Thursday, March 29, 2007

Your Doctor Is Making Jokes About You

And Other Things You Don't Want to Know About Medicine

You deserve to know the truth. The truth is, your doctor may be telling jokes about you. Well OK, not necessarily about you, personally. But about medicine. About the experience of treating patients with common conditions in common circumstances. Stories about patients with unreasonable demands or unreasonable behaviors who come back repeatedly for repair after refusing to change the very things causing them problems. With regard to psychiatry, doctors who have been assaulted by a patient in seclusion may use humor to relieve the fear and anxiety associated with caring for a potentially violent person. In situations like this it's better to make a joke than to scream, throw up your hands and walk away.

Sometimes in psychiatry you work with patients who aren't very nice to you. They may be angry and they may say things that are hurtful. As professionals it is our responsibility to take this dispassionately and allow the patient to be honest about their feelings. We cannot snap back or be retributive or let this influence our judgement. Psychiatrists must be dispassionate, supportive, sensitive and empathic.

Frankly, that's hard work.

Humor is one way of dealing with this. People who read this blog know that we use humor a lot. We tell jokes about medications, about diseases, about the pitfalls of psychiatric practice and about each other. (Well OK, usually about Dinah but that's just because she leaves herself so gosh-darn open to it. And because she takes it so well. Believe me, she can give it as well as she takes it.) According to our readers' comments one of the things people like about this blog is that it gives them a behind-the-scenes glimpse of the human side of psychiatry. That may be disturbing to folks who don't want to think about their psychiatrists in that way.

Every physician at some point in time has used humor to mediate stress and vent frustration. Heck, even an entire television series was based on this premise. The legendary Hawkeye Pierce used humor and practical jokes to highlight the idiocy of military (and medical) bureacracy all the while giving terrific patient care. I imagine my opthalmologist, my dentist, my primary care doc and even my gynecologist have their own brand of behind-the-scenes humor that I as a patient have never heard. (I have to admit I've come up with a few thoughts on my own while straddling the stirrups. And here's an informal survey: how many of you have gynecologists who post cartoons on the ceiling above the exam table?)

Personally, if it keeps my dentist sane and available for me and helps him be more tolerant of me as a patient I'm all for it.

I'll bet he's laughing at how I walk.


Warning: This blog features graphic scenes of psychiatric humor that may be disturbing to some readers. Reader discretion is advised.


ClinkShrink said...

To Dinah: Thanks for letting my razz you for the last twenty years without getting pissy about it. This is why abf loves you. I appreciate you too.

Dr. A said...

You'll probably think I'm kidding, but Hawkeye was one of my earliest influences with combining humor and medicine. Sure, it was only a TV show. But, growing up in the late 70s and early 80s, I think this tv show at least sparked my interest in medicine.

This topic would be great for your next podcast (hint, hint....). The verbal sparring on this would be interesting to listen to. HA!

Anonymous said...

It's so strange. How come shrinks don't use humor with their patients more? We know it's there. You should all lighten up a bit with the boundaries especially with the patients you know are the worried well. It might make us see how silly we are too have sooooo much anxiety over things that aren't that bad.

NeoNurseChic said...

Thank goodness you wrote this. ;)

One day when I was seeing my psychiatrist back at the old office, I was waiting for my appt and he came out to get my chart or some charts or something like that - and he made some comment along the lines of hearing voices, and then he said, "Well....not those kind of voices." And it was funny. I laughed. Granted, I don't hear voices - but I wasn't offended.

But then think about anhedonia - and who it hits.

I just wish sometimes people could (I'm going to refrain from saying something a bit more harsh) lighten up a little and take things with a grain of salt and maybe, just maybe, smile. Our ability to laugh at ourselves is one of the few saving graces we have. I realize sometimes it's not funny - but if I didn't laugh at myself and my life, then surely I would cry.

Laughter makes the rest of it bearable.....

Carrie :)

Roy said...

Clink's post on humor within the medical experience is timely and astute.

