Personal view or opinion piece
Open Access

Is It Ever Okay For Healthcare Students To Laugh About A Patient? [Version 2]

Simon Gay[1], Aqua Asif[1]

Institution: 1. University of Leicester School of Medicine
Corresponding Author: Prof Simon Gay ([email protected])
Categories: Professionalism/Ethics, Students/Trainees, Teachers/Trainers (including Faculty Development), Continuing Professional Development, Undergraduate/Graduate
Published Date: 23/09/2021

Author Revision Notes

This paper has been amended in response to reviewer comments to include:

1. A new section on the dynamics of humour which benefits from, amongst others, the work of Rees and Monrouxe on this topic.

2. An addition to the end of the "What Is Humour?" section of the paper to acknowledge the relevance of cultural context to the perception of humour.

3. A small expansion of the sentence regarding "Barnum statements" in order to make the use of this term slightly more explicit.

4. One of the original take home messages has been replaced by a new take home message arising from the work of Rees and Monrouxe.

Abstract

Humour is an element of communication that has evolved over many thousands of years to convey complex concepts and emotions in a succinct and efficient way. The transmission of “positive emotion and playfulness” by laughter is well recognised and it is relatively commonplace in clinical environments.

However, clinical environments are, at varying times, places of stress, fear and power differentials and where healthcare practitioners, students and patients all come together and use humour for a range of purposes.

This paper considers some of the boundaries to be respected when using humour in the clinical environment and whether it is ever okay for healthcare students to laugh about a patient.

Keywords: humor; medical student; healthcare student; clinician teacher; medical education; gallows humor; laughing; laughter; smile; smiling

What Is Humour?

Humour is communication which induces amusement, with or without laughing or smiling. Both smiling and laughing in humans are now considered to be signals of “good will”. However, smiling is believed to have once been an aggressive gesture involving the bearing of teeth and has over time evolved through an expression of submission and appeasement (Preuschoft, 2010) into a demonstration of a safe message to others. Laughter in comparison is thought to be “a medium for emotional contagion, a mechanism for transmitting positive emotion and playfulness” (Gervais, 2005) whose origins possibly lie in the pant - like vocalisations of the great apes during tickling and chasing (Darwin, 1872; Caron, 2002); and it is perhaps also worth remembering that smiling can be easily faked (Gunnery, 2012) but laughter less so.

Humour is an icebreaker; a bonding instrument; good bedside practice and a stress reliever (Dziegielewski, 2003). Several brain components are exploited to comprehend humorous situations – cognitive, muscle movement and areas responsible for emotion perception (Takeda et al., 2010). Respectively, these are used to understand, translate this information to a physical manifestation of appreciating (or not) the humour underlying the situation, and to feel either positive or negative emotions.

Humour and laughter are invaluable to medicine. Physiological responses to humour and laughter include increased respiration and exercise of the muscles associated with it, improved immune responses, better treatment responses, endorphin production, raised pain thresholds and tension release mediated through the autonomic nervous system (Fry, 1994). And regardless of whether patients use this ancient communication tool to brighten up a tough consultation with their doctor or other healthcare professionals use it to comfort their teams on a day-to-day basis, it can serve to build connections amongst all parties – the patient, the clinician, the patient’s family and the wider healthcare team.

However, it should not be forgotten that perception of humour is subjective and can be culturally specific (Haydon and Riet, 2014) and it is important to also bear in mind the various sociocultural elements that shape and contribute to it. For example, the cultural differences in humour perception between westerners and easterners are well documented (Jiang et al., 2019). The cultural dimensions of humour are then in turn superimposed on the natural variation, one person to another, in the individual’s sense of humour. It is perhaps therefore best to err on the side of respect when broaching humour in practice.

What Do Guidelines Say?

