Black and Blue: Dark Humor in Clinical Practice

The term frequent flyer is used to describe individuals who travel regularly by air. In this context it is not derogatory, and a high rate of airline travel is incentivized and rewarded through loyalty programs. The same label is often applied in a derogatory manner to patients who repeatedly visit emergency departments, hospitals, or other medical practices. According to a report published by the Center for Health Information and Analysis (CHIA), 1.2 percent of patients account for 9.4 percent of emergency department visits. 1 These patients not only visit emergency rooms more often, but they also spend more time there during each visit. The CHIA report states that patients who report abdominal pain spend 30 percent more time in the emergency department (their average stay is 4.8 hours), and “patients who presented at the emergency room with a behavioral health condition spent far longer in the department than patients who came with physical conditions…patients with schizophrenia or another psychotic disorder stayed in the emergency department for, on average, 20 hours.” 1 Applying a term describing a positive phenomenon (frequent air travel) to the negative phenomenon of perceived excessive or inappropriate use of medical services is an example of dark humor. Determining the cause of abdominal pain can be challenging, and when no physical cause is found, providers may suspect that the real reason for the medical visit is related to substance abuse. Mental illness can be more complex than physical injuries or ailments, and healthcare providers can be overwhelmed by the ineffectiveness of social and medical systems to care appropriately for many of these patients. Additionally, severe mental illness and difficult or dangerous behavior during an encounter can create even more stress for healthcare providers. Clinicians may also feel frustrated dealing with health conditions, such as obesity, for which they consider patients’ choices a significant contributing factor. Dark humor is often used to reduce the professional and personal burdens associated with these challenges. The term black humor was first used in 1935 “to describe a subgenre of comedy and satire in which laughter arises from cynicism and skepticism, often relying on topics such as death.” 2 The subjects of blue humor are “nudity, sex, and bodily fluids.” 2 Both types of humor can reflect an underlying cynicism about the legitimacy of patients’ complaints, the cause of their health problems, and their ability to manage their own care. They may also be a response to feeling overwhelmed by the disproportionate burden that certain patients and conditions place on the healthcare system and individual providers, or simply an attempt to provide comic relief in a notoriously stressful environment. Early Experiences Several examples of dark humor encountered early in my clinical training remain fresh in my mind. A classmate who was a physician assistant student reported witnessing an interaction in an emergency room during a clinical placement. After assessing a patient, the treating physician wrote a prescription that contained the letters “BSAPBTSOBOTD.” The student was told that it stood for “BS abdominal pain, boot this S.O.B out the door.” In another case, during an overview of imaging technology presented to O&P students, a radiologist displayed x-rays showing objects lodged in patients’ bodies. In some cases, the audience was asked to identify the object and why it appeared more or less translucent based on its material characteristics and capabilities of the x-ray technology. The presenter stated that this was also intended to hold the attention of the audience by providing humorous relief. His strategy had the desired effect, as members of the audience employed a combination of black and blue humor when the x-rays were displayed. Despite significant changes in societal, professional, and ethical standards in recent decades, the use of dark humor remains a common feature in clinical practice. The Functions of Dark Humor Wear, et al. published two papers reporting on the perceptions of medical students, residents, and attending physicians regarding “derogatory and cynical” humor. 3,4 These authors referenced the work of “philosopher John Morreal, who theorizes humor in three categories” to suggest why dark humor is used in clinical practice. 3 Medical providers and students enjoy a significantly higher status than many of their patients and making light of those who exhibit undesirable traits or behave inappropriately can be a way of expressing the providers’ sense of superiority. 3 Humor can also serve as “a release of pent-up nervous energy.” 3 Most of us can relate to the human instinct to laugh when we feel stress or are in uncomfortable situations. Certain undesirable patient factors and characteristics exacerbate the stress and pressure associated with providing medical care, and humor, even at the expense of the patient, may seem like a relatively harmless way of releasing that pressure. Finally, humor can be found in “the feeling or sense of an incongruity between what one knows or expects to be the case, and what the joke or quip expresses.” 3 We frequently encounter situations in clinical practice that we expected to occur differently, “and humor may be one way of managing these incongruities.” 3 Wear et al. conducted five focus groups with 46 third-year and 16 fourth-year medical students and six focus groups in surgery, medicine, and psychiatry departments with 70 doctors (49 residents and 21 attendings). 3,4 Participants in both studies identified dark humor as a coping strategy. “Most students believed that those who use such humor do so as a coping mechanism or an ‘outlet’ to deal with frustrating or depressing situations, particularly when patients do not take care of themselves in spite of the time, care, and resources spent on them.” 3 One of the attending physicians acknowledged that derogatory humor was wrong, but stated, “If we took everything we saw seriously every day we couldn’t make it through the day emotionally.” 