The AAMC Graduate Questionnaire has drawn attention to medical student mistreatment. Pimping, a form of Socratic teaching often used in medical education where students are singled out by faculty for questioning, may be considered by some students and faculty as mistreatment. To date, minimal research has been performed on the viewpoints of students and faculty regarding pimping and its relation to mistreatment.
This study aims to formally define pimping and determine if there is a difference in the perception of students and faculty on its role in medical education.
Medical students and faculty of Michigan medical schools were surveyed via electronic questionnaire. Chi-squared and Fisher’s exact tests were performed.
Medical schools within the state of Michigan
Students who had completed their core clerkships and faculty with experience educating medical students in a clinical setting
The student response rate was 42%; the faculty response rate could not be determined. The majority of students agreed with our operational definition of pimping and 100% had experienced pimping. 54% of students reported a positive experience with pimping, 26% neutral, and 20% reported a negative experience. The majority of students reported it was challenging and educational and should be used regularly. Several differences were found between students and faculty as to why faculty use pimping. Students’ perception of their role on the clinical care team influenced their perception of pimping as mistreatment, and students reported pimping made them feel more a part of the team.
This study helps to define pimping and sheds more light on the perceptions of pimping from students and faculty and their differences. Most medical students report a benefit from pimping, even though it may be stressful, and suggest it should be used regularly, which is in contrast to faculty opinion. Pimping may make students feel more a part of the clinical care team, but their role on the team may not influence whether they perceive it as mistreatment. Our data suggest medical schools should educate students and faculty on pimping and not move toward discouraging or banning it.
Implementation of the Association of American Medical Colleges (AAMC) Medical School Graduation Questionnaire (GQ) in 1978 started to reveal how often medical students experience mistreatment in the clinical setting. Since its initiation, medical students continue to report mistreatment when filling out the survey, with the highest prevalence in the clinical setting on surgery and ob/gyn clerkships.
Brancati published “The Art of Pimping” in 1989,
Using the work done by Wear et al, Williams et al
The present study aims to examine the viewpoints on pimping from fourth-year medical students and faculty across medical schools in Michigan. We hypothesized that there would be a significant difference in the viewpoints on pimping between students and faculty. We further hypothesized that students would perceive a benefit from pimping on their understanding and recall of information and that their perception of pimping as mistreatment would be related to their perception of the importance of their role in the patient care team.
This study was classified as exempt by the University of Michigan institutional review board (HUM00146515). The questionnaire for this study was modeled after that of Williams et al,
The target population was all fourth-year medical students in the state of Michigan. Central Michigan University, Michigan State University, Oakland University, University of Michigan, Wayne State University, and Western Michigan University were contacted and invited to participate. Three of the 6 schools allowed us to survey their students, and 4 allowed us to survey their faculty. The sample was restricted to medical students having completed their core clinical rotations (ie, fourth-year students).
Chi-squared and Fisher’s exact tests were performed for categorical data. Statistical significance was determined by p < 0.05. Responses were excluded from analysis if they were less than 30% complete in regard to essential items, ie, all questions not pertaining to demographic information. Responses were grouped for analysis; eg, “slightly positive” and “very positive” combined as positive and the same for negatives.
Two hundred seventy students responded; incomplete (35 with essential items incomplete) and duplicate (10) responses were discarded, leaving 225 responses for analysis. Institutional affiliations were as follows: 121 (54%) Michigan State University, 74 (33%) University of Michigan, and 52 (23%) Central Michigan University. Fifty-four faculty responded, with the following institutional affiliations: 23 (42%) Michigan State University, 18 (34%) Western Michigan University, 7 (13%) University of Michigan, and 6 (11%) Central Michigan University. The student response rate was 42% based on institution-reported class size. An estimated 940 students met inclusion criteria at the time of this survey, making our sample 24% of the target population. Faculty response rate could not be calculated due to institutional uncertainty or inability to report faculty numbers. For our student sample, 86 respondents (38%) identified as male and 135 (60%) as female, with an average age of 26 years. Regarding race, 149 students (66%) self-identified as white or Caucasian, 31 (14%) as Asian, 13 (6%) as Black or African American, 9 (4%) as Hispanic, and 20 (9%) as other.
Of 225 student respondents, 156 (70%) agreed with our definition of pimping, while 20 (11%) disagreed and 43 (19%) had not encountered this term before. In comparison, 35 faculty (65%) agreed with our definition, 9 (16%) disagreed, and 10 (19%) had not previously encountered this term. All of the students had experienced pimping as defined in our study. The survey found that 203 students (90%) experienced pimping in one-on-one and group settings, while 25 (10%) only experienced it in a group setting. Seventy-six percent of students reported that they experienced this on a daily or weekly basis during clerkships. Nearly all students (95%) witnessed someone else on their team experiencing pimping, most commonly other medical students and junior residents and rarely fellows or senior residents. From the faculty standpoint, all respondents experienced this form of teaching during some point in their medical education, either as a medical student or a resident.
Just over half of student respondents (116; 54%) reported a very positive or slightly positive perception of pimping. The remainder were nearly equally divided between a neutral view-point (56; 26%) and slightly to very negative perception of pimping (44; 20%) (
Values presented as percentage of total respondents. Student responses, N = 225: very positive, n = 33; slightly positive, n = 83; neither positive nor negative, n = 56; slightly negative, n = 33; very negative, n = 11; p < 0.001 denoted by *.
