The Pedagogy of Pimping Educational Rigor or Mistreatment

Pimping has a bad name. In medical education, the term is saddled with negative and malicious connotations, regardless of the intended meaning. Derived from the German Pumpfrage, it has nothing to dowith findingcustomers for prostitutes but instead refers to the practice of a teacher asking a student a series of questions.Therelationofmedicalpimpingto thebroaderquestion of studentmistreatment suggests that this association of homonyms, while unfortunate, is not purely coincidental. In the current issue of JAMA, George and Green1 describe theresultsof theircreativeuseofgraphic imagery—cartooning— to prompt senior medical students at Penn State College of Medicine toportray their experiences inmedical school.Of the 66 students in their Comics in Medicine elective, 47% drew horror-genre cartoons,with scenes of darkness, demons, and death perpetrated by supervising physicians. Although not specifically referencingpimping, theydescribehow“possessing too little information” factored into at least 1 sceneof a student’sbeheading.Theauthorscorrectlyobservethat thesecomics convey the students’ perspectives farmore viscerally than do their survey responses to the2015AssociationofAmerican Medical Colleges’ GraduationQuestionnaire, inwhich almost 40% of 13 886 medical students reported at least 1 form of mistreatment.2 Theauthors’ approach is simultaneouslydiagnosticandtherapeutic.Althoughthestudents’cartoonsarenecessarilyhyperbolic, togetherwith thedata theyaredisturbing. Alsointhis issueofJAMA,McCarthyandMcEvoy3 lookmore directly at the question of pimping, both as amethodof teaching and in relation to studentmistreatment. These authors acknowledgemedical studentmistreatmentasasignificantproblemanddrawadistinctionbetween“benign”and“malignant” pimping. They point out that the few existing studies of pimping have focused on the lowest Kirkpatrick-level outcome, the learner’s reactions, rather than higher-level outcomes such as changesinlearning,behavior,orpatienthealth.However, incontrast tothedarkcomic imagesofeducationalexperiencesdrawn by the students of George and Green,1 these authors cite several articles inwhich students gave favorable responses to certain formsofpimping.Although theyquestion the reliabilityof surveysofavulnerable researchpopulation, theauthorscall for more research on pimping to preserve its educational potential in the face of increased awareness of, and need to address, studentmistreatment. Canpimpingeverbegood, or is it studentmistreatmentby definition? In their 1989and2009commentaries,bothentitled “TheArt of Pimping,” Brancati4 andDetsky5 both implied that pimping, if done artfully, has value. Whereas Brancati’s bemused and ironic informal advice on pimpingwell was provided for attending physicians, Detsky, writing in a more student-centric era, also included advice for students on protecting themselves against pimping. Detsky was more cautiousabout thepotential harmsofpimping, counselingattendings to apologize if they inadvertently inflict embarrassment. Wearetal6providedmoredetailedviewsof thebenefitsand potential harms of pimping in their qualitative study characterizing the interview responses of senior medical students. Theydescribedhowpimpingcanallow teachers to assess their learners’ knowledge base and then gauge their further teachingaccordingly.Thestudents in their studydescribed thevalue of pimping in learning to think quickly, handle the pressure of the spotlight, and develop stronger spines. One student even identified acculturation to the medical profession— “becoming part of the society and... able to talk to your colleagues”—as a positive effect of pimping. Students identified “malignant” pimping by its intent to reinforce hierarchy, serve the ego of the teacher, and humiliate the student. One student reportedly saw value and motivation to learn in the humiliationofnotknowingananswer,notingcolloquially,“You have to kick people’s butt once in while.” Healy and Yoo7 reiterated this latter view. These authors acknowledged thedark sideofpimping that appearswhen the teacher’s motivation is not educational, but they saw “highstress, rapid-fire questioning that quickly imparts knowledge... inahighlymemorableway”as “truly a long-termkindness to the student, much like a vaccination that creates temporary discomfort to achieve a durable gain.” Kost and Chen8 rejected this sentiment and its terminology.Respondingtothenegativeculturalassociationsoftheword “pimping,” theyproposed that the termbe reserved strictly for behavior with negative connotations, specifically “questioningofa learnerwith theexplicit intent tocausediscomfort such as shame or humiliation as a means of maintaining the power hierarchy inmedical education.”Theyadvocated formoreconstructive formsof teachingbymakingquestionsmorepurposeful; more truly Socratic in aiming to activate critical thinking; and more grounded in adult learning theory, which considers the importanceofasafe, respectful, andsupportive learningenvironment. They argued unequivocally that pimping, by their definition, must be abandoned. In recent decades, the culture of academic medical centers has made significant strides toward becoming more respectful of students. Yet if a significant proportion of stuViewpoints pages 2345 and 2347 Opinion