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Department of Medicine, Division of Hematology-Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
Correspondence: Richard T. Penson, M.R.C.P., M.D., Department of Medicine, Division of Hematology-Oncology, Massachusetts General Hospital, Cox 548, 100 Blossom Street, Boston, Massachusetts, 02114-2617, USA. Telephone: 617-726-5867; Fax: 617-724-6898; e-mail: rpenson{at}partners.org
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LEARNING OBJECTIVES
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Learning objectives
Abstract
Presentation
Dialogue
Discussion
Conclusion
Disclosure of potential...
References
After completing this course, the reader will be able to:
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ABSTRACT |
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Key Words. Oncology • Cancer • Support • Psychosocial • Personal • Communication • Connection
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PRESENTATION |
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Physician: When is it okay to joke with patients? When is it not okay to joke with patients? When is it okay to laugh about cancer? Have we as caregivers found ourselves in trouble by going a little too far over the line? You may have felt that humor was incredibly effective at really cementing the patient/caregiver relationship. Are there times when you sense humor might have broken the rules and gone down like a lead balloon with a patient?
How do we as caregivers use humor with each other? When do we think it’s okay to laugh at the difficulties we all encounter as caregivers? How does it feel to be a patient in a room who just got diagnosed with recurrent ovarian cancer and to hear laughter down the end of the hallway? How have you effectively used humor as a team, and has humor sometimes caused breakdowns or unanticipated negative outcomes?
How does laughter play out on the clinical unit? I think one of the reasons that I chose these clinicians to speak on the panel is that, when I was thinking of whom we could ask to talk about humor, I thought, "Who of our colleagues have the most distinctive laugh?" Many people I asked said that we had to get these two because they have laughs that you can hear five blocks away and you know they’re there.
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I have a rule that I never crack jokes at the patient’s expense. I also have a few favorite topics; I like to joke about lawyers, I joke about doctors, and I also joke quite a bit about myself. I find if you joke about yourself, it definitely dethrones the doctor and relaxes the patient, particularly since I take care of women with ovarian cancer, and I’m a guy. There are a lot of sensitive topics we need to talk about, and if they know that you don’t feel too highly about yourself and you’re willing to make a joke, it opens up an opportunity for them to feel comfortable talking about things.
I also think the consultation benefits when you spend a little bit more time, and I like telling long jokes. Actually, if you take 4–5 minutes to tell a long joke, especially if you embellish on the joke and add lots of little details, the appointment doesn’t seem quite so rushed and the patient actually sits there and says, "Oh, that’s nice, you took 5 minutes to tell a joke." It’s a chance to share something other than what their tumor marker is or what is new on their computed tomography (CT) scan. I think it also helps you to communicate and connect with the patient versus, "I’m rushed, and this is what your CT scan shows and what sort of treatment you need." I think taking 5 minutes to share some humor is very useful.
Oncology Nurse: When I’m getting to know patients, I often share a little bit about my family with them, mainly talking about my sister. Patients often live to hear the latest story about her. She is two years younger than me and lives like a princess; it is just completely comical! We share stories about Sarah’s wedding and Sarah’s new baby, and it has worked out exceedingly well to have really, really funny stories about my sister to lighten the mood. While I am talking with the patient, I can slide in new information about their disease, treatment, or side effects. It’s funny because often my patients have notebooks of questions that they bring in and often one question is to ask about Sarah. Many of my colleagues have actually met my sister. So when she comes on the floor I think, "Oh no! I need to go and hide."
Oncology Nurse: A grant has been written to create a humor cart in the outpatient infusion area. There are a lot of different hospitals that are using humor in different ways to help patients and family members cope. I look around and I see all these people who look so sick and so sad. It will hopefully give people an opportunity to let go of some of that distress.
Physician: Timing in humor is critical. Humor works best when you allow the patient to deliver the punch line. When you set up an environment where people feel comfortable, patients will reach out and use humor in talking with you. Some of the patients I have had the best relationships with are patients who felt comfortable laughing with me or even at me!
