Does Laughter Make Good Medicine?
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《新英格兰医药杂志》
The medical teams convened for a ritual snack break at 10:45 on a recent call night. We ate our ice cream in the far corner of the Moffiteria — as we affectionately call the cafeteria at UCSF's Moffit–Long Hospital — fueling up before the onslaught of admissions. The evening's theme: funniest beeper pages in the middle of the night.
"I once got this page from a nurse," said an intern. "`Doctor, your patient is covered in ants.'" The table erupted in laughter. Apparently, the patient had come in off the streets and brought the ants with him. They crawled out from their hiding spots after the doctor had done the initial workup. 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.
Another resident chimed in. Her favorite page came from a Filipina nurse:
"Doctor, doctor," said the nurse. "Yes?" answered the resident. "Your patient — chicken-nut bread."
"Excuse me?" the resident asked.
"Chicken-nut bread!" the nurse pleaded. As it turned out, through her thick accent, she was saying, "She cannot breathe." We laughed until we could barely breathe. The night was young, and we needed a boost.
I probably wouldn't have thought twice about these jokes if it hadn't been for a recent panel discussion I had heard on "unprofessional" behavior. In confessional mode, the panelists shared some unsavory moments: intentionally avoiding a difficult patient, high-fiving one another after a patient's discharge because he was finally off the service. Then the task was upon us medical students. What kind of unprofessional behavior had we participated in or witnessed?
A few days after taking part in the cafeteria giddiness, I wondered whether those few moments of snarky backroom giggling were a case in point. A patient on fire or unable to breathe is a serious matter. Had I been unprofessional toward patients and nurses? What had driven this behavior? Was my compassion for patients and my respect for coworkers dwindling? Or were those acceptable and much-needed laughs shared among colleagues? What exactly is the role of humor in medicine?
Our deans started using the term "professionalism" the very first hour of medical school. It would be a cornerstone of our education. Professionalism, we learned, "demands placing the interests of patients above those of the physician, setting and maintaining standards of competence and integrity." Many of us had already formulated this notion in our own minds when we applied to medical school. At orientation, we signed a contract binding us to uphold these principles for the rest of our professional lives.
In retrospect, I realized that during that night in the Moffiteria, I had, strictly speaking, violated a central tenet of the professionalism contract, which states: "I will treat patients and their families with respect and dignity, both in their presence and in discussions with other members of the health care team." We had been laughing at the patients and their misfortune. They were the butt of the joke, their dignity violated. But they were also the ultimate reason why I had endured the rigors of training thus far — and why staying up late studying had been a labor of love. In hindsight, laughing seemed a bit like betrayal.
Why, then, in those few seconds of juvenile hilarity, did I not feel an ounce of guilt? Perhaps it was simply that being with a group of other medical "professionals" made it seem okay. Or maybe it was justified because laughing brought us together as a team in an important bonding moment, which would ultimately benefit our patients. Or perhaps laughing was less about making fun of patients and more about coping, finding humor in a day filled with suffering. We were witnessing more darkness in our 20s than many other people see in a lifetime.
A little laughter — if only behind closed doors — might make us better at our profession. Put another way, we laugh because we feel, because we are still sentient creatures. Allowing ourselves to laugh keeps us alive and aware, in touch with the emotions that allow us to care for other human beings. Suppressing our natural reactions might ultimately distance us from patients.
In House of God, a novel about the rite of passage of medical internship, the character Fats at first shocks the neophyte Basch with his crass nicknames for patients — Gomer (Get Out of My Emergency Room) and LOL in NAD (Little Old Lady in No Apparent Distress). Yet one could argue that Fats understands his patients at a deeper level than do many of his colleagues. He knows, for example, that Gomers are ready to die and the hospital won't let them. Compare his insight and effectiveness with those of Jo, his straitlaced counterpart with no sense of humor, who keeps pursuing medical interventions at all costs in order to "help" her patients: her patients slip downhill, whereas Fats's patients remain stable and are eventually discharged.
But even if humor reflects a more nuanced understanding of humanity, why can't such wisdom manifest itself differently? One of my classmates, anticipating lots of jokes before he started his surgery rotation, made a pact with himself never to laugh at the expense of a patient — even if it meant implicitly rejecting the hierarchy when his superiors poked fun. He tells me they respected him more for it. I did not have his foresight.
