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Laughter in Medicine

Thomasrobey72x722Thomas Robey -- In the past year, I’ve realized that experiencing strong emotions is part and parcel of a career in medicine. Should providers cry with patients? How do pediatricians manage the celebration of childhood with the heaviness of disease? Cancer elicits universal questions of “Why me, now?” Birth and death are each tied to pain and joy. And then there is laughter.

Laughter in medicine can be divided into two main categories: doctors with patients and doctors with doctors. Humor in both settings builds rapport, enables discussion of awkward topics, and is even therapeutic. Imagine yourself laid up in the hospital; the right type of levity in the right amount could make your day. One patient shared with me that my frequent bedside visits were better entertainment than cable television. One day, she asked if I could sing and dance. I encouraged her to look me up “on the outside,” but now regret not breaking out into an old musical number right then. We still shared a laugh about how I’d appear to my attending while belting out, “I am I, Don Quixote!” I’m daily amazed by how easy it is for someone to smile and laugh when they are in so much pain.

The other type of laughter -– between doctors -– is almost as important as the first. Care providers see much of what is broken in society. We see the worst of disease. We are witnesses to the ills of society. Injustice. Abuse. Addiction. When docs (and medical students!) get together, it’s natural to talk about these things, and this is how we understand each other. How do people in any stressful situation cope? The unique bonds between combat vets, firefighters, and social workers are echoed in medicine. Frustration and pain often expresses itself as gallows humor and cynicism. Is it wrong for a doc to speak pejoratively of an injection drug user if the patient’s identity is confidential and the comment is safely in the company of other docs?

My time as a surgery clerk has confused these two types of humor. I had been able to keep separate humor with patients and humor about them. This all breaks down in the operating theater. The patient is asleep -– sedated and paralyzed. If he can hear what is going on in the room, he will not remember it. When the drug user is on the table with necrotizing fasciitis because he muscled bad heroin and then sat in a hot tub for an hour, is it okay to make cynical jokes about the choices he made? His legs are spotted as a jaguar with injection ecchymoses and you’re cutting through intricately penned tattoos on his shoulders, hoping to excise the infected tissue before it spreads to his heart. When the surgeon dryly points out that it’s a shame this guy has to lose his tattoos, when in reality, he’s likely already lost his life, is it okay to laugh?

I almost cried.

May 9, 2008 in Thomas Robey | Permalink

Comments

You raise an excellent question. Can we really laugh about it? Personally, I agree with your own response. It is perhaps more appropriate that we cry. That there are those around us who can deteriorate to such a point should elicit within us two things: gratitude and empathy. Gratitude for being able to avoid such destruction, or having been protected by it; empathy, well, because that's a requirement of our profession. To teach and to aid, but not to judge.

As for the rest of the article, thanks. :) It was good to see that I'm not crazy to make it a point to joke with my attendings. Though a recent comment by a colleague has me wondering if humor might compromise the reputation of my professional integrity.

Posted by: Bhaijan | May 14, 2008 5:57:05 AM

Joking with a patient is perfectly acceptable. Joking about a patient is not, unless he or she is present and endorses it. It is a fine line.

As physicians, our patients look to us to embrace their problems with them and, at the very least, to alleviate their discomfort. Joking about them, no matter the intention, breaks this trust and is contradictory to our relationship with the patient.

I would like to share this story to illustrate the point: I was at a graduation party last night, where someone was joking about an STD patient getting an erection upon examination. While the situation is funny, no one joked about the patient, instead most were empathetic for the embarrassing situation. Then we discussed what to do or not to do in that situation. Then we joked heartily about what not to do.

Posted by: jtwhite | May 14, 2008 7:51:13 AM

Great entry, Thomas. I've had similar thoughts on this topic as well. And I've been in a similar situation to the one you described above (as I'm sure many of us have). I almost cried as well, but then somewhere deep down inside I laughed, and somehow the laughter prevented me from crying. It made me feel like a horrible person, but somehow it also made it okay. The line is indeed thin and convoluted.

You might also like to read this article in Academic Medicine: http://tiny.cc/article757

Posted by: Kendra | May 14, 2008 4:20:59 PM

Excellent article, and I agree with those who think that respect between doctor and patient should be always taking in consideration when trying to joke with them. I think this: if the patient is the one who starts joking about something that is not disrespectful, then it's OK if we share a laugh or two with him/her, but we should never engage in any joke that involves cruelty or disrespect for human life/dignity.

Posted by: Livingstrong | May 20, 2008 3:13:51 PM

I can tell you as a patient some of the laughter from medical people is perfectly allright. When I was in the ER and very woozy from morphine and being asked a million questions the ER doctor laughed when she asked if I'd had surgery before and I answered yes, a tubal ligation. Well, she knew I'd had seven children, so I could appreciate the laughter. Okay. But in a different hospital, different state, in the midst of a serious medical crisis, the hospitalist's sneering snorts that I needed a court-appointed guardian because I hadn't recognized sooner that I WAS in crisis infuriated me. Rest assured I wouldn't return to that hospital even if it would save my life. Seriously. Thankfully, it isn't the only one in this area.

Posted by: peggy | Jun 18, 2008 3:31:20 PM

That is funny

Posted by: stevecook | Jul 8, 2008 12:03:43 PM

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