Clinical Guide The Nerd's Guide to Pre-Rounding Table of Contents Part 7. Pimping and the Art of Self-Defense "Pimping" refers to superiors asking a med student "on-the-spot" questions to see if they paid attention in the first two years of school. Many students hate to be pimped, since it makes them feel, well, "on-the-spot." If you don’t know something off the top of your head, you feel (even if you don’t look) stupid. Have a Method The key to pimping is this: While it’s good to be able to give the particular answers your pimper is looking for, often what they want to see is that you have a systematic approach to thinking about a problem. Sometimes, even if you don’t know a patient’s particular diagnosis, showing you have a approach to the problem will earn you credit. I’ve often proceeded to give a particular diagnosis as an answer, only to have the resident stop me and ask for a broader differential. Let’s take the following example: ATTENDING: What do you think of your patient’s shortness of breath? STUDENT: (Ulp!)…. Well, uh… It’s due to her congestive heart failure… (I guess…) ATTENDING: Is that all? STUDENT: Um… Well, that’s what she has! I mean, I guess she could have pneumonia… Better approach: ATTENDING: What do you think of your patient’s shortness of breath? STUDENT: Well, I know our patient has CHF, which can cause this. But in general, when I think of shortness of breath, first I think of lung-related problems. Problems in the lung that could cause dyspnea could be infectious, such as pneumonia or empyema… Or could be vascular, such as an embolism… Or could be due to a cancer, or other space-occupying lesion…. Or surgical trauma, causing a pneumothorax. There’s also cardiac-related problems that could cause shortness of breath, such as congestive heart failure leading to pulmonary edema… There could be a hematological cause, like anemia… This latter example combines two approaches to creating a differential: The organ- or system-based approach, and the etiological approach. The latter style can be summarized with the mnemonic "CHOPPED MINTS," which stands for Congenital, Heme, Organ failure, Pregnant, Psych, Environmental, Drugs, Metabolic-endocrine, Infection, Neoplasm, Trauma, Surgery-iatrogenic. Similar mnemonics include "INDIRECT" and Dr. Molly Cooke’s favorite, "VINDICATE." This advice may not apply to every situation, but keep it in mind. Attendings have a stereotyped idea of what med students should know, and they often expect you to give answers in terms of mechanisms of disease, not specific diagnoses. Be Ready If possible, read up on as many of your patient’s problems as possible before you encounter a resident or attending. Use the Ferri manual or a similar quick reference. If you’re going into the OR, review the basic anatomy and nature of the procedure beforehand (Surgery Recall is an excellent resource for such ad hoc reviewing). During my surgery rotation, an unfortunate student (not from UCSF) went into the OR without even knowing what surgery was being performed. BAD IDEA! When he caught a glimpse of a vessel, he blurted out, "Is that the aorta?" WORSE IDEA! - because this was a popliteal bypass - he was looking at the patient’s knee! Ouch! The attending screamed, "Get him out of here!" (Not a very civilized reaction to a hapless student’s faux pas, but not surprising.) I suppose that’s one way to avoid getting pimped in the surgery suite… UCSF takes pains to enforce the rule that students go home as early as possible when not on call, so we can study. USE THE TIME. Be ready. By the way: JAMA ran an essay about pimping many years ago.[16] The piece is a satire advising young attendings on the best way to intimidate students and house officers with inane questions. It offers some funny, if not practical, examples of how students avoid answering tough questions—and how attendings can counteract these countermeasures. Weirdly, most of the letters written in response to the essay apparently took it seriously, and critiqued its historical inaccurancies; questioned the legitimacy of the word "pimping," which doesn’t appear in any English dictionary; and castigated the author for promoting a practice that has a negative effect on morale! Guys, lighten up! [16] Brancati, F. L. The art of pimping. JAMA. July 7,1989;262(1):89-90. Replies in Nov 10, 1989;262(18):2541-2.[Back]