I use humor every day with my pts. Not with every pt... it takes some skill to know when and how to use humor in clinical situations. I find such humor to be uniquely dependent on the relationship betweeen the doc and pt. An observer may easily misinterpret the nature of the humor based on their own personal history and perspective.

For example, Anon appears to have interpreted comments about "Seroquel smiles" to be some type of mockery, when it refers to the abuse of Seroquel by prisoners looking for an altered level of consciousness. This is why clinical humor is best used in dyadic relationship, and requires some testing of the water. "Start low, go slow" applies to such humor, not just to medication.

I'll never forget when someone very close to me, dying of cancer, attempted suicide via carbon monoxide. She sat in that car for several hours, waiting to succumb to asphyxiation -- taking control of her death rather than letting the cancer dictate when and where -- until a jogger passed by and rang the alarm. Standing at her hospital bedside, with several other family and friends present, the awkwardness and uncertainty was heavy and uncomfortable. I proceeded to explain, with a hesitant but calculatingly ironic tone, that when I retrieved the car from the parking lot, I couldn't help but notice the recent emissions testing receipt on the passenger seat. Her car had passed with flying colors, with negligible carbon monoxide levels. She laughed heartily at this, as did everyone else, and it served to open the door to a very frank and open discussion about the coming end of her life. Without this icebreaker, we might have never had this important and necessary and therapeutic interchange.

I am constantly looking for such opportunities in my work, which so often involves people who have attempted to take their lives, struggling in their hospital bed with family members who don't know how to talk about something which is easier to pretend didn't actually happen.

In these situations, perhaps surprisingly, I never find that my sometimes skillful, sometimes hamhanded, approach to humor is misinterpreted as mockery, or insensitivity, or belittling. It is always received, by the pt and the family, as a welcome opening that breaches a difficult topic.

NeoNurseChic said...

Roy - Very well said. It's the difference between two people in person and the written word here. My docs have used humor with me so many times, and it's helped so much in the face of some really crappy news and situations. When I had the anticholinergic reaction, my best friend James called my parents down to the ER in the middle of the night. James later told me that he thought my mom was a little annoyed that my dad was making a joke out of my delirium. It was just my dad's way of dealing with it. He said so many times how scary it was and that he never ever wanted to see me like that again, but sometimes he still makes fun of the things I said.

And I will always go back to what happened to my family back in the mid-90s. 4 days before I had surgery to remove a tumor, my dad was in a near-fatal car accident. And he and I were home alone while my mom was at work in the days after my surgery - I was drugged up, sleeping in their bed as my face had swollen to grotesque proportions - my dad was going down the stairs on his crutches, and he says he was taking them 2 at a time, and he fell and broke his arm. When my mom and brother got home, they took him to the orthopod, and the ortho told my dad he was going to aspirate the fluid, and my dad thought that meant he was going to spray aspirin on his arm. LOL But then my dad came home - and was in a wheelchair with a broken arm, broken leg, broken foot and dozens of stitches in his face and head.... And when my mom and brother brought him in the door, we all just laughed. If we didn't laugh, then we would surely cry.

I know I have a quote in my quote book that goes something like, "Humor is a great thing - a saving thing. Once it pops up, all other irritations fade away." That's not exactly it, but it's similar. When J was dying of cancer, she would tell us stories of her 'roid rage (her 'roid rage actually got the cops out to the house! haha I laugh just thinking about it...). I can't imagine what I would be like without humor - even with humor, things can be pretty bleak at times, but without it, it would be so much worse.

However I do know the sensitivity about certain things. Sometimes people will make fun of how I talk about headaches or about the meds I am constantly taking, and I get a bit defensive. It's fine when I make fun of myself but when people say it to me, it hurts. So I understand how some areas can be sensitive and cause people to feel defensive about them.

You are so right that it sometimes takes two however. When saying things here, someone can easily interpret it as mockery because they aren't coming from the same place and part of the same intimate moment. But I don't think that should make you all stop what you say, write, and feel. It's unfortunate, and it sort of makes everybody feel badly, but you know that wasn't the intent.

