This past June, I was able to observe a thoracic surgical team at a public hospital in southern Chile. After inviting me into a consultation of a new patient, the surgical team encouraged me to practise my Spanish by asking a few questions. I accidentally said the French word for lung, poumon, instead of the Spanish, pulmon. The resident I was accompanying politely corrected my mistake, smiling and nodding approvingly at the patient. Then, with a wink, he leaned in and whispered, “Es pulmon estupido,” loud enough for the patient to hear. We all burst into laughter. The resident’s lighthearted jab prompted a shift in the patient’s attitude. He settled back in his chair and sighed.
“Laughter is the best medicine” is a well-known saying touted frequently by humour advocates like writer Norman Cousins (Anatomy of an Illness) and physician/clown Hunter “Patch” Adams. Brian Goldman’s CBC radio show White Coat, Black Art ran an episode about laughter in the face of illness last year. Even Hippocrates seemed to recognize the importance of a certain amount of merriment, writing “dourness is repulsive both to the healthy and to the sick.”
I keep hearing about how important humour is, for both patients and physicians. But as a medical student, I find that humour gets little attention from my teachers. Medical students are encouraged to be professional, polite, respectful, and serious. Why isn’t humour endorsed in the same way?
At the moment, medical curriculums provide a comprehensive overview of the scientific side of medicine. Students learn about physiologic and disease states, gain hands-on anatomy experience by thoroughly dissecting cadavers, and are encouraged to be critical when presented with a clinical problem.
We are taught communication skills so as to empathize with patients. We practise using phrases like “I can’t even imagine,” or, “That must be difficult,” during mock interviews. Educators overtly promote the development of the CanMEDS roles (seven key roles forming the framework of physician competency; e.g. collaborator). Medical students are told physicians must abide by the highest standards of professional conduct. As we ease into the new responsibilities of patient care, amass a vast amount of medical knowledge, and work to uphold the stoic and compassionate image of a doctor, it seems to me that there is little room left for humour.
This is too bad, because humour has been shown to be therapeutic. It embraces rather than excludes. It reduces stress hormones, allows patients and families to establish autonomy, and fosters bonding between people (even strangers). Patients see humour as integral in health care experiences, as it impacts how they cope and assert their identity at a time of crisis. Through humour, patients attempt to affiliate with the health care team and develop rapport. Coming from health care providers, humour can create a joyous and positive atmosphere and foster a sense of assurance with patients. I’ve even heard about staff physicians who share a joke before beginning morning rounds, to engage team members.
It’s not that humour is discouraged in medical school, but I think it needs to be actively encouraged. The sheer stress of a demanding curriculum, coupled with the gravity of illness, often leaves a “doom and gloom” impression of medicine. It can be draining. Humour reminds us to be joyous and positive; it reminds us to be human. Medical trainees have argued that the stamina needed when caring for a patient with challenging conditions can come, in part, from the ability to find humour in the world of medicine.
During one of my clinical skills teaching sessions last year, I was asked to interview an elderly woman with another male medical student. When our tutor (also male) walked in to observe and provide feedback, the elderly patient quipped “Three of you?! My daughter always told me I am beautiful, but this is real proof!” The other medical student and I glanced nervously at each other, afraid to be the first one to crack. We were worried that by laughing, we would break our professionalism. I was also very caught up in trying to remember the “right” questions, think through the potential mechanisms of disease, and maintain a composed disposition. As soon as our tutor broke into a smile, we fell into laughter and felt the tension leave the room. It was so important for us to see the banter that ensued and to be invited to participate, laughing with patient and supervisor.
Not all humour is therapeutic and appropriate. Derogatory, sarcastic, and exclusive jokes made in closed rooms or at the end of quiet hospital hallways can be destructive to professional relationships and ultimately to patient care. But if there were an open dialogue about the use of humour in medicine, we could also talk about how to respond to inappropriate cynical jokes.
Guidelines for using humour in a clinical setting do exist, such as the one by Drs. Berger, Coulehan, and Belling. But perhaps there are ways to formally embed the importance of humour in medical school. Students could be prompted to share their funniest patient encounter. As an icebreaker game, rather than ask about former education training, tutors could ask students to share a favourite joke. Students could even be invited to join “improv” workshops. Improv not only promotes laughter but also adaptability, creative thinking, and a “yes, and…” positive attitude.
Recently, when I asked a patient about symptoms they were experiencing, they told me they occasionally felt dizzy. Dizziness, we learned, is a non-specific symptom and is not always helpful to narrow a diagnosis (the neurologist we were working with sarcastically told us it was the bane of his existence). “Hmm, that’s no good for either of us,” I told the patient. “Because… dizziness can make a doctor’s head spin!” The reaction I got was a soft chuckle and a head nod. I’ve got to work on my delivery.