Is The Socratic Method really just "Pimping"
Re-casting this ancient tradition as bullying is emblematic of the death of education
I come from a long line of teachers. My great-grandpa was a teacher of some renown back in Finland. Both of my grandmoms taught. Both parents were high-school science teachers—a noble tradition carried on by my older brother Tim, and another older brother taught sciences at university for several years. I nearly avoided the scourge, but in the end partially succumbed. I was the Education Coordinator for ER for about 13 years in Sydney, I’m officially an “Assistant Professor” at Dalhousie University and have been involved with medical education through work on several committees. Thus I’ve also had my own experiences with teaching.
All that to say I have had a long interest in and countless dinner-table discussions on teaching, which sadly means discussions around the decline of the education system.
One of my functions as a medical educator was to organize student experiences, or what we call “rotations” in ER. A medical student (first four years of training) or resident (graduated med school and now in the “apprentice” stage) would typically work with us in ER anywhere from a week for an elective, up to two months for a core rotation. I would slot them in to the melee which is our ER system, trying to come up with a shift schedule that worked for them. Ideally they would be placed with several different doctors to allow them to experience a range of styles and approaches (none of us does everything well). Teaching was not mandatory for ER staff physicians. We tried to pick doctors to teach who were willing but also competent, efficient, up-to-date, and interested in student experience.
One of those docs was known to be a little bit on the gruff side. We’ll call him Dr. G. He would ask a lot of questions. “Did you listen carefully to their heart?” “What is Lasegue’s sign?” “What are the signs of lidocaine toxicity?” “What do you want to do with the patient?” “Why do you want to do that?”
Dr. G didn’t suffer fools lightly. He expected students to know their stuff, and if they didn’t know it, they had better read about it by the next shift because he was going to remember they hadn’t known, and ask again. He was/is a VERY good teacher. We’ll come back to him later.
What is the Socratic Method and how is it used in medical education?
This teaching style was not invented by Dr. G. The questioning of a student by a teacher—probing to see what the student knows, making him think for himself rather than just lecturing to him—is 2500 years old. It’s called The Socratic Method.
Personally, my very best teachers in my medical training used this method. One—a small-town family doc—would quiz me on cases as we drove to house calls in his car (a K-car, in case you want to know why there are no family doctors anymore.) He would describe a patient’s symptoms, age and sex and then ask: “What do you think the patient might have?” “OK, how would you test for that?” “OK, why do you think that’s a better test than …?” And so on. He would fill in snippets of information for me, point out things I should read about, and within 10 minutes I knew a basic approach to that sort of patient, and had a number of subjects listed in my notebook to read up on.
The educational ground is shifting under our feet
I want to be very clear that I’ve had the great fortune to work with a ton of amazing students and residents. Many taught me more than I taught them. (The Socratic Method works in reverse when turned on the teacher.) The majority of medical trainees were smart, accomplished, committed, kind, interesting and interested. But through my years as education coordinator, I felt the ground shifting slowly under my feet.
Things started to feel strange. More students skipped shifts, with the expectation that they didn’t have to make up for them later. I actually had one message me and say that it was such a nice day they were planning on heading to the beach instead of work. More students seemed to be starting their ER rotation without the requisite basic knowledge, often saying “we never learned about that” when I asked them simple questions about anatomy or physiology. There was an increase in rules limiting schedules because of concerns about “student wellness”. These proliferated to the point that it became challenging to even schedule an average of 35-40 hours per week in ER. (This is a discussion in itself, but an important part of medical training is experience - which can only be gained by spending a lot of time around sick people). I even had a parent of a medical student call the ER one day looking for me, upset that her daughter had received a less-than-stellar evaluation. And all of this in medical training—one of the most highly-selected and rarified areas of education, where the students are already adults and presumably really, really want to be there. I can only imagine how much worse these issues are in the public school system.
The Socratic Method isn’t touchy-feely
Med school needs to be tough. There is a TON of information that needs to be absorbed in just 3-4 years if a student is to learn the basics necessary to become a safe and effective physician.
Even if you’re not in medicine, you’ve seen movie or TV scenes where a gaggle of trainees follow the head doctor around the hospital in their lab coats. The head doc barks out questions and students answer. Sometimes the interactions are negative. Think Dr. House. Although the movie version is a caricature of real life, there is some truth in this. Most of us who have gone through medical training have had experiences along these lines. One of the senior residents who did teaching rounds when I was a junior med student was very fond of singling people out and “finding their knowledge gaps.” More than once I was stumped. Not a great feeling, but let me tell you: there is no better study motivator than being told “You should know that. It’s important” in front of the whole group. Like most students, I needed a regular kick in the butt: I needed someone to point out what I didn’t know.
