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Brancati- The Art of Pimping and Other Articles

Brancati- The Art of Pimping and Other Articles

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Published by: Javid Moslehi on May 19, 2013
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The
Art
of
Pimping
IT'S
HARD
work
becoming
a
revered
attending
physician
in
a
university
hospital.
The
task
daunts the
newlyappointed
 junior
attending
as
he
strides
down the
corridor
of
his
first
ward
with
his
first
team.
Oh,
he's
made
some
changes
in
anticipation
of
his
new
position.
He's
wearing
a
long
coat
now,
an
all-cotton
coat
with
razor-sharp
creases
and
knit
buttons.
The
stained,
shrunken
polyester
white
pants
and
tennis
shoes
have
given
way
to
gray,
light
wool
slacks
with
a
cuff
and
polished
loafers.
Framed
certificates
bear
testimony
to
his
intelligence
and
determination.
He
should
be
ready
to
takethe
helm
of
his
ward
team,
but
he's
not.
Something's
missing,
something
important,
something
closer
to
art
than
to
science.
When
physicians
talk
about
the
"art
of
medicine"
they
usually
mean
healing,
or
coping
with
uncertainty,
or
calculating
their
federal
income
taxes.
But
there's
one
art
this
new
attending
needs
to
learn
before
all
others:
the
art
of
pimping.
Pimping
occurs
whenever
an
attending
poses
a
series
of
very
difficult
questions
to
an
intern
or
student.
The
earliest
reference
to
pimping
is
attributed
to
Harvey
in
Londonin
1628.
He
laments
his
students' lack
of
enthusiasm
for
learning
the
circulationof
the
blood:
"They
know
nothing
of
Natural
Philosophy,
these
pin-heads.
Drunkards,
sloths,
their
bellies
filled
with
Mead
and
Ale.
O
that
I
might
see
them
pimped!"
In
1889,
Koch
recorded
a
series
of
"Pümpfrage"
or
"pimp
questions"
he
would
later
use on
his
rounds
in
Heidelberg.
Unpublished
notes
made
by
Abraham
Flexner
on
his
visit
to
Johns
Hopkins
in
1916
yield
the
first
American
reference:
"Rounded
with
Osier
today.
Riddles
house
officers
with
ques¬
tions.
Like
a
Gatlinggun.
Welch
says
students
call
it
'pimping.'
Delightful."
On
the
surface,
the
aim
of
pimping
appears
to
be
Socratic
instruction.
The
deeper
motivation,
however,
is
political.Proper pimping
inculcates
the
intern
with
a
profound
and
abiding
respect
for
his
attending
physician
while
ridding
the
intern
of
needless
self-esteem.
Furthermore,
after
being
pimped,
he
is
drained
of
the
desire
to
ask
new
questions—questions
that
his
attending
may
be
unable
to
answer.
In
the
heat
of
the
pimp,
the
young
intern
is
hammered
and
wrought
into
the
framework
of
the
ward
team.
Pimping
welds
the
hierarchy
of
academics
in
place,
so
the
edifice
of
medicine
may
be
erected
securely,
generation
upon
generation.
Of
course,
being
hammered,
wrought,
and
welded
may,
at
times,
be
somewhat
unpleasant
for
the
intern.
Still,
he
enjoys
the
atten¬
tion
and
comes
to
equate
his
initial
anguish
with
the
aches
and
pains
an
athlete
suffers
during
a
period
of
intense
conditioning.
Despite
its
long
history
and
crucial
importance
in
training,
pimping
as a
medical
art
has
received
little
attention
from
the
educationalestablishment.
A
recent
survey
reveals
that
fewer
than
1
in
20
attending
physicians
have
had
any
formal
training
in
pimping.
In
most
American
medical
schools,
pimping
iscovered
haphazardly
during
the
third-year
medical
clerkship
or
is
relegated
to
a
fourth-year
elective.
In
a
1985
poll,
over
95%
of
program
directorsadmitted
that
the
pimping
skills
of
their
trainees
were
"seriously
inadequate."
It
comes
as
no
surprise,
then,
that
the
newlyappointed
attending
must
teach
himself
how
to
pimp.
