Editor’s Note: This post was previously published in Insights on Residency Training, which is hosted by NEJM Journal Watch.
Joseph Cooper, MD, is a Chief Resident in Internal Medicine at Geisinger Medical Center in Danville, Pennsylvania.
One of the most respected and skilled clinician-educators (and, of course, he is an Infectious Diseases specialist) at our institute came into my office, sat down, and immediately starting eating pretzels. “Let me know what you think about this,” he said between bites. He went on to recapitulate a recent interaction he had with the members of the Internal Medicine team (medical students, house staff, and the attending physician) about a week ago.
He described a presentation to our emergency department of a young woman with headache, neck stiffness, and fever, who was previously well and had young children at home who were currently ill. He reported the lumbar puncture results to the house staff — the results included a mildly elevated protein level, normal glucose level, and pleocytosis with a predominance of neutrophils and monocytes. He then asked the house staff to formulate a differential diagnosis and explain their reasoning for said diagnoses. Later, he addressed the case again, and changed the values of the cerebrospinal fluid on the patient to clearly illustrate a bacterial source rather than a viral source, and he asked this question: “The pharmacist is standing at the Pyxis machine asking what medications to give. What are you going to tell her?”
Granted, I was not present for any of these interactions, but the vignette seemed more than reasonable to me. He was clearly trying to teach and have the house staff work through the differential diagnosis of deranged cerebrospinal findings — different disease states, offending pathogens, and treatment modalities. From the tone of his recitation of the events, I knew he was expecting a bit more than what he received from the house staff. He then asked me, “How do our residents learn today without being questioned?” I answered, “I’m not sure, but I’ve always found that questions are the best method.” The ID specialist left me with one last question: “Do you think I was too hard on them? Was I being a ‘malignant pimper’? Because I surely don’t want to be that.”
Frederick L. Brancati first coined “the art of pimping,” in his 1989 JAMA article: the practice of posing particularly difficult questions to learners. There are undertones in Brancati’s article (which is older than Justin Bieber) about the separation of power between the teacher and the trainee. Notions of respecting the teacher and expecting the trainee to follow the “chain of command.” Critics state that much of the article was written tongue-in-cheek, and it even prompted a response article twenty years later by Allan S. Detsky about learners taking back their power. Although each article illustrated differing approaches to pimping, they agree pimping confers some value to learners.
Wear et. al published a study in 2015 in which researchers examined interview responses from 4th-year medical students on perceived harms and benefits of pimping. The results were quite interesting, and although the cohort of medical students was not large (and no residents were included), many fundamental issues came to light. Students saw the value of pimping as allowing them to learn on their feet, develop the proper diction to speak with their colleagues, handle anxiety and pressure, and, ultimately, to motivate them to learn on the spot or later if they did not know the answer. “Malignant” pimping was identified by the students as situations in which the teacher was exerting hierarchical power, asking questions which were outside the scope for the learner (much too difficult), was buffering the ego of the teacher, or was simply humiliating the students by exposing deficiencies in knowledge rather than trying to create new connections.
Hospital de Sant Pau. Barcelona, Spain. My Own Work. Canon DSLR.
Hugh A. Stoddard and David V. O’Dell made the ultimate comparison in their 2016 publication in Journal of General Internal Medicine, stating that psychological safety is the key difference between Socratic method of teaching and pimping. They defined the Socratic method as “prompting students, through cross-examination, into acknowledging their own fallacies and then asking them provocative questions to steer them towards realizing true knowledge via introspection.” The importance of psychological safety is highlighted when the learners feel they are in a safe environment, are comfortable with themselves and others, and feel valued and mutually respected without hostility and the threat of possible humiliation. The authors note that, even in a psychologically safe environment, Socratic teaching does not allow for a sub-par performance and that accountability is not a trade-off for the said safety.
This brings up a very strong and often overlooked point. I hear my administrators say all the time that residents should be more accountable. Accountability must be clearly defined and, at times in medical education, it is not. Sure, we have ACGME benchmarks and standards of what a “normal and average resident should be achieving by the time of independent practice.” At times, the sense of urgency and accountability seems to be lacking within the millennial generation. Learners expect to be spoon-fed lectures with important concepts and have protected time to learn those concepts, yet a very few seem to really possess that internal drive or accountability to own medicine, own the concepts, own the pathophysiology and disease process, and own their patients, because ultimately it is about their livelihood.
