A medical student and attending physician arrange to meet near a nursing station to discuss a recently admitted patient the student has reviewed. The patient has presented earlier that day to the emergency department with a severe headache and visual disturbance. The student relates a description of the symptoms, past history and physical findings, after which the attending asks:

 

“So, what do you think is going on?”

      “I think its migraine”.

“Really? Does the patient have any history of migraine?”

     “Not that I’m aware.”

“Did you ask?”

     “No.”

“Is it common for someone to get their first migraine at age 70?”

     “Guess not.”

“Is the patient on anticoagulants?”

     “Yes.”

“So what else might be in the differential?”

 

For the next 10 minutes or so they engage in a question and answer session regarding the findings and management plan. They develop a number of other possibilities and a diagnostic plan, which includes an urgent CT scan. At the end, the attending suggests the student reviews the features of both migraine headache and intracranial bleeding.

 

So, what just happened there?

 

It’s very likely that the attending physician and student left the encounter with vastly different impressions of what had transpired.

 

The attending physician likely feels they have provided a “teaching moment” in which some important issues of clinical management have been passed on to the student. They may feel they have left the student better prepared for having had this encounter, and may very well feel more confident in the ability of the student going forward. They likely leave feeling they have fulfilled their obligation as a teaching clinician. They may even feel they have engaged in a version of what’s been termed the Socratic method; a term used loosely to refer to a method of teaching that utilizes questioning as a means to promote learning.

 

The student involved in the interaction may feel differently. They will likely describe what they experienced as having been “pimped”.

 

Pimping, in this sense, isn’t referring to the practice of soliciting clients for prostitutes (a very unfortunate association). It refers, rather, to the practice of posing a series of increasingly difficult and obscure questions to a learner with the purpose of identifying knowledge deficiencies.

 

The term has a considerable history. A rather infamous 1989 JAMA article by Frederick Brancati1 provides a tongue-in-cheek review of the practice and is well worth reading. As he points out, the first known use of the term was by no less than the esteemed William Harvey who lamented in 1628 his students failure to understand his early theories about the circulation:

 

“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”.

 

Robert Koch, the prominent Dutch microbiologist of the mid nineteenth century recorded a series of “Pumpfrage” (pump questions) for use on ward rounds. Apparently William Osler was a master pimper. Abraham Flexner commented on his style after his 1916 visit to Johns Hopkins:

 

“Rounded with Osler today. Riddles house officers with questions. Like a Gatling gun. Welch says students call it ‘pimping’. Delightful.”

 

It’s often done in the presence of others, and has the potential to leave the learner feeling embarrassed and, possibly, humiliated. It’s felt by many that the main purpose of pimping is not to impart learning, but to establish an operational hierarchy – to put the learner “in their place”. It’s been characterized by many as an initiation ritual.

 

Its value is, at best, debatable. Detsky2, reprising Brancato’s article, concludes “the purpose of pimping is to increase retention of the key teaching points by being provocative”. In a contemporary commentary Kost and Chen3 take a much more negative view and suggest the term be reserved for undesirable behaviours, specifically:

 

“questioning of a learner with the explicit intent to cause discomfort such as shame or humiliation as a means of maintaining the power hierarchy in medical education”.

 

Medical students bring helpful perspective to the issue. In an interesting study carried out by fourth year students at a midwestern American medical school4, a differentiation was drawn between “malignant” pimping, and that done “with good intentions”. To quote from their conclusions:

 

“At its best, pimping assesses students’ knowledge and skills, stimulates critical thinking, and encourages self-assessment. At its worst, the competitiveness that pimping generates may inhibit students from learning how to work as a team, and how to rely on each other.”

 

It also seems that medical students not only accept that they will be subjected to directed questioning in their clinical rotations, but have adapted mechanisms to “manage” these situations. Interestingly, that management is intended not only to optimize their learning, but also to project a positive image of their skills and teachability. To quote a student interviewed as part of this study by Lo and Reghr5:

 

“I think my goal is basically to come away from that session with the instructor thinking that I do know my stuff, I know my material. And even if I got some questions wrong, it’s okay, because in the greater context I have a good understanding of the subject.”

 

It would seem that directed questioning is certainly eliciting an adaptive response, but perhaps not entirely what was intended.

 

In Canada, about 57% of graduating students report have been “publicly embarrassed” and 29% report having been “publicly humiliated” at least once during medical school6. Although not explicitly stated, it’s reasonable to presume that the majority of these relate to episodes of pimping.