It
is
to
this
most
junior
of
attendings,
therefore,
that
I
offer
the
following
brief
guide
to
the
art
of
pimping.Pimp questions
should
come
in
rapid
successionand
should
be
essentially
unanswerable.
They
may
be
grouped
intofive
categories:
1.
Arcane
points
of
history.
These
facts
are
not
taught
in
medical
school
and
are
irrelevant
to
patientcare—perfect
for
pimping.
For
example,
who
performed
the
first
lumbar
punc¬
ture?
Or,
how
was
syphilis
named?
2.
Teleology
and
metaphysics.
These
questions
lie
outside
the
realm
of
conventional
scientific
inquiry
and
have
tradition¬
ally
been
addressed
only
by
medieval
philosophers
and
the
editorsof
the
National
Enquirer.
For
instance,
why
are
some
organs
paired?
3.
Exceedingly
broad
questions.
For
example,
what
role
do
prostaglandins
play
in
homeostasis?
Or,
what
is
the
differen¬
tial
diagnosis
of
a
fever of
unknown
origin?
Even
if
the
intern
begins
making
good
points,
after
4
or
5
minutes
he
can
be
cut
off
and
criticized
for
missing
points
he
was
about
to
mention.
These
questions
are
ideally
posed
in
the
final
minutes
of
rounds
whilethe
team
is
charging
down
a
noisy
stairwell.
4.
Eponyms.
These
questions
are
favored
by
many
old-
timers
who
have
assiduously
avoided
learning
any
new
devel¬
opments
in
medicine
since
the
germ
theory.
For
instance,
where
does
one
find
the
semilunar
space
of
Traube?
Or,
whose
name
is
given
to
the
dancing
uvula
of
aortic
régurgitation?
5.
Technical
points
of
laboratory
research.
Even
when
gen¬
eral
medical
practice
has
become
a
dim
and
distant
memory,
the
attending
physician-investigator
still
knows
the
details of
his
research
inside
and
out.
For
instance,
how
active
are
leukocyte-activated
killer
cells
with
or
without
interleukin
2
against
sarcoma
inthe
mouse
model?
Or,
what
base
sequence
does
the
restriction
endonuclease
Z?coRI
recognize?
Such
pimping
should
do
for
the
third-year
student
what
the
Senate
hearings
did
for
Robert
Bork.
The
intern,
in
contrast,
is
a
seasoned
veteran
and
not
so
easily
rattled.
Years
of
relentless
pimping
have
taught
him
two
defenses:
the
dodge
and
the
bluff.
Dodging
avoids
the
question,
wasting
time
as
well
as
a
valuable
pimp
question.
The
two
most
common
forms
of
dodg-
From
the
Department
of
Medicine,
University
of
Pittsburgh
(Pa).
Reprint
requests
to
10404
Presbyterian-UniversityHospital,
DeSoto
at
O'Hara
streets,
Pittsburgh,
PA
15213
(Dr Brancati).
 
ing
are
(1)
to
answer
the
question
with
a
question
and
(2)
to
answer
a
different
question.
For
example,
the
intern
is
asked
to
explain
the
pathophysiology
ofthrombosis
secondary
to
the
lupus
anticoagulant.
He
first
recitesthe
clotting
cascade,
then
recalls
the details of
a
lupus
case
he
admitted
last
month,
and
closes
by
asking
whether
pulse-dose
steroids
are
indicated
for
lupus
nephritis.
The
experienced
attending
immediately
diag¬
noses
this
outpouring
as
a
dodge,
grabs
the
intern
by
the
scruff
of
the
neck,
and
rubs
his
nose
back
in
the
original
pimp.
A
bluff,
unfortunately,
is
much
more
damaging
than
a
dodge.
Allowed
to
stand,
a
bluff
promulgates
a
lie
while
undermining
the
academic
hierarchyby
suggesting
that
the
intern
has
nothing
more
to
learn
from
his
attending.
Bluffs
weaken
the
very
fabric
ofAmerican
medicine,
threatening
our
livelihood
and
our
way
of
life.
