s Life Project we read how birth cohorts went from ignored, chronically underfunded studies ran by a few eccentrics to celebrated, slightly less underfunded, flagship projects of British epidemiology and sociology. Since the 1990s, they have enjoyed a policy vogue in tandem with a political emphasis on “evidence-based policy.” My own thought on this is that it is one thing to have an evidence base for a specific therapy in medical practice, quite another for a specific intervention in society itself.

I am also reminded of a passage in the closing chapters of Donald Berwick’s Escape Fire (I don’t have a copy of the book to hand so bear with me) which essentially consists of a dialogue between a younger, reforming doctor and an older, traditionally focused doctor. Somewhat in the manner of the Socratic dialogues in which (despite the meaning ascribed now to “Socratic”) Socrates turns out to be correct and his interlocutors wrong, the younger doctor has ready counters for the grumpy arguments of the older one. That is until towards the very end, when in a heartfelt speech the older doctor reveals his concerns not only about the changes of practice but what they mean for their own patients. It is easy to get into a false dichotomy between doctors open to change and those closed to change; often what can be perceived by eager reformers as resistance to change is based on legitimate concern about patient care. There are also concerns about an impersonal approach to medicine. Perhaps ensuring that colleagues know, to as robust a level as innovation allows, that patient care will be improved, is one way through this impasse.

 

The perils of trying to do too much: data, the Life Study, and Mission Overload

One interesting moment at the CCIO Network Summer School came in a panel discussion. A speaker was talking about the vast amount of data that can be collected and how impractical this can be. He gave the example of – while acknowledging that he completely understood why this particular data might be interesting – the postcode of  the patients most frequent visitor. As someone pointed out from the audience, the person in the best position to collect this data is probably the patient themselves.

When I heard this discussion, the part of my that still harbours research ambitions thought “that is a very interesting data point.” And working in a mixed urban/rural catchment area, in a service which has experienced unit closures and admission bed centralisation, I thought of how illustrative that would be of the personal experience behind these decisions.

However, the principle that was being stated – that clinical data is that which is generated in clinical activity – seems to be one of the only ways of keeping the potential vast amount of data that could go into an EHR manageable. Recently I have been reading Helen Pearson’s “The Life Project” , a review of which will shortly enough appear. Pearson tells the story of the UK Birth Cohort Studies. Most of this story is an account of these studies surviving against the institutional odds and becoming key cornerstones of British research. Pearson explicitly tries to create a sense of civic pride about these studies, akin to that felt about the NHS and BBC. However, in late 2015 the most recent birth cohort study, the Life Study, was cancelled for sheer lack of volunteers. The reasons for this are complex, and to my mind suggest something changing in British society in general (in the 1946 study it was assumed that mothers would simply comply with the request to participate as a sort of extension of wartime duty) – but one factor was surely the amount of questions to be answered and samples to be given:

But the Life Study aims to distinguish itself, in particular by collecting detailed information on pregnancy and the first year of the children’s lives — a period that is considered crucial in shaping later development.

The scientists plan to squirrel away freezer-fulls of tissue samples, including urine, blood, faeces and pieces of placenta, as well as reams of data, ranging from parents’ income to records of their mobile-phone use and videos of the babies interacting with their parents. (from Feb 2015 article in Nature by Pearson)

All very worthy, but it seems to me that the birth cohort studies were victims of their own success. Pearson describes that, almost from the start, they were torn between a more medical outlook and a more sociological outlook. Often this tension was fruitful, but in the case of Life Study it seems to have led to a Mission Overload.

I have often felt that there is a commonality of interest between the Health IT community, the research methodology community, and the medical education community and the potential of EHRs for epidemiology research, dissemination of best evidence at point of care  and realistic “virtual patient” construction is vast. I will come back to these areas of commonality again. However, there is also a need to remember the different ways a clinician, an IT professional, an epidemiologist, an administrator, and an educationalist might look at data. The Life Study perhaps serves as a warning.

A Medical Informatics Education, 1996.

