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Yesterday I received this information in my inbox. It is a delightful appraisal of the externs perspective, as well as that of the Attendings / Residents and deserves a wider audience. As a seasoned practitioner currently exposed to the heat and pressure of student and extern, I have an uncommon perspective. I will be interested to know the experience of both, Doctors-in-Training as well as Residents / Attendings.

History lesson on the PIMPing you’re getting on externships.

“A lot of truth is said in jest.” ~Eminem 

Socratic questioning has been at the heart of clinical medical education many years. Traditionally, the educator asks a question so that the original question is responded to as though it were an answer. The central technique of Socratic questioning is known as elenchus, meaning a cross-examination for the purpose of refutation. In medical school, this technique of education is more commonly referred to as pimping. This style of teaching is seen as a way of the educator showing his/her greater knowledge of a subject. Depending on how and where it is enacted, pimping is perceived as a unique kind of questioning practice with a wide range of intentions from knowledge checking to humiliation. Some educators use elenchus for knowledge checking; others educators pimp. The students perspective of this style is the same regardless of the intended purpose.

The earliest use of the term pimping dates back to 1628 in a statement made by Harvey in London. Harvey, feeling his students lacked enthusiasm for learning the circulation of the blood, stated: "They know nothing of Natural Philosophy, these pin-heads. Drunkards, sloths, their bellies filled with Mead and Ale. O that I might see them pimped." In Heidelberg (1889) a series of questions titled "Pumpfrage" or "pimp questions" were recorded by Koch for use on his rounds. And the first American reference to this was by Flexner in 1916. He wrote about his visit to Johns Hopkins: "Rounded with Osler today. Riddles house officers with questions. Like a Gatling gun. Welch says students call it 'pimping.' Delightful."

Now, if we look truly at the Socratic questioning, its purpose is not politically motivated. It is for the purpose of educating and to improve the students understanding of a subject through questioning. On the other hand pimping can be more politically motivated. Many times pimping is used as a way for an attending to show his/her knowledge. Knowledge is power. Pimping sets the hierarchy.

In the art of pimping, questions should come in rapid succession and be somewhat unanswerable. Questioning can be grouped into approximately 6 categories:

  1. Arcane points of history - facts not taught in medical school that have no relevance to medical practice.
  2. Teleology and metaphysics - questions that lie outside the realm of conventional scientific inquiry. Most often found in the National Enquirer and addressed by medieval philosophers.
  3. Exceedingly broad questions - for example, what is the differential for a fever of unknown origin. These questions are best asked at the end of conference. Regardless of how many good points the student makes, s/he will always be criticized on the points missed.
  4. Eponyms - questions like, what is the Hoffa fracture? These are usually dated terms that should be struck from memory.
  5. Technical points of basic science research - enough said. These technical points, although showing academic prowess, have no clinical relevance.
  6. The Devil's Advocate (my personal favorite) - with this technique, the educator takes the opposing view. This challenges the learner to understand the strengths and weaknesses of both views. For learners, defending against this takes experience, skill, and understanding. Novice learners are easily swayed away from their correct thought process down the wrong path.

For a master pimp, these are important categories to understand. Their utilization, while at a nursing station or in front of many naive on lookers, can gain the questioner many power points. It is like flexing your muscle in the gym mirror in front of the elliptical machines.

While understanding the ways of pimping tactics is interesting, it is more important for the student to understand the classic defense strategies to stymie the master pimp. When using these tactics, the student must be careful not to anger the questioner making the situation worse. If done improperly or if the technique is not properly disguised, it will quickly be countered with quickly countered. There are several classic techniques: the stall, the dodge and the bluff.

  • The stall - this is commonly used in x-ray conferences. The student typically looks at the study squinting, and bring their face so close their nose almost touches it. Then the study characteristics are described. "This is an AP, Sunrise, Notch, and lateral in a skeletally mature patient dated January 5, 2007." The next step is to describe what is not present. It is important interject pauses, face holding, and pointing, as diverting gestures. The hope with this technique is that the questioner will fatigue and ask someone else.
  • The dodge - this is a way of avoiding the question and wasting time. The most common ways this is applied are by answering the question with a question and/or answering a different question.
  • The Bluff - (3 classes)
  1. Hand gesturing - this is making reference to hot topics in medicine without supplying either substance, detail, or explanation.
  2. Feigned erudition - answering as if you have an intimate understanding of the literature and a cautiousness born of experience. For example, "To my knowledge, that has not been addressed in a randomized prospective controlled study." These statements are usually made after clearing the throat, standing professorially, and while holding something, coffee cup, glasses, etc.
  3. Higher authority - this is done by referencing someone higher up in the hierarchy or another institution. Using a senior attending as a reference is common. "In my discussion with Dr. x, he stated ...." It is also common to mention another institution where the student may have trained. "At Duke we .... "

