“How would you determine if this patient has a pure or mixed high anion gap metabolic acidosis (HAGMA)?”
This was the question posed to me and my co-medical students by my attending (who I had met 3 minutes earlier) in front of two senior residents, two interns, and a nurse at 7:30 a.m. this March, during particularly hectic inpatient medicine morning rounds. Having taken the USMLE Step 1 exam just a few months prior, I should have been up to speed on my nephrology and answered quickly. Yet, frozen I stood. Perspiring in my embroidered medical school Patagonia jacket and feeling the windowless walls closing in on me, I realized I had just had my first introduction to a time-honored tradition of medical education: pimping.
The answer to the question would come readily to most attending internists: calculate the delta-delta, which in this case revealed a mixed rather than pure HAGMA. For me, however, the significance of the moment lay less in the calculation than in the discomfort of not knowing it. That emotional jolt drove me to study the concept with an intensity no textbook passage or Anki card had elicited (as the Yerkes-Dodson law predicts). Nephrology may never feel intuitive to me, but I am unlikely to forget the delta-delta again.
Pimping has been part of medical education for generations. Television shows like “Scrubs” and “Grey’s Anatomy” have popularized it among the public. Yet, outside of the fictional sphere, the practice is quickly fading.
A 2022 article in the Journal of Hospital Medicine by Benjamin Kinnear, MD, MEd, and colleagues, as part of the journal’s series “Things We Do For No Reason,” argued the practice is antiquated and toxic. It is important to note that Kinnear et al. do make a distinction between pimping — which is often synonymous with “teaching by humiliation” or “toxic quizzing” meant to induce shame, humiliation, or distress — and asking questions for the purpose of teaching. This delineation is great, in theory.
In the real world, it can be nearly impossible for clerkship and program directors to communicate which questions are fair and which ones are not; after all, most pimping is directly in relation to ongoing patient scenarios, each of which has its own nuances that cannot be easily predicted in guidelines. A senior general surgery resident at a major New York academic program recently told me his leadership explicitly told him and his co-residents they were not allowed to ask medical students questions. It appears that concerns over the harms of pimping have led to a boomerang approach at some institutions, potentially cutting down learning opportunities.
At such a transformational time for medical education, marked by pass-fail curricula and board exams, students are largely insulated from the academic impacts of getting questions incorrect. Thus, there is perhaps no better time to embrace pimping — students should not be fearful of getting questions wrong. Further, there may even be an imperative for real-world question-asking. So much of preclinical medical education is now conducted via online third-party platforms like Boards & Beyond, Online MedEd, and others (rather than through in-person lectures that incorporate real-world experiences of professors) that students may lack clinical context. Furthermore, learning how to rapidly retrieve information from memory is an important skill for budding physicians to develop. Pimping may be a great way to strengthen this ability.
Beyond medicine, the American educational enterprise is at a precarious moment. Rose Horowitch wrote in The Atlantic that professors are “coming under more pressure to tend to their students’ emotional well-being.” This increased attention to preserving students’ delicate temperaments has been partly, if not largely, responsible for grade inflation and weakening of standards. In another piece, Horowitch speaks of a conversation she had with a professor regarding a growing distaste for long-form reading among students, who said, “She [the professor] had to explain — to students at America’s most elite university, taking a course in a discipline rooted in written observation, argumentation, and analysis — that excerpts and summaries cannot capture the depth and sophistication of a complete primary text.”
The ironic banality of such discontentment for intellectual engagement amongst theoretically scholarly young learners is enough to wrench the mind. Yet, the stakes are even higher in medical education. A “bare minimum” mindset in which learning is done solely to clear some predefined threshold (a board exam with enumerated criteria, for instance) may raise risks for future patient safety. Pimping may be a protective mechanism to ensure learning is directly applicable and relatable to patient context.
As a field attracting similarly capable and intelligent students as medicine, law schools are also fielding analogous conversations. Established from the Socratic method, the practice of “cold calling” law students during case discussions is well described as a foundational method for building rapid recall and ensuring preparedness. Legal educators seem adamant about maintaining cold calling. In a debate about abolishing or reducing this practice in 2023, University of Chicago lecturer Adam Mortara wrote, “[judges] don’t let you put up the red light when you don’t want to answer.” Similarly, patients don’t let you pause to check OpenEvidence when they are decompensating.
Returning to Kinnear’s article, I do concur with much of their argument. Toxic educational environments are demoralizing. From a position of authority, asking students to name obscure eponyms is quite pointless, aside from the purposes of stoking egos and enforcing hierarchies. But when mutual learning is the goal, asking open-ended questions and being receptive to upward feedback only strengthens teaching. I fear that the boomerang that medical education has experienced has quieted even well-meaning educators out of fear of reprisal. As students, if we are to expect the best training possible, we owe our educators more.
