The Art of PimpingIT'S HARD work becoming a revered attending physician in auniversity hospital. The task daunts the newly appointedjunior attending as he strides down the corridor of his firstward with his first team. Oh, he's made some changes inanticipation ofhis new position. He's wearing a long coat now,an all-cotton coat with razor-sharp creases and knit buttons.The stained, shrunken polyester white pants and tennis shoeshave given way to gray, light wool slacks with a cuff andpolished loafers. Framed certificates bear testimony to hisintelligence and determination. He should be ready to takethe helm of his ward team, but he's not. Something's missing,something important, something closer to art than to science.When physicians talk about the "art ofmedicine" they usuallymean healing, or coping with uncertainty, or calculating theirfederal income taxes. But there's one art this new attendingneeds to learn before all others: the art ofpimping.

Pimping occurs whenever an attending poses a series ofvery difficult questions to an intern or student. The earliestreference to pimping is attributed to Harvey in London in1628. He laments his students' lack ofenthusiasm for learningthe circulation of the blood: "They know nothing of NaturalPhilosophy, these pin-heads. Drunkards, sloths, their belliesfilled with Mead and Ale. O that I might see them pimped!"

In 1889, Koch recorded a series of "Pmpfrage" or "pimpquestions" he would later use on his rounds in Heidelberg.Unpublished notes made by Abraham Flexner on his visit toJohns Hopkins in 1916 yield the first American reference:"Rounded with Osier today. Riddles house officers with questions. Like a Gatlinggun. Welch says students call it 'pimping.'Delightful."

On the surface, the aim of pimping appears to be Socraticinstruction. The deeper motivation, however, is political.Proper pimping inculcates the intern with a profound andabiding respect for his attending physician while ridding theintern of needless self-esteem. Furthermore, after beingpimped, he is drained of the desire to ask new questionsquestions that his attending may be unable to answer. In theheat of the pimp, the young intern is hammered and wroughtinto the framework of the ward team. Pimping welds thehierarchy ofacademics in place, so the edifice ofmedicine maybe erected securely, generation upon generation. Of course,being hammered, wrought, and welded may, at times, besomewhat unpleasant for the intern. Still, he enjoys the attention and comes to equate his initial anguish with the aches andpains an athlete suffers during a period of intenseconditioning.

Despite its long history and crucial importance in training,

pimping as a medical art has received little attention from theeducational establishment. A recent survey reveals that fewerthan 1 in 20 attending physicians have had any formal trainingin pimping. In most American medical schools, pimping iscovered haphazardly during the third-year medical clerkshipor is relegated to a fourth-year elective. In a 1985 poll, over95% of program directors admitted that the pimping skills oftheir trainees were "seriously inadequate." It comes as nosurprise, then, that the newly appointed attendingmust teachhimself how to pimp. It is to this most junior of attendings,therefore, that I offer the following brief guide to the art ofpimping.

Pimp questions should come in rapid succession and shouldbe essentially unanswerable. They may be grouped into fivecategories:

1. Arcane points of history. These facts are not taught inmedical school and are irrelevant to patient careperfect forpimping. For example, who performed the first lumbar puncture? Or, how was syphilis named?

2. Teleology and metaphysics. These questions lie outsidethe realmofconventional scientific inquiry and have traditionally been addressed only by medieval philosophers and theeditors of the National Enquirer. For instance, why are someorgans paired?

3. Exceedingly broad questions. For example, what role doprostaglandins play in homeostasis? Or, what is the differential diagnosis of a fever of unknown origin? Even if the internbegins making good points, after 4 or 5 minutes he can be cutoff and criticized for missing points he was about to mention.These questions are ideally posed in the final minutes ofrounds while the team is charging down a noisy stairwell.

4. Eponyms. These questions are favored by many old-timers who have assiduously avoided learning any new developments in medicine since the germ theory. For instance,where does one find the semilunar space ofTraube? Or, whosename is given to the dancing uvula ofaortic rgurgitation?

5. Technical points of laboratory research. Even when general medical practice has become a dim and distant memory,the attending physician-investigator still knows the details ofhis research inside and out. For instance, how active areleukocyte-activated killer cells with or without interleukin 2against sarcoma in the mouse model? Or, what base sequencedoes the restriction endonuclease Z?coRI recognize?

Such pimping should do for the third-year student what theSenate hearings did for Robert Bork. The intern, in contrast,is a seasoned veteran and not so easily rattled. Years ofrelentless pimping have taught him two defenses: the dodgeand the bluff.

Dodging avoids the question, wasting time as well as avaluable pimp question. The two most common forms ofdodg-

From the Department of Medicine, University of Pittsburgh (Pa).Reprint requests to 10404 Presbyterian-University Hospital, DeSoto at O'Hara

streets, Pittsburgh, PA 15213 (Dr Brancati).

ing are (1) to answer the question with a question and (2) toanswer a different question. For example, the intern is askedto explain the pathophysiology of thrombosis secondary to thelupus anticoagulant. He first recites the clotting cascade, thenrecalls the details of a lupus case he admitted last month, andcloses by asking whether pulse-dose steroids are indicated forlupus nephritis. The experienced attending immediately diagnoses this outpouring as a dodge, grabs the intern by thescruffof the neck, and rubs his nose back in the original pimp.

A bluff, unfortunately, is much more damaging than adodge. Allowed to stand, a bluff promulgates a lie whileundermining the academic hierarchy by suggesting that theintern has nothing more to learn from his attending. Bluffsweaken the very fabric ofAmerican medicine, threatening ourlivelihood and ourway oflife. Like outlaws in a Clint Eastwoodmovie, bluffs must be shot on sightno due process, noMiranda Act, no starry-eyed liberal notions of openness ordialoguejust righteous retribution.

Bluffs fall into three readily discernible categories:1. Hand waving. These bluffs are stock phrases that refer

to hot topics in biomedicine without supplying detail or explanation. For example, "It's a membrane transport phenomenon" or "The effect is mediated by prostaglandins." In manyinstitutions, they may evolve directly from the replies ofGrand Rounds speakers to questions from the audience.

