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I completed my medical school and background EM training from India (Christian Medical College, Vellore and Apollo Hospitals, Hyderabad) where I worked for 4 years. Following this, I devoted (with all my heart) about 1.5 years to do US Medical Licensing Exams. My stint towards an EM Residency in States did not work but it took me to places and it has been quite a journey. I then relocated to London, England to work as a Registrar (Non-Trainee) in A&E. This gave me an opportunity to better understand NHS, EM training pathways and more importantly the EM Mindsets in the United Kingdom. 

Currently, I am pursuing Higher Specialist Training in Emergency Medicine at South East Scotland Deanery where I have the honour and privilege of training under some of the most innovative brains in the field of Emergency Medicine. Over the past few years, I have realised that LEARNING and UNLEARNING (which can be challenging!) is equally important to deliver cutting edge care to our patients.And through this blog, I aspire to disseminate knowledge, assist trainees with exams and stay up to date with contemporary EM literature. I have always been an avid FOAMed supporter because FOAMed has always played an indispensable role during my training. 

Lakshay Chanana
ST4 EM Trainee 
Edinburgh, Scotland

Monday, July 6, 2015

Are you a good or bad PIMP?

What is pimping in Medical education?
In medicine, 'Pimping' refers to a more knowledgeable person (pimper) questioning others with less experience (pimpee) to test their knowledge. For example a students who has been questioned may say "Dr. XYZ pimped me about the Autonomic Nervous System today". 

Pimping is a thin line between education and bullying. You can look at PIMPing as an opportunity for the seniors to humiliate the junior members of their team OR as a valid educational tool: a provocative method that might help students to think and retain the knowledge. I call that good pimping.

But trainees very often report back, complaining maltreatment by seniors (Registrars, Attendings), that too in front of patients and colleagues during the grand rounds. Some seniors make nasty comments and justify that by saying that "the trainee is going to remember that forever" and thus is unlikely to make the same error again. So they say "Pimping did not hinder, it helped"

Though pimping and socrates method look similar, there are differences between them. Pimping (or Bad Pimping) often uses the power of status to embarrass and humiliate the learner in a group environment. The goal of pimping is evaluative and thus answering questions becomes a competition. Often, rhetorical questions are asked.  Students might be asked about vague facts of certain diseases, or faculty can push students by questioning them about something challenging beyond the normal expectations. With this approach students might walk away in shame and embarrassment if the don't come up with the correct answer. Many, also consider pimping to be an abusive type of questioning. 

Socrates Method of teaching
Pimping somewhat resembles the Socratic method of teaching through questions and answers rather than a lecture kind of teaching. Socrates method of teaching involves discussion between individuals, based on questions and answers to stimulate critical thinking and to illuminate new ideas. When using Socrates method the goal of the question is known and follow-up questions lead the learner to solve the problem himself using his baseline knowledge. Its focus is on diagnosing the level of the learner and then teaching them appropriately.

Is pimping good or bad?
In recent years pimping has been looked down by some in medical education because it involves embarrassing and humiliating the medical students. Students and trainees develop negative associations with group learning methods and after start avoiding the pimp (Registrar or Attending). If they don't come up with an answer, they are made to look like "fools". However, pimpers argue saying that some amount of stress as a result of pimping can enhance the performance of learners because it gives them a fear of being put to shame and humiliation. 

If you are pimping, make sure that the questions asked are focussed, make sense, must follow up with other thought provoking questions and an explanation should be provided if no one comes up with the answer. Almost always when we ask a question as an educator, we already know if the learner knows the answer or not! So, Students do benefit from pimping, rather I should say "good pimping".

  • Trivial facts
  • Evaluative
  • Rhetorical questions
  • Passing humiliating comments 
  • Embarrassing students
  • Incessant use of questions
  • Pushing the learner to his emotional as well as intellectual limits.

  • Focus is on concepts
  • Connects the new knowledge with existing knowledge
  • Questioning always starts from juniors, only then passed to the seniors 
  • Reframes the questions
  • Encouraging the learner to achieve his highest level of clinical reasoning
  • Offers an explanation and emphasise important learning points
  • Praise them
Surprisingly, a survey of medical students revealed that more than half like "being pimped" and even said that they would also pimp when they climb up the academic ladder though most of them made a distinction between good and bad pimping. So, Attendings and residents should feel free to pimp,  just as long as they are not demeaning or insulting. 

Key Point: It is okay to "pimp them" but don't be mean!

Further Reading:

  • Brancati, FL. The art of pimping. JAMA. 1989;262(1)89 
  • Detsky, AS. The art of pimping. JAMA. 2009;301(13):1379-81

Last week, one of our Trauma experts/ Prehospitalist and Resuscitationist (Dr. John Hinds) passed away in a road crash in Dublin. I never got an opportunity to meet him personally, but heard him few months back on emcrit.org and was totally amused with the kind of work he did. My heart felt condolences with his family. 

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