“Pimping”: Time-honored educational tradition or relic of the past?

The Socratic method, or directed questioning aimed at assessing and evaluating a learner’s knowledge, is a traditional teaching modality commonly used in the clinical setting.1,2 “Pimping,” on the other hand, is a line of questioning meant to affirm the hierarchical order of a small group of learners by cultivating feelings of humiliation, fear, and intimidation for those answering the questions.3 Some learners and medical educators have recently sought to determine why pimping is increasingly considered a form of the Socratic teaching method.

This article looks at the use of pimping as a common pedagogic technique throughout the history of formal medical education, describes the pros and cons of pimping, explains how medical students respond to this method, and offers suggestions to effectively engage in pimping.

Time-honored tradition

Pimping may have preceded the 17th century practice of medicine, but the technique’s earliest reference is attributed to William Harvey, MD, a London-based physician who first described the systemic circulation in 1628.3 German physician Robert Koch, MD, in 1889 and Sir William Osler, MD, at Johns Hopkins University, Baltimore, MD, in 1916 later referred to pimping in the medical literature, but it wasn’t until the Journal of the American Medical Association published an article by Frederick Brancat in 1989 titled “The art of pimping” that this method of teaching was popularized.3,4

Surgeons in particular are known for their use of pimping as an educational strategy. The art of pimping for the purpose of demoralizing students has certainly contributed to the perception that surgeons are difficult and may have turned off medical students who might otherwise have been interested in pursuing a career in the profession. However, the unique learning environment that a surgeon practices in, more than any other specialty, is conducive to the type of short, directed questioning that is characteristic of both pimping and the Socratic method. Over the past several generations, the definition of pimping has been reclaimed, in some respects, to characterize the type of teaching that is feasible during a busy surgical rotation and an approach that is not necessarily malicious.

An appreciation of different learning styles, the incorporation of technology into everyday learning, and an explosion in the amount of knowledge that must be mastered by the medical student has changed how learning occurs today. Educators who successfully navigate the blurred line between the Socratic method and pimping should consider the varying views of each generation of learners on topics ranging from career goals to core values (see Table 1). The pimping technique has many benefits. How can it be updated to apply to today’s generation of learners?

Table 1. Selected characteristics of each generation

Traditionalists Baby Boomers Generation X Millennials
Birth years 1900–1945 1946–1964 1965–1980 1981–2000
Core values
  • Discipline
  • Law and order
  • Respect for authority
  • Question everything
  • Team-oriented
  • Independent
  • Informal
  • Skeptical/cynical
  • Confident
  • Competitive
Attributes
  • Historical viewpoint
  • Rules of conduct
  • Trust hierarchy and authority
  • Challenge authority
  • Live to work
  • Political correctness
  • Unimpressed with authority
  • Crave independence
  • At ease in teams
  • Innovative
  • Want to please others
Work ethic
  • Age equals seniority
  • Pay your dues
  • Driven
  • Quality
  • Balance
  • Want structure and direction
  • Multitasking
  • What’s next?
View on respect for authority
  • Authority based on seniority and tenure
  • Originally skeptical but becoming traditionalist
  • Time equals authority
  • Will test authority repeatedly
  • Will test authority but will seek authority for guidance
Preferred work environment
  • Conservative
  • Hierarchical
  • Clear chain of command
  • Top-down management
  • “Flat” organizational hierarchy
  • Equal opportunity
  • Informal
  • Access to leadership
  • Access to information
  • Collaborative
  • Achievement-oriented
  • Want continuous feedback

Source: Allen R. Generational differences presentation. 2008. Available at: www.wmfc.org/uploads/GenerationalDifferencesChart.pdf. Accessed June 3, 2016.

The positives of pimping

More than 2,000 years ago, Aristotle wrote, “Exercise in repeatedly recalling a thing strengthens the memory.”5 Since then, psychologists and neurobiologists have conducted numerous studies supporting a phenomenon known as the testing effect. The testing effect posits that the retrieval of information produces better retention than restudying the same information for an equivalent period of time.5,6 Researchers who study this approach postulate that the active recall of information from memory creates retrieval routes, improving the likelihood that the information can be successfully retrieved in the future. The success of creating such retrieval routes is thought to relate to the amount of effort required to reprocess each memory, with more extensive and more difficult reprocessing correlated with greater retention.

Another critical component of information recall is instructor feedback. Receiving feedback after attempted memory retrieval, regardless of how detailed a student’s information recall is at that moment, improves the likelihood of successful future recall.5,7 Timing of feedback is important, with immediate feedback, rather than delayed feedback, leading to improved future performance.8

Pimping, as often performed in the modern era of medical education, requires the ultimate form of active recall. Pimping requires a learner to dig into his or her knowledge base to search for the appropriate response on the spot. While potentially stressful, the everything-is-fair-game nature of this technique creates a high-pressure situation ideal for augmenting the learning process. Individuals who have been “pimped” can often recall the details of the situation and their response (correct or incorrect) months after the event. By providing immediate feedback, the ideal “pimper” is engaged in the student’s learning and seeks to provide guidance and impart additional knowledge as needed, further enhancing retention.