I wonder, too, whether the very act of cracking a joke about a patient changes a doctor's behavior in some unconscious but tangible way. Could there be a Heisenbergian principle at work here, whereby the very presence of humor, whether or not the patient is privy to it, distorts the quantum relationship between doctor and patient? My best guess is that it depends on the context, the intent, and the type of humor.
Some dark humor is obviously toxic. For example, an obstetrician recently called me into the operating room to retract for a cesarean section because he needed an extra hand. The patient had a body-mass index of 51. As the doctor sliced through layers of greasy orange lobules, he sighed about the difficulty of the delivery. "This is veterinary medicine," he said.
"What do you mean?" asked the intern.
"I mean, it's disgusting."
All this, while the patient had only an epidural and a slim, blue sheet of paper to shield her from the physician's insults. Later that day, in the conference room surrounded by residents, he joked that anyone wanting to field a football team needed look no further than the OB service. A few people actually chuckled.
But what about the more subtle cases, such as the humor my team shared at the start of a tough night? In my own mind, I have justified that event, though I am biased. The jokes brought us together and provided essential comic relief. The laughter occurred at a distance — both spatial and temporal — from patients. Surely, such let-loose moments can enable residents and med students to take better care of patients.
During our time on service together, for example, the intern who had told us about her funny pages took care of a patient with a sickle cell crisis — a notoriously difficult type of case to manage. She did it with grace and patience, eventually transitioning the patient from high-dose IV pain meds to an oral regimen that he could go home on. I would bet that her stamina in caring for a patient with such a challenging condition could be attributed in part to her ability to find humor in the devastating world around her.
And the resident who told jokes that night led our team with confidence and skill during our month together. I watched her compassionately discuss end-of-life care with a family whose loved one was dying of a mysterious infection. I wondered whether her poise came from stability born of emotional balance. I hope one day to provide my patients with the kind of exemplary care that these two physicians gave.
Still, the purist's definition of professionalism dictates that patients should be respected at all times, even behind closed doors. Ideally, even a team that is tired and loopy from being on call at night should be able to find something else to laugh about — perhaps even themselves.
I hope always to uphold the code of proper patient care. But I also realize that to treat a human being well, one must remain human. And therein lies the quandary: How will we ever reconcile our inevitable — and necessary — human imperfections with our desire to abide by the highest standards of professional conduct?(Rachel K. Sobel)
"I once got this page from a nurse," said an intern. "`Doctor, your patient is covered in ants.'" The table erupted in laughter. Apparently, the patient had come in off the streets and brought the ants with him. They crawled out from their hiding spots after the doctor had done the initial workup. 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.
Another resident chimed in. Her favorite page came from a Filipina nurse:
"Doctor, doctor," said the nurse. "Yes?" answered the resident. "Your patient — chicken-nut bread."
"Excuse me?" the resident asked.
"Chicken-nut bread!" the nurse pleaded. As it turned out, through her thick accent, she was saying, "She cannot breathe." We laughed until we could barely breathe. The night was young, and we needed a boost.
I probably wouldn't have thought twice about these jokes if it hadn't been for a recent panel discussion I had heard on "unprofessional" behavior. In confessional mode, the panelists shared some unsavory moments: intentionally avoiding a difficult patient, high-fiving one another after a patient's discharge because he was finally off the service. Then the task was upon us medical students. What kind of unprofessional behavior had we participated in or witnessed?
A few days after taking part in the cafeteria giddiness, I wondered whether those few moments of snarky backroom giggling were a case in point. A patient on fire or unable to breathe is a serious matter. Had I been unprofessional toward patients and nurses? What had driven this behavior? Was my compassion for patients and my respect for coworkers dwindling? Or were those acceptable and much-needed laughs shared among colleagues? What exactly is the role of humor in medicine?
Our deans started using the term "professionalism" the very first hour of medical school. It would be a cornerstone of our education. Professionalism, we learned, "demands placing the interests of patients above those of the physician, setting and maintaining standards of competence and integrity." Many of us had already formulated this notion in our own minds when we applied to medical school. At orientation, we signed a contract binding us to uphold these principles for the rest of our professional lives.