2. Feigned erudition. The intern's answer, though withoutsubstance, suggests an intimate understanding of the literature and a cautiousness born of experience. "Hmmm ... tomy knowledge, that question has not been examined in aprospective controlled fashion" is a common form. Frequently, the bluff is accompanied by three automatisms: clearing ofthe throat, rapid fluttering of the eyelids and tongue, andchewing on the temples of the eyeglasses. This triad, whenfull-blown, will make the intern bear a sudden resemblance toWilliam Buckley and is virtually pathognomonic.

3. Higherauthority. The internattributeshisanswer to theteaching of a particular superior. When the answer is refuted,the blame of ignorance comes to rest on the higher authority,not on the obedient, accepting intern. The strength ofthe bluffdepends on just whom is quoted. An intern quoting a juniorresident about pathophysiology is every bit as cogent as Colonel Qaddafi quoting Ayatollah Khomeini about internationallaw. An intern from an Ivy League medical school quoting the"training" he received on his medical clerkship goes over likeDan Quayle explaining the Bill of Rights at an ACLU convention. The shrewd intern, however, will quote his Chairman ofMedicine or at least a division chief, pushing the nontenuredattending to the brink of political calamity. Did the chairmanactually say thatl The attending is powerless to refute thestatement until he is certain.

Indeed, a good bluff is hard to handle. Sometimes theintern's bluff sounds better to the ward team than the attend-ing's correct answer. Sometimes it sounds better to the at-

tending himself. Ultimately, the cunning intern is best discouraged from bluffing by aversive training. Specifically, eachtime he bluffs successfully, the attending should counter byinducing Sudden Intern Disgrace (SID). SID is induced in twoways:

1. Question the intern's ability to take a history. This technique depends on the phenomenon ofhistorical drift. That is, apatient's story will reliably undergo a significant change in the8- or 16-hour interval between admission and attendingrounds. The attending need only go to the bedside and ask thesame questions the intern did the night before. Now the entirecase is seen in a light different than that cast by the intern'sassessment. Yesterday's right upper quadrant cramping becomes right-sided pleuritic chest pain. Yesterday's ill-definedmidepigastric "burning" becomes crushing substernal heaviness radiating to the arm and jaw. Suddenly, the intern isdisgraced. He will never bluff again.

2. Question the intern's compulsiveness. In less rigorousprograms, this is easy. Did the intern examine the peripheralblood smear and the urine sediment himself ? If the interndoes routinely examine body fluids, a more methodical approach is required. In this case, results of the following tests,procedures, and examinations may be requested in rapidsuccession: Hemoccult slide test, urine electrolytes, bedsidecold agglutinins and serum viscosity, slit-lamp examination,Schi0tz' tonometry, Gram's stain of the buffy coat, transtra-cheal aspiration, anoscopy, rigid sigmoidoscopy, and indirectlaryngoscopy. Once the attending discovers a test or examination left unperformed, he asks the intern why this obviouslycrucial point was neglected. (The tension may be heightenedat this point by frequent use of the word "cavalier.") Theintern's response will generally revolve around time constraints and priorities in diagnostic evaluation. The attend-ing's rejoinder: did the intern eat, sleep, or void last night? Thescrupulous intern at once infers that he has placed his ownneeds before the needs of his patient. Suddenly, he is disgraced. He will never bluff again.

Clearly, pimpinggood pimpingis an art. There arestyles, approaches, and a few loose rules to guide the novice,but pimping is learned in practice, not theory. Despite its longand glorious history, pimping is in danger of becoming a lostart. Increased specialization, the rise of the HMO, and DRG-based financing are probably to blame, as they are for mostproblems. The burgeoning budget deficit, the changing demographic profile of the United States, the Carter Administration, inefficiency at the Pentagon, and intense competitionfrom Japan have each played a role, though less directly.Against this mighty array ofhistorical forces stands the beleaguered junior attending armed only with training, wit, andthe determination to pimp. It won't be easy to turn back theclock and restore the art ofpimping to its former grandeur. Ionly hope my guide will help.

Frederick L. Brancati, MD

populations suggest humor may be oftherapeutic benefit to hospitalized pa-tients.1 These studies are generally notcontrolled and suffer from possible sub-ject-selection bias as well as othermeth-odological problems. The present re-port suggests the helpful effects ofhumor in hospitalized patients may beless than previously indicated.

Studies. \p=m-\Afterapproval by the ap-propriate research committees, twogroups of volunteers were recruited forthese projects. All were competent,male veterans willing to sign the ap-proved consent form. One group (8 pa-tients) received transurethral prostatesurgery under local anesthesia2 and thesecond group (16 patients) received pe-ripheral (leg) arteriography.3

Subjects were randomly assigned toeither a humor or ocean sound (control)audiotape condition. The humor tapeconsisted of a recording of an old JackBenny radio show. About 85% of thehumor-tape subjects described the tapeas humorous in posttreatment assess-ment. After the tapes were adjusted tothe patient's hearing, both groups inboth procedures listened to the 1-hourtapes through stereo headphones during the procedure. In the transurethralprostate surgery group, six patientswere assigned to the humor conditionand two to the control condition. In thearteriography group, seven patientswere assigned to the humor conditionand nine to the control condition. Nosignificant (P

In 1916 Osler was in Oxford and since itwas World War I he was not once in theUnited States that year. Koch could nothave asked a single P\l=u"\mpfrage(muchless a series) since there is no such wordin German. And Harvey could not haveexpected his students to know muchabout circulation in 1628 in London,since De motu cordis was published onlythat very year (abroad, in Frankfurt amMain).

Claus A. Pierach, MDAbbott Northwestern HospitalMinneapolis, Minn

1. Brancati FL. The art ofpimping. JAMA. 1989;262:89-90.

To the Editor.\p=m-\Theother members ofmy division and I savored Dr Brancati'scommentary.1 We have become familiarwith the expression "pimping" from itsuse by our division chief. Curiosityprompted my consultation with severalunabridged American English dictio-naries as well as the first edition of theOxford English Dictionary. Thesesources fail to provide a definition con-sistent with the activity satirized in thearticle and understood by my colleaguesand me. In addition to describing a dis-reputable activity, the Oxford EnglishDictionary gives examples of its use in amore figurative sense for arrangingdeals ofdubious propriety. The only oth-er use of the word I could find was asomewhat archaic reference to the ac-tivity of getting oneself up in foppishfinery, perhaps a variant of primping.In any event, I amnow curious about theorigins of pimping as used by physi-cians, especially academicians, to referto needling questions by attending phy-sicians during rounds.