Now, once the offensive questioning tactic is put into play and the student's defense is chosen, where do the errors occur. Probably the most common error for the inexperienced student is the misuse of defensive tactics. When a student shows his/her hand early, it allows the educator to see their lack of understanding of the subject and is like blood in the water for some educators. These are easy pickings for malignant educators. Just as problematic as improper use of a defensive tacts is not having good control of the "Brain Mouth Filter." Although knowledge is power, welding a little knowledge without an understanding will get a novice in deeper than s/he can handle. Once a novice learner gains some experience and knowledge, they begin to overstep their understanding and bring up other topics and controversies without being asked. Students that has a running dialog of his/her thoughts, it opens them to more questioning.When this is done, one of 2 things can happen: the student can get an endless onslaught of questioning there by saving all others from questioning or the team will share in the beating. The learner must develop ways of diverting questioning and putting a closure to the questions. Filtering their thoughts prior to speaking is a must.

In the end, the pimping phenomenon is a game. The educator is the game master controlling the many of the parameters of play. With time, a learner will develop both a knowledge base and thought process. They develop there own styles of processing and answering "pimp" questions. Hopefully at end game, education occurs.

“Sometimes questions are more important than answers.”
~Nancy Willar


  • Comments (8)
  • I have read a lot of very good points thus far.  The biggest dilemma that I find with the art of effective pimping is in how it is utilized and to whom the pimping is directed towards.  As a person who is now involved in residency education, as well as one who is not so far off from residency training himself, I have made a personal decision not to enforce pimping when on rounds.  I simply use each patient as a teaching point and then ask questions in which I can readily answer if the resident or student is going astray.  To me I feel that I have in a way made the learning experience more "real" in a sense since I have tied in a patient with a particular symptom.  In my head I'd like to think that the person I affected will one day say, "Oh yeah I remember seeing that in residency and this is how we treated it". I really don't take a chance with trying to measure who can take a ribbing and who can't.

    For me, I know that I was the recipient of multiple pimping escapades and the way that I responded was by hitting up the literature to shore up my deficiencies.  However, I have found that the younger generation is not too keen on doing for themselves. Instead, they come with a sense of entitlement and very seldom with a sense of appreciation for the teachings and trials of our predecessors.  If you do not cater to their cravings for instant gratification, your good natured questioning can be viewed as insensitive interrogation.    

    -Justin

  • I think the problem can be perfectly summed up in the title of this thread, “P.I.M.P.”  We all know what a pimp is, and how low and disgusting they are.  They have no place in a center for higher professional learning.  Teaching is a tool used by high class professionals to build up people who will be the future of their profession.   PIMP’ing is an ego boosting, tearing-down exercise performed by low class individuals.  PIMP’ing should be replaced by something like IQ’ing, Intellectual Questioning, an exercise that is used to improve intelligence rather than belittle lack of knowledge.

    I am glad the times are changing.  These changes are positive, not negative, changes.  Doctors should be professionals, not schoolyard bullies.  Both learning and teaching should be on the professional level, should be done in a respectful manor.  One should not have to endure abuse while trying to learn a vital profession.  While it’s true that learning can occur anywhere, it is most positive and character building when done in an environment of mutual respect rather than in a toxic battlefield.

    Of course, there are extremes, as with anything.  Both the bullying of some educations and the laziness of some students have opened the door to strong opinions on both sides of this important subject.  They have allowed each side to inject both humor and dramatics into a serious problem.  They have overshadowed the great individuals who truly educate and the hardworking students who really want to learn. 

    It’s important that past abuses not be trivialized.  Inappropriate behavior by individuals in charge of teaching debases the whole learning process.  It can’t be seen as students who are looking for an easy road.  That’s not what the controversy is about.  What’s needed is a professional learning environment so students can excel without being treated like third class citizens.

    I was fortunate to have spent my last year of residency with some true educators, the surgical staff at the New York College of Podiatric Medicine.  They took their teaching responsibilities seriously and took the time to teach, not PIMP, their students.  Every minute spent with an attending was a minute of learning, and there was never any ego involved.  They asked questions often, taught vigilantly, and always did it professionally.

