Post on 28-Dec-2021
transcript
Full Terms & Conditions of access and use can be found athttps://www.tandfonline.com/action/journalInformation?journalCode=htlm20
Teaching and Learning in MedicineAn International Journal
ISSN: 1040-1334 (Print) 1532-8015 (Online) Journal homepage: https://www.tandfonline.com/loi/htlm20
Questioning Style and Pimping in ClinicalEducation: A Quantitative Score Derived from aSurvey of Internal Medicine Teaching Faculty
John W. McEvoy, John H. Shatzer, Sanjay V. Desai & Scott M. Wright
To cite this article: John W. McEvoy, John H. Shatzer, Sanjay V. Desai & Scott M. Wright (2019)Questioning Style and Pimping in Clinical Education: A Quantitative Score Derived from a Surveyof Internal Medicine Teaching Faculty, Teaching and Learning in Medicine, 31:1, 53-64, DOI:10.1080/10401334.2018.1481752
To link to this article: https://doi.org/10.1080/10401334.2018.1481752
Published with license by Taylor & Francis©John W. McEvoy, John H. Shatzer, Sanjay V.Desai and Scott M. Wright
Published online: 01 Oct 2018.
Submit your article to this journal Article views: 2176
View related articles View Crossmark data
Citing articles: 4 View citing articles
VALIDATION
Questioning Style and Pimping in Clinical Education: A Quantitative ScoreDerived from a Survey of Internal Medicine Teaching Faculty
John W. McEvoya , John H. Shatzerb, Sanjay V. Desaic and Scott M. Wrightc
aDepartment of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA; bSchool ofEducation, Johns Hopkins University, Baltimore, Maryland, USA; cDepartment of Medicine, Johns Hopkins University School ofMedicine, Baltimore, Maryland, USA
ABSTRACTConstruct: Pimping is a controversial pedagogical technique in medicine, and there is a ten-sion between pimping being considered as “value adding” in some circumstances versusalways unacceptable. Consequently, faculty differ in their attitudes toward pimping, andsuch differences may be measurable and used to inform future research regarding theimpact of pimping on learner outcomes. Background: Despite renewed attention in medicaleducation on creating a supportive learning environment, there is a dearth of prior researchon pimping. We sought to characterize faculty who are more aggressive in their questioningstyle (i.e., those with a “pimper” phenotype) from those who are less threatening. Approach:This study was conducted between December 2015 and September 2016 at Johns HopkinsUniversity. We created a 13-item questionnaire assessing faculty perceptions on pimping asa pedagogical technique. We surveyed all medicine faculty (n¼ 150) who had attended oninpatient teaching services at two university-affiliated hospitals over the prior 2 years. Then,using responses to the faculty survey, we developed a numeric “pimping score” designed tocharacterize faculty into “pimper” (those with scores in the upper quartile of the range) and“nonpimper” phenotypes. Results: The response rate was 84%. Although almost half of thefaculty reported that being pimped helped them in their own learning (45%), fewerreported that pimping was effective in their own teaching practice (20%). The pimpingscore was normally distributed across a range of 13–42, with a mean of 24 and a 75th per-centile cutoff of 28 or greater. Younger faculty, male participants, specialists, and thosereporting lower quality of life had higher pimping score values, all p< .05. Faculty whoopenly endorsed favorable views about the educational value of pimping had sevenfoldhigher odds of being characterized as “pimpers” using our numeric pimping score(p� .001). Conclusions: The establishment of a quantitative pimping score may have rele-vance for training programs concerned about the learning environment in clinical settingsand may inform future research on the impact of pimping on learning outcomes.
KEYWORDSbedside teaching; pimping;faculty traits
Introduction
Pimping is a well-known term in the medical lexicon,described by Brancati as occurring when an “attendingposes a series of very difficult questions to an intern orstudent [emphasis added].”1(p89) It is also a contro-versial pedagogical technique in bedside medical edu-cation.2,3 On one hand, pimping can teach, motivate,and involve the learner in clinical rounds;4–7 on theother hand, it may be interpreted as learner mistreat-ment.8,9 With reference to the latter, Kost and Chensuggested that the definition of pimping should berestricted to “questioning with the intent to shame or
humiliate the learner to maintain the power hierarchyin medical education [emphasis added].”3(p21)
Heightened concerns for medical student and traineemistreatment have recently placed renewed scrutinyon the practice of pimping.10,11 Nonetheless, thereremains a spectrum of opinion toward pimping inclinical practice and in the literature, with some pro-moting the potential virtues of this practice and otherswho feel it is a shameful relic of the past that shouldbe banished from modern medical education. Thisspectrum is enabled by the lack of a universallyagreed-upon definition for what pimping actually is;for example, the term can mean different things to
CONTACT John W. McEvoy jmcevoy1@jhmi.edu Division of Cardiology, Johns Hopkins University School of Medicine, Blalock 524C, 600 N. WolfeStreet, Baltimore, MD 21287, USA. Twitter handle: @johnwmcevoy; Institution Twitter handle: @HopkinsMedicinePublished with license by Taylor & Francis � 2018 John W. McEvoy, John H. Shatzer, Sanjay V. Desai and Scott M. WrightThis is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License (http://creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed,or built upon in any way.
TEACHING AND LEARNING IN MEDICINE2019, VOL. 31, NO. 1, 53–64https://doi.org/10.1080/10401334.2018.1481752
different people ranging from Socratic banter to amore malignant belittlement. Thus, there is a tensionbetween pimping being considered as “value adding”in some circumstances versus pimping as being alwaysunacceptable.
