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HUMOR IN MEDICINE
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HUMOR IN MEDICINE Richard C. Wender, MD
Humor is hot. Using humor in health care, one suspects, is as ancient as healing itself, but in the past 20 years humor has been ”discovered.” Spurred on by popular acceptance as well as by the funny and touching writings of Cousins4r9and Siegel19humor has become the object of scholarly investigation and inquiry. It has undergone poking, prodding, picking, and pondering, and the effluence has been a body of writing, including a definitive discussion by Robinson,’6 an embrace of the need to include humor to care for people optimally, and a recognition that humor facilitates our own survival as we cope with our daily stresses. On first inspection, humor in primary care appears to occupy a respected and accepted place. Conjure up an image of the seasoned competent family doctor seeing a long-time patient; compare it with the thirdyear student struggling in his or her first time visits with skeptical patients. Warmth and lightness pervade the former image; the serious business goes on not just in a social milieu but in an environment that reaches for, and occasionally attains, true fun. The doctor helps the patient feel better even if he or she cures infrequently. It takes students time and practice to rise above the tools with which we have armed them: the rules of history taking; the comprehensive review-of-systems list; the otoscope, ophthoscope, and stethoscope, and of course the much needed tuning fork, to infuse the examining room with warmth and humor. In fact, despite the humor explosion in medical care, little literature specifically examines humor in primary care. The nursing profession has led the study of humor including developing techniques to increase its use in clinical setting^.','^,^^,^^ There is no surprise here; no health care professional deals with stress, suffering, and loss as routinely and consistently as the hospital nurse. Efficiently functioning nursing teams weave From the Department of Family Medicine, Jefferson Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania
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VOLUME 23 NUMBER 1 MARCH 1996
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humor through all aspects of their work. Hospice care, intensive care units, and critical illness have all served as foci for humor, which helps staff and patients alike cope with stress and fear. This article attempts to apply some of those lessons to primary care settings. Why is humor important? What purposes does it fulfill? Can practitioners learn to interpret humor generated by patients and use these data to diagnose and treat? And finally, how can providers nurture their own humor and use it to enrich clinical practice?
THE ROLE OF HUMOR IN HEALTH CARE
Health care humor potentially fulfills the following f ~ n c t i o n s ~ , ~ : Narrows cultural and socioeconomic interpersonal gaps Relieves anxiety Communicates messages Provides an acceptable outlet for anger and frustration Enhances healing Communicates caring Nontherapeutic uses of humor, humor in the presence but exclusive of the patient, can do the reverse: widen interpersonal gaps, increase anxiety, prevent communication, promote anger, impede healing, and express a lack of concern. Fortunately, the chief defense to prevent these negative results is to keep a patient-oriented focus. Nontherapeutic humor occurs predominantly when providers stop considering patient needs. Let us examine a few of the roles of humor that are particularly important in primary care.
Narrowing Interpersonal Gaps A 58-year-old African American woman arrives for a new-patient visit to a white physician on a wintery day. Following an introduction, the doctor comments, "I'd have a warm fire going but the clinic keeps turning down my fireplace request."
The comment is warm and welcoming and is a thank-you for negotiating the rough weather. By sharing a light moment the physician breaks down inherent formality. Contrast this with: "Hello Mrs. Jones, I'm Dr. ~, What brings you to see me today?" This traditional greeting carries an abruptness that maintains formality and distance. In fact, politeness alone often is not a help. By itself politeness inherently promotes a set of social rules and restrictions. The vast array of sensitive issues, ranging from current fears to past traumas, that must be addressed in primary care are often not polite. Informality can be respectful. In fact, sharing friendly humor is a show of respect. It says,
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”I want you to feel comfortable and like me. I will take time to share some fun with you.” One physician had a special knack for finding a quick personal connection, no matter how simple. ”You and I were both born in September. September people are my favorites.“
On entering the office to greet a new, anxious-appearing patient, the physician said, “Congratulations for coming to see me. I’ve been meaning to get to the doctor myself, but I never get around to it.”
This greeting communicates empathy for the patient’s decision to visit, relieves anxiety, and lightens the mood. Relieving Anxiety
Every medical student who has ever walked into an anatomy laboratory or acted silly before a big examination knows that humor helps people cope with anxiety and fear. In fact, you know you are excessively anxious when you lose the ability to laugh. Patients use humor to relieve anxiety all the time in virtually every health care setting. This may be less dramatic in the office, but it is there. A diabetic patient developed a small toe ulcer and was worried about its consequences but coped with this situation by using humor. “Doc, why don’t you just cut it off and I’ll hop on my way.” The physician heard the anxiety and quickly reassured the patient by responding in kind. “I’m afraid I won’t get any surgical practice today. Your toe’s going to heal up fine on its own.”
In more dire situations, humor can help patients express profound fears. A cancer patient was facing recurrent disease and the advent of chemotherapy. He joked with his family doctor, ”Doc, if I’m having any pain, just call my vet. He’s good at putting things to sleep.”
The doctor needs to recognize this expression of fear and respond with reassurance about pain management and support; it is not a suicide wish. One of the challenges of interpreting humor is for the physician to understand that coping humor is often a sign of underlying anxiety. Although it may signify that the patient is coping effectively, efforts specially to address sources of anxiety can be helpful. A woman facing cardiac surgery responds to the information about intubation: ”My husband will be so happy . . . a whole day when I won’t be able to say a word.”
It might be helpful for the physician to ask if she has any questions about intubation. Her statement may be reflecting concern about her current level of support from her spouse or about the impact of surgery on family relationships. The primary care provider is the right person to probe these issues gently to provide the reassurance she needs. Physicians can use humor positively to relieve anxiety. One physician effectively used a deadpan style to relieve anxiety and to set the stage for
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being truthful. Before an aspiration of a ganglion cyst a patient asked how much pain to expect. The physician responded: “It hurts like heck, but pain is what we do here!“
The physician then changed to an empathic tone and described the procedure, including an honest report of expected pain. Note that this type of humor could backfire if the environment were formal and cool. In the context of a warm interaction with a known patient, it works well. In fact, owing to the long-term nature of relationships with patients, primary providers are ideally suited to use therapeutic, reassuring humor. Humor can be a great introduction to communicating potentially anxiety-provoking information. A physician was prescribing a beta blocker for a middle-aged married man and wished to warn him of potential side effects. ”By the way, I should tell you that you’ll never be able to have sex again. I hope that‘s okay?”
The honest report of potential impact on sexuality that followed provoked less concern that it might have if the physician had not felt comfortable joking about the issue. The doctor’s humor also set the stage for discussion of sexual issues in the future. This example illustrates one of the most common roles of humor in society: we laugh about those things that make us uncomfortable. Sexuality is the leading object for this use of humor. Using humor to confront sexual issues puts this potentially sensitive topic into a familiar context. Communication Humor is a wonderful form of communication. In several examples given previously physicians not only relieved anxiety, but also communicated a concern or raised a new topic. Most of us use humor as an acceptable way to communicate ideas; patients do this all the time as well. In the clinical setting, as opposed to daily social interaction, the physician should hear the humor and be prepared to interpret its message. A physician has attempted to reassure a secretary about some lightheadedness. The patient responds, ”I just tell my friends at work that if they find me passed out on the floor, finish typing my boss’ dictation first . . . then call 911.”