Today I walked to UCD much as I did nearly 20 years ago on 21st September 1996, to begin college. This time I was walking not to Belfield itself, but to UCD Nexus, located a little further on in Belfield Office Park, for a meeting in my new roles as CCIO liaison to ARCH (if that’s too many acronyms, don’t ask)

Various nostalgic impressions mingled. Cyclists seem more aggressive than they were. UCD is a slicker operation and more given to self-promotion than it was. It had been a while since I had actually walked through campus; the last few times I had driven in, found parking near-impossible, gone to a meeting, and left. Belfield seemed to have become a bit like Docklands , a rather alienating landscape dominated by massive buildings without human scale.

 

Walking through, however, I find Belfield reassuringly unchanged at its core. The Science Block has greatly expanded, but the central lecture theatre structure is unchanged. The Arts Block, the fundamental library structure, the lake, the restaurant – all are different only superficially. The cafe that was officially known as “Finnegan’s Break” and was always called “Hilpers” is now gone.

I was also a little taken aback by how much human interaction there was. I expected serried ranks of screen-focused students. In the restaurant, I saw only one person texting while talking to here friends, and while that wouldn’t have happened in 1996, it would have in 2000. A few years ago there were PC terminals all over the place, which seem to have largely disappeared.

Given the nature of of the  meeting I was going to, I thought about one of the academic highlights of that first year of medicine; medical informatics. This was a subject which, frankly, was much derided. Why? Because it seemed irrelevant, I think, somewhat beneath those who knew anything much about computers and somewhat irksome to those who didn’t. Crucially, I can’t recall anything specifically medical about medical informatics.

We had lecturers on what a CPU was and so forth (more of which anon) and workshops on the use of Word, Excel, Access and the other Microsoft biggies at the time. The undoubted highpoint was the lecturer, Mel ´Ó Cinneide, suddently pulling  a mouse out of his pocket with the immortal words “for those who haven’t seen one, this is a mouse.”

Now, the wheel has come full circle; one wonders how many of a laptop and tablet focused cohort of students would have seen a mouse. UCD Netsoc was, for a few years, the only way to get internet access as a student, and the enthusiastic queued up from early morning to get an account.

As with many other pre clinical subjects at the time, Medical Informatices teaching was by academics in their specific discipline who no doubt found the prospect of teaching medical students even less enticing than teaching students who at least were pursuing the subject at more length.

In subsequent years, Medical Informatics was revamped and, I gather, made more clinically relevant. And now as Ireland slouches towards eHealth the relevance of IT to medicine is much more obvious. I am sure that Medical Informatics in UCD and equivalent courses in other medical schools is now taught in a clinically relevant, pedagogically sound manner with defined learning objectives and so forth. Nevertheless, I have my doubts that in twenty years anyone will recall a moment from this teaching as vividly as what would (mostly) be the class of 02 recall Mel whipping out the mouse.

Sophistry, the Sophists and modern medical education. Medical Teacher Volume 32, Issue 1, 2010. Part 2.

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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Sophistry, the Sophists and modern medical education. Medical Teacher Volume 32, Issue 1, 2010. Part 1.

I’m sure on a Friday evening what the world is waiting for is the reposting of a paper on  (possibly) unfairly maligned Ancient Greek philosophers and the parallels between their thought and modern medical education theory. I fully expect this one to go viral. Re-reading it I am quietly happy with my discussion of the (mis)use of the term “sophistry” in the educational literature…. less admirably, I barely mention any of the Sophists themselves. Original is here

Sophistry, the Sophists and modern medical education

Abstract

The term ‘sophist’ has become a term of intellectual abuse in both general discourse and that of educational theory. However the actual thought of the fifth century BC Athenian-based philosophers who were the original Sophists was very different from the caricature. In this essay, I draw parallels between trends in modern medical educational practice and the thought of the Sophists. Specific areas discussed are the professionalisation of medical education, the teaching of higher-order characterological attributes such as personal development skills, and evidence-based medical education. Using the specific example of the Sophist Protagoras, it is argued that the Sophists were precursors of philosophical approaches and practices of enquiry underlying modern medical education.