Student responses, N = 225: use consistently, n = 116; use sparingly, n = 106; avoid entirely, n = 3. Faculty responses, N = 54: use consistently, n = 28; use sparingly, n = 21; avoid entirely, n = 5; p < 0.001 denoted by *.
The 225 respondents’ answers are not mutually exclusive; *denotes statistical significance.
There were several significant differences in student and faculty responses regarding reasons for the use of pimping (
Fisher’s exact and chi-square tests performed on groups. Student responses, N = 225; faculty responses, N = 54; *denotes significance of p < 0.01.
A majority of students report their role on the clinical care team as insignificant: 86 (38%) reported their role as observer, and 117 (52%) responded that the team would be minimally impacted by their absence. Were their role on the team more significant, 92 (41%) reported that pimping would feel more as learning, while only 9 (4%) reported that it would feel less as learning, and 47 (21%) reported that it would feel less as mistreatment versus only 16 (7%) who responded that it would feel more as mistreatment (p < 0.001). Nearly half, 101 (45%), stated that there would be no change in their view of pimping if their role on the team were more significant. In this regard, if the student’s role on the team were more significant, approximately 10 times more students would view pimping as learning and 3 times more students would view pimping less as harassment. When analyzing the converse, whether pimping made students feel more a part of the team, 70 (31%) stated that it did, 27 (12%) stated that it made them feel less a part of the team, and the remainder reported that it did not change their perceived role on the team (p < 0.001).
The majority of students (153; 68%) were not able to suggest any better alternative to pimping as it is presently used. Seventy-two student respondents (32%) did suggest an alternative. The most common suggestion was to use pimping with the addition of prior notification on the subject.
Over the past few decades, there has been increased attention on pimping, medical student mistreatment, and their potential relationship.
In our sample, 70% of medical students agreed with how we defined “pimping,” and 100% of students had experienced it as defined. This helps to solidify the definition as teaching by questioning the student on the subject at hand. The vast majority of students had experienced pimping in group and individual settings either on a daily or weekly basis. Over half of the sample responded that pimping should be used consistently. This is similar to data from Zou et al,
Interestingly, there were more female than male student respondents (p < 0.0001). While we found no significant difference in frequency or positive/negative perception of pimping based on gender, this does raise the question whether there is a gender-related difference in the use or impact of pimping. Higher survey response rates may be an indicator of level of interest in the survey topic. If this is the case, it may be worthwhile for similar studies to investigate the gender disparities with regard to pimping within the clinical education environment.
Students in our study described pimping more commonly as “challenging” and “educational” and less often as “prideful” and “humiliating,” suggesting that students find pimping stressful yet recognize it as educational. This is in contrast to Williams et al,
The majority of students could not suggest a better alternative to pimping. For those who could, the most common suggestion was informing students about the topic on which they would be questioned. Another suggestion was using more group-based questioning in which volunteers are requested instead of calling on a specific student. While it is reasonable in many circumstances to allow students time to prepare for a subject or ask for volunteer responders, it is important to acknowledge that these accommodations may not be possible or appropriate in all clinical teaching scenarios.
We had hypothesized that students’ perception of the importance of their role on the clinical care team would vary indirectly with their perception of pimping as mistreatment. Our data supported this. If given an increased role on the care team, 10 times more students reported that they would view pimping more as learning, and 3 times more students would view pimping less as harassment. Less than half of students (45%) stated that their perceptions of pimping would not change if their role on the care team were increased. In the present study, medical students most commonly reported that their role as a member of the care team was “minimal,” as an observer, or that, if the student were absent, the team would be minimally impacted, and responses regarding their perception of pimping as mistreatment did not vary based on this. Interestingly, however, post hoc we examined the reverse and found that as pimping increased, the number of students who felt more a part of the care team (70; 31%) was greater than that of those who felt less a part of the team (27; 12%) (p < 0.0001). These data demonstrate an area of opportunity for addressing medical student mistreatment and provide an avenue for faculty development.
This study has several limitations. There is an inherently negative connotation to the term “pimping” within the medical community. While we attempted to minimize this bias by using the term “Socratic teaching,” some negative bias was still likely present. Our sample was limited to medical schools within the state of Michigan, which may limit the generalizability of our findings. However, the multiple medical schools within Michigan span a range of clinical settings from academic tertiary care to community hospitals, within both large urban communities and more suburban ones, which broadens the demographic range to some degree. Furthermore, this study is limited by only a modest response from faculty.
This study begins to shed light on whether pimping is a contributing factor in medical student mistreatment reported by the AAMC GQ. Our data suggest pimping is a positive experience for the majority of the medical students in the state of Michigan. There are some differences in student and faculty perceptions of pimping, with faculty believing it opens to broader discussion and some students believing it is a demonstration of authority. Students’ perceived role or importance on the health care team did not influence their perception of pimping as mistreatment. Elimination of pimping in clinical education may have significant consequences, with students feeling less a part of the health care team, having less reinforcement of information, and developing poorer recall rates. Moreover, faculty may be further restricted in terms of engaging, educating, and communicating clinical knowledge. Although more specific research is still needed, our initial data do not support elimination of pimping as a means of reducing medical student mistreatment and instead suggest there may a benefit: pimping makes more students feel included in the care team. Possible gender differences in the experience or perception of pimping deserve further investigation.
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The authors have no conflicts of interest to disclose.