Kimberly D. Manning, MD, FACP, was near the end of a long shift several years ago at Grady Memorial Hospital in Atlanta when one of her residents tried to crack a joke. “We have a pretty substantial population of patients who use crack cocaine regularly. We had admitted 10 patients and eight of the 10 had some crack-related problem,” explained Dr. Manning, who is an assistant professor of medicine at Emory University.
“The resident says, ‘You know what we need in this hospital? We need a crack team.’ And everybody started laughing. ‘We need a crack pager and they can take crack call and everybody can follow up in the crack clinic. If it's slow, whoever the crack team is can go and drum up business around the hospital.’”
“His comic timing was actually very good,” said Dr. Manning. “It was coming out like Chris Rock.” As the other residents' laughter indicated, by comedic standards, he had succeeded. But toward the goal of being an ethical and professional physician, his bit may not have worked quite as well.
The Grady resident is far from the only physician to struggle with the ethics of humor in the hospital. An article in the September/October 2011 Hastings Center Report analyzed gallows humor and physicians' urge to make light of the deadly serious subjects that arise in medicine.
“It certainly occurs and so you have to ask yourself why. I do think that [gallows humor] has a function,” said Katie Watson, JD, author of the article and assistant professor of medical humanities and bioethics at Northwestern University in Chicago, Ill. “The ethical question is whether it is a helpful tool or a harmful byproduct of stress.”
Not a clear call
In some situations, the dark humor may be both helpful and harmful. “Some have argued that when doctors use humor amongst themselves and it's directed toward patients and their families it is used to relieve [doctors'] own suffering or their tension,” said Joseph Zarconi, MD, FACP, system vice president of medical education for Summa Health System in Akron, Ohio. But that doesn't necessarily make a joke acceptable. “While we might make ourselves feel better, we harm the profession,” he added.
Dr. Zarconi has studied medical students' experiences with this kind of humor and found that they are not always convinced of the ethical downsides. “In our studies, a lot of people said, ‘No harm, no foul. It's not intended to be in the face of the patient,’” he said.
As teachers and role models for these young doctors, many hospitalists may be particularly required to take a stance on the ethics of hospital humor. “The residents are products of their training environments,” Dr. Zarconi said.
Dr. Manning agreed, especially with regard to her resident's crack joke. “As the attending on the team, I felt like I had created a climate that allowed him to be able to say that, which bothered me,” she said.
The trick is figuring out how to deal with these issues without coming off as a humorless Grinch. “I don't want people to think you can work this hard with these extremes of life and death and emotion and not ever be able to have a place for humor,” said Dr. Manning. “I'm a big believer in humor in the hospital as long as the patient's in on it.”
In fact, she'll even poke fun at the occasional patient—when she knows he can take a tease. “One of my patients was kind of confused when he first got to the hospital,” she described. A few days later, the patient's mental condition was fine, and he and Dr. Manning had gotten to be friendly. “That day I had beat the team to his room and started with the now daily questions assessing his mental orientation, like where he was, his name, etc. He answered them all correctly. Then he said the hospital food was good and I gave him a funny look. My team came in and I said, ‘Uh oh. I think Mr. Jones might be disoriented again! He just said the food here was good!’ Everyone laughed.”
These sorts of situations highlight the difficulties of setting standards for humor. “Like so many ethical issues, bright-line rules are often unsuccessful. What you need is a sophisticated analysis of particular cases,” said Prof. Watson. Her article outlined a number of points to consider in an analysis of gallows humor among physicians behind closed doors, including the joke's target, frequency, audience, intent and likely impacts.
Dr. Manning has a simpler mode of decision making. “It all comes down to the ‘my momma’ rule. If you wouldn't want anybody saying that about your momma or your daddy, you probably don't need to say it,” she said.
Of course, everyone's mother has a different sense of humor, so the decision on some jokes can still be tough. James S. Newman, MD, FACP, has walked this fine line. “I was in a room with a patient that was in isolation and dying, with the family. They were mad about the whole situation,” said Dr. Newman, a hospitalist at the Mayo Clinic in Rochester, Minn., and ACP Hospitalist's editorial advisor and humor columnist.
“I was nervous and I was snapping my glove and it ripped. I'm standing there in the isolation room with a ripped glove and they just looked at me. I said, ‘Oh brother, that's why I have four kids.’ “The ice was broken,” he said. “They could have just as easily reported me and said ‘He made a prophylactic joke while we're talking about my dad dying.’ You have to be fairly sophisticated in your ability to read people.”
Part of the curriculum
Residents should be taught to keep their humor well within the safe zone, the experts agreed. They all also agreed that humor should explicitly be a subject of education and training.
“Just because there aren't always bright-line rules doesn't mean there's nothing to teach,” said Prof. Watson. “I would encourage [attending physicians] to address it head on, because gallows humor is a relevant part of the hidden curriculum.”
Dr. Manning agreed that failing to address the ethics of humor will only succeed in pushing questionable jokes out of your earshot. “I include it at the very beginning of my warm-ups when I'm talking to my team: ‘You will learn. You will have fun. You might cry. You will surely laugh. It's OK to laugh, but we don't laugh at people,’” she said. “I tell them the things I said or took part in or didn't protest as a resident that I'm not proud of.”
For example, Dr. Manning remembered a pediatric patient from her residency whose esophagus was destroyed when he drank some drain cleaner. “The team, including my attending, would crack jokes about it, the senior resident more than anybody,” she said, describing how the physicians made up numerous derogatory nicknames for the child. “When I was a resident, it did not even occur to me how foul that was.”
Her experience highlights two key issues. First, Dr. Zarconi and colleagues have found that residents are the most likely to engage in derogatory and cynical humor. “They're more cynical because they're more tired, they're more overworked, they're more in demand,” he said. “Fortunately, that starts to get better when they get into a better situation with regard to their workloads. I think the work hour restrictions have helped.”
Also, changes in the culture of medicine have made the joking that Dr. Manning witnessed as a resident less accepted. “Many institutions, ours for example, have focused on trying to create environments where we can have conversations, to say, ‘When we're really stressed, really tired, I notice we're making fun of people we shouldn't be making fun of. Let's find ways to change the conversation into things that are more constructive,’” Dr. Zarconi said.
His program has also distributed articles about derogatory humor to the medical students and encouraged them to discuss it with the residents and attendings on their teams. “It's not just, ‘I'll address it when you demonstrate it.’ Just becoming more conscious about the insidious negative humor will promote a greater degree of resistance,” Dr. Zarconi said.
Dr. Manning has also noticed a culture change. “We work hard to humanize patients a lot more. I don't think it will be as comfortable or as easy for people to do some of the things I saw as a resident,” she said.
Humanizing the patient was the solution she chose to her resident's joking about crack. “The default thing would be for me to pull the resident aside and wag my finger at him,” she said. Instead, Dr. Manning talked to the patient who had inspired his speech before she dealt with the issue.
“I met with the team and I talked about her as a person. ‘Her name is Diana and she has two sons…She's the same age as me and she started using crack cocaine when she was 19 and a freshman in college. She graduated sixth in her high school class. I know she's one of eight people that we admitted. I know it's frustrating, but she's one person. We kind of signed up for this, so we have to work hard to take the high road,’” she said.
“I let my resident vent a little bit. I talked to him about how the medical students will follow his lead. It ended up being really good,” she said.