Abstract

The term ‘sophist’ has become a term of intellectual abuse in both general discourse and that of educational theory. However the actual thought of the fifth century BC Athenian-based philosophers who were the original Sophists was very different from the caricature. In this essay, I draw parallels between trends in modern medical educational practice and the thought of the Sophists. Specific areas discussed are the professionalisation of medical education, the teaching of higher-order characterological attributes such as personal development skills, and evidence-based medical education. Using the specific example of the Sophist Protagoras, it is argued that the Sophists were precursors of philosophical approaches and practices of enquiry underlying modern medical education.

The Sophists and Medical Education

J

The Sophists

The Sophists were among the earliest philosophers of the Western world. Their name is now generally used as a term of intellectual abuse. ‘Sophist’ means a clever cheat, a casuist, a spin doctor, an insincere practitioner of misleading rhetoric. This is because what little we know about the Sophists comes from their opponents, especially Plato. Plato portrayed Socrates as a man of truth, seeking wisdom, as opposed to the quick-witted but superficial Sophists. They were also accused of being mercenary as they took payment for their teaching. Modern perceptions of the Sophists derive mostly from Plato’s depiction and Aristophanes’ comedy The Clouds. In this play, an Athenian father sends his son to a parodic academy of unworldly philosophers so he can learn how to win law cases. However ultimately his son questions and overthrows (literally) paternal authority using the rhetorical skills he has learnt. It suggests that young men would be distracted from dutiful, honest dreams of martial glory by a world of, at best, useless speculation and, at worst, logical hair-splitting that would allow them, literally and figuratively, to beat their betters (Sommerstein, 1973). This negative image of the Sophists has passed into both general discourse and educational philosophy. In this article I wish to discuss what the Sophists actually thought, insofar as we can elucidate it, and draw parallels with modern medical education theory and practice. Some of the most fundamental principles of medical education theory have their origins in the work of the Sophists.

There are three main strands of Sophistic thought which find parallels in the modern discourse of medical educationalists. Firstly, the whole idea of education as a professional enterprise requiring structured attention and of monetary recognition. Secondly, the idea that what are often seen as innate qualities can in fact be taught. Thirdly, an empirical, evidence-based approach to receive opinion and practice.

Who were the Sophists? The word is derived from the Ancient Greek sophos meaning ‘wise’, ‘skilful’, ‘clever’. In early Greek literature, a Sophist was a teacher, poet and wise man. This is how ‘Sophist’ is used by Homer and Hesiod in the seventh centuries BC (O’Grady 2008). A laudatory meaning was attached to the word when used by Homer. In the works of Herodotus (c. 490–420 BC), ‘Sophist’ is employed neutrally to mean ‘teacher’. The ‘Sophists’, as a term, now generally refers to philosophers of the fifth and fourth century BC. They were freelancers, mostly non-Athenian, independent teachers who travelled from city to city throughout Ancient Greece, charging for their services and making their living from a demand for education (O’Grady 2008). Kerferd (1981) identified distinguishing attributes of Sophists – they were paid for teaching, they were patronised by the wealthy, were mainly non-Athenian as well as itinerant, claimed to teach political arête (excellence) and how to be a good citizen, and emphasized the art of speaking. It was this focus on the art of speaking, and a delight in rhetorical innovation and, above all, a constantly questioning stance, which earned the Sophists their reputation. Although a later group of philosophers in the second century A.D. were also dubbed Sophists, ‘the Sophists’ generally refers to these fifth century B.C. intellectuals.

The Sophists brought tremendous intellectual excitement to Athens. This excitement brought with it anxiety, as is evident in The Clouds. All was up for grabs for the Sophists, from the nature of reality itself to the nature of the good to the existence of gods. For traditionally minded Athenians, this was a threatening stance.

