Pimping

The Art of Pimping
by Frederick L. Brancati, MD, Department of Medicine, University of Pittsburgh.
From JAMA 262(1):89, July 7, 1989.
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It's hard work becoming a revered attending physician in a university hospital. The task daunts the newly appointed junior attending as he strides down the corridor of his first ward with his first team. Oh, he's madesome changes in anticipation of his new position. He's wearing a long coat now, an all-cotton coat with razor-sharp creases and knit buttons. The stained, shrunken polyester white pants and tennis shoes have given way to gray, light wool slacks with a cuff and polished loafers. Framed certificates bear testimony to his intelligence and determination. He should be ready to take the helm of his wardteam, but he's not. Something's missing, something important, something closer to art than to science. When physicians talk about the "art of medicine" they usually mean healing, or coping with uncertainty, or calculating their federal income taxes. But there's one art this new attending needs to learn before all others: the art of pimping.
Pimping occurs whenever an attending poses a series ofvery difficult questions to an intern or student. The earliest reference to pimping is attributed to Harvey in London in 1628. He laments his students' lack of enthusiasm for learning the circulation of the blood: "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!"
In 1889, Koch recorded a seriesof "Puempfrage" or "pimp questions" he would later use on his rounds in Heidelberg. Unpublished notes made by Abraham Flexner on his visit to Johns Hopkins in 1916 yield the first American reference: "Rounded with Osler today. Riddles house officers with questions. Like a Gatling gun. Welch says students call it 'pimping.' Delightful."
On the surface, the aim of pimping appears to be Socraticinstruction. The deeper motivation, however, is political. Proper pimping inculcates the intern with a profound and abiding respect for his attending physician while ridding the intern of needless self-esteem. Furthermore, after being pimped, he is drained of the desire to ask new questions -- questions that his attending may be unable to answer. In the heat of the pimp, the young intern is hammeredand wrought into the framework of the ward team. Pimping welds the hierarchy of academics in place, so the edifice of medicine may be erected securely, generation upon generation. Of course, being hammered, wrought, and welded may, at times, be somewhat unpleasant for the intern. Still, he enjoys the attention and comes to equate his initial anguish with the aches and pains an athlete suffersduring a period of intense conditioning.
Despite its long history and crucial importance in training, pimping as a medical art has received little attention from the educational establishment. A recent survey reveals that fewer than 1 in 20 attending physicians have had any formal training in pimping. In most American medical schools, pimping is covered haphazardly during the third-year medicalclerkship or is relegated to a fourth-year elective. In a 1985 poll, over 95% of program directors admitted that the pimping skills of their trainees were "seriously inadequate." It comes as no surprise, then, that the newly appointed attending must teach himself how to pimp. It is to this most junior of attendings, therefore, that I offer the following brief guide to the art of pimping.
Pimpquestions should come in rapid succession and should be essentially unanswerable. They may be grouped into five categories:
1. Arcane points of history. These facts are not taught in medical school and are irrelevant to patient care -- perfect for pimping. For example, who performed the first lumbar puncture? Or, how was syphilis named?
2. Teleology and metaphysics. These questions lie outside the...