More On Pimping

CCpg5WPXIAAUrls.jpg_largeSince publishing my essay”Pimping Has No Place in Medical Education” on the BMJ blog the other day, I have received multiple tweets, and emails and comments about it. Most have been supportive. Some have been surprising. It is interesting to me that some physicians defend –  albeit sheepishly – the practice. Even some students and trainees I have talked to say that well, maybe they learned something because of being embarrassed or humiliated by a preceptor or mentor.

So I wanted to respond more fully. Consider, for example, one physician who is really a super guy and involved in rigorous efforts to try to change hospital culture for the better. He told me that he thinks that pimping is unacceptable when done maliciously, but not so bad if the attending presents the student with questions of escalating difficulty with some humor. This, he believes, can aid learning and be fun. My response  is twofold. First presenting students or trainees with complex questions that elicit what they don’t know and help them to learn it is not “pimping.” It is questioning, which is entirely different.

Second: Can we be sure that what we as “experts” regard as humorous and fun, is actually received that way by the novice?  We have to remember that these novices are often terrified of us and pretty much everything else. They are afraid of showing that they don’t know something – and in this culture where “pimping” is still considered to be a legitimate pedagogical strategy–  have probably been embarrassed by some attendings who utilize it freely. So how can an attending who intends to be humorous and fun be sure that his/her lessons are taken that way by someone who may have been deliberately humiliated the day before by someone with less noble intentions?  We always have to be aware of the power of negativity bias — the brain’s tendency to register negative experiences more strongly than positive ones and thus to be scarred ( rather than elevated) by them. Please read the literature on this.  It’s important!

I think we have to all remember that people may not be aware of our intentions and our goals – unless they are explicitly stated.   I know that I have often discovered that people are intimidated by some of the ways I have taught or asked questions when I thought I was being perfectly un-intimidating.  At least in my case, it just goes to show that as brain science is now documenting, we are often very poor judges of our own behaviors. (Daniel Kahneman’s Thinking, Fast and Slow is essential reading to understand this.)   I am also sure the physicians who I felt dismissed or put down by in my vulnerable state as patient may not have had a clue that they were intimidating.  I am not arguing here for PCness but just for more reflective and just practice and education.

I also think we have to consider whom we are serving when we teach or lecture or question. Is our major concern with what the student/novice/learner is learning or is it with our own performance? When we are trying to be entertaining or humorous, whose needs to we serve? Are we really engaging the learner, or showing how clever and knowledgeable we are?

To end on a positive note, I have spent much of the last six months at the Veterans Health Administration Hospital at Fort Miley in San Francisco and Jamaica Plain in Boston watching attending physicians, nurses, nurse practitioners, social workers, psychologists, pharmacists and chaplains (to name only a few) who work in primary care, geriatrics, palliative care and neurology precepting residents, and other health professional trainees. And I have been deeply impressed by their pedagogical style. I have never once seen anyone embarrass a trainee. Not a single time. Instead, after watching a trainee with a patient, a preceptor always begins by asking the trainee,” What did you do well?” and listens to the answer. Then he or she asks what they could improve and listens and advises. When questions are asked to ascertain the learner’s knowledge, questions are asked in an entirely non-judgmental and curious tone. What would you do? What do you know about…? These questions contain an invitation: What would you like to know? What would you like to learn? What do you need to know and learn? How can I help?” What is also impressive  (I will write about this more later), is that preceptors  themselves learn or refine skills in how to do Motivational Interviewing  orthe science and art of giving remedial feedback, (for more on this see Chuo’s Remediation in Medical Education). This creates a very different experience than that of “pimping.” This should be the model in all of education, whether healthcare or more general education.  In medical education, perhaps it’s time to apply the gold standard to pedagogical practice and test the assumption that even gentle pimping is kind of okay.  What we need to find out is what trainees really learn from even moderately embarrassing pedagogical practices — the facts or never to admit that you don’t know, need help and are not infallible?

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