“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.
The thing most disturbing about rotations is that asking questions lowers your grade, makes your evaluation look bad, and can even fail you. How do you expect to learn medicine in this environment? There is a reason you are a student. I have noticed there are gaps in resident knowledge, particularly of physical exam findings, because of this mess. Students are forced to inhibit their own education to try to make attending physicians happy.
Good read.
Though I’ll argue that pimping has its values. As a recent medical school graduate, my experience with pimping was more to learn the hierarchy of the hospital food chain – the medical students were given “softer” questions, then the intern was approached, and finally the senior resident stepped in to finish off the topic. As medical students we observed evolution of knowledge on rounds via pimping. Yes, certain attendings/senior residents also had a belittling attitude and that certainly isn’t helpful, but by and large I thought pimping was a valuable learning experience. Now whether it should be used to evaluate students is certainly debatable; 30 seconds of questioning surely cannot capture performance, but that is up to the evaluator to decide of course.
All in all, the socratic method is an age-old tool in medicine and one which I wish to see carried on.
Abraar, thank you for the article. Yous make many very good points. I would however divide your experience into 2: the questioning and the bullying. I still see value in the questioning.
The Socratic teaching that ensures things are going into you memory that may need to be there at the tip of your tongue and your brain when seeing patients. Things you need to know to even start to look up other things.
And there is the punishment, like “where did you go to medical school” and the like. I don’t think that is helpful. But there are some learners that need a push.
The position of power as a medical teacher is significant. It is easy to bully others and this can be one way. I try to use “pimping” to find out what someone doesn’t know to target my teaching. Hopefully never to bully.
Maybe, Bob: I just think that, independent of its implied educational and character-building aspects the mean spiritedness and arrogance that are the core of “pimping” sets you up for carry over in patient care, making malpractice cases more likely and not less.
And, similarly, will make juries less sympathetic and more willing to find against physicians.
For the love of God get over it. The purpose of “pimping” goes far beyond seeing if you know some vital facts! Wait until these dopes are “pimped” by a lawyer for hours during a malpractice case!!
nerd problems
As someone who graduated medical school 40 years ago I have always hated pimping: it degrades both the pimper and the pimpee and should have no place in the learning environment.
In patient interaction we either work collaboratively or not at all.
To the extent we stand aloof with arrogance we push away both our students and our patients.
Challenge, to be sure, but not with sarcasm, abuse, and humiliation
While you may be right, your comments don’t have a shred of data. Saying that practice should change based on anecdote is sloppy and dangerous. I have no problem with a commentary suggesting an old practice be studied, but don’t push for new practices without demonstrating that the old one is failing and the new practice has some evidence it works better. As an example, work hours restrictions made a great deal of sense, but they were still a bad idea as originally implemented. Unintended consequences bite us all the time. Switching from a “mistakes are bad” approach to a “mistakes are an opportunity to learn” approach is fine, once you show that this yields better outcomes. Personally, I hate mistakes because they can kill people. I am not sure that reducing that profound fear of mistakes would improve my care. Maybe it would, but show me the data first.
Hi Mark,
I appreciate your point, and you’re right that we don’t have data to support whether this culture change would positively affect patient outcomes. I think at the least it would make medical school a more positive learning environment for medical students, which is also important. And these “mistakes” are in the context of learning medicine, rather than taking care of patients (which is more the focus of residency rather than medical school).
I think the thing about “pimping” is a worldwide concern, at least for me. I observed this thing for quite a time already. That’ s why , I discerned that there is a schism between the academic process in the school and the training hospital where the students rotate. Something has to be done about it. Thanks.
What do you think would have happened if you had answered, “Jaundice, right upper quadrant pain, and I don’t remember the 3rd: I think it’s either fever or high white cell count.”?
The reaction would have been the same. Belittling those below you is a poor way of dealing with stress. It shows poor coping skills and is a character deficit.