Pimping for the pimpee

This post is part 2 of a 4-part series. The first part was “Pimping in perspective“.

There is little doubt that when pimping goes bad it can be a horrible experience. Malignant pimping can be humiliating for the pimpee, painfully uncomfortable for bystanders, and may even leave the pimper feeling guilty and apologetic if the consequences were unintended. At its worst pimping can be a form of medical student/ junior doctor abuse and bear similarities to the harsh dehumanizing methods of basic training in the military:

The military training area is spatially segregated from the larger community to assure the absence of competing authorities. Rewards and punishments are meted out according to how well one obeys. A period of several weeks is spent in basic training. Although its ostensible purpose is to provide the recruit with military skills, its fundamental aim is to break down any residues of individuality and selfhood.

Stanley Milgram. Obedience to Authority. 1817: 181

(WARNING: The video excerpt below is from Kubrick’s classic film, “Full Metal Jacket” – it contains extremely “colorful” and insulting language that is designed to offend – don’t let your grandmother see you watching it).

Brancati describes “the dodge”, and “the bluff” (in its various guises: “hand gesturing”, “feigned erudition”, or “appeal to higher authority”) as the classic defensive strategies for the pimpee.

The dodge –  an attempt to avoid the question and waste valuable pimping time. It generally comes in two forms, namely (1) answering a question with a question or (2) answering a question other than the one that was asked. A variant is “the stall” which involves a slow build up to an answer that never comes. The stall is is commonly employed when describing a chest radiograph, with excessive amount of time spent on describing the orientation of the film, for instance.

The bluff– Brancati describes 3 varieties of bluff, all of which imply that the pimpee is knowledgeable, but without providing any substance:

  • Hand waving – stock phrases that refer to hot topics in medicine, but lack any explanatory power. The word ‘process’ is often in there somewhere, e.g. “the process involved is a membrane transport phenomenon”.
  • Feigned erudition -Brancati describes this type of bluff succinctly: “The intern’s answer, though without substance, suggests an intimate understanding of the literature and a cautiousness born of experience.” For example, “Hmmm . . . to my knowledge, that question has not been examined in a prospective controlled fashion”.
  • Higher authority – the pimpee’s answer, although wrong in the yes of the pimper, is attributed to by the pimpee to a higher authority. The most effective short-term strategy is to attribute the quote someone who it would be politically inconvenient for the pimper to disagree with.

However, I think the pimpee needs more strings to their bow than just these gambits when it comes to defending against malignant pimping. Other approaches, largely based on Detsky’s “pimping protection procedures” [pubmed], include:

“Avoidance”– Detsky lists 3 variations of this strategy, all of which aim to avoid eye contact with the prospective pimper:

  • “the eclipse” – ensure another person’s head is between the eyes of the pimper and yours.
  • “the camouflage” – keep very still and try not to be noticed.
  • “the meditation” – lower your head, lean forward, and press your palms together. You might even try humming as a last resort if you feel like you’ve been spotted.
  • Another variant of the avoidance strategy is to stand to the left of the patient. As doctors ‘always’ examine a patient from the right side of the bed it is generally easiest to target a prospective pimpee standing in such a prime pimping position. However, the practiced pimper is never naive to this feeble formula and may well target the first potential pimpee that makes any move in the ‘leftward’ direction.

“The muffin” – a technique that relies on a basic human aversion to seeing other people speak with their mouths full (just ask my wife!). The position of the hand-held muffin should correlate with the product of the likelihood of being targeted by the pimper multiplied by the likelihood of the muffin-holder not knowing the answer. If a question is about to be directed at the pimpee, and the pimpee does not know the answer, the muffin should be rapidly inserted into the pimpee’s mouth. Detsky, clearly a physician of great wisdom, advises the pimpee to feign choking should the pimper be sufficiently inhuman (usually a surgeon) to still direct a question at a person with a muffin-filled mouth. If you then resuscitate yourself with a back slap – or even better, a precordial thump – bystanders will applaud you and you will never be pimped again.

“The hostile response” – this is a high risk maneuver that I personally do not advocate. Detsky claims 100% effectiveness if you say the words ‘I don’t know’ with a 1-second pause between each successively louder spoken word. I would add that the effectiveness is increased to 200% if, while saying this, you stare unblinkingly into the pimper’s eyes whilst unfolding the lapel of your white coat to unveil the protruding butt of a loaded Glock. Unfortunately, while you are unlikely to ever be pimped again, your career in medicine will be short.

“The list” – Detsky shows true cunning here – if the pimper asks “what are the life-threatening causes of chest pain?” (for instance) and other pimpees have already given answers, just pretend that you were checking your pager or attending to some other “putting patients first” task, then repeat the previously mentioned correct answers in your most innocent-sounding voice.

“The honorable surrender” – bit of a cop out this one, some would say it is only for the faint of heart. Tell the pimper, with utmost sincerity, that you’re uncomfortable being put on the spot in public. On second thought, this could be the ballsiest approach of all…

“The pimp back” – The skillful pimpee knows that pimpers can only ask questions about a topic they are certain they know more about than the prospective pimpees. There are two options here. The simplest is to be the quickest draw and shoot a question from the hip before the pimper has even got started. A more difficult technique is to use verbal jiu-jutsu to change the momentum of the question and throw it straight back at the pimper. The efficacy of the pimp back improves if you’ve had two, but not three, cans of beer just before the the pimp session begins.

“The politician’s approach” – I’d never use this approach because I’d hate to ever be mistaken for a politician. Nevertheless for the less scrupulous, here is the technique as described by Detsky. The pimpee receives the pimper’s question, then turns to the rest of the audience and answers the question the pimpee would have preferred to have been asked – while completely ignoring the pimper. Detsky claims that elite pimp protectionists can combine this with “the pimp back” to devastating effect.

“The PDA wave” – PDAs, or personalized digital assistants, give the pimpee the advantage of real time searches. The difficultly is in concealing the search from the pimper. One approach is to prophylactically wave the PDA in front of the pimper before being pimped so that they are aware of the unlimited source of “pimp backs” you have up your sleeve. Another approach is to collude with other pimpees so that those not in the spotlight can search for the answer and surreptitiously feed the spotlit pimpee the answer (important: be certain that you know the difference between friend and foe before attempting this).

Don’t sulk or cry or faint – You don’t want to be remembered for the wrong reasons do you? A house surgeon once fainted while assisting one of my old surgical bosses. Legend has it that after he hit the floor, the surgeon rolled him away with his foot and told the scrub nurse, “This house dog is broken, get me another one.”

You’ll have to wait for the fourth and final post in this series to learn about my favorite strategy: “The Get Out Of Jail Card” .

This post is part 2 of a 4-part series. The next post will focus on “pimping for the pimper” and pimping etiquette.

Life in the Fast Lane Pimping Posts

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of three amazing children.

On Twitter, he is @precordialthump.

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