The idea of allowing the family or patient to deliver the punch line can be helpful, and there are some classic ways to do it. There are some things that always tend to come up with families, and this one is so corny I don’t even want to say it! [Laughter] You’ll be going over the scan results, and you’ll talk about the positron emission tomography (PET) scan and the CT scan and you’ll say, "Of course the magnetic resonance image (MRI) of the brain was completely clear. There was nothing there whatsoever." Inevitably, one of the kids will say, "Well, mom, we knew you didn’t have much up there all along." I must have heard that 400 times; however, the family will laugh, smile, and someone will put their arm around their mom and hug her. It’s a tried and true old line you can set up for the family. The great thing about it is that if you’re wrong and the family isn’t going to laugh about it, they’ll interpret the MRI as clear, thus minimizing the risk.
Doctors’ Negative Use of Humor with Patients
Physician: I used to get in trouble fairly commonly when going through the side effects of chemotherapy. One of the side effects when talking to a male patient is that you don’t want the male patient necessarily to conceive a child while they’re on chemotherapy. For a couple of patients, I said, "It’s really important during this time that your wife not get pregnant." Then it dawned on me that if the wife had an alternate sexual partner, she could get pregnant and there wouldn’t be a problem. I said that once or twice and the patients loved it and they thought it was hilarious. Then I said it one more time and it went over horrifically because there were other sexual partners! I learned that was probably a little too close to cut it. You learn by those mistakes. Another example, I often close the curtain in the exam room and would usually say, "Okay, now we have instant privacy," which is fine. I made a mistake once and said, "Now we have instant intimacy." [Laughter]
Humor Between Health Care Professionals
Physician: If you see three or four people who have had bad breaks in a row, particularly if that happens on consecutive days, it can be overwhelming. I do find joking about some of the difficulties that cancer patients face can be useful. In fact, one that I usually give all my new nurses and some of the fellows is the "cat on the roof" joke. It is useful when dealing with how to break bad news.
A lot of patients live longer than expected. Sometimes, they get under the misconception that they can live forever with these problems, and we often have bad news to break. So, the joke goes something like this. Timothy is in college and he calls home to his younger brother and says, "Jon, it’s your big brother, Timothy. How are you doing?" "Oh, Timothy [pause]. Timothy, your cat died." Dead silence. There is a little bit of sobbing on the phone. Tim says, "Jon, don’t give bad news like that. You knew that cat was important to me. You should have said, ‘The cat is on the roof and we have been trying but we can’t get the cat down, it’s scared and we’ve called the fire department.’ You leave the phone conversation like that, knowing I’m going to call back in a couple of hours. When I called back, you could have said that the cat fell off the roof and it’s badly hurt, and it’s going to the veterinarian and everybody is concerned. Then, when I call back a few hours later, you tell me the cat died. That way, it comes in steps and it’s not such a shock to me." Jon says, "Tim, you are right. I’m sorry. I don’t know what I was thinking." Tim says, "You’re young; you’re my baby brother; you have a lot to learn." He says, "I learned, I learned." Tim then says, "Okay, what else is going on at home?" and Jon says, "Mom’s on the roof." [Big laugh]
If we see someone and its clear that their condition is deteriorating and we do not think the patient understands the gravity of the situation, we have a code in the group and we’ll say, "So-and-so came and we put the cat on the roof," meaning that we began to place hints at the gravity of the situation with a plan to meet again and continue the discussion.
Physician: Humor is an important piece of my survival skills. Over time, if I took home the weight of everything that goes on every day here, I wouldn’t be able to get out of bed in the morning.
Positive Aspects of Patient Humor
Oncology Nurse: I find that being able to use humor goes a long way in helping many patients cope. We have a patient who wanted to help her grandchildren cope with her illness and she would joke with them. They were really concerned about her losing her hair, and she didn’t know how they would deal with it. She decided to make it fun. So she let them put press-on tattoos on her bald head. She’d come in with little duck tracks across her head or something else wacky. Not only does it help her grandkids cope, it helps her grandkids and her join together. It also allows other people to joke with her. It tells people in the waiting areas, it tells people in the community, or her friends that she has a sense of humor about things. They can talk with her, and it opens doors.
