Humor in Medicine: Nasty, Dark, and Shades of Grey

Bioethics-in-the-News-logoThis post is a part of our Bioethics in the News series. For more information, click here.

By Tom Tomlinson, PhD

In mid-August this year, the Annals of Internal Medicine published an anonymously-written commentary titled “Our Family Secrets.” It describes in almost lurid detail the “joking” antics of some male surgeons caring for unconscious or sedated women undergoing surgery or childbirth. Since this is a family blog, I won’t provide the details. Readers can see for themselves. Suffice it to say that the behavior involved was nasty and despicable enough to attract a good deal of shocked media attention.

Part of the shock among the public was that these things were done as jokes, and reportedly every one present had a good laugh, except for the patients. For health care providers, however, this comes as no surprise. Dark humor of all kinds is very common among medical insiders. The examples reported in the Annals article stand at one extreme pole of a spectrum and were egregiously unethical. The question they raise for me is whether there are places further down the spectrum where dark humor—even when it has patients as its objects—is ethically acceptable.

Many people think the answer is “no.” A virtuous professional should never laugh at or about patients and their conditions. There’s nothing funny about illness or its treatment. Humor about patients is usually derogatory or cynical (Aultman).

But I don’t think this is right. Dark humor is inherent to the nature of medical work. And while some of it will be utterly objectionable, some of it will be ethically acceptable. The trick is how to tell the difference.

So what is “dark humor?” I like a Wikipedia entry’s take on it. “Humor in which topics and events that are usually regarded as taboo or tragic, or otherwise “nothing to laugh at,” are treated in an unusually humorous or satirical manner while retaining their seriousness. The effect of dark humor, therefore, is for the audience to experience both laughter and discomfort, often simultaneously” (adapted from the Wikipedia entry). Here’s an innocuous example.

What I especially like about this definition is the last part. First, it’s a clue to why we often find dark humor very funny. The laughter is first a response to the surprising incongruity between the perspective created by the comment or joke, and the actual situation. But second, the laughter serves as a release of the psychological tension between the pleasure the joke gives us, and our simultaneous feeling that we really shouldn’t laugh in the circumstances.

baby-doctor-comic

Image source: Flickr user Dugg Simpson. Image description: a four-panel comic strip depicts a doctor and nurse examining a baby. Text over the nurse’s head reads, “So what do think, Doctor?” Text over the doctor’s head reads, “I’m not sure what to make of it, Nurse. Usually, ‘third eye’ is just a metaphor…”

This definition also captures the source of dark humor’s ethical ambivalence. On the one hand, we generally think that wit, humor and laughter are natural, pleasurable, expressions of our human intelligence. But on the other, we think we should remain fully open to the tragedy before us, and the vulnerability of those who are undergoing it. But can we do both? That’s the ethical challenge.

So let me offer some examples along the spectrum, starting at the more benign end:

Jiffy: At M&M the resident presented the surgical challenges raised in the case of a psychiatric patient who had managed to insert a jar of peanut butter in his rectum. At the conclusion of his presentation, he asked if there were any questions.

After a long silence, someone in the back of the room demanded to know, “Well, was it smooth, or crunchy?”

The unexpected death: “I was visiting a ward at night, having been requested to see an old man who was about to die. Death was expected, we had made sure he was peaceful and comfortable, and the nurse and I stood by the bed watching him. Then, from the opposite end of the ward, we heard a dull thud. A patient had just fallen out of bed, stone cold dead. Nothing funny in that, you might think. And, no, in the cold light of day, it’s tragic. But at the time, we thought it was amusing” (chrispitts).

Doctor, your patient is on fire: “The evening’s theme: funniest beeper pages in the middle of the night… Another hilarious page: “Doctor, your patient is on fire.” The man in question was psychiatrically unstable and had ignited himself. We were howling in between spoonfuls of ice cream” (Sobel).

One might think that Jiffy is objectionable because it’s making fun of the patient. But that misunderstands the joke, which is parodying the formal conventions of morbidity and mortality rounds, rather than deriding the patient. It’s not mean, just raunchy.