Take care,
Carrie :)

NeoNurseChic said...

Oh one last thing. My date and I somehow got to talking about PC things tonight, and I mentioned the whole "walk like a psychiatrist" tonight - and in the movie "Reign Over Me" - at one point Adam Sandler's character starts screaming at this therapist saying he even eats like a shrink. So I leaned over to my date and whispered, "And he walks like a psychiatrist" - and we both busted up laughing.

Thanks for providing me with things to laugh about in my day to day life. ;)

I really think you guys should see this movie. It's a heavy one, but one that is soooooooooooo well-worth watching. I really think it would be a good one to see!

Take care,
Carrie :)

Alison Cummins said...

The humor on this blog has always been very gentle. I think it's because it takes two sides into account: the difficult patient and the shrink's uncomfortable response. (If you want crass, insensitive humour check out an ER blog - any ER blog. It's all about how awful patients are. I'm sure it's appropriate to the situation and serves an essential function, but probably shouln't be read by anyone who needs ER services.)

When my beloved is groaning, lying in the dark like a vampire and wishing for death, I use humour. Not to cheer him up really, but to contrast the dramatics of his emotions and everyday humdrum reality. Recognising the absurdity of the dramatic emotions helps us both cope while we wait for them to pass.

My handicapped friends mostly enjoy black humour, but not always. One friend told me about going ice fishing with a group and how they built a fire on the ice inside the ice-fishing shack: she hadn't known it was safe to do that. Oh, I said conspiratorily. It wasn't. It was an elaborate plan to drown the crips! And described the chaotic scene as all the people in wheelchairs slipped under the ice. No reaction. I told my story again. It still didn't go over. Oh, I thought. I guess it wasn't funny. I told her brother - also in a wheelchair - about the incident, including the bit about me telling it twice before figuring out that I was being an ass, and he was cackling away.)

And in case anyone missed it, I loved Clink's post about Max.

Anonymous said...

Humour can be an important part of the diagnostic process. I can always tell the hardcore pathology cases by the way they respond to my attempts at humour. Even an appropriate groan at a pun can be a sign that they're on the way to recovery. I once had a somewhat decompensated young man who started ranting on why nuns always wore black. Of course, I commented that it was due to habit. He didn't pick up on it and his condition didn't improve either.

Warning: make sure they don't think you're laughing at them.

jcat said...

P-doc, t-doc and I laugh at quite a lot of stuff, mostly things that would offend other people. It sort of helps.

But hey, at the end of the day they are taking home so much of my and other peoples pain, that if there is anything I have done or said that they find funny and want to share with other people - with my blessings. They deserve that, and a whole lot more.

Anonymous said...

I am laughing at this whole psychiatrist walk. I remember overhearing a couple of patients talking about my previous psychiatrist. This is what I heard, "He walks like a rooster with his chest thrust out and he struts." It really was true, he did walk like a rooster. From that point forward I had to bite my lip when I saw him walking around.

Sarebear said...

I've been thinking this for awhile, as I've noticed the picking at this issue, and was afraid you all would become too tightened up in your posts and stuff.

It's YOUR yard, have fun in it.

I like the humor, although I did comment on an OCD joke once. I had to stop myself from commenting on it 3-4 more times (hee hee hee, not really, but it's a funny thought. Once.)

Anonymous said...

There are many different types of humor.

You've used a picture of Patch Adams to illustrate your post. He used humor to connect with his patients and to help relieve their fear and pain and suffering.

But humor can also be used to disconnect from people, to try to alleviate one's own stress and sense of powerlessness at the expense of others. Using racial and religious slurs for example should never be permissible, no matter how difficult a doctor's day was at the hospital. Such jokes diminish both the teller and the group being targeted.

