“What are the three signs of Charcot’s triad?”
The resident asking the question, a budding trauma surgeon known as having a short temper and an aggressive teaching style, glared at me and a fellow medical student, waiting to see which one of us would come up with the right answer first. The two of us, both third-year medical students at the time, had our heads down, trying to buy some time as we looked at our respective notes. We knew that answering this question incorrectly would mean a lower score on our evaluations for the rotation.
I knew two of the three signs — jaundice (yellowing of the skin due to an accumulation of bilirubin in the blood), pain in the upper right side of the abdomen — and was pretty sure the third was either fever or a high white blood cell count. Feeling more and more nervous with the silence from my classmate, I blurted out, “Jaundice, right upper quadrant pain, and high white cell count.”
I instantly knew I was wrong about the third sign — it’s fever — when the resident frowned, raising her eyebrows in disbelief.
“What do they teach you in medical schools these days?” she mocked before walking into the patient’s room, leaving us dumbfounded in the hallway.
This kind of interaction, commonly known in medical schools as “pimping,” is the use of an aggressive style of Socratic questioning to test medical students’ clinical knowledge while on the wards, in the clinic, and often in front of patients.
Most medical students understandably don’t like pimping, though some use it to differentiate themselves from their peers based on how much they have memorized. Mostly it serves to scare students into silence rather than making educated guesses or admitting they don’t know something.
Pimping affects medical education beyond the clinic and hospital wards. The feeling of embarrassment at not knowing or understanding a medical concept while in front of one’s peers also plays out in the classroom. Every medical student knows the tense feeling of staying quiet when a teacher asks if everyone understands a concept, unsure if they are the only one who doesn’t.
The hesitation to learn through trial and error has become the norm for both cultural and structural reasons. Culturally, having large amounts of medical knowledge in rote memory has been lauded in the medical community for centuries, partly as a sign of intellectual achievement. That was certainly beneficial in the past, when finding information was difficult and time-consuming. Today, though, most facts like the components of Charcot’s triad are instantly at a young physician’s fingertips. Instead of being good at memorizing data, learning how to sift through it and leverage it for the benefit of patients is a far more important skill.
Structurally, pimping — especially when done aggressively — does a poor job of evaluating medical students’ clinical knowledge, plumbing their overall clinical acuity, and identifying how well they are improving. Given the vast amount of information in medicine, asking a few selected, random questions does not accurately reflect the full breadth of what a student knows. The practical outcome of pimping is that medical students tend to answer only those questions they are completely sure about and avoid speaking up when they are less sure. This reinforces the incorrect idea that mistakes are bad, rather than teaching them that mistakes are an opportunity to learn.
Of course, different people have different learning styles. Pimping worked for me — I would be asked Charcot’s triad at least three more times in medical school and never got it wrong again. I admit that getting the answer wrong in front of my classmate wasn’t a good feeling, but it helped me make sure I will get it right when it matters most — when I am a physician caring for a patient who has ascending cholangitis, an infection of the bile duct characterized by Charcot’s triad.
But that’s not to say it is a valid way to evaluate students. My mistake showed that I did not immediately know all three elements of Charcot’s triad. But it did not capture that I learned Charcot’s triad, and never forgot it.
Continuing to include pimping as part of evaluating medical students does not reward them for learning. Instead, it punishes them for doing so by highlighting what they did not know, and uses that lapse to represent their clinical performance more broadly.
That needs to change. Medical schools and those who evaluate medical students must create a culture in which answering questions incorrectly is not used to measure a student’s potential. Teachers should instead ask those questions again at a later time, and see if the student has learned from the earlier error. This is a far more important metric for evaluating one’s preparedness to enter medicine.
The tendency to value correctness above all else affects physicians later in their careers — those who are not used to being questioned or corrected are less likely to have open mindsets to potentially different diagnoses, and are also less amendable to disagreements within teams.
I have come to learn the value of answering a question, or many of them, incorrectly. It has allowed me to improve and learn more as a student, so that one day I can be a better doctor for my patients. But no student should have to feel embarrassed for making a simple mistake. Asking students questions is an important opportunity for clinical educators to help them learn and improve. We must create a culture in medicine that redefines pimping as a way to learn, rather than as a dreaded tradition.
Abraar Karan, MD, is a master of public health candidate at the Harvard T.H. Chan School of Public Health.