One might also think that it’s just not funny when someone drops dead unexpectedly. Indeed not. But the death is not what provoked the laughter. The laughter was triggered by the sudden ironic incongruity presented by the situation.

And of course it is never funny when someone sets himself on fire. But it’s not the patient that’s funny. It’s the page. The first thing that springs to mind is those reports of spontaneous human combustion.

So how about the other end, closer to “Our Family Secrets?”

400 pounders: On one surgery service, morbidly obese patients were routinely referred to as “400-pounders.” This would always make one medical student giggle.

Wacko: A medical student was shadowing a family physician who was counseling a diabetic patient. The patient began to recount all the difficulties she had in her personal life. The physician was doodling on a pad, appearing to take notes. As the patient continued, the physician wrote “wacko” and showed the pad to the student sitting behind him, as if sharing important information.

These obviously are directed against the patient.

If “400 pounder” provokes laughter, it’s because it pictures the patient as a slab of meat or a carcass. And it’s dehumanizing of obese patients is all the more insidious once it becomes a routine way of talking. No longer funny– if it ever was– it institutionalizes an attitude or perspective about patients. This poses higher risks to the quality of patient care from sheer repetition. And its routine and unreflective use encourages a coarsening of sensitivity in the provider.

“Wacko” doesn’t even have the redeeming feature of being funny, at least not among those older than 10. It’s just mean, and teaching future physicians to be mean to boot.

As a fan of dark humor, I don’t want to ban it from health care. Human beings are born to be funny, laughter feels good, and it’s a wonderful way to relieve tension. The trick is deciding when to laugh, and when to wince.

If any of you have examples, please post them…and explain where you think they lie on the spectrum.

Tom Tomlinson, PhD,tomlinson is Director of the Center for Ethics and Humanities in the Life Sciences and a Professor in the Department of Philosophy at Michigan State University.

Join the discussion! Your comments and responses to this commentary are welcomed. The author will respond to all comments made by Tuesday, October 13, 2015. With your participation, we hope to create discussions rich with insights from diverse perspectives.

You must provide your name and email address to leave a comment. Your email address will not be made public.

References

  1. 2015. Our family secrets. Ann Intern Med 163(4):321
  2. Aultman JM: When humor in the hospital is no laughing matter. The Journal of Clinical Ethics 20:227-35, 2009.
  3. Black comedy. Wikipedia: The Free Encyclopedia. Wikimedia Foundation, Inc., Sept 26 2015. Web. Sept 28 2015. https://en.wikipedia.org/wiki/Black_comedy
  4. “My Experiences and Advice.” DooYoo. DooYoo, July 17 2002. Web. Sept 28 2015. http://www.dooyoo.co.uk/archive-campus-careers/my-experiences-and-advice-125/#/tab/opi/
  5. “Commercial Ameriquest: At hospital.” Online video clip. YouTube. YouTube, Feb 23 2007. Web. Sept 28 2015. https://youtu.be/LRdebJrwn2s
  6. Friedman M. A Horrifying Anonymous Essay Exposes Doctors’ Sexual Assault of Unconscious Patients. Cosmopolitan 18 Aug 2015. Web. http://www.cosmopolitan.com/health-fitness/news/a45029/horrifying-anonymous-essay-exposes-sexual-assault-on-patients-in-the-operating-room/
  7. Kaplan K. Medical Community Reflects on ‘disgusting and Scandalous’ Episodes in the Operating Room. Los Angeles Times 22 Aug 2015. Web. http://www.latimes.com/science/sciencenow/la-sci-sn-sexual-assault-doctors-operating-room-20150821-story.html.
  8. Sobel RK: Does laughter make good medicine? N Engl J Med 354:1114-5, 2006

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27 Responses to Humor in Medicine: Nasty, Dark, and Shades of Grey

  1. Michael Braem says:

    I don’t see why doctors should be any less inclined to indulge in dark humor as, say, attorneys. As Hawkeye in the old T.V. series ‘M*A*S*H’€ said, you have to laugh to keep from going insane.

    Thank you.

