Please, no more ‘pimping’ in med ed

Trainees who've been grilled through the traditional practice of “pimping” have felt the burn of shame and humiliation, but now some medical educators think it's time to turn down the heat.

“There are other ways to challenge learners. If you want to add stress, challenge them with more complex tasks or challenge their clinical reasoning; don't try to make them feel challenged by making them feel belittled,” said hospitalist Benjamin Kinnear, MD, MEd, FACP, an associate professor and associate program director for the internal medicine and internal medicine-pediatrics residency programs at the University of Cincinnati Medical Center and Cincinnati Children's Hospital Medical Center in Ohio.

Although pimping in medical education has no universal definition, the literature has described it as asking trainees questions in a stressful manner that reinforces a dominant intellectual hierarchy, according to a perspective he cowrote, published in May by the Journal of Hospital Medicine. Some sources claim the term “pimping” comes from the German “pumpfrage,” for “pump questions,” although there is no clear evidence of this, according to the paper.

While the term is familiar to many physicians, it has misogynistic and exploitative undertones, the authors noted. Other terms for the same teaching style that may be preferable include “toxic quizzing,” “teaching by humiliation,” and “grilling,” said Dr. Kinnear.

The technique is distinct from but often confused with other educational methods like Socratic questioning, he said, noting that sometimes physicians who remember being pimped during training believe it was beneficial for their learning. “If you were to show a video of a supervisor asking questions to a student or a resident, you'd have people call that question-asking, Socratic method, and pimping. … They're not the same thing, but they're often terms that are used interchangeably.”

Dr. Kinnear spoke with ACP Hospitalist about what pimping is, why the practice continues, and what he believes hospitalist educators should do instead.

Q: What led you to write this perspective?

A: At our residency program, we really value educational safety. By that I mean … a learning environment where people feel safe to be curious and ask questions and focus more on growth than on looking smart, because as soon as you focus on looking smart, you stop asking questions, and it becomes kind of restrictive. That's something that we talk a lot about in our residency programs. Then people say, “Oh, so you can't stress people out,” and we're like, “No, of course you can stress people out.” The phrase we use is ‘safe, but not soft.’ You need to feel safe to make mistakes, but that doesn't mean it has to be easy. We're not saying that all stress is bad. It's just that when people try to induce stress through this kind of hierarchical, humiliating approach, many times it's not going to have the effect that people want it to have.

The other thing is I help run the medical education pathway here, which is a longitudinal pathway for residents, and as part of that, I give some talks on asking questions in the clinical environment. … Often at these lectures, I would have these seasoned physicians who would always pipe up and talk about being pimped when they were younger. And they were really kind of lauding this approach, and I would always push back. … I was getting a lot of really interesting back and forth at some of these talks, and it just really made me want to write down my arguments for why I think this practice should not be something that is part of medicine.

Q: Why should hospitalists avoid pimping?

A: Because it's terrible! You're treating people poorly. I think at a basic human level, we need to be kind to people. It used to be a badge of honor, and thankfully I don't think everyone sees it that way anymore.

Q: You finished residency in 2013. How has this practice changed throughout your career?

A: It happened to me more when I was a medical student than when I was a resident. I think it's probably somewhat specialty- and institution-specific. I don't think it is as accepted as it used to be, meaning I think if a resident or medical student feels bullied or belittled, there are a lot more mechanisms now for them to report what happens. And while I think that those mechanisms are probably way underutilized, those didn't even exist 10 or 15 years ago. So the practice is still there. I think a big reason why is because people still think it's good teaching practice, but I would have to guess it's less prevalent than it used to be.

Q: Why do some educators still practice pimping?

A: There are a lot of people who really think they're doing a good thing. If you ever want evidence of this, one of the articles we cited [“In Defense of ‘Pimping,’” Journal of Surgical Education, 2015] … was a commentary recalling [the authors'] surgical training, simultaneously lauding pimping and how effective it was, while also describing the experience as being akin to a battlefield. . … They [say pimping] is like a vaccine; it's a necessary pain to help somebody grow. That is not at all supported by evidence.

It's also misremembering and personalities. There's a term that Eric Holmboe [MD, MACP, chief research, milestone development, and evaluation officer at the Accreditation Council for Graduate Medical Education] coined, nostalgialitis imperfecta profunda. Basically, it's when people wax poetically about the good old days that weren't really so good: “Back in my day, we would work 175 hours a week and we were all the better for it.” But if you could rewind it, they were miserable. … And then, if I'm honest, I think there are some people who, if you put them in any situation where there's a power differential or hierarchy, they tend to lean into that, in sometimes ways that are destructive.

Q: What approach to questioning do you recommend instead?

A: Many of the types of questions people ask, if they're done in an educationally safe environment, can still be OK. You can still ask somebody about which antibiotics are indicated or the procedure that you're about to do or those kinds of things, but the learner has to know, No. 1, that their performance on these questions isn't going to be a determining factor for their grade, especially if they're a medical student. As soon as a performance on questions relates to honors or something like that, they're going to become performative and shut down.

No. 2, you have to set the stage ahead of time and let people know why you're asking questions. And don't make people feel singled out. The third thing is, I think there's not a ton of utility to using only fact-based questions on rounds. I mean, sure, they serve some purpose: “What antibiotic do you think we should use here?” That's a fact-based, right-answer question. But the more interesting question to me is asking about clinical reasoning. When you say, “Tell me more about why you chose that antibiotic,” it leaves them room to give a rationale that doesn't have a yes-no answer, and you can then dig into that and talk about how they arrived where they are.

The last thing, and this is a little harder … is to minimize the hierarchy [by] having a relationship with the learners. When you get on the wards with a learner, say, “Tell me about yourself. Where are you from? What are you interested in?” I think the more you actually try to form a relationship with learners, even in a short period of time, that in itself will create some educational safety. That allows you to ask questions that probe their knowledge and things like that, but will let them know that you're doing it in a way that isn't going to be tied to a grade and isn't trying to knock them down and make them feel lesser-than. There are some learners that really lock up in groups of people, and I just don't ask them questions because they panic, because they either have anxiety in front of the group or maybe they really don't know the answers. Then I try to work with them after rounds, not in front of other people, to teach them one-on-one, or I'll pull them into a room after rounds is finished with a patient and we'll talk about the physical exam. It doesn't always have to be in front of other people. Some people just can't escape that threatening feeling when questions are asked in front of others.

Q: What are your next steps in your fight against pimping?

A: I'm working with a really ambitious group of medicine residents through that same med ed pathway who are preparing to do a survey and qualitative interview-based study, trying to understand how nonphysicians feel about the term pimping—not the practice, but the term. So we're reaching out to nurses and pharmacists initially. … We don't really know how this term is received by nonphysicians, because it's so baked into our culture that we don't even cringe at it anymore. The term is used as if it just means asking questions. So I'm really excited to see how that plays out.

There have been a couple articles, at least one I cited in the paper, that really try to take down the use of the term itself, not just the practice. I find those arguments pretty compelling. Even though people are publishing these things, the term just keeps getting used. … The only way we're going to actually get people to de-implement the term is if we have people from outside of our field saying, “No, it's gross, it's misogynistic, stop using it.” It's just such an antiquated term itself, beyond even just the problematic practice.