Contributing to the controversy and uncertaintyregarding the value of this technique is the paucity ofresearch addressing the role of pimping in medical edu-cation.2 Multiple gaps in our understanding exist as tothe prevalence of pimping in modern academic medicalcenters, faculty perceptions about pimping, demographicand attitudinal correlates with pimping, and the impactof pimping on student satisfaction and learning out-comes. The objective of the current study was to exam-ine faculty perceptions about pimping and to develop aninstrument designed to characterize clinical teaching fac-ulty as “pimpers” or “nonpimpers.” Such an instrumentcould in theory facilitate faculty development efforts,quality improvement directed toward the local learningculture, and further research on the impact of pimpingon learner outcomes. Second, we set out to correlatepimping behaviors with other professional factors, suchas faculty demographics and their well-being. Whileattempting to be unbiased as to the pros and cons ofthis pedagogical technique, we hypothesized that facultyreporting diminished professional well-being (e.g., burnout or poor quality of life) would be more likely to becharacterized as pimpers. This hypothesis was groundedin prior literature suggesting that pimping may occur orbe perceived more frequently in negative learningenvironments.5
Method
Study design, subjects, and setting
For this cross-sectional study, we surveyedDepartment of Medicine faculty at one of two loca-tions: Johns Hopkins Hospital (a large, tertiary-referralacademic medical center) and Johns Hopkins BayviewMedical Center (a smaller academic hospital). Bothlocations provide comprehensive clinical education tomedical students and graduate medical educationtrainees (interns, residents, and fellows). Each has ageographically distinct internal medicine residencyprogram. The survey was sent electronically to all fac-ulty who had attended for 2 or more weeks duringthe past 2 years on any of the following three teachingservices at either hospital: general medicine wards,medical intensive care units, or cardiac intensivecare units.
Survey development
The survey instrument was designed with three objec-tives in mind: (a) to probe faculty perspectives onpimping as a pedagogical strategy, (b) to characterizefaculty respondents as pimpers or nonpimpers basedon their self-reported bedside teaching questioningstyle (using a pimping scale), and (c) to test relation-ships of these characterizations with other variablesof interest.
The survey instrument was developed using aniterative process over several months. First, theresearch questions, hypotheses, and candidate surveyquestions were presented to a group of Johns Hopkinsmedical education experts at a research-in-progressacademic conference in December 2015. The choice ofcandidate survey questions was informed by examin-ation of the literature. The literature review and feed-back obtained from content experts provided contentvalidity evidence to the pimping scale. This processresulted in a pilot survey of 40 questions. Of these, 25were core questions addressing the pimping construct,and 15 were supplementary demographic questionsand questions designed to establish relation to othervariables validity evidence.
Next, we conducted two rounds of survey piloting,analyzing responses, and soliciting feedback from 18purposively preselected faculty members. These facultywere selected to pilot the survey by the authorshipteam on the basis of their reputations and predilec-tions toward or against pimping behaviors. Questionswere modified and iteratively revised based on feed-back obtained during these two rounds of testing,whereas others were eliminated because of eitherskewed responses by all or an apparent inability todiscriminate between respondents. Ultimately, 11 corequestions tied to pimping questioning style remainedin the final pimping scale. To minimize any socialdesirability bias, these 11 core questions did notinclude any reference to the term pimping. Two fur-ther attitudinal questions were included at the end ofthe survey that directly asked faculty about their per-spectives on pimping (here we defined the termloosely as “repeatedly asking challenging questions toreveal medical knowledge deficiencies that may resultin embarrassment,” so as to strike a balance betweenthe benign and malignant interpretations of the prac-tice). As such, the survey included 13 questionsaddressing the pimping construct. Response optionsfor the survey questions used Likert scales. Thosequestions tied to frequency of behaviors had sixresponse options (never, rarely, sometimes, often, mostof the time, and always) and those tied to level of
54 J. W. McEVOY ET AL.
agreement had four response options (strongly dis-agree, disagree, agree, strongly agree; see AppendixTable A1, which provides details on the full survey).
Data collection
The survey was disseminated in July 2016, and responseswere collected and recorded through September 2016.The survey was hosted on the Qualtrics platform (http://www.qualtrics.com; Qualtrics, Provo, Utah) using asecure institutional account that allowed anonymouscompletion by faculty respondents. To encourage partici-pation, there were weekly drawings of Amazon gift cer-tificates for respondents. We targeted a response rate ofgreater than 80%. The Johns Hopkins University Schoolof Medicine Institutional Review Board approved thestudy protocol (date April 20, 2016; protocol numberIRB00098488).
Data analysis
Demographics and other baseline variables were com-pared among the faculty respondents using analysis ofvariance, Kruskal-Wallis, or chi-square testing, as appro-priate. Using similar statistical approaches, we also
compared survey question responses of general internalmedicine faculty versus specialty medicine faculty.
To characterize faculty respondents as pimpers ornonpimpers, we calculated a summative pimping scorefor each faculty respondent by adding up theirnumeric responses to the first 11 core questions in thepimping scale. Specifically, for the frequency ques-tions, a response of never was assigned a value of 1through always, which had a value of 6. Similarly, forthe level of agreement questions, the four responseswere assigned values of 1 through 4 (Appendix TableA1). Higher values of this summative score suggestmore of a predilection toward pimping behaviors; thetheoretical range of possible values was 11 to 50.Exploratory analysis prior to dissemination of the finalsurvey revealed that preselected faculty in our pilotwith known predilections toward pimping had highermean values on this summative score than thoseknown to have more supportive and less intimidatingeducational approaches (two-sided t test, p¼ .03).
