The senior medical student is hours into her on-call shift on her surgical rotation. She’s been up since four, exhausted, and can’t remember if she had eaten anything since breakfast. The staff surgeon on call “pimps” her on surgical anatomy, pointing at the various arteries and veins in the patient lying in front of them on the operating table. The student has difficulty remembering the various arteries and nerves while her stomach is grumbling, trying to stay alert. In response to the continuous line of questioning, she responds, “I’m not sure of the answer. I will make sure to look it up later this evening and study it tonight.” After a barrage of questions, the staff surgeon turns to her and says, “It is a privilege to be in this OR. You clearly don’t know your anatomy. Scrub out.”
Pimping, or repeated questioning, is often seen as an important teaching tool in medical education. There is a thin line between questioning as precipitating learning and questioning that leads to humiliation. Pimping is baptism by fire.
Humiliation is an unethical teaching tool and can elicit cognitive dissonance in learners. Students care deeply about the opportunity to be in the clinical arena and can be surprised to discover that the degradation that is permitted is contrary to the behavior taught in medical school and often in opposition to their beliefs about the profession. Many physicians remark that pimping is a rite of passage, taking the lead of teachers that utilized the same distorted Socratic method. Generations of physicians relay the same themes that have been tolerated through this mode of teaching: public embarrassment in front of peers, colleagues, and patients, an opportunity for degrading comments, palpable fear that elicits silence in lieu of educated guesses and reaffirming the medical hierarchy and gender disempowerment.
It is generally accepted that the hidden curriculum is as potent as the formal curriculum in medical education. Through modeling, physicians teach the requisite traits of moral medicine. Informally, most physicians do so by demonstrating quality bedside manners, treating colleagues and learners with respect, and displaying how to navigate difficult situations. If not cognizant, physicians can also convey inappropriate traits tolerated in the treatment of patients, colleagues, and learners.
In the “Formula of Humanity,” Kant states: “[To] act that you treat humanity, whether in your own person or in the person of any other, always at the same time as an end, never merely as a means.” Moral discourse maintains that treating people solely as a means is unethical. Medical students are often tasked with writing admission notes, completing physical exams, and answering repeated questioning. These means are often utilized to enhance the field of medicine by generating more knowledgeable and experienced physicians and ensuring future patients will receive better care. But when the means cannot create those ends, then students are used solely as a means. For example, students that are unheard, disrespected, or humiliated through pimping, often learn less, become disillusioned with the field, and end up being worse physicians.
While pimping has historically been a tool to promote long-term knowledge and teach students how to respond under pressure, research shows that pimping doesn’t motivate students positively. More importantly, knowledge gained through repeated questioning is not processed as long-term knowledge. For students that are incentivized by pimping, the motivation becomes impressing preceptors and avoiding ridicule and shame. This repeated questioning most often leads to disengaged students, shame, and embarrassment, all of which do not enhance the field of medicine. More knowledgeable physicians and ensuring future patients will receive better care are not the outcomes. As a result, the ends are unsurprisingly unfulfilled.
Besides repeated questioning causing students to be utilized as a means and an unethical teaching tool in and of itself, pimping can induce moral injury. On the receiving end of repeated questioning, students are exposed to behavior that goes against their own moral values and beliefs. More so, most students are unable to speak up due to the pervasive medical hierarchy. Students must weigh moral injury with the consequences of speaking up. This can manifest as a bad evaluation, comments made to other physicians, and a potential decrease in opportunities. Not only can physician-educators induce moral injury in the environment they create for students, but doing so abandons the fiduciary duty owed to students.
As medical students progress through rotations, they are sampling what life in that specialty will look like. They are sampling the culture, what the specialty tolerates, and what behavior is permissible. On the other hand, preceptors that are passionate about their field, have the drive to teach, respect learners and colleagues, and exemplify the traits of the physician students wish to be, have a great impact. Questioning on treatment plans, medications, management, and admissions is necessary for medical education, but not in the enclave of humiliation.
Moving away from repeated questioning as humiliation to appropriate methods of quizzing as sparking curiosity and promoting learning is essential. When students know that physician-teachers are not utilizing questioning to maintain a power differential, students are then able to push past their comfort zones and excel in medicine. More so, feeling safe enough to challenge oneself in medical situations and embrace uncertainty is what makes better physicians. While the one constant of medicine is that the field is continuously and rapidly changing, I think it’s time that pimping does too.
Elisheva Nemetz is a bioethicist and medical student.
