Socrates-239x300-circleWelcome to season 3, episode 6 of the ALiEM Medical Education in Cases (MEdIC) series! Our team (Brent Thoma, Sarah Luckett-Gatopoulos, Tamara McColl, Eve Purdy, John Eicken, and Teresa Chan) is pleased to welcome you to our online community of practice where we discuss difficult medical education cases each month. As usual, the community discussion will be reviewed using qualitative research methods to produce a curated summary that will be combined with two expert responses to create a functional teaching resource.

This month’s case takes us to a team on rounds. There is a rich history in medicine of questioning learners about the mundane, the weird, the esoteric, the wonderful and everything in between. At worst this approach is known as “pimping” and when done well it is known as the Socratic method. How can teachers question the team in a way that is supportive of learners? Similarly how can peers and near peers best support each other in these situations? We will have the discussion open for a whole two weeks before the expert commentaries are released!

[su_spoiler title=”MEdIC Series: The Concept” style=”fancy” icon=”caret”]Inspired by the Harvard Business Review Cases and initially led by Dr. Teresa Chan (@TChanMD) and Dr. Brent Thoma (@Brent_Thoma), the Medical Education In Cases (MEdIC) series puts difficult medical education cases under a microscope. On the fourth Friday of the month, we pose a challenging hypothetical dilemma, moderate a discussion on potential approaches, and recruit medical education experts to provide “Gold Standard” responses. Cases and responses are be made available for download in PDF format – feel free to use them! If you’re a medical educator with a pedagogical problem, we want to get you a MEdIC. Send us your most difficult dilemmas (guidelines) and help the rest of us bring our teaching to the next level.[/su_spoiler]

MEdIC: The Case of the Pimping Physician

by Dr. Heather Murray

Rahim, a resident, finished his presentation of the case: “So, in summary, this 27 year old female presented with a one week history of pleuritic left sided chest pain but she had become increasingly SOB. She was hypotensive and tachycardic in the ED with a pericardial rub on exam. A bedside echo confirmed a large pericardial effusion. She had a pericardiocentesis with 300 cc drained and she has stabilized overnight.”

The team stood outside the room. Dr. Lafleur, the attending on service, nodded. “Thank you, Rahim. Nice summary. Jeanette – tell us the top 5 causes of pericarditis?”

Jeanette was one of two medical students on the team. It was her first week on cardiology and she was definitely not fitting in. She had been up almost all night, admitting a series of chest pain patients that she could hardly keep apart in her head. The night resident hadn’t involved her in this case but she remembered him talking about the tap towards the end of the night. “Um…” She paused and looked around. “I think… one is you have an infection and… other things that cause inflammation?”

The team shuffled uncomfortably. There was a long silence. Dr. Lafleur furrowed his brow. “What do you mean, “Other things that cause inflammation”?”

“I’m not sure.” Her voice trailed off. “Can’t you get…uh…. inflammation sometimes from things like… lupus?”

There was another pause. Dr. Lafleur turned to Yumi, the other medical student on the team. “Yumi, help your colleague out here?”

Yumi smiled. She loved cardiology and came in early most days to review the diagnoses of the newly admitted patients so that she could be ready for the questions on ward rounds. “Well, viral infection, bacterial infection, malignancy, uremia and connective tissue diseases are all causes. Of course, in the context of this patient, we would have to consider her risk factors and past medical history to accurately tier this differential.”

Jeanette stared at the floor. She had known that – she remembered listing off those causes on her last exam of pre-clerkship. Why had she blanked? She could feel her face getting hot. She wished she could go back to pediatrics where she at least knew how to be a decent med student.

“Very good Yumi.” Dr. Lafleur turned to Rahim. “Let’s go and see this patient now.”

After rounds Yumi and Jeanette were sitting at the desk charting. Sarah, the team’s senior resident arrived. “Jeanette – what kind of performance was that? You know Dr. LaFleur likes to pimp everyone about the cases. Try to be more prepared tomorrow. You’re making us all look bad.”

“Yumi – nice job.” Sarah smiled over at Yumi. “Keep up the great work.”


Discussion Questions

  1. “Pimping” is a term used for the structured public questioning of medical trainees, usually during ward rounds or clinical care. There is some debate about the effectiveness of its use as a teaching tool. Do you think there is a role for it in medical education?
  2. A significant proportion of graduating medical trainees report feeling humiliated during their training. Should we, as medical educators, try to ensure that our trainees are protected from humiliation? What coping strategies can learners employ to protect themselves from feeling humiliated? Is this ever an effective method for learning, or for motivation?
  3. What strategies can medical educators use to conduct ward rounds in an effective manner? How could Dr. LaFleur have conducted this differently? How could the Sarah (the resident) or Yumi (the other student) have responded differently?

Weekly Wrap Up

As always, we will post the expert responses and a curated commentary derived from the community responses. We have decided to extend the discussion period to two weeks after the case is published. This time the two experts are:

  • Jeff Riddell is a Medical Education Research Fellow in the Division of Emergency Medicine at the University of Washington. He spends his time teaching, tweeting, researching, blogging, and speaking about digital media in medical education.
  • John Eicken is an emergency medicine ultrasound fellow at Brigham and Women’s Hospital. He is completing his Masters of Education at Harvard University.

On April 16, 2016 we will post the expert responses to this case! After that date, you may continue to comment below, but your commentary will no longer be integrated into the curated commentary.  That said, we’d love to hear from you, so please comment below!

All characters in this case are fictitious. Any resemblance to real persons, living or dead, is purely coincidental. Also, as always, we will generate a curated community commentary based on your participation below and on Twitter. We will try to attribute names, but if you choose to comment anonymously, you will be referred to as your pseudonym in our writing.

Eve Purdy, BHSc MD

Eve Purdy, BHSc MD

Queen's University in Kingston, Ontario, Canada
Student editor at BoringEM.org
Founder of manuetcorde.org
Eve Purdy, BHSc MD

@purdy_Eve

@QEmerg resident, @UNTanthropology, humanist, dog-lover, #FOAMed and #qmed enthusiast | #ALiEMMedic | @smaccteam |