Time Stamps + Show Notes:
- The Good
- The Bad, The Ugly
- Tips, Takeaways & Conclusion
- 41:11 Excerpt from Man’s 4th Best Hospital by Samuel Shem
Jafar: There are few men in the history of medicine as evil as Dr. William Palmer. A mid-19th century London physician, he was a degenerate gambler who would do just about anything to pay off his loans. He forged checks in his mother’s name, defrauded life insurance companies, and even murdered his brother, his wife, and his friends to collect money. His typical routine was to invite them to dinner, only to later lace their cocktail with strychnine, earning the title, “the prince of poisoners.” Charles Dickens once called Palmer “the greatest villain that ever stood in the Old Bailey.” He was finally convicted and sentenced to hanging in 1856, and as the story goes, he walked onto the gallows platform, tapped on the floor boards, looked at the noose hanging, and the trapdoor underneath him, and turning to the executioner asked him:
“Are you sure this thing’s safe?”
Jafar: Hi, I’m Jafar
Margot: I’m Margot
Tamar: And I’m Tamar. Welcome back to “At the Bedside”, the segment of CoreIM where we try to explore experiences and ethical issues beyond traditional algorithms of evidence-based clinical care. In today’s episode, we’re talking about gallows humor in medicine.
Jafar: So, Gallows Humor isn’t just in the life of dying physicians. It’s actually something I think speaks to the life we bring to the profession–a kind of levity in the face of our daily heaviness. Anyone being honest about their experiences in the hospital will tell you: clinicians joke about dark stuff all the time, not just death, but also illness, debility, catastrophes… almost any form of human tragedy, really. And oftentimes, this comes with a little cringe or twinge of guilt. “Was it ok to say that?” And whenever you have that “Ooo, was that ok” moment, there’s a voice of conscience, an ethical debate going on inside. So, let’s bring it outside.
Today we’re going to talk all about the good, the bad, and the ugly that comes with this so called “gallows humor” and humor more broadly. First, Margot is going to try and answer the question: why are we so drawn to humor, and what motivates us to use humor when dealing with death and illness? Then, Tamar will help us understand: What are the risks of gallows humor?
We were very lucky to sit down with two guests who have both used medical humor as major parts of their career. Katie Watson is a former lawyer, current sketch comedy and improv performer, and professor of medical ethics at Northwestern University Feinberg School of Medicine, whose landmark 2011 paper in the Hastings Center Report first set the stage for really looking at gallows humor in medicine as an everyday practice that could really be a legitimate concern for bioethicists.
Watson: The idea of like what we don’t talk about but we all do or many of us do is always a place as a scholar to go, because I care about actual practice and I care about actual behavior, not just theoretical models of behavior.
Jafar: Also with us is Dr. Stephen Bergman, who writes under the pen-name “Samuel Shem.” He is a former psychiatrist and current professor of medical humanities at NYU School of Medicine, best known for authoring The House of God, one of the most dark, funny, controversial but undeniably important accounts of modern medical training. At the end of the episode, stick around for a special reading from his new novel, coming out November 12th:
Shem: “Man’s 4th Best Hospital… it’s a sequel to The House of God”
Jafar: My first disclaimer for anyone listening is that while I love, love, love this topic, I do realize the let down that sometimes follows when you tune in planning to hear something funny, and instead get treated to a big plate of theory, and ethical reflection, and moral ambiguity. To paraphrase the great American writer E.B. White:
“Analyzing humor is a bit like dissecting a frog: You learn a lot about how it works, but in the end you’ve got a dead frog.”
Look. Just hang in there with us, and we promise to sprinkle in a little something along the way….
Definition of Gallows Humor
Jafar: Ok, so to start off, let’s just make sure we are on the same page. What is gallows humor? What makes gallows humor different from just regular humor? Professor Watson helps us out with this:
Watson: Formally speaking, gallows humor is joking about death or dying. The term is used more broadly and I think appropriately, particularly in medicine, to refer to joking about anything that is dark or macabre or frightening, and making jokes about those, those terrifying circumstances. And I think health and illness, uh, fall into that. You know, so it’s not always about dying per se, but about the difficulty and challenges of illness.