    In contrast, I knew of and personally witnessed some of the less professional behavior.  This behavior included attending s calling residents “whores” and other unprofessional names while in the surgical suite, surgeons throwing instruments and other objects for no legitimate reason, etc.  One “attending” (not a podiatrist) told me at the beginning of a rotation that my evaluation would depend on whether or not I would get him the phone number of one of my co-residents.  He specifically stated that if I didn’t get it I would get a poor evaluation.  Of course, my friend had no desire to give him her number, and he followed through with an unjustified, negative evaluation.  For me personally, this was not an important rotation and I didn’t put any weight on his remarks, but this was probably not the case for the medical residents rotating through, who probably had similar experiences.

    But I digress.  Essentially the point is that it’s not asking questions that is abusive, it is the way people are treated and the value they are getting from the process that are important.  By the same token, if a student has no desire to learn, they have to ask themselves why they are in the profession.   

     

  • Very well stated by Dr. Markinson. My, how the times have changed! Agreed, no one should be humiliated by any means, but depending on the individuals personality, humiliation may be an unintended consequence. Regardless, pimping should be used as a tool: motivational, educational and for the benefit of the student. Obviously, we have to pick and choose which students can take more "heat" than others and that is a shame. My generation of graduating class of residents may very well have beenthe end of an era. As I was graduating my Chief Residency, the laws were just being enforced pertaining restrictions on work hours as well as "harassment" lawsuits were just starting to be "en vogue". Bottom line, it was a culture of "equal pay, equal play". We were all residents together and all residents would be and should be pimped equally. Granted, in those days, the weaker residents may have been picked on more, but it certainly was not to humiliate them - the goal was to bring that weaker resident up to the same level as the others.

    I'm not sure if society's evolution into more political correctness is necessarily a good thing. In my humble opinion yes, we all have to be sensitive to cultures, lifestyle, and gender differences but things have come to a ridiculous level. Most people, myself included, have to be on a constant awareness level in regards to what we say, how we say something, and who we say it to. I have seen situations where an individual has not been questioned on a certain issue for fear by the person in leadership not being falsly accused of harassment. I also have seen instances where an attending has prodded a resident in an academic forum, only to be accused of harassment.  Dr. Markinson is right, we are in an era where it's "safest" to stay away from the water cooler. Casual conversation may be soon becoming a thing of the past in the professional realm. Pimping may be extinct within a few years once a big enough lawsuit gets publicised and yes, medical education will be affected for ever.

  • The whole discussion is a sign of the times. Before I begin, let me say that it is difficult to discuss the historical perspective without appearing to be on one side of the issue or without appearing to trivialize it. I assure you I am neither for harassment or bullying of any kind anywhere. However, the facts are the facts. What used to be benign flirtation at the office water cooler has morphed into sexual harassment. The definitions of "going too far" are forever changing, and depending upon the individuals, can be vastly different.

    The culture of PIMPING in medical training is somewhat of a different matter. When I was a resident, on the throws of complete physical exhaustion, I would get myself together and somehow participate with the simple suggestion of an interesting case going on somewhere. Now, it is commonplace for the resident to inform that they are approaching the work rules limit. Of course, evidence showing that medical mistakes increase when doctors are exhausted had to be considered and work rules had to be put in place and enforced. However, it is something different when the resident is keenly aware of the exact number of hours  they are working....a concept unknown to me when in that role.

    I am also aware that the enforcement of the rules mandates strict penalties for non-compliance...but again, I am sure all over the country, there are still some residents who quietly break the rules for the sake of learning more. I am not advocating that residents work exhausted; I am just delineating the culture shift in attitude towards the work. This shift creates an environment where the bells and whistles for abuse and harassment go off too easily, pre-maturely, and with sometimes devastating consequences to reputation.

    By today's standards, I and I am sure many of my contemporaries could easily today win a law suit for what in our day was simply dues-paying psychological torture, which in my case definitely resulted in learning.  I remember vividly a clinical situation where an attending humiliated me in front of a patient, as well as some fellow students. Suffice to say that regarding the subject matter involved, I poured over the available literature until my hurt feelings turned into the realization that a valuable learning experience occurred. I could have gone to human resources or called a lawyer, but that would have been outrageous. As I developed into a teacher myself, I vowed never to humiliate any student like that. However, I did carefully try to weed out those students who I thought could take a little prodding and those who could not. Why would I chose to overdo the PIMP exercise with some individuals and not others? Simple...because laying it on thick with the right personality gets the job done better than not doing it.