Oncology Nurse: When diseases reach a point where cure or even prolonged palliation is not likely, when patients have gone onto hospice or they are transitioning onto hospice, especially when the patients come back with their families, the rooms can often be as serious as a heart attack. Everyone is doom and gloom. I think patient families often just almost say, "This person is now dying of cancer, and I have no idea whether joking is inappropriate." Sometimes I think humor opens the door to show that there are still things to laugh about in life.
Difficult Aspects of Humor Use
Physician: But I do think in our business that humor comes second. When you deliver bad news, the patient really has to know you are there with them; they really palpate your compassion and your empathy. They appreciate if you look them in the eye when you are delivering terrible news. They need to know that you don’t think this is a joke. However, sometimes after you’ve had a 30-minute cry or a tough 30-minute session, if there is some way you can put something light into it before you stand up and walk out the door, they realize, "Okay. We just heard horrible news, but life itself is not over and we are still going to be able to laugh again in the future."
Physician: I would say that when you are breaking bad news, that is one time when I tend to never inject humor.
Psychiatrist: In serious moments, you can’t use humor because it’s not funny. Later in your discussion, when you are trying to make a transition from having said something awful, at that point you can get back to normal again. It makes it easier to walk out of the room rather than just dropping the bomb and walking out.
Physician: There are also very raw people. Sometimes their emotions are just too raw. It’s hard for us to always judge and be able to assess where a patient is in terms of what they can handle.
Physician: I have seen doctors use humor to make themselves feel better. When I’ve done that, I have often paid the price, and it can ruin a relationship. Not only does the joke fall flat, but now you have distanced the patient and put a barrier between you. You can do the same thing between staff members if doctors use humor to cut down other doctors or staff. That really hurts, and I would say that’s probably the biggest problem.
Social Worker: I think it is important to try and build an environment where humor is welcome, an environment where we welcome people. We must remember what our jobs are and not use humor to always minimize the emotional, spiritual, and psychological aspects of dealing with difficult situations. We must make sure our relationships are balanced so that they know if they want to talk about the hard things, they can, and we are not going to cut them off with humor.
Physician: I very seldom use a lot of humor during my first visit because I’ve got to figure out acceptable boundaries of communication. I have a couple of testers and I will usually spend a little extra time with the patient’s social history, trying to figure out how they work. I like to ask people about their job, if they have adult children, and how many kids they have. If they say, "Four," I’ll say, "How old are they?" and if any of them are over 20, I’ll ask, "Do they live at home or do they live near you?" If they say they live at home, I will usually ask, "Is that good or bad?" I’m just trying to get an idea. Are they really supportive or are they sucking every penny out of their parents’ checkbook? Patients will often give you a big tip as to how they think. They might sit there and say that the bum will never get a job, and if they crack a couple jokes, you know they’re okay. It’s clear that there is some humor about them.
The Best Thing about Humor
Physician: Humor is a way we get to enjoy a moment and appreciate the day, or appreciate the funny little things. If it is done well and if you are careful about your audience, it really does connect you and gives you time to just appreciate a moment, regardless of all the other things that are going on, or even taking into account all the other things that are going on. It is human to human, getting to connect.
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DISCUSSION |
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Physiology of Laughter and Humor
Although physiological research on the effects of humor on the body is only just developing, there may be quantifiable health care benefits to humor, and specifically laughter [4]. Each person’s laugh is unique and is usually an expression of happiness involving typical facial movements and contractions of the respiratory muscles [5, 6]. Laughter is the physiological opposite of crying, and laughter disorder research suggests a neuroanatomical circuitry for the production of laughter [7]. This may include the anterior cingulated gyrus that provides emotional consciousness to an individual’s experiences and is partially under frontal cortical control [8]. The caudal hypothalamus is also involved, acting as the center of coordination for emotional changes including laughter, and the temporal-amygdala structures may provide emotional coloring to perceptions and aid in humor comprehension [8, 9]. Finally, the ventral pontomedullary center for laughter coordinates facial expression, expirations, and emotional vocalization [6].