Not only does the doctor recognize that some more reassurance and explanation is necessary, but the patient may be pointing the way to a cause of the problem. In fact, the physician went on to discuss the stresses and lack of control she felt at work that helped lead to a better appreciation of the roots of her symptoms. Expressing Frustration and Anger It is difficult for patients and providers to deal with frustration and anger. The provider feels that expressing frustration is unprofessional and
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potentially hurtful, and the patient may be intimidated, unwilling to offend, or feel powerless. Expression of frustration through humor communicates the message without threatening the relationship. In primary care, traditional sources of patient frustration and anger are the telephone and ”the wall.” Patients respond most of the time with creativity (if not unrestrained affection). “I finally figured out your phone system. I put your voice mail on my voice mail and they just bounce the call back and forth all day.“ “Phone worked great, Doc. By the time somebody picked up, I was better.” ”Waiting for you is something else, Doc. Everyone in the waiting room just diagnoses each other. I’m thinking of accepting Medicare.”
These comments all call for a response, such as an apology, explanation, or both, but the relationship remains unthreatened. When the anger is expressed without the humor, the physician knows to apologize and to repair the damage. Incidentally, one of the best strategies to defuse frustration from a long wait is to thank the patient for waiting to see you. The thank you is not only an apology but a sign of respect for their time expenditure. When the source of anger and frustration is more serious, humor can be even more healing. The primary physician can help encourage this response as a part of treatment. A 36-year-old woman was undergoing treatment of multiple myeloma and was in the midst of a long hospitalization with daily tests and treatments. At the end of each day her family physician would see her on his daily rounds and greet her with: “Having fun yet?“ Or “Any fun today?” It was their personal shared code that it was all right for the patient to report the daily trials and tribulations. Often she would respond, ”Oh, they really planned a fun time today.” One day she looked distraught and the physician picked up on the cue to avoid the playful greeting but the patient used the code to set the tone. ”Oh Dr. ,nothing fun today.”
Having created a lighter tone, the physician was readily able to pick up on the patient’s added anger and fear when the humor content dropped. Cousins4provides us with a classic example of communicating frustration. JohnsonI6repeats this Cousins’ story: During a long hospitalization for his seronegative spondyloarthropathy, Mr. Cousins’ lunch tray arrived, followed shortly by a nurse bearing a specimen jar which she placed on the tray as she requested a urine sample. Cousins opened his apple juice, filled the specimen jar, and rang for the nurse to return. When she arrived, he held the apple juice-filled jar up to the light and claimed, ”It looks a little cloudy. I think I’ll run it through one more time”. . .and proceeded to down it!
In addition to being a wonderful way to vent frustration, Cousins’ anecdote illustrates a potentially profound power of humor. Humor allows the patient to re-establish a sense of control and autonomy. As providers, we easily can underestimate the sense of loss of control, powerlessness, and blurring of individual identity experienced by patients, particularly in the hospital or when suffering from acute illness. Cousins’
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purposeful humorous ploy was a gentle way to get back at the system and to re-establish autonomy while maintaining fundamentally sound relationships with the care providers. This example begins to get at humor's role in healing: it can provide a comfortable conduit to transport a patient from passivity and sense of victimization to involvement and partnership with the care team. Humor in Chronic Disease
In the ambulatory setting, patients use humor to express frustration with chronic illness. The elderly patient with multiple diagnoses, medications, and doctor visits uses this mechanism frequently. "I'm going to start my own drug store." "Why don't I just move in and save the bus fare."
At times it is therapeutic for the physician to respond to the humorous message. "Are you able to keep all those medicines straight?" "Are you getting tired of all the visits here?"
One physician was able to use exaggerated honesty to change patientgenerated frustration into a common doctor-patient bond. A patient had been having intermittent abdominal pain for 6 months and had undergone many tests and consultations. Her primary physician had patiently and persistently pursued an explanation for the pain and tried a variety of treatments. The likelihood of a life-threatening diagnosis was low. The patient asked the doctor, "So what do you think is wrong with me?" The physician replied, "I have no idea."
This frank reply catches us by surprise; it departs from the usual professional approach and demeanor. In the context of an established, caring relationship, it communicated a shared sense of frustration, opened the door to discussing emotional aspects of the symptom, and served as an introduction to an honest appraisal of where things stand.
DOES THE HUMOR REALLY MATTER?
The importance of using humor in health care has been well documented in a variety of settings. Nursing units that routinely use humor have higher staff and patient satisfaction. Many studies have been done of the physiologic effects of laughter; a positive impact on circulatory7and respiratory status,8 relaxation? and immune fun~tion,2,~,~ has been detected. Hospitalized patients who are less passive and who take more control have improved outcomes; as mentioned previously, humor is one technique to establish this sense of autonomy and control. Much has been written about the beneficial role of humor in Despite these positive reports, little is known with precision about
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the importance of humor in primary care. Of course, both physicians and patients may generate humor, and it is useful to consider these separately.
Humor Generated by Physicians Physicians are able to narrow interpersonal gaps, communicate warmth, confront sensitive issues, and deal with frustration and anger without generating humor. For certain patients, however, generating humor is the most effective communication style. Having humor in the repertoire provides a valuable tool to create an open, warm atmosphere. Assessing the importance of physician-generated humor in primary care affords a fruitful opportunity for future research. Much of the humor in medical literature derives from nursing units' use of humor to alleviate their own tensions and frustrations. Primary providers are far from immune to these stresses. Humor can be particularly useful in helping physicians deal with their own sources of frustration while delivering important messages: A 70-year-old man with severe hypertension was struggling to remember to take all his medications. Despite clear instruction, he did not take his medicines on the morning of a physician visit and, not surprisingly, his blood pressure was out of control. The physician asked, "Do you have an extra bed?" When the patient responded affirmatively the physician exclaimed, "Great, I'll be moving in tonight. From now on I'm your personal medicine consultant." The physician also playfully expressed his frustration with body language and facial expressions. The patient got the point while sharing the laughter.
Humor Generated by Patients
All physicians care for patients who use humor to lessen anxiety, cope with frustration, and communicate messages. The provider who correctly interprets and understand these messages is better able to respond to patient needs and can open important doors. The devoted wife of a schizophrenic man with a history of substance abuse reports her concern that her husbands been "eating the neighbor's flowers. The neighbor's been complaining." When the physician asks him why he's been eating flowers, the patient answered, "fiber." The provider responds, "How about trying Metamucil?" They all laugh about the dilemma and the physician asks the man, "You don't worry much if something harms you, do you?" Wife and patient agree this is true, and the physician uses the opportunity to discuss with the husband and wife their respective investments in the husband remaining alive. Although the patient does not worry about the consequences of his behavior, he does care about his wife's happiness and wishes.
The initial interaction was playful and light, but the physician grasped this opportunity to discuss more serious issues. Patients with serious illness or frightening symptoms often cope through humor, and the physician needs to be prepared to respond.
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A diabetic patient was facing her second amputation. She frequently joked about ”instant weight loss” and “saving money on shoes.“ Her physician smiled at the mildly shocking humor but also took the opportunity to address her sense of loss.
