Pimping (in Medicine): the delicate art of making someone feel small
I have been promising this post for ever!
Pimping. Pimping is a time-honoured tradition in medicine. Not exclusive to the healthcare field, this practice has been shaping young clinical clerks and residents, or their ancestors, since the time of Socrates. There are many perspectives on what pimping really is, but to me it is a simple concept. Basically, the smarter, older doctor asks you about some medical fact; usually it’s a series of questions, designed to test the bounds of your knowledge. Rarely will they ask a trainee’s opinion of something, though I’ve found universally that ER doctors do, and I thank them for it! Seeking an opinion is not an act of “pimping” but if they do so without being genuine, it can easily turn into a pimpfest.
It’s probably healthy to have one’s ego knocked-down a peg or two, especially in the “I’m going to be a doctor, ohhh yeahhhh” stage. Some attending physicians take pleasure in this, but others believe it is essential to identify knowledge gaps so that learning can begin.
It is a fine art, meant to encourage growth and to keep students on their toes. Shame-based learning is at the heart of medicine. It happens to everyone, and even if you know your stuff, you will be made to feel like an idiot; Vitum Medicinus – a senior medical student and fellow blogger – was not immune. No one is safe.
Sometimes it is straightforward fact recall. If your brain is a little fuzzy that day, or it’s been ages since you dissected a cadavre, have fear:
The worst time ever was standing in the orthopedic operating room, holding a retractor while we explored an ankle. The orthopod asked me which structures ran behind the medial malleolous (that lumpy bone on the inside of your foot). I blanked. I feebly tried “well, there’s a mnemonic for them.” He encouraged me, patronizingly. It probably took me 20 minutes before it popped back into my head: “Tom, Dick, And Not Harry.” “Uh hunh,” he said, “and what are those structures?” I paused again. Shit!
It came back to me a few minutes later. “Tibialis Posterior, Flexor Digitorum Longus, Posterior Tibial Artery, Posterior Tibial Nerve, Flexor Hallicus Longus.”
Frick. It was like pulling teeth. He was the dentist and I the poor patient with no analgesia.
More often, the question is “tell me what I’m thinking?”
- Super Smart Old School Neurosurgeon: “Jessica, what are the three main principles of surgery?”
- Me on my first day on a surgical rotation, happens to be in Neurosurgery of all things: Frig. “Uh…. hemostasis?”
- Surgeon: “Yes! What else?”
- Me: “Visualization?”
- Surgeon: “Okay, yep, and the last?”
- Me, growing worried: “Er, I, uh, I umh… sterile technique?”
- Him: “No no no! It’s Anatomical Dissection” (you fool!)
- Me (please with myself, actually): “Oh. Right.” (holy crap, I can’t believe I got two out of three right!)
Sometimes it is totally irrelevant medical history crap; history is important, and all those cells and organs and findings and whatnot are named after old dudes for a reason. However, knowing how something was discovered doesn’t often help the clinical picture. Lots of old guys still think historical pimping is important. I’ve had the history-pimp many a time.
And there are things that doctors LOVE to pimp on. They come up time and time again, so we know the answers:
It was my first ER shift as a resident. It seemed like my preceptor was a pretty nice guy, so I felt I’d ease in well. He asked me to look at an x-ray, see the patient (who he’d already assessed), and tell him the diagnosis. Okay, I’ve gotta prove myself on this challenge! I looked at the x-ray. Hmmm. Something a little funny in the mid-foot, I think. I went to see the patient, introduced myself and my purpose – to learn from her interesting foot. Ah. It’s tender where I expect.
Back to the ER doctor. “Uhm, I think it’s a Lis Franc’s. She needs to see the orthopod.”
He praised my ability to see that on the x-ray. I was surprised too, because I’m no radiologist or even ER doctor and it was probably just a fluke that I noticed it. Oh well, I feel good. I’ll take it!
“So, tell me about that fracture”
Normally, I’d be freaking out quietly inside. I don’t know a lot about fractures but somehow, I knew this. I had been ‘pimped’ before on this. “Well, blah blah blah (describing the fracture) and it was named after Napoleon’s surgeon; his soldiers kept getting these kinds of fractures because they got their feet stuck in the stirrups when they were knocked off of their horses.”
*ding ding ding!*
The most difficult for me is the “this is so easy, but is it really that easy?” pimp. I experienced that in the OR the other day. The OBGYN had a cystoscope in hand, in the middle of a Burch repair (a surgery for urinary incontinence). During this surgery, some monkeying around happens in the pelvis, and then the result of this monkeying around must be checked by looking inside the bladder:
OBGYN, pointing to what look like round ligaments connecting to the uterus: “So, which ligaments are these?”
Me: (in my head… “round ligaments! wait! no! it’s a trick!) “uhhhhhhhhh”
OBGYN: “round ligaments. okay.”
OBGYN now holding a cystoscope (camera) in the bladder: “Hmm, what’s this here?”
Me: (in my head… “I don’t see anything weird, that’s just a bubble”) “Uhhhhhh”
OBGYN: “A bubble!” (nurses laughing)
OBGYN: “okay, how about this?” (pointing out a sort of indentation in the bladder, something that isn’t normally there)
Me: (in my head, “well, it’s just sort of dented in where someone’s sponge and hand are pushing in the pelvis on the outside wall of the bladder”) “Uhh, it looks like uhhh normal, I mean, there’s nothing wrong, it’s just . . .”
OBGYN: “it’s our sponge!”
I was feeling mentally deficient even though I knew exactly what he was talking about the whole time. I just didn’t have the confidence not to second-guess myself. Usually, the pimpers are a little harder on us than this, and I suppose I was expecting the worst. Not an Obs keener, and not really meant to be in the OR during my OBS rotation (except if the perinatal unit is slow) I wasn’t that read-up on my Burch procedures or surgical gyne anatomy. It didn’t matter, since that’s wasn’t what I was being asked about. Sigh.
Developing a comprehensive strategy for handling pimping is not that important, so long as you come out knowing that the feeling of uselessness won’t last; unless you are a hardcore academic, vying for top spot in some super subspecialty, no one will even remember that you got that question wrong. Just don’t cry.
And for the pimpers, Medschool Hell has one golden rule for you: Don’t be a jerk.
There are papers in legitimate medical journals on the subject, but only three that I could find (and one letter response):
- The Art of Pimping by Brancati FL in JAMA. 1989;262(1):89. THE seminal paper; this paper defined it;
- The Art of Pimping by Detsky AS in JAMA. 2009;301(13):1379-1381. This hilariously details some strategies for “pimpees” and “pimpers” alike; I don’t think any of the listed avoidance strategies are really effective, but they might give you a laugh;
- Pimping: perspectives of 4th year medical students. Wear D, Kokinova M, Keck-McNulty C, and Aultman J in Teach Learn Med. 2005 Spring;17(2):184-91. These folks say that “understanding how students define and experience the pimping phenomenon prepares medical educators to scrutinize pimping as a pedagogical tool and to provide the most effective and encouraging environment for students.” Ha ha ha;
- A response to #3, Pimping perspectives: response to Wear. Teach Learn Med 2005 Spring;17(2):184-91. “These questions encourage students to think and not just regurgitate factoids; that is, achieving higher levels on Bloom’s taxonomy.” Not necessarily!
Have you been pimped? What was your worst experience?