My first introduction to medical education was via the TV show “Scrubs”. My favorite character has always been Dr. Cox. His classic rants and merciless verbal attacks on JD are hilarious. The teenage me found it wildly entertaining. Now when I watch Scrubs my right eye twitches and I start to sweat. I’m fortunate to have never encountered a “Dr. Cox” during my training, but the tradition of “Pimping” is still going strong, and I’ve endured my fair share of it.
The Socratic method
“Pimping” is the sad knockoff version of a more sophisticated teaching method known as the “Socratic method”. Pimping is the age-old tradition of asking medical students and residents questions with the intent of making examples of them or embarrassing them in front of their peers. The term first appeared in a JAMA article in 1989 but the practice had been around for decades before this. The Socratic method was a teaching style employed by the philosopher Socrates.
Socrates used open-ended, probing questions to help students identify their own knowledge deficits and motivate them to expand their understanding. Using questions, in a non-judgmental environment, he would foster critical thinking among his students. Allowing them space and opportunity to use logic and reasoning as a guide towards more robust philosophical truths.
In medicine, the use of questions to encourage learners to think critically about problems is nick-named the “Socratic method”. It helps to prime their minds for further knowledge acquisition. It is a method of instruction that has been around for a long time. You most frequently encounter it during the clinical years. It is distinct from the traditional didactic style and the popular “problem-based” methods of instruction.
This interesting article published in Journal of General Internal Medicine explores these two teaching methods. Here is one of my favorite descriptions of how Socratic questioning is used:
“An effective use of Socratic questioning is to ascertain learners’ current knowledge and provide a foundation for teaching at a level that they can comprehend. This probing can be done by posing a series of increasingly difficult questions until the teacher finds the limits of the learners’ knowledge.”
The Socratic method helps assess a learner’s understanding or their “fund of knowledge”, as you will see it described on your grading rubrics. It identifies the point at which to begin teaching and can serve as a method of instruction itself.
It’s hard to comprehend what Socratic questioning looks like until you are on the receiving end of it. During my medicine rotation I had an attending who pulled me aside to talk about one of my patients. The patient was admitted for alcohol withdrawal and his blood pressure was climbing to the point where we really needed to do something about it. Through a series of questions, she helped me consider my patient’s admitting diagnosis, the underlying physiology, what we were doing to treat it, and the mechanism of action of several blood pressure medications. At the end of her questioning, I had come up with a solution and experienced how a hospitalist might work through a clinical problem.
Difference between Socratic method and “Pimping”
My attending’s goal was to help me reason through the clinical question. She discovered that I understood enough, then gently guided me in applying my knowledge to figure out an answer.
Much of what separates the Socratic method and “pimping” is the intent behind the questions. “Pimping” is often intended to put learners in their place and elicit admiration for the questioner’s vast knowledge. Or it’s wielded as a weapon to demean or make an example of someone. There’s no intent to instruct, just expose ignorance.
Proper application of Socratic questioning requires careful crafting of a learning environment where students have the opportunity to answer without needing to protect their ego or self-worth.
You will encounter both forms in medical school and residency. “Pimping” is unfortunately quite common. But there are ways to navigate both and come out the other side better off than JD from Scrubs.
“Question etiquette” in the presence of other learners
Grading during clerkships is subjective. You have brief interactions with residents and attendings, so it is imperative that you put your best foot forward. These are my tips for question answering etiquette.
Answer the questions that are directed to you. Do not answer someone else’s question. I know it sucks when they hit you with a ridiculously specific question and then lob an easy one to your compatriot. Keep in mind that the only thing worse than getting a question wrong is trying to one-up your colleagues.
If you know an answer to a question directed at someone else, I’ve found it works best to look to the questioner, smile, and nod once or twice. You will be on deck if the other student fails. And if they get it correct, the attending will know you also knew it. It’s subtle and dignified and won’t make your colleague uncomfortable.
Definitely don’t answer a question asked to a resident. Wait until it’s opened up to the group and even then, employ some tact. You don’t want to embarrass the resident.
Don’t be a question hog. If an attending is throwing out rapid fire questions not directed at any one person, then you should answer a few and then give time for others to answer. Some folks just need a minute to ponder. Try looking around at other students and give them encouraging glances. Read the expressions on their faces to see if they are trying to come up with an answer. Give them time. If they give you the “I have no clue” look, then you can answer. It’s great to be super smart, but it’s even better to help out your fellow students. That gets noticed as well.
Think before you speak. If you don’t know something, you can always say “I don’t know, but I will look that up”. You can write down the question or pull out your phone to look up the information (if appropriate for the setting). Sometimes an attending will ask you a tough question on purpose. They want you to try and work through it. You can talk out loud so your attending can hear your thought process and ask more pointed questions if they know where you are stuck. You can always say, “I might need a minute to think about that one” if you just need more time.
If you get a question and immediately say “I don’t know” without any thought, then it may discourage any further questions. It communicates that you feel threatened by questions or just aren’t engaged.
Never pimp a resident or attending. This has got to be up there with the some of the cringiest things I’ve ever experienced on rotations. Like it or not, there is a hierarchy in medicine. Medical students can know a lot of stuff, but they are not the instructor unless specifically given that assignment.
