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]

12 thoughts on “Socrates was not a Pimp…

  1. I was happy to see you bringing up this very important question “How can you increase students critical thinking skills without embarrassing them?” Repetition is a key component of long term learning but too often teachers confuse this technique with rote learning instead of with helping students build links between pieces of knowledge. Questions such as these encourage higher order thinking.
    In classroom settings, anonymous use of audience response systems provide a safe environment for checking on understanding but they are impractical for clinical settings. In a clinical setting, try asking “what questions need to be answered before this patient can be diagnosed/treated?” and build an environment where errors are a pathway to knowledge, not a statement of hierarchy.

  2. Thank you. I am curious as to the distribution of your message. Is it to the University faculty members who comprise perhaps 25% of teachers, or is it distributed to all teaching faculty in University and Community practice, in Saskatoon and Regina, and in many other areas who play a role in the teaching of our students?
    I fear that those of us who teach in the most gentle and effective manner (the majority) will be offended by being seemingly painted with the broad brush of pimping practice.

    • Hi Geoff
      The message goes to all who teach. We actually have over 1000 clinical faculty. I agree the majority due a fabulous job and for that I thank all of you. With dialogue we can improve even more.

  3. I trained at U of S and found it a very positive place to do my training. Of course I was embarrassed when I didn’t know something, but that was because I wanted to know what I needed to know. It was hard to accept feedback in front of others, but our learning (and mistakes) generally occur in front of others. Generally, I felt faculty treated me as a future colleague and challenged me to be the best I could be. Do you think we have a culture of humiliation here?

    • I have always heard U of S grads get a great clinical education and I had grads in my programs at Dal so I know that is true. I appreciate your comment. I think our culture is like most schools but we want to be better than most schools! Good questioning is definitely necessary for learning.

  4. Thanks Preston. As you point out, I don’t think the negativity comes from the technique itself, but rather the culture around it. ‘Scaffolding’ questioning technique is a way to find out what your learner already knows, and take them one notch up. I think the bigger issue is trainees feeling embarrassed or humiliated in public. This of course has to be balanced with the ‘failure to fail’ and ‘leniency bias’ we have that leads to physicians who struggle in practice. Complex issues will require complex solutions.

    Rob Woods

  5. When I was in training no one questioned the professor, and professors were actually easier to tolerate than the new assistants, who disproportionately exhibited ego problems. Now that I am a professor, I find that the recent diplomats do a lot of talking back, and sometimes not listening to the professor, arguing before thinking, I find. So, 1) having a level head is important no matter what the stage of your career is, 2) Thinking things through, out loud if necessary, helps those with whom one has dealings, 3) It tends to be those who are hurting most who try to hurt others, 4) Don’t let it bother you, it isn’t your problem unless you agree to inherit it.

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