Pimping in perspective

A while ago a post titled “The zen of questioning” appeared on the now defunct orthopedics blog “Them bones… “. Leaning on the landmark 1989 JAMA paper by Brancati, it provided an erudite discussion of the phenomenon of “pimping” in medical education. Coincidentally, this preempted the timely April 1st 2009 update of “The art of pimping” by Detsky (also in JAMA) [pubmed].

“When we discuss pimping in polite company, we state that we use the Socratic method in our teaching.”
On medical pimping – from DB’s Medical Rants

Pimping is not a term widely used in the Australasian medical systems but we all know what it means. It’s the dark side of the Socratic method of teaching. The history of pimping in medicine is long and is stamped with the illustrious names of some of our greatest forebears. According to Brancati, pimping (in the medical sense) was first coined by William Harvey as early as 1628, became established in the German system under Robert Koch, and was continued in America by William Osler himself.

“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!”
William Harvey laments his students’ lack of enthusiasm… –  from Brancati, FL. The art of pimping. JAMA. 1989;262(1)89 [fulltext]


“Osler was a pimp”

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

What is the purpose of pimping? Well, the Socratic method is meant to involve carefully chosen questions that challenge the preconceived ideas of the student, and through a process of rational discussion and refutation allow the student’s knowledge to grow. However, pimping is not always used for this purpose…

“On the surface, the aim of pimping appears to be Socratic instruction. The deeper motivation, however, is political. Proper pimping inculcates the intern with a profound and abiding respect for his attending physician while ridding the intern of needless self-esteem. Furthermore, after being pimped, he is drained of the desire to ask new questions…”
– Brancati FL. The Art of Pimping. JAMA 262(1989):890. [fulltext]

“I must say that pimping accomplished only four things for me: (1) establishment of a pecking order among the medical staff; (2) suppression of any honest and spontaneous intellectual question or pursuit; (3) creation of an atmosphere of hostility and anger; and (4) perpetuation of the dehumanization for which medical education has been criticized.”
– Stanton C. Letter. JAMA 262(1989):2541-2 [pubmed]

The only attempt at studying students perspectives on pimping that I’m aware of is by Wear, D et al (2005):

“All students noted the hierarchical nature of pimping, viewing it as a tool for attendings or residents to assess students’ levels of knowledge. Although some students experienced malignant pimping, humiliated by incessant questioning or questions inappropriate to their level of training, all the students in the sample were positive about pimping and its effectiveness as a pedagogical tool.
– Wear D, Kokinova M, Keck-McNulty C, Aultman J. Pimping: perspectives of 4th year medical students. Teach Learn Med 2005;17(2):184-91 [pubmed]

This generally positive student appraisal of pimping is interesting, and probably surprising to many. As a student I personally found pimping a fun and generally comical experience, even when it bordered on persecution (mind you, I thought the same thing about basic training in the New Zealand Army – a sense of humour and a deep understanding of Catch 22 and/or the House of God goes a long way…). However, pimping may mean different things to different people:

“Students whom I have precepted over the years would more likely than not have viewed pimping as a derogatory term…. In this study, what the students referred to as “positive” pimping probably occurred in a learning environment that felt “safe” and in fact, may not represent pimping at all. The types of questions associated with learner-centered education in a safe environment include probing, clarifying, open-ended, and hypothetical. These questions encourage students to think and not just regurgitate factoids”
– Greenberg L. Pimping Perspectives: Response to Wear. Teach Learn Med 2006;18(1):87.

Thus it is clear that pimping, or at least some form of questioning students in a clinical setting, can be a positive and useful learning experience. I suspect that’s why Osler was a practitioner of positive pimping.

“I desire no epitaph… than the statement that I taught medical students in the wards, as I regard this as by far the most useful and important work I have been called upon to do.
– Sir William Osler (from ‘The Fixed Period’ in Aequanimitas)

This post is part 1 of a 4-part series. The next post will help the “pimpee” develop their defensive armamentarium…


Life in the Fast Lane Pimping Posts

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