I was a third year med student before I found out what pimping was. No. Not that kind, the medical kind. See, the insider slang in medicine for a certain type of aggressive questioning is…well, pimping.
Doc Gurley Med Slang Dictionary: pimping; (def.) verb, as in to pimp; was pimped; got pimped; will be pimped. Used in a sentence “Dang. I can’t believe how badly I got pimped this morning on rounds.”
Being pimped means to be asked serial questions, kind of like being tortured by a 3 year-old who keeps saying “but why?” Except, unlike with the 3-year-old, the person doing the asking is your clinical supervisor. And the goal is to keep asking until you can’t answer. In other words, the goal is, basically, humiliation.
The justification for pimping is that it is a form of education. It is called a version of the Socratic method, although I doubt Socrates would approve. Socrates argued (har) that people learn better when they’re asked questions, rather than being lectured to all the time. Classically, extreme pimping is a surgical rounds event, optimally done to someone after maximum sleep deprivation while surrounded by a crowd of hostile observers. “You. In the back. Can you (smirk) tell us the three surgical approaches to the lesser sac?”
Woe be the person who can’t answer. Or, worse yet, dissolves into tears. It took the young Doc Gurley longer than it should have to realize that your first answer should be the most obvious answer. I would get asked something like “Can you tell us what this patient has?” and the only possible answer (to me), based on the patient’s two-week hospitalization that had baffled eight sub-specialty services and their nineteen invasive procedures, was “uh, no.” Unfortunately, the correct first answer was “This patient has a fever. It won’t go away. No one knows why.” The next correct answer was “A fever of unknown origin can be divided into two categories - true and false.” Sigh.
So what does pimping have to do with you? While it’s probably not the only reason, pimping may be one of the reasons why your doctor doesn’t ask you what you think. Pimping is such a hostile, aggressive part of medical training that many doctors become ask-averse. Well, except for the consummate pimpers, who believe they have the right to pimp anyone. If you get the feeling that you’re being mocked when your doctor asks what you think is going on with your body, there may be some truth to that. Perhaps you are, especially if the question is coming from a certain type of pimping doctor.
For doctors who (like me) despised the act of bullying pimping, I realized that one outcome of the experience is that I rarely asked patients, honestly and sincerely, what was going on - because I didn’t want to seem like I was pimping. One of my goals post-training has been to ask more often than I tell. It’s a shockingly positive thing to do - when done gently and considerately - and a wonderful form of post-pimping-rehab for those of us in recovery from the trauma of medical residency. When you ask someone what they think is going on, the answer can be really surprising. Everything from “I just want to know I’m not pregnant,” to “I’m pretty sure I’m dying” (when he is…). Learning goes both ways when you find out what’s going on inside someone’s thoughts before you launch into your spiel about tests/drugs/symptoms/disease. That’s what Socrates was trying to teach.
Post-Pimping Tips for the Doctor-Patient Relationship:
1) If you’re a medical provider, pick a time period (one month? one week?) and genuinely ask each patient what they think is going on. You may be shocked by some of the responses. Help us all learn by posting what you learned in the comments section below.
2) If you’re getting medical help, try out saying this to your doctor: “You know, here’s what I’m thinking about these symptoms.” And then spit it out, even if you’re not asked. Don’t make the Doc Gurley mistake of believing the only answer is…well, the answer. Tell your provider what you think, starting with the most basic options. If you have a provider who asks you kind questions, trust them and open up - say things like “I’m worrying that it’s cancer,” or “I don’t care what it is, I just want to know it won’t kill me,” or whatever else you’re thinking. Help us medical providers learn by sharing your experiences in the comments section below.
3) If you get a provider who smacks of pimping, as in, “so what do you think is your diagnosis- can you share that with me and my staff? Did you find that on the Internet?” call him/her on it. And then get yourself another provider.
Socrates would approve.
Doc Gurley is a Board-certified Internist physician and the only Harvard Medical School graduate to have been awarded a Shoney’s Ten-Step Pin for documented excellence in waitressing.
21 responses so far ↓
Dr. R // Aug 29, 2008 at 5:49 pm
Get yourself another provider? It would be easier to go find yourself a new philosopher.
