Emerging uses of an ancient art: the Socratic method

A recent commentary in The Journal of the American Medical Association brought back some “fond” memories for me, as well as apparently for its author. Entitled “The Art of Pimping,” the column was an update of a similarly titled article from 20 years ago about a time-honored academic tradition.

Anyone who has spent some time on the wards of a hospital knows something about this curiously named but unforgettable practice.

Loosely based on the Socratic method, this is a ritual in which an individual at the top of the hierarchical chain of command will ask a series of increasingly difficult questions about patient care or pathophysiology to someone closer to the bottom (almost always in front of his/her peers). In theory, and when done correctly, this is in the service of teaching. In its worst form, this can serve more effectively to reinforce the team’s power structure by demonstrating how much the questioner knows in relationship to the one being questioned, or as the term is thought to sometimes stand for, to be “Put In My Place.”

In the recent JAMA article, the author includes a hilarious tongue-in-cheek box of suggestions for handling the practice — which he refers to as “pimping protection procedures” — my favorite being “The Muffin.” In this defense mechanism, the one being questioned uses a muffin (or other breakfast item) in order to pretend to eat (or actually eat) to avoid being called on for particularly difficult questions.

There’s a reason why the Socratic method has been around since ancient Greece and why the practice of “pimping” has flourished throughout generations of medical trainees.

William Wood

This is because this kind of question-and-answer technique is a surprisingly effective way for an examiner to assess an examinee’s skills and understanding, and an equally effective and memorable way for a student to learn from a teacher.

Learning through Q&A

During my recent trip to ASCO in Orlando, I was a first-hand witness to three newer uses of the question-and-answer learning and teaching procedure, each of which I think provides a little insight into the modern world of oncology and the use of this technique.

On Friday night I attended a clinical satellite symposia with colleagues from my program in order to see one of our faculty deliver a talk. In this case, the entire room was asked a series of questions by another faculty moderator, and after responding via an electronic audience-response point-and-shoot system, the attendees could see how everyone else answered too. In addition to the usual teaching and learning of question and answer, this new approach brought in the element of a little peer pressure — we could gauge our performance by not only seeing what the right answer was, but by seeing how many other people had figured out the question correctly.

After several intervening lectures, a post-test with the same questions as the pre-test demonstrated just how effective this technique had been; the audience managed to correctly increase their selection of specific treatment approaches by 10% to 15% (which just happened to be the drugs marketed by the pharmaceutical underwriter of the event).

On Saturday morning, I spent several hours standing next to a poster I was presenting. At one point, I was approached by a man in a dark suit who asked me how many patients with chronic lymphocytic leukemia were represented in my study. I found the question somewhat curious, and showed that the answer was 1 out of 62.

The gentleman then transitioned awkwardly to a series of increasingly difficult questions about my usual treatment approach for CLL; after I volunteered a few answers that must have been deemed insufficient or inadequate, he abruptly left, only to be replaced 20 minutes later by a woman from the same (pharmaceutical) company who gently offered to provide me with an educational in-service so that I could learn how to better treat the disease.

A third experience happened later that same morning. In this case, a faculty member from a top academic institution came by my poster to humbly ask me to explain for him the index that I had used in my retrospective study. After glancing quickly at his name tag, I realized that he was one of the national experts in his disease area and that he clearly already knew the answer to the question that he was asking. But this question served as a gentle lead-in to another series of questions that allowed me to explain my study and my poster in some detail.

This was actually a rewarding and empowering experience. I don’t think that I would have ever thought in a million years that I would have something useful or interesting as a fellow to say to this national expert. But by the way that he asked his questions, he empowered me to feel like a real clinical investigator, with the opportunity to talk about something I’d poured a lot of time and effort into, in order to (possibly!) teach something to one of the country’s great teachers.

The importance of teaching

I’ve learned in my time so far in academic medicine — as a medical student, then resident, and now fellow — that there are some faculty who are particularly skilled as teachers and mentors. I’ve been lucky to already meet a few of the best, including my own mentor at my own institution, as well as a few who are farther away. The investigator who came by my poster that morning was clearly in the club of excellent mentors too.

In reflecting on my experiences at ASCO, and thinking more about the article that I used to introduce this column, I came to realize that the true measure of the Socratic method, question-and-answer, “pimping,” or whatever one wants to call it, is the motive and agenda of the questioner. If in the service of the consolidation of power, or the sales of drugs or devices, or other ulterior motives, this is how the practice can get a bad reputation. But if truly in the service of teaching and mentorship — when the questioner approaches the one being questioned with a sense of humility, teaches through example, and seeks to empower and inspire — the Socratic method can be one of our best tools in academia and clinical medicine.

William Wood, MD, is a second year Hematology/Oncology Fellow at the University of North Carolina, Chapel Hill and is a HemOnc Today Editorial Board member.

For more information:

• Detsky AS. JAMA. 2009;301:1379-1381