Socrates was not a Pimp…

Do you know what ‘pimping’ is in medical education or, maybe more importantly, what is its understood meaning by learners?

It was first described in the literature in 1989 as the process of an attending physician asking a series of increasingly difficult questions to a student or resident. It has since been variously described as any form of questioning in a learning setting to a line of questions that are clearly intended to reinforce the hierarchy in medical education, and embarrass or humiliate the learner. In fact students categorize it into good and malignant categories – and actually express the hope they will become “good pimpers” when they become attending physicians.

I recall being a clerk placed for two weeks on a Cardiovascular Service (a long time ago, in a galaxy far, far away) and starting each day at 7 AM in CV ICU with a faculty member who resolved all of his innermost challenges and frustrations by serially eviscerating the most junior members of his team. (I also question the pedagogic value of a CV ICU experience for a third year student, but that is an entirely different discussion.) To this day I can remember that place at the end of the bed and feel my color turn red as I relive the intentional humiliation.

I recommend for your perusal the excellent article by Kost and Chen in the January edition of Academic Medicine entitled “Socrates Was Not a Pimp: Changing the Paradigm of Questioning in Medical Education.”  They do a great job of challenging both the technique and the term of pimping, and rightfully point out that questioning when done correctly is an essential tool in clinical education.  The term itself is indeed unfortunate, and while students aspire to some day be “good pimpers,” there is plenty of evidence in life and in the education literature that we are very prone to teach the way we were taught.

So how do we change this part of our culture?

Some faculty members may see their technique as a use of the Socratic method but very few of us are Greek scholars or have ever even read any Plato. Kost and Chen point out that much questioning is fact-based done with the implication that there is only one right answer. In that case it certainly does not develop critical thinking skills, which I believe should be the first goal in clinical education particularly in the day of bedside databases on our phones. They advocate for a modern interpretation of Socratic teaching that has three components: “working collaboratively in groups, exploring interpretive questions that lack a specific answer but activate prior knowledge, and reflecting on the discussion.”[1] I do recommend the article – I found it excellent.

Why is this important to us? Preparation for our accreditation visit in May provided me the opportunity to review some data from the Canadian Graduate Questionnaire, which students from all schools complete at the end of fourth year. Approximately 53.3% of our students report being publically embarrassed, and 23.7% report being publically humiliated during their time at the U of S. These experiences are almost always in the clinical environment. The good news is that our numbers are on par with the aggregated data from all schools. The bad news is that it continues today. All medical schools will be working to change this culture and bring these numbers down, as must we!

Further evidence from Bould et al in the March issue of the Canadian Journal of Anesthesiology demonstrates “how a negative hierarchical culture can adversely impact patient safety, resident learning and team functioning.”[2] The article is entitled “Residents’ reluctance to challenge negative hierarchy in the operating room: a qualitative study”.

In the quantitative component of the study a simulation was done in which residents were told by an attending physician to give a transfusion in the OR to a Jehovah’s Witness patient against the patient’s explicitly stated wishes. The majority of the trainees did not question authority and gave the blood. In the qualitative component the authors explore the trainees reflections on that experience and the hierarchal nature of the learning environment. Both articles are thought provoking and challenge us to constantly work to improve our learning environment and enhance our teaching skills and, more importantly, our culture as we strive to have the best medical education programs in the country.

As always I am interested in feedback and dialogue. You can respond directly to the blog, stop me in the corridors and my door is always open.

[1] Academic Medicine, Issue: Volume 90(1), January 2015, p 20–24

[2] Can J Anaesth. 2015 Mar 20. [Epub ahead of print]