Doc Gurley // Aug 30, 2008 at 9:15 am
Change philosophers? I’d love to, but I Kant…
Ian Furst // Aug 31, 2008 at 3:10 pm
good advice to patients to say your want to make sure it’s not cancer — recently saw someone with vague facial pain and spent 1/2 hour trying to sort out weird symptoms when he told me that his father had died of sinus cancer. 1. 99% sure it’s nothing on clinical exam, 2. positive after a CT. Problem solved.
http://www.waittimes.blogspot.com
James // Sep 2, 2008 at 9:24 am
I never agreed with those who say that pimping is a form of education. In the educational sphere, information should be flowing from those with more knowledge to those with less - not the other way around. I don’t learn anything by being asked questions, I learn by being given answers to questions.
Personally, I don’t care much about benig pimped. If I don’t know an answer, I have no qualms about saying so. But what aggravates me to no end is being hit with a question in response to my question.
Snogger // Sep 2, 2008 at 11:17 am
Boo hoo. I put up with crap like that in law school for three years. Cry me a freaking river.
Doc Gurley // Sep 2, 2008 at 12:51 pm
Ah, besides the fact that you undoubtedly went home to sleep each night and were allowed to pee when you wanted, the bigger question remains - is the point of law school to prepare humans to sit and hold the hand of a weeping, dying person in the ICU? Or is pimping actually a good hostile-witness occupational skill for lawyers to acquire?
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Ben // Sep 2, 2008 at 3:52 pm
Don’t you think the problem you have with pimping is related to ego? If you don’t care that you don’t know the answer to a question does it matter as much if it you get the question wrong? I was pimped old school in morning report for years but at the end I knew that it didn’t make me a worse doctor for not knowing the answer it just meant that I was inexperienced and still learning. When someone lectures and you just sit there and listen my eyes tend to glaze over. Asking questions demands active participation in the learning process. Pimping can be done non-aggressively and contribute to a resident’s/medical student’s education in a good way.
Signout // Sep 2, 2008 at 4:04 pm
I dunno–I kind of love being pimped, and I’m definitely not the kind of resident who always gets questions right. I feel that a good teacher tries to find out how much I know, and helps me identify gaps in my knowledge before helping me fill them. The quickest way to do this is by asking me–or pimping, or whatever you want to call it–and going from there.
It’s a little different in a group setting, I guess–no one likes to look stupid in front of others–but recognizing that there are lots of people who don’t know everything is an important part of medical education, and learning to say “I don’t know,” even when it’s embarrassing, is one of the most important skills a doctor can have. On the evaluations I get from medical students, one of the most consistent positive remarks is that they loved that I taught by asking them questions. But I suppose everyone’s different.
There’s a lot in the delivery of the question, and the response to “I don’t know.” Rarely is humiliation justified, and never in front of a group. If the goal is really to teach, learning shouldn’t be a painful experience.
mike in tn // Sep 2, 2008 at 5:08 pm
It can be brutal. It’s been 20 years since med school, but I still remember the horrible feeling.
I think it also why we don’t like to say “I don’t know” in response to a patient’s question, though it would be true quite often.
What is the optimal way of teaching med students?
I don’t know, but humiliation probably shouldn’t be part of it.
Medical students might be the most motivated people on the planet - let’s try to harness it for good instead of producing hard shelled bastards. Like me.
Robin // Sep 2, 2008 at 7:47 pm
Thanks for the tips, Dr. Gurley. I think this is a good thing for patients to realize. Now, how does one ask his/her doctor if s/he’s pimping. Oh, boy…..
Adrienne Zurub // Sep 3, 2008 at 6:42 pm
My Gawd! You are so wonderfully human and funny!
I love your definitions and examples.
For a brief shining moment…albeit brief…I think I understood that perhaps a doctor(s) could have PPSD (post-pimp stress disorder) as a result of these experiences thus affecting dealings with patients.
Great post-pimp advice.
Adrienne Zurub
http://adriennezurub.typepad.com
Okey // Sep 6, 2008 at 8:02 am
Sounds like whinning to me, Gurley.
Med school should be tough. Practicing medicine is not for wimps. Law school (which, like most of academia, is restricted to the classroom) cannot compare to the rigors of med school. MS is a fatigue-inducing gauntlet in the 3rd and 4th year… an apprenticeship that is subject to a lot of personal style of the supervising doc. Then to residency, a new level of mental, physical, emotional marathon running. It’s all Navy Seal training of the mind.
Man up, dude.
