December 22nd, 2016

“Pimping”: Malignant or Not?

Joseph Cooper, MD

Joseph Cooper, MD, is a Chief Resident in Internal Medicine at Geisinger Medical Center in Danville, Pennsylvania.

One of the most respected and skilled clinician-educators (and, of course, he is an Infectious Diseases specialist) at our institute came into my office, sat down, and immediately starting eating pretzels. “Let me know what you think about this,” he said between bites. He went on to recapitulate a recent interaction he had with the members of the Internal Medicine team (medical students, house staff, and the attending physician) about a week ago.
He described a presentation to our emergency department of a young woman with headache, neck stiffness, and fever, who was previously well and had young children at home who were currently ill. He reported the lumbar puncture results to the house staff — the results included a mildly elevated protein level, normal glucose level, and pleocytosis with a predominance of neutrophils and monocytes. He then asked the house staff to formulate a differential diagnosis and explain their reasoning for said diagnoses. Later, he addressed the case again, and changed the values of the cerebrospinal fluid on the patient to clearly illustrate a bacterial source rather than a viral source, and he asked this question: “The pharmacist is standing at the Pyxis machine asking what medications to give. What are you going to tell her?”

Granted, I was not present for any of these interactions, but the vignette seemed more than reasonable to me. He was clearly trying to teach and have the house staff work through the differential diagnosis of deranged cerebrospinal findings — different disease states, offending pathogens, and treatment modalities. From the tone of his recitation of the events, I knew he was expecting a bit more than what he received from the house staff. He then asked me, “How do our residents learn today without being questioned?” I answered, “I’m not sure, but I’ve always found that questions are the best method.” The ID specialist left me with one last question: “Do you think I was too hard on them? Was I being a ‘malignant pimper’? Because I surely don’t want to be that.”

Frederick L. Brancati first coined “the art of pimping,” in his 1989 JAMA article: the practice of posing particularly difficult questions to learners. There are undertones in Brancati’s article (which is older than Justin Bieber) about the separation of power between the teacher and the trainee. Notions of respecting the teacher and expecting the trainee to follow the “chain of command.” Critics state that much of the article was written tongue-in-cheek, and it even prompted a response article twenty years later by Allan S. Detsky about learners taking back their power. Although each article illustrated differing approaches to pimping, they agree pimping confers some value to learners.

Wear et. al published a study in 2015 in which researchers examined interview responses from 4th-year medical students on perceived harms and benefits of pimping. The results were quite interesting, and although the cohort of medical students was not large (and no residents were included), many fundamental issues came to light. Students saw the value of pimping as allowing them to learn on their feet, develop the proper diction to speak with their colleagues, handle anxiety and pressure, and, ultimately, to motivate them to learn on the spot or later if they did not know the answer. “Malignant” pimping was identified by the students as situations in which the teacher was exerting hierarchical power, asking questions which were outside the scope for the learner (much too difficult), was buffering the ego of the teacher, or was simply humiliating the students by exposing deficiencies in knowledge rather than trying to create new connections.

Hospital de Sant Pau. Barcelona, Spain. My Own Work. Canon DSLR.

Hospital de Sant Pau. Barcelona, Spain. My Own Work. Canon DSLR.

Hugh A. Stoddard and David V. O’Dell made the ultimate comparison in their 2016 publication in Journal of General Internal Medicine, stating that psychological safety is the key difference between Socratic method of teaching and pimping. They defined the Socratic method as “prompting students, through cross-examination, into acknowledging their own fallacies and then asking them provocative questions to steer them towards realizing true knowledge via introspection.” The importance of psychological safety is highlighted when the learners feel they are in a safe environment, are comfortable with themselves and others, and feel valued and mutually respected without hostility and the threat of possible humiliation. The authors note that, even in a psychologically safe environment, Socratic teaching does not allow for a sub-par performance and that accountability is not a trade-off for the said safety.

This brings up a very strong and often overlooked point. I hear my administrators say all the time that residents should be more accountable. Accountability must be clearly defined and, at times in medical education, it is not. Sure, we have ACGME benchmarks and standards of what a “normal and average resident should be achieving by the time of independent practice.” At times, the sense of urgency and accountability seems to be lacking within the millennial generation. Learners expect to be spoon-fed lectures with important concepts and have protected time to learn those concepts, yet a very few seem to really possess that internal drive or accountability to own medicine, own the concepts, own the pathophysiology and disease process, and own their patients, because ultimately it is about their livelihood.

Returning back to the pretzel-eating, bow-tie wearing ID specialist’s question: Was he too hard on them? Was he being a malignant pimper? Although I did not witness the entire interaction, I would have to say no, absolutely not. I know he wants the house staff to learn, and he does not exhibit hierarchical power in his line of questioning, and he does not need to buffer his ego (he has won numerous teaching awards at our institution) or humiliate anyone. I offered him a morsel of constructive criticism, echoing what I’ve detailed above.

Lembongan Island, Bali. My Own Work. Canon DSLR.

Lembongan Island, Bali. My Own Work. Canon DSLR.

As I continue on throughout my chief year and move into fellowship, I must heed my own advice. Setting the stage and creating an environment of psychological safety is key when questioning learners. Numerous studies and evidence prove that posing questions at an appropriate level to the learner is the foundation to clinical reasoning and teaching, and we should not stray from this. Posing questions to our learners gives us a better understanding of their knowledge, their ability to explain concepts, and their deficiencies. The best clinician-educators take this information from their learners and expand on information that fills in deficiencies, or explain concepts in a way that the learners will never forget. Better yet, they motivate the learner to independently seek knowledge or skills they are lacking, with a continued thirst for learning.