It is important to distinguish between an Ob-gyn who jokes about cold speculums and one who complains about having to look at c***s all day and who has a drawer full of disparaging wisecracks about women. While misogynistic jokes may help a physician 'mediate stress and vent frustration,' using humor in this way is hostile and damaging. Instead of warding off burn-out it heralds it.

Patients needn't be surprised that their doctors are telling jokes. Using humor is a wonderful aspect of being human. But there is humor and then there is humor. Having a stressful job should not be a free pass to say anything you like. There needs to be a line in the sand.

For example, dissecting cadavers for the first time can be very troubling. Some medical students coped by playing jokes with the corpses until medical schools took a stand and began expelling students that did not treat the bodies with the dignity they deserved.

Midwife with a Knife said...
This comment has been removed by the author.
Anonymous said...

"we don't joke about them because they're funny, but because laughing at them is a little better and probably a lot better than crying all the time"

I find this stance so curious. It is used repeatedly by doctors to justify insensitive comments (or humourous ones I guess, depending on your perspective).

What would be so terrible about crying? Why is laughing so preferable that you will make jokes that you acknowledge other people would be horrified by in order to keep yourself from weeping?

You would honour yourself and your patients more by crying than by making jokes about them.

Allowing yourself to be moved by your patient's pain would make you a better doctor, I think.

While I am not a doctor, I am in a caring profession that has it's fair share of tragedy and sorrow and I've never felt the need to mock the people in my care. I can't imagine how doing so would make me feel better about doing my job

ClinkShrink said...

Anonymous you make good points.

This is what is so terrible about a physician crying:

You can't do your job if you're crying. You can't do CPR or advanced cardiac life support or run a cardiac arrest code if you're distressed, in pain and sobbing. As a psychiatrist you can't care for horribly depressed people if that patient comes in to your office and sees you with red rings around your eyes. I refer you to Shiny Happy Person's blog for painfully vivid examples of trying to work while distressed. The lifeguard by definition is probably going to need to be a stronger swimmer than the person he is helping.

The examples of humor you cited are extreme and I don't think anyone reading would disagree that they are insensitive. However, humor exists along a continuum and Roy gave an artful example of the challenge of using it appropriately. So it is with this blog. Some people find the humor gentle, others may think it insensitive. The range of potential responses makes it a bit difficult to avoid problems by anyway other than refusing to use humor entirely. And that, I think it's safe to say, is something I'm not willing to do.

Thank you for prompting a "meaty" and thought-provoking discussion.

Midwife with a Knife said...
This comment has been removed by the author.
Anonymous said...

Of course you can't do CPR if you are crying. But you can't do CPR if you are laughing either.

The joking happens afterwards, behind the scenes. My point was crying could happen just as easily behind the scenes too.

Crying doesn't mean that you aren't strong. It only means that you are human.

I completely agree with you that humor happens along a continuum. The way that Roy cited using humor in his comment shows his skill as a psychiatrist.

ClinkShrink said...

Forgive me and I hope I'm not dominating this topic but it really has brought up some good issues. One other area where humor has been invaluable to me has been while working with some of my violent offenders.

When you walk down the hallway of a correctional facility you often end up walking in front of a crowd of inmates somewhere. The inmates react like it's open mic night at the comedy club. They'll make comments about your appearance, your job, your...uh...other things.

Some of our nurses find this upsetting or intimidating so they quit relatively quickly. Others learn to give quippy responses and bounce the handball right back. In situations like this humor is a valuable professional tool and you have to be a bit thick-skinned to be able to use it in this setting.

Once early in my prison work I was walking down a hallway when an inmate hollered out, "Doc, you got any males at home?"

"You bet," I said instantly. "Two of them. And they're both neutered."

The rest of the inmates burst out laughing and the quipper acknowledged, "That was a good one, doc."

Bounce-back humor improved my credibility with my patients. It showed I could work with them comfortably, without feeling intimidated, and without making them feel they had to walk on catfeet (with apologies to Carl Sandburg) around me.

I'm not sure this was actually on point with the topic, but it's an experience that just came back to me since my last comment.

