Should Health Care Providers Joke About Patients?

Source: By NBC Television (eBay front back) [Public domain], via Wikimedia Commons

In Samuel Shem’s seminal 1978 novel about medical internship, The House of God, the protagonist calls patients “GOMERs,” an abbreviation for “Get Out of My Emergency Room.” This term of “endearment” is the tip of the iceberg for a particular brand of dark humor medical providers like doctors and nurses often use, sometimes referred to as medical “gallows” humor.

This humor is not your warm, fuzzy Patch Adams and clowns in the childhood cancer ward type of humor. This is Joan Rivers meets death metal meets hydrochloric acid humor.

During the treacherous process of transformation from medical student to doctor, I noticed that my sense of humor changed in these embittered, bizarre ways. There is little left to the imagination after medical school, between cutting through cadavers, then live people, poking and prodding strangers in their most vulnerable states. What would be deemed inappropriate, even criminal, in another context becomes professional and caring in the hospital. But sometimes the contrasts and discrepancies that arise in the process lead to situations that one might view with horror, or with humor, or an uneasy admixture of both.

Psychiatrist George Vaillant cited humor as one of the most mature ego defense mechanisms—mature, at least, relative to more primitive defenses like anger, projection, denial and the like. But the content of humor is highly subjective, and oftentimes the more regressed and obnoxious it is, the more “immature” if you will, the funnier for some, the more offensive for others. Gallows humor skirts this line in a unique way.

Sigmund Freud mentioned gallows humor in his 1927 essay “Humour” as a way for the ego to transform suffering and trauma (“the provocations of reality”) into something “to gain pleasure” instead. Antonin Orbdlik, a Czech sociologist who lived under Nazi occupation, notes in his 1942 essay “’Gallows Humor’—A Sociological Phenomenon” that oppressed victims during this occupation used this humor to “bolster the resistance of the victims and…undermine the morale of the oppressors.” By making light of an otherwise dangerous situation, they no longer completely feared their enemy and were able to mock them and feel a sense of control and social empowerment. (One might argue that the controversial movie “The Interview” does the same thing against the toxic regime in North Korea.)

In medicine, extremes of mortality, pain, illness, suffering—the darkest experiences around—confront medical providers. Our empathy is stretched to the breaking point numerous times, all the while under intense pressure to perform perfectly, within cost and time constraints, and sometimes without sleep. We are trained to remain calm in the face of blood, piss, vomit, shit, agitation, shrieking pain, and still administer tests and procedures and medications flawlessly, lest we cause more suffering and death. We must also simultaneously cater to the patient’s emotions, as human beings going through illness and stress, comfort them even if they are driven to occasionally abuse us in the throes of their understandable agony.

So as human beings ourselves pushed to the highest standards of responsibility, doctors and nurses often rely on this gallows humor, a pressure valve for what we face. I’ve heard similar types of humor expressed by members of other high-pressure fields that confront daily mortality, like the military or the police. According to Dartmouth Medicine Magazine, a 2005 survey of 608 paramedic and emergency medical service (EMS) professionals by Victoria Corum, a flight paramedic, found that nearly 90% admitted to “using dark humor.” Other coping mechanisms like talking with colleagues and family and friends ranked a distant second and third at 37% and 35% respectively. In a 2012 Mayo Clinic Proceedings article, Lewis Cohen MD discussed a survey of 633 palliative care providers where about 72% had heard darkly humorous comments about them like “Dr. Death” mainly from other physicians (59%) and health care professionals (49%), but also from family members and friends as well, and even patients and their companions (21-31%).

Yet, people outside these fields are sometimes horrified, angered when they hear some of these jokes, particularly if directed at patients. They, understandably, see the jokes as dehumanizing, objectifying, belittling, particularly of patients who are already felt to be in a vulnerable, dehumanized state. I have admittedly been caught off guard by lay people chiding me for incidental comments I’ve written or spoken, that made me step back and wonder what has changed in me, and is it all bad? Have I become a callous person? Or am I more in touch with reality than people who haven’t slogged through the same trenches?

