How Clinicians Joke About Patients, Illness, and Death
Many groups develop a backstage language not meant to be understood by outsiders. It's how they talk "when it's just us." Teachers in the teachers' lounge, firefighters in the firehouse, war correspondents in the hotel bar—none of what they say "backstage" is meant to be heard by anyone outside the group. Backstage humor might be a demographic postscript on "you had to be there" to think it's funny; it's also "you had to be us." Asking who exactly is "us" can reveal subtle divides within medicine: a rehab physician told me she feels rehab physicians are entitled to joke about disability, but she gets angry when she hears surgeons do it; a senior psychiatrist told me she sometimes jokes about patients, but she feels young physicians have not earned the right to do it yet. But the larger "us" is health care providers, in contrast to people not working in medicine.
"Humor is what happens when we're told the truth quicker and more directly than we're used to," writer George Saunders observes in his analysis of the gallows humor in Kurt Vonnegut's war novel Slaughterhouse Five. "The comic is the truth stripped of the habitual, the cushioning, the easy consolation… . This rapid-truthing is what Vonnegut does with the war."
I love that term—"rapid-truthing." It made me think differently about a joke I heard a senior neonatologist tell years ago:
A group of medical professionals and ethicists were considering the case of a neurologically devastated newborn. The discussion focused on the medical facts for an extended period of time (but what about this test, what about that test, how can you predict A, B, and C …) until Bill ended the debate by saying, "Look. He's more likely to be second base than play second base."
As someone new to these types of conversations, I was shocked. But I also noticed that this crude summary of the baby's medical status served the function of moving the conversation on to other issues, like what range of options should be available to parents in situations like these. A few fleeting expressions of disapproval were shot Bill's way (miniature head shakes, eye rolls, and sighs), but no one seemed to disagree on the merits, and it seemed to free them to move the analysis forward. So maybe this neonatologist was playing the role of Court Jester, using a joke about a tragic circumstance as functional shorthand to speak a truth no one else was willing to say. Maybe this is an example of gallows humor serving the function of rapid-truthing.
Or maybe it isn't. As a nonphysician, I cannot independently confirm or reject the neonatologist's summary of that infant's medical status. Freud points out the danger of humor as a form of rhetoric: "While argument tries to draw the hearer's criticism over on to its side, the joke endeavors to push the criticism out of sight. There's no doubt the joke has chosen the method which is psychologically the more effective."
Opinions, thoughts, and arguments framed as jokes bribe and confuse our powers of criticism—if we laugh at them, by definition we're not in a critical mode. And if I say, "Wait, wait, I want to respond to that joke with a rational counter-statement challenging its underlying suppositions," then I'm a drag and everyone laughing will resent having to stop playing. So positions promoted through jokes somehow seem stronger than those supported by arguments. They also have a built-in protection against criticism: "Hey, it was only a joke."
Another analysis of backstage joking like Bill's focuses on humor as deployment of power. Bullies use jokes as weapons of humiliation, and brainy victims of physical aggression sometimes retaliate with humor, shifting the fight to terrain where they stand a chance. Since laughing renders us physically vulnerable for a moment, even the innocent pleasure of making a friend laugh can be understood as an act of (consensual) physical dominance and submission, and it is often observed that the language of comic performance is one of physical destruction (he killed, we slayed them). The teller of a spontaneous joke or funny story also wields the narrator's power to frame and interpret events. When someone wonders if "it was wrong to make a joke" backstage, perhaps they are really asking about the use and abuse of the power that comes with asserting oneself as the (comic) narrator of someone else's tragedy.
But a sophisticated analysis of power and humor includes assessment of relative power. This is captured in the concept of "joking up"—the idea that it's okay for the less powerful to make fun of more powerful individuals or groups, but the reverse (joking down) is not. Joking up is what allows medical students to publicly mock their professors in the annual variety show; joking down is why professors doing a show that mocked students would be shocking. In clinician-to-clinician gallows humor, those most likely to suffer direct harm (in Bill's case, the neurologically devastated child's parents) are not backstage to hear the joke, but in jokes about people less powerful than the teller, the "punch" of the punchline can feel too literal.
In focus groups conducted by Delese Wear and colleagues, medical students, residents, and attending physicians agreed that patients who were perceived as "difficult" (including the noncompliant) and whose medical problems were perceived as "their own fault" (including obese patients) were "consistently the objects of derogatory or cynical humor." An intuitive objection to this is that it's joking down: healthy medical staff are more powerful than sick laypeople. But more complex power dynamics might be at play, too—when physicians need to change patient behavior instead of biology, they often feel powerless to heal. If people who need (and resist) behavior changes are framed as patients like any other, then physicians are framed as failures. By reframing these people as less than full patients, derisive joking does the unspoken work of reframing physicians as blameless for their inability to help.