Jafar: Another helpful definition I’ve heard… is that gallows humor generally looks at human suffering as ABSURD rather than PITIABLE. And healthcare professionals have no monopoly on this market. Examples of gallows humor abound in TV, in movies, books, pushing out to the boundaries of taste and becoming popular precisely because they touch on this fundamental human fear. One essential element of humor in general is the violation of expectation, the juxtaposition of mismatched parts, you know, that playful unexpectedness of a punchline, and nothing hits you with a surprise more than playing with Death. So it’s no wonder, then, that it becomes a favorite jumping off point for comedians, especially for one of my personal heros George Carlin:
George Carlin – Death: (1:06-1:45)
Jafar: Something different happens, though, once the humor leaves the stage and gets pulled into the real world, and into the illnesses and tragedies of real people. There are many examples of patients using gallows humor to help take control of their own lives and stories. For instance, I’ve seen a lot of different funny breast cancer t-shirts for patients, with lines on them like “save 2nd base”, or “my oncologist did my hair”, and “yes they’re gone, they tried to kill me!” These kind of jokes have actually been shown to decrease feelings of isolation, maybe because humor has a way of easing the discomfort others feel around the patient’s illness, and as a result draws in more social support. Even survivors of the most horrific war crimes including the holocaust describe using a kind of gallows humor, not only after but during their suffering in the camps. You can watch a masterful take on this subject in the 2016 documentary, the Last Laugh:
The Last Laugh (2016 Trailer): 0:52-1:02
Jafar: You know, while it may make us squeamish, ethically, there’s something reassuring about the fact that, again, this is their suffering, and they are the ones choosing to make a joke about it. However, when someone else wants to make a joke about that person’s suffering, that’s when we might run into problems, and that’s why we want to focus on that today. Specifically, we’ll focus on how we as healthcare professionals joke amongst ourselves about the dark things we see in practice every day, often in ways we don’t necessarily want others to know about, especially patients. We want to make clear the distinction between gallows humor and cruel humor, and show both its value and its risks. We’ll see why we find it so irresistible, and Margot is going to help us solve the riddle of exactly why it is I’m always try to scrape up a joke during rounds…
Benefits/Function of Humor in General
Margot: At the most basic level, humor is defined as anything meant to be comical or amusing. It’s not only a primary form of human interaction, it cuts across species –even chimpanzees joke with each other.
There are a lot of great things about humor – it can help people bond, form a sense of social identity, and feel better about themselves, particularly if they get a laugh or two. There was this interesting meta-analysis that tried to understand how humor worked in the workplace, and it found that humor improves cohesion and leadership dynamics, and makes people better at coping, and it can reduce rates of burnout.
I will say, though, that the benefits of humor really depend on what kind of jokes you’re telling. Broadly speaking, there are two types of humor: adaptive humor, and maladaptive humor. Adaptive humor includes subcategories like “coping humor”, which is where people tell a joke to cope with a tough situation. For example, here’s a clip from the comedian Gary Gulman, who talks about his struggle with mental illness in his special “The Great Depresh.”
Margot: Then there’s affiliative humor, where people joke around with friends or colleagues, and there’s a category called “self-enhancing” humor, where it’s one person, all by themselves, just being amused by the absurdity of the world. Then there’s skilled humor, which is where one person will crack a joke to put others at ease. These 4 sub-types of adaptive humor have been associated with greater self-esteem, lower depression and anxiety levels, and more positive self-competency judgments.
But coming back to maladaptive humor, there are two main types. The first is self-defeating humor, where people make jokes at their own expense; self-defeating humor is associated with poorer self-esteem, greater depression and anxiety, and poorer judgments of self-competence. Think about Rodney Dangerfield, funny to listen, but maybe hurts at the end of the day?
Margot: Then there’s aggressive humor that makes other people the butt of the joke, which didn’t seem to have any impact on personal well-being.
Gallows Humor as Connection/Cementing Social Support
Margot: Coming back to gallows humor – let’s talk for a second about how it can play a role in social bonding. Shem spoke with us about some of the lessons he learned about humor.
Shem: “What I’ve come to realize years after the House of God is that what really was destructive for us in that internship was that we got isolated…If you walk through suffering with caring others, like us, you’re not going to suffer as much and you’re not going to spread more suffering around. So when you’re scared and you’re floating around this big hospital and you don’t know who, what you’re doing, if somebody uses humor, that’s a connection.”
