Humor in Clinical Encounters—It’s Not About Being Funny
July 2019 Issue
Humor and laughter have been the subject of casual curiosity and philosophical inquiry for thousands of years. It's easy to think of humor as enjoyable entertainment, and laughter as a natural consequence of that enjoyment. Humor and laughter are widely purported to have health benefits, but "current research is insufficient to validate such claims."1 In the context of healthcare there is more value in understanding how humor functions as a communication strategy within clinical encounters. Pediatrician and author Howard Bennett, MD, points out that humor can be part of setting "the emotional tone of medical encounters," provide opportunities for connection between physicians and patients, and improve patient satisfaction.1 Physicians' use of humor even appears to reduce the risk of malpractice claims: "Primary care physicians with no history of malpractice claims…spent more time with patients, used facilitative statements more often, and relied on laughter and humor more often during their encounters than did physicians who had been sued for malpractice."1 Despite E.B. White's warning about the dangers of analyzing humor too closely, this article describes insights about the use of humor in medical encounters by sampling articles that address this topic.
Coping, Denial, and Distance
Most of us would agree that humor is frequently used as a way to deal with and address discomfort and difficulties in everyday life. Consistent with Mark Twain's observation, humor is often a response to negative experiences and emotions rather than simply an expression of happiness or other positive emotions. Medical treatment gives rise to many opportunities to use humor "to reduce the anxiety and frustration associated with being in the hospital—the insecurity of being sick, having to deal with hospital routines and submission to authority figures, and the loss of control over bodily functions."1
In their 1999 article, "A Laughing Matter? The Uses of Humor in Medical Interactions," Francis, Monahan, and Berger describe the way humor is used as a coping mechanism.2 Individuals can cope with stress by focusing either on the problems causing stress or on their own emotional responses to those stressors. When the problem is controllable, focusing on the problem is considered a more effective coping strategy, since that focus can result in finding solutions that mitigate or eliminate the problem. However, "when the stressor is uncontrollable, coping with the associated negative emotions is more effective."2 A patient's emotional responses may obscure the problem and possible solutions, so "in some cases, mastering the emotion is an essential first step to mastering the problem."2
These authors point out that "severe illnesses, particularly life-threatening or disabling conditions, have in them extremely emotional components. Thus, while we may expect some variation in use of strategies based on the illness experience, the use of at least some emotion-focused strategies is liable to be a constant."2 There is little doubt that this is the case for many patients we work with, since traumatic events or chronic diseases often cause irreversible damage to body structures and functional capabilities.
To gain insight into how humor is used by patients as an emotion-focused coping strategy and a method of social support, Francis et al. conducted semi-structured interviews with 22 medical professionals, including physicians, nurses, social workers, a chaplain, and a dietician. The researchers asked open-ended questions about the providers' "experiences of the use of humor in interactions with patients and with other health professionals."2 The providers reported that patients commonly used humor in two different ways: "denial or distancing of the threat of diagnosis or impending treatment, and expression of anger or frustration with the providers, treatment, or illness."2 Denial can be a constructive way for patients who are dealing with a serious illness or condition to diminish anxiety and prevent it from becoming overwhelming. Humor can help patients put a stressor in perspective and prevent negative emotions from dominating their responses. "Humor bolsters denial in that it creates a momentary ‘psychological pause,' allowing the person to adjust to a discomforting reality."2 This allows them to make rational decisions when considering their problems and potential solutions.
Humor between individuals of similar status is used to "emphasize the similarity of status and reinforce the sense of group cohesion."2 However, patients and physicians use humor as a relational tool for navigating the inherent difference in their status: "When interacting with providers, patients use humor either to deny or distance the problem or to express anger at providers."2 Humor allows patients to present a serious health condition as less threatening, perhaps as a way of making it easier for them to deal with, and it can be an indirect way to criticize or contradict the provider. If this feedback is perceived by the provider as an attack, the patient can deny any bad intent by claiming, "It's only a joke; I didn't mean anything."2 On the other hand, providers tend to use humor to reduce distance when they employ it to "build rapport, to calm and reassure, or to reduce embarrassment or other distancing emotions."2 These constructive aims explain why there is general agreement about topics (sex, gender, ethnicity, and politics) and situations (times of extreme emotion, parental anger, psychological impairment) when humor should be avoided, since "humor use in those areas may, depending on the context, be more likely to cause offense."1,3
Humor to Overcome Roadblocks and Achieve Goals
A group of researchers at the Mayo Clinic School of Medicine recently evaluated 112 recordings of encounters in primary and specialty care settings. They found that "humor was most commonly used in the counseling portion of the encounter" with a focus on the patient's medical condition, and used "to relate to general life or to discuss adherence and other difficult topics."4 The researchers suggest that humor allows the patient-provider interaction to remain productive when discussing the uncomfortable topics that typically arise during the counseling portion of the appointment. Communication roadblocks such as "power imbalance, gender differences, age discrepancy, and varied cultural and socioeconomic backgrounds…can affect the patient experience and the efficacy of the clinical encounter."4 By providing common ground for connection on a simple level, humor can help navigate these roadblocks, and pave the way for a discussion of more serious and personal topics.