Among faculty who completed the final survey, wetested the distribution and normality of this pimpingscore using Kernel Density plots and the Shapiro-Wilk test. Associations between faculty exposure vari-ables (e.g., demographics, teaching setting, and self-
Table 1. Baseline faculty demographics according to self-reported attitude toward pimpingNegative Attitude Toward Pimpinga Positive Attitude Toward Pimpingb p
Age, Years 46.3 ± 10.3 46.0 ± 8.7 .87Male, % 39 (56%) 37 (66%) .36Race, %White 49 (71%) 39 (70%) 1.00Black 3 (4%) 3 (5%)Asian 14 (21%) 11 (20%)Other 3 (4%) 3 (5%)
Academic Hospital TypeTertiary, Larger 24 (35%) 39 (70%) < .001�Smaller 45 (65%) 17 (30%)
Clinician TypeInvestigator 23 (41%) 23 (41%) 1.00Educator 34 (49%) 27 (48%)Other 7 (10%) 6 (11%)
Weeks on Service 8.6 ± 8.3 8.0 ± 6.8 .66ServiceGeneral Internal Med 34 (49%) 17 (30%) .03�Specialty Med 35 (51%) 36 (70%)
SettingGeneral Ward 57 (83%) 41 (73%) .27ICU 12 (17%) 15 (27%)
Poor Quality of Lifec 1 (1%) 4 (7%) .17Poor Work–Life Balancec 14 (20%) 9 (16%) .65Feelings of Callousnessc 11 (16%) 16 (29%) .09Feeling Burnoutc 26 (38%) 17 (30%) .45Depression Screen Positivec 6 (9%) 2 (4%) .29
Note: Items are mean (standard deviation), number (%), or median (interquartile range). Faculty who agreed orstrongly agreed with the statement “Being pimped by my teachers helped me learn when I was a medicaltrainee” were allocated to the positive attitude category. �p < .05. ICU¼ Intensive Care Unit.
aN¼ 69.bN¼ 56.cPoor quality of life was defined as a score of either 1 or 2 on Question 22 of the survey (see Appendix TableA1). Poor work–life balance was defined as a score of on Question 1 or of 2 on Question 23. Callousness wasdefined as a score of 3 or 4 on Item 28. Feeling burnout was described as a score of 4–7 on Item 27.
TEACHING AND LEARNING IN MEDICINE 55
reported metrics of well-being) and the pimping scorevalue were determined using unadjusted and adjustedmultivariable linear and logistic regressions (depend-ing on whether the pimping score was analyzed as acontinuous or a categorical outcome variable). In thecategorical analyses, we defined the binary (yes/no)outcome of pimper phenotype based on whether afaculty member was in the fourth quartile of thepimping score distribution (i.e., a pimping score �28)and then used logistic regression to identify predictorsof being designated a pimper.
Relation to other variables validity evidence wasassessed by correlating the binary pimper phenotypewith responses to the two direct attitudinal pimpingquestions included at the end of the survey. Toaddress response process validity evidence, facultyparticipating in the pilot testing commented on theirinterpretation of what the questions were asking andrated clarity and lack of ambiguity for each. Further,for analytic purposes, we included data only from fac-ulty who answered all survey questions. In addition,we reviewed the distribution of responses for eachsurvey item to ensure that faculty were not selectingthe same option for each item to complete the surveyquickly. All analyses were performed using STATA-13(Stata, College Station, TX) and two-sided p valuesless than .05 were considered statistically significant.
Results
Of the 150 faculty who received the survey, one facultymember disclosed that they were ineligible because theyhad not served as an inpatient teaching attending withinthe last 2 years. Of the 149 eligible faculty, 125 responseswere obtained (84% response rate). The mean age of thefaculty sample was 49 years; 61% were male, and 70%were White. The median number of weeks per year thatfaculty reported serving as inpatient teaching attendingwas 6, with an interquartile range from 3 to 12weeks.Approximately 40% of respondents reported they weregeneral internal medicine physicians, and 49% self-iden-tified as clinician educators. With respect to well-beingin the sample overall, 4% of faculty reported poor qual-ity of life, up to 18% reported being dissatisfied withwork–life balance, 34% reported feeling burned outmore than once a month, and 22% reported feelingmore callous toward people over their time practicingmedicine (see Appendix Table A1, which tabulatesdescriptive data for aggregate responses to the sur-vey questions).
Comparison of faculty based on positive ornegative attitude toward pimping
Table 1 compares demographic and well-being dataamong faculty who agreed with the statement “Beingpimped by my teachers helped me learn when I was amedical trainee” (n¼ 56) versus those who disagreed(n¼ 69). The faculty with positive attitudes toward hav-ing been pimped were more likely to work in the largertertiary-referral academic medical center (p< .001) andwere more likely to be specialists (p¼ .03). Faculty whoappreciated being pimped also appeared more likely toendorse a poor quality of life (7% vs. 1%) and feelingsof callousness (29% vs. 16%), although these differencesdid not reach statistical significance.
Responses to survey questions addressingthe core construct of pimping
Table 2 summarizes the responses to each of the coresurvey questions pertaining to pimping, comparingthe general medicine to the specialty faculty. Specialtyfaculty were more likely to provide affirmativeresponses in 11 of the 13 questions, with four of thesereaching statistical significance. In addition, specialistswere also statistically more likely than generalists toassert that pimping of learners is an effective teachingmethod during rounds (p¼ .01).
Distribution of the summative pimping score
The range of values for the summative pimping scorederived from faculty responses to the first 11 pimpingsurvey questions was 13 to 42 (potential range of11–50), with a mean and median of 24 and a normaldistribution (Figure 1; Shapiro-Wilk p value¼ .4). Thequartile cutoffs for this score were as follows: first quar-tile �20 (n¼ 32), second quartile 21–23 (n¼ 30), thirdquartile 24–27 (n¼ 33), and fourth quartile �28(n¼ 30). The mean summative pimping score value wassignificantly higher among specialists (25) than that seenin the generalist faculty members (22, p¼ .05; Table 2).
