Bioethics Discussion Blog: "Pimping": Not About Sex-- About Medical Education"

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Sunday, December 13, 2015

"Pimping": Not About Sex-- About Medical Education"




This cartoon below is certainly a good example of "pimping" which has been for years, really generations a technique of medical education. I recently wrote the following to a professional medical educator's listserv:


The December 8 2015 issue of JAMA (Volume 314 No. 22) presents a Viewpoint article which I believe challenges us medical school teachers to find evidence of educational value in a practice carried out by medical school teachers and attendings  which is apparently not rarely applied to their students.  The practice is "pimping"  and is defined in the article by referring to an 1989 JAMA article by Brancati: "a series of difficult and often intentionally unanswerable questions posed to a medical student or house staff in quick succession.  The objective of pimping is to teach, motivate, and involve the learner in clinical rounds while maintaining a dominant hierarchy and cultivating humility by ridding the learner of egotism."

So what we must decide is whether this "pimping" is an effective and benign form of Socratic teaching or in most cases really a form of medical student "mistreatment"
To learn more about "pimping" in medical education, read this outline of the practice in eTalk.




The cartoon also brings up another issue as to whether "pimping" medical students, interns and medical residents not only may intimidate and emotionally "harm" them but could this behavior eventually harm the patient.  A second year medical student writing in the Pulse website describes not only her own "pimping" but also witnessing her teacher "pimping" a clinic patient. 

However, a surgical resident who read the Pulse story wrote me the following:
I may be in the minority when I say, I'm "pro"-pimping/Socratic method. I didn't think it was a fair analogy for the student to compare herself to the patient--the patient is not a medical professional. Making decisions with incomplete information is part of all of our jobs.  I say this from the perspective of someone that still has to take written and oral boards as part of my board certification process.  Practicing for oral boards is serial escalation of difficult questions.

Pimping exposes the things that "I don't know that I don't know".  It is normal to feel defensive when you don't know the answer to a question and pimping teaches you to repress the "fight or flight" response, to acknowledge gaps in understanding, to maintain humility and to remain poised in the face of uncertainty.  I consider pimping the surgical love language. How else does the attending quickly assess where deficiencies lie? How do you otherwise also motivate the student that gets great scores on standardized exams to keep studying?  You don't take the time to pimp people when you're not invested in their education.You just ignore them. 

My favorite attendings can always find me in a crowd of residents and call me out--it's how I know they still care. 

So, what do you think about this form of "pimping"?  Have you experienced such questioning as part of your own occupation or experience?  If you are or were a medical educator would you use this technique to educate your students or could this really be only a form of self-interest on the part of the physician educator and intimidation of the student of any sort should not be part of the education process.  Let's hear from you on this behavior. ..Maurice.

Graphic: From Google Images. Referred source: https://euuuh.com/






9 Comments:

At Tuesday, December 15, 2015 8:54:00 AM, Blogger A. Banterings said...

From the German Pümpfrrge. It refers to the practice of a teacher asking a student a series of questions.

Pimping uses the kind of questions that cause public humiliation, but for the student’s benefit of learning. Like genital exams in teaching hospitals…?

I digress.

It is a form of bullying. It was supposed to deflate those arrogant personalities, but it only seemed to make them even bigger.

Like dysfunctional families, abuse (and hubris) is learned.

—Banterings

 
At Wednesday, December 16, 2015 11:30:00 AM, Anonymous Hospice Valley said...

In a way I do agree that it is bad for many clients. But I do believe they can also decline anyone who enters the room and say no to students. A lot of the times I have found that many clients get lonely over time and appreciate being visited by students.

 
At Thursday, December 17, 2015 8:51:00 AM, Anonymous María said...

Pity that patients are pimped too. I mean,
humilliating questions and practices to
make them compliant and do what the pro-
vider(s) want.

 
At Saturday, January 23, 2016 11:11:00 AM, Anonymous kyrani eade said...

I can see some value in being asked questions in a way that tests your knowledge under pressure. However does it not lead to the type of doctors that have an encyclopedic knowledge base but lack intellectual reasoning about the patient's condition in a way that would increase their understanding about disease? It seems to me that this sort of training destroys free thinking and thinking outside the box.

I have had doctors not willing to consider my testimony about symptoms disappearing just prior to being diagnosed because they placed too much emphasis on their tests. I can understand it from one view because they are guided by their results but they were wrong. What do you say? Does this sort of training limit doctor's thinking?

 
At Saturday, January 23, 2016 4:46:00 PM, Blogger Maurice Bernstein, M.D. said...

I agree, does this approach to teaching really increase and benefit the necessary clinical reasoning or does it lead to making too many assumptions which become heuristic errors of thinking?

..Maurice.

 
At Sunday, February 28, 2016 12:10:00 PM, Anonymous Anonymous said...

I have occasionally been the patient during pump questioning (note the sexual humiliation in shift to 'pimp,' indicative of experience and resentment), conducted by the attending or senior resident saying, after a student/junior reply, "Or?" and continuing so until reaching the desired answer. I didn't mind; on one occasion I offered answers, because the rate of questioning seemed to me too rapid for new ideas to occur to the student. The purpose seemed good, to require and encourage multiple hypotheses/diagnoses, and to reinforce active memory. It can be humiliating, clearly. My experience was in a very thoughtful training hospital, where humiliation wasn't socially accepted. Simply telling the student/junior what to think can be as bad. Power corrupts and can become abusive; teaching techniques, I think, aren't abusive in themselves. The link between knowledge and power in medicine, unless carefully monitored, can lead to intellectually abusive treatment of juniors and patients. That root is more important than this branch.
- Richard

 
At Sunday, February 28, 2016 4:09:00 PM, Blogger Maurice Bernstein, M.D. said...

Richard, amen! That's why both "juniors" and patients should have the opportunity to "speak up" their experience to those mentors who listen and respond without injuring the "speakers" and provide a pathway to improve the medical education system. ..Maurice.

 
At Thursday, September 15, 2016 8:14:00 PM, Blogger Alexandra Young said...

I don't think it's pimping. Medical students will soon enter the medical field, these unlicensed professionals will soon be licensed to take over the exact things being exploited as pimping in this article. Yes, there are some instances where it is inappropriate but in a controlled setting with other med professionals available who can give their patient the undivided attention needed I see no problems.
I do believe patients should have more say so. Possibly integrate a form patients sign first to allow students in the room during care and set limits to how involved they want the pupils. Ex: Pt doesn't mind student being present for procedures and care but would not like student in room should a code occur. Although it's a great learning experience, the patients life and needs should be addressed prior to.

 
At Thursday, September 15, 2016 9:05:00 PM, Blogger Maurice Bernstein, M.D. said...

Do my visitors think that it is proper for the "pimping" teaching technique to be performed in the presence of the patient where the patient can hear the "back and forth" dialog and witness the effect of this activity on the medical student or intern?
Is this in any way considered of therapeutic value for the patient to be a witness? Or would it only cause harm in one way or another? ..Maurice.

 

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