Margot: Gallows humor allows people to bond when faced with the unique kinds of stressors that outsiders might have difficulty understanding. This is part of the reason that it’s used a lot in other professions that regularly deal with traumatic issues, like firefighters, soldiers, journalists, and policemen. Gallows humor can develop into a set of in-jokes that cement the group’s common identity. Telling that in-joke says, “we’re all in this together.” In-jokes can turn into a whole set of dark euphemisms – saying “Discharge to heaven” instead of death, or calling a gunshot wound a bad case of “acute lead poisoning.” Sometimes, these euphemisms turn into slang – for example, in House of God, Shem created a whole humorous vocabulary that has made its way into day-to-day medical lingo, terms like gomer, turf, and bounce. A study of British medical trainees found that use of slang incrementally increases throughout med school, peaking in internship. It’s probably also worth noting that other studies have shown that empathy decreases over this same period of time, though to my knowledge there isn’t a study that has looked at the relationship between empathy and gallows humor directly.
Gallows Humor as Coping/Catharsis/Emotional Shielding
Margot: Let’s talk for a moment about the ways that gallows humor can help people cope. Sometimes gallows humor serves the function of emotional shielding, whereby someone deflects the trauma of witnessing something terrible like a code in order to keep working, maintain stability, or just preserve a more positive worldview. For example, Jafar has a story to share from a night shift a few years back:
Jafar: So I remember there was this helicopter crash in the East River in the middle of Winter, and it dragged these three young people down into the water for over 45 minutes. When it came to our ED, as part of our resuscitation we had to rewarm them, and this turned into a marathon of chest compressions and procedures, even though everyone in the room knew it probably wasn’t going to be successful. I don’t know, I left that code – we did it for over an hour – and I texted my wife who is a resident at another hospital. She sent me a meme.
Katherine: Yes, so the meme I sent you was a picture of Jack and Rose at the end of the movie Titanic, where Jack is dying in the icy waters after the ship sinks, and below that picture is a picture of Halley Joel Osmond from his character in The Sixth Sense, with the covers drawn up to his chin, and written over him was the phrase “Icy Dead People”, but “I see” was spelled I-C-Y.
Jafar: So why–what made you think of that?
Katherine: Well, I know what it’s like to be in those terrible codes, and I just wanted to show you that. Show you that I get it, and that it’s a terrible part of this job, but that’s the job, and you can’t take it so seriously all the time.
Jafar: Yea it did help, I mean, I had to admit four more patients that night, and it’s really great that we were able to share that, though.
Margot: Gallows humor can also help people cope by offering closure to the grieving process. A study found that after major disasters, like a hurricane or a flood, humor marks the end of the grieving period, giving people permission to move forward. Personally, I get really torn up when I have a young, kind patient who comes in with a horrific, terminal illness. It always seems to happen to the nice ones. Often, after I’ve had a bit of time to process, I’ll give myself closure by joking that I’m trying to get meaner as I age so that I’ll live forever. That example also shows how gallows humor can be a means of cognitive reappraisal, whereby I let myself reflect on a situation in a more abstract way. (Atkinson, 2006) By joking about this, I distance myself from the deeply sobering thought that if these patients could die young, I could too.
Gallows humor can ultimately help facilitate catharsis. It can be what Freud calls a “mature” psychological defense mechanism, whereby someone channels otherwise overwhelming feelings into a socially acceptable form.
I would say, though, that it’s important not to take this entirely at face value – a study in 2002 found that police officers stratified by reported use of gallows humor showed no differences in perceived stress. I imagine a lot of this is pretty individual – some people use humor to blow off steam, but others end up ruminating, and the jokes are a reflection of the thoughts they can’t get away from.
Gallows Humor as Resistance Against Oppression
Margot: Gallows humor can also serve as a way of resisting oppression. When we were speaking with Professor Watson, she was helping us piece apart the reasons that clinicians joke around with each other. She wondered whether it was a way for us to blow off steam.
Watson: I think our physicians in America are by and large exploited, I think you are often in very difficult training situations and then you go on to high pressure practice situations that don’t account for your humanity. And so I think some of this is coping mechanisms for unfair labor practices.
Margot: Usually, the scope of gallows humor in resisting oppression is pretty modest – just a way for us to be open and honest with each other about the messed-up things we see on a daily basis. But the theme also came up over and over in our discussions with Shem, where gallows humor played out in a powerful way on a national stage.. Part of the reason House of God was such a landmark book was that it spoke truth to power. As Shem said:
Shem: “One of the basic things that I didn’t realize we were doing consciously in the House of God was, uh, was a way of resisting what we saw as an unjust system where we really were being abused in various different ways that I describe.”
