I’m hanging out on a cliff with this post… if you disagree with me, you’re not alone! Let’s start a discussion. Comment below and let me know your thoughts.
Pimp (medicine, acronym): “Put In My Place” Pimped (medicine, historical)): to be asked a question you don’t the answer to for the sake of making you feel small and insignificant. Pimped (medicine, colloquial): to be taught something new
The word “pimp” is stupid. The phrase “yo, dawg, he just got his ass pimped!” is also stupid. I think Akash said it once. Doesn’t matter. Recently, medical learners have revolted against the time-old model of medical pedagogy that involves standing in a circle and being quizzed. It shatters confidence and makes people feel vulnerable, they say. It’s for “sport”, others posit. Regardless, it’s application is highly debated by both learners and teachers alike.
Pimping can be bad.
I must admit, it can be awful if done poorly. Pimping has certainly been used for evil. To shame, to “make an example of” or simply to draw delicious tears to feed the maniacal mind of an old-school physician to pompous to think he (or she, but let’s face it…) should occasionally leave his narcissistic mind, are all examples of pimping-gone-wrong. I should say that the most horrifying evisceration of an intern I have ever seen was executed by a female consultant, and at my institution the male consultants seem to be more vile in their treatment of learners and housestaff than the women.
But, ultimately, it is the culture, not gender, that predispose some of the smartest people in the world to pimping in the dumbest of ways. But most consultants, I would suggest, pimp appropriately. It is the learners who need to change.
Pimping can be good.
You see, I like to be pimped. It lets me know what I am expected to know, and whether or not I know it. It has identified flawed mental frames (normal speak: ideas) so deeply installed in my brain that a hurricane could not shake them. It has, quite simply, made me better at what I do.
When done well, the pimper feels like a mentor, a big sister, a teacher. But pimping is often done wrong. It shatters my confidence. It isn’t fun. It feels like the pimper is out to get me, judging me, hating me.
These episodes of “bad pimping” have given a negative to connotation to any type of pimping at all. It seems to me that if someone senior asks someone junior a question, the whole room of learners turns red with anger as their eyes roll as if the questioner were trying to light a fire with flint.
Pimping is misunderstood by learners
Learners, so coddled by a societal shift in education in general, and medical education along with it, feel insulted to dawn upon the idea that they might not know the answer to a question. To summarize what could turn into a rant, learners seem to think the teacher should teach until the learner has learned, that learning is passive. But learning takes work, and I think learners today don’t work as much as the learners of yesterday.
(If you read through the lines, I’m calling modern learners lazy. I don’t mean all modern learners, but I am comparing them to learners of the past, generally. This theory of mine blames societal and cultural shifts detached from medicine; I attach no negative feelings to any learners, past or present.)
Now, there are better ways to create new doctors than lectures, textbooks, and public humiliation. My MedEd Heroes can speak more elegantly than I on this topic (although it is likely to be the topic of a future post, which they will think is “cute”). But to prevent becoming tangential, lets just say that at some point in time a medical learner will need to leave the black-and-white security of a (flipped) classroom and enter the grey clinical environment, where people aren’t textbooks and procedures are harder than YouTube would have you believe. And at that point, someone smarter than you should, must, ask you questions.
Why is pimping essential to the learner?
- To get to know YOU. Each learner is unique. They have unique development needs. You don’t want me treating you like everyone else.
- To diagnose your difficulty and keep you safe. See, most of us make the same mistake as the last learner, and good preceptors can anticipate your challenges. Maybe you think the vein is medial to the artery. (Sometimes it is, like when starting a femoral line, but sometimes it isn’t, like when starting a jugular line). By questioning you, I can get to that misconception, give you a trick or two to fix it, and watch you succeed.
How I make sure I never cannulate an artery when placing a central line:
- To advance your abilities. A house is made of bricks. Adding one brick at a time will help you become a competent physician. If I give you one brick, you can place it on whichever wall needs building right now. If I give you some drywall, you won’t know where to put it yet; it will get wet, or damaged, or you’ll just forget all about it by the time you’re finishing the basement.