Anticipate the questions you will be asked
Remember studying for Step 1? You became so familiar with the USMLE style question that you could anticipate where the question was going before you finished the stem. With a little awareness you can similarly anticipate the questions your attending will ask you.
The first thing to realize is that an attending will only quiz you on what they know. Seems obvious, but it’s important to realize. That means obscure enzyme pathways and the minutia of pathophysiology you learned for Step 1 will never be what you get asked. Attendings care about differentials, diagnostic studies, management of disease, mortality benefit, and can’t miss diagnoses (litigation risks). They are years removed from USMLE exams so don’t waste time flipping through First Aid to prepare for rounds.
The next key is to recognize where your attendings get their inspiration. Your patients’ problems are like the Qbank they source their questions from. If you scan the list of patients and identify their most important problems, then you know the most likely subject matter. Just remember that attendings care about diagnosis and management and you’ll know to look up diagnostic criteria, important labs to get, risk stratification calculations, what medications or interventions are indicated, and how you assess response to treatment.
During my outpatient family med rotation, I would get to clinic 30-45 minutes early and browse my first 3-4 patients’ charts to see if there were any items in their problem list that were unique or unfamiliar. I’d spend a few minutes on Up to Date or Google and then blow my attendings away when they would probe my knowledge reservoir. Little did they know that an hour beforehand I hadn’t the foggiest idea what microscopic colitis even was, much less how you diagnose or treat it. The more you practice this the better you get at anticipating their questions. Just like Step 1.
If you’re on a surgical specialty, you will get absolutely hammered during operations and it will be 90% anatomy. Prepare by pulling out your anatomy app/text and find a good YouTube video that shows the procedure and highlights the anatomical landmarks. These pimping questions are the easiest to anticipate. Try to pay attention to which tissue plane you are in, where the blood supply travels, where the big scary blood vessels are, and where the other stuff you don’t want to injure is hiding. That’s at least half of what you will be asked. Here’s a cool laparoscopic view of abdominal and pelvic anatomy I’ve easily watched 50 times here.
Find the right resources
Knowing where to look is probably just as important as knowing what to look for.
One of the very best resources you may have available to you is a resident. They remember what it was like to be a med student. They also have a lot more experience being “pimped” so they can give you clues about what you should know. Several of the seniors I worked with on medicine would “stack the deck” for our med students. For example, they would say “Look up and calculate the Canadian Syncope Risk Score because I’m going to ask you what it is on rounds.” The med student looked like a genius. We have the best Seniors.
Another resource is Pocket Medicine. This is the First Aid of the wards if there ever was one. It is intuitively organized by organ system and incredibly dense. It has everything you need to know about both common and slightly less common conditions you’ll encounter in the hospital or clinic. I highly recommend the pocket size book to always keep with you. It seriously has everything.
If your program has access to Up to Date then I would use this as well. You kind of need to know exactly what you are looking for to use Up to Date though. The articles are long and the answers you’re looking for might be spread out between several different entries. Definitely a good resource for a more comprehensive overview of conditions.
Visual diagnosis is another subscription-based website and app. I used it early on for help generating broad differentials when I had no clue what was going on with my patient. More helpful when completing a history and physical or seeing odd rashes in the clinic.
Google is also a solid resource that’s readily accessible and typically gives you a quick and dirty answer if you need to get some basic info quickly.
For medication stuff I usually use Up to date, Epocrates, or just Google works well.
The USPSTF recommendations are also a great place to go when you are trying to figure out which screenings you should be aware of for your patients. This is very popular quiz material, and these recommendations will find their way onto your shelf exams as well.
How to demonstrate a fund of knowledge if your attending doesn’t ask questions
So, what do you do if you’re rotating at a small community hospital or clinic and the attending isn’t big on the Socratic method? How are you supposed to impress them with all that knowledge you’ve been accumulating over the course of your rotation?
I have encountered this several times. It’s unnerving. You never know if they think you’re too dumb to quiz or if they just don’t like you. What I found to be super fruitful was to show some initiative and demonstrate what I was learning in other ways.
Write short summaries. Whenever I would see something interesting in the hospital or clinic, I would just write up a short summary of the condition, its typical presentation, typical work-up, and management then email it to my attending. I had a semi virtual neurology rotation during the height of COVID and had very little interaction with my attending. I sent him these summaries once a week about patients I saw from our 1 day in clinic. He commented on my review that I was “one of the most engaged and proactive students [he] ever had”. Each of these summaries only took about an hour to do.
Volunteer to present on a topic. On my pediatrics rotation I volunteered to present on the common causes and imaging findings of osteomyelitis in pediatric patients after rounds and I gave a presentation on pyloric stenosis to the MAs and clinic staff during one of my outpatient weeks. Pick topics that are likely to appear on your shelf, so you get a presentation out of the studying you were going to be doing anyways. Make sure you use trusted and established resources for this.
Bring in an article to discuss with an attending. You can show how you are going above and beyond by sharing an interesting paper you find related to the specialty you’re rotating with. Make sure you actually read the article and are familiar with the methods and results. You don’t want to just grab a random article. Also, if the article presents something that challenges your attendings current paradigm you should be ready to discuss the article in a little more depth! This usually starts a great conversation about how the practice of medicine has changed over time.
Give this a try on your rotations and see if it’s helpful. Hopefully you can avoid the Dr. Cox’s of the world. If you spend any significant time in an OR I wouldn’t get my hopes up.