A recent review article examining 20 years of humor and laughter research describes a broader interpretation, whereby laughter expression depends on two partially independent neuronal pathways [10]. One is the "involuntary" or "emotionally driven" system and involves the amygdala, thalamic, hypothalamic, and subthalamic areas and the dorsal brain stem [10]. The other system is "voluntary" and originates in the premotor opercular areas and leads through the motor cortex and pyramidal tract to the ventral brain stem. According to the authors, these two systems and the laughter response appear to be coordinated by a single center in the dorsal upper pons [10]. However, the Society for Neurosciences has conceptualized neuronal control into three main brain components: (a) cognitive areas, such as sections of the frontal lobe that help the person understand the joke; (b) a movement area (probably the supplemental motor area) that triggers muscle movements to induce a smile or laughter; and (c) an emotional component that actuates perception of happiness after an amusing experience, possibly facilitated by the nucleus accumbens [11].
Research involving additional measurements of sense of humor, including self-report instruments, peer ratings, and comedy monologues, suggests that humor moderates the impact of stressful life events on mood disturbances such as depression and anxiety, salivary immunoglobulin, and positive affect [12–14]. Similar moderating effects of humor have also been identified for depression, insomnia, loneliness, and self-esteem, although not for anxiety [15–18]. Therefore, fostering a jovial atmosphere in the health care setting may improve the happiness and well-being of staff as well as patients.
While these perspectives on the effects of laughter and humor may be valid, research in this area has generally proved inconclusive to date because of numerous confounding variables. These include the effect of the emotional state of the research participant during the experiment, personality differences among participants and their reactions to different forms of humor, and participants’ educational status, gender, and sex [10].
Sociological Agenda
Though laughter and humor are everyday occurrences, few people pause to consider why we laugh, simply enjoying the emotions that accompany it. Darwin theorized about the social role of laughter, suggesting that particular vocal expressions most often linked to internal emotional states may also function to influence others [19]. In contrast, Bachorowski and Owren emphasized that this vocal expression is often an attempt to shape the emotional and behavioral responses of others rather than display one’s own emotions [20]. Their research, examining 120 undergraduate students in a variety of social pairings while watching humorous movie scenes, illustrated that individuals varied the number and kinds of laughter they produced depending on the sex of the social partner and whether the partner was a friend or stranger. In accordance with this theory, laughter may therefore be considered a tool of social influence, used to capitalize on listener sensitivities and facilitate group bonding [20].
Laughter may also have evolved to form alliances, using a smile to communicate positive disposition [21]. In primates, the smile is said to have emerged from the silent bared-teeth display and is thought to convey social affinity, reassurance, sympathy, or greeting while laughter emerges from the relaxed, open-mouthed display and occurs during rough play in chimpanzees [7]. In humans, the smile may have become easy to fake, hence the need for a more complex signal—laughter. As it involves the use of more neural systems than smiling does, laughter requires a greater effort on the part of the individual and is harder to fake, and it perhaps became a more honest signal of an interest in joining together with others [21]. This may perhaps be too cynical an explanation for laughter, and instead it may simply be an evolutionary device that can calm aggression, speed information transfer, and preserve social unity by forming a common bond [22]. This was confirmed in a study of 1,200 incidences of naturally occurring laughter in ordinary social settings, where mutual playfulness, in-group feelings, and positive emotional tone were found to be the most frequent causes of laughter [23]. Less than 20% of this laughter was a response to anything resembling a formal effort at humor. An appreciation of this concept may help health care providers to foster a positive environment for their patients, encouraging humor where appropriate to boost spirits and potentially improve the health of patients and themselves.