Katherine Watson, a medical ethics professor and lawyer at Northwestern University, wrote a detailed and enlightening treatise on the use of gallows humor in medicine in The Hastings Center Report in 2011. In it, she cites some of the power dynamics that come into play with this type of humor, where patients who make doctors feel helpless become the butt of jokes. In particular, difficult or noncompliant patients are made fun of those most, because they are an easy target for the futility doctors feel about their control of some illnesses.

For example, when I worked on an inpatient psychiatric unit, several patients were frustrating repeat visitors, due to poor adherence with medications, severe illness, entrenched personality disorder traits, and/or other difficult socioeconomic circumstances (homelessness, drug abuse, etc.) While some patients would improve and get discharged quickly, others would have a tough time and a prolonged stay, due to refusing medications, repeatedly threatening to harm themselves or threatening staff, being combative, cursing psychotically, and more. Despite claims (and sometimes realities) that patients feel mistreated on psychiatric units, oftentimes overworked clinicians themselves also can feel used and abused. So sometimes, during our rounds and internal meetings, the staff would often crack sarcastic comments about “frequent fliers,” and more.

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Does this type of humor help or harm the doctor-patient relationship? On the minus side, providers might fall into a cynical mindset, where the patient becomes at best annoying and at worst a punching bag or mortal enemy. Our capacity for empathy might deteriorate when we get into the habit of mocking suffering on a routine basis; we may even miss actual serious clinical findings when we stop believing our patients because we assume they are exaggerating or manipulating us, like the boy who cried wolf.

I will always remember one particular patient who had the typical “difficult” patient profile of multiple hospital visits asking for various pain or anxiety medications for vague somatic complaints. This time the already obese patient complained again of not feeling right, and swelling breasts, which seemed stereotypically hysterical or attention-seeking. Our first instinct was to roll our eyes and laugh about her symptoms, to think GOMER all the way. But thankfully, we still ran routine tests, and it turned out that the patient had a lung tumor releasing hormones that indeed caused breast swelling. This time, sadly, she had very real cancer.

On the positive side, our morbid sense of humor can promote bonding between team members and help relieve stress when faced with patients who are genuinely tough to handle or get through situations that are unspeakably tragic. Watson’s article opens with an exhausted emergency room team who ordered a pizza, and the delivery boy ended up becoming their trauma patient after he was robbed and shot. The patient died; faced with this horrible set of circumstances, they decide afterwards to joke about how much to tip the poor victim, and they ate the pizza that was found at the scene. While one might initially think, how cruel to joke in such a circumstance, one might also think, what else could this team do to push through a devastating, guilt-ridden situation? Watson concludes that the joke remained “ethical” because no direct harm was done to the patient (it would of course be different to joke in front of family members or patients directly), and perhaps, it even helped the doctors remain sane in the face of horror.

So when doctors and nurses decide to partake in their own taboo humor, is it such a jawdroppingly bad thing to do? Are patients so sacred in their vulnerability that any mockery of their weakness or illness feels like a breach, an act of bullying or even abuse? Or is it the opposite; do the providers feel like the bullied victims in this era of malpractice and managed care and patient satisfaction scores, and their mockery is a form of peaceful rebellion, of civil liberty against the hegemony of the defiant, entitled patient? As Watson notes, the power dynamics are constantly in flux behind the scenes of the doctor-patient relationship, and imbue this humor with varying nuances accordingly.

I would say that doctors and nurses and other medical professionals have earned the right and should have the freedom to laugh about anything, even death and illness. They should watch out for signs of burnout and seek other sources of help accordingly. And they should try as much as possible to crack the jokes behind closed doors. But if you as a patient happen to hear one slip out, instead of righteous anger, try to think about where it comes from. Clinicians feel helpless too sometimes, and humor is the best way for them to stay sane.