Jack G. Kleinman, MDMedical College ofWisconsinMilwaukee

1. Brancati FL. The art ofpimping. JAMA. 1989;262:89-90.

To the Editor.\p=m-\I was most impressedby Dr Brancati's article on the art of"pimping" in the July 7 issue of TheJournal.1 His grasp of the subject issuperb. He has provided us with a co-gent summary ofmaterial critical to suc-cess in the academic world. He has filleda void left when the most creativeamong us began to devote our time toobfuscating insurance companies in-stead of each other. I am grateful for histimely article.

However, I find a major omission inDr Brancati's otherwise excellent arti-cle. Regrettably, he has failed to men-tion one of themore effective techniquesof SID (Sudden Intern Disgrace), em-ployed by advanced practitioners of theart in leading medical centers (althoughperhaps not widely known in Pitts-burgh) and termed "the Feint."

When aparticularly intense intern (or

other antagonist) completes an exten-sive and thorough evaluation ofa clinicalproblem, the attending's status is mo-mentarily threatened. Immediate ac-tion is required. At such times, theFeint is especially useful.

Begin by praising the presenter'sgrasp of the subject, erudition, andclear explanations. Wax effusive. Unused to praise, your adversary will bedisarmed, sheepish, and vulnerable. Atthis moment, pounce on him with a vicious "However. ..." Sink your fangsin with the deprecatory adjective "otherwise." Make a pointed reference tothe presenter's previous failures. Finally, make a veiled condemnation of theindividual's prior training or city oforigin.

As the intern's limp but still warmbody quivers before you, thrust the finaldaggermore compliments. Victory isyours.

To understand the Feint, imagine acobra, swaying back and forth, thensuddenly striking. The Feint succeedsby lulling your opponent to sleep withpraise and then attacking at an unexpected moment.

Having said all that, I thank Dr Bran-cati for a clear and organized review. Inall my years in medicine, I have not seenits equal.

Terry A. Rustin, MDUniversity ofTexas

Medical School at Houston1. Brancati FL. The art ofpimping. JAMA. 1989;262:89-90.

In Reply.\p=m-\Mentors and colleagueswarned me that I'd be playing with firewhen I went on record about pimping.They were right. On the one hand, DrStanton worries that I have fanned theflames. The thought of unleashing anangry horde of chief residents and at-tendings bent on dehumanizingdefense-less interns does make me feel a bit likeJ. Robert Oppenheimer watching thatfirst mushroom cloud rise above theNew Mexico desert. On the other hand,Dr Pierach fears that I've doused thelast embers of a once proud traditionwith the icy water of deceit. Further-more, the prospect of contributing tothe growingproblem ofattending-rounddullness chills me. I am, however, heart-ened by Dr Pierach's lusty attack on myslick historical bluffs.

Let me come clean about pimping. Ilove it\p=m-\when it's done right. Pimpingcan entertain and teach at the sametime. It can promote a feisty esprit decorps among the pimped, as when in-terns begin to quiz each other ("cross-pimping") and even the attending (thedreaded "reverse pimp"). Sometimespimping can be the only way to keepthe ward team awake, let alone in-

volved. Nevertheless, roundsmanshipmust never be allowed to force patientcare and honest inquiry into the backseat. My own approach is to pull eachstudent and intern aside individually atthe start of the rotation to explain thedistinction I make between style andsubstance in patient care and medicaleducation. I emphasize that I will evaluate students and interns based on honesty, thoroughness, and knowledge ofmedicine relevant to the patients currently under their care, not based ontheir ability to handle pimp questions.When this line is not clearly drawn,pimping may indeed become as repressive as Dr Stanton describes.

Having been warned that pimpingseemed an unsavory topic for an augustjournal, you can imagine my pleasure inreading Dr Kleinman's letter. I can assure him, however, that a variant of aword meaning "to get oneself up in foppish finery" just wouldn't play in Pittsburgh. The Oxford English Dictionarydoes note the use ofpimping as an adjective meaning petty or insignificant. Didpimping questions echo down the mustycorridors of Guy's, Bart's, and StThomas'?

I found Dr Rustin's vivid descriptionofthe Feint" delightfully and unexpectedly venomous, even as the fangs brokemy skin. We should applaud his couragein mixing metaphors. When I read hisdescription of the sheepish intern'swarm body quivering in the shadow ofthe attending's dagger, I thought, "Myword, what can we do to attract morepeople like this into psychiatry?"

Frederick L. Brancati, MDTheJohns Hopkins University

School ofMedicineBaltimore, Md

Lines Missing An error occurred inthe Original Contribution entitled "Func-tional Status and Well-being of PatientsWith Chronic Conditions," published inthe August 18 issue of THE JOURNAL(1989;262:907-913). On page 910, the thirdsentence in the first paragraph in column 1Should have read as follows: "(When we ad-justed the mean scores for the general-popu-lation sample to reflect sociodemographiccharacteristics of the patient sample, differ-ences [not 'differencesthout chronic condi-tions (P

tens of millions of our citizens who haveno health insurance, and many needcare now. This approach can help.

And, yes, in contrast to some, thiseditor recognizes an ancient ethic thatespouses that we all are indeed "ourbrother's keeper."

George D. Lundberg, MD1. Lundberg GD, Bodine L. Fifty hours for the poor.JAMA. 1987;258:3157.2. Lundberg GD, Bodine L. Fifty hours for the poor.JAMA. 1988;260:3178.3. Lundberg GD, Bodine L. Fifty hours for the poor.JAMA. 1989;262:3045.4. Bodine L. It pays to stick your neck out: fifty hours forthe poor. JAMA. 1988;260:3127.5. Davis JE. Let's work together! A call to America's physi-cians and the public we serve. JAMA. 1988;260:834-836.6. Gunby P. First public service award goes to Kentucky.JAMA. 1988;260:3106.