Margot: House of God spends much of its time critiquing the medical training process, casting light on elements that needed reform. It was an act of defiance, and an attempt to return some semblance of power to those who felt powerless. Shem gave an example where he and his fellow interns made light of a pretty morbid metric the hospital was asking the interns to adhere to.
Shem: “The higher ups in charge of all of us interns decided we weren’t getting enough postmortems right. And that they were going to, uh, give a prize at the end of the year for the intern with the most postmortem permissions. And we thought this was absolutely despicable. You know, that, that we were getting rewarded for dead bodies basically. But what we did with it in the book is that a couple of the guys, and this was true, we started making fun of it. We called it the Black Crow award…And it became a real bonding thing that carried us, carried us through.”
Margot: The black crow award also illustrates the principle of using humor as a means of “rapid truthing”. Rapid truthing means saying it like it is, bypassing the cautious and sometimes circumcuitous language people use to describe sensitive topics. In this way, it can facilitate communication by stripping the niceties off an ugly truth, and by shocking the audience out of complacency.
Gallows Humor as a Authenticity/Reflecting the Humanity of the Provider
Margot: At the bottom of it all, I think gallows humor is a way for us to maintain our sense of self in this very serious business. I may be a doctor, but I’m a human too – and humans tell jokes.
Watson: “I’ve noticed the question is when is it okay to joke? Like the assumption is that healthcare is serious business, and you wouldn’t make a joke at work unless you had some, like, deep psychological need to do so in order to process this terrible event. And I find that so interesting and diagnostic in this Rorschach-y way about personality types and expectations and can we be who we are 24 hours a day. And I really am very into that integrated personality and integrated workplace concept of like, if you have to be a different self at work that you’re probably not going to flourish in that profession.”
Margot: One of the funniest moments in our interview with Professor Watson was a story she told about an interaction between a urologist and his patient.
Watson: “A teenager came to urologist saying he had lost a piece of plastic and he was sure it was in his bladder and the urologist as like, well, what, what do you mean he fell asleep? But then he was, the plastic was gone and he’s sure it was in his bladder. And you know, you don’t have to be a physician to be like, I feel like what you’re telling me is you put a piece of plastic in your penis and you lost it. And, and that is a medical thing that needs to be taken care of. Right. … And the urologist said to, I believe a nurse in the hallway where the patient couldn’t here just said, oh, I hope he doesn’t lose his cat.”
Margot: She went on to point out that the situation is funny on the surface, but the more you think about it, the trickier it gets. So with that I want to turn it over to Tamar, who explores this question: Is there something worth investigating underneath the laughter?
Tamar: As Margot just walked us through, humor in medicine, or in any stressful or high stakes situation, can be invaluable – it can serve as a way to connect under pressure, a way to cope or shield our emotions, and a means of resisting a sometimes oppressive environment. But, we also wanted to touch on some of the aspects of gallows humor that can be a little less adaptive, and can maybe even have negative impacts both on those making the jokes and those who overhear them. To start, Professor Watson began by making an important distinction:
Watson: And I, I think that’s really important to distinguish that the cruel humor is just cruel, cruel humor. I think that’s a fair like bullying mean jokes. That’s a separate category. I guess we made a Venn Diagram, there could be some gallows humor that also sounds mean and maybe it is mean, but it’s not the same thing. And so when my piece, I was really trying to separate out the joking about death and dying and disease and overwhelming existentially challenging circumstances.
Tamar: You know those jokes on the wards that make you chuckle but, at the same time, kind of cringe or shake your head? So, when joking, how far is too far? What differentiates coping from cruelty? And is there even always a discrete line between the two? What’s the right context? Who should be the audience? Of course, many times, the quote-unquote appropriateness of a joke depends on so many factors, so we don’t mean to propose any concrete, hard rules here, rather we wanted to raise some food for thought when it comes to joking on the job.
Danger to patients
Tamar: The first things that, of course, come to mind are our obligations to our patients and the potential problems of joking around them. Professor Watson’s 2011 article talks about possible quote “use and abuse of power that comes with asserting oneself as the comic narrator of someone else’s tragedy.” Even Shem, who has made a literary career exploring the role of humor in medicine, mentioned to us his own jarring experience when his doctor’s attempt to lighten the mood didn’t quite land.
