PERSPECTIVES
J Oral Maxillofac Surg
A Foundational Framework for
Andragogy in Oral and Maxillofacial
Surgery II: Interactive Andragogies
Eric R. Carlson, DMD, MD, EdM,* and R. John Tannyhill, DDS, MDy
Interactive andragogies have been effectively intro-
duced into postgraduate medical education settings
for quite some time. One purported, although counter-
productive, interactive andragogical technique is
medical pimping. Medical pimping is an educational
strategy in which an attending physician rapidly
proposes difficult questions to residents during
conferences, inpatient rounds, or operating room
activities. In 1916, Abraham Flexner witnessed Sir
William Osler quickly and somewhat indignantly
questioning his residents, which was described as
‘‘pimping’’ according to students at Johns Hopkins
Hospital.1 Although the goal of medical pimping might
be to motivate residents, medical pimping often falls
short of this goal because a knowledge hierarchy is
established that is counterproductive. Pimping
becomes a one-on-one exercise between an academic
physician equipped with medical trivia and an intimi-
dated resident where questions are considerably
esoteric such that the answers are strategically under-
stood only by the faculty member asking the
questions. In fact, the questions might be so trivial
that they are essentially unanswerable.2 The andra-
gogy can be defined as a sport in which a fine line
exists between educational rigor and mistreatment.
In graduate medical education, pimping possesses
4 negative characteristics: the creation of a pecking
order, the suppression of honest and spontaneous
intellectual questions, the establishment of a hostile
environment, and the perpetuation of dehumanization
for which graduate medical education has occasionally
been criticized.3
*Professor and Kelly L. Krahwinkel Chairman, Department of Oral
and Maxillofacial Surgery, Director of Oral and Maxillofacial Surgery
Residency Program, University of Tennessee Medical Center, and
Director of Oral/Head and Neck Oncologic Surgery Program,
University of Tennessee Cancer Institute, Knoxville, TN.
yInstructor in Oral and Maxillofacial Surgery, Harvard School of
Dental Medicine, and Director of Oral and Maxillofacial Surgery
Residency Program, Massachusetts General Hospital, Boston, MA.
Conflict of Interest Disclosures: Dr Carlson receives book
royalties from Wiley Blackwell and Elsevier.
1101
77:1101-1102, 2019
Many faculty have incorrectly equated medical
pimping with the Socratic method of teaching. The
questions Socrates posed to his students were
intended to place their knowledge base under intense
scrutiny that would lead to the refutation of their
beliefs. This practice is commonly carried out in didac-
tic conferences and inpatient rounds when a resident
is given the opportunity to defend his or her beliefs
about medical or surgical care. Because care is tailored
to individual patients, decisions are often not clear-cut
and the Socratic method of teaching results in
residents having to justify their patient care decisions
based on such questioning. In doing so, Socratic teach-
ing is based on the belief that knowledge exists within
a learner and is divulged through a series of humanely
posed questions with group collaboration. The deter-
mination of knowledge occurs through group collabo-
ration, exploring questions lacking a specific answer,
thereby activating prior knowledge, with reflection
on the collaborative discussion taking place.2
The use of Socratic teaching, the quintessential
interactive andragogy, is very effective in graduate
medical education.1,2 The goal of medical pimping is
to evaluate residents through hierarchal order; by
contrast, the goal of the Socratic method of teaching
is to connect new knowledge to existing knowledge
and to effectively teach. Whereas the setting of
medical pimping is a one-on-one focus of esoteric
questions, the goal of the Socratic method of teaching
is group learning through probing and leading and
thereby making educationally meaningful connec-
tions. With proper professional development, faculty
Address correspondence and reprint requests to Dr Carlson:
Department of Oral and Maxillofacial Surgery, University of Tennes-
see Medical Center, 1930 Alcoa Hwy, Ste 335, Knoxville, TN 37920;
e-mail: ecarlson@mc.utmck.edu
Received January 26 2019
Accepted January 27 2019
Ó 2019 American Association of Oral and Maxillofacial Surgeons
0278-2391/19/30130-2
https://doi.org/10.1016/j.joms.2019.01.054
1102
will instill critical thinking capabilities in their
residents through interactive andragogies with 3
educational objectives.2 First, questioning should be
purposeful in that the question’s primary objective
should be firmly established by the faculty member.