Pimping score values and independent predictorsof the ‘pimper’ phenotype
Faculty who were younger, were male, were workingin the larger tertiary-referral academic medical center,and practice as specialists were statistically more likelyto have higher mean values of the pimping score (seeAppendix Table A2, which demonstrates results fromunadjusted linear regression models and modelsadjusted for faculty age, gender, and race). Similar to
56 J. W. McEVOY ET AL.
the findings for differences in mean pimping scorevalue, crude and adjusted logistic models demonstratedthat pimpers (i.e., faculty with pimping scores in fourth
quartile) were more likely to be younger (approximately5% lower odds of being a pimper per year increase inage) and working at the larger tertiary-referral academicmedical center (Table 3). Specialists were also 3 to 4times more likely to be pimpers than nonspecialists (e.g.,odds ratio [OR]¼ 3.7, p¼ .01), and there was a signifi-cantly lower odds of being a pimper among facultyreporting higher quality of life. As expected, facultymembers who answered often, most of the time, oralways (N¼ 12) to Question 3 of our survey were 9times more likely to be identified as pimpers using ourscore, after adjustment for age, gender, and race(p¼ .003).
Correlation between pimper phenotype andreported pimping attitude (construct validity)
Faculty designated as pimpers based on their pimpingscore value were more likely to agree that “Pimping of
Table 2. Responses to questioning style survey questions according to general versus specialist med-ical practice
General Internal Medicinea Specialty Medicineb p
“When serving as the teaching attending on clinical rounds with the team, I …”; most of the time or always, n (%)Ask general medical knowledge ques-
tions specifically directed to indi-vidual trainees
26 (51%) 51 (69%) .04�
Ask the most junior trainee questionsfirst, even if the question is abovetheir expected level of knowledge
15 (29%) 24 (32%) .84
Ask the same trainee another similaror more challenging medical know-ledge question if they don’t knowthe answer to my first question
6 (12%) 6 (8%) .55
“In the context of my role as teaching attending, …”; agree or strongly agree, n (%)My style of questioning is stressful for
trainees on clinical rounds1 (2%) 8 (11%) .05�
I am “hard” on my clinical trainees 3 (6%) 8 (11%) .52Clinical questions on rounds should
reveal deficiencies in a train-ee’s knowledge
11 (22%) 26 (35%) .11
Stress can improve the learning ofmedical students and house-staff
11 (22%) 29 (39%) .04�
Teaching on clinical rounds shouldhave an unspoken hierarchy
13 (26%) 29 (39%) .12
It is OK to embarrass trainees if neces-sary to improve learning
3 (6%) 14 (19%) .04�
If I avoid embarrassing my trainees atall costs, they will learn lessfrom me
11 (22%) 25 (34%) .16
Trainees should never “speak theirminds” during clinical rounds
5 (10%) 5 (7%) .74
Pimping of students or residents is aneffective teaching strategyon roundsc
4 (8%) 19 (26%) .01�
Being pimped by my teachers helpedme learn when I was a med-ical traineec
17 (34%) 39 (53%) .03�
Pimping score,d mean value ± stan-dard error
22 ± 0.6 25 ± 0.5 .05
Note: Other items as defined in Table 2. �p< .05. CI¼ confidence interval.aN¼ 51.bN¼ 74.cThe last two attitudinal questions were not included in the summative pimping score but, rather, were used as variablesto test the construct validity of this score.
dThe pimping score was derived by adding the numeric responses to each to the first 11 questions on the survey.
Figure 1. Distribution and range of pimping score derivedfrom faculty survey responses.
TEACHING AND LEARNING IN MEDICINE 57
students or residents is an effective teaching strategyon clinical rounds” (OR¼ 4.9, p¼ .002), 95% CI [1.8,13.4], adjusted for age, gender, and race. Similarly,pimper faculty were more convinced that “Beingpimped by my teachers helped me learn when I was amedical trainee” (OR¼ 6.6, p< .001), 95% CI [2.4,17.7], adjusted for age, gender, and race. Our pimpingscore also accurately discriminated faculty who agreedwith these latter two direct questions, with results pro-vided in the appendix.
Discussion
This study characterizes the questioning practices ofattending physicians who lead teams of learners ininpatient settings at two academic teaching hospitals.Almost half of the faculty surveyed reported somepositive attitudes about the value of pimping. The sur-vey responses were used to derive a novel quantitativepimping score that is supported by validity evidenceand allows for discrimination of faculty who are pim-pers from those who are not. This score may enablefurther medical education research, including the abil-ity to link faculty pimping behavior to higher leveleducational outcomes. Further work from our group
is under way in this regard. In the current study, wewere able to describe demographic features and othercorrelates that were associated with the pimpingphenotype in our sample.
To our knowledge, this is one of the first publishedworks to describe clinical teaching faculty’s viewsabout pimping.12 Accordingly, these results informour understanding of faculty perceptions about pimp-ing of medical trainees. For example, although almosthalf the faculty appeared to recall being the subject ofpimping in positive terms, they were much less likelyto report that they themselves thought pimping waseffective in their own teaching practice. This phenom-enon has been seen in a similar survey of pharma-cists.12 One may hypothesize that many faculty havepurposively chosen not to be the source of pimpingthemselves, perhaps because of their preference to beviewed as a source of support rather than an instiga-tor of stress. Nonetheless, faculty with stronger self-reported predilections toward pimping behavior intheir teaching practice (based on the numericresponses to our pimping scale) were more likely torecall and believe that being pimped had helped themto learn when they were training. As such, it appearsthat, for pimping, prior learning experiences mayinform future teaching behaviors.
