The Art of Pimping

I am NOT talking about managing sex workers.  In 1989, Dr. Brancati published a tongue-in-cheek article in the Journal of the American Medical Association titled “The Art of Pimping”.  It is a true classic which I think anyone bound to be a specialist would enjoy.

Pimping is the term used when the senior clinician asks those on the team a series of questions.  Pedagogically, it is intended to encourage Socratic thought and discussion.  It determines the knowledge level of the students (and interns and residents) to allow more specific, targeted teaching.  It ties basic theoretical knowledge with practical clinical knowledge.

The usual format goes something like this:

  1. Discussion of a case.
  2. Senior clinician poses a question, typically to the entire team.  Some examples from my recent rounds sessions:
    1. “Does anyone know why we might want to avoid acepromazine in this patient?”
    2. “What do you all think may happen when we give this 2-year-old Labrador midazolam?”
    3. “Why might we prefer propofol over alfaxalone in this case?”
  3. Silence ensues as people reflect on their knowledge and attempt to formulate an answer.  I personally tell students that I can outwait them, and will let the silence stretch uncomfortably long, particularly if I know they know the answer (e.g. “What’s typical normal blood pressure in an awake dog?”).
    1. If the question is a little challenging, I may go ‘up the ladder’ and ask the intern or- if they don’t know- the residents if silence stretches for very long.
  4. Eventually some student puts forth an answer, often in the form of a return question because they are unsure in their answer.  If it isn’t exactly correct, I’ll try to shape it to provide a learning opportunity for the team.  Some examples:
    1. “Acepromazine isn’t reversible?”  “Yes, that’s a very important consideration when deciding on selecting acepromazine, but I don’t think is relevant to this particular case.”
    2. “It may not get sedated?”  “That is true!  And, moreover, it may get particularly excited.”
    3. “Propofol is less expensive?”  “Actually, on a mL-per-kg basis, propofol and alfaxalone cost about the same, even though propofol is less expensive than alfaxalone on an mL-per-mL basis.”
  5. If the answer is correct, I will try to provide some positive commentary and possibly lead into further discussion.

This structure may be anxiety-inducing (particularly for introverts or shy people), but I believe it is a valuable tool.  In addition to the reasons noted in the opening, pimping:

  1. Mimics your clients.  Although clients may not ask as technical questions as the senior clinician, they will certainly ask you questions to which you need to have answers.  Developing this answering skill will prepare you for the exam room.
  2. Tests your knowledge.  If you don’t know the answer (or if you can’t hazard a guess), that suggests you need to study that topic more.  If you routinely have no idea what the answer is, that strongly suggests you need a lot more study time.
  3. Provides opportunities for discussion.  Answers (correct, partially correct, and incorrect)  provide learning opportunities to help clarify important points.  The back-and-forth also encourages subsequent questions from students which can improve their individual understanding.

Pimping sometimes has a negative connotation and does indeed have a dark side.  Asking clinically insignificant questions, obscure esotera, and similar impossible-to-answer questions can make students feel incompetent and worsen their sense of self-confidence.  Indeed, in Brancati’s farcical article, he says “Proper pimping inculcates the intern with a profound and abiding respect for his attending physician while ridding the intern of needless self-esteem.  Furthermore, after being pimped, he is drained of the desire to ask new questions- questions that his attending may be unable to answer.”  Obviously, pimping, like any tool, can be used for good or for ill.

On occasion I do ask a question which is difficult, but I honestly don’t expect to get an answer.  Some examples:

  1. “Does anyone know why dogs with portosystemic shunts have a hemogram consistent with iron deficiency?”
  2. “Any idea what we call the reflex which causes the heart rate to go down after ligating an aortic aneurysm like a PDA?”
  3. “Any of the residents know what metabolite of atracurium can be associated with seizures?”

To be clear, I don’t ask these questions to humiliate anyone and I try to make it clear this is esotera.  Some of the information the senior residents should know for boards, but I make that clear, “This is ridiculous information you should know for boards but has no clinical implication.”

Brancati notes two dangerous responses to a pimping question: the dodge and the bluff.  I have seen students, interns, and residents use both of these strategies.  Dodges typically manifest as the student asking a different question.  I have no problem with this- I love it when students ask questions- and I use the question as a learning opportunity.  But I get back on topic.  

The most common bluff I see is feigned erudition, where a student provides some answer which is, in itself, esoteric and not answering the (usually clinically relevant) question I am asking.  I suspect students (and interns and residents) do this to appear knowledgeable.  In some residents, it does reflect a deeper understanding, which I appreciate.  But when students start going on about coronary steal phenomenon, I know they’re just trying to appear knowledgeable and may not know the practical clinical knowledge I want them to have.

Some students seem to focus on and crave esotera.  Esotera is often distinct, definite, and manageable.  It is facts.  Clinical medicine is fuzzy.  We often don’t know the answer.  We have to make educated guesses.  I think some students are intimidated by that and seek refuge in certainty and data.  I try to encourage them to focus on clinically meaningful information.  I’ll often say something like, “I appreciate your depth of knowledge.  I want to make sure you have the important clinically-significant information down before exploring that depth.”  Most specialists love esotera, but we realize we aren’t training specialists- we’re training general practitioners.  We need to focus students on what is clinically relevant and what they will see in day-to-day practice.

The art of pimping is not taught directly- it is taught by example.  Just as one might watch someone dance and attempt to mimic the movements, so most instructors learn pimping.  New faculty have a tendency to ask esoteric questions but, as they gain experience in this art form, their questions evolve to clinically meaningful ones.  Pimping is not intended to undermine, dismiss, or invalidate students.  It can be a valuable, useful skill for elevating everyone’s knowledge.

What do you think?  Have you ever been subject to an “aggressive” pimping?

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