    Michael Braem, J.D.
    College of Human Medicine
    Michigan State University
    965 Fee Rd., E. Fee Hall -Rm. A114
    East Lansing, MI 48824
    (517) 353-7813
    michael.braem@hc.msu.edu
    http://humanmedicine.msu.edu/
    [msu_extraordinary]

  2. Carrie Summers says:

    Doctors who make patients laugh or who are able to connect with them on a more human personal level I think tend to make the patient more open to asking questions, discussing more complex or even issues that they are reluctant to discuss. Even dark humor can still make a patient feel at ease. The medical model, is often cold and uncaring, so if a doctor is able to use dark humor or any other kind of humor to connect with a patient, which can be very empowering. So I believe that they should be able use dark humor, if they choose too.

    • I worry about expressing “dark humor” regarding a patient’s body or disease being much less than of therapeutic value and, in a way, harmful to the doctor-patient relationship. ..Maurice.

    • Tom T says:

      I think it is risky for a clinician to *initiate* the use of dark humor in direct patient interactions, without some direct or indirect invitation by the patient. And this can happen– patients themselves use dark humor to make light of their situations. Clinicians should feel comfortable enough with such humor to laugh along with the patient. And in the right kind of relationship, clinicians who are comfortable with dark humor (and good at it!) can themselves use it with the patient. This can deepen their connection, and make difficult circumstances easier to bear for both.

  3. Jody says:

    It’s human to make light of serious situations. It helps to relieve stress and tension. These people who do this are educated people who understand when to do it and when not to it. When it is cold and unethical is when it is a direct attack on a person, is another story. Recently we were counseling a middle-aged women who has a serious case of food addiction. When she started to talk about potatoes She named every way you could possibly have a potato. Fried, baked, broiled, hash browns, french fries with and without salt, mashed and in chips both fried and baked and finally, a sweet potato. It reminded me of the scene in the Forest Gump movie with bubba gump shrimp. It took everything I had not to break out laughing. Now this is a serious disorder but there certainly is some humor in it. She spent 5 minutes of her session naming the various kinds of potatoes. I will never look at a potato again in the same way!

    • Tom T says:

      Thanks, Jody. I laughed just reading this. The laughter was spontaneous, and innocent, I hope–not motivated by any ill will toward the patient. We’re laughing not at the patient, but as you illustrate, at the image or alternative perspective that the patient’s story conjures up, suddenly and out of the blue. That fun house mirror world can exist alongside the real one, but most people know the difference, and know when it’s time to get back to the real world and attend to the work at hand.

  4. Jennifer Onwenu says:

    Being a doctor can be an extremely stressful job. Physicians are often running off of few hours of sleep, and spending time away from their family, although it may seem insensitive to some I see it as a coping mechanism amongst the profession. As long as the jokes are not told with the intent to harm, and does not affect the quality of service to the patient I believe they are appropriate. If medical professionals are not using this humor to harass or harm patients, dark humor in medicine doesn’t violate any ethical principles.

  5. I certainly would agree that there is a “humor spectrum” as outlined by Dr. Tomlinson and utilizing humor carefully is of value for the physician’s emotional status especially in times of stress. However, clearly Tomlinson has focused the recipient of such humor to be other healthcare providers and not the patient. There is a certain collegiality and understanding between healthcare colleagues as to what humor is practiced and what is accepted. What is unknown to the physician is how this specific humor will be accepted by the patient who is already in distress. Perhaps jokes that deal with other aspects of our lives and experiences will be accepted, tolerated and perhaps enjoyed by the sick patient but to present descriptions of the patient (anatomy, behavior,illness or treatment) which is thought by the physician to be humorous and of some educational or therapeutic value to the patient may likely be disastrous for immediate benefit and may destroy further, hopefully therapeutic, relationship. This “dark humor” emotional and stress ventilation by a physician should, if appropriate, be directed to colleagues but not to the physician’s patient. ..Maurice.

    • Tom T says:

      Yes, I agree that clinicians tread a very precarious line when they are using dark humor around patients. Like a lot of humor in any workplace, it’s for insiders only, that draws on a shared set of experiences, annoyances, and attitudes. Those on the outside often won’t get it, or will misunderstand it.
      But there are exceptions, like the one noted above.