Schöpf, Martin, and Keating evaluated 50 recorded conversations of seven physicians, eight nurses, and six dietitians during consultations with people with diabetes.5 They focused on how humor was used to achieve different types of goals that were sometimes conflicting. "Instrumental goals are associated with the achievement of particular tasks whereas relational goals refer to how providers and patients seek to negotiate their relationship."5 Balancing these two types of goals "is particularly important in chronic care settings, such as diabetes care, because providers and patients must work collaboratively to support patients' self-management."5 Collaboration between O&P practitioners and patients is crucial for the same reason.
The research by Schöpf et al. focused on the concept of "face work." They describe "face" as "the public self-image that every member [of society] wants to claim for himself," and explain that it involves "the desire to be liked and to have one's wants approved" and "the desire that one's actions be unimpeded by others."5 Certain interactions, known as face-threatening acts (FTAs), prevent these desires from being realized.5 In that context, the researchers identified two general functions of humor and discussed the relationship between these two functions and the achievement of different types of goals: Relationship-building humor is used to accomplish relational goals, and relationship-protecting humor is used to achieve instrumental goals in a way that avoids damaging the patient-provider relationship by avoiding actions that threaten the face of the patient, provider, or both parties.5 (See Table 1 below.) Medical encounters are challenging because sensitive information is exchanged, and lack of adherence, criticisms of the provider, and disagreements about treatment options can be FTAs that "can potentially damage the provider-patient relationship, which is central to chronic illness management."5 Humor that builds the relationship can relax the tone of the encounter, and "pave the way for more serious talk," while relationship-protecting humor provides a way to express serious messages in a way that is less likely to damage the relationship.5 These researchers found that "patients used more humor than providers (75.3 percent versus 24.7 percent)" and that "relationship-protecting humor was much more common than relationship-building humor (66 percent versus 34 percent of all humor events)."5 Humor can be used to reduce FTAs for both the provider and the patient. "Humor initiators can protect their own positive face in case their serious message is rejected; in other words, they can revoke the serious message by stating that it was just a joke…."5
To Laugh or Not to Laugh
Beach and Prickett evaluated "how cancer patients initiate, and doctors respond, to laughter and humor during" during oncology appointments.6 They found that "most laughter gets initiated by patients, and in the majority of cases, patients laugh alone."6 However, this does not indicate that the physicians had poor communication skills. According to the researchers, "patients' actions are typically not designed to invite reciprocal responses from doctors. Rather, patients delicately display the kinds of troubles they are managing, which…may involve actions discrepant with doctors' positions."6 The appropriate response to patient-initiated humor is not necessarily to laugh with them (which could actually be interpreted as not taking their contribution seriously), but to take that humor as an indication of what the patient finds difficult to discuss. "Doctors with a basic grasp of how and when laughter and humor occur can increase their awareness of patients' often personal concerns and wellness priorities. By recognizing what patients treat as delicate, doctors can be in a better position to devise effective ways of not just acknowledging but partnering with patients to address their concerns."6
What Is the Underlying Message?
It is important for clinicians to recognize that humor initiated by patients during a clinical encounter is less about joy and more about sorrow—or at least, more about serious topics than funny ones. Bennet advises that providers pay attention when patients use humor, and regard these instances "as jumping-off points to discuss a patient's deeper concerns."1 According to Schöpf et al., "humor is not necessarily a sign that the message is meant less seriously," and "when patients use humor, providers should pay attention to whether they can detect an underlying serious message and be careful in how they address it."5 By listening closely to our patients' use of humor and correctly discerning the deeper message, we will be better prepared to address the concerns that are important to them, allowing them to save face (theirs and ours) in the process. Practitioners should also be aware that "transitions from humorous to serious communication can be face-threatening. That is why providers should carefully explore the significance behind a humorous comment. However, if a hearer does not attend to the serious message, he or she might miss an opportunity to talk about an important topic."5
Many of the interactions we have with patients are positive and provide occasions to contribute to significant improvements in their well-being and function. In many other instances, patients fail to adhere to a treatment plan, disagree with our advice, or are dissatisfied with some aspect of our services. It is helpful to know that in those encounters, they are likely to use humor to soften their message to preserve a positive working relationship with us. Dissecting patients' use of humor by listening and thinking carefully about the deeper meaning can improve our care and positively impact their lives. "Laughter and/or humor initiated by patients should not be taken for granted, or discounted, but treated as portals providing further access to patients' personal health circumstances."6
John T. Brinkmann, MA, CPO/L, FAAOP(D), is an assistant professor at Northwestern University Prosthetics-Orthotics Center. He has more than 20 years of experience treating a wide variety of patients.
Bennett, H. J. 2003. Humor in medicine. Southern Medical Journal-Birmingham Alabama 96(12):1257-61.
Francis, L., K. Monahan, and C. Berger. 1999. A laughing matter? The uses of humor in medical interactions. Motivation and Emotion 23(2):155-74.
McCreaddie, M., and S. Wiggins. 2008. The purpose and function of humour in health, health care and nursing: a narrative review. Journal of Advanced Nursing 61(6):584-95.
Phillips, K. A., N. S. Ospina, and R. Rodriguez-Gutierrez et al. 2018. Humor during clinical practice: Analysis of recorded clinical encounters. The Journal of the American Board of Family Medicine 31(2):270-8.
Schöpf, A. C., G. S. Martin, and M. A. Keating. 2017. Humor as a communication strategy in provider-patient communication in chronic care setting. Qualitative Health Research 27(3):374-90.
Beach, W. A., and E. Prickett. 2017. Laughter, humor, and cancer: Delicate moments and poignant interactional circumstances. Health Communication 32(7):791-802.