 

 

In a recent perspective, Soddard and O’Dell posit “the term ‘Socratic method’ has been so often misapplied that Socrates himself might not recognize the clinical education techniques that often bear his name.”7.

 

Socrates, prominent Greek philosopher of the fourth century BCE, believed his role as a teacher was not to simply deliver information, but tosocraticmethod1 help his students develop their own methods of thinking and examining the world. In fact, it seems he seldom made statements of fact but, rather, provoked his students by posing a series of challenging questions, many of which had no clear answer, but required examination of their own assumptions and values. These “dialogues” subsequently recorded by Plato (his most famous student) were probably not comfortable experiences for his students who may have felt challenged, cross-examined, and perhaps even attacked. (Interesting to speculate what sort of teaching evaluations Socrates would get today). The opposite of the Socratic method is the Didactic, which entails the teacher delivering information with a minimum of student participation. It is certainly more comfortable for the student and simpler for the teacher, but fraught with limitations regarding the appropriateness of information provided, and benefit for the learner.

 

Moreover, it’s a long way from the Athenian agora to the wards and hallways of our teaching hospitals. It’s therefore more than a little presumptuous to refer to what we’re doing as Socratic teaching. However, perhaps the message for us is that there is great value and potential in questioning if questions are appropriately posed, and posed for the right purpose. We need to carefully consider what features differentiate effective questioning in clinical education from what students rightfully identify as “malignant pimping”.

 

  • Why is the question being asked, and for whose benefit? The issue of intention is central and critical. Questions should be posed for one of two purposes: to advance the student’s understanding and comfort with clinical medicine or to ensure optimal patient care. The concept of “toughening up” students in preparation for perceived future abuses is archaic and never justifies, but potentially perpetuates, demeaning behaviour.
  • Is the question reasonable and relevant? Does it relate to the clinical issue under discussion? Will the answer advance the student’s understanding or patient care? Does it really matter whose name is historically associated with pulsatile nailbeds?
  • Is this the time and place? Questions asked in highly public places or with patients in attendance can be highly-charged for students, and are not rendered more educationally valuable by that added scrutiny.
  • How well do you know the student? Within the context of a continuing relationship, a degree of trust develops between teacher and learner that allows the student to contextualize criticism and eventually demonstrate improvement. Brief, or one-time encounters, have no such trust, resulting in considerable vulnerability on the part of the student.
  • Questioning in the workplace should be provided in the spirit of formative educational experiences. However, students may perceive they are being formally assessed through these questions.

Based on these considerations, I would not consider the exchange described at the beginning of this article to be an example of pimping, but rather directed questioning intended to both teach and ensure optimal patient care

To return to my initial question, was Plato being pimped? Given the definitions we’ve developed and what we understand of the Socratic approach, almost certainly not. But he was certainly being questioned, likely aggressively, but by a benevolent teacher intent on making him a better person and more accomplished philosopher.

Seems that turned out fairly well.

 

 

Anthony J. Sanfilippo, MD, FRCP(C)

Associate Dean,

Undergraduate Medical Education

 

 

  1. Brancato FL. The Art of Pimping. JAMA 1989; 262(1). 89.
  2. Destsky AS. The Art of Pimping. JAMA 2009; 301(13). 1379.
  3. Kost A, Chen FM. Socrates was not a Pimp: Changing the Paradigm of Questioning in Medical Education. Academic Medicine 2015; 90(1). 20.
  4. Wear D, Kokinova M, Keck-McNulty C, Aultman J. Pimping: Perspectives of 4th Year Medical Students. Teaching and Learning in Medicine 2005; 17(2). 184.
  5. Lo L, Regehr G. Medical Students Understanding of Directed Questioning by Their Clinical Preceptors. Teaching and Learning in Medicine 2016. (http://dx.doi.org/10.1080/10401134.2016.1213169)
  6. Canadian Graduation Survey National Report. Association of Faculties of Medicine of Canada. 2016.
  7. Stoddard HA, O’Dell DV. Would Socrates have Actually Used the “Socratic Method” for Clinical Teaching? J Gen Intern Med 2016; 31(9). 1092.

 

Many thanks to Sarah Wickett, Health Informatics Librarian, Bracken Library, for her valuable assistance in the compilation of information for this article.