In Reply. \p=m-\DrEvans will be interestedto know that 100 000 lawyers participateeach year in some 500 organized probono programs for the poor in this coun-try. This does not include private, non-reported pro bono work for the localchurch, art center, or service club. SinceAugust 1988 \p=m-\7months after the edito-rial was first published in the ABA Jour-nal and JAMA \p=m-\it has been the officialpolicy of the American Bar Associationthat lawyers should devote at least 50hours of their time to the poor each year.

Dr Haynes misses the point. I believethat the moral price for holding a licenseto practice a profession of specializedknowledge is devotion of some of one'sskills at no charge to the needy. Thecountry cannot afford otherwise.

Dr Tauber is wrong. The duty to de-vote time to the poor arises not from thewealth of attorneys and physicians, butfrom their privilege to practice theirskilled arts for pay. Government cannotdo it all, as Medicare and the Legal Service Corporation demonstrate. Thecountry also needs the pro bono effortsof its professionals.

Laurence Bodine, EsqLawyer's AlertWheaton, Ill

History and ExaminationShould Precede TestsTo the Editor. \p=m-\Dr Kolder,1 in his dis-cussion of a patient who suffered loss ofvision following cataract surgery, cor-rectly indicates the unlikelihood of theproffered diagnosis of multiple evanes-cent white dot syndrome. He also brief-ly lists a potpourri of entities that mayhave resulted in visual loss following asurgical procedure. If Dr Kolder hadbeen less kind, he might have pointedout that a markedly restricted peripher-al vision in,an eye with permanent lossof central vision is not compatible withthe physical findings as given, specifi-cally, a normal optic disc and a "dissi-pated" swollen retina. He also might

have pointed out that a brain scan, elec-troretinogram, and fluorescein angio-gram would have little likelihood ofshowing an abnormality that was notsuspected on the basis of a careful oph-thalmologic examination.

It seems to me that this problem isanother illustration of how readily phy-sicians discard the use of a careful histo-ry, physical examination, and logic infavor of easy technological proceduresand their reported results. Physical examination takes the physician's time,tests do not.

One of the initial allures of ophthalmology for many physicians, and I amsure that this is true in other specialtiesas well, is the gratification that comesfrom being able to make a presumptivediagnosis on the basis of a careful history and physical examination. In my oph-thalmologic experience, a presumptivediagnosis can be made on this basis 95%of the time and tests are only confirmatory. If the patient in question had normal visual function prior to cataract surgery, then it is not anatomically orphysiologically possible for the patientto have a malfunctioning optic nerve ormalfunctioning retina without there being evidence of that disorder in thephysical examination. Physical examination tests such as pupillary response,color vision, stress test, noncomputerized visual field, and biomicroscopic examination of the retina invariably indicate the site and pathophysiology of anydysfunction, if not the exact clinical entity. A proper physical examination demands the recognition by the examinerof the incompatibility of normal ocularfindings in the presence of significantvisual pathology. If the questioner desires the explanation for the patient'spoor visual acuity, she should be evaluated by someone who is experienced inthe use of traditional medical methods.

Michael Rosenberg, MDNorthwestern University

Medical CenterChicago, Ill

1. Kolder H. Vision loss after cataract surgery. JAMA.1989;262:3058.

Potassium Iodide Stockpilefor Nuclear AccidentsTo the Editor. \p=m-\The American ThyroidAssociation (ATA) has long had an in-terest in the thyroidal consequences ofnuclear reactor accidents because of thelarge amounts of radioiodine that wouldbe released into the atmosphere. TheATA also has endorsed the use ofpotas-sium iodide as an effective radioprotec-tive agent. In light of the Chernobyldisaster, the ATA has reexamined theissue ofpotassium iodide stockpiling foruse in the event of a core melt accident

and has adopted the following state-ment:The recent reactor accident at Chernobyl, inwhich large amounts of radioactive iodinewere released into the atmosphere, againraised questions about proposed methods ofprotecting those at risk of exposure. In aprevious statement,1 the ATA reviewed thescientific information available about theusefulness of potassium iodide as a blockingagent to prevent radioactive iodine from en-tering the thyroid gland of those exposed tofallout. It also reviewed available data aboutthe possible effects on the thyroid of low-level radiation exposure from radioiodine aswell as the potential toxic side effects of distribution of potassium iodide to large, unsu-pervised populations.

It was concluded at that time that information necessary for the development of a suitable public health strategy required risk/benefit data (ratio of the risk of the hazards ofradioiodine exposure to those of stable iodineadministration) but that such informationwas not available then. The ATA is aware ofno new information that alters the issuesraised at that time.

It was concluded in that report that although the general distribution of potassiumiodide was not recommended except in special locations and under special circumstances, advanced planning for possible distribution was advisable, and it urged that anational task force of specialists be convenedto review the issues in potassium iodide distribution and to develop alternate nationaldistribution strategies for consideration.

As best as can be determined at this time,no substantial stockpile ofpotassium iodide isavailable for public use. Despite the improbability of an emergency that requires its use,the ATA believes that the option of potassium iodide distribution should be available forconsideration to those responsible for publichealth measures. To this end, the ATA believes that it would be prudent to have available at central locations a suitable stockpileofpotassium iodide for possible distributionshould its use be contemplated.

It is hoped that this recommendationwill generate renewed discussion of thisimportant question.

American Thyroid AssociationDavid S. Cooper, MD, The Johns Hopkins University

School of Medicine, Baltimore, Md; David V. Becker, MD,New York (NY) Hospital-Cornell Medical Center; BertrandBrill, MD, University of Massachusetts Medical Center,Worcester; John T. Dunn, MD, University ofVirginia SchoolofMedicine, Charlottesville; Eduardo Gaitan, MD, University of Mississippi School of Medicine, Jackson; RaymondLindsay, PhD, University of Alabama School of Medicine,Birmingham; Marvin Mitchell, MD, Tufts University Schoolof Medicine, Boston, Mass; and Lester Van Middlesworth,MD, UniversityofTennessee SchoolofMedicine, Memphis.1. Becker DV, Braverman LE, Dunn JT, et al. The use ofiodine as a thyroidal blocking agent in the event of a reactoraccident: report of the Environmental Hazards Committeeof the American Thyroid Association. JAMA. 1984;252:659\x=req-\661.