    As a resident, during a lesser metatarsal osteotomy surgery which was being filmed by a second attending in the OR ( I considered myself friendly with both the scrubbed attending and the filming attending), a set of circumstances arose where I caused the metatarsal head to fall on the floor. I can still recall my heart thumping in my chest at that moment. The attending filming the procedure aimed the camera at the metatarsal head on the floor and then slowly panned the camera from my feet up to my face and recorded the following: "This is the idiot resident who just ruined this whole procedure and will regret it for the rest of his residency." The case continued with ongoing jokes about my future. Everyone laughed, as the "kidding" was obvious."  In fact, it actually lessened the tension in the room and my chest. But the psychological outcome was dependent on my ability to take it. This assumption is at the heart of what now is deemed bullying. We sometimes miscalculate. About two years after the incident I just described, another such situation occurred where a resident was the butt of some ongoing prodding in the OR during a case. Afterwards, that resident went into the woods and shot himself in the head. Yes, this must be viewed as extreme, lest we never be critical in any way of anybody. But what about the in-betweens?  In teaching situations, one student's humiliation is another student's motivation. Because we are not always evaluating these aspects of our students and residents, and because the times they are a changing, it is now prudent for all of us in academic settings to stay away from the water cooler. Sad

  • Very interesting Topic begun here by Dr. Fellner.  I love the way you broke it down - one of the common characteristics of this type of idiosyncratic behavior is that so often, the perpetrator isn't consciously aware of doing it.  They have a general sense that doing it is right, that it is justified, that, in fact, it represents justice.  But if you ask them why they do it, they'll mutter something about it being Socratic,  "good teaching technique".  But in the spirit that "no good deed ever goes unpunished", it is so often taken to extremes, and at it's extremes, it simply constitutes bullying.

    On August 9, 2012, a very interesting article was published in the NY Times that is quite germane to this issue, entitled, "The Bullying Culture of Medical School".  I sent it to my son, who is a 2nd year pediatric resident at Columbia, to ask him if it's accurate and he confirmed it certainly is.  The article is based on a survey taken of medical students over a 13 years period, and concludes that, "more than half of all medical students said that they had been intimidated or physically or verbally harassed".  With half of medical student now being female, this takes on an even greater meaning.

    Now don't get me wrong - I do believe that the best training for dealing with pressure, which all physicians and particularly surgeons need, is to apply pressure to them and give them a chance to perform under that condition.  It's all a matter of when, how its done and how much is done. And that is where the ART of teaching comes in.  What hasn't been said in this Topic, yet, is that so many of our Teachers, Attendings, Chief Residents and Residency Directors apply JUST ENOUGH pressure, intimidate and hassle student/resident JUST ENOUGH, and are really very skilled users of these tactics that, when taken to extreme, are harmful.  In the spirit of mentorship that has served medical education so well over the centuries, we should credit the good teachers, and try to reign in the bad.

  • Interesting piece.  Questioning the student is a vital learning tool, especially when used responsibly.  When the teacher uses them to help the student advance, and the student appreciates the lesson, great things follow.  When the teacher is flexing muscle or boosting ego, or the student is slacking and shying away from learning, opportunities are lost.  Worse case scenerio are the educators who don't care enough to question and teach the students, and students who don't care to persue the hot seat of questioning.

    Thanks for sharing.

  • Let me begin by quoting the name of the hit single by Big Daddy Kane in 1989: " Pimpin' Ain't Easy".

    Personally, in my interaction with students & residents alike I do "pimp". I pimp because I have been pimped, I pimp because it's a right of passage, but most importantly I pimp because it's an effective teaching tool if used appropriately. Pimping for the sake of making the attending look better / smarter, etc is complete absurdity since that individual had BETTER be on a higher educational & experience level than the trainee. One of the purposes of being an attending at an academic institution is to pass down this experience and knowledge so that the younger generations can benefit from the such.

    I have pimped because when I was on the receiving end - I was obligated to perform under pressure, at times in public. If I didn't know the answer or if I doubted by attendings logic, you'd better believe I read up on that topic that night; it made me more knowledgeable and a better student. I have had experiences where Chief Residents  pimp students or interns. While the goal here may be educational, this very well be an aexample of where "muscles are being flexed" as it is more important in the development of the residect / student / intern pecking order.