In defense of good pimping: the Socratic methodGregory M Marcus, MD

University of California, San Francisco, United States

Socrates was executed for berating ancient Athenians with questions inorder to test their knowledge. I try to keep this in mind when badgeringtrainees for the same purpose. Of course, questioning to the point of what ismaybe best described as “learner discomfort” is no longer acceptable inmany institutions, even when the questioner is motivated by a genuineintent of providing education. Such a teaching style has been describedpejoratively as “pimping,” a verb that conjures visions of a senior clinicianridiculing and humiliating a medical student or trainee with a barrage ofquestions that are unanswerable. In stark contrast, it is my observation thatthe great majority of physicians in both academia and clinical practice view“the Socratic Method” as something to be emulated, a logical and effectivemethod of teaching with a degree of sophistication, steeped in tradition,and carried down from one of the greatest thinkers in the history ofWestern civilization.

Assuming all that is true, we are faced with a paradox: both “pimping” and“the Socratic Method” are dispensed with the intent of teaching by askingquestions, but the connotations of each are negative on the one side andpositive on the other. Therefore, it is likely worthwhile to explore each ofthese terms to better arrive at an understanding of what is in fact good andbad about teaching via questioning. Ideally, such an exploration will guideus toward an appropriate balance in using this technique withouttrepidation for fear of “pimping” while maintaining sufficient intensity tocarry out the “Socratic Method” in the best possible sense of the term.

What is the origin of the term in medicine, and how is it understood? Aclassic article addressing the term’s etymology is a hilarious and insightfulsummary, with wonderful references from Sir William Osler and other

figures from as far back as the 17th century.1 Notably however, the articlehas no references, and, in fact, the colorful quotes revealing the origins ofthe term arise from the author’s creativity rather than any historical fact(confirmed by personal communication with Dr. Brancati). The point is thatthe meaning of the word relies on our use of it and our interpretation—there can be Good Pimping, and there can be Bad Pimping.

Anecdotally, it has amazed me how the term has permeated Americanmedical institutions: regardless of where a physician attended medicalschool or received their training, knowledge of “pimping” appears to beubiquitous. An informal poll of faculty at one institution revealed that,while all were certainly familiar with the term, “pimping” was universallythought to have a negative connotation. Does this mean then that we, asteachers, should shy away form challenging our students by askingquestions? Should our concern regarding potential discomfort by havingthem think on their feet dissuade us from using this conventional andpotentially stimulating teaching technique? In fact, there has been only onepublished study on the subject, showing that pimping was viewed by fourth-

year medical students as a potentially useful learning tool.2 And so, perhapspimping can be “good”, but, before it can recommended, I submit that thereare three criteria that should be followed, each gleaned from anexamination of the true “Socratic Method” as found in the works of Plato.

Of note, there are no known historical documents written by Socrateshimself. His philosophies are provided primarily in the writings of one ofhis students, Plato, who portrayed Socrates as a central figure in his works.

In order to understand the Socratic Method, first one must understandPlato’s epistemology, his theory of the nature of knowledge.

Plato, and presumably Socrates, believed that all humans are born with allknowledge. This theory is explained in Plato’s Meno, a work composed of a

dialogue between Socrates and his friend, Meno.3 They attempt to answerthe question, “Can virtue be taught?” Meno initially makes the point that ifyou do not known what virtue is, you will never be able to recognize it, and,if you already know what it is, you will never have any motivation to searchfor it. Socrates answers with his theory of the nature of knowledge: “Theysay that the human soul is immortal . . . As the soul is immortal, has beenand has seen all things here and in the underworld, there is nothing which ithas not learned.” In short, we are all born with knowledge of everything. Hegoes on to explain, “For searching and learning are, as a whole,recollection.” So, we do not learn anything new, we simply come torecognize or remember things we already know. Meno is doubtful. Socratestherefore provides a demonstration.

Socrates invites one of Meno’s “many attendants” for a lesson. The chosenattendant is an uneducated young man, for whom Socrates draws a squarein the sand. Socrates begins with a few simple questions, demonstratingthat the young man understands that the square has four equal sides and,given the information that one side is two feet long, can then calculate thearea of the square. “You see Meno, that I am not teaching the boy anything,but all I do is question him.”

Socrates continues, now asking his learner what the length of the sides of asquare twice the size of the original square would be. The learnerconfidently answers that they would be twice that of the original (four feet),but, with Socrates’ help (via more questioning), soon realizes that this

would make a 16 foot rather than an 8 foot square. The learner stands silentand dumbfounded. With the attendant wrapped in confusion, Socrates asksMeno, “Have we done him any harm by making him perplexed and numb?”Meno agrees that no real harm has come to his attendant. Socratescontinues, “Indeed, we have probably achieved something relevant tofinding out how matters stand, for now, as he does not know, he would beglad to find out.” By leading the learner until he struggles, Socrates hasaccomplished two things: first, he now better understands the extent of thelearner’s knowledge base and so better knows where to concentrate hisefforts. Perhaps more importantly, he has stimulated the learner to learn.Before meeting Socrates, this attendant likely cared little for geometry, butnow yearns to understand.