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8 Responses to ““Pimping”: Malignant or Not?”

  1. Scott Helmers, M.D. says:

    I almost always read an item with “pimping” in its title. I am now retired but always remember an episode as a junior med student in 1968. On pediatric rounds the faculty person asked a question of a group of students and house staff. I volunteered an answer, which was wrong, and I was belittled and berated. I have always remembered that faculty person with intense hatred. I was somewhat rescued by a kindly resident who was with us who simply told me, “I can’t say that it is ideal, but I survived as a student by never volunteering any answer.” I followed that advice from there on with some safety. Throughout my career, I avoided where possible teaching situations, never wanting to embarrass a student in any way as I was. Teaching techniques are crucially important. “Pimping” as it has come to be understood is abuse, absolutely and indefensibly.

  2. Roger Felix, MD says:

    My brother is a teacher, and he has the same problem with young students wanting to be spoonfed their learning without “owning” the material and getting their minds around the difficult parts. I don’t know what we do about that — education in this country has degenerated. Someone did a great article acouple of years back where they interviewed foreign exchange students about their experience of American schools. They had two consistent responses: coursework too easy, and too much emphasis on athletics (disclaimer: I’m an athlete and sports fan). As far as pimping goes, there are good ways and bad ways to pimp. When I was a resident, I asked my interns questions, but if they seemed really stressed out, I tried to do it in a more entertaining tone that did not look like “come up with the answer instantly or you’re a moron!” I observed another resident in my year pimping her interns sternly and relentlessly. They were always unhappy as a result. I don’t think my interns came out of the year less educated than hers, but they certainly were less stressed, because I tried to make the learning part more enjoyable.

  3. Robert H Bowden Jr M.D says:

    Medical training is not just what you know,but also how respond to difficult situations.What do you do when the patient doesn’t fit your diagnostic acumen? Unfortunately we learn the most when we are wrong,training is not about your psyche it is about doing the best you can for this patient!

  4. As a patient and health care researcher, as well as teacher, I argued in my article in the BMJ on Pimping.
    that pimping has no place in medical education. None. While it’s critical to make the distinction you do between questioning and pimping, it’s equally critical to get rid of the term pimping entirely. Why, in the 21st century, would medicine want to be tethered to word with such a pernicious history and contemporary connotations? Rather than trying to make arcane distinctions between malignant and non-malignant pimping, why not just define pimping as the way most medical students and residents define it — as a deliberate act of humiliation and hierarchical power? Then make the distinction between the act of asking hard questions, which is entirely appropriate — while insisting that pimping is not. Problem solved — at least the definitional problem at any rate.
    If some people feel that asking any hard questions creates a lack of psychological safety that’s their problem. But as Supreme Court Justice Potter Steward wrote about pornography — ” I know it when I see it,” most people know pimping when they are pimped and it is not the same as asking hard questions.
    Humiliating students, learners, colleagues or team members is never appropriate. Indeed it’s a patient safety risk and undermines any efforts to create high reliability in health care, . In medicine — and healthcare in general– our problem is not people speaking up too much to protect patients but speaking up too little. The consequences of “pimping” are significant. For example, when I ask residents if they would tell an attending that he or she had forgotten to clean their hands after touching a patient with MRSA, the answer I invariably get is “it depends.” Upon what does it depend, I ask? On what I think the response of the attending will be. Does anyone think that an attending who “pimps” his or her students will be reminded to clean his/her hands? My life should not depend on the pedagogical choices of attending physicians. But it will, if medicine doesn’t once and for all abandon a pedagogical practice that has never had any usefulness at all — except in teaching trainees to shut up.

  5. david kaufman says:

    As one whose ego has been bruised on rounds on many occasions, I think this is a balanced presentation of at the bedside teaching. However, the term should be ‘buffing’ when related to the ego (buffering related to acid base chemistry!)

  6. Joseph Cooper, MD says:

    Thank you for all the great comments and discussion from all above.

    As a junior Staff now, I agree with Dr. Bowden, Jr, much of the training that residency prepares young physicians for (in any field) does not address or “teach,” how one responds to difficult situations. Continued experience, an open mind, open heart, and humility is needed in this profession to continue to be the best clinician as possible. Thank you again for the comments.

  7. Jacob Wagner says:

    Interesting article. I would quarrel with the premise that “the sense of urgency and accountability seems to be lacking within the millennial generation”

    As a millennial trainee I take strong exception the overgeneralization of an entire generation. Yes, there are some students and trainees who do not treat medicine as a calling. Undoubtedly there are more senior faculty who have the same flaw. I cannot imagine what benefit there might be to stereotyping an entire generation of new physicians in such a manner.

    I am also inclined to agree with Suzanne Gordon that the more vulgar definition of “pimping” is far too well established for us to try and parse out the difference between “malignant” and “non-malignant” pimping. We all know pimping when we see it, likewise we can all appreciate an eloquent demonstration of the Socratic Method when we see it. The former is always uncomfortable and hard to watch, the latter is refreshing and novel, and enjoyable to participate in. Let’s give Socrates his due, and leave pimping in the 20th century.

    • Jacob Wagner says:

      Edit: “Undoubtedly there are [just as many, possibly] more senior faculty” -JW

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