Physician Humor: Intervention and an Alternate Approach Supported by Observation
by Chinmay Joshi, Genetics and Philosophy
Abstract: In this paper I propose a modification to the current framework of acceptable physician humor, which is often derogatory towards patients. Based on supporting examples from shadowing British and Indian physicians and the findings of Wear et al. (2006) as to the factors responsible for such humor, I proposed promoting more impersonal forms of humor that do not implicate patient identities or backgrounds by attendings and residents. I identify the primary reasons for derogatory humor towards patients, which include perceived burdens to the medical system and a lack of empathy for difficult life circumstances and suggest that these outght to be directly addressed during medical training in the context of appropriate and inappropriate humor. My shadowing experience strongly supports the use of role modeling for such education, because of how early future physicians are exposed to older role models in medicine.
observation, physician humor, professionalism, medical education
In “Making Fun of Patients,” Wear et al. (2006) describes the cynical and derogatory humor used by residents and attendings toward specific groups of patients—obese or psychiatric patients, for instance—from the perspective of medical students at the Northeastern Ohio Universities College of Medicine (NEOCOM). Their analysis of the potential origins of this humor has interesting implications for how better, more empathetic, and more professionally appropriate interaction could be fostered among physician trainees and residents. Further, my observation by shadowing physicians in India and the UK supports their observations on the origins of the frustration that can lead to humor and affirms their emphasis on the importance of good role modeling in medical training.
A key motivating factor for the humor that Wear et al. (2006) describes is the superiority that physicians implicitly feel over their patients, which can lead to a lack of empathy for burdensome patients with unknown circumstances. This underlying frustration with patients who stray from the ideal and into “fair game” territory must be resolved if derogatory humor is to be addressed. I could observe this line of thinking in the UK. The National Health Service often has long wait times to see physicians and undergo procedures because of the large population of patients relying on its services compared to a relatively small number of providers. A primary care physician I shadowed reminded me of this fact as they recounted their frustration at a twenty-five-year-old male who had come in for nonspecific inguinal pain that had lasted for a short amount of time, and who they concluded had nothing wrong with him. While they did not make fun of this patient, they emphasized that they felt that the patient had been a burden when he should have known better than to take a waitlist spot from someone with a true illness. This rhetoric of burdens and the effect on the greater medical system is similar to the reasoning that makes obese patients or alcoholics “fair game” according to the NEOCOM medical students: these patients bring preventable stresses to a medical system that is overworked and often overwhelmed. These may seem justifiable, but focusing exclusively on what appears to be the patient’s fault neglects the social circumstances that could have led these patients to their current situations. Preventing such judgments can be difficult due to the differences in social status and backgrounds between physicians and patients, but modeling an understanding and empathetic attitude towards frustrating patients can show trainees that derogatory humor does not need to be the go-to method of dealing with antagonistic feelings towards patients. Further, education that highlights the origins of anxiety and unhealthy habits in local and global populations can combat potential feelings of superiority or a lack of understanding that are associated with medical education and a higher social status, as Wear et al. (2006) highlights in their discussion. Instructional vignettes during shadowing should address both sides—the burden on the medical system as well as social factors that may lead to health anxiety in certain groups of patients.
Overcoming derogatory humor towards patients does not necessarily mean eliminating humor from the hospital; modifying it is more likely to make meaningful changes across professional generations. It is important to set boundaries for humor. Like the “off-limits” wording brought up by the NEOCOM medical students, the bounds of acceptable or even encouraged humor can be determined by the object of the humor. Acceptable humor should maintain an emphasis on the medical situation and not the patient. Examples where a patient has an object stuck in their rectum, for example, are relatively straightforward in that the humor is tied directly to their situation as opposed to more personal attributes. However, this becomes more complicated when dealing with psychiatric patients whose actions or words may seem so bizarre as to be interpreted as humorous. Wear et al. (2006) focuses on the more personal forms of humor in this situation, highlighting acts like imitating or making fun of certain behaviors. These feel more offensive because a person’s behaviors are tied to their present identity, even if that behavior stems from their pathology. When humor is directed at the idiosyncrasies of people unaffected by a psychiatric condition, the implication is that the person exhibiting the behavior does not suffer because of their behavior. The tragedy of someone’s identity—their beliefs and behaviors—being a source of suffering makes it an inappropriate object of humor. The distinction between personal and impersonal forms of medical humor is important when determining what kinds of humor can be seen as acceptable. When shadowing a senior oncoplastic surgeon in India, I observed a setting that incorporates humor of the most impersonal kind—one that lacks any patient-directed remarks. Humor was directed at other physicians more innocently, such as commenting on a person’s ability to complete a surgery or the progress of an active surgery. Laughing along to healthy jabs made at other physicians (something I admittedly felt I had to do, as echoed by NEOCOM students when faced with jokes made by attendings) is much more innocuous than going along with comments made by an attending about a patient’s excessive weight or sexual attractiveness. If this becomes the new standard for acceptable humor, levity can continue to act as a de-stressor in the hospital environment without promoting damaging views of patients.
How can more informed and responsible forms of professionalism and humor be transmitted across generations? Wear et al. (2006) concludes that better role modeling is important to encourage medical students to develop a professional identity that is empathetic and does not use humor in a disparaging or superior manner. Due to the prevalence of shadowing by undergraduate students interested in medicine, such role modeling is extremely important since it can be a student’s first glimpse into what medicine is like. Not all the physicians I shadowed were deliberate about emphasizing teachable moments. I took away far more from interacting with the physicians who approached shadowing as an overtly pedagogical experience, which demonstrates how intentionality in modeling good practices can shape a budding student’s professional identity. I shadowed a radiologist specializing in neonatology in India who exemplified this approach to modeling the sound characteristics of a physician. Between each patient, they talked about how they tried to keep their patients at ease and inform them about the kind of scan they were performing. This models the suggestions offered by Innui et al., who encourages mindfulness during the conversations that comprise the “informal curriculum” in medicine. Interestingly, they did not seem to employ humor at all. This may be reflective of their approach to medicine, but it could also have been because the patients were pregnant women, who are an especially vulnerable kind of patient. I observed a consultation with a patient’s family where the physician had to explain the possibility of the fetus having Down’s syndrome, and the radiologist made sure not to overstate the likelihood of the condition given their observations at the time. They debriefed their thought process during the meeting with me afterward, and this set the standard as the only example of a family consultation I observed, which stayed with me for a long time. A study like Wear et al.’s (2006) focused on undergraduate shadowing experiences would be quite informative as to the first perceptions students have about ideal interactions between doctors and patients.
My overall conclusion after having observed physicians myself is to affirm Wear et al. (2006) in encouraging an education centered on the sociological factors that lead to certain “types” of patients that might draw out negative physician attitudes and that acknowledges the importance of good role modeling. My perspectives also showed me an alternate version of humor—one that is more innocent and directed among physicians—that was not addressed by the study and could reasonably replace the derogatory humor that is so commonplace today. Medical culture can be entrenched in a lot of aspects, but treating patients with respect does not need to be one of them.
Works Cited
Wear, Delese, Julie M. Aultman, Joseph D. Varley, Joseph Zarconi. “Making Fun of Patients: Medical Students’ Perceptions and Use of Derogatory and Cynical Humor in Clinical Settings.” Academic Medicine, vol. 81, no. 5 (2006): 454-462. Accessed February 20th, 2024. 10.1097/01.ACM.0000222277.21200.a1.
Acknowledgements: Dr. James Coverdill, Dr. Chaitanyanand Koppiker, Dr. Kishori Kulkarni, Dr. Saket Thakar
Citation Style: Chicago