Table 3. Unadjusted and adjusted associations of faculty demographics with odds of beingcharacterized a “pimper”
Likelihood of Being a PimperOdds Ratio [95% CI]
Unadjusted Model pModel Adjusted for Age, Gender,
and Race p
Age, Years 0.95 [0.90, 0.99] .04� 0.95 [0.90, 1.00] .05�Male 1.39 [0.59, 3.30] .45 1.85 [0.85, 4.64] .09RaceWhite 1 [reference] — 1 [reference] —Black 1.81 [0.31, 10.67] .51 1.50 [0.24, 9.35] .66Asian 2.04 [0.78, 5.34] .14 1.92 [0.68, 5.39] .22
Academic Hospital TypeSmaller Hospital 1 [reference] — 1 [reference] —Larger Tertiary-Referral 2.0 [0.91, 4.76] .09 2.32 [1.01, 5.88] .04�
Clinician TypeInvestigator 1 [reference] — 1 [reference] —Educator 0.71 [0.30, 1.67] .44 0.71 [0.29, 1.76] .46Other 0.20 [0.02, 1.68] .14 0.24 [0.03, 2.16] .20
Weeks on Servicea 1.42 [0.87, 2.34] .16 1.47 [0.88, 2.48] .14ServiceGIM 1 [reference] — 1 [reference] —Specialty 2.83 [1.11, 7.24] .03� 3.74 [1.33, 10.49] .01�
SettingGeneral Ward 1 [reference] — 1 [reference] —-ICU 0.66 [0.23, 1.94] .45 0.69 [0.22, 2.14] .52
Quality of Lifeb 0.61 [0.37, 1.00] .05 0.55 [0.30, 0.98] .04�Work–Life Balanceb 0.89 [0.63, 1.27] .54 0.94 [0.64, 1.37] .74Callousnessb 1.24 [0.75, 2.06] .39 1.16 [0.67, 1.99] .59Burnoutb 1.91 [0.64, 5.70] .25 2.23 [0.68, 7.32] .18Depression Screen Positiveb 1.06 [0.20, 5.55] .94 1.26 [0.22, 7.22] .80
Note: Faculty with a pimping score value at 28 or higher were characterized as pimpers. �p< .05.CI¼ confidence interval; GIM¼General Internal Medicine; ICU¼ Intensive Care Unit.
aWeeks on service is log transformed.bQuality of life point estimate is per unit increase in Item 22 of the survey, work–life balance is per unitincrease in Item 23 of the survey. Other items as defined in Table 2.
58 J. W. McEVOY ET AL.
The association between younger faculty, male fac-ulty, and specialists with higher pimping score valuesis of interest and may reflect, at least in part, a desireby faculty with these characteristics to be respected andfeared by their juniors.7,13 Such a position is hard toprove definitively, and there may also be other morebenign reasons behind this finding. Furthermore, theassociation between faculty reporting lower quality oflife with predictions toward pimping behavior is inkeeping with the more negative perspectives on thispedagogical practice.3,14 In the quarter century sinceBrancati’s publication on the topic,1 the pimping oftrainees has been increasingly called into question byvirtue of its presumed link with student mistreat-ment.3,8,11 However, whether pimping truly representslearner mistreatment is unclear, and there remains acase in favor of the practice depending on how onedefines it. We believe that pimping is an interactionalphenomenon and that its virtues or drawbacks mayultimately come down to one’s perceived definition of“pimping,” how it is internalized by the learner,15 thelearning environment, and the intention of the attend-ing physician.2
The few small studies published on pimping todate have reported inconsistent findings and evaluatedlower level educational outcomes only, such asstudents’ reactions to pimping.14–17 Our pimpingscore may be useful in future medical educationresearch on this topic or for educational programleaders wanting to learn the style and approaches ofthose selected to teach learners (and how theseapproaches may or may not be grounded in best prac-tices for learning). First, the survey is short and canbe easily disseminated via e-mail. Second, the 11 corequestions included in the scale do not make referenceto the term pimping and as such minimize any biasin responses. If the two attitudinal questions makingdirect reference to pimping are included in futurescholarly efforts using our pimping scale, we recom-mend that these questions be included at the end ofthe survey so that they do not influence responses tothe 11 core questions. Third, the pimping scorederived from these data appeared to help identifycohorts of faculty (e.g., younger, males, specialists) inwhom pimping may be more likely to occur andcould identify target groups where interventions toreduce pimping behaviors may be more necessary. Inaddition, it is known that learners themselves havevaried opinions about pimping2,14,15; thus, our scorecould be used to match students with faculty whoexhibit either pimping or nonpimping phenotypes,based on students’ preferences regarding the practice.
Finally, we are conducting follow-up studies testingwhether our pimping score can be used to assess therelationship between faculty pimping behaviors andhigher level educational outcomes (such as knowledgeacquisition) and clinical outcomes (like accuratediagnoses versus medical errors and more thoughtfultesting with efficient high value care).18 Futurestudies are also necessary to determine the signifi-cance of differences in our score on meaningful edu-cational outcomes.
Several limitations of this study should be consid-ered. First, self-report of teaching style is subject tosocial desirability and other biases. The pimping scoreis a surrogate for teaching behavior, and it is notbased on direct observations. Therefore, we cannotalways be sure that faculty identified as pimpers usingour score are pimpers in reality. However, because thescore is based largely on frequency of performing spe-cific acts, this may be more accurate than attitudinalassessments.19 Second, faculty who responded to thesurvey may have been more interested or favorablypredisposed toward pimping as compared with non-respondents. However, our 84% response rate amongall eligible faculty is reassuring that the resultsshould be internally generalizable. With regards toexternal generalizability, one cannot assume that theperspectives in this cohort would match those of fac-ulty affiliated with other departments or schools, soadditional validation studies in other cohorts isnecessary. Third, there are limitations to this type ofsurvey research when dealing with a topic like pimp-ing, which often incites emotional responses andwhich tends to polarize opinion. Finally, we under-stand that program-level attitudes, cultures, andbehaviors20 may have an even greater impact on thelearning environment or trainee well-being than doindividual, faculty-level behaviors.
In conclusion, pimping behaviors continue atteaching hospitals in contemporary medical education.This study describes a pimping scale as a tool thatallows for the identification and phenotyping of clin-ical teachers who use this questioning style in theireducational approach. Although there may be manyapplications of the tool and possibilities for futureresearch, it may be most useful for faculty to be awareof and reflect upon how they relate to learners.
Ethical approval
This study was approved by the Johns HopkinsSchool of Medicine Institutional Review Board onApril 20, 2016 (reference number 00098488).
