Yesterday, I read two articles in JAMA on pimping. (Yes, I still get JAMA.) The article suggested that pimping medical students and residents may be “old school.” Used inappropriately, it may serve more as a tool off abuse and humiliation as opposed to a pedagogical art.
Duh.
Anything used inappropriately can be viewed as abusive or, well…er, inappropriate.
That includes language, relationships, guns, medications….The list is long.
First, to those reading this who believe I am talking about business oversight of prostitutes. Nope. In medicine, pimping is the art of asking those junior to you rapid-fire medical questions. About your patient. About patient care. About medical trivia. About ontogeny recapitulating phylogeny.
It’s a rite of passage. And it is often stressful.
For those teachers who are using it the right way, they hope their students will “come to class” prepared. Most teachers want curious students to learn and succeed. It’s actually less time consuming to just pass the below-average medical student and make him/her someone else’s problem down the road. Pimping is labor intensive for both the pimper and the pimpee. The pimper has to remember the Krebs cycle and brachial plexus anatomy to stump the pimpee.
Socrates used the same techniques.
Next, pimping gets the student used to stress. Practicing medicine is stressful. Taking care of patients is not easy. Why pretend otherwise? Keeping medical students and residents in a cocoon will only delay that day of reckoning. If doctors are to perform, they need to be tested. This is no different for military personnel, police officers, and professional athletes.
Does pimping have other less beneficial purposes? Of course. When I took my oral neurosurgical boards, each session had two examiners. In one session, one of my examiners had been in practice for decades. He was seasoned with gray hair. He believed his job was to ensure I would represent the field honorably. He wanted to make sure my judgment was sound and that I would not hurt any patients.
The other examiner was green. He had graduated from his neurosurgical residency a few years earlier. He was junior faculty at an academic institution. And, he was working his way up the food chain. The questions he asked were nothing like those of his more senior colleague.
I was being pimped.
I got the impression his questions had more to do with impressing his senior colleague, than actually testing me.
Still, I passed.
A rite of passage.
If a pimper is focused solely on humiliation and abuse and has no interest in pedagogy, then, that person has no place in teaching. But, most pimpers believe a greater goal is being served.
My vote: Let the pimping continue. What do you think?
Yes, I agree
Pimping to challenge and stimulate for educational purposes is an important aspect of the medical education of physicians.
Yes, from personal experience I can say it is abusive.
A good teacher teaches. Firing away questions is something any idiot can do.
I was so much more capable of thinking on my feet and defining preparedness at the end of my third-year medical school rotations than I was at the beginning. Pimping was essential. I can recall specific facts from those encounters to this day–28 years later. I had the privilege of completing a neurosurgery residency under the training of true gentlemen who never abused their authority over me, but pimped and maintained very high expectations.
Work hour restrictions have diluted residency training too much as it is. If we eliminate pimping, turning medical education into a “safe zone,” graduates will become less and less prepared for the stress and unpredictability of the real world. I did not go into the medical field expecting it to be easy. Is that the current expectation?
Depends. If it actually furthers someone’s education and/or ability to stand up to stress, fine. If it’s just to make the pimper feel superior to the pimpee, it’s bullshit.
Here’s a non-medical example: friend of mine, another retired surgeon, was with a flight instructor. Chuck was concentrating on flying, the instructor on being irritating–kept asking him trivial questions that had nothing to do with what was going on in the cockpit at the time. Chuck became increasingly annoyed until he decided to do something. As he was flying, he kept trimming the plane nose up until he couldn’t any more. The pimper/instructor didn’t notice this since he was too busy being a pain in the ass.
Then Chuck said “your plane” and took his hands off the yoke. The plane immediately stalled and started acting very non-linearly. As all of us do, Chuck knew how to pull the bacon out of the fire–it’s a simple thing to do–and as he was watching the instructor flail and anticipate his imminent death, he kept asking him over and over again, “how much is 2 + 2?” He never got an answer.
Fired the guy as soon as they landed–you get to choose and hire your own flight instructors. Was there a useful motivation for the pimping? No. He just wanted to be a rock in his shoe because hey — he was the instructor.
Turned out he responded worse to being the pimpee. What a surprise.
If you think pimping in the medical profession is abusive, try a law school class, here my friends lye the true pimping artists….
George R. Vito, DPM, MBA, JD
In surgical residencies this was done to humiliate the intern or junior resident. There was no teaching involved. Expecting people to know that which they could not possibly know without direction or some head’s up ahead of time is humiliation. Due to psychology the humiliation aspects are remembered long after the medical information looked up after the incident is forgotten.
