Pimpin’ Ain’t Easy

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To clarify the intentionally click-bait title (and also rivetingly poetic phrase by the distinguished lyricist/rapper Big Daddy Kane): the definition of pimping in the medical field is different than the colloquial usage by artists like Jay-Z, Snoop, and Kendrick Lamar. Although most people are aware of pimping in the vernacular language (which will not be discussed further, I would suggest avoiding most rappers terminology if you desire to research), the medical use of the word is a little more nuanced and opinions on the practice are split.

Pimping in the medical field is the modified—some may say corrupted—version of the Socratic method of teaching which was a dialogue of questions and answers to stimulate critical thinking. Socrates would query his students to find differences in opinions and then offer a compelling objection or alternative theory. In this pursuit of knowledge, it became a discussion rather than a declaration of opinion. The difference is that pimping is much more one-sided than the Socratic method. The New York Times wrote an article in 2016 describing pimping which stated that the term is said to be derived from the German word pumpfrage, which refers to asking students a rapid series of questions, from thought-provoking and relevant to esoteric and unanswerable. Pimping usually involves the attending physician (or senior resident) asking medical students or interns a series of increasingly difficult questions to assess their knowledge. It is meant to stimulate learning in an engaging manner but can be distorted to become a tool to intimidate and break down the learners and elevate the educator. This process further solidifies the hierarchy of the medical unit.

An example of malignant pimping comes from a satirical instructional on “The Art of Pimping” which was published in JAMA in 1989 by Frederick L. Brancati, MD. In the article, he amusingly advises that the attending should use certain techniques such as asking questions that should come in swift succession and also be essentially unanswerable. For example, “What is the differential diagnosis of fever of unknown origin?” If an intern happens to answer a question correctly, the attending should demoralize them by continuing the interrogation or questioning his or her clinical skills.

The pimping ordeal can become quite a spectacle when the questions start firing. A medical student or resident begins to start to feel trepidation creeping in from being placed in the proverbial hot seat. Due to the pressure of the crowd of other residents, students, nurses, and pharmacists gathered around the exhibition, the learner begins to doubt even the most basic answers for fear of the humiliation from responding incorrectly to the barrage of questions. Due to experiences like these many medical learners have a staunch distaste for pimping. Students know that a correct or incorrect answer can mean the difference between high or low marks for their rotation grade. They may even avoid certain attendings who are known for their ruthless pimping.

Although pimping has negative connotations discussed above, it does have a place in medical education. Some, myself included, have a positive outlook on pimping when it is performed in an appropriate way. The way to do that is to return to the foundation of the Socratic method. The questioning should enable the learner rather than bolster the superior.

One of the clerkships in medical school where I learned the most was my surgical rotation. I had the opportunity to work directly with an attending surgeon without any residents. Every night I was assigned to read from the textbook “Swartz’s Principles of General Surgery”. The next day—usually during a colonoscopy procedure—he would ask me questions about the reading or create a sample patient case. The questions were probes to find where I was competent and where more education was required. Instead of asking esoteric, rapid-fire questions to display his dominance, he would pose them with a medical and patient-care focus. When I would miss-answer he would either walk me through the correct answer or have me reexamine the textbook. If there was a disagreement or new research I would examine journal articles and usually find that I was wrong, but if I could make a strong enough case, he would change his practice accordingly. This helped both parties to learn and grow. During surgeries he would ask what my next steps would be for a patient and practice full verbal admission orders. This prevented me from being a medical student stuck standing in the operating room holding a retractor or standing off to the side and following the adage of “be seen and not heard”. Having to be prepared at any time kept me engaged in monitoring the anatomy, considering complications, and thinking through the next steps for recovery.

In the pursuit of avoiding pimping, we may be neglecting the education of the learners. It is much easier to simply shadow and not have to engage academically. If they are only shadowing there is no concern of belittling the student, but it puts the responsibility of learning solely on the student to only absorb the material rather than actively interact with it.

Verbal questioning is a different type of education than the multiple-choice options given in the first two years of medical school. With verbal inquiry there is no luxury of guessing, you either know the answer or not. It is important to have the opportunity to clear away ignorance as a student rather than later while running the ward as a resident. Although it doesn’t feel good in the moment when you get a question wrong, you make sure that you never forget it ever again.

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Zachary Fredman, MD, is a second-year Family Medicine resident in the Division of Family Medicine at the University of Utah. 

 

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