I'll shut up and let other people talk now.

NeoNurseChic said...

Well - I'll give my perspective on not crying all the time - not necessarily telling jokes - but more along the lines of not crying over every very sad story. I see a lot of sad stories - in the last week, I've seen a handful of heart-wrenchingly awful situations. But I cannot cry over every single one....even behind the scenes while I'm not at work. And the reason why is that if I let each and every one of these stories eat me up that way, then I will burn out, and I will not be able to keep up with my work. It takes a lot of energy to feel each and every heartbreak, and it'll zap the life right out of you to cry over every sad story.

I'm not afraid to cry over the sad stories, and I have done so many times...but this is often when I connect with a particular family or just feel particularly sad over one. And it's not that I don't care.

Actually just this week I was discussing with my own psychiatrist about my feeling strange about not crying when I would normally think that I should. He said to me, "If you don't cry, does that mean that you don't care?" No... And he asked if getting upset and heartbroken each time is the only way I can show that I care. No... Then he asked me how I think he feels when I tell him things that are sad and upsetting. I said I don't think about it. (Because I don't...) And then I hopped out of that topic because it tread near things I don't like discussing.

But he's right - I care deeply for my patients, but that doesn't mean I need to cry and become fully involved in each and every one. In fact, that's probably not a good thing to get so attached like that. It's always important to care and to treat each case with the utmost importance, but it's not a requirement to carry it home with you and think about it 24/7 until you go in the next time.

In stressful jobs, it's important to be able to define that balance for yourself. So while this isn't about humor necessarily, this is my bit on why I can't cry over every sad story, even in private....

Take care,

Midwife with a Knife said...
This comment has been removed by the author.
Anonymous said...

It's funny (ironic, not HaHa) but someone, maybe ssitoc, made a comment on a post a little while ago about how it might be troubling to be my patient and then read my sarcasm on the blog, and my first thought was "But my patients know I'm sarcastic!"

The topic is confusing here, humor is a broad topic, one can laugh with patients (I'll call this humor) and one can laugh at patients (I'll call this insensitive mocking).

I'm careful about my sarcasm (can't we call it Wit?) early in treatment, people come in suffering and I don't know them well enough to know if it will sit as light, funny, appreciated, YaGottaLaughAtYourselfToSurvive, or as dismissive and underappreciative of their distress. Once I know someone, I'm just me. And I was...hmmm...witty before I was a doc. I don't think, for me, it's about the stress, I think it's part of who I am.

The other thing that's getting talked about here is more of a sense of Laughing At or demeaning patients to blow off stress. I'm not sure I quite get the thrill, though sometimes when someone has a strange constellation of symptoms, there's the Wow Did You See THAT response. Not really humor. I think a lot of the desire to mock/dehumanize patients comes as a form of Revenge (can I say this, it's kind of awful), when patients push our buttons, strike out in up close and personal ways.

There's a lot out there that's not politically correct. I wish I could plead innocent.

I don't mind being the punch line for anyone (even Clink), as long as they don't call me fat. But, Clink, don't think it escaped me when I mentioned that I'd seen Dr. X and she'd put on weight and was now my size, and you looked aghast, and said ,"Really? She runs all the time and used to be thin!" Haha.

Anonymous said...

'Yes you can cry behind the scenes. And no, it doesn't mean that you're not strong if you cry. But I couldn't tolerate feeling that way all the time.'

But you wouldn't feel that way all the time.

Allowing yourself to feel sorrow doesn't mean you will be swept away by it, annihilated, rendered completely unable to do your job.

The work that you do is both miraculous and tragic. If you can feel the joy when it is joyful and the pain when it is painful you will find that all feelings are fleeting. You will not need to be making horrifying jokes about your patients in order to try to escape from your feelings. You don't truly escape when you use humor in this fashion anyway.

Your choice is not necessarily to either make these horrifying jokes about your patients or do drugs.

If you can feel your painful feelings you will see that they do end.

