Teaching by intimidation: medical students’ perspective

Abstract

The clinical years of medical school place a large importance on “bedside teaching”. Students, often in front of their peers, are expected to demonstrate their knowledge and are pushed until gaps in that knowledge are bridged. However, the environment in which these sessions take place may not always be conducive to effective learning. Teaching by intimidation, also known as “pimping”, has long had a place in traditional medical education and is perpetuated by each generation of doctors teaching in the manner that they were taught. Students describe this as an intimidating questioning style overridden by a hostile attitude aimed at belittling the learner whilst reinforcing a dominant hierarchy.1,2 Although its persistence may be evidence of its inherent success, the approach certainly has as its detractions. Questionnaires across two medical schools demonstrated that 83% of the student cohort had witnessed “teaching by humiliation” and 74% had experienced it first-hand.1 As a result, these students were more likely to disengage with the given specialty. After an episode of humiliation, a student may become more reluctant to join future ward rounds, sacrificing their learning in order to avoid further insult.1,2 Rote learning is re-enforced and intellectual curiosity stifled by the fear of embarrassment.2 Studies highlight mistreatment during teaching as a factor in inducing stress by creating a toxic work environment.2 Furthermore, mental health and professional performance are negatively affected.3 Clinical years represent a protected time in medical training where mistakes can be made and learnt from. However, when students are too scared to be admit not knowing something in fear of being humiliated, that safe learning environment is conceded. This perpetuates a culture where medical students and junior doctors feel unable to ask for guidance. The most sinister consequence of which may be the compromising of patient safety.4 Bedside teaching led by a clinician who has an experiential wisdom of what is clinically relevant is vital during the final years of medical school. This is reflected by the fact that almost half of the cohort that witnessed or experienced this method of teaching still found it useful.1 Furthermore, practical skills such as physical examinations demand practice; teaching at the bedside provides a valuable opportunity for students to hone their skills under the supervision of experienced clinicians. Whilst unpleasant, the experience of being put on the spot provides important simulation of day-to-day clinical practice where effective recall and execution of knowledge is essential.5 “Pimping” is a model that allows doctors to actively maintain the hierarchy of authority in the medical team.2 However, clinicians may also reinforce this model of teaching with the intention of enabling efficient learning and retention of knowledge. Its persistence may further be attributed to a paucity of alternative validated teaching methods.2 Here, qualitative results from diverse focus groups with clinicians would be helpful in developing novel approaches and elucidating the reasons behind the perpetuation of “pimping”. Despite benefits to “teaching by intimidation”, the perturbation reported by students, demands reform of the practice. Although doctors remain a great source of teaching, the manner in which that it is delivered can be detrimental to students’ learning and negatively color their professional relationship. Moreover, given the increasing importance afforded to mental well-being, addressing triggers in the workplace must become a priority. For instance, open streams of communication between students and university faculty can aid in early reporting and intervention when required. Investing more time and resources into training doctors as teachers may help to erode this inherited culture of intimidation and produce confident, well-rounded clinicians.