- To frame your knowledge. My head has a lot of knowledge in it. None of it is useful at 4:00am during a cardiac arrest. What is useful are the algorithms, mind maps and strange stories I have created to organize that knowledge. When I shock a heart with a defibrillator, I’m not thinking about the joules travelling through the thorax or the cardiac action potential, or sodium and potassium and calcium and actin and myosin and lactate and the kreb cycle. I’m thinking “2 minutes is up, I see VF. Clear!” I became a clinician years after becoming a paramedic when a very smart critical care paramedic named Jonathan Lee drew a triangle on a piece of paper that he pulled out of the garbage can. Five minutes later, shock made sense to me.
- To keep you on track. Because we all like to binge-watch on Netflix.
- To challenge you. If you don’t like it, tell me, and I’ll stop. But I like to be challenged. I like to be confused and unclear and then set off on a mission to figure it out for myself. I like to know “why” or “why not”, the “what if” and the “unless”. I’m so engaged in sorting out my own frames that I’ll call out obfuscation by saying “Wait, but you just said…” This aggressive learning style has gotten me in trouble for being too “confident” or “cocky” or “questioning my attending” but has served me well when it comes to retaining knowledge, recalling concepts and defending my clinical decisions. Be challenged! It makes you better.
So, to all my teachers, peers, students and student-teacher-peers, let’s accept our own weaknesses, drop the sense of vulnerability that we hold dear in our construct of what it means to make a mistake, and learn always. For me, it’s a must, because medicine is way too cool to ignore, and way too important get wrong.
Here is How I Pimp: An example.
Please remember, I used to be good at something else [see above image] before I became a doctor, and I taught others how to do it well. I am not trying to be the PGY1 who tells his senior residents and consultants they have it all wrong; this whole pedagogical philosophy I am sharing is probably outdated and unsupported by evidence, and I look forward to developing it further through the mentorship afforded to me at McMaster.
I’m not the best preceptor, but I have about 20 emerg and critical care topics in my head that are my go-to’s. They translate well from paramedicine to medicine, and can be executed at different levels of advancement depending on my audience.
Here’s an example of my sepsis pimping session, which is accompanied by a sketch on a piece of paper that the learner can take home. I’ve had this conversation with at least 100 learners over the past decade.
- Identify if/what the learner wants to learn
We have a few minutes, would you like to go over any topics?
- Spend a few moments sorting out where the pimpee is at
What can you tell me about sepsis?
- Set up question one for success
Can you think of a few conditions that can lead to sepsis?
- Tell a story as you flow through your pimping questions… lead up to the true message. Foreshadow future questions.
What do all those conditions have in common? *infections
What is the systemic effect of infections on the body? *inflammation
What clinical or lab signs might indicate inflammation?
Now here’s where I get really excited, since I’m a medic! *foreshadow
How does sepsis kill someone? *they got stumped!
- Explore pauses to see if the pause is healthy (is the pimpee trying to recall, do calculus, access memory?) or is the pause unhealthy (is the pimpee anxious, sweating, fidgeting?). Healthy pauses can be prolonged. Unhealthy pauses should prompt redirecting/rewording of the question.
- Have forks in the road you can take if a question is too hard/easy. Apologize/normalize when a question is too hard.
Ok, that’s a broad question, I forgot you were a CC2. *apologize
What’s the difference between sepsis and septic shock?
What clinical or lab findings might lead you to call for help?
- Make it clear you are getting to the whole point of this
Ok, here’s the punchline:
- Do brief teaching. One or two bricks, no more. Use a memory aid.
Septic shock: Think A, B, C! Antibiotics, Boluses, Constrictors
Septic Shock: Kill a Wet Cat! Kill the bugs, Fill with fluid, Catecholamines
- Reinforce the point of the lesson. Get the learner to lead this summary.
Septic shock kills people. It’s important to recognize and treat it early.
- Allow for questions in an open, nonthreatening environment.
Sepsis is complicated, and we went through that quickly. Was any of that confusing? Do you have any questions?
- Give homework or resources.
If you have time, see if you can sort out the difference between cold shock and warm shock. It comes up on exams frequently! There’s a great blog post that explains it.
- Thank and encourage the learner.
Thanks, that was fun! You know your stuff, and you ask great questions. Keep it up! And remember, sepsis is deadly! Kill a Wet Cat!
Total time for me run through this with the average learner: 5 minutes.
How do you pimp? What do you think of my method? How can I improve? Comment below or on facebook/twitter! Thanks!