PimpingPimpingPimpingTo the Editor. \p=m-\In the November 10,1989, Letters column, Dr Kleinman1quite correctly calls attention to the factthat the word pimping does not exist inany dictionary.

at Duke University on July 7, 2011jama.ama-assn.orgDownloaded from

Lest this word, possibly used as asensational catchword, become a neolo-gism, I would like to call attention toan error that must have occurred andthat I cannot understand escaped yourreviewers.

What is obviously meant is pumping.It is found in all dictionaries defined as"to question persistently." In its milderand more modern form it is referred toas "debriefing." The German word thatDr Brancati misused is the samepumpe \p=m-\without an umlaut. It has theidentical meaning to its English coun-terpart and was much used with respectto the interrogation ofprisoners.I have no reason to believe that Wil-

liam Harvey would have used a wordwith as bad a connotation as "pimp" oras inconsequential as "pimping."

We look to JAMA as a guide andwould hope that they would discoverrather obvious misuse of language.

William C. Beck, MDDonald Guthrie Foundation

for Medical ResearchSayre, Pa

1. Kleinman JG. Pimper pimped. JAMA. 1989;262:2542.In Reply. \p=m-\I applaud Dr Beck for recog-nizing that, despite my best effort tofeign erudition, my historical attribu-tions were nothing more than cleverbluffs. Calling the bluff and chastisingthe bluffer are crucial skills for the at-tendingwho practices the art ofpimpingand I thank Dr Beck for his timelydemonstration.

I must, however, disagree with hischaracterization of the word pimping asa neologism coined either by mistake orwith the intent to sensationalize. I firstlearned the term 6 years ago as a medi-cal student at Columbia. An informalsurvey of my colleagues reveals use ofthe word at Pitt, Maryland, BowmanGray, Johns Hopkins, BU, and Harvard.I have received more than 30 lettersfrom physicians throughout the countrywho understand the word as I do. (Onecorrespondent, an attending physicianat the Mass General, went so far as toreveal that he had earned the nickname"Pimp-monster" from his house offi-cers.) In general, physicians unfamiliarwith pimping either have trained abroador are older than 40.

Dr Beck's suggestion that pimp derives from pump deserves serious consideration. Remember, however, thatthe pumper wants to get somethingfrom the pumped while the pimperwants to give something to the pimped.

The derivation that comes closest tocapturing the subtle flavors of the wordin its current usage is offered by DrNelson H. Brown of Atlanta. He refersto Slang and Its Analogues,1 whichnotes use ofpimp as a verb meaning "to

curry favor or to act meanly" and ofpimping as an adjective meaning "feeble or inconsiderable." The earliest reference is attributed to Smollett in 1749:"They care only for pimping sycophants." And unlike my apocryphal attribution to William Harvey, this quoteis no bluff.

Finally, allow me to apologize for theersatz umlaut. As Dr Beck points out,the word "Pmpfrage" does not exist inGerman, and even if it did, it would notcarry an umlaut. Please excuse my reviewers at JAMA who let this misuseslip by. They knew I could use all thepunctuation I could get when they heardme speaking with tongue in cheek.

Frederick L. Brancati, MDThe Johns Hopkins University

School of MedicineBaltimore, Md

1. Farmer JS, Hanley WE. Slang and Its Analogues. NewYork, NY: Arno Press; 1904:204.

Editorial Note. \p=m-\ Althoughover 40 andbrought up in what Dr Brancati calls the"musty corridors of Guy's,"1 I was soastonished at Dr Beck's unfamiliaritywith the word pimping that I decided toprint his letter, and I respond only be-cause he takes JAMA to task for miss-ing a "rather obvious misuse of lan-guage." Pimping is used by persons inpower to put their juniors in place byharassing them with esoteric questionsthat, if answered, gain neither creditnor relief.

The interrogating pumper is inter-ested in answers, the pimper in self-esteem. I first heard the term pimpingused in this way 9 years ago in Chicago,at about the time it became popular touse the bullying term to "jerk around":something pimpers are good at.

I don't know what pimping, in itsmodern, medical sense, has to do with"feeble or inconsiderable," but I'd sug-gest that Smollett's sycophants weregood old-fashioned pimps.

Eric Partridge,2 quoting from Barrer and Leland's A Dictionary ofSlang, Jargon and Cant, published in1890, says that the verb pimp meant, atUniversity College (London), "to do little, mean, petty actions." Not too different from the practices of our modernmedical pimpers.

Drummond Rennie, MD1. Stanton C, Pierach CA, Kleinman JG, Rustin TA, Bran-cati FL. Pimper pimped. JAMA. 1989;262:2541-2542.2. Partridge E. Supplement to A Dictionary ofSlang andUnconventional English. 8th ed. London, England: Rout-ledge & Kegan Paul Ltd; 1974.

Ibuprofen and Aspirin in AcuteRheumatic FeverIbuprofen and Aspirin in AcuteRheumatic FeverTo the Editor. \p=m-\Iwould like to clarifyone point in the article "The Return ofAcute Rheumatic Fever in Young

Adults."1The authors state that the onepatient with rheumatic nodules re-sponded to ibuprofen therapy.

This patient presented to the hospitalwhile taking ibuprofen and continued itsuse for a short period. His anti-inflam-matory therapy was changed from ibu-profen to a delay-release, enteric-coat-ed aspirin preparation. He required adaily dose of 5850 mg (80 mg/kg per day)to clear the arthritis.

I point this out to emphasize that aspi-rin has been and should still be the indi-cated anti-inflammatory drug of choicefor the arthritis of acute rheumatic fe-ver so that no one may falsely be misledto believe this young man responded tothe ibuprofen therapy alone.

R. Larry Marshall, MDFort Worth, Tex

1. Wallace MR, Garst PD, Papadimos TJ, Oldfield EC III.The return ofacute rheumatic fever in young adults. JAMA.1989;262:2557-2561.