As mentioned earlier, patients use humor to express frustration. The physician who creates a welcoming atmosphere gives his or her patients a chance to express their frustration without damaging the relationship. A patient with sarcoidosis and chronic depressed personality gradually learned to use humor to communicate her sense of futility and disappointment at not feeling better. On being introduced to a medical student at the beginning of a visit, she said, “That’s right, my doctor will just smile and say, ’see you in 6 weeks.’ It‘s always, ‘see you in 6 weeks.’ ” On one occasion she added a joke about the doctor’s bills.
The provider had created a safe environment to permit this chronically ill patient to direct some of her frustration and disappointment at the physician. Some physicians may respond defensively; her physician recognized the role that humor played for the patient and validated her frustration by responding in kind. When the visit was finished the provider said he was about to make a major announcement and proclaimed, ”I’ll see you in 6.5 weeks!”
In summary, the use of humor characterizes the therapeutic doctorpatient relationship. Although the provider may not feel comfortable generating humor, he or she needs to be ready to hear the patient’s humor and to respond appropriately. For some patients, humor is a primary coping technique. Physicians can help support and encourage this use of humor with warmth and receptivity even if they do not generate humor themselves. The physician who does learn to initiate or respond through humor has the advantage of a universal communication tool and intervention that enhances healing interactions. THERAPEUTIC USES OF HUMOR IN PRIMARY CARE
Anxiety Threshold One of the challenges facing health care providers is knowing when initiating humor is not appropriate. In fact, there do not appear to be any specific topics or aspects of care that preclude humor. Humor has been used to help patients cope with all aspects of wellness and illness. No subjects are absolutely taboo. A proper and private woman was being treated for cervical cancer including intravaginal radiation therapy. This required many pelvic examinations by different professionals. As her privacy disappeared she increasingly used humor. She made every potential examiner pay a dime and started to refer to examinations as “searching for treasure.”
Under usual conditions, this woman would have never considered joking about something so private, and yet humor became a key survival
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mechanism for her in this tense setting. In contrast, humor can be inappropriate and unappreciated in seemingly unthreatening circumstances. How can the provider tell when humor will not work? A useful concept is to assess the anxiety or tension threshold.I6When an event or situation produces excessive tension, anxiety, or fear, humor has the potential to be experienced as inappropriate, not funny, and even hurtful. Interestingly, sadness by itself does not preclude using humor. The person who is mourning the recent death of a spouse following a long illness often is comforted by sharing humorous anecdotes from the spouse’s life. If the death were sudden, the spouse often is coping with shock, fear of the future, and anxiety, as well as sadness, and humor is less likely to be helpful. A young woman presented with an infected sebaceous cyst; she was extremely anxious. On follow-up visits, despite unequivocal evidence that the infection was clearing, she required repeated reassurance and was unresponsive to the physician’s lighthearted attempts to downplay the significance of this problem.
The patient’s persistent fear and anxiety rendered her unreceptive to the use of humor. Society’s response to events in 1994 and 1995 well illustrates this ”threshold” effect. Jokes about the O.J. Simpson trial circulated throughout the country within weeks of his arrest. On the other hand, the pain, anxiety, and fear generated by the Oklahoma bombing suppressed all humor for many months. Coping humor may eventually surface but not until the tension level is lessened by time and societal processing. Certain scenarios virtually always exceed this anxiety threshold. The patient who reports being the victim of incest, rape, or other violation provides a clear example. As the patient travels the arduous road to recovery from these profoundly hurtful live events, coping humor may emerge at various points in the process. This humor may be communicating diverse messages and, as described previously, the provider should be ready to respond. The humor threshold should be contrasted with the apparent lack of sense of humor seen in some depressed patients. In these individuals, helping patients to see some humor may help put their stressors in perspective. It may also help the physician maintain his or her own investment in the relationship. A physician had been caring for a lonely, chronically depressed woman with somatization disorder. The doctor frequently felt frustrated at his inability to help this patient, perceived her as humorless, and contrary to his usual humorous style, did not use humor at visits. On one visit he asked an excellent medical student to see her first. After 40 minutes, the physician entered the examination room to the strains of laughter and a mood of frivolity. The doctor was clearly surprised and quite amazed when the patient observed, “This student is hilarious; why aren’t you ever that way?” From then on he always tried to inject playfulness and mirth, and the doctor-patient relationship became more rewarding and therapeutic for both.
The physician learned an important lesson from this patient. The provider’s sense of frustration sapped his own energy and investment in
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the relationship; he lost the ability to tap into humor's beneficial effects, a loss he projected to the patient. This wonderful student revitalized the entire doctor-patient relationship and helped the physician remember that gentle humor with patients who are feeling burdened can lessen life's load a bit and help patients realize they have a companion in their journey.
HUMOR WITH SPECIAL POPULATIONS Humor With Children
When people meet a funny doctor they often ask if he or she cares for children. In fact, humor with kids can be helpful but should look quite different than humor with adult^.^ The verbal content is replaced by playfulness, magic, slapstick, body humor, music, and facial expressions. As with adults, humor helps to relieve anxiety but these are generally the immediate anxieties associated with the office visit. An almost infinite number of variations to physician-child humor are practiced. The singing doctor (must be up on latest Disney releases), the magic doctor (quarters have been pulled from a thousand ears), the never ending hand shake ("We're stuck), the seeing through the ear to the wall on the other side of the office, finding diverse objects deep in the throat, the dramatic flourish while examining Mom or using the otoscope to examine the wrong body part, the world famous examining-glove balloons, and many others. The key to each style is that the doctor has to feel comfortable and sincerely playful. Each provider needs his or her own style but, as for all great comedians, plagiarism of others' successful attempts is perfectly acceptable. Children can also provide magical moments that enrich the lives of their doctors and make the daily trials worthwhile. A 3-year-old Greek American bilingual girl never spoke during visits. At the end of one visit, the doctor thought she had figured out the trick to hear her little patient speak. She said, "You speak Greek don't you?" The girl nodded. The Doctor asked, "Can you say goodbye in Greek?" The girl nodded. The Doctor requested, "Then say, goodbye to me in Greek." The little girl waved goodbye.
Humor With Adolescents
Of all uses of humor, working with adolescents poses perhaps the greatest challenge and calls for the most caution. Adolescents can easily interpret the humor as making fun of them or pointing out a flaw. They may interpret it as over-familiarity, over-identification, or abandonment of the physician role. Caution with adolescents until or even after the relationship is sound is often warranted. With this caveat in mind, humor can serve identical purposes with adolescents as with adults. A matter-of-fact approach to potentially sensitive topics can create a light, receptive atmosphere.
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After discussing confidentiality, having a general sense of the parent-adolescent relationship and adolescent attitude toward the office visit, the physician asked the parent to step out and announced, with a light style, “I need to go over all the usual adolescent issues: sex, drugs, alcohol, and smoking.”
This matter-of-fact pronouncement reassured and informed the parent that these key items would be reviewed and provided a clear agenda for the adolescent as well. The doctor’s pronouncement also communicated his own comfort and confidence in addressing these potentially sensitive areas. Although the statement is not truly funny, the contrast between the inherent privacy of the topics and the open, casual style created an entertaining paradox that achieved a specific purpose. One useful approach to humor with adolescents is for the physician to point fun at himself or herself or the older generation in general. This can be done by inquiring about adolescent lingo or behavior. Again, the goal is to establish and maintain a respectful doctor-patient relationship while creating an open, light atmosphere.