      • So.. I teach first and second year medical students in the “Introduction to Clinical Medicine” course how to interact with patients, take a history and perform a physical examination. We have never advised students to make “jokes” about their patients to others (colleagues or others) and certainly not back to the patients themselves. I stress to my students that a patient should be looked as a subject of an illness (a person with a name who is sick) and not an object (their anatomy or their pathology or their hospital room number for identification).

        Should I warn my students that the upcoming “hidden curriculum” is going to find them observing “dark humor” told about a patient while watching a procedure or later, Should I tell them when they hear or see this to stop paying attention, walk away or even stand and speak up to the one making the joke (if they have the courage) and not just standby smirking, a little smile and with a little giggle.

        I feel that if “dark humor” is so valuable as a professional form of therapeutic emotional ventilation, why not joke about the medical system itself or your colleagues? Or might some find joking about those “objects” objectionable? ..Maurice.

  6. Tom T says:

    Some of you might enjoy this, sent to me by my friend, Martin Benjamin:
    Brain-Dead Teen, Only Capable Of Rolling Eyes And Texting, To Be Euthanized
    http://www.theonion.com/video/brain-dead-teen-only-capable-of-rolling-eyes-and-t-27225

  7. Kevin says:

    Humour is important to mental health and helps team-build etc. However, targeting it at someone who comes to you for care is objectionable. While I can understand how joking about traumatic events helps providers process; I cannot see how ridiculing someone vulnerable is anything different than bullying. It objectifies patients and reinforces the them vs. us mentality; when you can no longer identify with someone you lose empathy and this directly impacts the care and outcome. We have all observed this in grade school – remember how the fat/skinny/four-eyed/buck-toothed etc kids were singled out? Looks like a lot of us never grew up – maybe its time we did? If the patient would be hurt by your words then perhaps you shouldn’t say them? To quote Thumper form Bambi “My daddy says – if you can’t say somethin’ nice; don’t say nothing at all”.

  8. Crista Lebens says:

    You mention that it is a matter of drawing a line between appropriate and inappropriate jokes. It is worth noting that, as you describe the blog, the jokes told were told by male doctors about female patients, specifically female patients who were unconscious or sedated. I have not read the blog, and I shudder to think of what I’d find. I share Dr. Bernstein’s concern. I would go further and say that such humor threatens the therapeutic relationship between such a physician and any of his female patients.

  9. May I suggest for those interested in reading a very well written and extensive presentation by Ray (my blog thread visitor) specifically regarding Dr. Tomlinson’s article here, presented in a continuous series of 8 postings, go to his initial post on my Bioethics Discussion Blog thread “Patient Modesty: Volume 73” at http://bioethicsdiscussion.blogspot.com/2015/08/patient-modesty-volume-73.html#c4609451357515502852

    I also suggest that “medical slang” be eliminated such as referring to patients as “dirt ball” for a patient who enters the emergency room filthy and smelling badly or “druggie” for patients known or suspected for illicit drug use or “goldbrick” for a patient who demands more attention than their (minor) condition warrants or the acronyms LOBNH for “lights on but nobody home” for a patient with suspected dementia and, of course, GOMER for “get out of my emergency room!”. Not only are these expressions disrespectful for the dignity of the patient but they can lead physicians into heuristic (logical) errors with patient harm as the consequence. Physician emotional ventilation about their work and the system should be exercised in more humanistic and constructive methods. How about taking a run around the block? ..Maurice.

  10. Tom Tomlinson says:

    I don’t think that anything I said implied that whatever passed for “dark humor” is perfectly OK. The examples Dr. Bernstein mentions, and the assaults on patients described in the Annals article are beyond the pale because they are unambiguously disrespectful and insulting. But not all dark humor is like this, as I tried to illustrate and explain with examples. What’s called for is judgment, not a blanket censure that makes no distinctions.

  11. Dr. Tomlinson, If you read the postings on my blog by Ray, he fully supports your expression of a spectrum of tolerable to intolerable behaviors. What I am concerned about all this from an instructor of first and second year medical students is how to provide them or educate them as to what is “light” and what is “very dark” humor, what is tolerable and what is intolerable. They are going to be challenged starting in just a year or two. What should I declare as distinguishing factors and what should I teach them should be the student (and later, the physician’s) response when they are present and exposed to this by a colleague or a superior? ..Maurice.