As an aside,"teaching rounds” is a tradition that is as old as modern medicine itself, dating back to the time of Sir William Osler (he’s Canadian, eh!) and even before.
What the heck is “Pimping”?
Part of this shift in the bedrock of medical education that I perceive includes a push to rethink the appropriateness of the Socratic Method. Its opponents have renamed it “Pimping”. The word doesn’t have the roots one would assume it does. Instead, it is thought to come from the German word “pumpfrage” which means “pump question.” Still, I find the word grating and pejorative, and it is used mainly by those who think that asking hard questions is mean.
“The Socratic Method” is wise, honourable, and has lasted for 2500 years. “Pimping” is nasty, self-aggrandizing, and bad for the learner’s self-esteem. But aren’t they basically the same thing?
One man’s pimp is another man’s Socrates
Several years into my tenure as education coordinator, there was more of a push towards students’ evaluations of teachers, and I was instructed to email them evaluations that they had to fill out for each preceptor they had worked with. I often discussed these with them directly, as well as collecting the forms.
The very opposite reactions of two students towards Dr. G were emblematic of how the Pimping and The Socratic Method overlap greatly in a Venn diagram.
Both students had done their rotation concurrently. Both did a number of shifts with Dr. G. I sat with them to give them their summative evaluation and to collect their teacher evals. Both passed, although one was clearly a better student. (I’ll leave you to guess which.)
When I asked student A about Dr. G, she was extremely negative and actually upset. She said he should not be teaching. “He just keeps asking you a bunch of questions until he finds something you don’t know. He is just trying to make you look stupid.” She told me he was “pimping” (the first time I had heard the word). When I asked student B, she replied “He’s great! You can think you know something inside out, but he makes you realize that there are things you need to read more about. I feel like I really know a topic once I go through it with him.”
Was Socrates just a pimp?
Is pimping really just misogyny in disguise? Is it just another symptom of the (obviously!) massive racism problem that helpful critical race theorists have identified in medicine?
Julie was the half of the Pairodocs who was the standout in med school. I was not a great student. When I reflect on my medical training, I learned far more from teachers like Dr. G than from many “softer” teachers who were perhaps prioritizing my feelings over my learning. In fact, there is data showing that students learn more from teachers who are harsher graders. And we know that students rate their teachers more highly when they give higher grades. Putting these two factors together, it supports my belief that it’s the teachers who push and challenge us that actually make us learn. Sometimes this is hard on us. But many of us need it. I sure did.
Is it more important that we avoid hurting the feelings of med students by assiduously avoiding exposing their knowledge gaps in front of peers and colleagues? Or does throwing out the Socratic Method jeopardize the safety of the patients for whose care these students will someday be responsible, by allowing them to breeze through training thinking that they know it all?
If Socrates was simply “pimping” to fluff his own ego, he was never accused of it. But Dr. G was. Were they actually doing something different? Or was that difference, like beauty, only in the eye of the beholder.
Perhaps the difference now, 2500 years on, is that Dr. G is teaching a generation of students who have never failed in any way. They are rarely corrected. In the words of humourist David Sedaris, "Kids have gotten to be like animals without natural predators." They were rarely questioned, corrected or disciplined compared to previous generations. They grew up getting top grades and getting participation trophies. They have parents, family, and Deans of Student Experience and Wellbeing who attend to their every need and focus on building their “self-esteem” rather than suggesting they attend to their deficiencies.
Even though I had teachers who pushed me, I look back at how many things I still didn’t know when I first graduated and shudder for the patients I cared for. Thank God I at least had the sense to be nervous. Hell, I still shudder for my patients! Medicine is vast, and I’m a small fish swimming in a big ocean of information. I sometimes felt—and still feel—stupid because I WAS—and am—sometimes stupid. I’m still trying hard to learn.
So to all you educators out there I say: Keep up the pumpfrage! And long live So-Crates.
Interesting! Scary to think that the “everyone gets a trophy “ crowd will be in charge of health care!
Interesting article, to “think”rather than to regurgitate is basic and having to provide an answer to a question seems like a smart plan. I was a keener student and would have been busting my butt to “have” that answer. It would have been my challenge!