Pimping Has No Place in Medical Education

Just had this published in the 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 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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  • gta morris

    I attended medical school & post grad training 1955-1963 without experiencing HUMILIATION as teaching method. The origin could reside in an overdeveloped presence of academic competition in college ( or earlier ) where the immature nerds highly value their intellectual skills . These individuals may progress to elevated levels in business and academia politics etc and are not limited to academic medicine. Some have personality disorders. That they are present in medicine is regrettable but they tolerated by the institution for many reasons.

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