The history of ideas is sometimes seen as a series of reactions and counter reactions — Reformation and Counter-Reformation, Romanticism and Neo Classicism, Postmodernism versus modernism. In educational theory, we see parallel dichotomies of behaviourist and constructivist paradigms. The Socratic movement and the Sophists can be seen as being in a similar opposition. Of course, all these developments derive from the other and each depends upon the other. Socrates and the Sophists were not mutually exclusive camps. Aristophanes’ portrayal of Socrates in The Clouds, for instance, is very clearly of a Sophist. And the intellectual excitement which the Sophists kindled in Athens surely had much to do with Socrates setting himself up as a philosopher, and with Plato, at later date, writing his dialogues.

Later generations have been harsh to the Sophists. They were described by the classicist Henry Sidgwick in 1872 as ‘a set of charlatans who appeared in Greece in the fifth century, and earned an ample livelihood by imposing on public credulity; professing to teach virtue, they really taught the art of fallacious discourse, and meanwhile propagated immoral practical doctrines’ (Sidgwick 1872). Right up to the present day, ‘Sophist’ carries this meaning, as can be seen in the words of the contemporary Catholic apologist Peter Kreeft: ‘Socrates made a point that he never took a fee for his teaching. (Neither did Jesus.) This proved that he was not one of the Sophists, who sold their minds as a prostitute sells her body’ (Kreeft 2002).

‘Sophistry’ in modern educational theory

In educational theory and philosophy, similar views prevail – Socratic and Sophistic approaches to education are often contrasted, usually unfavourably to Sophistic ones. For instance Furedy and Furedy (1982) propose a Socratic-Sophistic continuum, positing that Socratic approaches are characterised by enquiry while the Sophistic approach is characterised by persuasion and a focus on rhetoric. Elsewhere, the same authors (1986) argue that Socratic approaches are conterminous with critical enquiry and that Sophistic influences have been mainly implicit and manifested in tendency towards instrumentalism and affective learning as well as in the choice of curricula and curricula development. The title of this latter paper — On Strengthening the Socratic Strain in Higher Education — strongly suggests where the authors’ sympathies lie. As Furedy and Furedy acknowledge, the Sophistic–Socratic dichotomy, like all dichotomies, is overly simplistic, and in this ariticle I will argue that when we look at what the Sophists themselves thought and taught, we find a strong commitment to critical enquiry and the questioning of assumptions.

Boyles (1996), writing from the perspective of teacher training, collapses the Socratic–Sophistic dichotomy in his analysis of the Socratic dialogue Meno – but in a way unfavourable to both schools. He argues that Socratic dialogue is an example of coercive Sophistic rhetoric rather than disinterested enquiry. Hall (1996) in his commentary on Boyles’ paper takes the view that ‘sophistry is deficient insofar as it panders to the desire of the unwise, untutored, and unreflective for quick acquisition of knowledge. If one had enough money, one could with great speed acquire knowledge about, for example, political affairs together with the ability to speak persuasively on virtually any subject’ (Hall 1996) This statement, coming as it does within a sophisticated discussion of a Socratic dialogue, summarises the dominant view of the Sophists within educational philosophy. Stabile (2007), in his analysis of the clash between ‘virtue’ and ‘Sophist’ trends in education, depicts Sophist approaches as synonymous with utilitarian ones. In educational discourse, ‘Sophist’ has become a pejorative term in a more specific way then the general pejorative usage. These negative views are counterbalanced by a modern awareness of the importance of the Sophists, and awareness that their thought was more subtle and less focused on persuasion by any means necessary than their critics wrote.

Thoughts on a Hackathon (Tribute)

I plan on continuing to use this blog mainly as an ongoing personal curation project, reviewing my prior medicine related writing and reflecting on my reaction to my former self’s writing. However, occasionally I may break cover and blog in a more “traditional” form.

I haven’t posted here in a few days, because I was in the wonderful city of Glasgow at the wonderful AMEE (Assocation for Medical Education in Europe) Hackathon. The official site of the hackathon is here  and it was organised by the wonderful Hack Partners 

I had a great time, and learned a lot. Here I have written a fairly reflective blog piece on the Hackathon, which contains a certain amount of rumination on the technology-health-education interface. None of this is intended as criticism of the Hackathon, AMEE, Elsevier or anyone else.