Humor With Older Patients
Aging is associated with loss: loss of strength, vitality, health, social supports, and social meaning. One attribute that is absolutely not lost is sense of humor.13In fact, much of the humor in the elderly relates to the very issues that are subject to deterioration. An elderly man shared with a friend, ”Sex is getting difficult. I can’t tell if I’m achieving orgasm or having angina.”
One of the special forms of humor that many older patients, particularly men, bring to the doctor visit is the telling of jokes. The joke-telling may occupy an important place in the world-view for these individuals. The jokes become a world commentary, a path to intimacy, and a tool to aid coping with loss. Most physicians do not have the repertoire to match the patient joke-for-joke but do have the ability to listen and enjoy, even if the laughter needs to be forced a bit. Giving these patients the time to tell a few of their favorites confirms your interest in the relationship and validates the patient’s sense of importance to the provider. Many students and young physicians struggle with the manifold health dilemmas facing the elderly. Encouraging the use of humor helps the learner enjoy providing care to older patients and enhances care.
LEARNING TO USE HUMOR
Some people can tell a joke and some cannot. Some providers generate humor readily and spontaneously and others rarely elicit a smile let alone a guffaw. No matter how important humor may be to primary care, is it possible to change one’s style to take advantage of humor’s therapeutic power. Studies confirm significant variation in individuals’ ten-
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dency to generate or appreciate h ~ m o r . ’ ~ Given ,~,~ that ~ it is critical to be natural and comfortable, is humor right for all physicians? The answer is yes. Humor is a fundamental aspect of communication, a critical component of coping, and a vital source of comfort. Physicians must create a receptive environment for patient-generated humor and should attempt to introduce humor when it aids healing. The provider should be able to create the kind of light, informal atmosphere that fosters communication. RobinsonI6describes four steps to promote personal use of humor. Step one is to increase knowledge; the physician who understands the importance of humor as a healing agent is likely to be receptive to promoting its use. The second step is acceptance. As discussed previously, the provider needs to be receptive to humor used by patients and coworkers. Step three is examination of one’s own behavior: what role does humor play in your own world including your role as a health professional? The final step in behavior change encompasses the conscious decision to generate humor and to create an environment that encourages its use. In many respects these steps parallel Procha~ka’s’~ stages of behavior change: precontemplative, contemplative, readiness, action, and maintenance. The precontemplative physician who is not considering using humor should spend a few moments contemplating the limits that he or she is putting on the doctor-patient relationship. Humor can improve diagnostic acumen, help patients cope better, promote healing, and enhance the doctor’s sense of personal reward. The physician in the contemplation phase recognizes the value of humor but is not sure that he or she can use it and is, perhaps, worried that humor will not work well. This physician should realize that humor encompasses a broad range of behaviors, from light informality to full slap-stick and joking; start small and test the waters. The response will keep you coming back for more. The physician who already has discovered that humor enhances practice can experiment with wider applications of humor. How can the physician increase the use of humor? First, the doctor needs to be willing to take some chances; some comments may fall flat but do not be discouraged. More often than not, humor attempts are met with comfortable chuckles if not outright laughter. The physician may be helped by a change in mindset: “How would I establish a friendship with a stranger?”, a process that is not dissimilar from narrowing interpersonal gaps with a patient. Robinson16describes a comprehensive approach, including practice techniques to increase humor. Many women may find it difficult to introduce humor. In fact, women generate less humor than menlo (although the explosion of female comediennes over the past 5 years may reflect a fundamental change in societal attitudes toward female-generated humor). Women do tend to use more coping humor than men, and this can be a great opportunity to work with patients. Put yourself in the patient’s place and call on coping mechanisms; share with the patient the humor that emerges.
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SUMMARY A 56-year-old woman with chronic somatization was perpetually fearful that she had a terminal illness. One thing she had going for her was a 15-year relationship with a doctor who shared the lighter side of life with her. Her doctor once said, "Someday I'm going to find something wrong with you, and we won't know what to do. We'll be so surprised!" The patient was commenting that despite the fact that she felt terrible, her friends told her she looked good. She then added, "I'm just glad I'll look good when they lay me out." The doctor shared a laugh and promised that she'd hold the undertaker accountable. A 75-year-old woman had struggled with obesity throughout her life. For years her doctor had tried to boost her self-esteem and help her overcome her frustration with being overweight. The woman was then stricken with metastatic colon cancer that led to marked weight loss. As she approached her death and negotiated pain and loss, she took great comfort from the visits with her longtime physician. When discussing funeral plans, her doctor took a chance and advised, "Oh, go for the open casket. Everyone will always remember you skinny!" The patient's laugh was long and heartfelt and the visit ended with an embrace and a few tears.
Humor will work. Just remember these rules: 1. Assess receptivity to humor; make sure that the anxiety and fear do not exceed the anxiety threshold. 2. Make sure the humor is shared; it must be inclusive for the patient. Exclusive humor between professionals in the presence of the patient has no role. 3. Be receptive to patients' humor. Hear, interpret, and respond to its messages. 4. Take some humor chances. The rewards will be great.
It is time to change our image. As the 5-year-old said to her family doctor, "You're too funny to be a doctor." A good motto should be, "You're too good a doctor not to be funny." Have fun.