Ultimately, again with the help of Socrates’ persistent inquiry, the attendantdeduces the correct answer. Meno agrees that, since Socrates onlyquestioned the learner, the attendant must have found the knowledgewithin himself; he must have recollected what he appeared to be learning.

Does this mean that, to believe in the Socratic Method, we have to believe inreincarnation and an all-knowing immortal soul? What about informationthat is only recently generated, such as findings from clinical trials? Am Isuggesting that Socrates and Plato were born with the knowledge that theHOPE study demonstrated the utility of ACE inhibitors or that MADIT IIshowed that implantable cardioverter defibrillators save lives? No. There isa role for closely questioning learners about facts, but mainly for thepurpose of assessing knowledge level. Facts can be memorized, they can beresearched in the literature if forgotten, and findings from trials arerelatively transient—focusing all questions on these matters constitutes BadPimping. It is not the Socratic Method (or Good Pimping) if one only asksabout memorized facts at which the learner can only guess. When writing

about the immortal, all-knowing soul, Plato likely meant that we are allborn with the capacity to grasp certain concepts. Good pimping works toteach these concepts, ideas that the learner can deduce and has the capacityto understand.

The Meno therefore provides evidence of at least two necessary criteria inthe practice of Good Pimping: first, the questioning should be based on arespect for the learner, arising from the expectation that he has the capacityto understand; second, the questions should predominately focus onteaching concepts, something that the learner can truly deduce with theassistance of the teacher.

For example, if I want to teach an intern that right ventricular pacing isassociated with a paradoxically split second heart sound, I can simply tellhim that fact. Of course, the intern might find the fact difficult to rememberand unintuitive, a detail devoid of inspiration. However, if I ask him a seriesof questions such as “What happens to blood flow into the left and rightventricles during inspiration?” “On exhalation?” “What happens to thetiming of right and left ventricular activation during right ventricularpacing?” and so forth, he can struggle through the logical sense of thisconcept. It may not be an easy process, but it can be stimulating,invigorating, and a way for the learner to understand rather than simplyremember.

The third criteria required to practice Good Pimping is best described in

Plato’s The Apology.4 Here, Socrates is depicted defending himself againstthe charges of heresy and corrupting the young that ultimately led to hisexecution. He presents evidence that his frequent interrogations of hisfellow Athenians (his habitual use of his own method) have motivated thecharges against him and provides an explanation for his constant

questioning. He states that the Oracle at Delphi had reported that no onewas wiser than him. Socrates felt that he knew nothing and was unworthy ofsuch a statement. He subsequently set out to question all those known to bewise or skilled, hoping to prove that many were in fact wiser. To hisdisappointment, he determined that those who were known for theirwisdom had some knowledge, but, in fact, thought they knew more thanthey actually did. In the end, he was forced to agree with the Oracle’sstatement—at least he realized he did not know anything. The point is this:if one is to bring questions, one must be prepared to accept and evenembrace the answer, “I don’t know.” In fact, the acceptance of this phrasemore than anything else distinguishes Good from Bad Pimping. From TheApology, “This ignorance, which thinks that it knows what it does not, mustsurely be ignorance most culpable.”

It seems that we in medicine have an opportunity and responsibility to give“pimping” its meaning. We can shun it or run away from it, concernedregarding negative connotation or the possibility that we might make thelearner uncomfortable. Or, in our teaching, we can equate it with theSocratic Method, challenging our students, questioning them carefully withspecific concepts in mind, allowing them to struggle and discover, andaccepting “I don’t know” as an answer. At the root of this method must bethe mutual understanding that our questions stem from a respect for thelearner, and our belief that he has the innate capacity to understand theconcepts we hope to teach.

I would like to thank Amy J. Markowitz for her assistance in thepreparation of this manuscript.

References

1. Brancati FL. The art of pimping. JAMA 1989;262:89-90.2. Wear D, Kokinova M, Keck-McNulty C, Aultman J. Pimping:

perspectives of 4th year medical students. Teach Learn Med2005;17:184-91.

3. Plato, translated by G.M.A. Grube. Meno. Indianapolis, Indiana:Hackett Publishing Co., Inc., 1976.

4. Plato, translated by Hugh Tredennick. The apology. London, England:Penguin Group, 1969.

GREGORY M MARCUS, MD cardiac electrophysiologist and Director ofClinical Research in the Division of Cardiology at the University ofCalifornia, San Francisco. As an undergraduate major in philosophy, he wasawarded the Eric Paul Allison Memorial Prize for Outstanding Merit inPhilosophy at that University of California, San Diego. The following workoriginated as a talk while a Medicine Chief Resident given at StanfordUniversity Medical Center’s Medicine Grand Rounds.