Category Archives: Education

You’ve Been Pimped! Origins And How To Survive It!

What exactly is pimping? If you have ever been a medical student or resident in any discipline, you probably already know. It’s ostensibly a form of Socratic teaching in which an attending physician poses a (more or less) poignant question to one or more learners. The learners are then queried (often in order of their status on the seniority “totem pole”) until someone finally gets the answer. But typically, it doesn’t stop there. Frequently, the questioning progresses to the point that only the attending knows the answer.

So how did this time honored tradition in medical education come about? The first reference in the literature attributes it to none other than William Harvey, who first described the circulatory system in detail. He was disappointed with his students’ apparent lack of interest in learning about his area of expertise. He was quoted as saying “they know nothing of Natural Philosophy, these pin-heads. Drunkards, sloths, their bellies filled with Mead and Ale. O that I might see them pimped!”

Other famous physicians participated in this as well. Robert Koch, the founder of modern bacteriology, actually recorded a series of “pümpfrage” or “pimp questions” that he used on rounds. And in 1916, a visitor at Johns Hopkins noted that he “rounded with Osler today. Riddles house officers with questions. Like a Gatling gun. Welch says students call it ‘pimping.’ Delightful.”

So it’s been around a long time. And yes, it has some problems. It promotes hierarchy, because the attending almost always starts questions at the bottom of the food chain. So the trainees come to know their standing in the eyes of the attending. And they also can appreciate where their fund of (useful?) knowledge compares to their “peers.” It demands quick thinking, and can certainly create stress. And a survey published last year showed that 50% of respondents were publicly embarrassed during their clinical rotations. What portion of this might have been due to pimping was not clear.

Does pimping work? Only a few small studies have been done. Most medical students have been involved with and embarrassed by it. But they also responded that they appreciated it as a way to learn. A 2011 study compared pimping (Socratic) methods to slide presentations in radiology education. Interestingly, 93% preferred pimping, stating that they felt their knowledge base improved more when they were actively questioned, regardless of whether they knew the answer.

So here are a few guidelines that will help make this technique a positive experience for all:

For the “pimpers”:

  • Make sure that the difficulty level of questions is reasonable. You are testing your learners’ knowledge, not spotlighting your own mental encyclopedia
  • Build the level of difficulty from questions that most can answer to one or two that no one knows, then switch to didactice teaching of the esoterica
  • Don’t let one learner dominate the answers; gently exclude them and solicit answers from others so they get a chance to participate
  • Provide positive reinforcement for correct answers, but don’t resort to negative reinforcement (insults) when they are wrong
  • Go Socratic when the answer is not known. Step back and review the basic concepts involved that helps your learners arrive at the correct answer.

For the “pimpees”:

  • Read, read, read! You are in this to learn, so study all the clinical material around you.
  • Talk to your seniors to find out your attending’s areas of interest. There’s a lot of stuff to learn, and this may help you focus your rounding preparation a bit. It still doesn’t absolve you from learning about all the other stuff, though.
  • Don’t be “that guy (or gal)” who tries to dominate and answer every question
  • If all else fails, and it’s one of those “percentage” questions, use my
    “85/15 rule.”
    If the issue you are being asked about seems pretty likely, answer “85%.” If it seems unlikely, go with “15%.” It’s usually close enough to the real answer to satisfy.

Bottom line: Pimping is a time-honored tradition in medicine, but should not be considered a rite of passage. There is a real difference in attitudes and learning if carried out properly. Even attendings have a thing or two to learn about this!

Reference: The art of pimping. JAMA. 262(1):89-90, 1989.

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You’ve Been Pimped!

You know what I’m talking about. It’s a mainstay of medical education for physicians. It starts in medical school, and generally never stops. And when you finish your residency,  you graduate from being pimped to being the pimper.