Psychological Perspectives on Humor
Freud’s psychodynamic viewpoint described humor as one of the strongest of the defense mechanisms that allow an individual to face problems and avoid negative emotions [24]. It is believed to be effective in distancing oneself, framing problems with perspective, and proactively managing distress [25–29]. In Lazarus and Folkman’s cognitive behavioral "transactional theory of stress," stress is formulated as occurring when a situation in the relationship between a person and their environment is perceived as a threat or a challenge, as with a cancer diagnosis [30, 31]. The subject may use cognitive reappraisal to evaluate the significance of cancer stressors upon their personal well-being (primary appraisal) and to examine the resources available for coping (secondary appraisal) [32]. This process will vary among patients as a result of the unique characteristics of the individual, but they will attempt to cope with these stressors by trying to reinterpret the meaning of the threat by changing their environment, and may choose to do so by using humor [30, 31]. If these theories are correct, humor is used as a defense mechanism in an adverse setting and has obvious value.
Humor is found in almost every medical setting. Emerson found only three circumstances in hospitals in which it did not occur: when patients were seriously threatening not to cooperate with staff, when patients were extremely upset, and when staff were interacting with the relatives or visitors of dying patients [33]. Providing guidelines to physicians and nurses for the use of humor in cancer care is difficult, and there is little literature on the topic, possibly because it is not always recognized as "true medicine" by the medical profession. While the aforementioned psychological theories may be valid, current research is woefully inadequate in these hypotheses, with little data on validating the health benefits of humor, not least because of a lack of a firm definition of what exactly constitutes "humor." This can make results unreliable, as each piece of research may be examining something slightly different, and until homogeneity of theories occurs, all researchers may be examining slightly different perspectives on what they believe to be the same entity. The majority of research also focuses specifically on only one aspect of humor, such as neural pathways or psychosocial responses, without combining multiple approaches to obtain a broader perspective. In addition, it can have different meanings for different people, making research complex, as a variety of different patient scan have a multitude of responses to the same humorous stimulus [34]. Further research is necessary to explore family perspectives on humor, the effect of national and ethnic affiliations, and the influences of the overall environment upon humor itself [35].
Despite this, support for humor use in patient–physician communications, in the psychological aspects of care, in medical education, and as a means of reducing stress in health professionals is growing [36]. Such support was illustrated with the formation of the Association for Applied and Therapeutic Humor (AATH), a volunteer organization that advocates the use of humor in health care. Although there is little scientific evidence to support the efficacy of laugher in enhancing well-being, the popularity of such groups suggest that they have some worth in helping people feel better, even if it is only psychosomatic.
Health Care Workers’ Positive Use of Humor
The use of humor and laughter in health care is generally perceived as positive, and nurses in particular have been shown to use humor to foster deeper, more trusting relationships with their patients [35]. Its benefits are seen in three main areas: the psychological, communication, and social arenas. And it can help narrow interpersonal and cultural gaps by aiding doctor–patient communication [37]. In oncology, a recent review suggested that this humor usually occurs in two forms–spontaneous repartee that occurs during conversation between the oncologist and patient and prepared humor that is found in patient literature and is designed to make patients see the lighter side of their treatment [38]. Humor may help to relax the patient, acting as a "leveling agent" among the patient, family, and oncologist, as it can often relieve the tension caused by intimate questions or exams [38]. When a positive attitude is shared by the patient and doctor, it can also have a positive effect on emotional–affective and cognitive functioning and help with the introduction of new treatment options and when curative challenges are encountered [39, 40].
Negative Use of Humor
Patients may be more sensitive to jokes than health care providers. In a qualitative study of 250 consecutive encounters in 15 medical practices, results from self-report questionnaires showed that physicians reported using humor in 95 of these 250 encounters (38%), whereas almost 60% of patients reported that, "The doctor used some humor during the visit." However, 60% also agreed with the statement, "We didn’t laugh; it was a serious encounter," and 48% agreed with "The doctor did not use humor; we just laughed," and the subtleties appear hard to quantitate [41]. The authors concluded that humor was used in a large proportion of encounters, and that patients were more sensitive because of high stress levels during medical encounters [41].