  12. MC says:

    I am a second year medical student, and I worked as an ED scribe between undergraduate and medical school. One I remember from the EM physicians I used to work with was talking about arrested or unresponsive patients presenting with the “O” sign or the “Q” sign- the first being open-mouthed, and the second being open-mouthed with a lolling tongue. I think in context it was used appropriately. A sick trauma patient had just been stabilized, and the situation had been tense, and when my attending told me about it, we shared a laugh and felt better. But then he grew serious and said “If you see a positive “O” sign or especially “Q” sign, you’d better be ready to go b*lls deep as soon as they roll in the door, because the tail in that Q points to ‘check-out time’.”

  13. Tom Tomlinson says:

    Dr. Bernstein, here’s what I’ve done with 3rd year students, who are newly immersed in the clinical environment, and encountering medical dark humor perhaps for the first time. I draw a line on the white board. At one end is “highly objectionable”, and at the other end is “acceptable” (notice the other pole is not “Admirable.”). Then as we discuss examples, we place them on that spectrum, and discuss why they belong there. I prime the pump with a couple of examples, and then we turn to the examples they’ve brought with them. The goal is to illustrate, and exercise, the use of judgment. I hope they leave as more informed consumers– and users– of dark humor, who are better equipped to know when the line’s been crossed.

    I’m sorry I haven’t yet had the time to look at your blog, but will do so later today.

  14. Oh, Tom, I hope you do. I must say I am truly impressed by the scholarly and clear way that my blog visitor Ray has been commenting on the entire issue you brought up here. I would be pleased to post his comments directly here but I haven’t asked for permission to do so. However, I will present here the links to today’s postings by Ray for readers here to have rapid access. I am sure you and the other readers here will find pertinence and valid arguments presented by Ray.
    Ray’s first posting today: http://bioethicsdiscussion.blogspot.com/2015/08/patient-modesty-volume-73.html#c7495052270938581077
    and is continued on a second posting:
    http://bioethicsdiscussion.blogspot.com/2015/08/patient-modesty-volume-73.html#c7460750361342187834

    I would be most pleased to read how you and the others here evaluate Ray’s presentation and his arguments.
    I think medical professional behavior of the issue brought up in the Annals of Internal Medicine article and extended here by you Dr. Tomlinson demands now attention since this “dark humor” may be only a symptoms of a defect in our medical system that perhaps healthcare providers tend to ignore or explain but represent further unethical or unhumanistic behavior that our patients experience but fear to speak up. . . .Maurice.

    • Tom Tomlinson says:

      Maurice, I’m not sure that dark humor as such is a symptom of defects in the health care system, although I do think that the behavior of the physicians in the Annals article reveals a defect in their professional character and judgment. Sometimes people characterize dark humor as a coping mechanism used to relieve the pent up stresses and emotions of the work, some of which is clearly a product of a dysfunctional system. There is no doubt that dark humor can serve this purpose, but I don’t think all dark humor needs a psychiatric diagnosis. The urge to joke around is a too basic and universal human impulse, and in itself nothing to be ashamed of.
      Tom

  15. Tia Coles says:

    I feel that those in the medical profession need to be careful using humor. Humor can often be misconstrued, which can lead to a slippery slope between other professionals as well as with the patient. Often times professionals will use the excuse of only using dark humor with each other and never with the patient. My questions is when the dark humor is exchanged between colleagues, is the patient’s well-being really the priority, or is someone just getting a laugh at the patient’s expense? I do not think that any person professional or otherwise would appreciate their medical concern being the brunt of a joke. As professional who address and advocate for the well-being of others, I feel it is important to take note and reflect on all aspects of how we accomplish this. It is never ok to get a chuckle at the expense of another’s hardship.

    • Tom Tomlinson says:

      I agree that patients should not be the “brunt” of the joke–i.e., disparaged or belittled by it. But not every joke that refers to the patient’s situation is against the patient, or even directly about the patient, as I hoped to illustrate with some of my examples. Of course, this is a fine line sometimes, requiring that we understand what’s funny about the joke and that we use good judgment in when and how we tell it.