Shem: Um, you’d be amazed at how bad doctors talk to patients are. I was a runner and I was getting just terrible pain in my knee. And so finally I went to a doctor and I said, Geez, I got this pain in my knee. And he said, okay, we’ll get you an x-ray or I’ll get your x-ray. So you got the x-ray and he put it up on the screen. And I loved running every day, you know, I was addicted to running, you know, I loved it. It was my way of life at that time. And I’m thinking, okay, I got a little strain at worst maybe or cartilage in my knees, you know, injury … he puts the thing up. And he laughs. He said ‘Ah, you’re going to need a total hip replacement!’ … just like that. Total hip. I mean, I was shocked. I was shocked. I mean, I didn’t know what to say. I was speechless. You can really hurt somebody if you crack a joke. I think that’s where he thought he was doing. So we have to be really, when you go see a patient, you have to be on, in terms of there’s a suffering person there who’s rooting for you. That’s who we’re thinking about. We’re not thinking about ourselves, it’s an unbridgeable gap up the way we laugh about it all and what they’re going through.
Tamar: Joking with patients about their situations or illnesses is not always wrong. In fact, it’s been shown to be a hope-giving behavior after you’ve established a real relationship and good rapport. But it is a very sensitive thing to navigate. On a bit of a different note, there have been a few major lawsuits that gained publicity over the past few years where clinicians were recorded making really insulting jokes about patients during colonoscopies or surgery. Relating to this, Professor Watson interestingly raised a concept she calls “corporeal joking”.
Watson: I assumed in my article a division between front stage and backstage. Either you’re with a patient or a family member or within earshot or your backstage just with your colleagues and of corporeal cases, uh, are cases in which the patient is present but unconscious. And it really challenges that boundaries, the patient present or not. And I think the joking happens because it’s as if the patient is not present, like you’re talking to the colleague that’s across the body. But the patient of course is physically present and you’re acting as if they’re not. So at level one of that analysis, I want to say that any joking about the patient when the patient is present, even though they’re unconscious, is unacceptable. I do think there’s something about the disrespect to a person who’s right in front of you. I do think there’s something corrosive about that.”
Tamar: And even when we make sure we’re only in the company of others on the care team, does a joke really only become misconduct when the wrong person hears it? Professor Watson again spoke about needing to push ourselves to reflect on how vulnerable patients are, and not just when they’re physically present to hear something mean.
Watson: Um, in my article I talk about being clear about what you’re making fun of. So as making fun of yourself, sometimes you’re making fun of death or the absurdity or the futility of rolling that rock up that mountain one more time. You know, like I, so I think I want to be careful to lump it all together. Um, so that would be one thing. Like it’s maladaptive when it’s, it’s um, starting to make fun of patients versus making fun of circumstances and one’s own foibles and fallibility and fears. Joking up versus joking down. And I think that is maybe a helpful rule of thumb too, that am I making a joke where the, the circumstance or the um, person who is really the butt of the joke has less power than me? And if so, that’s usually a, something we avoid, we should avoid.
Danger to trainees
Tamar: Considering power dynamics, and this concept of joking up versus joking down, is also so important to think about around medical trainees. We know that medical educators – they don’t only teach us clinical reasoning and physical exam maneuvers, they’re also supposed to be our role models in terms of professionalism and humanism in practice. Which brings us to the hidden curriculum in medicine, and the socialization of negative behavior. To our listeners, we know you might have seen this one coming, and there is so much to be said about this topic. For now, we want to focus on how jokes contribute to this hidden curriculum.
A joke can highlight and improve a difficult shared experience, but also, it can contribute to desensitizing us to moments that should be difficult or kind of uncomfortable to grapple with. So, again, just to warn you, we’re going to offer a lot more questions here than concrete answers: Are some jokes only appropriate to make around clinicians with a certain amount of experience? And what does it say about those jokes if they would seem callous or offensive to a newer trainee? Do you earn the right to be humorously jaded – meaning, can the same joke be ok if an experienced attending tells it, but wrong by an intern? And most importantly, what do trainees take away from hearing a role model behave this way? Professor Watson spoke to some of this:
Watson: The academic term for it is the process of de-idealization. So young people come into really excited to help people and if they hear these cynical, jaded, dark comments, they’re just like, oh, like I don’t want to end up like that. And are these supposed to be my role models? And this guy sounds like a dirtbag.
Tamar: Sometimes the unintentional message this can send is that it’s ok to behave this way, to make fun of patients, families, other doctors or nurses. Other times, even when trainee know they feel uncomfortable, they sometimes feel that they have to pretend to go along with it to be likeable or a good team player. And the tension in these types of situations contributes to the moral injury students and residents experience during their training.
Watson: The recruitment into the laughter, the performative role when they are required to laugh, is horrific. It’s a forced false confession.
