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Suzanne Gordon: Pimping has no place in medical education

15 Apr, 15 | by BMJ

suzanne_gordonUntil recently I thought I knew the meaning of the term “pimp” or “pimping.” But a couple of weeks ago a friend who is a student in a physician’s assistant program at a major medical school gave me new insight into the word when she told me how stressed she was because she was being “pimped out” by so many attending physicians during her training rotations. “Pimping out,” I asked her, what is that? Surprised that someone who’s written about medicine didn’t know the term, she explained that “pimping” occurs when attending physicians deliberately ask trainees questions that the senior physician knows the trainees cannot possibly answer. When, as expected, trainees couldn’t answer the unanswerable, they would be deliberately humiliated. “It’s horrible,” she said. “They roll their eyes, look at you like you’re an idiot, and, make you feel like a piece of dirt. When this goes on during a procedure, it makes it really hard to concentrate.”

My friend also described the advice students and trainees receive when they are “pimped out.” “We’re told to respond with confidence and pretend we know stuff we don’t know.”

I was surprised to learn about “pimping” not because I was unaware of the fact that medical training can be an exercise in humiliating and even abusive practices. What surprised me was that there was an actual term for this particular pedagogical practice as well as a “scholarly” literature extolling its virtues.

In 1989, for example, JAMA published an article entitled, “The Art of Pimping,” by Frederick L. Brancati. Today, as in centuries past, Brancati explains, attending physicians deliberately ask medical trainees a series of questions “in rapid succession,” which “should be essentially unanswerable.” Humiliation averse students will try to “bluff” their way through the encounter but the skillful attending, aware of this tactic, will adopt clever practices to make sure to “disgrace” the intern or resident who tries to avoid ignominy. The purpose of this exercise, as Brancati puts it is to infuse, “the intern with a profound and abiding respect for his attending physician while ridding the intern of needless self-esteem. Still, he (the trainee) enjoys the attention and comes to equate his initial anguish with the aches and pains an athlete suffers during a period of intense conditioning.”

Although Brancati wrote the article in a tongue in check manner, neither he nor most of the readers who responded to his article in JAMA’s letters to the editor, were critical of pimping practices. One physician commented that “pimping” only served to instill in him and his fellow trainees a lack of curiosity and fear of questioning, but most of the other letters supported the practice. In his own response to these comments Brancati explained that he considers pimping, when correctly done, to be invaluable—particularly because it instills a “feisty esprit de corps,” in medicine, and can “entertain and teach at the same time.”

In 2009, another JAMA article by Allan S. Detsky updated Brancati’s. This article appeared ten years after the Institute of Medicine’s highly publicized report To Err Is Human, which highlighted the pernicious impact of medicine’s culture of shame and blame. Yet, a prominent physician and medical educator was unabashedly promoting a practice that could not be better designed to produce physicians who are terrified of admitting doubt, lack of knowledge, or asking for help. Detsky proudly proclaimed that “pimping is indeed alive and well within academic medicine,” and advises attending physicians that “the right balance between humiliating the student who gives incorrect answers, and boring the audience by simply providing the answers is a real skill.”

What does not concern either Desky or Brancati is how the “art of pimping,” impacts patient safety, interprofessional education and practice, and the patient-doctor relationship.

Consider the impact of “pimping” on patient safety and interprofessional practice. We have known for decades that patient safety depends on professionals’ willingness to admit to mistakes so they can, and others can, learn from them. Patients will never be safe if physicians can’t acknowledge what they don’t know, ask for help when they need it, and to speak up when they see someone—particularly a medical superior—about to do something wrong, dangerous, or reckless. If a fundamental communications skill learned in medical training is to confidently communicate knowledge that one does not actually possess, never express doubt, and avoid at all cost embarrassing a medical superior then patient safety truly becomes a mission impossible. If physicians learn to revere the medical hierarchy, when they have attained seniority in it they may interpret genuine concerns expressed by other professionals as unacceptable challenges to their status and authority. After bluffing their way through their education, they will rebuff attempts at the kind of critical cross-monitoring that is essential to any kind of genuine teamwork.

Finally, consider the impact of pimping on the doctor patient relationship. In my decades long journey as a patient and professional observer of doctor-patient encounters, I have seen and personally experienced how some physicians—too many in fact—respond to even the hint of a challenging question or comment. As a patient, I’ve watched residents who were taking care of me be humiliated by a senior physician and wondered what would happen to me if I dared to displease my physician. I have also longed for a physician to simply say, “I don’t know what’s wrong, but we will figure this out together,” or to apologize if a mistake was made. Given their socialization, what’s surprising is that some—although not enough—actually respond in this way. Nor is it surprising that some don’t only pimp out trainees but actually pimp out their patients.