TEACHING AND LEARNING IN MEDICINE 59
Previous presentations
Oral abstract presentation in Baltimore, Maryland onJuly 2017 at the JHU Masters of Education in theHealth Professions (MEHP) Summer Conference:Advancing Careers through Interprofessional HealthProfessions Education-Teach, Research, Lead.
Acknowledgments
This paper represents the thesis work Dr. McEvoy under-took as part of his MEHP degree course. Dr. Wright is theAnne Gaines and G. Thomas Miller Professor of Medicineand is supported through the Johns Hopkins Center forInnovative Medicine.
Funding
Dr. McEvoy is supported by the following grants: NIH/NIDDK-R01DK089174, NIH/NIDDK-R01DK108784, andAHA-17MCPRP33400031.
ORCID
John W. McEvoy http://orcid.org/0000-0001-6530-5479
References
1. Brancati FL. The art of pimping. JAMA.1989;262(1):89–90.
2. McCarthy CP, McEvoy JW. Pimping in medical edu-cation: lacking evidence and under threat. JAMA.2015;314(22):2347–2348.
3. Kost A, Chen FM. Socrates was not a pimp: changingthe paradigm of questioning in medical education.Acad Med. 2015;90(1):20–24.
4. Antonoff MB, D’Cunha J. Retrieval practice as ameans of primary learning: Socrates had the rightidea. Semin Thorac Cardiovasc Surg. 2011;23(2):89–90.
5. McConnell MM, Eva KW. The role of emotion in thelearning and transfer of clinical skills and knowledge.Acad Med. 2012;87(10):1316–1322.
6. Hautz WE, Schroder T, Dannenberg KA, et al. Shamein medical education: a randomized study of theacquisition of intimate examination skills and its
effect on subsequent performance. Teach Learn Med.2017;29(2):196–206.
7. Healy JM, Yoo PS. In defense of “pimping.” J SurgEduc. 2015;72(1):176–177.
8. Reifler DR. The pedagogy of pimping: educational rigoror mistreatment? JAMA. 2015;314(22):2355–2356.
9. Lucey C, Levinson W, Ginsburg S. Medical studentmistreatment. JAMA. 2016;316(21):2263–2264.
10. Mavis B, Sousa A, Lipscomb W, Rappley MD.Learning about medical student mistreatment fromresponses to the medical school graduation question-naire. Acad Med. 2014;89(5):705–711.
11. Fnais N, Soobiah C, Chen MH, et al. Harassment anddiscrimination in medical training: a systematic reviewand meta-analysis. Acad Med. 2014;89(5):817–827.
12. Williams EA, Miesner AR, Beckett EA, Grady SE.“Pimping” in pharmacy education: a survey and com-parison of student and faculty views. J Pharm Pract.2018;31(3):353–360.
13. Angoff NR, Duncan L, Roxas N, Hansen H. Powerday: addressing the use and abuse of power in med-ical training. J Bioeth Inq. 2016;13(2):203–213.
14. Scott KM, Caldwell PH, Barnes EH, Barrett J.Teaching by humiliation and mistreatment of medicalstudents in clinical rotations: a pilot study. Med JAust. 2015;203(4):185–186.
15. Lo L, Regehr G. Medical students’ understanding ofdirected questioning by their clinical preceptors.Teach Learn Med. 2017;29(1):5–12.
16. Wear D, Kokinova M, Keck-McNulty C, Aultman J.Pimping: perspectives of 4th year medical students.Teach Learn Med. 2005;17(2):184–191.
17. Zou L, King A, Soman S, et al. Medical students’ pref-erences in radiology education a comparison betweenthe Socratic and didactic methods utilizing power-point features in radiology education. Acad Radiol.2011;18(2):253–256.
18. Parker K, Burrows G, Nash H, Rosenblum ND. Goingbeyond Kirkpatrick in evaluating a clinician scientistprogram: it’s not “if it works” but “how it works.”Acad Med. 2011;86(11):1389–1396.
19. Ajzen I, Fishbein M. The prediction of behavior fromattitudinal and normative variables. J Exp SocialPsychol. 1970;6(4):466–487.
20. Slavin SJ, Schindler DL, Chibnall JT. Medical studentmental health 3.0: improving student wellness throughcurricular changes. Acad Med. 2014;89(4):573–577.
60 J. W. McEVOY ET AL.
TableA1.
Aggregaterespon
sesto
thefullsurvey
Cor
e Pi
mpi
ng Q
uest
ions
(N=1
3*)
Supp
lem
enta
ry Q
uest
ions
(N=1
5)"W
hen
serv
ing
as th
e te
achi
ng a
tten
ding
on
clin
ical
rou
nds a
nd w
ith m
ost o
r al
l oft
he te
am p
rese
nt, I
……
"14
. Age
(mea
n an
d SD
)46
(9) y
ears
1. A
sk g
ener
al m
edic
al k
now
ledg
e qu
estio
ns
spec
ifica
lly d
irect
ed to
indi
vidu
al tr
aine
es
(ver
sus t
he e
ntire
gro
up)
Nev
er2
(1.6
%)
Rar
ely
14 (1
1.2%
)So
met
imes
32 (2
5.6%
)O
ften
29 (2
3.2%
)M
ost o
f the
tim
e 31
(24.
8%)
Alw
ays
17 (1
3.6%
)
15. G
ende
rM
ale
76 (6
1%)
Fem
ale
4
9 (3
9%)
2. A
sk th
e m
ost j
unio
r tra
inee
(e.g
., m
edic
al
stud
ent o
r int
ern)
que
stio
ns fi
rst,
even
if th
e ge
nera
l med
ical
kno
wle
dge
ques
tion
is a
bove
th
eir e
xpec
ted
leve
l of k
now
ledg
e
Nev
er11
(8.8
%)
Rar
ely
29 (2
3.2%
)So
met
imes
46 (3
6.8%
)O
ften
24 (1
9.2%
)M
ost o
f the
tim
e 10
(8%
)A
lway
s5
(4%
)
16. R
ace
Whi
te
88
(70%
)B
lack
6
(5
%)
Asi
an25
(2
0%)
Oth
er6
(5
%)
3. A
sk th
e sa
me
train
ee a
noth
er si
mila
r or m
ore
chal
leng
ing
med
ical
kno
wle
dge
ques
tion
if th
ey
does
n’t k
now
the
answ
er to
my
1st q
uest
ion
Nev
er47
(37.
