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Pimped

Anne Whetzel

It's two months into my second year of medical school, and I'm at the clinic, preparing to shadow Dr. Neiland, a primary-care physician.

I didn't want to come here this morning.

Yesterday, one of my preceptors decided that it was my turn to be "pimped." Pimping, in medical education, is when the preceptor asks you questions until you get one wrong. Then he asks more questions, highlighting your ignorance. Theoretically, this ensures that once he tells you the correct answer, you'll never forget it. This works for some students, but not for me. I get defensive, and the right answer, whatever it is, goes in one ear and out the other.

I'm still on edge. I considered calling in sick, because I was scared that my jangled nerves might interfere with my ability to function. But here I am.

"This next patient is puzzling," Dr. Neiland tells me. "She has a high-school education, and she's coherent, but she just can't stay on top of her medications. We tested her for Alzheimer's, but that isn't it. We think she might have a learning disability. We went over her medications with her at the last visit, and that helped, because her labs look good. So today we'll just check in with her."

We knock on the exam-room door and enter. Mrs. Slate, who's in her late seventies, has gray hair, soft eyes and an easy smile. Her chart mentions high blood pressure and asthma.

"Hi, Mrs. Slate," Dr. Neiland says, speaking slowly and distinctly. "We're really proud of you--your blood pressure is right on target! You must be taking your medications. Are you feeling better?"

Mrs. Slate smiles proudly, then looks down shyly. "Yes," she answers. "I've been feeling good."

"Okay, great." Dr. Neiland takes a seat; I stand off to the side. "I see you brought your medications. Can we go over those again?"

Mrs. Slate hands him a paper bag.

"Okay, great." Dr. Neiland places its contents on the exam table: two inhalers, six small prescription bottles, two wide-brim prescription bottles and a slip of paper.

"What's this?" he asks, pointing at the paper.

"Oh, that's my reminder for the appointment today." Mrs. Slate reaches for the typewritten note, reads it and nods. "Yes, this is my reminder."

Dr. Neiland nods.

"Okay, let's start with this." He holds up an inhaler. "How many times do you take this when you use it?"

Mrs. Slate squints at the label.

"I take that..." She pauses to think, then says confidently, "Three times." She smiles at us.

"Why three times?"

"Because"--she nods--"that's what I was supposed to do."

"Okay, you're supposed to prime once, meaning you spray it into the air to get the medication flowing, and then you take it for two breaths. Okay? And you do that every day, okay?"

"Oh," Mrs. Slate responds slowly. "Yes, okay."

"What about this one?" He holds up a large bottle.

"Oh, that. I take two pills, two times a day." Her right foot begins to tap the linoleum floor.

"Every day?"

"Yes, every day."

"Why every day?"

"Oh, because"--Mrs. Slate rolls her eyes--"I thought that was what you told me!" She tisks, then lets out an embarrassed laugh, looking down.

"Well, this one is for pain. You shouldn't be taking it daily. You only take it when you need it. What about this one?" Dr. Neiland holds up a small bottle.

Mrs. Slate reaches for it, her hand shaking slightly. She opens the bottle, spills a few pills into her palm.

"These"--she nods again--"I take one twice a day."

"What about this?" As the quiz continues, Mrs. Slate begins to wring her hands. She directs her answers to the floor. Time and again, she gets the details wrong. As Dr. Neiland writes notes on the chart and reminders on the pill bottles, Mrs. Slate smiles weakly, and her foot keeps bouncing against the floor.

I feel like shouting, "She doesn't have a learning disability! She's trying! And you're not teaching her--you're just making her feel even worse!"

I want to storm out, to make a scene. I want to tell Dr. Neiland just what's wrong with this approach to patient education. I want to spend an hour with Mrs. Slate, drawing pictures of the pills and spelling out exactly what she needs to take, when and how.

Her eyes meet mine. I give a half-smile, trying to convey my sympathy.

The quiz is over. Mrs. Slate didn't pass. Packing up the bottles, Dr. Neiland asks, "How have your lungs been?"

"Oh, my lungs." She shakes her head. "Not good."

"Didn't we give you oxygen at home?" Dr. Neiland types something on the computer.

"Yes." She takes a breath, then continues, "I have oxygen, and I use it when I sleep."

"How long have you had the tank? Have you ever had a refill?"

"Oh," Mrs. Slate chuckles, seeming more relaxed. "I've had it forever. Maybe a year or two? I haven't had it refilled, because it's electric--you just plug it in."

Dr. Neiland adjusts his stool. I saw my preceptor do this yesterday after one of my responses. I brace myself.

"Okay, the oxygen tanks don't refill themselves. You need to get them replaced. Have you been using it correctly?" He already knows the answer.

Mrs. Slate looks at the ceiling, wringing her hands, then back at the floor.

"Yes," she says uncertainly. "My daughter and I plug it in, and we turn it up all the way"--she mimes turning up a dial--"and it makes a lot of noise." Her foot taps faster.

"Okay."