In Reply. \p=m-\The single patient withrheumatic nodules described in our arti-cle and referred to by Dr Marshall hadan interesting clinical course. Believedby many observers of our outbreak tohave the most severe case ofacute rheu-matic fever, he presented with fever, se-vere polyarthritis, carditis, and rheu-matic nodules. He had been receivingibuprofen prior to admission to the hos-pital, but compliance was uncertain. Onadmission he began ibuprofen therapy,800 mg every 8 hours. As noted in hishospital record, he had a "dramatic im-provement" within 48 hours of admis-sion, with defervescence and markedlydecreased joint pain, swelling, and stiff-ness. This rapid response was typical ofthe other nine patients, all of whomwere treated with aspirin. Several daysinto his hospitalization the house staff,now convinced the diagnosis was acuterheumatic fever, considered a change toaspirin. However, the rheumatologystaff physician (Dr Marshall) recom-mended the continuance of ibuprofenadministration as it was "controlling"the patient's symptoms. Twelve days after admission the patient was discharged; he was still taking ibuprofenand complaining only of morning stiffness. Subsequent to discharge, the patient changed from ibuprofen therapy toadministration of an aspirin preparation, with total resolution of residualjoint symptoms.

We agree with Dr Marshall that thepatient's later clinical course may be additional evidence that aspirin should remain the anti-inflammatory drug ofchoice for acute rheumatic fever. However, we believe that the potential foribuprofen, a widely used nonprescrip-tion drug, to dramatically alter the clinical course of acute rheumatic fever

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Morning DistortYou're a proud new second-year resident. You've tackled

internship and you've prevailed. You're a giant, a marine, apillar of granite. Okay, so you overcame anxiety, anger, anddepression. But you have not yet faced terrornot until thismorning. Today you face the terror of morning report for thefirst time. In the eerie morning light you see the long, ponderousoak table like some sacrificial altar; the pantheon of former chiefresidents judging you from portraits on every wall; the icystares of the attending and the chief resident, their hands foldedas if in contemplation before an ancient ritual. You notice thatyour cardiac rhythm has jumped from a traditional march intoprogressive jazz. Coffee splashes out of your Styrofoam cup asan adrenergic surge rattles your forearm. Yet, as you lookaround the table, the senior residents are smiling, some withtheir feet up, others leaning back with hands clasped behindtheir heads. Why are they so relaxed? It so happens they'vebeen there. They've lived it, they've learned the rules. Yes,they've learned the rules ofmorning distort.

Rule #1. Make it pat, but not too pat. Morning report is nota forum for sorting out hundreds of unrelated facts. That's a jobfor naive third-year medical students and compulsive attend-ings. The resident who wallows in messy details and multiplediagnoses is soon bound to feel the cold edge of Occam's razoragainst his or her neck. After all, the chief resident wants tohear a story. Make the story short and pat, aiming for what Poecalled the "unity of effect." Each word should point unerringlyto one diagnosis and create a mood of solemn certitude. You mayeven wish to drop verbs from your presentation: For example,"Middle-aged man, tobacco, dyspnea, wheezing, sputum, barrelchest, COPD exacerbation." But too many pat stories willarouse suspicion. After presenting several pat cases, present anopen-ended, confusing case, just to appear earnest.

Rule #2. Be bold. Nobody likes a wimp. Nowadays medicalschools offer so many courses on humanism and ethics that manygraduates quiver like gelatin in the face of real disease. Internship should have already taught you to think less like Schweitzer, more like Schwarzkopf. Your chief resident will want tohear that you've driven a needle deep into every lump, space,and swelling. Or better yet, a trochar. To highlight your courage, call in an interventional radiologist from home for anemergency procedure after 2 AM. Whatever you do, don't say'We observed the patient carefully" or "We waited watchfully."Even if you've done nothing beyond taking the H&P, saysomething like "We monitored him aggressively and sat on himhard."

Rule #3. The best defense is a good offense. Some mornings even the best residents are unprepared. If you feel weak,go on the attack. For example, say the attending taking report isa crackerjack endocrinologist and you have a case of multipleendocrine neoplasia to present, but you're unprepared. Why notpresent a cardiomyopathy case first, stress the patient's unusual rhythm disturbance, and corner the attending into interpret-

Edited by Roxanne K. Young, Associate Editor.

ing a 10-foot-long rhythm strip? Or, if you believe that the chiefresident might attack, launch a preemptive strike. Within earshot of the attending, turn to the chief resident and say, "Gee,you look tired. Must be all that moonlighting, huh?" Just don'ttry to hide at the far end of the table. The chief resident, bred tosmell fear, will lunge at you like a Doberman.

Rule #4. Image is everything. Your superiors are going toput you in a pigeonhole, so you might as well choose which hole isyours. One effective image is the hardworking, straightlacedgrunt look. Garb is the same for men and women: white polyester coats and slacks accented by pressed scrubs. White tennisshoes and a synthetic pocket protector complete the look. Whenpresenting, play it straight: no jokes, no colloquialisms, justfacts read directly from note cards. It's functional, but tedious.Another image is the uptown intellectual, dolce-vita look. Women wear dresses, light makeup, and heels. Manicures are optional, but recommended. Men wear light wool slacks and Italianties. The presentations are lyrical and witty, often presentedfrom memory (note cards are so bourgeois, n'est-ce pas?). Foreign eponyms are properly accented. It's fun, but it takes workto look the part, and it doesn't play well in the Midwest. A thirdchoice is the look of total desperation. The resident doesn'tshave or bathe and rushes into every morning report 10 minuteslate wearing oversized scrubs. The aim is to recreate the imageof Jimmy Stewart on the verge of collapse at the climax of MrSmith Goes to Washington. It's okay for sympathy, but doesn'tgarner much respect.

Rule #5. Stay calm. They are going to rattle your cage andthey are very good at it. Don't act like a trapped animal; collectyourself and stand straight. For example, they are going to askwhether you sent some fancy test last night: an alpha,-antitryp-sin level maybe, or a urine for porphobilinogen. Of course, theyfigure that you didn't send it. It's your choice. You can nervouslywhimper, "Shoot, I didn't think of that. I'm awfully sorry.Please forgive me, I'm a worthless slug. I'll send it right away."Or you can confidently declare, "Sent." You see, "Sent" is reallyshort for "I'll send it so fast, you can consider it sent" or "It's asgood as sent," and it makes a much better appearance at report.They are also going to ask you to summarize cases that you don'tremember. You can sweat and make excuses or you can calmlyexplain that "After a thorough assessment, we rounded up theusual suspects and took the traditional measures." Finally, theyare going to ask you for laboratory results that you didn't writedown. If you take a blank index card from your pocket, scrutinize it, flip it over a few times, and say "Nothing remarkablehere, " you've learned your lesson.