In its purest form, this technique allows the instructor to ask scaffolding questions, which involves asking more difficult questions or questions that encompass an increasingly greater span of knowledge in a sequential order to ascertain the limits of the student’s understanding. This is a powerful tool when performed without judgment. It allows the teacher to tailor instruction to the student’s current level of knowledge rather than simply reiterating what the student already knows or lecturing above the student’s current level of understanding.

Notably, pimping allows students to acquire and apply knowledge in clinically relevant situations. The constructivist theory of active learning, initially described by American psychologist John Dewey, is based on the idea that learning occurs most naturally in the context of problem solving and immersion in the learning experience.9 Pimping acts as an extension of this theory by presenting the learner with a problem regarding a clinical scenario. If executed successfully, this contextual questioning prepares the student for independent practice.

Pimping pitfalls

Like many aspects of surgical training, pimping has its share of detractors and has recently come under attack as an educational tool that is past its prime. In fact, some institutions prohibit the practice altogether.10 Students have traditionally reacted poorly to pimping for several reasons: it promotes an old-fashioned hierarchy, it creates a stressful learning environment, and it may be perceived as humiliating or embarrassing by some students. Furthermore, pimping is often used as a narrative foil to highlight actual humiliation in the clinical setting, which is, of course, not to be tolerated.11,12

By its very nature, this technique promotes the hierarchy within medicine. As the team gathers on rounds outside a patient’s room and the attending physician begins a line of questioning, slowly progressing from the third-year medical students to fourth-year students to first-year residents and so on up the chain of command, it becomes clear to everyone on the team not only where they stand in the attending’s view (as most attendings pimp “up the chain,” not down it), but also how their medical knowledge stacks up against that of their peers.

Anyone who has ever been on the learner side of pimping has experienced their mind going completely blank when asked a question. This phenomenon is often the questioner’s goal: force the student or resident to quickly think on his feet and deliver the correct answer. If the trainee can successfully fend off the fear of the moment and answer the question, he may be more prepared to do so when faced with an emergent, stressful patient scenario.

However, the stressful environment that pimping is designed to create is one reason students often find it counterproductive, as not all medical students intend to enter a discipline where they will have to make immediate and consequential decisions.4 Even those who do plan careers in such specialties, including surgery, are often unaccustomed to performing in such conditions and are unable to work past their initial mental block.

Although it is important to recognize that some of the utility in pimping comes from the embarrassment that students feel when they publicly provide the wrong answer to a question, not all learners will experience the advantages of this educational strategy.13 Some students may be so turned off by the public embarrassment that they are unable to recover and effectively participate in future learning opportunities. Recent surveys by the Association of American Medical Colleges have shown that almost 50 percent of students report being publicly embarrassed during their clinical rotations.14 It is unclear whether all of this reported embarrassment is due to pimping. But in an environment where medical student mistreatment is increasingly recognized, and recruiting students into a surgical career is becoming increasingly important, any technique that by design elicits embarrassment warrants close scrutiny.

How students respond to pimping

Despite recent literature criticizing the use of pimping in medical student education, few studies have examined student preferences and their response to pimping. Wear and colleagues interviewed 11 fourth-year medical students regarding their experience with pimping during their clinical years.15 All student respondents said they had experienced pimping at some point in their medical education. Although some students had experienced embarrassment or humiliation after being asked questions they felt were above their level of education, all students responded positively to the pimping technique. They noted an appreciation for pimping as a way to learn and for their instructors to measure the student’s level of knowledge.

A study from 2011 by Zou and colleagues compared teaching third- and fourth-year medical students using the Socratic method with standard PowerPoint-based didactic lectures.1 Of the 74 medical students evaluated in the study, 81 percent preferred the interactive dialogue of the Socratic method to a standard lecture, and 73 percent of students found pimping to be an effective method of learning. Two-thirds of the students preferred interactive sessions in which students volunteered answers as opposed to the historical approach of pimping in which students are called upon randomly to answer questions. Overwhelmingly, when asked the preferred method of small-group learning (five to eight students and one instructor), 93 percent of students preferred the Socratic method to didactic lectures. Student comments included a sense of improved knowledge when they were actively questioned (whether they answered correctly or incorrectly) and a preference for volunteering answers rather than being singled out. These studies affirm that—when done in a positive way that focuses on interactive learning as opposed to reinforcing the traditional surgical hierarchy—students favor this type of instruction.

Successful pimping strategies

Strategies for productive pimping

  • Ground the Q&A in a clinical scenario
  • Be cognizant of the effects of a dominant or aggressive learner on others
  • Ask questions with multiple answers to involve everyone
  • Apply the 50/50 principle: 50 percent core or easy knowledge, 50 percent challenging
  • Apply scaffolding questioning
  • Provide immediate and constructive feedback

The primary goal of successful pimping should be to create an interactive learning environment that effectively highlights knowledge deficits without humiliation. Several important considerations can be incorporated to easily create a positive learning environment, even when a strategy like pimping is used (see sidebar).