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8. Fry WF Jr: The respiratory components of mirthful laughter. Journal of Biological Psychology 19:39-50, 1979 9. Goldstein JH: Therapeutic effects of laughter. In Professional Resource Exchange (ed): Handbook of Humor and Psychotherapy, Advances in the Clinical Use of Humor. Sarasota, FL, Professional Resource Exchange, 1987 10. Johnson MA: Language ability and sex-affect humor appreciation. Percept Mot Skills 75:571-581,1992 11. Kuhlman TL: Humor and Psychotherapy. Homewood, IL, Dow Jones-Irwin, 1984 12. Lefcourt HM, Martin RA: Humor and Life Stress. New York, Springer-Verlag, 1986 13. Nahemow L, McCluskey-FawcettKA, (eds): Humor and Aging. Orlando, FL,Academic Press Inc, 1986 14. Parish AB: It only hurts when I don’t laugh. Am J Nurs 8:4&47, 1994 15. Prochaska J: Assessing how people change. Cancer 67805-807,1991 16. Robinson VM: Humor and the Health Professions, ed 2. Thorofare, NJ, SLACK, Inc, 1991 17. Robinson V: The purpose and function of humor in O.R. nursing. Today’s O.R. Nurse 15:7-12, 1993 18. Rose GJ: King Lear and the use of humor in treatment. J Am Psychoanal Assoc 12:927940,1969 19. Siege1 B S Love, Medicine, and Miracles. New York, Harper and Row, 1986 20. Sousing N: The Healing Heart. New York, W.W. Norton Company, 1983 21. Strickland D: Seriously, laughter matters. Today’s O.R. Nurse 15:19-24, 1993 22. Thorson JA, Powell FC: Development and validation of a multidimensional sense of humor scale. J Clin Psychol 49:13-23,1993 23. Thorson JA, Powell FC: Sense of humor and dimensions of personality. J Clin Psychol 49~799-809.1993
Address reprint requests to Richard C. Wender, MD Department of Family Medicine Jefferson Medical College Thomas Jefferson University 1015 Walnut Street, Suite 401 Philadelphia, PA 19107
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HUMOR IN MEDICINE Richard C. Wender, MD
Humor is hot. Using humor in health care, one suspects, is as ancient as healing itself, but in the past 20 years humor has been ”discovered.” Spurred on by popular acceptance as well as by the funny and touching writings of Cousins4r9and Siegel19humor has become the object of scholarly investigation and inquiry. It has undergone poking, prodding, picking, and pondering, and the effluence has been a body of writing, including a definitive discussion by Robinson,’6 an embrace of the need to include humor to care for people optimally, and a recognition that humor facilitates our own survival as we cope with our daily stresses. On first inspection, humor in primary care appears to occupy a respected and accepted place. Conjure up an image of the seasoned competent family doctor seeing a long-time patient; compare it with the thirdyear student struggling in his or her first time visits with skeptical patients. Warmth and lightness pervade the former image; the serious business goes on not just in a social milieu but in an environment that reaches for, and occasionally attains, true fun. The doctor helps the patient feel better even if he or she cures infrequently. It takes students time and practice to rise above the tools with which we have armed them: the rules of history taking; the comprehensive review-of-systems list; the otoscope, ophthoscope, and stethoscope, and of course the much needed tuning fork, to infuse the examining room with warmth and humor. In fact, despite the humor explosion in medical care, little literature specifically examines humor in primary care. The nursing profession has led the study of humor including developing techniques to increase its use in clinical setting^.','^,^^,^^ There is no surprise here; no health care professional deals with stress, suffering, and loss as routinely and consistently as the hospital nurse. Efficiently functioning nursing teams weave From the Department of Family Medicine, Jefferson Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania
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VOLUME 23 NUMBER 1 MARCH 1996
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humor through all aspects of their work. Hospice care, intensive care units, and critical illness have all served as foci for humor, which helps staff and patients alike cope with stress and fear. This article attempts to apply some of those lessons to primary care settings. Why is humor important? What purposes does it fulfill? Can practitioners learn to interpret humor generated by patients and use these data to diagnose and treat? And finally, how can providers nurture their own humor and use it to enrich clinical practice?
THE ROLE OF HUMOR IN HEALTH CARE
Health care humor potentially fulfills the following f ~ n c t i o n s ~ , ~ : Narrows cultural and socioeconomic interpersonal gaps Relieves anxiety Communicates messages Provides an acceptable outlet for anger and frustration Enhances healing Communicates caring Nontherapeutic uses of humor, humor in the presence but exclusive of the patient, can do the reverse: widen interpersonal gaps, increase anxiety, prevent communication, promote anger, impede healing, and express a lack of concern. Fortunately, the chief defense to prevent these negative results is to keep a patient-oriented focus. Nontherapeutic humor occurs predominantly when providers stop considering patient needs. Let us examine a few of the roles of humor that are particularly important in primary care.
Narrowing Interpersonal Gaps A 58-year-old African American woman arrives for a new-patient visit to a white physician on a wintery day. Following an introduction, the doctor comments, "I'd have a warm fire going but the clinic keeps turning down my fireplace request."
The comment is warm and welcoming and is a thank-you for negotiating the rough weather. By sharing a light moment the physician breaks down inherent formality. Contrast this with: "Hello Mrs. Jones, I'm Dr. ~, What brings you to see me today?" This traditional greeting carries an abruptness that maintains formality and distance. In fact, politeness alone often is not a help. By itself politeness inherently promotes a set of social rules and restrictions. The vast array of sensitive issues, ranging from current fears to past traumas, that must be addressed in primary care are often not polite. Informality can be respectful. In fact, sharing friendly humor is a show of respect. It says,
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”I want you to feel comfortable and like me. I will take time to share some fun with you.” One physician had a special knack for finding a quick personal connection, no matter how simple. ”You and I were both born in September. September people are my favorites.“
On entering the office to greet a new, anxious-appearing patient, the physician said, “Congratulations for coming to see me. I’ve been meaning to get to the doctor myself, but I never get around to it.”
This greeting communicates empathy for the patient’s decision to visit, relieves anxiety, and lightens the mood. Relieving Anxiety
Every medical student who has ever walked into an anatomy laboratory or acted silly before a big examination knows that humor helps people cope with anxiety and fear. In fact, you know you are excessively anxious when you lose the ability to laugh. Patients use humor to relieve anxiety all the time in virtually every health care setting. This may be less dramatic in the office, but it is there. A diabetic patient developed a small toe ulcer and was worried about its consequences but coped with this situation by using humor. “Doc, why don’t you just cut it off and I’ll hop on my way.” The physician heard the anxiety and quickly reassured the patient by responding in kind. “I’m afraid I won’t get any surgical practice today. Your toe’s going to heal up fine on its own.”
In more dire situations, humor can help patients express profound fears. A cancer patient was facing recurrent disease and the advent of chemotherapy. He joked with his family doctor, ”Doc, if I’m having any pain, just call my vet. He’s good at putting things to sleep.”
The doctor needs to recognize this expression of fear and respond with reassurance about pain management and support; it is not a suicide wish. One of the challenges of interpreting humor is for the physician to understand that coping humor is often a sign of underlying anxiety. Although it may signify that the patient is coping effectively, efforts specially to address sources of anxiety can be helpful. A woman facing cardiac surgery responds to the information about intubation: ”My husband will be so happy . . . a whole day when I won’t be able to say a word.”
It might be helpful for the physician to ask if she has any questions about intubation. Her statement may be reflecting concern about her current level of support from her spouse or about the impact of surgery on family relationships. The primary care provider is the right person to probe these issues gently to provide the reassurance she needs. Physicians can use humor positively to relieve anxiety. One physician effectively used a deadpan style to relieve anxiety and to set the stage for
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being truthful. Before an aspiration of a ganglion cyst a patient asked how much pain to expect. The physician responded: “It hurts like heck, but pain is what we do here!“
The physician then changed to an empathic tone and described the procedure, including an honest report of expected pain. Note that this type of humor could backfire if the environment were formal and cool. In the context of a warm interaction with a known patient, it works well. In fact, owing to the long-term nature of relationships with patients, primary providers are ideally suited to use therapeutic, reassuring humor. Humor can be a great introduction to communicating potentially anxiety-provoking information. A physician was prescribing a beta blocker for a middle-aged married man and wished to warn him of potential side effects. ”By the way, I should tell you that you’ll never be able to have sex again. I hope that‘s okay?”
The honest report of potential impact on sexuality that followed provoked less concern that it might have if the physician had not felt comfortable joking about the issue. The doctor’s humor also set the stage for discussion of sexual issues in the future. This example illustrates one of the most common roles of humor in society: we laugh about those things that make us uncomfortable. Sexuality is the leading object for this use of humor. Using humor to confront sexual issues puts this potentially sensitive topic into a familiar context. Communication Humor is a wonderful form of communication. In several examples given previously physicians not only relieved anxiety, but also communicated a concern or raised a new topic. Most of us use humor as an acceptable way to communicate ideas; patients do this all the time as well. In the clinical setting, as opposed to daily social interaction, the physician should hear the humor and be prepared to interpret its message. A physician has attempted to reassure a secretary about some lightheadedness. The patient responds, ”I just tell my friends at work that if they find me passed out on the floor, finish typing my boss’ dictation first . . . then call 911.”