Whether you call it morning report, morning retort, or morning distort, the rules remain the same around the country. Thebottom line is style above substance. It worked in the 80s and itcan still work for you in the 90s. Go ahead, then. Lean back, putyour feet up, and smile. Be happy. Now you know what theseniors know. You know the rules ofmorning distort.

Frederick L. Brancati, MDBaltimore, Md

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The Generic H & P8 AM\p=m-\the end ofanother long call night and time for attend-

ing rounds. Your team awaits you."Gee, you look terrible. How many did you get last night?""Seven. Actually, eight if you count that ICU transfer. Not

too bad."Not too bad for an intern like you, but a killer call night for a

lesser house officer. You know it and they know it\p=m-\you'reChiefResident material.

You reach into your pocket for that stack of index cards,your notes from last night. Instead, you discover a Hemoccultcard, some Kleenex, and a gum wrapper. No note cards. Yourcheeks flush. Beads of sweat collect on your upper lip. You feelyour esophagus twist like a rubber band in a model airplane.You spent most of last night learning the intricacies of yourpatients' lives and illnesses, but right now your mind's a blank.How can you honestly present seven cases without a shred ofdetail and still preserve your stellar reputation? How indeed.Only one approach can preserve your dignity without makinga total mockery ofthe truththe generic history and physical.

In presenting the traditional, personalized H & P, the intern strives to focus his or her audience on what is special ordifferent about each particular case. By necessity, the personalized H & P is chock-full of detail. The chief complaint isanalyzed exhaustively, minutiae ofmedical history are scrutinized, dates and times are checked and rechecked. In contrast, the generic history fosters broader outlook, emphasizing what is common to all cases.

Your voice crackles as you cautiously begin to present yourfirst patient's reason for admittance.

Mr Jones is a middle-aged man with a long history ofmultiple medical problems who was admitted last night withan exacerbation. We don't have old records, the patient's apoor historian, and no family was available, so most of thehistory comes from the ER sheet and his nameplate. He wasin his usual health until recently, when he noticed that"something wasn't right." He said he used to have spells likethis once or twice a year, then he developed longer bouts, andnow he's having very frequent episodes. He was seen by anoutside physician who told him he had the "flu" and startedhim on a third-generation cephalosporin. When his symptoms persisted he was admitted to an outlying hospital.Records were not available. Reportedly, they ruled him out,performed an MRI, and sent him home on thyroid extract.He continued to do poorly at home and finally called theparamedics last night.

Current medications include a tiny white pill, a largerpink pill, and a foul-tasting powder.

Most of his family have been ill at one time or another,and several of them have died.

There's a question ofalcohol and tobacco use. He used towork and currently lives at home.

His medical history includes several inconsequentialsurgical procedures when he was younger. About 10 yearsago he was admitted to another hospital with an acuteillness. After a number of tests they told him he might getthis again and to call his doctor immediately if he did.So far, so good. The generic physical examination is, how

ever, a little harder to finesse. Of course, salient findings areeasily recalled and apt to be mentioned even without the aid ofnote cards. What really gives texture and depth to the presentation, though, are the subtle nuances that are virtually irre-

producible on successive examinations. Your confidence waxing, you resume.

MrJones is found lying in bed. The vital signs are stable.There are several small, ill-defined, pigmented lesions ofthe skin that he says have always been there. A 5-mm,soft, movable, nontender lymph node is palpated in thesubmandibular area. Subtle anisocoriais appreciated. Thethyroid is top-normal. Basilar rhonchi are heard to clearafter coughing. There's a 1/6 systolic murmur at the baseand a question of an intermittent S3. An ill-defined firmness is palpated by some examiners in the epigastrum.Genitalia are present, with prominent scrotal rugations.Last night there was trace ankle edema, which was absentthis morning. The neurological examination is grosslynonfocal.The generic physical examination reminds your audience

that each patient is a little different without bogging themdown in a quagmire of nit-picking details. Moreover, itsoothes your attending to the point of somnolence. Fullysatisfied that a thorough examination was performed, theattending can settle back and doze off until you reach theassessment. (You can deepen the slumber by carefully enumerating every negative finding and by frequently repeatingthe phrase "regular rate and rhythm.") Contrast this with theso-called normal examination. Every attending knows thatnobody's exam is completely normal. If you imply that yourexam is normal, even the most docile conference room couchpotato is bound to become a rabid diagnostic pit bull who willdrag you and your team all the way to the bedside just toprove you wrong. Fortunately, you know better. You can seein their faces that they're buying the whole presentation.Emboldened, you close with a concise assessment and plan.

In summary, Mr Jones is a middle-aged man with anexacerbation of a chronic illness. His course is complicatedby several underlying conditions, some ofwhich are poorlycontrolled. Our plan is as follows:

1. Tb perform some specialized blood work.2. Tb obtain high-resolution images of the involved

organs.3. Tb consult a subspecialty service for an invasive

procedure.4. To follow his clinical course closely after a trial of

empirical therapy.5. To get support services involved and start discharge

planning. If there's been no progress after 1 or 2 weeks,we'll reassess and consider further therapy using modalities with a higher risk-benefit ratio. If there's still noimprovement at that point, we'll pursue a code status andarrange transfer to the rehabilitation service.There you have itthe generic history and physical. It's a

tried-and-true approach to presenting under fire, recommended by experienced interns in all 50 states. So sit down,straighten your coat, take a deep breath, and relax. With nosleep, no notes, and no wealth of knowledge, you can stillpresent like a star. Yes, indeed. You are Chiefmaterial.

But do wipe that sweat from your lip.Frederick L. Brancati, MDBaltimore, Md

We welcome contributions to A Piece of My Mind. Manuscriptsshould be sent to Roxanne K. Young, The Journal of the AmericanMedical Association, 535 N Dearborn St, Chicago, IL 60610.Edited by Roxanne K. Young, Associate Editor.