Like
outlaws
in
a
Clint
Eastwood
movie,
bluffs
must
be
shot
on
sight—no
due
process,
no
Miranda
Act,
no
starry-eyed
liberal
notions
of
openness
or
dialogue—just
righteous
retribution.
Bluffs
fall into three
readily
discernible
categories:
1.
Hand
waving.
These
bluffs
are
stock
phrases
that
refer
to
hot
topics
in
biomedicine
without
supplying
detail
or
expla¬
nation.
For
example,
"It's
a
membrane
transport
phenome¬
non"
or
"The
effect
is
mediated
by
prostaglandins."
In
many
institutions,
they
may
evolve
directly
from
the
replies
of
Grand
Rounds
speakers
to
questions
from
the
audience.
2.
Feigned
erudition.
The
intern's
answer,
though
without
substance,suggests
an
intimate
understanding
of
the
litera¬
ture
and
a
cautiousness
born of
experience.
"Hmmm
...
tomy
knowledge,
that
question
has
not
been
examined
in
a
prospective
controlled
fashion"
is
a
common
form.
Frequent¬
ly,
the
bluff
is
accompanied
by
three
automatisms:
clearing
of
the
throat,
rapid
fluttering
of the
eyelids
and
tongue,
and
chewing
on
the
temples
of the
eyeglasses.
This
triad,
when
full-blown,
will
make
the
intern
bear
a
suddenresemblance
to
William
Buckley
and
is
virtually
pathognomonic.
3.
Higher
authority.
The
intern
attributes
his
answer
to
the
teaching
of
a
particular
superior.
When
the
answer
is
refuted,
the
blame
of
ignorance
comes
to
rest
on
the
higher
authority,
not
on
the
obedient,
accepting
intern.
The
strength
of
the
bluff
depends
on
 just
whom
is
quoted.
An
intern
quoting
a
 junior
resident
about
pathophysiology
is
every
bit
as
cogent
as
Colo¬
nel
Qaddafi
quoting
Ayatollah
Khomeini
about
international
law.
An
intern
from
an
Ivy
League
medical
school
quoting
the
"training"
he
received
on
his
medical
clerkship
goes
over
like
Dan
Quayle
explaining
the
Bill
of
Rights
at
an
ACLU
conven¬
tion.
The
shrewd
intern,
however,
will
quote
his
Chairman
of
Medicine
or
at
least
a
division
chief,
pushing
the
nontenured
attending
to
the
brink
of
political
calamity.
Did
the chairman
actually
say
thatl
The
attending
is
powerless
to
refutethe
statement
until
he
is
certain.
Indeed,
a
good
bluff
is
hard
to
handle. Sometimes
the
intern's
bluff
sounds
better
to
the
ward
team
than
the
attend-
ing's
correct
answer.
Sometimes
it
sounds
better
to
the
at-
tending
himself.
Ultimately,
the
cunning
intern
is best
dis¬
couraged
from
bluffing
by
aversive
training.
Specifically,
each
time
he
bluffs
successfully,
the
attending
should
counter
by
inducing
Sudden
Intern
Disgrace
(SID).
SID
is
induced
in
two
ways:
1.
Question
the intern's
ability
to
take
a
history.
This
tech¬
nique
depends
on
the
phenomenon
ofhistorical
drift.
That
is,
a
patient's
story
will
reliably
undergo
a
significant
change
in
the
8-
or
16-hour
interval
between
admission
and
attending
rounds.The
attending
need
only
go
to
the
bedside
and ask
the
same
questions
the
intern
didthe
night
before.
Nowthe
entire
case
is
seen
in
a
light
different
than
that
cast
by
the
intern's
assessment.
Yesterday's
right
upper
quadrant
cramping
be¬
comes
right-sided
pleuritic
chest
pain.
Yesterday's
ill-defined
midepigastric
"burning"
becomes
crushing
substernal
heavi¬
ness
radiating
to
the
arm
and
jaw.
Suddenly,
the
intern
is
disgraced.
He
will
never
bluff
again.
2.
Question
the
intern's
compulsiveness.
In
less
rigorous
programs,
this
is
easy.
Didthe
intern
examine the
peripheral
blood
smear
and
theurine
sediment
himself
?
If
the
intern
does
routinely
examine
body
fluids,
a
more
methodical
ap¬
proach
is
required.