Dr. Neiland looks directly at her.

"I'm going to get someone to come to your house," he says, speaking quickly. "You aren't using it correctly, and we need you to use it correctly. Before that, though, I'll do a quick oxygen check. Wait for the nurse to come back, and we'll get an O2 sat of you standing, sitting and walking with and without oxygen. This is to see how much oxygen is being delivered to your body. Okay?"

"Yes," Mrs. Slate says, looking confused. "Okay."

This is the same answer I gave to my preceptor. I know what it means: Just make the questions stop.

"Great, wait for the nurse. Thank you, Mrs. Slate, it was nice to see you. Keep up with those medications."

I follow Dr. Neiland out. We leave Mrs. Slate sitting there holding her medications and turning her reminder sheet over in her hand, her foot still tapping the floor.

I want to go back and hug her, tell her that it will be all right, that I'm on her side--that I appreciate the effort she's putting into learning her medications and understanding her oxygen tank.

And all the while, I'm asking my own set of questions: Can't we stop pimping Mrs. Slate? She's like me--a student struggling to learn the material. There must be a better way to take care of her. What help does she need? Can we make sure that she gets it?


About the author:

Annie Whetzel is an osteopathic medical student. Writing, yoga and biking are her havens of relaxation amid the stress of school. "As a student, I know that every patient encounter is a learning opportunity. When I reflect on one that was awkward and made me uncomfortable, or on one that went well, it gives me a chance to relive those situations and to understand where things went smoothly, and why, or where I derailed the conversation, and why."

Story editor:

Diane Guernsey

Comments   

# Robert Meier 2015-06-10 13:49
As a nurse within an academic medical center, I saw this occurring time and time again. As my career progressed and I moved into my current position as the Director of the Employee Assistance Program, now I get to try to assist many residents and interns each year who are berated using this strategy. Some of them do not ever recover from the emotional scars this leaves. We see even the US military changing their strategy on how Drill Instructors interact with troops in order to reduce the risk of PTSD in soldiers, so when will we see the Medical profession realize there is a better way than "I survived it, and so should you!".
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# Lynn Burgess 2015-06-08 14:55
Annie, As a longtime participant in Lit & Med discussions, this story hit me right where I am! Literally. Last week
I sat on four board certification committees for candidates seeking BCC status. We have 29 competencies to address,and some, we hope most have already been satisfied. It is an intense process. I felt my committee was grilling (pimping?) the candidates. Later, perhaps because that method of interview DOES NOT work for me, I was unable to separate from the candidates. Annie, your story covers many levels of care and humanity. Thank you!
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# Warren Holleman 2015-06-05 16:43
Annie, thank you for telling this story. Abuse such as this--whether of the student or the patient--will only end when we break the silence, tell these stories, and call out those who in the name of patient care do everything but.
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# Stanley Brysacz 2015-06-03 12:38
Annie an extremely well written and timely student narrative as the " Hidden Curriculum " is discussed in Medical Education literature. I know you accepted that experience as a learning one and will work to make sure you do not become a " patient pimper ". Most patients with a bag full of drugs and an Oxygen tank to keep O2 flowing to their brain will be in need of help in managing their medicines. If you do not have the time involve another health professional.
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# Jan 2015-06-01 09:14
Excellently written article...I felt as if I was right there in the room with you and Mrs. Slate. Thank you for your candor.
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# Diane Hage 2015-06-01 08:36
Annie, Unfortunately we see this so often and then blame the patient for not being "compliant". I am blessed to work with a team of Community Health Workers who have been trained in Health Literacy and Medication Reconcilliation . They are the eyes and ears of the team, boots on the ground. I would not practice any other way.
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# Scott Newport 2015-05-31 06:57
I really felt like I was standing behind you in the room as I read the story. I can’t wait to see the look on the doctor’s face when he realizes the patient had an oxygen concentrator. Maybe now he will never forget. Great story, thanks for sharing.
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# Carol Lee 2015-06-03 12:22
Ditto on that. How could he NOT realize it was an O2 concentrator!
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# Margaret Fleming 2015-05-30 16:49
Thank you for this courageous story. Now that I have grey and white hairs, I never know what some doctors will say next.