The question should not be esoteric and should permit
a step-by-step pathway to the correct answer in a
collaborative fashion. Second, the faculty member
should ask questions that encourage residents to apply
their existing knowledge base to a clinical or didactic
scenario. Supportive of this statement is the circum-
stance of establishing a differential diagnosis of a
patient’s condition. The acquisition of additional
patient historical information, refinement of the phys-
ical examination, and more sophisticated testing
should be requested by the resident and will demon-
strate critical thinking and a collaborative assessment
regarding the patient’s problem. The resident will
ask questions of the faculty member, whereby the
educational exercise becomes interactive and collabo-
rative. In clinical environments, therefore, questions
should be asked to permit residents to build on their
existing knowledge that could in fact include trivia,
although the trivia should not be directly questioned
by the faculty member. Third, the condition of the
learning environment should be as identically
important as the knowledge obtained within it. The
learning environment must be psychologically and
emotionally safe and respectful during teaching
sessions. Praxis—the concept that learning represents
a continuous process of reflection, action, and refine-
ment—represents assistance to the roles of residents
and academic physicians.2 In the final analysis, we
interpret medical pimping to be an example of posi-
tivism whereas Socratic teaching is an example of
constructivism. When correctly applied, the Socratic
method of teaching is an effective interactive andra-
gogy. It is very engaging and highly rewarding for
faculty and residents in graduate medical education
settings. Socratic teaching is time-consuming and
labor-intensive, and proper execution can only occur
in a teaching environment that possesses psychological
safety.
In addition to Socratic teaching, the flipped-
classroom concept is an interactive andragogy that is
a progressive, effective curricular model that permits
residents to study information before a didactic lecture
and then apply that information during a conference
through small group discussions. Graduate medical
education conferences represent an effective means
for the flipped classroom owing to the small sizes of
the audiences, whereby more efficient use of time
occurs, and for increasing the satisfaction with
learning the necessary didactic information.4 An
example of traditional didactic information delivery
in graduate medical education is a lecture delivered
INTERACTIVE ANDRAGOGIES
by an expert lecturer at a podium. In a flipped class-
room, the academic physician is no longer the author-
ity on the podium (sage on the stage) but instead
becomes a mentor for residents (guide on the side).
An example of a flipped classroom is a journal
club session for which residents independently
read articles and then meet with a team of residents
and an academic physician to discuss the applicability
of the articles’ findings to clinical practice. Flipped
classrooms might accommodate the simultaneous
demands of off-site learning and patient care while
also permitting compliance with resident duty-hour
restrictions.
Wittich et al5 conducted a national survey of 368
internal medicine programs in the United States. Of
the program directors, 227 (61.7%) responded to the
survey and 206 completed the flipped-classroom
perception instrument. Of the 206 program directors
who completed this instrument, 34 (16.5%) reported
they never used the flipped-classroom model, 59
(28.6%) reported occasional use, and 9 (4.4%)
reported they very often used the flipped-classroom
model. Program directors who were women and
younger had a more favorable perception of flipped
classrooms compared with male program directors
or those who were older. In general, program directors
viewed the in-class activity more favorably than the
pre-class activity. In the final analysis, the flipped class-
room is an effective educational tool because of its
ability to promote learning beyond a mere understand-
ing of theory to the development of more substantial
cognitive skills. The enhanced learning develops
through a process of developing active learning while
focusing on a learner’s educational gap. The flipped-
classroom model is a particularly useful teaching
modality for the instruction of millennial residents
and should be used with intentionality in the graduate
medical education arena including oral and maxillofa-
cial surgery settings.
Interactive andragogies represent an effective
means for deep learning in oral and maxillofacial
surgery. Such teaching techniques are collaborative
and, under ideal circumstances, executed with the
concept of emotional intelligence.
References
1. Carlson ER: Medical pimping versus the Socratic method of teach-
ing. J Oral Maxillofac Surg 75:3, 2017
2. Kost A, Chen FM: Socrates was not a pimp: Changing the para-
digm of questioning in medical education. Acad Med 90:20, 2015
3. Oh RC: The Socratic method in medicine—The labor of deliv-
ering medical truths. Fam Med 37:537, 2004
4. Morgan H, McLean K, Chapman C, et al: The flipped classroom for
medical students. Clin Teach 12:155, 2015
5. Wittich CM, Agrawal A, Wang AT, et al: Flipped classrooms in
graduate medical education: A national survey of residency
program directors. Acad Med 93:471, 2018