Not only does the doctor recognize that some more reassurance and explanation is necessary, but the patient may be pointing the way to a cause of the problem. In fact, the physician went on to discuss the stresses and lack of control she felt at work that helped lead to a better appreciation of the roots of her symptoms. Expressing Frustration and Anger It is difficult for patients and providers to deal with frustration and anger. The provider feels that expressing frustration is unprofessional and
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potentially hurtful, and the patient may be intimidated, unwilling to offend, or feel powerless. Expression of frustration through humor communicates the message without threatening the relationship. In primary care, traditional sources of patient frustration and anger are the telephone and ”the wall.” Patients respond most of the time with creativity (if not unrestrained affection). “I finally figured out your phone system. I put your voice mail on my voice mail and they just bounce the call back and forth all day.“ “Phone worked great, Doc. By the time somebody picked up, I was better.” ”Waiting for you is something else, Doc. Everyone in the waiting room just diagnoses each other. I’m thinking of accepting Medicare.”
These comments all call for a response, such as an apology, explanation, or both, but the relationship remains unthreatened. When the anger is expressed without the humor, the physician knows to apologize and to repair the damage. Incidentally, one of the best strategies to defuse frustration from a long wait is to thank the patient for waiting to see you. The thank you is not only an apology but a sign of respect for their time expenditure. When the source of anger and frustration is more serious, humor can be even more healing. The primary physician can help encourage this response as a part of treatment. A 36-year-old woman was undergoing treatment of multiple myeloma and was in the midst of a long hospitalization with daily tests and treatments. At the end of each day her family physician would see her on his daily rounds and greet her with: “Having fun yet?“ Or “Any fun today?” It was their personal shared code that it was all right for the patient to report the daily trials and tribulations. Often she would respond, ”Oh, they really planned a fun time today.” One day she looked distraught and the physician picked up on the cue to avoid the playful greeting but the patient used the code to set the tone. ”Oh Dr. ,nothing fun today.”
Having created a lighter tone, the physician was readily able to pick up on the patient’s added anger and fear when the humor content dropped. Cousins4provides us with a classic example of communicating frustration. JohnsonI6repeats this Cousins’ story: During a long hospitalization for his seronegative spondyloarthropathy, Mr. Cousins’ lunch tray arrived, followed shortly by a nurse bearing a specimen jar which she placed on the tray as she requested a urine sample. Cousins opened his apple juice, filled the specimen jar, and rang for the nurse to return. When she arrived, he held the apple juice-filled jar up to the light and claimed, ”It looks a little cloudy. I think I’ll run it through one more time”. . .and proceeded to down it!
In addition to being a wonderful way to vent frustration, Cousins’ anecdote illustrates a potentially profound power of humor. Humor allows the patient to re-establish a sense of control and autonomy. As providers, we easily can underestimate the sense of loss of control, powerlessness, and blurring of individual identity experienced by patients, particularly in the hospital or when suffering from acute illness. Cousins’
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purposeful humorous ploy was a gentle way to get back at the system and to re-establish autonomy while maintaining fundamentally sound relationships with the care providers. This example begins to get at humor's role in healing: it can provide a comfortable conduit to transport a patient from passivity and sense of victimization to involvement and partnership with the care team. Humor in Chronic Disease
In the ambulatory setting, patients use humor to express frustration with chronic illness. The elderly patient with multiple diagnoses, medications, and doctor visits uses this mechanism frequently. "I'm going to start my own drug store." "Why don't I just move in and save the bus fare."
At times it is therapeutic for the physician to respond to the humorous message. "Are you able to keep all those medicines straight?" "Are you getting tired of all the visits here?"
One physician was able to use exaggerated honesty to change patientgenerated frustration into a common doctor-patient bond. A patient had been having intermittent abdominal pain for 6 months and had undergone many tests and consultations. Her primary physician had patiently and persistently pursued an explanation for the pain and tried a variety of treatments. The likelihood of a life-threatening diagnosis was low. The patient asked the doctor, "So what do you think is wrong with me?" The physician replied, "I have no idea."
This frank reply catches us by surprise; it departs from the usual professional approach and demeanor. In the context of an established, caring relationship, it communicated a shared sense of frustration, opened the door to discussing emotional aspects of the symptom, and served as an introduction to an honest appraisal of where things stand.
DOES THE HUMOR REALLY MATTER?
The importance of using humor in health care has been well documented in a variety of settings. Nursing units that routinely use humor have higher staff and patient satisfaction. Many studies have been done of the physiologic effects of laughter; a positive impact on circulatory7and respiratory status,8 relaxation? and immune fun~tion,2,~,~ has been detected. Hospitalized patients who are less passive and who take more control have improved outcomes; as mentioned previously, humor is one technique to establish this sense of autonomy and control. Much has been written about the beneficial role of humor in Despite these positive reports, little is known with precision about
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the importance of humor in primary care. Of course, both physicians and patients may generate humor, and it is useful to consider these separately.
Humor Generated by Physicians Physicians are able to narrow interpersonal gaps, communicate warmth, confront sensitive issues, and deal with frustration and anger without generating humor. For certain patients, however, generating humor is the most effective communication style. Having humor in the repertoire provides a valuable tool to create an open, warm atmosphere. Assessing the importance of physician-generated humor in primary care affords a fruitful opportunity for future research. Much of the humor in medical literature derives from nursing units' use of humor to alleviate their own tensions and frustrations. Primary providers are far from immune to these stresses. Humor can be particularly useful in helping physicians deal with their own sources of frustration while delivering important messages: A 70-year-old man with severe hypertension was struggling to remember to take all his medications. Despite clear instruction, he did not take his medicines on the morning of a physician visit and, not surprisingly, his blood pressure was out of control. The physician asked, "Do you have an extra bed?" When the patient responded affirmatively the physician exclaimed, "Great, I'll be moving in tonight. From now on I'm your personal medicine consultant." The physician also playfully expressed his frustration with body language and facial expressions. The patient got the point while sharing the laughter.
Humor Generated by Patients
All physicians care for patients who use humor to lessen anxiety, cope with frustration, and communicate messages. The provider who correctly interprets and understand these messages is better able to respond to patient needs and can open important doors. The devoted wife of a schizophrenic man with a history of substance abuse reports her concern that her husbands been "eating the neighbor's flowers. The neighbor's been complaining." When the physician asks him why he's been eating flowers, the patient answered, "fiber." The provider responds, "How about trying Metamucil?" They all laugh about the dilemma and the physician asks the man, "You don't worry much if something harms you, do you?" Wife and patient agree this is true, and the physician uses the opportunity to discuss with the husband and wife their respective investments in the husband remaining alive. Although the patient does not worry about the consequences of his behavior, he does care about his wife's happiness and wishes.
The initial interaction was playful and light, but the physician grasped this opportunity to discuss more serious issues. Patients with serious illness or frightening symptoms often cope through humor, and the physician needs to be prepared to respond.
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A diabetic patient was facing her second amputation. She frequently joked about ”instant weight loss” and “saving money on shoes.“ Her physician smiled at the mildly shocking humor but also took the opportunity to address her sense of loss.