Turning to joking at the expense of building therapeutic alliance, dealing with hardship
Tamar: So at this point, I hope we’ve made our point clear and that I’ve really convinced you that joking is simply dangerous and you should never crack another joke. Ever. I’ll spare you a laugh track here, but I’m of course kidding and, if anything, joking in medical practice is something we’re wholeheartedly trying to endorse. What we took away from our discussions with Shem and Professor Watson, though, was the incredible importance of always reflecting on what jokes we make and really why we make them.
For one, does humor ever come at the expense of other reactions? Returning quickly to the story of the young man who fell asleep and lost a piece of plastic in his bladder, Professor Watson shared some further thoughts:
Watson: I worry that by going to the joke and the relationship and the fun exchange with the nurse, I worry that, or I think that he potentially, he risked disrupting the therapeutic alliance with the patient, which is a very different emotional space of empathy. And so that’s a time where I think the humor is diverting the emotional energy from a more productive route, which is to sit down with that patient. Cause the kid is saying, I didn’t do it, but we all know that just defies reality. So what’s going on there? Why can’t he tell the clinician the truth? And if they could have an open conversation about that, what could that teach that young person about health care and the possibility of alliance and partnership and honesty and safety. Um, instead of just being a technician who pulls a piece of plastic out of somewhere funny.
Tamar: And it of course doesn’t have to be one or the other, we can joke and be empathic and caring to our patients at the same time, but Professor Watson reminded us to be thoughtful about not sacrificing one for the other. Lastly, she pointed out that while humor can be a mature coping mechanism, it probably isn’t entirely healthy for it to be the only one.
Watson: Um, I think it’s also maladaptive when it’s your go to every single time. If someone cried in the hospital, resident cried in the hospital, I would not, if I were their supervisor, I think that was automatically terrible where they couldn’t handle their job. If something that happens with some regularity in our discipline, they cried every time. I’d say like we want to talk to someone about that. It seems like your coping mechanisms are, or your, you’re on thin ice all the time and it, and I think that the, the cut to the dark joke is the equivalent of isn’t it is a crying equivalent sometimes and accepted more socially acceptable one and kind of be checking in with myself about how come I’m always doing this. Some seems like maybe I’m low resource right now and you know, should I have better coping skills or wider range of coping skills?
Challenging Inappropriate Jokes
Jafar: We want you to leave this episode with a few practical suggestions on how to approach gallows humor when it may be falling off its mark, when it’s moving from adaptive to maladaptive. By its nature, humor is elusive, and whenever you try and hold someone accountable to it, the defense is simple — “Hey man, it’s just a joke, lighten up!” And so just like that, the weight falls right back on you for spoiling the party. But as we’ve mentioned, the adaptive use of gallows humor is NOT cruel humor! I would argue that we need gallows humor to survive our work, but we don’t need to degrade ourselves by joining in the cruelties of others. So the question is how we can skillfully bring up our concerns. Professor Watson had some very helpful suggestions for how we can challenge inappropriate jokes in a non-confrontational way, even when working in a hierarchy where voicing any kind of opinion can be very difficult.
Watson: So if the patient was, being “difficult”, and the joke is about the patient and it’s premised on the complaints they had and you think it’s inappropriate, maybe go back to the patient’s complaints, and take the appropriate stance of curiosity and the empathic stance of curiosity, saying, “Huh, I wonder why she was so anxious, you know?“ And so the joke, if the joke is about her behavior, the second person could come back to you and like, “Yeah, she did have a lot of questions. She seemed super anxious to me. I wonder if she’s had bad experiences at the doctor before this one. Hmm, maybe we should talk to her about when she wakes up.” You, um, silently challenged the joke when you reorient to whatever was the raw material that sprung, that, that generated the joke, go back to the raw material, and take it in the direction you think it should go. And it might give the joker an opportunity to say, yeah, you know what? I’m being too hard on her. She’s, she did seem scared, I’m sorry.