6%)
Rar
ely
51 (4
0.8%
)So
met
imes
15 (1
2%)
Ofte
n8
(6.4
%)
Mos
t of t
he ti
me
3 (2
.4%
)A
lway
s1
(0.8
%)
17. W
hat i
s you
r D
ivis
iona
l aff
iliat
ion
in th
e D
epar
tmen
t of M
edic
ine?
Gen
eral
Inte
rnal
Med
icin
e
51
(
41%
)C
ardi
olog
y22
(
17%
)Pu
lmon
ary
23
(1
8%)
Ger
iatri
cs13
(11%
)O
ther
16
(1
3%)
“In
the
cont
ext o
f my
role
as t
each
ing
atte
ndin
g, I
belie
ve th
at…
.”18
. Wha
t is t
he a
vera
gew
eeks
per
yea
r th
at
you
are
teac
hing
att
endi
ng?
(Med
ian,
IQR
)6
(3-1
2) w
eeks
4. M
y st
yle
of q
uest
ioni
ng is
stre
ssfu
l for
tra
inee
s on
clin
ical
roun
ds
Stro
ngly
Dis
agre
e39
(31.
2%)
Dis
agre
e77
(61.
6%)
Agr
ee8
(6.4
%)
Stro
ngly
Agr
ee1
(0.8
%)
19. W
hich
hos
pita
l do
you
pred
omin
antly
se
rve
as te
achi
ng a
tten
ding
? JH
H†
6
3
(50
%)
JHB
MC
†
62
(
50%
)
5. I
am ‘h
ard’
on
my
clin
ical
trai
nees
Stro
ngly
Dis
agre
e47
(37.
6%)
Dis
agre
e67
(53.
6%)
Agr
ee10
(8%
)St
rong
ly A
gree
1 (0
.8%
)
20. I
n w
hat s
ettin
g do
you
pre
dom
inan
tly
serv
e as
the
teac
hing
att
endi
ng?
G
ener
al W
ard
98
(7
8%)
Inte
nsiv
e C
are
Uni
t
27
(2
2%)
6. C
linic
al q
uest
ions
on
roun
ds sh
ould
reve
al
defic
ienc
ies i
n a
train
ee’s
kno
wle
dge
Stro
ngly
Dis
agre
e26
(20.
8%)
Dis
agre
e62
(49.
6%)
Agr
ee28
(22.
4%)
Stro
ngly
Agr
ee9
(7.2
%)
21. I
see
mys
elf a
s pri
mar
ily a
: C
linic
ian
Educ
ator
61
(49
%)
Clin
icia
n In
vest
igat
or49
(39%
)O
ther
15
(1
2%)
(Continued)
TEACHING AND LEARNING IN MEDICINE 61
TableA1.
Continued.
7. S
tress
can
impr
ove
the
lear
ning
of m
edic
al
stud
ents
and
hou
se-s
taff
Stro
ngly
Dis
agre
e38
(30.
4%)
Dis
agre
e47
(37.
6%)
Agr
ee35
(28%
)St
rong
ly A
gree
5 (4
%)
22. W
hich
of t
he fo
llow
ing
best
des
crib
es y
our
over
all q
ualit
y of
life
?
As b
ad a
s it c
an b
e2
(1.6
%)
Som
ewha
t bad
3 (2
.4%
)So
mew
hat g
ood
52 (4
1.6%
)A
s goo
d as
it c
an b
e68
(54.
4%)
8. T
each
ing
on c
linic
al ro
unds
shou
ld h
ave
an
unsp
oken
hie
rarc
hy (e
.g.,
from
stud
ent,
to in
tern
, to
resi
dent
, to
fello
w, t
o at
tend
ing)
Stro
ngly
Dis
agre
e26
(20.
8%)
Dis
agre
e57
(45.
6%)
Agr
ee38
(30.
4%)
Stro
ngly
Agr
ee4
(3.2
%)
23. H
ow sa
tisfie
d ar
e yo
u w
ith th
e ba
lanc
e be
twee
n yo
ur p
erso
nal a
nd p
rofe
ssio
nal l
ife?
Ver
y di
ssat
isfie
d6
(4.8
%)
Som
ewha
t dis
satis
fied
17 (1
3.6%
)So
mew
hat s
atis
fied
61 (4
8.8%
)V
ery
satis
fied
41 (3
2.8%
)
9. It
is O
K to
em
barr
ass t
rain
ees i
f nec
essa
ry to
im
prov
e le
arni
ng (e
.g. c
orre
ctin
g w
rong
ans
wer
s to
impo
rtant
clin
ical
que
stio
ns)
Stro
ngly
Dis
agre
e82
(65.
2%)
Dis
agre
e26
(20.
8%)
Agr
ee16
(12.
8%)
Stro
ngly
Agr
ee1
(0.8
%)
24. I
’m b
ette
r th
an m
ost p
eopl
e at
mos
t th
ings
.
Stro
ngly
Dis
agre
e3
(2.4
%)
Dis
agre
e67
(53.
6%)
Agr
ee50
(40%
)St
rong
ly A
gree
5 (4
%)
10. I
f I a
void
em
barr
assi
ng m
y tra
inee
s at a
ll co
sts,
they
will
lear
n le
ss fr
om m
e
Stro
ngly
Dis
agre
e50
(40%
)D
isag
ree
39 (3
1.2%
)A
gree
30 (2
4%)
Stro
ngly
Agr
ee6
(4.8
%)
25. I
feel
une
asy
whe
n I a
m th
e fo
cus o
f at
tent
ion.