Haven't the courage to get a tee shirt that says: I'm not stupid. You're not being clear.
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# Jean Smith 2015-05-30 11:38
It seems you should have addressed your questions to the doctors in both cases to make them aware of another way to handle the situation instead of sitting silently. It could have been a learning situation for all.
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# Martha Rhodes 2015-06-26 10:22
The author found herself in a position of little or no power. Speaking up may have helped, or it may have lead to even worse outcomes. She chose a prudent course of silence at the time, then wrote a thoughtful article that will touch the lives of many healthcare providers and patients. Chuck Joy below has a helpful comment.
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# Ron Banner, MD 2015-05-30 11:17
Thank you, Anne, for sharing this painful experience, for you and the patient. You have shown how this experience painfully impacted the patient. You are insightful enough to realize that it is something that you do not want to repeat when you are an attending. However, for many medical students and residents this type of behavior will become a model for how they behave. HOW SAD, FOR HEALTH CARE PROFESSIONALS AND THEIR PATIENTS.
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# Chuck Joy 2015-05-30 10:58
Real nice read. Not sure if metaphor is the right word but I enjoyed the parallel between the attending's problem-maintai ning behavior toward the patient and his presumed similar behavior toward the student. We are all so socialized to be submissive. I encourage you to develop skills to be assertive, gentle and gracious, but assertive.
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# Suzanne Gordon 2015-05-30 10:55
Congratulations for this excellent piece. In a recent article I did for the BMJ blog I talked about the terrible toll pimping has on patient safety. I mentioned the same problem Anne Whetzel highlights here. Physicians who pimp others or who are pimped by others will eventually end up pimping patients. I am one of those patients who has been pimped and I can tell you it does leave an impression -- one that drives physician instructions about how to take your meds correctly right out of your head. Humiliating/yel ling at or otherwise making people feel like idiots does indeed ensure that you retain an important lesson -- one in hierarchy not patient care
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# Ginna Crowe 2015-05-30 09:10
Very well written - felt and heard the story. As an adult educator I find few appreciate or understand the varied and multiple ways we learn... and that telling is not teaching! What you call pimping - I call academic bullying - it is pervasive in higher education and built on false assumptions and beliefs. Research in learning supports far different methods. My hope is that later you did sneak back to Mrs. Slate and help her learn.... and give here some peace. Thank you very much for shedding some light on this issue of learning. We could eliminate much pain and angst just by learning about learning.....
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# Karen 2015-05-30 07:00
As an RN, this is what we do. We manage the patient's response to their condition. I have made more medication charts and explanations of use for both patients and family members. The physisicans I worked with in Epilepsy were caring and often spotted these needs in clinic as well as our monitoring unit, asking for my assistance. It was a wonderful team. You sound like you will be a wonderful, caring physician. Do not forget your nurses. :-)
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# Nancy Tune 2015-05-29 23:57
Your writing illuminated the scene beautifully. The description of the patient--her words and expressions and gestures--broug ht her into my mind and heart. I am grateful to have read this piece, which I think applies to even more than the doctor-patient relationship. It's a cry for being more open-minded, open-hearted, and patient in all our interactions.
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# Charlene 2015-05-29 23:24
Yep,..

Thank You, ....Annie,....R ight On!
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# Sue Roselle 2015-05-29 20:28
The Care Transitions Program is designed to help the elderly learn medication and disease management. Rather than being faced with a Q&A, they receive coaching not education!!! The tools for the patients are Health Booklet which the patient completes with a coach so they learn and retain by writing. The coaches are trained in the Coleman Method of Care Transitions. It is a great program and has been proven to make a difference!
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# Slou 2015-05-29 20:22
Disheartening to read this poignant, but oh-so-true story. My mom is 91 and is of a generation when an M.D. was a god, and often an intimidating one. Whatever he said was the gospel.

My mom, of her own accord, has been switching to female docs over the past decade and feels much more confident and comfortable with them. Not suggesting this is the answer, but wonder if female M.D.'s display more compassion? They certainly seem to listen to her and treat her concerns with empathy.

Anyway, food for thought.
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# Celia Engel Bandman 2015-05-29 18:29
Annie,
For students as well as doctors -each patient encounter is a
learning opportunity. Next time, I hope you feel empowered to go back, hug the patient and ask if she or he have any questions!

Celia
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# Cortney Davis 2015-05-29 18:18
oh how often we nurses see this, the attending' s quiz that even intelligent patients might fail! All physicians might read this and reflect upon their own methods. And not just doctors, nurses and students too. We can forget that what's second nature to us is a foreign and unfriendly language to the layperson. Thanks Annie for writing this.
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# Pris Campbell 2015-05-29 17:51
For whatever reason, clearly she has some cognitive problems. Add to that a sack full of medicine and hou have a recipe for confusion. She mentions a daughter. Perhaps the focus should hsve been bringing the daughter in to see what help she could be in setting up the pill tsking in a way her mother can understand. Seventy may sound old to some but I'm seventy-teo and these are not problems zi would have. She needs additional home help, nkt embarrassment in front of a group of interns. Thanks fir the compassion of the author!
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# Marianna Crane 2015-05-29 17:23
Could Mrs. Slate have had a room oxygen condenser (one that does run on electricity) and not a tank of oxygen?

How sad it must have been to watch this interaction. What a thoughtless, arrogant, and ineffectual doctor Neiland shows himself to be.
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# Sharon Obadia 2015-06-02 14:15
Annie! As always, I am so proud to have you as our student. You write so well, and I, too felt as if I were in the room with you with Mrs. Slate. I have often reflected on the amazing parallel in the way I treat a student and the way I treat a patient. This solidifies it for me even further. Well Done! Keep writing!
Dr. Obadia :0)
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