Moving Away from the Battlefield:  Stress and Learning in MedEd

By Ben Kinnear (@Midwest_MedPeds)

In their 2015 commentary in the Journal of Surgical Education, Dr. James Healy and Dr. Peter Yoo recall being “pimped” as medical students about diseases of the esophagus.

It’s an interesting account, with painful descriptions such as “I contemplated whether I had committed some grievous offense and was now being gunned down for it, executed in front of my peers”, and “It was a battlefield.  Some were outright slaughtered. . . The wounds to our collective pride and individual egos were laid open, fresh, and bare.”1  A learning experience for which the best analogy is warfare.


A widely used tactic for trying to stress physician trainees into learning is “pimping”.  Given the hierarchy, misogyny, and exploitation this term connotes,2 for the rest of this post we will use the term “toxic quizzing” in its place.3

While toxic quizzing has no standard definition, it generally is thought to be the practice of questioning junior learners (often with fact-based right/wrong answer questions) in a manner that reinforces hierarchy, belittles the learner,4 and robs them of social capital.5

A qualitative study by Goebel et al. shows illustrations from medical students explaining how toxic quizzing makes them feel, and how harmful this practice can be.6  Pictures include students being run over by a truck, interrogated while tied up, and burned at the stake.  The people who use toxic quizzing may be only seeking to show dominance and reinforce hierarchy, but often they think it is for the betterment of the learner.1

The logic is that aggressive questioning, even at the expense of learner emotional safety, leads to better knowledge retention.  This logic may stem from oversimplified models about the relationship between stress and attention, such as the Hebbian version of the Yerkes-Dodson law.  It’s undeniable that toxic quizzing has potential to harm learners.  The question is, is the risk of harm justified by a payoff of better learning?

For the last several years I have been on a crusade against toxic quizzing.  It seems to be a remnant of the “good old days” of medicine, anecdotally often glorified by “seasoned” physicians who are lamenting the “soft” modern culture of psychological safety in medicine.  Maybe those physicians are truly “tougher” than us youngsters, or perhaps this is simply a case of, as the good Dr. Eric Holmboe would say) “nostalgialitis imperfecta profunda”7 (at topic for a future ICE blog post).

Also, I was not convinced that toxic quizzing stimulated learning.  In fact, I was convinced that the emotional stress it caused likely reduced learning.  How a person feels about a situation in part determines how much attention is paid to learning.8  Working memory prioritizes data that affect emotions over data for new learning, potentially blocking out learning when emotions are high.8  Was toxic quizzing all good (as some contented) or all bad (as I thought)?

Despite my concerns, I repeatedly encountered physicians who champion toxic quizzing, convinced learning is improved and thus worth the potential for learner harm.  Surely, I thought, these people were either maladjusted, delusional, or just suffered from the aforementioned nostalgialitis imperfecta profunda.

But more recently, I learned about the more nuanced relationship between stress and learning.

This year in Medical Education, Rudland et al. reviewed the literature on stress and learning, and developed a conceptual model of how the two are related (see Figure 1 of their paper).9  The authors describe that when faced with a stressor (in MedEd this is a challenge or learning expectation) learners may experience distress (negative affective result) or eustress (positive affective result).  This affective reaction is separate from, but related to, whether or not learning takes place.

A host of factors influence both the affective result and learning outcome, including amount and type of stressor, learning environment, support structures, stress training, learner motivation/mindset/personality, and coping skills.

Educators only control some of these factors (e.g. learning environment), and many of the learner factors are dynamic and unknown to both the learner and teacher.  For example, if a learner has a growth mindset, is well rested, has good stress coping skills, is not overwhelmed with work, and is in a supportive learning environment, then “pimping” may indeed promote learning.  However, how can an educator know when these factors are right for producing eustress and/or learning?

The wrong combination of these factors may turn “toxic quizzing” into a damaging experience that leaves learners demotivated and feeling judged.6

So, my perspective on “toxic quizzing” has shifted. . . . slightly.  Does it stimulate learning?

Maybe. . . for some people. . . under the right conditions.

For those educators who tout “toxic quizzing” as beneficial, perhaps for them it was.  They may have had the right set of personal and environmental circumstances for it to promote learning or eustress.

However, that is likely not the case for many students and residents.  Given the major concerns with learner burnout, the complexity of factors contributing to stress outcomes, and our inability to measure those factors in any given moment, I believe the risk still outweighs the benefits, and “pimping” (both the word and the practice) should be put to rest.

Instead we should use Rudland et al.’s model to create a milieu that promotes eustress and learning.

  1. Create a learning environment and culture that promotes psychological safety and a growth mindset.
  2. Develop support structures for heavy trainee workloads and for trainees in distress.
  3. Train learners how to deal with stress, including development of healthy coping mechanisms.
  4. Once this has happened, apply stressors that do not denigrate or humiliate learners.

Imagine a MedEd environment in which battlefield analogies would no longer be needed.



1. Healy JM, Yoo PS.In defense of “pimping”. Journal of surgical education. 2015;72(1):176-177.

2. Nagarur A, McEvoy JW, Hirsh DA, James BC. Words Matter: Removing the Word Pimp from Medical Education Discourse. Am J Med. 2019.

3. Purdy E. An Overdue Rant on Toxic Quizzing. In. ICE blog.

4. Oh RC, Reamy BV. The Socratic method and pimping: optimizing the use of stress and fear in instruction. AMA Journal of Ethics. 2014;16(3):182-186.

5. Purdy E. A Rant on Pimping and Social Capital. ICE blog.

6. Goebel EA, Cristancho SM, Driman DK. Pimping in Residency: The Emotional Roller-Coaster of a Pedagogical Method – A Qualitative Study Using Interviews and Rich Picture Drawings. Teach Learn Med. 2019:1-9.

7. Nostalgialitis imperfecta profunda. @boedudley, Twitter. 

8. Sousa DA. How the brain learns. Corwin Press; 2016.

9. Rudland JR, Golding C, Wilkinson TJ. The stress paradox: how stress can be good for learning. Medical Education. 2019.


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