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Humour is universal in health care. Doctors and nurses crack jokes and tease one another, just like people in any walk of life. We use humour with patients to lighten the mood, or simply to show we are human. Most of us give little thought to the whys and wherefores of humour in medical settings. This is probably just as well: the last thing we need is to have training courses for medics in how to tell jokes. However, I recently taught on a course for paramedics and was struck by their continual light-hearted banter. I learned that there is a well-established culture of humour in their profession.1 ,2 ,3 Their job involves working at a very fast pace, bringing them into daily contact with trauma and tragedy, and they regard humour as essential in order to sustain their morale. Their use of humour develops progressively alongside clinical experience and, according to one researcher, becomes “an adaptive method for coping with stress”.4 Discovering this led me to look more closely at the whole phenomenon of humour in health care, and the pros and cons of using it.
Psychologists have identified two broad categories of humour. One is aimed at enhancing relationships with others, and the other designed to boost oneself. Each of these can have either a benevolent or destructive intent, so the different combinations lead to four distinct styles of humour that are often used as the basis for research. The first of these is “affiliative” humour. This is well-intentioned, amuses others and is used in order to consolidate friendships. The second is a “self-enhancing” style. It involves laughing at oneself in a kindly way, for the same positive reasons. Next there is an “aggressive” style that includes put-downs, sarcasm and the like, and can hurt people's feelings. The fourth style, a “self-defeating” one, is designed to make oneself seem laughable in order to please others – but does so at one's own expense.
Like most systems in psychology, these definitions are neither watertight nor exclusive. At the same time, you should be able to notice them fairly easily if you start to look out for them. A standard questionnaire based on the “four styles” has led to some useful findings about particular styles of humour and how these correlate with psychological well-being.5 This shows that affiliative humour is associated with higher self-esteem, self-enhancing humour with optimism, aggressive humour with neuroticism, and a self-defeating style with depression. Not surprisingly, perhaps, males score more highly than females on their use of both aggressive and self-defeating humour.
One challenge to thinking about humour comes from so-called “gallows” humour. This was originally named after the wisecracks that people made immediately before their execution, but is now applied to any jokes told in extreme circumstances. For example, in a study of staff who managed aggressive patients in a maximum security facility, the psychologist Thomas Kuhlman has described it as “a way of being sane in an insane place”.6 He argues that gallows humour flourishes “when all else fails and where there is no reasonable hope for improvement.” Nevertheless, many people might still be concerned that it can function as a psychological defence, used in order to distance oneself from suffering, or to trivialise it. The effect of humour may not always be the same on the person delivering and receiving it. It can also show insensitivity to people's personal or cultural backgrounds. This may especially be true of non-verbal humour, such as making gestures or pulling faces.
Writing for the Hastings Centre, a bioethics research institute in the United States, ethicist Katie Watson has offered helpful guidance about when joking about patients, or with them, is appropriate or not.7 She distinguishes between jokes genuinely aimed at supporting a doctor “who is defenceless against death, decay, and chronic illness” and those mocking defenceless patients. Among other criteria for deciding whether a joke is ethical, Watson suggests we also ask whether it part of a systematic pattern of objectifying vulnerable patients or sharing prejudices. What is always crucial, she proposes, is who is listening and how they might be affected by it.
To counterbalance these concerns, humour can clearly have positive effects on patients too. In one study carried out in primary care, patients appreciated spontaneous humour from their doctors and actually perceived that this occurred more often than their doctors recalled using it.8 One explanation for this discrepancy may be that doctors use humour so routinely that they become unaware of it. Reviewing the evidence on how people sustain resilience after adverse events, George Bonanno from Columbia University has described the factors that can help some people to maintain equilibrium, when others might fall prey to post-traumatic stress.9 These factors include positive emotions and laughter. Humour certainly appears to have a more powerful impact on patients that we may realise.
The value of humour
Possibly the most detailed examination of humour in health care comes from two ethnographic studies carried out in critical and palliative care in Winnipeg, Canada. From nearly 300 hours of observations, the researchers found that humour served to “enable co-operation, relieve tensions, develop emotional flexibility, and to ‘humanise’ the healthcare experience.”10 The two studies also included conversations with patients as well as health professionals, regarding how they felt about humour in medical settings. The authors conclude: “The value of humour resides not in its capacity to alter physical reality, but in its capacity for affective or psychological changes which enhances the humanity of the experience, for both care providers and the recipients of care.”
The paramedics I taught clearly had an intuitive understanding of the value of humour, both for themselves and their patients. On the whole, their belief is supported by the evidence. If there is one additional lesson to be learned from looking at humour more closely, it may be that we need to develop more self-awareness about how we use it. In the context of medical education and training, this might mean looking back on occasions when humour was either used effectively or caused discomfort, and reflecting on why this was the case. On the whole, it seems a good idea to use humour in an affectionate way to lighten the mood when others around you – whether patients or colleagues – are under undue stress, but it should never be used aggressively or to put people down. Apart from that, the message seems to be a fairly simple one: carry on laughing.