Ex as a very young surgical intern I was second assisting a very senior surgeon, author of several surgical textbooks, and former head of an illustrious surgical training program in NYC. (One of these texts was given to me years later by a retired surgical colleague and consisted of three senior surgeons bashing each other’s surgical technique in print for different surgical operations. Now it would be malpractice fodder but this text was written before the malpractice crisis of the 1970’s). The surgeon asked me what a hernia was. I responded to the best of my limited ability and stated that it was a defect in the abdominal wall. He stated “WRONG”. He never said another word the entire case. After the surgery I went to the chief resident who had first assisted on the case and asked, what was wrong with my answer. His reply was, that the answer he was looking for was that a hernia was a defect in the transversalis fascia. He also stated it was a typical question the senior surgeon asked to trip up interns. Not quite pimping but similar in concept. The goal is not teaching but humiliation. This is not a guided education approach but a cudgel to humiliate junior residents and interns. It was a terrible way to teach then, and it remains so now. So many people have endured the so called Socratic method in residency and in law school (“The Paper Chase”), that they think that because they endured it, it is a good way to learn. It isn’t. Humiliation is humiliation and psychologically there are far better ways to bring people along and educate them.
I loved being pimped because I could show I knew more than the other residents. I would feel bad for the others getting humiliated. But how much sympathy should i have had for a resident who did a case but didn’t read up on it?
The fear of rounds drove me to find a moment to read up on all my patients. As self-motivated as i am, there is no doubt that the pressure of looking smart on rounds drove me to read more and more intensely.
And it puts you in your proper place. Here’s an example: on my chairman’s service in general surgery it was just a chief resident and an intern. When i was chief the intern was an ent. Pimping begins with the intern and works its way up to the chief. After two days my chairman realized he needed to start with me and then move on to him! How humiliating. But guess what? This guy scored in the 99th% of general surgery boards as an intern in ent! He put me (and everyone else including some faculty) in their proper place.
My favorite story: the chairman asked me whether a woman could get a hydrocele. I had never heard of it, thought for a moment, and said that i guessed so. He asked me the eponym and i didn’t know. He turned to the ent intern and asked him. A he calmly answered, “Is it not a Cyst of the Canal of Nuck?”
That one was so esoteric it didn’t make me feel stupid. But you only should feel stupid if you don’t know the answers to things for which you should know the answers. This is how we learn. I’d much rather get pimped on rounds than have formal written exams every week.
I’m so tired of this politically correct garbage. People need to learn to take some knocks. And if you don’t like being pimped, read more and you’ll shine and it will be your favorite part of the day.
I love pimping! I use it to teach my children, new employees, and medical personnel every day. I regularly get positive feedback from all involved. I live being pimped! I prepare for every thing I do. If I can’t answer correctly, I appreciate the lesson and/or look it up. In my opinion, if you can not take pimping, you shouldn’t be in medicine or any other profession. If you can answer the attending’s pimping, the student has learned and the teacher has taught. Abusive professors are just that. We all know who they are/were. I don’t respect them and will forget them. The ones that pimped me to improve me will live in my memory forever and inspire us all to be better. I think JAMA isn’t representative of the medical profession on this topic.
Great blog, Doc.
Yes, let pimping continue for the sake of the patients we are here to serve.
I can tell by the responses that some of the folks are a bit soft. Mother Nature (disease and critical illness) does not cater to our wishes, folly or politically correct ideas about how things should be. I Love the profession of medicine and the great works of Medical art that can be done by master physicians. And, I will teach anyone and everyone what I know in accordance with the Hippocratic Oath. But, the expectation is that each “student” will pledge to “first do no harm” and “do good” and “do the right thing always”. And, I pimp gently, unless or until the student proves to be arrogant, impenetrable, block headed, untrainable and dangerous. The “always certain and often wrong student”, no matter what level of training, requires discipline, if not dismissal from the profession. Pimping is one good way to help weed the bad apples out, before they get into positions where they can be licensed to kill.
But, of course, that is just my opinion.
Dr. Mike
Michael F. Mascia, MD, MPH
I am in complete agreement with Drs Teitelbaum, Burden, and Mascia.
If you aren’t prepared for a little pimping, you most likely are not prepared to treat the patients.