Fortunately, the issue of the toll that harassment and humiliation takes on medical trainees is starting to be discussed. The other day, for example, I was presenting at a medical conference and shared a luncheon table with a patient safety physician and an internist who is a proponent of a more humane medical system. Both work in large teaching hospitals. We got into a discussion of pimping and the internist commented that she could not imagine teaching residents without occasionally “pimping them out.” Given her reputation, I couldn’t imagine that she was actually serious, and asked her if she was being sarcastic. No, she said brusquely, I think it’s a useful strategy. The patient safety physician sitting next to her didn’t skip a beat and adamantly interjected, “No,” he said, “there is no excuse for humiliating students or trainees. Ever.”

Suzanne Gordon is a healthcare journalist and co-editor of The Culture and Politics of Healthcare Work Series at Cornell University Press. Her latest book is Collaborative Caring: Stories and Reflections on Teamwork in Healthcare, which she co-edited and she is co-author of Beyond the Checklist: What Else Healthcare Can Learn from Aviation Teamwork and Safety. Most importantly she is a patient.

Competing interests: None declared.

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  • Murray Guy

    The physician / nurse relationship does not have exclusive rights to the practice of humiliation and intimidation. This behaviour pattern is evident throughout all walks and works of life. It is unacceptable in them all!
    Thank you.

  • Marielena DiBartolo

    Definitely alive and well; not a technique I will ever use; and I can’t even begin to describe the revulsion I feel at the fact that a word commonly understood to mean a person (or the act of) profiting off the sexual exploitation of others is in any way considered acceptable in medical education.

  • Robin Scott

    As a pilot who went through rigorous communication and teamwork training throughout my career in aviation, it’s surprising and disturbing to discover that some attending physicians — the equivalent of captains in our cockpits — are still humiliating medical trainees — the equivalent of first officers. Forty years ago, humiliating or silencing subordinates was routine behavior on the flight deck. After a series of crashes in the 1970’s aviation researchers, regulators, and companies recognized that any behavior that discouraged subordinates from speaking up, raising concerns, admitting mistakes or challenging higher ups contributed to airplane crashes and preventable deaths. After years of rigorous l, teaching communication and teamwork skills through Crew Resource Management training, captains now solicit and welcome the input of first officers and flight attendants (among other personnel) and anyone who silence subordinates would never be considered to be a legitimate role model.
    Throughout my training as a pilot, I was constantly encouraged — and taught how to speak up. When I got out and started “flying the line,” I definitely felt this training empowered me. You’re on probation for almost a year and you don’t want to ruffle any feathers. You don’t want any captain to blacklist you or start spreading the rumor that you’re one of those big mouths who thinks he knows it all. You want to get along. So I was concerned about where to draw the line with safety. What to do if it was a gray area. But CRM taught us, “No, you have to speak up, this isn’t a one man show.” I was never taught to pretend I knew things I didn’t know, and was always encouraged to ask questions, and admit doubt. And when I started flying, that’s just what I did. I would hope medicine would reconsider “pimping” and emulate the aviation safety movement by thoroughly delegitimating this kind of practice just as we did in aviation. It’s the only way to make healthcare safe and reliable.

  • Patrick Mendenhall

    In 1989, on my first revenue trip as a new-hire commercial pilot, I began to seriously question my career choice. The captain on the trip dutifully hazed me for five days and I had no recourse, but to put up with it. Although I didn’t have a label to place on it, I know now that I was being “pimped.”

    Thanks in large part to the CRM culture that began to take hold in the airline industry about the same time frame, I never had another such pimping experience. Now, 26 years later, as we have described in our book, “Beyond the Checklist: What Else Healthcare Can Learn from Aviation Teamwork and Safety,” the commercial airline culture has evolved to the point that such behavior would simply not be tolerated.

    Hazing, pimping, harassment – whatever you want to call it – is completely contradictory to a safe operating environment by every measure – whether in the cockpit, the office, or on the floors.

  • MN

    This is a really great article, shedding light on an important topic. As a medical student on the verge of graduation, I’ve been
    pimped a lot. And to be quite honest, pimping doesn’t bother me. In fact, there have been times when I’ve really enjoyed it and have learned a lot from it. I think for me, what’s important is how it’s done. I agree that there is no place for humiliation or learning by shaming in medical education – that’s bad pimping, and I have certainly experienced that. Most of my experience,
    however, has been “good pimping,” ie residents or attendings have taken a genuine interest in my learning so they fire one question after another not with the intention to humiliate, but to test the limits of my knowledge to figure out what they can teach me. When I can keep up, they’re impressed, and when I don’t know the answer, I say something like, “I don’t know, but let me
    see if I can think through it out loud”. I’ve found that often, especially when I’m asked a question that doesn’t have a clear-cut answer, people are more interested in the way I reason through a problem, rather than the answer itself. And in my mind, that’s the best kind of pimping – ask me a challenging question, and then teach me how to correct the missteps in my thought process, so that rather than teaching me an answer, you teach me how to think.