4 A medical student put it more starkly: “Life is hell...but it’s less hell if you’re joking about it.” 3 Dark humor can serve as a barrier “to keep sick people at arm’s length…whereby the patient can be seen as a case rather than a person.” 3 One medical student explained that viewing a patient as an object, rather than a person, can help avoid being “caught up with your emotions.” 3 According to Wear et al., “Humor…is a form of cultural-insider knowledge” and “having a common sense of humor is like sharing a secret code.” 3 Being “in on the joke” establishes and strengthens connection with others who understand what is funny about a situation. The physicians in their later study spoke of dark and cynical humor “as a means of promoting camaraderie and as a method of shorthand when communicating with peers.” 4 Those of us who work in O&P have inside knowledge about the unique features and challenges of providing this type of care, and humor of all types may be employed to establish and reinforce a connection with other insiders. The Rules of Dark Humor Wear et al. reported that “the person or group with the least authority, particularly students, almost never initiated derogatory and cynical humor directed at patients” and that “most [students] reported that the residents are usually the first to initiate humor.” 3,4 According to one student participant, “If the ice has been broken by someone of a higher level, then it is okay to say anything.” 3 Students and junior clinicians have less experience dealing with the difficult cases and institutional barriers that contribute to cynicism, and their sensitivities and values may differ significantly from those of senior clinicians. Their superiors’ use of dark humor can conflict with how students or junior clinicians understand their professional roles and make them feel complicit in behavior they consider unprofessional if they are “expected to laugh or at least not object.” 3 The Impact of Dark Humor Students, residents, and attendings in Wear et al.’s studies all asserted “that the practice of derogatory and cynical humor is never a mean-spirited diatribe directed toward individual patients; the practice is, rather, about the frustration and stress that patients’ addictions, disorders, behaviors, values, and attitudes evoke in those who are trying to care for them.” 4 However, we must consider the unintended consequences of our actions, and be aware of the detrimental effects of dark humor. Medical residents in Wear et al.’s 2009 study “believed that derogatory humor might lead to preconceived ideas about a patient that may not always be accurate or true.” 4 One resident stated that this type of humor could “give someone a very predetermined idea of this patient which may or may not be fair,” and another believed it could “cloud your judgement.” 4 Using dark humor to establish emotional distance from patients can result in becoming “nonattached to taking care of patients in the most optimal way to assist their recovery.” 4 Lighter Options Those of us inclined to use dark humor must develop more appropriate ways of responding to the very real frustrations of clinical practice, including those related to patient characteristics and behaviors. One option is to turn our focus “toward positive possibilities in the denigrated patient’s life rather than surface features that cause negative knee-jerk responses…” and “direct attention to the life world of suffering patients….” 4 Developing a personal connection with a challenging patient need not increase frustration and cynicism and may actually reduce those feelings. One attending physician in Wear et al.’s 2009 study reported encouraging residents “to ‘reframe’ a patient after a cynical comment is made….” If derogatory comments are made about a drug-addicted patient, he asks, “How many of you have an addicted person in your family? There are things that are happening that are difficult for this person, and I want you to just enter into their world so you can understand.” 4 When working with psychiatric patients, another attending asks her trainees, “Can you imagine being this person? How would you have developed a coping style for this? How does anyone cope with this?” Closing Thoughts Clinical practice provides abundant opportunities to interact with individuals who do not fit our expectations or criteria of a “good” patient. We will see some of these patients repeatedly, and they can test our patience and professionalism. How we talk about them is not only a reflection of how we view them, but it can negatively affect clinical judgement. Dark humor can also impact our colleagues, particularly those early in their professional development. Honest and frank discussions with colleagues and a genuine interest in even the most challenging of patients can help us cope with frustrations more effectively than dark humor. John T. Brinkmann, MA, CPO/L, FAAOP(D), is an associate professor at Northwestern University Prosthetics-Orthotics Center. He has over 35 years of experience in patient care and education. References https://www.chiamass.gov/frequent-flyers-account-for-9-4-of-er-visits https://en.wikipedia.org/wiki/Black_comedy Wear, D., J. M. Aultman, J. D. Varley, and J. Zarconi. 2006. Making fun of patients: Medical students’ perceptions and use of derogatory and cynical humor in clinical settings. Academic Medicine 81(5):454-62. Wear, D., J. M. Aultman, J. Zarconi, and J. D. Varley. 2009. Derogatory and cynical humour directed towards patients: Views of residents and attending doctors. Medical Education 43(1):34-41.

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