Students who recall pimping as a negative experience frequently cite instructors who asked nearly impossible questions, sometimes about less-than-relevant historical trivia, which the students perceived as a way to further promote surgical hierarchy and to spotlight the instructor’s knowledge rather than to teach.2 This situation can be avoided by using clinical scenarios as the framework, thereby providing a meaningful and pertinent foundation for the remainder of the question-and-answer (Q&A) session.

An educational session that incorporates the pimping method can easily be dominated by an outgoing or overly aggressive learner. To engage all learners and not just those students who naturally respond well to this type of teaching, it can be helpful to ask questions that have multiple answers and require each student to supply an answer. For example, instead of asking for a volunteer or calling on an individual to list the lab abnormalities seen in sepsis, the surgeon teacher can ask each person in the group to answer the question. Using this technique, students are able to work together as a team, yet retain an individual responsibility to be prepared.

Pimping can be an effective way for instructors to identify a learner’s baseline level of knowledge, which can help to alleviate redundancy and boredom. Instructors can use the 50/50 principle to help tailor the difficulty of the questioning;4 50 percent of the questions should address knowledge that the instructor already expects the students to know. Not only do these questions serve as positive reinforcement, but they show the instructor that this is information with which the students are already comfortable and more time can be spent on high-level questions. The remaining 50 percent pertains to information that the instructor feels is important to the topic but does not expect the learner to already know. This higher level of questioning not only provides the framework for getting at the “meat” of the instruction, but also highlights knowledge deficits and guides further assignments.

Positive reinforcement is an important part of creating an engaging learning environment where students can feel comfortable both answering questions and asking for clarification when there is uncertainty. While it is important to give praise and encouragement for correct answers, the more difficult task is to keep learners involved and confident when they are mistaken. When a student is unable to provide the correct answer, diagnosis, or treatment, it can be helpful to take a step back in the questioning and start with more basic questions that will help the student arrive at the correct answer as he thinks through the problem.

For example, if a student is unable to recall the correct treatment for cholangitis, the instructor can take a step back and ask the learner to describe the primary problem in cholangitis. If the student is able to identify that an obstruction resulting in infection is the root of the problem, the student may be able to recognize that relieving the obstruction with decompression will be the treatment. Using this method, not only will the student have thought through the problem and reached the correct answer independently, but the student also will gain confidence in his ability to solve clinical problems.

Undoubtedly, many practicing surgeons recall their experiences with being pimped as trainees with a fond nostalgia, as a rite of passage, and many also would likely agree that it was an invaluable part of their training and education. It is important that, as surgical education strives to keep pace with new methods of transmitting information, the tried-and-true methods continue to be applied—but perhaps with some updating and forethought in order to engage all generations of learners.

The time-honored tradition of questioning and “high stakes” learning that motivated each of us to take an active part in the learning process cannot be underestimated. It is this type of education that prepares medical students and residents for the true high stakes to come as they advance in their careers.


References

  1. Zou L, King A, Soman S, et al. Medical students’ preferences in radiology education: A comparison between the Socratic and didactic methods utilizing PowerPoint features in radiology education. Acad Radiol. 2011;18:253-256.
  2. Oh RC, Reamy BV. The Socratic method and pimping: Optimizing the use of stress and fear in instruction. Virtual Mentor. 2014;16(3):182-186.
  3. Brancati FL. The art of pimping. JAMA. 1989;262(1):89-90.
  4. Healy JM, Yoo PS. In defense of “pimping.” J Surg Educ. 2015;72(1):176-177.
  5. Roediger HL, Butler AC. The critical role of retrieval practice in long-term retention. Trends in Cog Sci. 2011;15(1):20-27.
  6. Karpicke JD, Roediger HL. The critical importance of retrieval for learning. Science. 2008;319(5865):966-968.
  7. Kang SH, McDermott KB, Roediger HL. Test format and corrective feedback modifying the effect of testing on long-term retention. Eur J Cog Psychol. 2007;19(4/5):528-558.
  8. Kulik JA, Kulik CC. Timing of feedback and verbal learning. Review of Educational Research. 1988;58(1):79-97.
  9. Kolb AY, Kolb DA. Learning styles and learning spaces: Enhancing experiential learning in higher education. Acad Manag Learn Edu. 2005;4(2):193-212.
  10. van Schaik KD. A piece of my mind. Pimping Socrates. JAMA. 2014;311(14):1401-1402.
  11. Burcher P. Pimping: Report or do nothing? Virtual Mentor. 2014;16(3):161-164.
  12. Anderson J. Can “pimping” kill? The potential effect of disrespectful behavior on patient safety. JAAPA. 2013;26(4):53-56.
  13. Kost A, Chen FM. Socrates was not a pimp: Changing the paradigm of questioning in medical education. Acad Med. 2015;90(1):20-24.
  14. McCarthy CP, McEvoy JW. Pimping in medical education: Lacking evidence and under threat. JAMA. 2015;314(22):2347-2348.
  15. Wear D, Kokinova M, Keck C, Aultman J. Pimping: Perspectives of 4th year medical students. Teach Learn Med. 2005;17(2);184-191.

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