The fact that bullying jokes might be motivated by an underlying sense of powerlessness does not make them healthy or desirable. But understanding that possibility may explain why for some otherwise upstanding clinicians they seem to be reflexive. Power might even be relevant to the senior psychiatrist who said younger doctors have not "earned the right" to joke about patients. Why would seeing something a lot earn one an entitlement to make jokes about it? Perhaps the senior physician's underlying justification is that ongoing exposure to this type of patient or situation has worn her down over time, and "earning it" is actually a reference to a reduction in physician power relative to patients—a reduction in their power to defend against feelings of frustration or despair over time, and an increased need for levity to compensate.
Even The House of God—a physician's dark comic novel about residents in the late 1970s trying to survive the hell of hospital life that's still read today—benefits from an analysis of relative power. Some readers see the characters as joking down, as bullies who use cruel humor to (rhetorically) beat up on patients and nurses. But 1978 was the height of a particular kind of physician powerlessness: physicians were able to sustain life with new machines, but still lacked legal authority to withdraw noncurative treatment (even when unconscious patients' families begged them to stop), and hospitals profited from continuing treatment that felt like torture to the physicians administering it. Readers who think the characters' gallows humor is driven by an underlying helplessness may see them as victims joking up, mitigating their vulnerability by expressing it as bravado.
One reason the risqué joking that comprises gallows humor typically travels backstage among peers is the risk inherent in joking across categories. Joking and laughing together can establish or affirm intimacy. But when joking reveals that we do not see the world similarly, it can harm relationships.
Yet sometimes a health care provider takes the risk of crossing categories and initiates a joke with a patient about a topic that the patient might find painful or frightening—the patient's medical condition. When the joking is successful, one reason it might feel good is that the exchange puts them in a peer relationship for a moment: they share inside information and they see it the same way—there's a spin on the patient's condition that makes them both laugh. But who defines whether provider-initiated joking with a patient is successful? A few years ago my sister and I had radically different reactions to a provider's joke about my medical condition:
A porcelain shower handle broke in half as I was turning it off, and the deep gash in my thumb quickly pumped enough blood on the shower curtain to make me feel like I was reprising Janet Leigh's role in Psycho.
I sobbed as I threw on clothes and drove to an ER a few blocks away (not my own institution). I was still weepy when I met the medical student, who told me she'd never done the halo block anesthesia stitching my thumb would require. The supervising nurse teased the student about how gently she was draping my hand. "I'm not gentle," Nurse Toughlove quipped. "My dog runs when she sees me coming with a Q-tip."
The first needle stick in the base of my palm was so painful that sparks showered behind my closed eyes like a rocket on reentry. I panted through the shock, tears streaming down my face. My sister had arrived, and I squeezed her hand. Nurse Toughlove stepped in to demonstrate proper technique, jamming the second shot in fast and deep. The medical student tried again … and again … and again. I gasped as the needle probed my cut, and Nurse Toughlove laughed.
"Have you ever had a baby?"
"May I suggest you don't?" Nurse Toughlove joked.
"Hey!" my sister barked. "That isn't nice! She's being very brave."
"I'm just saying! There are a lot of nice ones out there to adopt."
The nurse's joke about my pain reaction may have been a form of rapid-truthing intended to give me perspective ("C'mon lady, you're fine"). Or maybe it was intended for the medical student, a coded way to say, "Don't freak out, her tears are out of proportion to the physical pain you're actually causing her." (Though honestly the proportion seemed about right to me: turns out there are a lot of nerves in there!) My sister interpreted the joke as kicking me when I was down—that someone who should be helping me was making fun of me—and she thought I should file a complaint. I thought the nurse was trying to help me by teasing me, to cheer me up or distract me out of my tears. She did not succeed, but I was not offended. I did, however, wonder why crying was unacceptable. I was mostly talking and joking while the tears streamed down my face, but it was oddly liberating to weep at pain and surrender to care, and I resented being pulled away from a coping mechanism that was working for me.
Sometimes patients initiate jokes about their medical conditions with their doctors, crossing categories in the reverse direction of the power differential. An emergency department physician I'll call Ben told me this story:
A thief escaping from a bank robbery crashed his car, and the police brought him to Ben's emergency room for a trauma evaluation on his way to jail. That includes a rectal exam, and Ben expected the prisoner to object, as many of the big tough guys he treats do. Instead, when Ben said, "I need to do a rectal exam," the prisoner looked out at the sea of cops and said, "I guess I have to get used to it."
I don't know if this joke is about prison rape or cavity searches, but either way it covers a topic I generally classify as not funny, and if the doctor made that joke to the patient it would have been horrific. But as writers of their own lives patients have authority to turn their tragedies into comedies, and those who joke about the saddest or hardest elements of illness may make the physician's job more pleasant. Freud suggests the reason the unafflicted like it when victims joke about their plight is that it relieves us of the burden of sympathy. In Ben's case, the prisoner's joke humanized the patient, and this ordinarily jovial doctor did not laugh. I asked Ben what happened in that moment, and he said, "The joke bridged the us-him divide. Here's a guy who has the same dark sense of humor as me. It made me think perhaps in a different time we could be friends." Instead of relieving Ben of sympathy, the patient's joke seems to have created some.
The Hastings Center Report. 2011;41(5):37-45. © 2011 The Hastings Center
Cite this: Gallows Humor in Medicine - Medscape - Sep 01, 2011.