Year : 2010 | Volume
: 23 | Issue : 3 | Page : 533-
The Use of Cynical Humor by Medical Staff: Implications for Professionalism and the Development of Humanistic Qualities in Medicine
S Dharamsi, M Whiteman, R Woollard
The University of British Columbia, University Boulevard, Vancouver, BC, Canada
300-5950 University Boulevard, Vancouver, V6T 1Z3
Humor and laughter in medicine has received much attention in the medical literature. The use of humor by medical students, residents and medical personnel is not uncommon. Laughter can be therapeutic, for patients and practitioners alike. However, when inappropriately directed towards patients humor can be seen as unprofessional, disrespectful and dehumanizing. How physicians interpret their day-to-day professional experiences, and when and how they use humor is influenced by the perspective that is taken, the social distance from the event, culture and context. Some argue that social and physical distance makes it more acceptable to laugh and joke about patients, but not everyone agrees. To laugh with and not at others is the appropriate use of humor in medicine. To cry against the suffering of others and the injustice behind that suffering and not with them in their agony and frustration is the appropriate response to tragedy.
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Dharamsi S, Whiteman M, Woollard R. The Use of Cynical Humor by Medical Staff: Implications for Professionalism and the Development of Humanistic Qualities in Medicine.Educ Health 2010;23:533-533
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Dharamsi S, Whiteman M, Woollard R. The Use of Cynical Humor by Medical Staff: Implications for Professionalism and the Development of Humanistic Qualities in Medicine. Educ Health [serial online] 2010 [cited 2021 Jan 16 ];23:533-533
Available from: https://www.educationforhealth.net/text.asp?2010/23/3/533/101467
“Tragedy is a close-up; comedy, a long shot”
Buster Keaton was a seminal American actor of the silent film era. His insight into the way in which we approach our world is more than a metaphor and has a particular relevance for those who style themselves as healers and those who profess to teach people to be healers. As our world simultaneously expands to embrace a global vision as a whole and shrinks through the capacity of technology to allow us to observe distant events (both tragic and comic), it behooves us to think deeply about social distance and its meaning for physicians. When must we laugh off tragedy and get on with the job? When should we cry at the humorous foibles that form part of the human condition? When does emotional distance, however managed, become a form of neglect? What kind of a lens must we teach our students to use as they prepare to confront, on a daily basis, patients – “those who suffer”?
The use of humor and laughter in medicine has received much attention in the medical literature1,2,3. In this article, we reflect on the use of cynical humor in medicine and the related implications for medical professionalism, empathy and the development of humanistic qualities in medicine. Our analysis comes from a predominantly Western/North American viewpoint, but can likely be applied within a broader international context. We acknowledge, however, that the appropriate use of humor in various cultures may differ, although there is little published literature on how humor and laughter is used in medical settings in non-Western countries. We also provide some guidance on how medical educators might address matters of empathy and professionalism in the training of students and residents.
Watching a person fall down on America’s Funniest Home Videos – an American “reality” television program featuring accidents and mishaps that ordinary people experience and that are caught on home videos – we laugh easily, even when there is real pain involved. Indeed, a dose of laughter can be good medicine: it can help to reduce discomfort sensitivity4, it can be therapeutic5, and it is often used as a coping mechanism6. But comedy also carries a strong element of Schadenfreude – finding amusement in the blunders and misfortunes of others. Some brush off guffaws at their misfortunes more easily than others, although it certainly adds to the pain of anyone who is hurting7. While the use of derogatory and cynical humor by medical students, residents and medical personnel is not uncommon8, when directed towards patients it is unprofessional, disrespectful and dehumanizing9. There is disturbing but compelling evidence that medical education and acculturation are partly to blame10,11, by tolerating and even fostering a certain detachment12 and cynicism13. Recent moves to encourage the development and evaluation of professionalism in medicine14 embrace concerns about this issue and the distinction between dark humor about the human condition and the particular observations of those who style themselves as healers.
How physicians interpret their day-to-day professional experiences is influenced by culture, the perspective that is taken, the social distance from the event, and the context. Some argue that social and physical distance makes it more acceptable to laugh and joke about patients, but not everyone agrees15. Seeing someone fall on a bus or on the street usually brings forth an immediate reaction of compassion and care; a reaction that is perhaps instinctive but among many healthcare professionals is seen as a matter of social and ethical responsibility. Tragedy can elicit this emotive response; it involves sympathy or empathy; it draws us closer to the pain others feel and it invites us to look out for the well-being of others. Social distance can influence whether a person gets help and concern instead of ridicule. As social distance increases, it seems to become easier to remain passive to tragedy, even on an enormous scale. Nevertheless, Peter Singer, in his 1972 paper “Famine, Affluence and Morality”, argues well that suffering and pain don’t discriminate; a child in pain at your doorstep is as tormented as one who lives across the sea and far away.
Susan Sontag in her last book, Regarding the Pain of Others16, wrestled with the effect of repeated exposure to disturbing images from people suffering around the world and felt that it is our stance of passivity, rather than the overwhelming of our senses, that lets our fellow citizens down.