Using Gallows Humor as Signal for Internal Distress
Jafar: So I found this really helpful, it’s a tool to kind of clean-up or jujitsu the energy in a more positive direction, when the humor is getting dangerous or degrading. I think far more important than regulating humor in the room, though, is taking what we learned today to help better understand what’s going on inside of US when we’re using gallows humor. This kind of humor can show us a lot about how we handle the stresses of being on the front lines of human illness, which some researchers define as a kind of secondary traumatic stress. Some studies looking at criminal investigators have even found a correlation between higher levels of secondary stress and the use of gallows humor when it’s directed at the victims of crime. So how do we see it building up? Professor Watson takes us back to the analogy with crying:
Watson: Laughing is a lot like crying. If you find yourself crying about something and you’re sort of like, why am I crying at this? Even if it’s like a TV show and you’re like, wow, that really hit me. Why? Why am I crying about this show? I hope you spend two minutes thinking about like, oh gosh, I guess I have some unresolved issues about “X”, or my dog died and I didn’t really process that, or whatever it is. I, the crying is like the canary in the coal mine telling you like something’s going on, right? Similarly, when you make a really mean joke, particularly about a patient, as a person who became in this profession to help heal and save people, that shouldn’t be the equivalent of crying to be like, oh, what’s up with me today? Haha! What’s going on here?“
Checklist of Reflective Questions
Jafar: The central struggle with humor is that it can be so ambiguous. It’s hard to know exactly what might be going on behind any particular joke, even within ourselves, let alone in other people. But if you walk away from this episode with one thing, it’s that we can reflect on our use of gallows humor in practical and productive ways. “Physician, you CAN know thyself.” The next time you’re thinking about the use of humor in a medical situation, ask yourself these questions:
Watson: Will making this joke, is it potentially the only way for the professional to cope with a difficult situation? Will it help them go to the next patient fresh or do the job that they need to do? Is it positive in, in that sense of as a coping mechanism? Is that something they are not turning to every five minutes and which shows a, a dearth of coping mechanisms or an absolutely unsustainable, horrible workload. Right. Um, is it something, is it the kind of joke that degrades a category of patient and makes them less likely to be empathic to the patient who the next patient who is in that category of patients? Those kind of criteria are important.”
Keeping the Faith
Jafar: It’s funny, I used to be so lacksidaisical with my joking, but the more you look at it, putting together all of the suggestions here, if you wanna start using gallows humor, it’s almost like using a power tool: it can be really effective, maybe even the best way to get something done – in this case a kind of coping or bonding – but you have to know how to use it, be mindful of safety, use it with discretion, and you really gotta understand: What kind of job am I trying to do here? What’s my intention? It’s not amateur night at the Apollo, ok?
And lest you feel I’ve squeezed every bit of joy from this topic and turned it into an utterly unfunny mine-field of ethical risks, in the final analysis, both of our guests unequivocally made the case for keeping the laughter in medicine.
Watson: So it’s easier to say, don’t ever joke about anything. Right. And that just to me, that’s just not consistent with human experience and human flourishing. And particularly when you are asked to do or you have chosen, you have volunteered to do a hard job, I don’t know why we would take any of your joy and any of your coping mechanisms away. I think the goal is to figure out are there missteps when that coping mechanism is not productive or when it’s productive for you, but it’s harmful to others, or it’s going to be harmful to you in the long run cause it’s gonna desensitize you in ways that won’t be productive for your therapeutic alliance in the future, or hurtful to other people. But, but we’re smart. We can do it. And the cost of the humor, we were really looking at and trying to figure out, let’s, let’s avoid those, some of those costs. But I think that some people have missed the fact that to just say don’t joke about anything, um, has a cost too. And to me that’s the higher cost in some ways, and that’s why I’m willing to do the work.”
Jafar: In our whole discussion with Shem about the House of God, about his latest novel, and his personal journey through a life in medicine, this idea of the “higher cost” was a theme that came up over and over again: specifically, we have to recognize and respond to our shared humanity as doctors, and the power of connection through humor that’s just too important to give up on. In his words:
Shem: I’m not convinced that you should be barred from using the slang or whatever in ways that patients don’t know about, you know, I think that’s, it’s a relief. It’s a connector. You, why would you squelch that? As long as you’re all careful, which we were. Nobody, I never said Gomer in front of a Gomer. And I didn’t invent that word either!
Talk about gallows humor, it’s that pressure of going to the gallows. We gotta let it out somehow. You gotta. You can’t just keep it in all the time. You know, the people that did keep it in, didn’t joke around, and were isolated, were the ones who suffered the most. The way out of suffering is connection, period. You got to be with other people, in a lot of different ways, but one way is a humor.