In
this
case,
resultsofthe
following
tests,
procedures,
and
examinations
may
be
requested
in
rapid
succession:
Hemoccult
slide
test,
urine
electrolytes,
bedside
cold
agglutinins
and
serum
viscosity,
slit-lamp
examination,
Schi0tz'
tonometry,
Gram's
stain of the
buffy
coat,
transtra-
cheal
aspiration,
anoscopy,
rigid
sigmoidoscopy,
and
indirect
laryngoscopy.
Once
the
attending
discovers
a
test
or
examina¬
tion
left
unperformed,
he
asks
the
intern
why
this
obviously
crucial
point
was
neglected.
(The
tension
may
be
heightened
at
this
point by
frequent
use
of
the word
"cavalier.")
The
intern's
response
will
generally
revolve around
time
con¬
straints
and
priorities
in
diagnostic
evaluation.
The
attend-
ing's
rejoinder:
didthe
intern
eat,
sleep,
or
void
last
night?
The
scrupulous
intern
at
once
infers
that
he
has
placed
his
own
needs
before
the
needs
of
his
patient.
Suddenly,
he
is
dis¬
graced.
He
will
never
bluff
again.
Clearly,
pimping—good
pimping—is
an
art.
There
are
styles,
approaches,
and
a
few
loose
rules
to
guide
the
novice,
but
pimping
is
learnedin
practice,
not
theory.
Despite
its
long
and
glorious history,
pimping
is
in
danger
of
becoming
a
lost
art.
Increased
specialization,
the rise
ofthe
HMO,
and
DRG-
based
financing
are
probably
to
blame,
as
they
are
for
most
problems.
The
burgeoningbudget
deficit,
the
changing
demo¬
graphic
profile
ofthe
United
States,
the
Carter
Administra¬
tion,
inefficiency
at
the
Pentagon,
and
intense
competition
from
Japan
have
each
played
a
role,
though
less
directly.Against
this
mighty
array
of
historical
forces
stands
the
belea¬
guered
junior
attending
armed
only
with
training,
wit,
and
the determination
to
pimp.
It
won't
be
easy
to
turn
back
the
clock
and
restore
the
art
of
pimping
to
its former
grandeur.
I
only
hope
my
guide
will
help.
Frederick
L.
Brancati,
MD
 
populations
suggest
humor
may
be
of
therapeutic
benefit
to
hospitalized
pa-
tients.1
These
studies
are
generally
not
controlled
and
suffer from
possible
sub-
 ject-selection
bias
as
well
as
other
meth-
odological problems.
The
present
re-
port
suggests
the
helpful
effects
ofhumorin
hospitalized
patients
may
beless
than
previously
indicated.
Studies.
\p=m-\After
approval
by
the
ap-
propriate
research
committees,
two
groups
ofvolunteers
were
recruitedfor
these
projects.
All
were
competent,
male
veterans
willing
to
sign
the
ap-
proved
consent
form.
One
group
(8
pa-
tients)
received
transurethral
prostate
surgery
under
local
anesthesia2
and
the
second
group
(16
patients)
received
pe-
ripheral
(leg)
arteriography.3
Subjects
were
randomly
assigned
to
either
a
humor
or
ocean
sound
(control)
audiotape
condition.
The
humor
tape
consisted
of
a
recording
of
an
old
Jack
Benny
radio
show.
About
85%
of the
humor-tape
subjects
describedthe
tape
as
humorous
in
posttreatment
assess-
ment.
After
the
tapes
were
adjusted
to
the
patient's hearing,
both
groups
inboth
procedures
listened
to
the
1-hour
tapes
through
stereo
headphones
dur¬
ing
the
procedure.
In
the
transurethral
prostate
surgery
group,
six
patients
were
assigned
to
the humor
condition
and
two
to
thecontrolcondition.
In
the
arteriography
group,
seven
patients
were
assigned
to
the humor
condition
and
nine
to
the control
condition. No
significant
(P<.05)
differencesbetween
groups
receiving
either
procedure
were
found
in
age,
admission
heart
rate,
overall
hospitalization
distress
ratings,
initial
anxiety
scores,
personality
style
scores,4
or
ratings
ofthe
patients'
ability
to
hear
and
understand the
tapes.