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Clinical Years

Readers of the Lost Chart: An Archaeologic Approach to the Medical RecordFrederick L. Brancati, MD, The Johns Hopkins University School of Medicine

The first 2 years of medical school are spent in classmemorizing biochemical details such as the Krebs cycle,visualizing the anatomy of the pterygopalatine fossa andmaking up lewd mnemonics for the cranial nervesfactsthat instructors insist will be crucial to becoming a successful clinician. Why, then, once finally arriving on the wards,do students feel as clueless and misinformed as Dan Quayleat a cabinet meeting?

Think. While students perform excruciatingly completehistories and physical exams and continuously reviewpocket notes on inborn errors of metabolism, the residentis focused on the ever-expanding document of patientknowledgethe medical record.

The medical record is regarded as an object of awe,much as historians revere the Dead Sea Scrolls or Harvardgraduates worship their diplomas. Although it contains thedistilled wisdom of past physicians and scholars and theresulting truths of prior tests and studies, these revelationsare obscured by strange idioms and are buried in an avalanche of bureaucratic landfill. Like IndianaJones, theastute physician must take an archaeologic approach tobecoming a reader of the lost chart; plunge courageouslyinto these dark tomes in search of the grail of knowledge.

Adventitious Markings. Food stains related to note writing in the hospital cafeteria are easily identified by colorand aroma. A clear stain is pathognomonic for the drool ofan exhausted intern who has fallen asleep while writing,sandwiching the chart between cheek and desktop. Thefinding of a long, straight pen line trailing off the side ofthe page confirms the impression of sudden somnolence.Such markings often precede a collection of medicalmumbo-jumbo that reflects neuronal activity emitted solelyfrom deep in the midbrain and should prompt skepticismof the chart's reliability.

The Nursing Note. Exploration of nursing notes is risky.They have the potential to contain buried clinical treasuresperhaps the first mention of delirium or a criticalsummary of important psychosocial factors. On the otherhand, they may contain no data at all. An "alteration incomfort" may signify anything from nasal congestion to aruptured aortic aneurysm. An "alteration in bowel habits,"although more specific, is hardly news in a hospitalizedpatient. Especially worrisome, however, is a flat-line flowsheet, in which the same values (most commonly respiration 20, pulse 80, blood pressure 120/80 mmHg, and temperature 37C) are recorded for 3 consecutive days. Thestatus of patients during the flat-line interval is uncertain;they may be gravely ill, dead, or vacationing in the Caribbean.

The Surgical Note. The beauty of the surgical note is itssimplicity. For example: "Post-op day #2, afebrile, vital signsstable, exam unchanged, continue post-op care." It's refreshingly clear, free of the detail, insight, and deliberationthat so often mars the notes of internists. Do not, however,underestimate the significance of even small deviations in

the content of the note from day to day. For example:"Post-op day #3, temp 37.5, vital signs now stable, examimproved, continue current management" means that theprevious night, the patient developed septic shock, waspancultured and started on a third-generation cephalos-porin, and will possibly require transfer to the surgicalintensive care unit later in the morning.

The Consultant Note. To the untrained eye, this noteappears to be divine scripture written with the authorityborn of specialization. Textual analysis, however, revealsthat it is actually the work of several all-too-human authorswriting at different times. The "M Source," or medicalstudent, composes the bulk of the treatise, usually one anda half pages of transcribed text that avoids providing anyopinion or recommendation. The "R Source," or resident,generally edits the work of the M Source and provides

"The medical record is regarded as anobject ofawe, much as historians reverethe Dead Sea Scrolk or Harvardgraduates worship their diplomas. "

commentary. The written tone of the R Source is one ofrighteous indignation, heaping judgments on medicalstudent, patient, and referring physician alike.

Squeezed on the bottom edge of the second page arethe cryptic markings of the "A Source" or attending physician. The A Source is best recognized by its constant repetition of two phrases: "Agree with above plan" and "Willfollow with you." Since neither the M nor the R Source everreally describes a plan of action, and since it is unusual forthe A Source to inscribe even one follow-up note, expertsbelieve that these phrases are to be understood in purelymystical terms. Special reverence is accorded the traditionalrhyming incantation of the A Source found only in neurology notes: CT, LP, EEG, EMG, and NCV.

The Medical Student Note. Warning: these notes aredangerous. Many physicians have been missing for hours oreven days sifting through the seething miasma of verbiagespewed out by earnest medical students. Moreover, becauseof their prodigious length, these notes are hard to avoid.Scientists estimate that medical student notes account formore than 60% of the chart's weight. Fortunately, severalfeatures make medical student notes easily recognizable:(1) compulsively neat penmanship, (2) unusual ink colors(including the popular lavender and green), (3) diagramsof family pedigree so extensive as to include deceased in-laws and close childhood friends, (4) stencils of neck andabdominal anatomy, and (5) liberal use of stick figures.These notes should be explored only by teams of experienced, well-rested professionals in brightly lit rooms using(Continued on p 1861.)

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Abstract jf&Noninvasive Determination of Coronary Artery Reperfusion in Patients

With Acute Myocardial Infarction Using Plasma Myoglobin MeasurementsGerard A. Dillon, State University of New York at Buffalo School of Medicine

The aim of this study was to determine whether the rate of myoglobin entry into the blood is an accurate indicator ofmyocardial reperfusion following therapy in patients with acute myocardial infarction. Myoglobin is one of several intracar-diac proteins that rapidly enter the blood following coronary artery reperfusion.

Detailed myoglobin concentration-time curves were reviewed in 20 patients undergoing attempted reperfusion for acutemyocardial infarction. Using a biexponential flow-based, one-compartment model, rate constants for myoglobin appearance in blood (ka) were calculated for each patient by nonlinear least squares analysis and compared with the occurrenceof vessel opening as detected by immediate posttreatment angiography. In patients unsuccessfully reperfused (controlgroup), ka averaged 0.005 + 0.003 min1 (range, 0.002 to 0.009 min1). In 16 patients successfully reperfused, the rate constant (ka) was significantly higher (P