In retrospect, I realized that during that night in the Moffiteria, I had, strictly speaking, violated a central tenet of the professionalism contract, which states: "I will treat patients and their families with respect and dignity, both in their presence and in discussions with other members of the health care team." We had been laughing at the patients and their misfortune. They were the butt of the joke, their dignity violated. But they were also the ultimate reason why I had endured the rigors of training thus far — and why staying up late studying had been a labor of love. In hindsight, laughing seemed a bit like betrayal.
Why, then, in those few seconds of juvenile hilarity, did I not feel an ounce of guilt? Perhaps it was simply that being with a group of other medical "professionals" made it seem okay. Or maybe it was justified because laughing brought us together as a team in an important bonding moment, which would ultimately benefit our patients. Or perhaps laughing was less about making fun of patients and more about coping, finding humor in a day filled with suffering. We were witnessing more darkness in our 20s than many other people see in a lifetime.
A little laughter — if only behind closed doors — might make us better at our profession. Put another way, we laugh because we feel, because we are still sentient creatures. Allowing ourselves to laugh keeps us alive and aware, in touch with the emotions that allow us to care for other human beings. Suppressing our natural reactions might ultimately distance us from patients.
In House of God, a novel about the rite of passage of medical internship, the character Fats at first shocks the neophyte Basch with his crass nicknames for patients — Gomer (Get Out of My Emergency Room) and LOL in NAD (Little Old Lady in No Apparent Distress). Yet one could argue that Fats understands his patients at a deeper level than do many of his colleagues. He knows, for example, that Gomers are ready to die and the hospital won't let them. Compare his insight and effectiveness with those of Jo, his straitlaced counterpart with no sense of humor, who keeps pursuing medical interventions at all costs in order to "help" her patients: her patients slip downhill, whereas Fats's patients remain stable and are eventually discharged.
But even if humor reflects a more nuanced understanding of humanity, why can't such wisdom manifest itself differently? One of my classmates, anticipating lots of jokes before he started his surgery rotation, made a pact with himself never to laugh at the expense of a patient — even if it meant implicitly rejecting the hierarchy when his superiors poked fun. He tells me they respected him more for it. I did not have his foresight.
I wonder, too, whether the very act of cracking a joke about a patient changes a doctor's behavior in some unconscious but tangible way. Could there be a Heisenbergian principle at work here, whereby the very presence of humor, whether or not the patient is privy to it, distorts the quantum relationship between doctor and patient? My best guess is that it depends on the context, the intent, and the type of humor.
Some dark humor is obviously toxic. For example, an obstetrician recently called me into the operating room to retract for a cesarean section because he needed an extra hand. The patient had a body-mass index of 51. As the doctor sliced through layers of greasy orange lobules, he sighed about the difficulty of the delivery. "This is veterinary medicine," he said.
"What do you mean?" asked the intern.
"I mean, it's disgusting."
All this, while the patient had only an epidural and a slim, blue sheet of paper to shield her from the physician's insults. Later that day, in the conference room surrounded by residents, he joked that anyone wanting to field a football team needed look no further than the OB service. A few people actually chuckled.
But what about the more subtle cases, such as the humor my team shared at the start of a tough night? In my own mind, I have justified that event, though I am biased. The jokes brought us together and provided essential comic relief. The laughter occurred at a distance — both spatial and temporal — from patients. Surely, such let-loose moments can enable residents and med students to take better care of patients.
During our time on service together, for example, the intern who had told us about her funny pages took care of a patient with a sickle cell crisis — a notoriously difficult type of case to manage. She did it with grace and patience, eventually transitioning the patient from high-dose IV pain meds to an oral regimen that he could go home on. I would bet that her stamina in caring for a patient with such a challenging condition could be attributed in part to her ability to find humor in the devastating world around her.
And the resident who told jokes that night led our team with confidence and skill during our month together. I watched her compassionately discuss end-of-life care with a family whose loved one was dying of a mysterious infection. I wondered whether her poise came from stability born of emotional balance. I hope one day to provide my patients with the kind of exemplary care that these two physicians gave.
Still, the purist's definition of professionalism dictates that patients should be respected at all times, even behind closed doors. Ideally, even a team that is tired and loopy from being on call at night should be able to find something else to laugh about — perhaps even themselves.
I hope always to uphold the code of proper patient care. But I also realize that to treat a human being well, one must remain human. And therein lies the quandary: How will we ever reconcile our inevitable — and necessary — human imperfections with our desire to abide by the highest standards of professional conduct?(Rachel K. Sobel)