Dependent
variables
assessed
during
the
transurethral
prostate
surgery
con¬
dition
were
heart
rates at
time of
resec-
toscope
insertion,
10
minutes
later,
and
after
its
first
use
for
cutting;
immediate
postoperative
State
Trait
Anxiety
In¬
ventory
scores;
postoperative
and
re¬
covery
room
heart
rates;
total
recovery
room
scores;
subjective
estimates
of
procedure pain
and
anxiety;
and
1-hour
postsurgical
heart
rate,
State
Trait
Anxiety
Inventory
score,
and
recovery
room
pain
levels.
Dependent
variables
assessed
during
the
arteriography
pro¬
cedure
were
heart
rates at
time
of
nee¬
dle
insertion,
at
time
of
dye
insertion,
and
3
minutes
after
dye
insertion;
imme¬
diate
postprocedure
State
Trait
Anxi¬
ety
Inventory
and
heart
rate
scores;
and
subjective
estimates
of
procedure
pain
and
anxiety.
No
statistically
significant
group
dif¬
ferences
were
found.
Small
patient
numbersmay
limit
study
generaliza-
tion.
However,
there
were
also
no
con¬
sistent
trends
between
groups
when
considering
both
physiological
(heart
rate)
and
psychological (subjective
anxietyratings)
variables.
For
exam¬
ple,
transurethral
prostate
surgery
pa¬
tients
in
the
control
group
reported
more
procedure
anxiety
but
less
proce¬
dure
pain
than
the
humor-tape
group.
Comment.—Caution
is
urged
in
ad¬
vocating
extensive
resources
for
"hu¬
mor
therapy.
"
While
the
therapy
proba¬
bly
does
not
hurt,
this
as
well
as
other
controlled
studies6
cast
doubt
on
the
ef¬
ficacy
of
humor-
or
music-tape
ap¬
proaches.
Further
controlled
research
is needed
to
find
out
if
humor
therapy
works
and,
if
it
does,
with
what
patients
and
under
what
conditions.
Joseph
K.
Neumann,
PhDVeterans
Administration
Medical
Center
Quillen-Dishner
College
ofMedicine
Johnson
City,
Tenn
Appreciation
is
expressed
to
Jo
Ann
Blankenship,
RN;
Dexter
Brummitt;
Carolyn
Cross,
RN;
Ellen
Ford,
RN;
Leo
Harvill,
PhD;
Helen
Hunt,
RN;
Jennifer
Ivey,
RN;
Piysuh
N.
Jnshi,
MD;
Senter
Jackson,
CRN
A;
Sankar
Lakshman,
MD;
Anthony
Paulantonio,
MD;
Hilton
W.
Pittman,
MD;
Steve
Simerly;
and Janice
Sutter,
RN.
Further
informa¬
tion
may
be
obtained
by
writing
to
the
author
at
Psychology
Service
(116B),
Veterans
Administra¬tion
Medical
Center,
Mountain
Home,
TN
37684.
1.
Ljungdahl
L.
Laugh
if
this
is
a
 joke.
JAMA.
1989;261:
558.2.
OrandiA.
Urological
endoscopic
surgeryunder
local
an-
esthesia:
a
cost-reducing
idea.
J
Urol.
1984;132:1146-1147.
3.
Srikantawsamy
S,
Segal
LI,
Chandramouli
S.
Percuta-
neous
Angiography.
Springfield,
Ill:
Charles
C
Thomas
Publisher;
1977.4.
Miller
SM,
Mangah
CE.
Interacting
effects
of informa-
tion
and
coping
style
in
adapting
to
gynecologic
stress:
should
the doctor
tell
all?
J
Pers
Soc
Psychol.
1983;38:223\x=req-\
236.5.
Reynolds
SB.
Biofeedback,
relaxation
training,
and
mu-
sic:
homeostasis
for
coping
with
stress.
Biol
Self-Reg.
1984;9:169-179.
Smiley's
People
To
the
Editor.\p=m-\Hospitals
are
stressful
places,
not
only
for
patients
and
fam-
ilies,
but
for
staff
as
well.