    I think there’s also something to be said about this culture of “false confidence” that we promote so widely in medicine – this dogma that we don’t always understand but blindly accept. Recently, when a neurology resident was pimping me, I followed up my answer with “you know, I say that because I know that’s the right answer, but to be honest, I don’t really get it…can you explain that to me?”. The resident said something like “huh, that’s
    a good question…” and then began to reason it out loud for himself and I understood. I wish I had had this same confidence to admit that I was just telling someone what they wanted to hear earlier on in my training, because I certainly would have benefited more this way.

    I don’t think we need to eliminate pimping per se – I think more residents and attendings need to be better trained in “good pimping,” which in large part, requires a paradigm shift towards acknowledging the finite limits of our understanding without shaming trainees.

  • As a physician and veteran of the medical education system, i totally agree that pimping is an act that leads to bad behavior. Arrogance is one ramification, another is the idea that as doctors our primary job is to have more knowledge than our colleagues. The attitude persists, especially between generalists and specialists, and between hospital doctors and non-hospital doctors. I always have someone trying to tell a patient that i have done the wrong thing, and i am personally guilty of the same behavior toward other doctors. Pimping is but one aspect of medical education that emphasizes competitiveness, personal knowledge accumulation, and fear of reprisal at the expense of compassion, cooperation, and humilty. it is some of the latter traits that really are ingredients of a good doctor, and the former that are not. Why, then, does this system persist? Sadly, it shows no sign of letting up.

  • Pugilistic pimping has no place in patient care.

    Thank you for initiating this important discussion.

    I am an emergency medicine physician educator who has “pimped”
    and been pimped over my 20 year career. In my opinion and echoing the thread initiated by MN, “pimping” is a problem when it originates from a place of superiority and intimidation. Pimping has indeed been a tool used by many educators in healthcare education for generations. Many unenlightened clinicians would argue that it is the only way that a senior clinician is able to get a sense of what a trainee knows during the short few weeks of a clinical rotation. This is unacceptable. If I can ask a question to help a trainee gain a bit of knowledge then I should ask. I need to check in to make sure that everyone is on the same page. It is essential to ensure that each trainee gains knowledge from a clinical encounter. However, many clinicians use pimping as a method to brandish their intellectual expertise rather than a formative assessment tool. This is where pimping gets its negative brand.

    In this day and age where healthcare has begun to appreciate
    lessons learned from aviation, we now know that hierarchical structure and intimidation lead to poor communication. Poor communication is the cause of many patient care errors and impairs quality patient care. Yet, numerous healthcare leaders have climbed their ladder of success exerting intimidation as their primary leadership tactic and have few other communication tools in their toolbox. I have learned so much about the non-technical skills (NTS) of healthcare and know that I have so much more to learn and to teach. NTS are teamwork, communication and leadership. By definition, NTS include any skill other than a technical skill such as learning how to perform a procedure or operate. The greatest leadership pearl that I have acquired over the years is that it is not important that I know the answer; but that any team member who knows the answer will speak up and offer their thoughts for discussion.

    If I were to spend my time teaching from an intimidating pedestal,
    then my team would be less likely to offer their thoughts and suggestions in times of crisis. I have personally learned to embrace that I don’t know everything and it is okay if I let everyone know that I don’t know everything.

    I still ask questions and I will continue to do so. However, I will continue to ensure that my trainees know that my goal is as an educator, not an intimidator. I need my trainees to learn, I want them to be the best clinicians they can be and I want them to safely provide quality care to their patients. There is no place for shame and blame in healthcare. The stakes are too high to let our patients down. It isn’t about me and my pride. It isn’t about how much I know compared to anyone else.

    Much of my personal confidence in conversation has been the
    result of the opportunity to practice difficult conversations in a simulated environment outside of patient care. I have had the advantage to practice my NTS in a safe place both as a learner and as an educator. Better communication results in better patient care. I hope that someday, all healthcare educators have the opportunity to practice their NTS and patient care in simulated environments. Perhaps other healthcare educators can learn communication techniques other than pugilistic pimping.

    Thank you again for initiating this discussion.

    This is the opinion of Sharon Griswold, MD MPH, Director of the Drexel Master of Science in Medical and Healthcare Simulation Program.

    http://www.drexelmed.edu/MSsim

    @mssimdrexel

  • This is a super statement of what pedagogy should and should not do.

  • I think we need to distinguish between pimping and questioning. It’s like the difference people in occupational health make between stress and challenge. Or between bullying and rudeness or incivility. Stress is always bad, challenges are good. Bullying is different than routine garden variety rudeness (of which there is way too much in healthcare).
    So could we all agree that there is a difference between “pimping” and questioning to reveal someone’s lack of knowledge and help them gain the knowledge and confidence they need.
    Just as it’s important to determine the correct diagnosis and treatment it’s important to use language precisely. If anyone doubts that “pimping” is essentially a bad practice, check out the dictionary definition of the word pimp from which the term pimping is derived, herewith attached.

    A Pimp is either:.

    ”1. a person, especially a man, who solicits customers for a
    prostitute or a brothel, usually in return for a share of the earnings; pander;
    procurer.

    2. a despicable person. “ http://dictionary.reference.com/browse/pimping

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