Looking back at med school and residency, I would divide “pimpers” into two categories. In the first group were those who might make me miserable but taught me much because they were good at what they did, knew their stuff, and were ultimately able to convey useful knowledge. In the other group were those who were quite the opposite. Claude Organ, “The Malignant Melanoma”, comes to mind. Couldn’t cut their way out of a wet paper bag, thought they knew far more than they actually did and were often dead wrong. Their only purpose seemed to be to abuse and humiliate in order to serve their own inflated egos. I hope the former group will be able to survive the next generation of “microaggression” sensitized cream puffs who will no doubt go running to the ACLU every time they feel they have been victimized by a pimper. As for the second group….good riddance if they cease to be found in our places of learning.
In the “old days”, we prepared thoroughly for rounds with our chairman. If you survived the pimping, you looked like a stud in the eyes of all. If you didn’t know an answer, you remained silent and the hot potato would be tossed. This was not used to embarrass – just to make you better and smarter.
Pimping is probably dead. Residents today are weak, apathetic, and scared, with hundreds of thousands of dollars of debt, and a bleak future looking forward.
I was pimped. As a result of this and other teaching techniques, I worked/studied harder. It was at times humiliating, at times exciting. I was haized, especially in residency, with other cruel techniques, but only by a few attendings we all tried to avoid. Others were great! My experience trained me well to be a very good doctor…I got over the stress, only to have it replaced with that of a lifetime career in private practice, and I love what I do. In the end, medicine is not for everyone.
Pimping. V/N. To ask a question fully knowing the answer in advance. i.e. the Socratic method of learning in which the teacher poses a question of the students, in fact offering the lesser in the relationship: Teacher vs. Student, to take on the role of Teacher who then is judged by their own peers on the content of their thoughts and the merits of their work. It seemed to work well for Socrates, until some former students tiring of his failure to realize they had already graduated to running Athens, and they invited him out for a drink. As long as the students are permitted to provide feedback on their medical educators: short of offering a glass of hemlock to determine whether their professors too, were paying attention during second-year pharmacology, and there is no hint of bias, other than against the unprepared mind, then pimping, like taking call is one of those rites of passage, which can illuminate more than it burns. In my personal opinion, it is best when used to increase understanding, rather than to castigate the lack thereof.
Outstanding!
Ideal for U.S.M.L.E. Step III!
Ideal for A.B.I.M. Certification!
Humble thanks!
When I was a resident going through an anesthesiology rotation, the chief asked me to calculate a CO2 concentration, given certain parameters. I didn’t have a pencil or paper, but SOMEHOW got the right answer. I have no idea where it came from. He told me that I was one of the only residents who ever got it right. I was stunned. I also reviewed the math immediately just in case he might ask me again. He never did.
I was also a residency co-director in my career and responsible for teaching residents. I would ask them questions. This was usually done when we were preparing to do the case, often in the change room. For female residents, it might occur during scrub, or as we were walking into the OR. Their answer and management of the questions might determine if I would allow them to do it. But the key was that the questions had to be “relevant” to the procedure we were doing that day.
An example might be: “When freeing up the posterior tibial N for tarsal tunnel release, what are the names of the muscle groups and bands that need to be fully retracted, in order to “clear” the course of the N?
This question was highly relevant, because failure to know and perform this often resulted in a poor result. I would help the resident with the anatomy and we would process this through together if he/she didn’t come up with an immediate, correct answer. I wanted to make sure they were prepared for the case that day. Most of the time they missed one or two sections of the answer, and that gave me an opportunity to “make a teaching point.”
But I was not dismissive or cruel. My purpose was to “encourage” them to look at the schedule the day before to “research” the cases for that day. Or at least mine. I know they were nervous encountering me but I also knew they wanted to do the surgery. An unprepared resident probably would not get that chance.
It’s not a matter of “humiliation.” It’s a matter of teaching. After a while my “reputation” got around and I rarely encountered an unprepared resident. I think that would improve our results, or at least allow me to judge whether a particular resident should be doing the case at all.
Unfortunately in surgery, “book learning” does not always indicate who is a good surgeon. I encountered one resident who was very smart at rote recitation but during an implant case overly ground down the bone because he was not aware of the frontal-plane “slope” of the anatomy of the proximal phalanx of the hallux.
The purpose is teaching and encouraging prior preparation, not humiliation. It is done best in a cheerful, academic, yet competitive spirit without leaving a trail of blood behind. That way we both enjoyed the process.