As mentioned earlier, patients use humor to express frustration. The physician who creates a welcoming atmosphere gives his or her patients a chance to express their frustration without damaging the relationship. A patient with sarcoidosis and chronic depressed personality gradually learned to use humor to communicate her sense of futility and disappointment at not feeling better. On being introduced to a medical student at the beginning of a visit, she said, “That’s right, my doctor will just smile and say, ’see you in 6 weeks.’ It‘s always, ‘see you in 6 weeks.’ ” On one occasion she added a joke about the doctor’s bills.
The provider had created a safe environment to permit this chronically ill patient to direct some of her frustration and disappointment at the physician. Some physicians may respond defensively; her physician recognized the role that humor played for the patient and validated her frustration by responding in kind. When the visit was finished the provider said he was about to make a major announcement and proclaimed, ”I’ll see you in 6.5 weeks!”
In summary, the use of humor characterizes the therapeutic doctorpatient relationship. Although the provider may not feel comfortable generating humor, he or she needs to be ready to hear the patient’s humor and to respond appropriately. For some patients, humor is a primary coping technique. Physicians can help support and encourage this use of humor with warmth and receptivity even if they do not generate humor themselves. The physician who does learn to initiate or respond through humor has the advantage of a universal communication tool and intervention that enhances healing interactions. THERAPEUTIC USES OF HUMOR IN PRIMARY CARE
Anxiety Threshold One of the challenges facing health care providers is knowing when initiating humor is not appropriate. In fact, there do not appear to be any specific topics or aspects of care that preclude humor. Humor has been used to help patients cope with all aspects of wellness and illness. No subjects are absolutely taboo. A proper and private woman was being treated for cervical cancer including intravaginal radiation therapy. This required many pelvic examinations by different professionals. As her privacy disappeared she increasingly used humor. She made every potential examiner pay a dime and started to refer to examinations as “searching for treasure.”
Under usual conditions, this woman would have never considered joking about something so private, and yet humor became a key survival
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mechanism for her in this tense setting. In contrast, humor can be inappropriate and unappreciated in seemingly unthreatening circumstances. How can the provider tell when humor will not work? A useful concept is to assess the anxiety or tension threshold.I6When an event or situation produces excessive tension, anxiety, or fear, humor has the potential to be experienced as inappropriate, not funny, and even hurtful. Interestingly, sadness by itself does not preclude using humor. The person who is mourning the recent death of a spouse following a long illness often is comforted by sharing humorous anecdotes from the spouse’s life. If the death were sudden, the spouse often is coping with shock, fear of the future, and anxiety, as well as sadness, and humor is less likely to be helpful. A young woman presented with an infected sebaceous cyst; she was extremely anxious. On follow-up visits, despite unequivocal evidence that the infection was clearing, she required repeated reassurance and was unresponsive to the physician’s lighthearted attempts to downplay the significance of this problem.
The patient’s persistent fear and anxiety rendered her unreceptive to the use of humor. Society’s response to events in 1994 and 1995 well illustrates this ”threshold” effect. Jokes about the O.J. Simpson trial circulated throughout the country within weeks of his arrest. On the other hand, the pain, anxiety, and fear generated by the Oklahoma bombing suppressed all humor for many months. Coping humor may eventually surface but not until the tension level is lessened by time and societal processing. Certain scenarios virtually always exceed this anxiety threshold. The patient who reports being the victim of incest, rape, or other violation provides a clear example. As the patient travels the arduous road to recovery from these profoundly hurtful live events, coping humor may emerge at various points in the process. This humor may be communicating diverse messages and, as described previously, the provider should be ready to respond. The humor threshold should be contrasted with the apparent lack of sense of humor seen in some depressed patients. In these individuals, helping patients to see some humor may help put their stressors in perspective. It may also help the physician maintain his or her own investment in the relationship. A physician had been caring for a lonely, chronically depressed woman with somatization disorder. The doctor frequently felt frustrated at his inability to help this patient, perceived her as humorless, and contrary to his usual humorous style, did not use humor at visits. On one visit he asked an excellent medical student to see her first. After 40 minutes, the physician entered the examination room to the strains of laughter and a mood of frivolity. The doctor was clearly surprised and quite amazed when the patient observed, “This student is hilarious; why aren’t you ever that way?” From then on he always tried to inject playfulness and mirth, and the doctor-patient relationship became more rewarding and therapeutic for both.
The physician learned an important lesson from this patient. The provider’s sense of frustration sapped his own energy and investment in
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the relationship; he lost the ability to tap into humor's beneficial effects, a loss he projected to the patient. This wonderful student revitalized the entire doctor-patient relationship and helped the physician remember that gentle humor with patients who are feeling burdened can lessen life's load a bit and help patients realize they have a companion in their journey.
HUMOR WITH SPECIAL POPULATIONS Humor With Children
When people meet a funny doctor they often ask if he or she cares for children. In fact, humor with kids can be helpful but should look quite different than humor with adult^.^ The verbal content is replaced by playfulness, magic, slapstick, body humor, music, and facial expressions. As with adults, humor helps to relieve anxiety but these are generally the immediate anxieties associated with the office visit. An almost infinite number of variations to physician-child humor are practiced. The singing doctor (must be up on latest Disney releases), the magic doctor (quarters have been pulled from a thousand ears), the never ending hand shake ("We're stuck), the seeing through the ear to the wall on the other side of the office, finding diverse objects deep in the throat, the dramatic flourish while examining Mom or using the otoscope to examine the wrong body part, the world famous examining-glove balloons, and many others. The key to each style is that the doctor has to feel comfortable and sincerely playful. Each provider needs his or her own style but, as for all great comedians, plagiarism of others' successful attempts is perfectly acceptable. Children can also provide magical moments that enrich the lives of their doctors and make the daily trials worthwhile. A 3-year-old Greek American bilingual girl never spoke during visits. At the end of one visit, the doctor thought she had figured out the trick to hear her little patient speak. She said, "You speak Greek don't you?" The girl nodded. The Doctor asked, "Can you say goodbye in Greek?" The girl nodded. The Doctor requested, "Then say, goodbye to me in Greek." The little girl waved goodbye.
Humor With Adolescents
Of all uses of humor, working with adolescents poses perhaps the greatest challenge and calls for the most caution. Adolescents can easily interpret the humor as making fun of them or pointing out a flaw. They may interpret it as over-familiarity, over-identification, or abandonment of the physician role. Caution with adolescents until or even after the relationship is sound is often warranted. With this caveat in mind, humor can serve identical purposes with adolescents as with adults. A matter-of-fact approach to potentially sensitive topics can create a light, receptive atmosphere.
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After discussing confidentiality, having a general sense of the parent-adolescent relationship and adolescent attitude toward the office visit, the physician asked the parent to step out and announced, with a light style, “I need to go over all the usual adolescent issues: sex, drugs, alcohol, and smoking.”
This matter-of-fact pronouncement reassured and informed the parent that these key items would be reviewed and provided a clear agenda for the adolescent as well. The doctor’s pronouncement also communicated his own comfort and confidence in addressing these potentially sensitive areas. Although the statement is not truly funny, the contrast between the inherent privacy of the topics and the open, casual style created an entertaining paradox that achieved a specific purpose. One useful approach to humor with adolescents is for the physician to point fun at himself or herself or the older generation in general. This can be done by inquiring about adolescent lingo or behavior. Again, the goal is to establish and maintain a respectful doctor-patient relationship while creating an open, light atmosphere.