  16. But “good judgment” is difficult during periods of tension, frustration, fatigue, competition, uncertainties, demands by others, non-professional concerns and….. (did I cover all or is there more?) Oh, I probably missed “showing off” to one’s professional inferior..or even superior.

    Speaking or even worse acting out a “dark humor” scenario can never be to the betterment of the patient who is being erroneously categorized (perhaps stigmatized) or as described (for one example as in the Annals article) in some instances unknowingly physically abused. And, if it isn’t about a specific patient, it becomes about “patients in general” and thus sets a professional bias.

    What we are discussing here is “dark humor” as occurring virtually by definition, as an expression or physical act in the presence of a bystander. The bystander is often a colleague or a student. The defect in the medical system is total lack of bystander education by the system with regard to appropriate and effective reaction when such “dark humor” is observed. As an example, I would like to find in the Code of Ethics of the American Medical Association http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics.page? a specific description of “dark humor’ and instructions regarding how a bystander should deal with it when experienced. That would be a simple beginning system change. ..Maurice.

  17. Heather Ketzler says:

    The mere fact that we are classifying what type of humor is being used (dark humor), indicates to me that whomever is using it knows that it is dark (bad or otherwise inappropriate). As professionals we are to do our best for our patient; this is to be completed both expeditiously and with respect. Taking the time to tell a coworker a joke is not in our patients best interest, nor ours. Our thoughts are powerful they impact our behavior, as well as the behavior of others. When our thoughts are focused on inappropriate conversations we are not giving our best to our patient. When a professional engages in “dark humor,” they allow themselves to participate in conversations that can lead to ethical challenges. The person should be at the center of our treatment, as professionals we must ensure that the individual we are treating is a human being and not a body part.

  18. Tom Tomlinson says:

    Of course, it is clear from my comments that I do not equate “dark” with “bad”, even though dark humor can also be bad. And I agree with Dr. Bernstein that professionals in training (and in practice!) need some guidance about both using and responding to dark humor. In an earlier comment, I described one technique I use with medical students. And I also urge them to report egregiously disparaging comments like “Wacko” above. Of course, they are often afraid to do so, because they have no confidence that we can protect them from retaliation. But I think bans on dark humor, let alone bans on laughing at it, are hopeless, and unwarranted.

  19. randyhillard says:

    I do not find either of the “peanut butter” or the “on fire” are benign. There is nothing funny about psychiatric illness, although psychiatric patients have been laughed at for centuries.

    If a patient accidently aspirated while eating peanut butter, would it be funny to ask “Was it smooth or crunchy?” I do not think so.

    The page stating “Your patient is on fire,” presumably represented an attempt at humor by whoever paged the doctor. No one would use such language if they were not trying to be funny. It is not funny, and we should not laugh at it. If the page had said “Your patient just croaked,” would that be funny? I do not think so.

    I think that given the continuing stigma associated with mental illness, we need to be particularly careful in “humor” relating to them. If we have lower standards for what is “benign” humor with reference to psychiatric patients than we have for patients with other illnesses, then we are trivializing terrible afflictions and tacitly buying into society’s prejudices against patients with this type of disorder.

    Lest you think that I have no sense of humor, my latest post (coming out next week) for my American Society of Clinical Oncology (ASCO) blog is about “cancer humor.” I will post it below.

  20. randyhillard says:

    So, as I said, I have a blog on ASCO Connect (https://connection.asco.org/authors/James%20Randolph%20Hillard,%20MD) The entry below will be posted there in the next week or so.

    Cancer Humor

    One of the limited number of positives about having cancer is being able to get away with making cancer jokes. Before I got cancer, I thought up what I believe is the greatest ever pun involving Mid-Western geography and malignant neoplasms, but I was never able to share it—until now. I will include it later in this post, unless I chemobrainedly forget.

