Gregory Marcus
San Francisco, California, USA

Socrates was executed for berating ancient Athenians with questions in order to test their knowledge. I try to keep this in mind when badgering trainees for the same purpose. Of course, questioning to the point of what is maybe best described as “learner discomfort” is no longer acceptable in many institutions, even when the questioner is motivated by a genuine intent of providing education. Such a teaching style has been described pejoratively as “pimping,” a verb that conjures visions of a senior clinician ridiculing and humiliating a medical student or trainee with a barrage of questions that are unanswerable. In stark contrast, it is my observation that the great majority of physicians in both academia and clinical practice view “the Socratic Method” as something to be emulated, a logical and effective method of teaching with a degree of sophistication, steeped in tradition, and carried down from one of the greatest thinkers in the history of Western 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 asking questions, but the connotations of each are negative on the one side and positive on the other. Therefore, it is likely worthwhile to explore each of these terms to better arrive at an understanding of what is in fact good and bad about teaching via questioning. Ideally, such an exploration will guide us toward an appropriate balance in using this technique without trepidation for fear of “pimping” while maintaining sufficient intensity to carry 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? A classic article addressing the term’s etymology is a hilarious and insightful summary, with wonderful references from Sir William Osler and other figures from as far back as the 17th century.¹ Notably however, the article has no references, and, in fact, the colorful quotes revealing the origins of the term arise from the author’s creativity rather than any historical fact (confirmed by personal communication with Dr. Brancati). The point is that the 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 American medical institutions: regardless of where a physician attended medical school or received their training, knowledge of “pimping” appears to be ubiquitous. An informal poll of faculty at one institution revealed that, while all were certainly familiar with the term, “pimping” was universally thought to have a negative connotation. Does this mean then that we, as teachers, should shy away form challenging our students by asking questions? Should our concern regarding potential discomfort by having them think on their feet dissuade us from using this conventional and potentially stimulating teaching technique? In fact, there has been only one published study on the subject, showing that pimping was viewed by fourth-year medical students as a potentially useful learning tool.² And so, perhaps pimping can be “good,” but, before it can recommended, I submit that there are three criteria that should be followed, each gleaned from an examination of the true “Socratic Method” as found in the works of Plato.

Of note, there are no known historical documents written by Socrates himself. His philosophies are provided primarily in the writings of one of his students, Plato, who portrayed Socrates as a central figure in his works. In order to understand the Socratic Method, first one must understand Plato’s epistemology, his theory of the nature of knowledge.

Plato, and presumably Socrates, believed that all humans are born with all knowledge. This theory is explained in Plato’s Meno, a work composed of a dialogue between Socrates and his friend, Meno.³ They attempt to answer the question, “Can virtue be taught?” Meno initially makes the point that if you 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 search for it. Socrates answers with his theory of the nature of knowledge: “They say that the human soul is immortal . . . As the soul is immortal, has been and has seen all things here and in the underworld, there is nothing which it has not learned.” In short, we are all born with knowledge of everything. He goes on to explain, “For searching and learning are, as a whole, recollection.” So, we do not learn anything new, we simply come to recognize or remember things we already know. Meno is doubtful. Socrates therefore provides a demonstration.

Socrates invites one of Meno’s “many attendants” for a lesson. The chosen attendant is an uneducated young man, for whom Socrates draws a square in the sand. Socrates begins with a few simple questions, demonstrating that 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 the area 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 a square twice the size of the original square would be. The learner confidently 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 silent and dumbfounded. With the attendant wrapped in confusion, Socrates asks Meno, “Have we done him any harm by making him perplexed and numb?” Meno agrees that no real harm has come to his attendant. Socrates continues, “Indeed, we have probably achieved something relevant to finding out how matters stand, for now, as he does not know, he would be glad to find out.” By leading the learner until he struggles, Socrates has accomplished two things: first, he now better understands the extent of the learner’s knowledge base and so better knows where to concentrate his efforts. Perhaps more importantly, he has stimulated the learner to learn. Before meeting Socrates, this attendant likely cared little for geometry, but now yearns to understand.

Ultimately, again with the help of Socrates’ persistent inquiry, the attendant deduces the correct answer. Meno agrees that, since Socrates only questioned the learner, the attendant must have found the knowledge within 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 in reincarnation and an all-knowing immortal soul? What about information that is only recently generated, such as findings from clinical trials? Am I suggesting that Socrates and Plato were born with the knowledge that the HOPE study demonstrated the utility of ACE inhibitors or that MADIT II showed that implantable cardioverter defibrillators save lives? No. There is a role for closely questioning learners about facts, but mainly for the purpose of assessing knowledge level. Facts can be memorized, they can be researched in the literature if forgotten, and findings from trials are relatively transient—focusing all questions on these matters constitutes Bad Pimping. It is not the Socratic Method (or Good Pimping) if one only asks about memorized facts at which the learner can only guess. When writing about the immortal, all-knowing soul, Plato likely meant that we are all born with the capacity to grasp certain concepts. Good pimping works to teach these concepts, ideas that the learner can deduce and has the capacity to understand.

The Meno therefore provides evidence of at least two necessary criteria in the practice of Good Pimping: first, the questioning should be based on a respect for the learner, arising from the expectation that he has the capacity to understand; second, the questions should predominately focus on teaching concepts, something that the learner can truly deduce with the assistance of the teacher.

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

The third criteria required to practice Good Pimping is best described in Plato’s The Apology.⁴ Here, Socrates is depicted defending himself against the charges of heresy and corrupting the young that ultimately led to his execution. He presents evidence that his frequent interrogations of his fellow Athenians (his habitual use of his own method) have motivated the charges against him and provides an explanation for his constant questioning. He states that the Oracle at Delphi had reported that no one was wiser than him. Socrates felt that he knew nothing and was unworthy of such a statement. He subsequently set out to question all those known to be wise or skilled, hoping to prove that many were in fact wiser. To his disappointment, he determined that those who were known for their wisdom had some knowledge, but, in fact, thought they knew more than they actually did. In the end, he was forced to agree with the Oracle’s statement—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 even embrace the answer, “I don’t know.” In fact, the acceptance of this phrase more than anything else distinguishes Good from Bad Pimping. From The Apology, “This ignorance, which thinks that it knows what it does not, must surely 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, concerned regarding negative connotation or the possibility that we might make the learner uncomfortable. Or, in our teaching, we can equate it with the Socratic Method, challenging our students, questioning them carefully with specific concepts in mind, allowing them to struggle and discover, and accepting “I don’t know” as an answer. At the root of this method must be the mutual understanding that our questions stem from a respect for the learner, and our belief that he has the innate capacity to understand the concepts we hope to teach.

I would like to thank Amy J. Markowitz for her assistance in the preparation 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 Med 2005;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.