Humor With Older Patients
Aging is associated with loss: loss of strength, vitality, health, social supports, and social meaning. One attribute that is absolutely not lost is sense of humor.13In fact, much of the humor in the elderly relates to the very issues that are subject to deterioration. An elderly man shared with a friend, ”Sex is getting difficult. I can’t tell if I’m achieving orgasm or having angina.”
One of the special forms of humor that many older patients, particularly men, bring to the doctor visit is the telling of jokes. The joke-telling may occupy an important place in the world-view for these individuals. The jokes become a world commentary, a path to intimacy, and a tool to aid coping with loss. Most physicians do not have the repertoire to match the patient joke-for-joke but do have the ability to listen and enjoy, even if the laughter needs to be forced a bit. Giving these patients the time to tell a few of their favorites confirms your interest in the relationship and validates the patient’s sense of importance to the provider. Many students and young physicians struggle with the manifold health dilemmas facing the elderly. Encouraging the use of humor helps the learner enjoy providing care to older patients and enhances care.
LEARNING TO USE HUMOR
Some people can tell a joke and some cannot. Some providers generate humor readily and spontaneously and others rarely elicit a smile let alone a guffaw. No matter how important humor may be to primary care, is it possible to change one’s style to take advantage of humor’s therapeutic power. Studies confirm significant variation in individuals’ ten-
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dency to generate or appreciate h ~ m o r . ’ ~ Given ,~,~ that ~ it is critical to be natural and comfortable, is humor right for all physicians? The answer is yes. Humor is a fundamental aspect of communication, a critical component of coping, and a vital source of comfort. Physicians must create a receptive environment for patient-generated humor and should attempt to introduce humor when it aids healing. The provider should be able to create the kind of light, informal atmosphere that fosters communication. RobinsonI6describes four steps to promote personal use of humor. Step one is to increase knowledge; the physician who understands the importance of humor as a healing agent is likely to be receptive to promoting its use. The second step is acceptance. As discussed previously, the provider needs to be receptive to humor used by patients and coworkers. Step three is examination of one’s own behavior: what role does humor play in your own world including your role as a health professional? The final step in behavior change encompasses the conscious decision to generate humor and to create an environment that encourages its use. In many respects these steps parallel Procha~ka’s’~ stages of behavior change: precontemplative, contemplative, readiness, action, and maintenance. The precontemplative physician who is not considering using humor should spend a few moments contemplating the limits that he or she is putting on the doctor-patient relationship. Humor can improve diagnostic acumen, help patients cope better, promote healing, and enhance the doctor’s sense of personal reward. The physician in the contemplation phase recognizes the value of humor but is not sure that he or she can use it and is, perhaps, worried that humor will not work well. This physician should realize that humor encompasses a broad range of behaviors, from light informality to full slap-stick and joking; start small and test the waters. The response will keep you coming back for more. The physician who already has discovered that humor enhances practice can experiment with wider applications of humor. How can the physician increase the use of humor? First, the doctor needs to be willing to take some chances; some comments may fall flat but do not be discouraged. More often than not, humor attempts are met with comfortable chuckles if not outright laughter. The physician may be helped by a change in mindset: “How would I establish a friendship with a stranger?”, a process that is not dissimilar from narrowing interpersonal gaps with a patient. Robinson16describes a comprehensive approach, including practice techniques to increase humor. Many women may find it difficult to introduce humor. In fact, women generate less humor than menlo (although the explosion of female comediennes over the past 5 years may reflect a fundamental change in societal attitudes toward female-generated humor). Women do tend to use more coping humor than men, and this can be a great opportunity to work with patients. Put yourself in the patient’s place and call on coping mechanisms; share with the patient the humor that emerges.
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SUMMARY A 56-year-old woman with chronic somatization was perpetually fearful that she had a terminal illness. One thing she had going for her was a 15-year relationship with a doctor who shared the lighter side of life with her. Her doctor once said, "Someday I'm going to find something wrong with you, and we won't know what to do. We'll be so surprised!" The patient was commenting that despite the fact that she felt terrible, her friends told her she looked good. She then added, "I'm just glad I'll look good when they lay me out." The doctor shared a laugh and promised that she'd hold the undertaker accountable. A 75-year-old woman had struggled with obesity throughout her life. For years her doctor had tried to boost her self-esteem and help her overcome her frustration with being overweight. The woman was then stricken with metastatic colon cancer that led to marked weight loss. As she approached her death and negotiated pain and loss, she took great comfort from the visits with her longtime physician. When discussing funeral plans, her doctor took a chance and advised, "Oh, go for the open casket. Everyone will always remember you skinny!" The patient's laugh was long and heartfelt and the visit ended with an embrace and a few tears.
Humor will work. Just remember these rules: 1. Assess receptivity to humor; make sure that the anxiety and fear do not exceed the anxiety threshold. 2. Make sure the humor is shared; it must be inclusive for the patient. Exclusive humor between professionals in the presence of the patient has no role. 3. Be receptive to patients' humor. Hear, interpret, and respond to its messages. 4. Take some humor chances. The rewards will be great.
It is time to change our image. As the 5-year-old said to her family doctor, "You're too funny to be a doctor." A good motto should be, "You're too good a doctor not to be funny." Have fun.
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8. Fry WF Jr: The respiratory components of mirthful laughter. Journal of Biological Psychology 19:39-50, 1979 9. Goldstein JH: Therapeutic effects of laughter. In Professional Resource Exchange (ed): Handbook of Humor and Psychotherapy, Advances in the Clinical Use of Humor. Sarasota, FL, Professional Resource Exchange, 1987 10. Johnson MA: Language ability and sex-affect humor appreciation. Percept Mot Skills 75:571-581,1992 11. Kuhlman TL: Humor and Psychotherapy. Homewood, IL, Dow Jones-Irwin, 1984 12. Lefcourt HM, Martin RA: Humor and Life Stress. New York, Springer-Verlag, 1986 13. Nahemow L, McCluskey-FawcettKA, (eds): Humor and Aging. Orlando, FL,Academic Press Inc, 1986 14. Parish AB: It only hurts when I don’t laugh. Am J Nurs 8:4&47, 1994 15. Prochaska J: Assessing how people change. Cancer 67805-807,1991 16. Robinson VM: Humor and the Health Professions, ed 2. Thorofare, NJ, SLACK, Inc, 1991 17. Robinson V: The purpose and function of humor in O.R. nursing. Today’s O.R. Nurse 15:7-12, 1993 18. Rose GJ: King Lear and the use of humor in treatment. J Am Psychoanal Assoc 12:927940,1969 19. Siege1 B S Love, Medicine, and Miracles. New York, Harper and Row, 1986 20. Sousing N: The Healing Heart. New York, W.W. Norton Company, 1983 21. Strickland D: Seriously, laughter matters. Today’s O.R. Nurse 15:19-24, 1993 22. Thorson JA, Powell FC: Development and validation of a multidimensional sense of humor scale. J Clin Psychol 49:13-23,1993 23. Thorson JA, Powell FC: Sense of humor and dimensions of personality. J Clin Psychol 49~799-809.1993
Address reprint requests to Richard C. Wender, MD Department of Family Medicine Jefferson Medical College Thomas Jefferson University 1015 Walnut Street, Suite 401 Philadelphia, PA 19107