Haig described the overuse of humor by either patient or doctor as a mechanism to avoid sensitive issues, and its inappropriate use by a doctor could undermine the patient’s confidence in therapy or medical care [42]. It seems that the most appropriate time to use humor is when there is mutual understanding of the therapeutic goals between doctor and patient [43]. This confidence or trust between the joke teller and the receiver is an important aspect of humor, as people are prompted to laugh when they identify with the teller, and as trust is important between doctor and patient, establishing this trust is a prerequisite to introducing appropriately timed humor (R. Buckman, personal communication). However, if one side is defensive or angry, they may find humor use by the other party offensive or insulting [39, 40]. Patients may also become upset about jokes being made at their expense, fearing humiliation and stigma [43]. Therefore, the use of humor must be timed wisely (as any good comedian knows) and be used carefully during discussions about initial diagnosis, disease progression, and end-of-life care. There are no definitive rules, but humor should generally be introduced slowly; if there is no response or the response is negative, it may be a good idea to abandon all attempts to introduce humor, at least during that clinical encounter [38]. However, if the patient initiates the use of humor, the oncologist should generally feel free to reply (R. Buckman, personal communication).
Humor Between Health Care Workers
Oncologists often report an understandable need to protect themselves from the harsh realities they face daily in the clinic. Therefore, they may use humor in difficult situations, a phenomenon termed "gallows humor" by Freud [24]. This use of humor by physicians has been studied by the sociologist Fox, who observed transplant physicians frequently playing "games of chance" during operations, wagering about outcomes of risky procedures as surgical bravado between coworkers [44]. Fox suggested that this use of gallows humor allows doctors to express a wide range of emotions, including anxiety, guilt, disappointment, anger, and grief, in ways they find acceptable [44]. It has also been described as a coping mechanism for those in difficult situations, whereby negative feelings can be transformed into positive acceptance within the group and for themselves [45]. The type of humor that is deemed acceptable may be determined by group norms, and it can be viewed as a method of socialization to affirm common values, teach, learn, and provide support [46, 47].
Positive Use of Humor by Patients
People often use humor in an attempt to make themselves more socially acceptable, to identify with other patients, and to distance themselves from their troubles. "Applied" humor is used by some patients in social settings to challenge assumptions others hold about the disease, and in health settings it is often used to manage feelings, hide embarrassment, reduce tension, share a sense of solidarity with others, or encourage others to examine themselves [43]. Jokes can dispel tension, introduce "awkward" topics, and convey messages about difficult subjects, such as death, that might be unacceptable if conveyed seriously [43]. Some patients and people with disabilities see humor as their only means of making contact with others [48, 49]. A descriptive study of 14 terminally ill adult cancer patients reported that a sense of humor established rapport, promoted relaxation, provided the distance to examine alternatives, and evoked feelings of joy, lightheartedness, happiness, and hope [50]. A similar study described how patients found humor as important for social bonding toward the end of life, with 64% reporting that it helped them to alter their perceptions of situations that would otherwise be overwhelming [51]. A further 85% described humor as fostering hope, which they felt to be of the utmost importance to help them face the realities of their everyday existence [51]. Another study in nine women with breast cancer used open-ended interviews to identify their use of humor, its influence on spirituality, and their perceptions of how their nurses used humor when caring for them during treatment [35]. Patients saw humor as an important coping factor, as it played a role in spirituality and their perception of the meaning and purpose of life [35]. Another study of terminal patients involved the exploration of the communication process using participant observation over 7 weeks, in which notes were taken on individuals in a day care environment [52]. Patients were found to talk readily about their cancer, illness, and death, and the researchers proposed that the lighthearted and humorous nature of this "death talk" served an important psychological function in allowing patients to distance themselves from their own deaths while simultaneously permitting an acknowledgment of their terminal condition [52].
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