{"id":2203,"date":"2016-12-22T09:51:59","date_gmt":"2016-12-22T14:51:59","guid":{"rendered":"http:\/\/blogs.nejm.org\/general-medicine\/?p=2203"},"modified":"2016-12-22T10:10:50","modified_gmt":"2016-12-22T15:10:50","slug":"pimping-malignant-or-not","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/general-medicine\/index.php\/2016\/12\/pimping-malignant-or-not\/","title":{"rendered":"“Pimping”: Malignant or Not?"},"content":{"rendered":"
\"Joseph<\/a>

Joseph Cooper, MD, is a Chief Resident in Internal Medicine at Geisinger Medical Center in Danville, Pennsylvania.<\/p><\/div>\n

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. \u201cLet me know what you think about this,\u201d he said between bites. He\u00a0went 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.
\nHe 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 \u2014 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: \u201cThe pharmacist is standing at the Pyxis machine asking what medications to give. What are you going to tell her?\u201d<\/p>\n

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 \u2014\u00a0different 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, \u201cHow do our residents learn today without being questioned?\u201d I answered, \u201cI\u2019m not sure, but I\u2019ve always found that questions\u00a0are the best method.\u201d The ID specialist left me with one last question: \u201cDo you think I was too hard on them? Was I being a \u2018malignant pimper’? Because I surely don\u2019t want to be that.\u201d<\/p>\n

Frederick L. Brancati first coined \u201cthe art of pimping,\u201d in his 1989 JAMA article:<\/a>\u00a0the practice of posing particularly difficult questions to learners. There are undertones in Brancati\u2019s article (which is older than Justin Bieber) about the separation of power between the teacher and the trainee. Notions of respecting\u00a0the teacher and expecting the trainee to follow the \u201cchain of command.\u201d 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<\/a> about learners taking back their power. Although each article illustrated differing approaches to pimping, they agree pimping confers some value to learners.<\/p>\n

Wear et. al published a study in 2015<\/a> 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\u00a0of medical students was not large\u00a0(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\u00a0anxiety and pressure, and, ultimately,\u00a0to motivate them to learn on the spot or later if they did not know the answer. \u201cMalignant\u201d 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\u00a0was simply humiliating the students by exposing deficiencies in knowledge rather than trying to create new connections.<\/p>\n

\"Hospital<\/a>

Hospital de Sant Pau. Barcelona, Spain. My Own Work. Canon DSLR.<\/p><\/div>\n

Hugh A. Stoddard and David V. O\u2019Dell made the ultimate comparison in their 2016 publication in Journal of General Internal Medicine,<\/em><\/a> stating that psychological safety is the key difference between Socratic method of teaching and pimping. They defined the Socratic method as \u201cprompting students, through cross-examination, into acknowledging their own fallacies and then asking them provocative questions to steer them towards realizing true knowledge via introspection.\u201d 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,\u00a0Socratic teaching does not allow for a sub-par performance and that accountability is not a trade-off for the said safety.<\/p>\n

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 \u201cnormal and average resident should be achieving by the time of independent practice.\u201d At times, the sense of urgency and accountability\u00a0seems to be\u00a0lacking 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.<\/p>\n

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\u00a0hierarchical 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\u2019ve detailed above.<\/p>\n

\"Lembongan<\/a>

Lembongan Island, Bali. My Own Work. Canon DSLR.<\/p><\/div>\n

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\u00a0questioning learners. Numerous studies and evidence\u00a0prove 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.<\/p>\n

 <\/p>\n

\"NEJM<\/a><\/p>\n

Residency isn\u2019t easy. But it doesn\u2019t have to be quite <\/em>so hard. Explore NEJM Resident 360.<\/a><\/p>\n<\/blockquote>\n","protected":false},"excerpt":{"rendered":"

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. \u201cLet me know what you think about this,\u201d he said between bites. He\u00a0went on to recapitulate a recent interaction he had with the members […]<\/p>\n","protected":false},"author":1279,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[2],"tags":[19,34,37,69],"class_list":["post-2203","post","type-post","status-publish","format-standard","hentry","category-about-residency","tag-communication","tag-residency","tag-resident-experience","tag-teaching"],"yoast_head":"\n"Pimping": Malignant or Not? - Insights on Residency Training<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/blogs.nejm.org\/general-medicine\/index.php\/2016\/12\/pimping-malignant-or-not\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\""Pimping": Malignant or Not?\" \/>\n<meta property=\"og:description\" content=\"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. \u201cLet me know what you think about this,\u201d he said between bites. 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