Yesterday evening I had (very little) time to kill between the end of the Hackathon and departing for the airport. It was a beautiful sunny evening by the Clyde (not a sentence one is used to reading) and I drafted some profound reflections for a blog post on the Hackathon. However, when I got to the airport and decided to write some more, the draft had disappeared. So this is an effort to replicate my thoughts.

The hackathon and me

I had come across the Hackathon via the AMEE mailing list, put my name forward listing my interest and being upfront about my lack of coding and upfront about my mix of enthusiasm and scepticism about technology’s role in healthcare (brief version: I’m enthusiastic about the positive changes technology can make to both, but sceptical of claims and promises of UTTER TRANSFORMATION BEYOND RECOGNITION)

There are a few disclaimers I should make about my personal Hackathon perspective, that perhaps disqualify me from being too dogmatic about the experience.
Firstly, I missed out on the all nighter element on the Saturday night. In my defence, at 36 with three children, a night’s sleep is one of the major attractions of a weekend away. For non-Hackathon reasons I had poor sleep the week leading up to Glasgow, and I had the option of staying in a hotel as family members were also around Glasgow. At 7 pm on Saturday I availed of the option to lie down for a couple of hours. 12 hours later, I awoke.

Secondly, I don’t use Facebook anymore, and it seems the Hackathon Facebook page was probably the best pre-Hackathon resource. As a neophyte Hackathoner, it would have been good to have done some networking prior and to have had a clearer idea about the structure (particular the pitches and team buildings)

Thirdly, for reasons I’ll discuss, I think our team was a little atypical of the Hackathon participants.

Fourthly, I don’t code, and possibly over the course of the Hackathon realised I’m not that much of a techie of any stripe. And while the Hackathon was welcoming to all, when it comes down to it the tech skills are the prized skills.

Pitching and team building

One aspect of the Hackathon was the initial pitch. I hadn’t intended to pitch, but at the last minute decided to talk about an idea I had a few years back – OSCEbuilder, essentially a way of automating much of the process of developing and running OSCE exams. It isn’t a very exciting idea, and it turned out that a) Dundee are using something like it anyway and b) a poster from NUI Galway at AMEE suggested that examiners actually take longer to examine with a tablet than the pen-and-paper. Not surprisingly, OSCEbuilder wasn’t very enticing to anyone much. I hadn’t even thought of it until five minutes before pitching, so I wasn’t exactly emotionally invested.

However in retrospect I do wish I had come up with a pitch prior to attending that I had some personal investment in – while it probably wouldn’t have been selected, it would have given me a starting point for involvement, rather than being to a certain degree passive in the process.
Anyhow, the pitchers than circulated around trying to get post-it notes from the other Hackathoners. The top 10 would become the nucleus of the team. This process slightly passed me by. In retrospect, I was overly self-conscious about not being able to code.

In ways our team ended up coalescing because none of us, except the original pitcher, had found a team before this. The pitchers idea was for “Ultrascan”, in brief a VR approach to training radiologists in ultrasound. The basic idea of simulation of ultrasound remained, but the focus shifted considerably from training radiologists to training healthcare workers in the developing world. In retrospect I think the technical challenge on our team was one of the most formidable (certainly in terms of getting a working demo in 24 hours) and this factor meant that the team was more about realising one team member’s vision rather than an overall team idea.

Feedback/Mentoring
The best hackathon moment for me was the mentoring from Prof John Sandars of the University of Sheffield  . We had quickly discovered that someone was doing more or less exactly what the pitch said http://www.medaphor.com/ and were kicking around various ideas on the Saturday morning. John Sandars instilled in us a sense of mission and of hope, and brought to our attention the massive need that ultrasound can meet in the developing world. On Saturday I learnt massively about the lack of access to ultrasound in African nations especially, and the preventable maternal mortality that results. I made contact with Kirsten deStigter of Imaging the World and read about the massive strides her organisation has made in address this issue. I am grateful for her extremely gracious response and I am hoping to further my knowledge of this issue.