Midwife with a Knife said...
This comment has been removed by the author.
Anonymous said...

'That sounds like a great answer, but I really don't think you understand. Again, not to sound dismissive, but maybe it isn't something you can understand unless you've been there.'

Unfortunately I think I understand only too well.

You have posted in your own words that you make what could be considered horrifying and demeaning jokes about your patients. You seem to think that it is completely acceptable to this because your job is stressful.

But you made a conscious decision to be a doctor. You knew that choosing that profession meant that you would have to deal with tragedy. You chose to be a healer. Your patients trust you with their lives and because of that trust they share intimate details about themselves with you.

You have an opportunity to share in the greatest joy of their lives, having a child, and the greatest pain, losing one. But you diminish both yourself and your patients when you reduce that privilege to a joke.

The world is a terrible place. Terrible things happen, not only to ob-gyns. But there are other ways to cope with that fact that do not involve using humor in hurtful ways.

You think that telling jokes this way is helping you to do your job. I am saying that it just may be harming you. It certainly does not honour your relationship with your patients.

Some people do have "sad sucky lives." How much sadder is it that the doctors they go to for help and trust when they are most vulnerable make fun of them.

Dinah said...


I read your last comment detailing the types of jokes/disparaging comments ob-gyns tell, and it had more of a Confessional feel. I thought of taking it off because I thought it would incite a riot-- Anyone who's been to med school is well aware of the "humor"-- be it a defense or stress-managing strategy (I, for one, think that's a copout excuse), but no one who has been a patient wants to think that their doc is anything but interested in and respectful of their distress. That doesn't mean that I'm always either interested in or respectful of everyone's distress (believe me, there are moments when it's hard, and I'm not innocent). I'm not sure of the place this has on a blog. I'll leave it and watch the fuss. Never mind Hawkeye, it's all a little more House Of God (Samuel Shem's book, and he became a shrink).

Midwife with a Knife said...

Dinah: I appologize for behaving badly on your blog. I didn't mean to incite a riot. I'm really sorry.

jcat said...

I read House of God recently, as p-doc's recommendation of one of the funniest books he's ever read. Have to say that most of the humour to me was sad, rather than funny. He reckoned that maybe you have to have been a medical resident to laugh at it.

I've been in and out of the animal care field for the last 22 years. Yeah, not people, I know, but in some ways also a caring, healing profession. There has been lots of stuff that even now, years on, makes me cry. So what we do is laugh at the odd funny bits instead. Crying doesn't help. Crying just takes something bad and internalises it even more.

And if I look back at some of that and it still hurts, God only knows how people like p-docs who are opening themselves up to pain all day do cope.

I don't think that going home and crying helps at all. I don't think laughter is disrespectful to patients most of the time.

There are times when laughing at something that maybe non-med staff would think "unfeeling" is about the only thing that stops vets and paramedics and nurses and (probably) doctors from going home and beating their heads on the wall. And if something I have said or done, as a patient, can help with that - to me it's not even an iota of what they've done for me.

terri c said...

Chiming in waaaay late on this but I appreciate the good discussion. From the patient side, I tend to have a dark, irreverent sense of humor. I also have a brachial plexus injury and some other neuro stuff and I see a very dark, irreverent neurologist, and one thing I love is the humor. Like the day I was having quite a pain exacerbation resulting from scouring a shower stall with my bad arm. My neurologist paged through my voluminous chart, pantomimed tearing of hair and rending of garments, and at length announced that, after X years of managing my condition, realizing that I should not scrub shower stalls with my bad arm should be taken as evidence of a learning curve. Of sorts. I was in stitches. I can tease said neurologist back as well which is what makes it extra fun. In fact I need very sharp, sometimes rather darkly funny, docs, because anyone who is Terribly Earnest makes me frankly nuts.

Ali said...

I suffer from obsessive compulsive disorder.I personally don't mind ocd jokes unless they are directed on me,i feel humour is a great way to deal with ocd.