Stro
ngly
Dis
agre
e10
(8%
)D
isag
ree
61 (4
8.8%
)A
gree
48 (3
8.4%
)St
rong
ly A
gree
6 (4
.8%
)
11. T
rain
ees s
houl
d al
way
s ‘sp
eak
thei
r min
ds’
durin
g cl
inic
al ro
unds
(e.g
., sp
eaki
ng u
p if
they
di
sagr
ee)
Stro
ngly
Agr
ee‡
4
3 (3
4.4%
)A
gree
72 (5
7.6%
)D
isag
ree
6 (6
.4%
)St
rong
ly D
isag
ree
2 (1
.6%
)
26. H
ave
you
felt
depr
esse
d or
sad
muc
h of
th
e tim
e in
the
past
yea
r?Y
es8
(6.4
%)
No
117
(93.
6%)
*12.
Pim
ping
(e.g
. rep
eate
dly
aski
ng
chal
leng
ing
ques
tions
to re
veal
med
ical
kn
owle
dge
defic
ienc
ies t
hat m
ay re
sult
in
emba
rras
smen
t) of
stud
ents
or re
side
nts i
s an
effe
ctiv
e te
achi
ng st
rate
gy o
n cl
inic
al ro
unds
Stro
ngly
Dis
agre
e61
(48.
8%)
Dis
agre
e41
(32.
8%)
Agr
ee22
(17.
6%)
Stro
ngly
Agr
ee1
(0.8
%)
27. H
ow o
ften
do
you
feel
bur
ned
out f
rom
w
ork?
Nev
er12
(9.6
%)
A fe
w ti
mes
a y
ear o
r les
s54
(43.
2%)
Onc
e a
mon
th16
(12.
8%)
A fe
w ti
mes
a m
onth
26 (2
0.8%
)O
nce
a w
eek
11 (8
.8%
)A
few
tim
es a
wee
k4
(3.2
%)
Ever
y da
y2
(1.6
%)
*13.
Bei
ng p
impe
d by
my
teac
hers
hel
ped
me
lear
n wh
en I
was a
med
ical
trai
nee
Stro
ngly
Dis
agre
e29
(23.
2%)
Dis
agre
e40
(32%
)A
gree
44 (3
5.2%
)St
rong
ly A
gree
12 (9
.6%
)
28. I
hav
e be
com
e m
ore
callo
used
tow
ards
pe
ople
ove
r m
y tim
e w
orki
ng in
med
icin
e.
Stro
ngly
Dis
agre
e51
(40.
8%)
Dis
agre
e47
(37.
6%)
Agr
ee25
(20%
)St
rong
ly A
gree
2 (1
.6%
)
� The
last
2qu
estio
nswereno
tinclud
edin
thesummativepimping
scorebu
t,rather,w
ereused
asvariables
totest
theconstructvalidity
ofthisscore
†JHH¼TheJohn
sHop
kins
Hospital,JHBM
C¼John
sHop
kins
Bayview
MedicalCenter
‡Notethat
theorderof
preference
isreversed
forthisspecificqu
estio
n,so
asto
facilitatederivationof
thesummativepimping
score.
62 J. W. McEVOY ET AL.
Table A2. Unadjusted and adjusted associations of faculty demographics with mean differences in self-reported pimpingscore value
Difference in Pimping Score Value* Mean (95% CI)
Unadjusted Model p-value Model adjusted for age, gender, and race p-value
Age, years† −0.07 (-0.17, 0.03) 0.16 -0.11 (-0.21, -0.14) 0.04Male† 2.40 (0.53, 4.27) 0.01 2.78 (0.82, 4.73) 0.005Race-White 1 (reference) - 1 (reference) --Black −0.09 (-4.54, 4.35) 0.97 −0.36 (-4.74, 4.02) 0.97-Asian −0.62 (-3.01, 1.77) 0.61 −0.55 (-3.00, 1.91) 0.66-Other −1.26 (-5.71, 3.18) 0.58 −0.05 (-4.81, 4.71) 0.98
Academic Hospital Type-Smaller hospital 1 (reference) - 1 (reference) --Larger tertiary-referral 2.57 (0.76, 4.39) 0.006 2.02 (0.12, 3.92) 0.03
Clinician Type-Investigator 1 (reference) - 1 (reference) --Educator −0.56 (-2.55, 1.42) 0.58 −0.74, (-2.76, 1.28) 0.47-Other −1.76 (-5.01, 1.49) 0.29 −1.66 (-4.98, 1.65) 0.33
Weeks on service‡ 0.54 (-0.58, 1.67) 0.34 0.49 (-0.64, 1.61) 0.40Service-GIM 1 (reference) - 1 (reference) --Specialty 2.84 (0.00, 3.72) 0.05 1.99 (0.09, 3.88) 0.04
Setting-General Ward 1 (reference) - 1 (reference) --ICU 1.47 (-0.79, 3.73) 0.20 1.28 (-1.05, 3.62) 0.28
*Values are mean differences in pimping score between groups derived from linear regression beta-coefficients.†Difference in mean score for every additional year of age and between men and women faculty.‡Weeks on service is log transformed.
TEACHING AND LEARNING IN MEDICINE 63
Figure A1. (a) The ability to predict faculty who agree or strongly agree with the first attitudinal question about pimping was sig-nificantly improved by adding the pimping score to a base model that included age, gender, medical practice (GIM versus spe-cialty), and teaching location (c-statistic for base model of 0.69 vs. c-statistic of 0.83 for base model plus pimp score p=0.006)(eFigure 1a). (b) The ability to predict faculty who agree or strongly agree with the second attitudinal question about pimpingwas also significantly improved by adding the pimp score to the same base model (c-statistic for base model of 0.66 vs. c-statisticof 0.81 for base model plus pimp score p<0.001) (eFigure 1b).
64 J. W. McEVOY ET AL.