Trending in 2014: <scp>H</scp> ippocrates

After witnessing a conference keynote presentation a few years ago, I spoke with an educator who was in absolute anguish. Her exact words escape me, but her sentiment was unforgettable: ‘We just invested 2 years and lots of energy in modernising our practices, and now they're telling us they're out of date.’ The conversation reminded me of both how frustrating it can be not to have a straightforward answer to an educational problem and how easy it can be to dismissively launch the non-specific critique: ‘That's just the latest trend.’ Every one of our readers who has been involved in a discussion about whether or not to invest in simulation technologies, for example, is likely to have heard such critique in one form or another. In fact, ongoing debate about the value of simulation is simply a modern incarnation of a long standing discussion about the role of the latest fashions in education and practice.1-3 This discussion is so common that one can actually review the history of technology by tracking the education literature. Examining the compendium of research collected by Russell illustrates that nearly every broadly available technology from reliable mail delivery through to film, television, computers, and now social media, has been seen by someone as a cure to some educational ill.4 The title of that compendium, The No Significant Difference Phenomenon, could lead one to conclude it's all just a waste of time and effort. My purpose in constructing this editorial is quite the opposite. The fact that trends exist in education, and that they get people excited only to be discarded when the next big wave hits, is not necessarily a bad thing. If there were no fads, there would be no excitement about new ideas and no scholarly thought put into how to use or adapt those ideas for educational initiatives. Educational theory might be a moving target, but that is fundamentally problematic only for those who adopt the view that there is a single right way to teach or learn. More distressing would be if there were no inspiration, no energy, and no motivation to try new things. Technology changes, culture changes, and people change, indicating that educational practices, just as Frank argued with reference to sociological thinking,5 must reflect ‘the fate of our times’. That constant evolution means never being able to fully answer the question of where the evidence is, let alone to determine conclusively that one practice is better than another forevermore. It is for this reason that I tried to console the distraught educator by quoting Lorne Michaels, the Canadian creator of a live televised sketch comedy show in the USA, who is reputed to have said: ‘The show doesn't go on because it's perfect. It goes on because it's 11.30.’ ‘That's just the latest trend,’ said with a cynical sneer, implies there is nothing lasting to be gained from the exploration of new ideas and technologies because the trend is bound to give way to something new. As such, any individual paper comparing the pedagogical effectiveness of a new technology against an old one might wind up in the No Significant Difference compendium, the accumulation of effort has led to both greater insights (e.g. recognition that the technology itself is not the main determinant of learning6) and more sophisticated questions such as those concerning how technological elegance can sometimes interfere with human cognition.7 Every new trend creates motivation to explore relevant issues in different ways and to test the extent to which lessons learned in prior circumstances generalise to new contexts. Although it is important not to reflexively discount the latest trends simply because their rate of spread surpasses the accumulation of evidence. At the same time, paying attention to fads does not mean abandoning the hard-earned lessons of yesteryear. Therein lies the answer to why the title of this editorial suggests that a man who lived nearly 2500 years ago could still be considered to be influence a valuable trend in 2014. The doctor's oath, commonly ascribed to Hippocrates, has been used for centuries to inculcate newcomers into the medical profession in many parts of the world. As time has marched on and trends in understanding have come and gone, the oath has been revised numerous times to take advantage of modern perspectives, but the underlying ethic that medical practice must live up to lofty standards has persisted. Shortly after World War II, the newly formed World Medical Association (WMA) created and adopted the Declaration of Geneva as a modern statement of the medical profession's values.8 Exactly 50 years ago this year, Louis Lasagna (then associate professor at Johns Hopkins Medical School), wrote an article in the New York Times Magazine in which he indicated that neither the WMA's oath nor its predecessor had achieved broad uptake.9 In that article, Lasagna humbly offered his own modernisation of Hippocrates’ perspective and encouraged others to take up the charge and improve upon it. Four years later the WMA amended the Declaration of Geneva, a practice of adjustment to account for modern trends which the Association has adopted roughly every decade since. In this special issue of Medical Education, we celebrate the 50 years since the publication of Lasagna's call to arms by offering reflections on the current stance of health professional education with respect to the issues highlighted in Lasagna's version of the oath. We created the issue by first dissecting the oath line by line. The editors then presented a particular line to a particular author and challenged that person to write a state-of-the-science review inspired by that piece of text. As you will see, some of the authors used the lines with which they were provided literally,10 whereas others used them metaphorically.11 Finally, our commentators were offered the list of all articles and were asked to provide overarching thoughts on how the articles and the oath itself are reflected in their current geographic and temporal climates. I think you will find that the effort, in aggregate, provides interesting insights into where we currently stand as a field as we continue to evolve from what might have once upon a time been seen as a fleeting trend: the Hippocratic school of thought. ‘I swear to fulfill, to the best of my ability and judgment, this covenant: I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow. I will apply, for the benefit of the sick, all measures which are required, avoiding those twin traps of overtreatment and therapeutic nihilism. I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon's knife or the chemist's drug. I will not be ashamed to say “I know not”, nor will I fail to call in my colleague when the skills of another are needed for a patient's recovery. I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know. Most especially must I tread with care in matters of life and death. If it is given to me to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty. Above all, I must not play at God. I will remember that I do not treat a fever chart, or a cancerous growth, but a sick human being, whose illness may affect [the person's] family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick. I will prevent disease whenever I can, for prevention is preferable to cure. I will remember that I remain a member of society, with special obligations to all my fellow [human beings], those sound of mind and body, as well as the infirm. If I do not violate this oath, may I enjoy life and art, respected while I live and remembered with affection thereafter. May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help.’

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