There
are
many
methods
of
stress
reduction
avail-
able
to
the
health
care
professional,
but
few
are
readily
accessible. We
suggest
the
use
of
a
simple
but
poorly
studied
method
of
decreasing
stress,
the
smile.
Smiling
is
an
unsophisticated
yet
effec-
tive
means
of
social
contact.
Selye1
noted
that
a
lack
of
socialization
plays
a
rolein
perpetuating
the
"stress
re-
sponse."
Increased
smiling
between
health
care
professionals
could,
there-
fore,
play
a
role
in
decreasing
stress.
The
followingstudy
was
undertaken
to
determine
the
effectiveness
of
a
smile in
eliciting
a
smiling
response.
A
multicenter
trial
using
a
prospec-
tive,
randomized
design
was
undertak-
en
to
test
the
followinghypothesis:
med-
ical
personnel
who
are
smiled
at
will
smile
more
than
those
who
are
not
smiled
at,
or,
in
medical
terms,
a
smile
is
contagious.
Three
hundred
medical
per-
sonnel
were
randomly
assigned
(coin
flip)
to
either
an
experimental
or
control
group.
Subjects
inthe
experimental
groupreceived
eye
contact
plus
a
smile
as
they
passed
the
investigator
in
the
hall,
while
those
in the
control
groupreceived
only
eye
contact.
The
resultsof
this
study supported
our
hypothesis.
Eighty-seven
percent
ofthe
staff
who
were
smiled
at
smiled
at
the
investigator,
while
only
8%
of
thecontrolgroupdid the
same
{\2,P<.
001).
Interestingly,
60%
ofthe
subjects
in
the
experimental
group
offered
a
"Hi"
or
other
salutation in addition
to
smiling.
This
research
supports
the
theory
that
a
smile
begets
a
smile.
Implementation
of
this
technique
has
the
potential
to
in¬
crease
socialization
and decrease
stress
in
large, impersonal
medical
centers.
It
is
highly
recommended
that
this
study
be
replicated
at
other
institutions,
not
only
with
staff,
but
with
patients
and
families
as
well.
Keep
smiling.
Beth
Henneman,
RN,
MSN
Janice
Hanc,
RN
UCLA
Medical
Center
Los
Angeles,
Calif
Philip
L.
Henneman,
MD
Harbor-UCLA
Medical
Center
Torrance,
Calif
1.
Selye
H.
The
Stress
of
Life.
New
York,
NY:
McGraw-HillInternational
Book
Co;
1974.
Pimper
Pimped
Pimper
Pimped
Pimper
Pimped
Pimper
Pimped
Pimper
Pimped
To
the
Editor.\p=m-\While
I
was
training
from
1971
to
1976,I experienced
"pimp-
ing"
on
several
occasions.
After
reading
Dr
Brancati's1
commentary
in
a
recent
issue
of
JAMA,
I
must
say
that
pimping
accomplished
only
four
things
for
me:
(1)
establishment
of
a
pecking
order
among
the
medical
staff;
(2)
suppression
of
any
honest
and
spontaneous
intellectual
question
or
pursuit;
(3)
creation
of
an
atmosphere
of
hostility
and
anger;
and
(4)
perpetuation
ofthe
dehumanization
for
which
medical education
has
been
criticized.
Thislast
point
is
probably
the
most
serious
complication
of
pimping.
Dr
Brancati
fears
that
pimping
is
"in
danger
of
becoming
a
lost
art."
Let
us
hope
that
it
becomes
exactly
that.
Pimp-
ing
has
no
place
in
the
medicine
that
I
practice
today.
Christopher
Stanton,
MD
FeatherRiver
Physicians
Portola,
Calif
1.
Brancati
FL.
The
art
of
pimping.
JAMA.
1989;262:89-90.
To
the
Editor.\p=m-\I
hope
that
Dr
Branca-
ti's
commentary1
will
not
render attend-
ing
rounds
dull
by
discouraging
all
"pimping."
He
gives
advice
on
how
not
to
pimp.
Medicine,
like
good
pimping,
should
stick
to
the
truth.
What
a
bluff:
 
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