Returning back to the pretzel-eating, bow-tie wearing ID specialist’s question: Was he too hard on them? Was he being a malignant pimper? Although I did not witness the entire interaction, I would have to say no, absolutely not. I know he wants the house staff to learn, and he does not exhibit hierarchical power in his line of questioning, and he does not need to buffer his ego (he has won numerous teaching awards at our institution) or humiliate anyone. I offered him a morsel of constructive criticism, echoing what I’ve detailed above.
Lembongan Island, Bali. My Own Work. Canon DSLR.
As I continue on throughout my chief year and move into fellowship, I must heed my own advice. Setting the stage and creating an environment of psychological safety is key when questioning learners. Numerous studies and evidence prove that posing questions at an appropriate level to the learner is the foundation to clinical reasoning and teaching, and we should not stray from this. Posing questions to our learners gives us a better understanding of their knowledge, their ability to explain concepts, and their deficiencies. The best clinician-educators take this information from their learners and expand on information that fills in deficiencies, or explain concepts in a way that the learners will never forget. Better yet, they motivate the learner to independently seek knowledge or skills they are lacking, with a continued thirst for learning.
Clearly Joe Cooper and his ID attending friend got it right.
I attended a medical school in the 1970s where malignant pimping was the norm, long before the term was coined. Later, once having joined the faculty, I inevitably came to practice a hopefully much more benign version. “Hey, it’s efficient and cuts quickly to the ‘assessment of fund of knowledge’ line on the eval sheet.”
This is clearly one of those ambiguous domains where both good and bad can come of this business of “probing the sore spot.” On the one hand I remember how devastated I felt when no one explained “the rules” to me in advance, but suddenly subjected me to what amounted to real humiliation. Final grades were impacted both negatively and (for those savvy enough to anticipate the rules) positively. On the other hand, pimping isn’t just a hidebound practice–tradition doesn’t make it right–but also within bounds a useful means of imparting learning.
Two practical suggestions, for which I claim no novelty whatsoever. First, tell students and house staff in advance what this practice is all about–and remind them that it’s imperative to do one’s homework when the code “let’s both look that up tonight” is voiced by the attending. Should be part of the orientation. Maybe by now already is.
Second, resist the temptation even to obliquely imply ridicule if the respondent is struggling. Too many attendings slip up at just this point. Do they feel they’ve “earned” their power-up position and wish to mete out what they once received? Pay-back? Frat-boy rite of passage? A lesser but still inexcusable form of abuse, with a whiff of other, worse, forms. It’s easy to soften the probing utterances with a hand of support–“let’s think this through together.” Put yourself in their shoes.
And that’s where attendings really break down into two groups, a situation which I frankly think will change at a pace that’s unacceptably slow–or never. The “soften it” dictum will be dismissed by hard-asses as too liberal, or feminine, or whatever. “Suck it up” is the reflex response.
Conversely, a lot of younger attendings, not as imbued in old-school doctrine, will understand that the ancient, starchy hard-assed days deserve to have come and gone. But the change is excruciating slow. In the meantime, some students and residents will continue to suffer at the hands of those who really don’t believe there’s a better way, who’re convinced that abuse, in mini-doses, somehow makes you better in the real world. “Hey, I’m stronger for it, hazing and all.”
If anyone in that latter group is reading this, I’d love to hear their answer to a simple question. For such a patently absurd idea, beyond some diffuse pay-it-forward notion, where’s the clinical evidence?
Meanwhile I’ve heard fellow attendings voice both of these viewpoints. Each derives from attitudinal and emotional predispositions that go far, far beyond notions of best-case learning environments.
I totally agree with the statements, than more important than the Answer, are the Quality of the Question that can do the Physician who is teaching. When some one is teaching, talking about an issue,the possibility of learning it is less that when the Dr ,using the right question, addressed to students, and waiting that they can develop all important items that the answer needed.This can be the start of a very rich analysis of an complete point of view of an theme, that otherwise, could be missed.
In my Practice, like Professor, I saw, how students could develop advanced ideas, Ex=Which Tests will be useful to confirm the Diagnosis or which action could be better, in some patient(Ex=To Call a Surgeon etc )
But, what is fundamental=the Good and Skilled Physician,needs, that all Students, have a high level of knowledge in Medicine. and deep commitment with our career