Jafar: Thanks everyone for listening, this was a really fun episode to put together. As promised, we wanted to leave you with a little something special, a sneak-preview reading Shem shared with us from his latest novel and sequel to The House of God, titled Man’s Fourth Best Hospital, which will be coming out November 12th. Just as he critiqued the medical training process in House of God, Shem described to us that the goal in this book is to highlight problems that electronic medical records and the financial pressures of medicine create for clinicians today. This is an excerpt of a scene where Basch, Chuck, some of the other House of God originals, and some new folks are all undergoing training in the new EMR, called “HEAL”
Shem: We docs had had an orientation to HEAL. A four hour long video and workshop with the rosy cheeked and smiling clean young guy, dressed casual, name tag Bob. Bob’s first step was to pass out a single sheet of actual paper for our signatures or routine form required for your employment, stating that you will not in public say or write anything negative about HEAL. Your usual gag order, like EPIC’s, but a lot better.
“Okay folks,” Bob said, clicking on the first slide, which printed out his exact words, “We are at war against the health insurance companies.”
As he went on, it turned out that this war, like all wars was about money. On our side of the screen, we are fighting for the highest payment for our work. On their side of the screen, they are fighting for the lowest payment of our work. And how did we fight this war? By gaming HEAL codes of each disease, diagnosis and treatment to max out money.
In principle, we could max out cash by clicking on little boxes in two ways. The first was qualitative: clicking on the worst disease diagnosis, most severe form, requiring the most treatment. The second was quantitative: also clicking on as many different, worse than severe disease diagnoses, requiring the most elaborate treatment for as long as possible. Health insurance, the army on the other side of the screen, tried to minimize our maximums of money.
“Bad News,” said Bob, “They have lawyers trained to catch us in an illegal like lying, which we do not do. The good news, we have 334 people in the billing building. The billables, they called them.
“We nicknamed our elite billing enforcer team “Coders for Cash.” They work out of a war room at an undisclosed location. We are watching each of you for your choice of click codes from admission to discharge. Fiscally, doing procedures on patients makes the most money. Surgical procedures make the most, most money. Medical care makes the least.” He paused, and said fiercely, “EXCEPT for the diagnosis of sepsis, severe.”
After you click Sepsis, the popups ask mild, medium, or hot (severe), like at a Thai restaurant. But sepsis is by definition a life threatening blood infection–always severe! Monetized compared to mild or medium, severe is a cash cow that wins, hands down. We will dog you till the sun goes down. If you click sepsis , you always click severe–THE code for cash.”
“But then why,” I asked, “do you have boxes for mild and medium at all?”
“Camouflage!” He said “In this fatal disease we have no choice, Hippocratically, but to click severe.” He went on, I tuned out, but caught his summary (and this is true): “It all boils down to ear wax.”
He spoke passionately about how to squeeze the most money out of earwax. First, in a moving historical tour, he said, “Earwax is an untapped pool, rampant our senior citizens, a cause of deafness. How many of you routinely earwax your patients?” We took this as rhetorical and did not reply.
“The money in earwax flows by clicking this diagnosis in almost all patients and removing as much volume as you can.” Bob then showed on the big screen a doctor ad-HEAL-ing. “You have to choose between the two codes for ear wax removal. 40773 is for taking a syringe and washing it out, reimbursed at $77. But 40774, using the metal scooper thingy to remove it, $182.57. The difference? $105. And doing both? $359.90, more than the sum of its parts! Multiply per person, per year… millions! Guess which procedure for full extraction and max liquidity is preferable? BOTH. Do the right thing.”
The right thing for all of us of the Fat Man clinic was to walk out. I was with Chuck and Nidoo, walking down the hallway.
“So Chuck,” I said, “What’d you think of that?”
“Man, it all went in one ear and out the other.”
Jafar: Thanks again for tuning in. We know these topics can stir up more questions than answers, and we look forward to hearing more about your experiences and reflections on gallows humor. Please continue the conversation with us online at our facebook page, on twitter, or email us directly. Put up any of your favorite jokes, or ones you’ve been struggling with, and if they’re not funny we’ll send the joke police to find and arrest you. Find show notes and contact information for us on our website: www.coreimpodcast.com
If you enjoyed listening to our show, give us a review on itunes or whichever podcast app you use; it helps other people find us. We work really hard on these podcasts so we’d love to hear from you. Let us know what we are doing right and how we can improve. And as always opinions expressed in this podcast are our own and do not represent the opinions of any affiliated institutions.
Finally, special thanks to all our collaborators on this episode, our wonderful editor Julia Skubisz, our illustrator Michael Shen, our music composers Gabe Stern and Peter Kendall, endless technical support from Harit Shah, and most importantly thanks to you, our listeners!
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