"Compassion is an unstable emotion. The question is what to do with the feelings that have been aroused, the knowledge that has been communicated. People don't become inured to what they are shown – if that's the right way to describe what happens – because of the quantity of images dumped on them. It is passivity that dulls feeling."
Similarly, doctors, occupied with the immediate demands and stresses of their profession, are not immune from the numbing effect of social distance, and some use derogatory humor as a coping mechanism2. In this way tragic events that patients experience are sometimes trivialized because they are seen as a distraction. Yet, others see it as a lapse of professional standards that can have an adverse effect on patients17. As Rudolph Virchow observed over a century ago, “it is the curse of humanity that it learns to tolerate even the most horrible situations by habituation”. Even so, the fact remains that our students and residents frequently encounter tragedy under stressful circumstances. Most of them are overworked and tired18, and have not been taught how to respond appropriately to this volume of tragedy19. Indeed, there appears to be a volume effect in the human response to observed tragedy as witness to the frequency of post-traumatic stress disorder following events such as war and disaster when death counts and suffering are elevated beyond the regular grind of traffic accidents and casual violence. As educators, we should not merely look to remove those who react inappropriately and unprofessionally after such exposure. We should be actively equipping our learners and staff with more functional and empathetic ways to cope. The capacity of the profession and its educators to address these issues depends fundamentally on our ability to accept the reality our physicians face, explore their origins and articulate our expectations of ourselves and our future colleagues.
Equipping future physicians with the competences required of a professional that include humanistic values such as integrity, respect and compassion will require pedagogical approaches that are transformative20. The development of reflective skills and critical consciousness are essential components of transformative education, and coupled with service-learning are seen to have a positive influence on the development of professional and humanistic behaviors21,22,23. The development of reflective skills enables students to explore and examine their own behavior and attitudes and to consider how best to prevent inappropriate responses24. The learning environment also needs to move from one that is hierarchical, teacher-centered and top-down, to one that is dynamic, student-centered and reciprocal. Learners must be given the opportunity to become actively engaged in fostering a level of critical awareness of medicine’s position of power and privilege25. The curriculum must provide real (not just hypothetical) clinical case studies that enable learners to experience what professionalism looks like in practice. The educator’s role is to provide opportunities for analyzing the benefits (and costs) of being a good clinician and a caring person26. This can be done through role modeling, which plays a key role in the development of humanistic qualities27. Educators must model professionalism and compassion, and provide learners with opportunities to establish rigorous and attainable goals toward becoming a more humanistic physician. Learners identify attributes such as enthusiasm, compassion, openness, and integrity from their role models28.
However, humorless pedagogy, like a humorless life, is neither pleasant not attractive to learners. It is the use of humor that marks the distinction between learning and healing on the one hand, and distancing and destructiveness on the other. Humor, like relationships, can be overanalyzed to the point of neither happiness nor effectiveness, but can be an area where skills and knowledge on the part of physicians can make a real difference in the real lives of patients. In neither case is crudeness helpful but in both, subtlety and skill are paramount. We need to provide students with the skills to reflect deeply and use lightly the turn of phrase that brings hope in tragedy and laughter in the face of otherwise overwhelming exposure to the tragedy of others.
Medical educators and their curricula are only recently appreciating the importance of social determinants on health outcomes29. There is a growing sense that if we understand how our humanistic, cultural, and professional surroundings influence health, the more likely we are to care about it, the more likely we are to think about the factors that influence it, and the more likely we are to be concerned and try to mitigate the suffering of those affected by it. We can remain distant while acknowledging the tragedies around us – as Sontag says. We can help people without ever learning their name or their history. It happens every time we drop a few coins into a humanitarian relief box at the grocery store or even into the cup of a person begging on the street as we leave. But suppose we bridge those distances? Suppose we confront critically both tragedy (because, as health practitioners, we care and must care) and comedy (because life can be absurd)? The truth is that tragedy and comedy exist in the stance we take in greeting the world. To laugh with and not at others is the true joy of comedy. To cry against the suffering of others and the injustice behind that suffering and not with them in their agony and frustration is the appropriate response to tragedy. Both require the long shot and the close up. We must articulate this in the objectives for our programs and in our mutual expectations as doctors.
Buster Keaton made his trenchant observation when film was young and at a time that it offered, on the one hand, distance and distraction while, on the other hand, a near universal intimacy. His words reflected both technical elements and thoughtful meaning. Both film and medicine have wandered into a century-long and frequently uncritical love affair with technology – the modern tertiary health center as “Avatar”. Along the way, much of the human connection and possibility of bringing out the best in humanity and thoughtful caring for the person has been lost. This may be fine for commercial film-making but medicine should call itself to a higher account. The unacceptable level of morbidity and mortality that attend being admitted to a modern hospital is not a joke but a tragedy in spite of the dark and often dismissive humor that is seen daily in the corridors – perhaps because we see this reality and feel powerless to change it. Do we need a new Semmelweis or a new Keaton? Or both? We seem to be covering the distance shot rather too well. But close-ups are uncomfortable. Can we find that intimacy that was once so promising?
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