John Paul // Sep 7, 2008 at 7:47 am
Having been a program director for years and seeing how the pimping “whiners” perform in real life, I must say that it is reasonable way of testing “situtational medical knowledge”. The whiners are usually folks who do great at tests but have a hard time applying that knowledge to the care of their patients. But I admit that the pimping needs to be done in a profesional manner and not what is often seen on some surgical services.
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PinchingAbe // Oct 2, 2008 at 12:47 pm
This is an interesting subject. In today’s age, patients wait an un-Godly amount of time to see a doc and then you feel like you just drove through McDonalds when you are finished. Having been told at one appt. that “you get one complaint” I became incensed. Really, just one? How then does the doc figure out what is wrong with me then? I think coaching the patients to hold back information is a bad plan. Many times symptoms are related or more obscure symptoms to a condition.
Then you have the docs who get upset with patients asking questions on their way out the door. Very rare do you get a doctor who asks you if there’s anything else you’re concerned about.
As for patients cyber diagnosing themselves… I recently asked my obgyn if I had a hernia… symptoms fit. But turns out it is a cyst that may need removed. Yeah, I was wrong, but my ego isn’t hurting (just something else!) but it was a great way to open a discussion about what was going on with me and that it was serious enough that I wanted a yes/no answer to be able to quit wondering about it.
Atticus Osler // Dec 4, 2008 at 11:28 pm
While the tone of Snogger’s comment indicates what can happen to your attitude in law school [after three or four years of actually being expected to show up for class and being prepared to answer in front of a large classroom as well as take your own notes as opposed to a "lecture note service," and taking all essay questions on exams rather than multiple choice and multiple multiple choice] law school is still being asked to do the humanly impossible or develop all kinds of strategies on how to appear to be doing it until you can. Sleep is not that abundant to the earnest law student, either.
We have used the term “pimping” indiscriminately, and many times it is not intended to humiliate, it is just taken that way by fatigued, overwrought, sensitive, or new-to-the-exercise medical students. Sometimes it is taken that way by the calloused and the cynical-about-everything student or resident. There is usually a touch of that before many enter medical school, you can’t blame it all on the training. (You may more rightly blame it on years of playing the game of dollar-dollar-who’s-got-the-dollar “managed care” or “third party payor,” and the use of the term “provider” and other devaluation of the physician).
Having seen some of the other side, I find that a defensive or cynical attitude is rather unjustly blamed on the law profession and the fear that it engenders in many doctors. Comparing the two professions, I note that law has a built-in respect for its history because it evolves gradually, even with the legislatures passing new laws all the time, as opposed to becoming medical knowledge and techniques 50% obsolete every 5-10 years. Medicine denigrates its own spiritual heirs, considering their methods ignorant and antiquated (because duh many occurred in antiquity).
As opposed to a doctor not wanting to admit not knowing, many specialists with personality, as well as I, a primary care “provider” bouncing from room to room before everybody starts coming out of the rooms and staring as I rush up and down the hallway, have many times put on an intended-to-be-obvious dumbfounded or exasperated body language and said, “I don’t know”! when asked what is wrong or what are we to do. It often immediately disarms the patient into a relaxed and chuckling partner. If it does not, I then say, determinedly, “but we’re gonna find out.”
In my Spartan medical school, it was actually stated as a principle: “You can’t not know.” I took that to mean: “Be as sharp a clinician as soon as you can, because you’re going to need it out there.”
Having sat in on many trials before I started law school, I saw many attorneys putting their arm around their client, in a show of support and caring. Many doctors don’t even touch their patients anymore. In spite of the mean, steely, greedy stereotypes in both professions, do not judge the law profession until you have known a competent but kind lawyer. Their insisting that they get $250 an hour is a fair warning for involvement in your unfortunate life and is no worse than your office staff’s second question being, “well, what kind of insurance do you have?”
Amy Hengst // Dec 17, 2008 at 4:59 pm
From a patient’s perspective, thanks for your explanation of one reason doctors might be averse to just admitting when they don’t know something, or asking the right follow-up questions. It took me years coping with asthma, repetitive stress injuries and strange foot pain to learn that I had to give the doc as much info as possible if I wanted treatment. And I learned that only *maybe* would they have an answer, diagnosis or appropriate treatment. I finally found a great doctor–one who was attentive and knew when to send me to a PT or specialist! Now I am healthy again at last.
Doc Gurley // Dec 17, 2008 at 8:01 pm
Yeah! Sooo glad you found someone. Be well,
Doc Gurley
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