December 16, 2009

Rethinking the Art of Pimping

By Courtney Patterson, Pharm.D., PGY2 Oncology Pharmacy Resident, Johns Hopkins Hospital

The art of  medicine, the art of patient counseling, the art of using medications sound wonderful when discussed in the context of patient care, but there is another art that’s often used in the training of these fields - - it’s called pimping.

Palms sweating, beads forming on my forehead, and my mouth becoming dry as my preceptor hovers over me asking absurd questions that I am sure he / she knows I have no clue what the answers are. I knew there had to be a reason as a student, as a first year and now a second year resident, that there was a method behind making me so uncomfortable - - it’s called pimping.

Where there is established hierarchy, whether it be in the medical profession, pharmacy or nursing, there is a certain style of questioning that oftentimes prevails- - it’s called pimping.

Earlier this year an article by Detsky entitled, “The Art of Pimping” (JAMA 2009; 302: 1379-981) appeared in my social networking email.   Unfamiliar with the concept , I opened my email to find this art hit close to home - striking several personal nerves. Amazingly, a previous article written by Brancati also entitled “The Art of Pimping” appeared in JAMA some twenty years ago (JAMA 1989; 262: 89-90). This blog essay is my attempt to delve into this “art” and offer some advice on how to revamp this feared form of questioning.

Pimping occurs when an attending or preceptor (the Pimper) poses a series of difficult questions to a student or resident (the Pimpee).  The setting for this style of teaching typically occurs during rounds, topic discussions or in a circumstance where the Pimper has the expectation to retrieve direct answers from the Pimpee.  In this situation, the Pimper exudes power and fear as they are evaluating the Pimpee’s performance and are their superior.

Pimping is quite an old concept, as the earliest reference dates back to 1628 where Harvey, a physician, laments his students lack of enthusiasm, “O that I might see them pimped!” In 1889, Koch recorded a series of “Pimp Questions” that he later used on medical rounds. This concept has even fluttered through Johns Hopkins - in 1916 Abraham Flexer made the observation, “Rounded with Osler today. Riddles house officers with questions, like a Gatling gun. Welch says students call it ‘pimping.’ Delightful.”

In the 21st century, pimping has survived because it’s based in the age-old style of question and answer. In this light, pimping can resemble the Socratic method but there are some distinct differences. The Socratic method is a kind of questioning that requires the student or resident to do more in depth thinking, it oftentimes presumes that the student knows the answer and the instructor is attempting to allow the student to answer their own question by bringing about questions that will better formulate the student’s answer. Pimping however, is asking questions with minimal expectation that the pimpee will know the answer. This form of questioning is used to either bring about a teaching point or show superiority of the pimper. Thus the difference between these methods is the intent behind the questioning.

I have alluded to the technique utilized in pimping, but there are only two components at its center: fear and power. A rapid fire session of questions combined with fear and power --you’ve got a pimping session.  Power is needed because it reinforces the relationship between the preceptor and the student or resident. Fear is present because the student or resident wants to know the answers to the questions and grimaces at not being able to respond in a manner that will quench the preceptor’s satisfaction.  And for those fellow residents, upcoming residents, and students I offer three tokens of advice in avoiding the dreaded feeling of being pimped.

First, attitude is everything.  During rounds, topic discussions, and presentations, the goal should be to learn. Even with sweaty palms as questions are being fired away at you, take it in stride, right the questions down and look them up later. There is no need to feel downtrodden; if you are being pimped then you should understand that the expectations are low for you to answer spot on. Second, be okay with not knowing the answer.  I know this is hard, maybe because of embarrassment or ego or a type A personality, but you aren’t going to know everything. Third, just because it was done to you doesn’t mean that you have to perpetuate it. Pimping is different from the Socratic method. Pimping utilizes fear and relies on the system of hierarchy. I know as a future preceptor, I hope to ask my residents what they should know and not emphasize what I know. I plan to give them the tools, assist in the search of articles and journals to assist them in order to make them better equipped when questions are posed.

Pimping is an old concept that needs to be re-examined. Going forward, I hope to use the term (it’s still a great word!), but rewire the concept by tossing out the thought that my residents should fear me or that I should be asking questions I know they don’t know. After reading these articles, I walked away with the view that I will rewire pimping by crafting questions to increase retention and hone in on key points … and diminish the embarrassment and diffuse sweating.

[Editor's Commentary:  There is a subtle difference between asking questions with the intent to teach ... and asking questions with the intent to ridicule, embarrass, or establish hierarchy.  However, on the surface it can be difficult, based solely on the phrasing of the question being asked, to determine the intent.  Questions that have very specific answers and require only factual recall of information are more likely to be "pimping" questions intended to demonstrate the superior knowledge of the questioner.  But even open-ended, analytical questions which have several potential solutions can be "pimping" questions if the intent is to exert power and fear.  Thus, context and non-verbal communication are important.  Context is the circumstances under which the question is being asked and its sets the stage (for success or failure).  Does the student have prior knowledge or experience ...  or an opportunity to prepare for the question(s) being asked?  Is the question being asked in a group setting ... and if so, is everyone encouraged to answer the question or contribute to the discussion?  Non-verbal communication also informs the student or resident about the questioner's intent.  An encouraging smile and a nod of the head can set the student at ease.  Moreover, patiently waiting and allowing the student sufficient time to think through the question and its potential solutions is important.  A preceptor or instructor who quickly answers his or her own questions really isn't interested in hearing what the student has to say - rather they just want to tell students about what HE / SHE knows.  Finally, creating an atmosphere of open dialog requires the questioner to be open to being asked questions, to expanding on important points, and redirecting statements that might not be articulated very well.  Effective questioning requires practice, practice, practice ... but its important to understand your own motivations and intent.  Pimping is about power and fear ... effective questions is about facilitating learning.  -S.H.]

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