Exam room comedy best used with caution

Careful use of humor can humanize physician encounters with patients.

By Damon Adams — Posted May 24, 2004

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When a husband and wife walk into his exam room, orthopedic surgeon John D. Kelly, MD, may ask the man: "Is this your older daughter or the middle one?"

The wife usually laughs, and Dr. Kelly succeeds at putting his patients at ease. One time, though, a husband didn't think it was funny and blurted, "It's my wife, damn it."

That humor mishap hasn't changed Dr. Kelly's belief that a little levity relaxes patients and helps build a connection.

But in these highly litigious times, in which, thanks to managed care, the physician-patient relationship is often short-term and unstable, physicians are being more careful about pulling their punch lines. To joke or not to joke, that is the question.

Laughter may be the best medicine in some cases. "Sometimes it's easier to put things in perspective with a little joke here and there. It's a wonderful tool in making people happy. That alone is a reason for using it," said Dr. Kelly, vice chair of orthopedic surgery at Temple University Hospital in Philadelphia.

A 1997 Journal of the American Medical Association study on physician-patient communication said primary care physicians with no medical liability claims laughed and used humor more often during patient visits than did primary care physicians who had claims filed against them. The researchers concluded that how a doctor says something may be as important as what is said.

An article in the April 26 Archives of Internal Medicine takes a serious look at humor in the physician-patient encounter. It notes that while some experts say humor is therapeutic, there is little evidence to support the idea that it has a significant effect on physical disease. However, the authors say humor is a useful coping and defense mechanism that helps people handle emotional conflict and reduce stress.

Careful use of humor can strengthen and humanize physician-patient encounters, promote bonding and enhance patient satisfaction, they said.

"Humor is appropriate when you have a sense of who your patient is and what's the context of the visit," said Jeffrey Berger, MD, article co-author and director of clinical ethics at Winthrop-University Hospital in Mineola, N.Y. "It's important to relate to patients as a person to break down the power differential. It can make medicine more enjoyable to patients."

Finding the right kind of humor

During a routine Pap smear, Maine family physician Douglas Farrago, MD, may turn to his nurse and say: "Did you mistakenly switch the Crazy Glue with the Vaseline again?"

When an overweight male patient rolls on his back on the exam table, he may utter, "I think you'll do fine once you deliver this baby."

Dr. Farrago said doctors should try to figure out which patients may appreciate humor before injecting it in the exam room.

"I know which ones are going to laugh and which ones it's not going to work with," said Dr. Farrago, editor in chief of Placebo Journal, which pokes fun at medicine.

California psychologist Steven M. Sultanoff, PhD, believes humor can build relationships or break them apart. Making fun of a patient is dangerous, he said. If a doctor makes fun of a situation or himself or herself, that's safer humor.

Racial or gender humor is a no-no. Doctors should consider any cultural differences that could lead to a misunderstanding. They said humor is not about being a stand-up comic but about creating a sense of warmth and building trust.

Pain specialist Gail Gazelle, MD, treated a woman with chronic neck pain who was distrustful of physicians. The woman said she was injured while she was playing around with her boyfriend and he tossed her on a couch. "Guess that didn't do too much for the relationship," the doctor said. The woman laughed and changed her attitude from distrust to hope, said Dr. Gazelle, president of Palliative Care Associates and assistant clinical professor of medicine at Harvard Medical School.

Patients and humor experts said doctors should use gentle humor that doesn't offend patients. It's OK to tickle their funny bone as long as you treat them, too. "You titrate your humor. Start with a low dosage and then increase it until you get the desired result," said Bob Mankoff, cartoon editor of The New Yorker.

Humor between physicians has its good and bad sides, too.

The Archives article said the intensity and long hours of medical training promote "gallows humor," a grim, ironic wit used among doctors. But such humor may become a bad habit that leads to emotional numbness.

"It's not professional to make fun of your patients or to laugh at them behind their backs," said Jack Coulehan, MD, MPH, article co-author and head of medicine in society at the State University of New York at Stony Brook School of Medicine. "Most doctors would be uncomfortable doing it. [But] there are people who do it."

Some physicians said gallows humor is natural. But it needs to be tempered or it may make a young physician jaded to medicine or disrespectful of patients.

"If you cannot employ humor, medicine can become overwhelming and depressing," said emergency physician Frank McGeorge, MD, residency program director at William Beaumont Hospital, Royal Oak, Mich. "If we don't let our hair down with each other, we end up bottling it up inside."

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Before you joke

Consider your patient "audience" and the situation when injecting humor.

  • Be conservative in selecting the content and manner.
  • Use gently self-deprecating or externally focused humor for the least amount of risk.
  • Don't rely exclusively on humor for communication or you may give the impression of flippancy.
  • Be receptive to a patient's attempts at constructive humor.
  • Know your patient and assess how receptive he or she is to humor.
  • Don't use racial or sexual jokes or profanity.
  • Avoid humor in a crisis.
  • Stay clear of humor if you have any doubts about how your patient may respond.

Sources: "Humor in the Physician-Patient Encounter," Archives of Internal Medicine; Steven Sultanoff, PhD; Douglas Farrago, MD

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External links

"Humor in the Physician-Patient Encounter," abstract, Archives of Internal Medicine, April 26 (link)

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