Showing patients respect, treating them without discrimination and acting honestly are all clearly emphasised in Maintaining Trust, Domain 4 of the UK General Medical Council (GMC) document Good Medical Practice (2013). However, if patient dignity and their trust in healthcare professionals and the wider NHS is to be maintained as highlighted a number of questions need to be answered: How far can healthcare practitioners and their students take their jokes within either their school or the clinical workplace? What is ‘gallows humour’? And is any use of humour ever really appropriate?

What Is Gallows Humour?

Gallows humour, also known as “dark humour”, is frequently encountered in medicine. Being able to laugh or find humour in hopeless, dark situations, which are sometimes life-threatening or worrying, is an integral part of healthcare.

Indeed, Freud stated that humour is an essential protective shield from life’s harsh realities (Freud, 1963) and in palliative care, for example, humour plays an enormous role in the coping mechanisms of both healthcare professionals and the patients themselves (Collicutt and Gray, 2012). Furthermore, such gallows humour is also sometimes adopted by both patients and clinicians as a strategy for managing uncertainty (Bosk, 1980) when clinicians are unsure about a diagnosis or treatment.

Humour In The Workplace

Humour is regarded as highly social and even “infectious”. A problem or diagnosis becomes less threatening when the team can laugh through it, along with the patient. For a team to be effective and efficient it must have a strong sense of cohesion. Just as “shared understanding” is deemed as a positive trait in a “good” doctor-patient consultation, “shared laughter” is important and treasured in the workplace.

“Humour is not a substitute for clinically competent care – but it can be a powerful adjunct to therapy.” (Goodman, 1992)

Laughter encourages teambuilding and provides all healthcare professionals with a sense of belonging through insider jokes or humorous comments said during common experiences. This shared laughter is a well-recognised stress reliever (Martin et al., 1993).

Humour In Schools Of Healthcare

Whilst ideally ‘teachers should aim to be stimulating rather than entertaining’ (Preston-Whyte and Fraser, 1999), humour has been documented to promote a positive environment for learning (Ziegler, 1998). Humour injects desire and curiosity to learn through thought-provoking material. Upon listening to a joke, the student’s arousal levels rise until the tutor’s punchline is delivered, ensuring that the educator has the learner’s attention. In this way, fictional characters or anonymised patients can be employed to aid the learning of medical students as long as the raconteur is careful to avoid such tales being received in a “Barnum statement” (Meehl, 1956) like way, where the learners believe they know the patient even though that is not actually the case, or perceive the tutor as behaving in an unprofessional manner.

The Dynamics of Humour

Humour in a bedside teaching scenario functions in a triadic and competitive nature as the three common parties (patient, student, and clinical tutor) aim to wrestle conversational power from one another (Janicik and Fletcher, 2003). Humour innately creates a conversational power imbalance wherein the individual telling the joke gains power and the butt of the joke loses power. This is subconscious – either to demonstrate authority by those in actual positions of power (tutors) or by someone not in a position of authority (student or patient) to take power or demonstrate competency (Holmes, 2000). The mechanics of humour dictate that someone is often the butt of the joke, and thus a degree of caution must be exercised to both maintain professionalism and avoid alienation (Rees and Monrouxe, 2010). Partington (2006, pp. 156-162) as explained by Rees and Monrouxe (2010) categorised jokes as drawing from one of four types of teasing: frustration (withholding information), fallibility (accusation of a shortcoming), mimicry (imitation of the butt of the joke), and cynicism (questioning honour or intention) and a fifth category (sexual) though often sexual teasing is derivative of one of the major four categories Humour is not always used competitively to obtain power but can be used collaboratively as common ground and allows all parties the comfortability to talk about difficult topics as required by medicine.

What About Negative Aspects Of Humour In Healthcare?

