The New York Times, 14 March 2006
Does grilling medical students with questions make them into better doctors? For years, many professors routinely peppered students with relevant and arcane queries, often embarrassing them. Things may be gentler today, but the practice, referred to as the “pimping” of students, still has its advocates.
“Such questioning has always been used in medical education,” said Dr. Kenneth M. Ludmerer, a physician and historian of medicine at the Washington University School of Medicine and the author of “Time to Heal.”
A favorite time to grill students has been on rounds, when doctors and students examine hospitalized patients. Here, senior attending physicians may ask students to list the various types of lymphomas, point out structures on X-rays, describe clotting disorders or choose among antibiotics.
At times, particular students are singled out, especially if they are following the patient in question. If the student is having difficulty and the senior doctor keeps pushing, rounds may suddenly become very uncomfortable. At other times, other students or resident physicians may be allowed to bail out their colleagues.
Perhaps the most notorious location for this questioning is the operating room. Here, as organs are removed or repaired, students and professors may be in close contact for hours.
One surgeon who used the operating theater as a classroom was Alfred M. Markowitz, a longtime professor at the Columbia-Presbyterian Medical Center in New York.
Students preparing to scrub in with Dr. Markowitz quickly learned that they needed to read extensively about the operation they were about to witness. They were asked, of course, to identify various blood vessels or to describe how the liver, kidneys or intestines worked. But Dr. Markowitz was well versed in medical history and loved to ask students about obscure medical conditions.
One was primary alveolar hypoventilation, in which patients breathe without problems while awake but stop breathing when they sleep. The disorder, Dr. Markowitz would explain, was also called Ondine’s Curse, in honor of a mythological water nymph who was cursed to die if she ever fell asleep.
He also quizzed students about Meckel’s diverticulum, a small pouch on the intestinal wall of 2 percent of the population. And, yes, students were expected to know about Meckel, a 19th-century German physician who figured out that the diverticulum was a piece of leftover tissue from the embryo.
David D. Markowitz, Dr. Markowitz’s son, now an internist at Columbia, said his father asked questions “to make students reflect on the history of the medical profession.”
The father’s teaching was “a nonthreatening way to start a dialogue,” the younger Dr. Markowitz said, harking back to an era when senior doctors saw themselves as mentors.
Not all professors were so avuncular. This is what led Dr. Frederick L. Brancati, then a chief resident at the University of Pittsburgh Medical Center, to publish an article, “The Art of Pimping,” in 1989 in The Journal of the American Medical Association.
The article was satirical, chiding medical schools for not adequately training professors in pimping. But beneath the humor was a serious message. Pimping was used by insecure senior physicians to belittle vulnerable students and show them who was boss.
Dr. Brancati’s article was part of a growing literature on “medical student abuse,” which criticized the practice and other hazing rituals for traumatizing and dehumanizing vulnerable medical students. At one medical school, upperclassmen even provided new matriculants with an advice manual titled “Pimping and the Art of Self-Defense.”
A few physicians continued to support pimping, like one who advocated some “denting” of students’ “immense egos.”
Indeed, the relentless questioning has not gone away. A current medical student told me that she and a classmate were repeatedly subjected to it on a particular rotation. The classmate cried each day after rounds.
Still, the technique is used less frequently and with less intensity. As medical schools increase attention to students’ emotional well-being, Dr. Ludmerer says, pimping plays a diminished role.
Or it has changed in nature. In a recent article in the journal Teaching and Learning in Medicine, Delese Wear, a professor of behavioral sciences at the Northeastern Ohio Universities College of Medicine, reported that modern pimping was rarely malignant but rather supportive and “spine building.”
As a result of changes, Dr. Wear concluded, many students now see it as an effective pedagogical tool.
And what has become of operating room trivia? In an era of laparoscopic and robotic surgery, students are less likely to have extended interactions with senior surgeons.
And so they may not learn why surgical tape is white, something that Alfred Markowitz taught Arlene H. Markowitz, his daughter, now an ear, nose and throat specialist in New York. The tape is white, she remembers a quarter of a century later, because it contains zinc, which helps to fight infections.
Correction: March 21, 2006 A commentary article in Science Times last Tuesday about medical professors’ grilling of their students, especially on hospital rounds, referred incorrectly to a disorder that was the subject of one such quiz. The disorder, Ondine’s curse, was named for a mythical nymph who cast a spell on her unfaithful husband, leaving him unable to breathe if he fell asleep. Ondine herself was not cursed.