    So, that last paragraph contained at least two attempts at cancer humor (not counting the ridiculous pun that I am hoping to forget to share): 1) comparing the very huge burden of having cancer with the very modest consolation of being able to joke about it 2) making light of chemobrain. (In the interest of full disclosure, I am not actually Jewish, but I am a psychiatrist, which is probably the next best thing.) Were those first paragraph attempts at humor funny? If so, why? If not, why not? For that matter, why is anything funny?

    Freud, of course, thought of things in terms of the id, ego and super ego: the id is all about “what I want or feel right now,” sex, aggression, fear, that sort of thing 2) the superego is all about what I should be doing and 3) the ego has the often thankless task of mediating between both of these irrational entities and the demands of the outside world.

    Freud’s main theory of humor was that when the id feels something that the superego disapproves of, the ego can trick the superego into letting the id get away with it. To do this, jokes often start out seeming to go one socially acceptable direction, and then suddenly change direction to allow the id to share something else entirely. That is when we laugh. (BTW, Freud never said “I don’t want to belong to any club that would accept me as a member” (although it is something that he would have probably found funny). That quote is really most appropriately attributed to Groucho Marx, in spite of what Woody Allen or Annie Hall might say.)

    Of course, Freud’s formulation does not cover all types of humor, if you would prefer another formulation, then just google “Why are jokes funny?” You will get “About 79,800,000 results (0.34 seconds).” Interestingly enough, if you google “cancer” plus “humor,” you will get “About 38,500,000 results (0.34 seconds).”

    From a semi-Freudian point of view, all both jokes in my first paragraph express fear of my cancer. My superego thinks admitting fear is weak and childish. Each joke allows some of that fear to come out by seeming to be going towards one place and then ending up in another. My superego is tricked into thinking (probably incorrectly) that this makes me look witty and intelligent, which my superego approves of.

    But seriously…..How should cancer clinicians respond to cancer humor? Smiling is usually good. Smiling shows that you appreciate that the patient is doing his/her best to deal with a bad situation and that they want you to be a fellow human being with them, not just a clinician. But laughing may not the best response when a patient (for example me) says something like “I always wanted to be first in my medical school class. Now I will be; I will be the first one to die!” This joke is expressing, although indirectly, feelings of bitterness and hopeless. When you laugh at it, you can be perceived as accepting that these are exactly the feelings that the facts of the patient’s illness demand.

    How do you make the differential diagnosis of whether or not a situation is laughable? 1) Pick up on the affect that the patient is expressing, rather than just on the content. If patients say something that they genuinely find funny and that you genuinely find funny, of course you can laugh with them. 2) If the affect and the content do not match, whatever the patient said is probably not something to laugh at. Under those circumstances, it is better to ask yourself what impulses or hopes or fears the patient may be hiding through humor. You do not need to get all psychiatric; but in response to the “first in the class” joke above, it is probably good to say something like “It is too soon to conclude that you are going to be dying right now.” If you are feeling a little humorous yourself, it might be good to say something like “Hey, it is not time to start planning your valedictory address quite yet.”

    That brings us to the question of whether you, as a clinician, are safe in being humorous with patients. When I was in residency, the general response from psychiatrists would have been “No, the two main things that your id wants to express are sex and aggression, and you do not want to express those to your patient, do you?” Well, it is a good idea to do a quick check to make sure that your humor on a particular occasion is not letting out anything that could be perceived as sexual or aggressive. On the other hand, if your humor is letting you share “weak” feelings about how difficult the human condition can be for your patient and for you, that sort of humor will probably be reassuring. If you say something that a patient is offended by, you can always apologize.

    If you cannot ever express humor with patients or accept patients’ expressions of humor, your patient may read that as your feeling that the situation is completely hopeless. For what it is worth, I would encourage you to have the courage to share some humor with your patients. You can trust your intuition to know which ones will respond well and which ones will not.

    Oh, and that reminds me….The head of the Cancer Center at the University of Cincinnati, where I used to work, was always referring to Cincinnati as “Cancer City.” This was because Cincinnati had a somewhat higher rate of cancer deaths than the country as a whole. When she referred to the city this way one time too many, I wanted so badly to ask her whether it was “Cancer City, Cancers” or “Cancer City, Misery.”
    Thank you for letting me get that off my chest. :-)

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