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Words Matter: Removing the Word Pimp from Medical Education Discourse

      The history of medicine is littered with antiquated and harmful words that our profession has replaced with more appropriate and descriptive terminology. The word pimp, used to convey a style of teaching by question-asking, remains a persistent holdover propagated by medical educators, researchers, and trainees. As the #TimesUp and #MeToo movements demonstrate, we must identify and end sexual harassment and sexual assault in the workplace. Now is the time to critically examine the use of this oft-cited term and advocate for its removal from the lexicon of medical education.

      Separating Practice from Language

      Medical educators and researchers have described, opined upon, and studied the merits and demerits of using Socratic questioning with various types of learners.
      • Detsky A.S.
      The art of pimping.
      • McCarthy C.P.
      • McEvoy J.W.
      Pimping in medical education: lacking evidence and under threat.
      • Reifler D.R.
      The pedagogy of pimping: educational rigor or mistreatment?.
      We applaud discussions and investigations into how to optimize the learning environment and encourage deepening the state of research around question-asking practices and perceptions. At the same time, we call attention to the medical education community’s alarming use of the term pimp in various iterations (the art of pimping, bad pimping, benign pimping, worthwhile pimping, pimpingas a sport, pimper phenotype, pimping score). Since question-asking as an educational practice is an area of well-reasoned debate, we confine this commentary to the disparaging language used to name this activity, not the practice itself.

      Origins and Definitions

      Medical education has traditionally used questioning as a teaching practice. This method relies on teachers using a series of intentional questions to lead a learner on a journey of discovery. This method can also refer to using a series of intentionally unanswerable questions to humiliate and maintain the teacher’s hierarchy, or even domination, over the learner. Either as a whole, or only in relation to the latter, the pedagogical technique of asking questions has been referred to as pimping. With origins as early as the 17th century and possibly derived from the German word, pumpfrage (pump questions), the term pimp was described as a medical education method by Brancati in JAMA in July 1989.
      • Brancanti F.L.
      The art of pimping.
      Regardless of the term’s origin, many of us in medicine associate the word pimp, if not with this pedagogical exercise, with its colloquial use: a criminal, usually male, who solicits and exerts control over sex workers.

      A Poor Attempt at a Synonym

      Medical educators have questioned the use of the word pimp, with Martin and Wells
      • Martin G.C.
      • Wells D.M.
      Nothing artful about the term 'pimping.
      writing, “a word that refers to an immeasurably harmful practice is an ill-suited synonym for a pedagogical exercise.” As this term has exploitative and abusive connotations, it must be abandoned, even when selectively applied to question-asking styles that have negative intent.

      Replacing Historical Relics with Descriptive Terminology

      Some eponyms evolve into definitions (such as the Socratic method); however, as with many medical eponyms, some terms in medicine may be of historical interest but are not the most effective or professionally aligned means to describe a concept. There are precedents in medicine of eponyms and language being discarded, at times because the eponymous person was a perpetrator of heinous crimes (Reiter’s syndrome, now termed reactive arthritis) or because the language was stigmatizing and an impediment to care (drug abuse, now termed substance use disorder). The replacement terminology is more precise and descriptive, a concept that can guide us in a search for an alternative to the word pimp.

      Everyone is Listening

      The conversations we have in our classrooms, workspaces, clinics, and hospitals permeate far and wide into the educational ecosystem. Trainees, many of whom are in a vulnerable position by virtue of their role in the learning environment, are listening. We cannot predict how individuals will incorporate degrading vocabulary into their perceptions of the medical education culture.
      Germane to this matter is the expanding female physician workforce and alarmingly high rates of mistreatment.

      Association of American Medical Colleges. 2017 applicant and matriculant data tables. Available at: https://aamc-black.global.ssl.fastly.net/production/media/filer_public/5c/26/5c262575-52f9-4608-96d6-a78cdaa4b203/2017_applicant_and_matriculant_data_tables.pdf. Accessed April 14, 2019.

      A meta-analysis of 51 studies reported 59.4% of medical trainees experienced harassment or discrimination, with female trainees being more likely to have these behaviors directed at them.
      • Fnais N.
      • Soobiah C.
      • Chen M.H.
      • et al.
      Harassment and discrimination in medical training: a systematic review and meta-analysis.
      Educators have called for systematic and institutional approaches to this problem, including dismantling harmful power differentials, encouraging faculty interventions, and strengthening commitments to inclusion and respect for all.
      • Dzau V.J.
      • Johnson P.A.
      Ending sexual harassment in academic medicine.
      A medical school or residency program that uses inherently gendered and demeaning words like pimp to describe a pedagogical technique could offend, alienate, or even trigger a portion of the training cohort and their allies. If a disparaging (let alone unhelpful) term such as pimp could negatively affect even a fraction of our learners, it is simply not worth using. Changing our language is an essential means by which we can support trainees and fortify our educational communities. As educators abandon such terms, we could precipitate a shift in the educational climate such that trainees feel empowered to stop using these words to describe faculty, reinforcing a mutual culture of respect.

      Our Patients

      We must consider how degrading this terminology may be to our patients. Undoubtedly, most patients associate the word pimp with sex traffickers, not with medical education pedagogy. In response to an editorial on the practice of pimping, Ravi
      • Ravi A.
      Pimping as a practice in medical education.
      writes about her experiences as a physician caring for sex trafficking survivors who have been victims of unimaginable violence perpetrated by pimps. If these patients hear the word pimp used in a clinical setting to refer to a teaching technique, or if they read the word in a medical journal without context, they will likely interpret this negatively. To associate traumatic experiences with a form of medical education pedagogy runs counter to the compassion we should model as health care providers.

      Possibilities

      What would happen if this word were removed as a term in medical education? Perhaps we could reprioritize focus on the principles of the question-asking practice itself. Trainees may be more likely to participate in teaching that was not called pimping. Educators may be more likely to engage in conversations and introspection into good question-asking principles if they were not called pimpers. Researchers might have more precision when describing elements of the educational exercise with terminology that is not a derivative of the word pimp. Alternative names for this teaching style (particularly when used with negative intent) that are more descriptive include improper Socratic method or malignant questioning.
      We support educators who are properly employing Socratic questioning and those who are researching this pedagogical tool. We call for a robust change in language when referring to this activity. Although the adoption of new vocabulary may be gradual, redefining terminology has a precedent in medicine. The language of medical education should be precise, descriptive, devoid of stigma, and not undermine teaching. We see an opportunity to remove the term pimp from our medical education vocabulary to the benefit of our learners and our profession.

      Acknowledgments

      We thank the Harvard Medical School Academy Medical Education Fellows class of 2018-2019 for their important intellectual input. We also acknowledge Dr. Richard Schwartzstein for his thoughtful review of the work.

      References

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        JAMA. 1989; 262: 89-90
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      1. Association of American Medical Colleges. 2017 applicant and matriculant data tables. Available at: https://aamc-black.global.ssl.fastly.net/production/media/filer_public/5c/26/5c262575-52f9-4608-96d6-a78cdaa4b203/2017_applicant_and_matriculant_data_tables.pdf. Accessed April 14, 2019.

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        Harassment and discrimination in medical training: a systematic review and meta-analysis.
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        Ending sexual harassment in academic medicine.
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        Pimping as a practice in medical education.
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