Though to outsiders it may seem strange, for staff in the emergency department (ED), humor is as common as chest pain or dizziness. Writer E.B White is credited with asserting that “humor can be dissected, as a frog can, but the thing dies in the process…” While this may hold true when attempting to analyze the mechanics of the unique humor found in the hospital setting, given its ubiquity, it’s worth considering its impact on both patients and staff, as well as some best practices for using it on shift.

Intuitively, we know that laughter makes us feel better. This certainly isn’t a new concept. The Greek physician Hippocrates is thought to have encouraged his patients to “contemplate on comic things” during their healing process. [1] In modern times, research has shown that humor can improve cognitive function, pain tolerance, and mood as well as reduce stress and insomnia. [2] Therefore, perhaps it’s not surprising that humor therapy is viewed as a key non-pharmacologic intervention in caring for a variety of patients. [3] In the fast-paced emergency department environment, judiciously employed humor can quickly create a therapeutic bond with patients. Additionally, many patients with chronic conditions that present to the ED already use humor as a way to cope with and normalize their illness, and if invited to follow their patient’s lead, physicians may find laughter to be a powerful adjunct in these scenarios as well.

But what about the less structured, more organic humor that crops up among colleagues in the emergency department? Often referred to as “gallows humor” or “dark humor” also found in other high-stress fields such as the military, this tends to be more controversial. An important distinction should be made here. Though sometimes considered disturbing or offensive to those outside of the intended audience, gallows humor is ideally an adaptive response to a traumatic or stressful situation and is meant to help the one making the joke and those around them cope. Conversely, while cynical humor can be confused for its relatively benevolent sibling, it’s a maladaptive way of expressing one’s response to the same scenario without care for its impact on others. [4]

Gallows humor has the ability to create what bioethicist Katie Watson refers to as a backstage language, allowing colleagues to feel like part of a family that can provide support they may not be able to otherwise find. [5] When choosing a specialty as medical students, we are in part searching for this feeling of community and may use shared sense of humor as a criterion in our endeavor. Gallows humor can also function as a means of dealing with parts of our job that induce fear and can provide an emotional shield to help us get through a particularly intense shift. [6] Finally, humor can be used in place of stress or anxiety when considering external issues over which we have no control, such as insufficient compensation or administrative policies we don’t agree with or understand. [5]

Of course, making use of gallows humor is not without its pitfalls. The idea of a backstage language is great as long as it stays behind the curtains, but when patients or their families hear these jokes out of context, an immediate and potentially irreversible breakdown of trust and respect can follow. [4] Similarly, when trainees hear what they consider to be crude or unprofessional humor, or feel forced to participate in this type of behavior, it can cause them to lose faith in the senior physicians or internalize this humor inappropriately, becoming cynical and detached from their work. [7]

Even when this humor stays within the hospital staff, though, it has the potential to have negative consequences. Joking at the expense of other specialties can sometimes be harmless banter between colleagues. However, when executed without care, it can instead lead to disrespect and a division between physicians that should be relying on each other to provide the best patient care. [8] Similarly, jokes among colleagues within the same field at the expense of their patients can create bias toward the patient and negatively impact their care, and if nothing else, can make the joke teller seem crass or insensitive. [5]

No individual is the sole arbiter of good taste, and the line between acceptable and unacceptable humor is a moving target, varying by situation and audience. That said, in order to enjoy the benefits of humor in the emergency department while avoiding its drawbacks, there are a few best practices to keep in mind. First, if you’re going to joke with your patients, make sure you’re accurately reading the room and that you let them set the tone. If your humor tends to lean more towards the dark side, always think about the purpose of your joke. Are you trying to express a shared frustration in a therapeutic way or are you just lashing out? Aim your jokes at a situation or shared experience as opposed to an individual if possible. Joking about yourself, a colleague, or some nameless entity in a position of power may be acceptable if executed deftly. However, joking about a patient or someone else over whom you exert some degree of power such as a junior resident or medical student is almost never justifiable. Finally, if you choose to use a “backstage language”, always remember that your intended audience may not be the only ones within earshot.

Take-Aways:

·      Humor has the potential to help patients in both quantitative and qualitative ways

·      Benefits for staff include fostering a supportive community and helping each other deal with the most difficult parts of our jobs

·      Potential drawbacks include damaging various relationships and creating harmful biases

·      Follow your patient’s lead, choose your target carefully, and always be mindful of who is listening

Keywords:

Therapeutic humor, gallows humor

Author: Sean Reid, MD is a fourth year emergency medicine resident at Brown University/Rhode Island Hospital

Faculty Reviewer: Kristina McAteer, MD

References:

1.     Piemonte N.M, Abreu S. Responding to callous humor in health care. AMA Journal of Ethics. 2020;22(7). doi:10.1001/amajethics.2020.608

2.     Akimbekov NS, Razzaque MS. Laughter therapy: A humor-induced hormonal intervention to reduce stress and anxiety. Curr Res Physiol. 2021;4:135-138. doi:10.1016/j.crphys.2021.04.002

3.     Humor Research Library: Association for Applied and Therapeutic Humor. AATH.org. https://www.aath.org/research-publications. Accessed February 12, 2023.

4.     Aultman JM, Meyers E. Does using humor to cope with stress justify making fun of patients? AMA Journal of Ethics. 2020;22(7). doi:10.1001/amajethics.2020.576

5.     Watson K. Gallows humor in medicine. Hastings Cent Rep. 2011;41(5):37-45. doi:10.1002/j.1552-146x.2011.tb00139.

6.     Oczkowski, Simon. “Virtuous Laughter: We Should Teach Medical Learners the Art of Humor.” Critical Care, vol. 19, no. 1, 1 Dec. 2015, https://doi.org/10.1186/s13054-015-0927-4.

7.     Piemonte, N.M. Last Laughs: Gallows Humor and Medical Education. J Med Humanit 36, 375–390 (2015). https://doi.org/10.1007/s10912-015-9338-4.

8.     Nagler J, Mannix R. Are “Other Doctors Are Stupid” Jokes Appropriate? AMA Journal Of Ethics. 2020;22(7). doi:10.1001/amajethics.2020.583