Michael M. Rosenblatt, DPM
I think that you need to define “pimping” better. Is it rapid-fire questions until the resident turns blue and drops? Is it inane questions that no one knows the answer to that makes the questioner look really smart?
I like to ask questions on rounds to show the interns and residents how to think about a patient and their management. My pet peeve from the time that I was a medical student is the “numbers question”…i.e. “What percentage of x people get Y disease if they have Z symptom?” etc etc.
One morning a cardiology attending was going around asking percentage questions and no one was getting it right…the patient, a young, cocky, IVDA with SBE, sat up smiled and yelled out a percentage…the attending admitted that the patient was right!
so it shows the stupidity of the question when the answer was really up to chance….
I like to start with questions that are really general…a trivia science question…such as “why is the sky blue?”…to make the atmosphere a level playing field…I have asked questions like that of a specialist if they happen to come into the room and they look taken aback and usually answer incorrectly…that way, we all know that we’re all mostly just as good as whatever we read the night before….and then we move beyond the “do you know this fact question because you were lucky enough to look it up last night?” to questions that involve clinical DECISION -MAKING, which I think is the really useful type of teaching you add that does not come from a book or an article…My residency director when i was a resident was a master at this…he would present a patient or symptoms to you, ask you some management questions and sometimes lead you down a garden path that would have killed off the patient…you saw the error of your decisions and you remembered….he was very funny, so you were able to laugh at yourself but you always remembered the consequences of a faulty decision…that is an amazing teaching method…if that qualifies as pimping, then I think its great…but if its just men who need to prove whose is longer….I’d rather skip it!
disclaimer: Yes, I am a female physician and I have been around for decades so I don’t offend easily….
I agree completely with Dr. Holmes above. Pimping is fine. What I noticed in my training and even now in my practice, is that prepared and capable (i.e. “Strong”) students do not mind being pimped by a good professor (not abusive). It is the unprepared (i.e. “weak”) students who whine and complain about how unfair, or demoralizing, pimping feels.
I was fortunate in that I worked long hours and not confined to only 8 hours per day. That caring for and being able to be apart of the patients entire stay gas me the hands on experience that is the best way for me to learn. I didn’t have any real pimp trainers so hard for e to comment on its effectiveness. In my fellowship I don’t pimp since most of the fellows are sharper didactically then me though I do have them on the clinical experience side.
I’m surprised no one has objected to the term, nor thought about how this term (in common usage involving exploitation by a male of usually younger, more-or-less powerful females) in a conservative, historically male-dominated profession.
I think that probably a less emotionally-charged term might be found.
As for the “pimping” itself, judging it goes to intent. Clearly it is used as motivation to be prepared. Clearly also it is used to humiliate, for whatever reasons the party might have.
A long-dead professor of mine who was quite openly sexist and racist with hundreds of witnesses present–there was no question. That it came from a department chairman, who had no fear of reprisals from the school, the intent to degrade and humiliate was the prime motivation.
That has nothing to do with questioning, even aggressive, tough questioning, with a legitimate goal.
It has been well covered here that the fear of pimping gave incentive to many of us to study and prepare harder, to the benefit of ourselves and our patients. By the way, I was comfortable enough in my own skin to say “I don’t know” without becoming suicidal over it. If it was a rare, zebra, esoteric question, I didn’t beat myself up over a best estimate, and stating that it was a best estimate.
The main question seems to be about the malignant, “abusive” attendings. I would suggest that these were just as useful. Fear of my residency’s “worst” attending, an oncology surgeon, had me on the ward at 04:30 q day making sure I knew all my patients’ details before surgery started at 07:00. Consequently, he let me do lots of good surgery. My last day of my chief rotation with him he really let me have it, abusing the heck out of me in 4 consecutive surgeries. Having been driven to exceptional preparedness for three straight months, I laughed this off and had no problem that he just needed to rip me one for the heck of it. He told me I left my ass in the O.R. and said “let me buy you a coffee” (free in lounge of course).
If you’re an underling, even a brilliant prodigy, LIGHTEN UP. Take your lumps. Work hard and learn. And if you survive to teach, employ the style YOU like but allow others their’s for crying out loud.
I learned more how to care for patients as an independent, thinking physician from that “humiliating, abusive” attending than pretty much the rest of my whole residency combined.
One final thing; I don’t know about “evidence based medicine” or “best practices”, but my experiences with that attending helped hone my skill to detail the reasons for everything I did based upon good studies, data and experience.