There is an inherent arrogance in imagining that in a bit over 24 hours we could manage to solve the problem, especially when so many talented people are working on it already. However this gave us a focus, a sense of social mission, and the impetus to put together a pitch.

The feedback from Alejandro and River from HackPartners was also amazing. They managed to combine realistic, even harsh appraisal with an enthusiasm and encouraging attitude. I realised how tricky this kind of mentoring is. The world of startups and Hackathons is one which blends giddy, nearly manic enthusiasm and ambition with the most hard-nosed, querulous realism. One minute we are encouraged to dream big, to throw around words like “transform” and “revolutionise”, the next we are being closely questioned on just what our business model is. The HackPartners mentors (and the other mentors) were highly skilled at managing this.

Technology and practice

It is nearly a cliche in discussing tech and health (and tech and education) that the technology shouldn’t determine the clinical / educational use, but the clinical (or educational) need should determine the technology approach. I myself have pontificated along these lines  (Before going on, in this section I will use “healthcare” to encompass both clinical and medical-educational needs, otherwise this will all get even more unwieldy)

It was therefore richly ironic when it was I who, on the Saturday morning, was contributing to the team discussion words to the effect “let’s just get something together, and then we can think of the healthcare application.”

In the end, Prof Sandars’ intervention saved us from that possibility. However, this dynamic – of technology determining the healthcare use – is interesting. I reflected later that perhaps there is something subtler going on, if I – whose entire approach to this field is based on the idea that the technology must follow the educational/clinical need, rather than vice verse – was drawn into this line of thinking. The dynamic may be more than just a planning failure to consider or involve clinicians or teachers or service users, but more inherent to the tech/healthcare interface.

I don’t have an answer, even a half formed one, as to what this dynamic actually involves. One train of thought I’ve had involves the possibility that in the encounter between the technologist and the clinician, the technology is concrete, “practical”, while the clinical problem (in the context of this encounter) is something abstracted. I don’t mean that healthcare problems are “abstract” themselves. What I mean is this – all concerned are sitting round a table, laptops at the ready, and at that moment the healthcare problem is something abstract and disembodied. The technological aspects of the challenge become the practical, concrete thing that needs to be done – the healthcare need is abstracted and can therefore be shunted around as the practical technological work is done. The setting is technology-heavy – the laptop is the working tool. The healthcare scenario is abstract, remote.

These are very preliminary thoughts. Essentially the dynamic is more subtle than I previously thought, and perhaps more deeply embedded than I thought. I hesitate to say “inherent”, although I do suspect the cultural valorisation of technology contributes as well.

Would a hackathon located directly in a clinic, or a ED, or coordinated with a beside tutorial or somewhere where healthcare is actually happening, have a different dynamic? Would involving clinicians/teachers with little interest in technology, or even an overt hostility, actually make for a more rigorous dialectic? Or does something else have to happen?

Do “quiet” ideas get shunted aside?

The pitch is clearly a vital part of startup culture. A good pitch requires good discipline, and a clarity of thought about the product or service. Certainly the successful pitches at #ameehacks were both entertaining and informative. It was pretty clear the judges valued a working demo very highly.

I do wonder if quieter ideas can get shunted aside in pitch culture. TED talks are in many ways wonderful, but I have always been concerned that presenters that make a slick show and give the audience what they want can trump more difficult, more genuinely challenging, more meaningful ideas.

There is a tendency for healthcare startups to promise to UTTERLY TRANSFORM HEALTHCARE and education startups to REVOLUTIONISE HOW WE LEARN and so on. The quieter, smaller solution (and perhaps the genuinely revolutionary one) gets lost.

Closing thoughts

I would love to see a Hackathon in my own clinical field, mental health, involving service users as equal participants. I would love to see community hackathons spread. I would love to see the positivity, friendliness and warmth that I witnessed in hackathon culture become a model for wider engagement in ideas and practices. I would love to see hackathons where the hacks were not necessarily technological.

I will think and read a bit more about the interplay between technical innovation and education/clinical practice before further blogging. Any suggestions for reading are warmly welcomed.