How did this all come to be? Is it good for education? Bad? Tune in tomorrow to learn more. In the meantime, enjoy this algorithm on how to get through a pimping session. Click to view full-size.

pimping

Source: Posted by Dr. Fizzy on The Almost Doctor’s Channel

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Are Graduating General Surgery Residents Qualified To Take Trauma Call?

Trauma training during general surgery residency has changed dramatically over the past two decades. Although we like to blame the 80-hour work week rule on everything, there are other factors that may be at play. Increasing use of nonoperative management, availability and increasing scope of interventional radiologists, and the increasing number of surgical subspecialists are certainly significant.

The surgical group at LAC+USC looked at changes in operative caseloads, type of surgery performed, and the impact that concurrent subspecialty training has had on trauma operative volumes. The authors reviewed 16 years of ACGME data on resident surgical procedures in various body regions by year of training. They specifically looked at the impact of implementation of the 80-hour work week.

Here are the factoids:

  • There was a trend only (p=0.07) toward decreased operative trauma cases
  • The number of trauma laparotomies increased, vascular procedures decreased, and neck explorations and thoracotomies remained stable
  • Trauma vascular procedures decreased for surgical residents, but increased for vascular fellows
  • Individual resident operative volumes in chest, abdomen, solid organ, and extremities decreased after implementation of the 80-hour work week
  • Based on this, the authors recommend residents who are interested in a career in trauma and acute care surgery have fellowship training (??)

Bottom line: Well, it was a catchy title, at least. Or is it a promotion for trauma fellowships? The differences between pre-80 hour and post-80 hour in the table are not that impressive, and although a number of the operative case comparisons reach statistical significance, they represent a difference of only 1 case! Not clinically relevant! And other than the number of laparotomies going up, the other numbers looked fairly constant. 

The exposure to operative cases overall appeared to remain constant for most procedures with the exception of laparotomies increasing and vascular cases decreasing. In my opinion, one of the most apparent changes is in resident comfort with critical decision making. I don’t believe that this is due to any change in operative experience, but rather to closer oversight by attending surgeons and less opportunity to independently come to those decisions.

Reference: Is your graduating general surgery resident qualified to take trauma call? A 15-year appraisal of the changes in general surgery education for trauma. J Trauma 82(3):470-480.

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Rural Trauma Team Development Course Impact On Trauma Transfers

The Rural Trauma Team Development Course (RTTDC) is yet another quality program developed by the American College of Surgeons (ACS). It is designed for all trauma professionals in rural areas including doctors, nurses, advanced practice providers, prehospital providers, and administrative support. The course is presented over the course of one day and covers a number of topics including:

  • Organizing a rural trauma team
  • Preparing rural hospitals to manage trauma patients
  • Identifying local resources and limitations
  • Resuscitation of trauma patients
  • Initiating early transfer
  • Developing a performance improvement process
  • Building relationships between rural hospitals and regional or state trauma systems

The trauma group at Vanderbilt compared a group of six non-trauma hospital in rural Tennessee who had participated in the RTTDC with six other rural hospitals matched for size, volume, and distance from the Level I center.

Here are the factoids:

  • A total of 130 RTTDC patients were compared with 123 from hospitals that had not participated
  • Overall demographics and number of imaging studies were the same
  • The call to transfer occurred 41 minutes sooner in the RTTDC hospitals
  • Length of stay in the referring ED was 61 minutes shorter in the RTTDC hospitals
  • Number of images obtained pre-transfer and mortality were unchanged

Bottom line: The numbers were small and the review was retrospective, but the results are nonetheless impressive. Granted, there was no decrease in mortality, but this is a relatively crude indicator, especially when small numbers are involved. But time to phone call and time spent in the referring ED were significantly shorter. Does anyone think that longer times to transfer are somehow good for patients?

Rural hospitals should consider attending RTTDC in order to improve the care of patients from their communities.

Reference: Rural trauma team development course de-creases time to transfer for trauma patients. J Trauma 81(4):632-637, 2016.

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