A clinical environment is vulnerable and sensitive. It depends and thrives on teamwork, trust and integrity. Most patients in critical conditions are in fear for their health and some are left in less than favourable states. Cynical, degrading humour in these circumstances is not acceptable and cannot be justified (Berk, 2009). Degrading humour can cause real harm, especially when it disrespects people according to race, nationality, disability, sexual orientation or some other personalising characteristic. In a place where we are expected to heal, treat and lift people’s spirits we can easily crumble their self-esteem and even induce anxiety or depression (Borins, 2003). Patients are less likely to comply with treatment or speak openly about what is bothering them if they do not trust healthcare professionals after previous negative experiences. Nobody should be humiliated, embarrassed or disrespected when their weaknesses are “out in the open” and sometimes patients who find themselves in this situation act strangely and express their deep mental insecurities, concerns and frustrations via heightened and exaggerated physical responses, which occasionally escalate demonstrative anger or physical violence. Even so, despite their immediate tribulations some patients also provide open invitations to subtle humour if they utter witty sentences or nuances themselves, further demonstrating the use of humour as a valid, ‘socially acceptable’ defence system.

Take Home Messages

  • Ultimately, abusing a patient, their trust and a healthcare professional’s power is where humour becomes inappropriate and unethical. We should never take pleasure in our patients’ suffering.
  • A degree of caution must be exercised when utilising humour to both maintain professionalism and avoid alienation (Rees and Monrouxe, 2010).
  • We can simultaneously take our work seriously whilst taking ourselves lightly (Goodman, 1992).
  • Humour is a vehicle of positive human interaction amidst the stresses of medical practice.
  • Humour is an important bridge that allows us to show patients that we are as human as they are and have their best interests in mind.

Notes On Contributors

Aqua Asif is a 3rd year medical student and course representative at the University of Leicester School of Medicine in the UK. Her interests include medical education, surgery, social prescribing and diabetes mellitus. ORCID ID: https://orcid.org/0000-0003-3233-7428

Simon Gay is a General Practitioner and Professor of Medical Education (Primary Care) at the University of Leicester School of Medicine in the UK. His current interests include clinical reasoning, consultation skills development, reflection and professionalism. ORCID ID: https://orcid.org/0000-0002-1743-9824

Acknowledgements

None.

Bibliography/References

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Borins, M. (2003) ‘Are you suffering from a laugh deficiency disorder?’, Canadian Family Physician, 49(6): pp. 723-724.

Bosk, C. L. (1980) ‘Occupational Rituals in Patient Management’, New England Journal of Medicine, 303(2), pp. 71–76. https://doi.org/10.1056/nejm198007103030203

Caron, J. E. (2002) ‘From ethology to aesthetics: Evolution as a theoretical paradigm for research on laughter, humor, and other comic phenomena’, Humor - International Journal of Humor Research, 15(3), pp. 245–281. https://doi.org/10.1515/humr.2002.015

Collicutt, J. and Gray, A. (2012) ‘“A merry heart doeth good like a medicine”: humour, religion and wellbeing’, Mental Health, Religion & Culture, 15(8), pp. 759-778. https://doi.org/10.1080/13674676.2011.630385

Darwin, C. (1872) The expression of the emotions in man and animals. London: John Murray. [Reprint 1972. New York: AMS Press].

Dziegielewski, S. (2003) ‘Humor’, International Journal of Mental Health, 32(3), pp. 74-90. https://doi.org/10.1080/00207411.2003.11449592

Freud, S. (1963) Jokes And Their Relation To The Unconscious. New York: W. W. Norton & Company, Inc.

Fry, W. F. (1994) ‘The biology of humor’, Humor – International Journal of Humor Research, 7(2), pp. 111-126. https://doi.org/10.1515/humr.1994.7.2.111

General Medical Council. (2013) Good Medical Practice. Available at: https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/good-medical-practice (Accessed: 09 May 2020).

Gervais, M. and Wilson, D. S. (2005) ‘The Evolution And Functions Of Laughter And Humor: A Synthetic Approach’, The Quarterly Review of Biology, 80(4), pp. 395–430. https://doi.org/10.1086/498281

Goodman, J. B. (1992) ‘Laughing matters: taking your job seriously and yourself lightly’, JAMA: The Journal of the American Medical Association, 267(13): p. 1858. https://doi.org/10.1001/jama.267.13.1858

Gunnery, S. D., Hall, J. A. and Ruben, M. A. (2012) ‘The Deliberate Duchenne Smile: Individual Differences in Expressive Control’, Journal of Nonverbal Behavior, 37(1), pp. 29–41. https://doi.org/10.1007/s10919-012-0139-4

Haydon, G. and Riet, P. V. (2014) 'A narrative inquiry: how do nurses respond to patients' use of humour?', Contemporary Nurse, 46(2), pp. 197–205. https://doi.org/10.5172/conu.2014.46.2.197

Holmes, J. (2000) 'Politeness, power and provocation: how humour functions in the workplace', Discourse Studies, 2(2), pp. 159–185. https://doi.org/10.1177/1461445600002002002

Janicik, R. and Fletcher, K. (2003) ‘Teaching at the bedside: a new model’, Medical Teacher, 25(2), pp. 127–130. https://doi.org/10.1080/0142159031000092490

Jiang, T., Li, H., and Hou, Y. (2019) 'Cultural Differences in Humor Perception, Usage, and Implications', Frontiers in Psychology, 10, 123. https://doi.org/10.3389/fpsyg.2019.00123

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Partington, A. (2009) The Linguistics of Laughter. A Corpus-assisted Study of Laughter-Talk. London: Routledge.

Preston-Whyte, M. E. and Fraser, R. C. (1999) ‘Teachers should aim to be stimulating rather than entertaining’, BMJ, 318(7180), pp. 394–394. https://doi.org/10.1136/bmj.318.7180.394a

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Appendices

None.

Declarations

There are no conflicts of interest.
This has been published under Creative Commons "CC BY-SA 4.0" (https://creativecommons.org/licenses/by-sa/4.0/)

Ethics Statement

Opinion piece only, no research study has taken place and no data has been collected from any participants.

External Funding

This article has not had any External Funding

Reviews

Julie Hunt - (07/10/2021) Panel Member Icon
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This opinion piece, written by a medical student and a primary care professor, focuses on the use of humor in treating patients and, to a lesser degree, in teaching students. The authors describe the different types of humor and how they may be applied to the clinical or teaching setting. Although not every reader will agree with the premise of the article (that the use of humor is beneficial in the clinical and teaching environment, and should be encouraged), the article is well referenced and the authors' opinion is well investigated and reported. I appreciate that the authors highlighted some times or formats in which humor is inadvisable.

I agree with the previous reviewer that the title doesn't represent the article accurately and is perhaps overly controversial. Perhaps a simple revision to "Is it okay for a healthcare team to laugh with a patient?" would bring it into closer alignment with the material presented in the article.
Possible Conflict of Interest:

For transparency, I am an Associate Editor of MedEdPublish.

Dimitri Parra - (07/10/2021) Panel Member Icon
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Following a request by the MedEdPublish editorial team, I have read this personal view/opinion piece with attention.
The authors present their reflection about humour in clinical teaching.
A review of humor is presented which is succinct but clear. Different types of humor are described and the role of it in healthcare and in working teams is mentioned.
The authors present a revised version after comments from previous reviewers which has improved the document.
Some of the topics or opinions mentioned can be controversial, however this is explicitly mentioned by the authors. The take home messages are adequate and is positive that are supported by the literature.
My main disagreement with this article is the title, because I believe does not communicate well with the text, is confusing for the reader and excessively provocative. First, I do not think the paper answer that question explicitly, which may be because there is not a single answer, therefore it may be better not to use as a title a question that does not have a clear answer. For me the answer to the question is no, however I encourage humour within my team and with my patients, that is why, for example we have therapeutic clowns. This is a happy environment, “laughing with the patient” which is different to “laugh from a patient”. It would have also been interesting to have a section about professionalism which is a very relevant area related to this. I am really against of reviewers who try to re write other’s papers, however in this case I believe that a better title could be “benefits and boundaries of humour in clinical teaching and practice” or something like that, less controversial and communicating better with the text.
It was nice to read this paper and congratulations for reaching to a publication.