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Friday Dec 02, 2016

Gallows Humor Is No Laughing Matter

Jeremy had vomited multiple times in the 12 hours before I saw him at the pediatric emergency department (ED). I took a history and did an exam. He had eaten at a fast-food restaurant the night before, and it was obvious that the 5-year-old didn't feel well. His parents and siblings had ordered something different and avoided the same misfortune. He was dehydrated and still nauseated, so we got to work giving him IV fluids, checking labs and giving him medication to calm his stomach.

I was a second-year resident, so I had to staff the case with the pediatric ED fellow. I told him the patient's story, and he made a few derogatory quips about the family's weight and dietary choices. (Jeremy, his mother and four siblings were all obese.) I went back into the exam room with the fellow, who also obtained the history and did an exam. We then went through the same motions with the attending, giving him the history and exam findings. Then we endured jokes similar to those the fellow had made. All three of us joked about how we never would eat the same meal the patient had, and we would never be found at such a restaurant, especially now that we associated that particular food with copious amounts of vomit.

The attending physician went through the same drill of history and physical, gently teasing the boy about his experience and how he had not ordered as wisely as the rest of his family. We went forward with the initial care plan and, despite all the jokes regarding Jeremy's food, the attending remarked -- nonfacetiously -- after we left the room, "Is it just me, or does that sound really good right now?"

Ethicists have repeatedly discussed the role and import of physicians engaging in gallows humor(meded.duke.edu). Some have likened the difference between gallows humor and its crueler cousin derogatory humor to "the difference between whistling as you go through the graveyard and kicking over the gravestones(www.ncbi.nlm.nih.gov)" Some physicians argue that this type of joking among themselves is necessary to survive the rigors of training and practice. Indeed, it is common for people in many high-stress professions to use such humor among themselves to diffuse frustrations. We as physicians see so much pain and sorrow on a daily basis that such an outlet can be helpful. But considering how toxic humor can become, is there a relationship between these types of jokes and the burnout epidemic among physicians?

My subjective experience suggests that the more disrespectful the humor, the more burned out the physician likely is.

One physician I worked with as a resident referred to certain patients as "sheddies" and others as "trolls." A "sheddie" was someone who appears as if they live in a woodshed -- unkempt, dirty and most often homeless. A "troll," according to my colleague, was someone who was obese and uneducated. He never called patients by these terms directly, but he used them in conversation with everyone else. The implication, sometimes overtly stated, was that he saw these people as unworthy of his time and care. They became mere objects instead of people.

These comments were extremely inappropriate and insulting, but some of our colleagues seemed to have no problem with it. My experience suggests his repeated comments represented the classic signs of burnout -- emotional exhaustion, depersonalization and lack of accomplishment. He admitted to looking for anything he could do to get out of medical practice.

Is the way we talk about patients behind their backs a reflection of our own feelings of burnout, or are physicians who are more disparaging of patients more likely to burn out because of the way they think about those they care for? Does gallows humor contribute to seeing people as objects rather than human beings? Does it allow us to prolong our empathy by better coping with our frustrations or diffuse it so we don't carry the immense emotional burdens of our patients? It's tough to say, but there is most likely a large, nebulous continuum. My favorite definition of gallows humor epitomizes the "sheddies and trolls" comments as the extreme end of the continuum:  "Joan Rivers meets death metal meets hydrochloric acid(www.psychologytoday.com)." Much like the behavior of a bully with a perceived power differential, such comments typically reflect personal issues being expressed in a more "playful" manner.

But humor can also diffuse stress(www.sigmundfreud.net), and can thus play a role in delaying or eliminating burnout. Joking among colleagues can be beneficial without demeaning patients. It can be something that encourages and provides camaraderie among peers, which is important to professional and personal well-being. But we should always remember that disparaging comments are contrary to healing relationships.

So what are we to do? Does gallows humor help with burnout and stress or make things worse by biasing us against our patients and burning us out? We just have to be honest with ourselves. The fellow and attending from my experience with Jeremy did not seem to perceive their bias, and in the end, they had a connection and understanding with the patient. To be a good physician, we have to recognize how such thoughts and behaviors may influence our treatment of patients, as well as our own experiences of burnout, whether consciously or subconsciously.

Kyle Jones, M.D., is a faculty member at the University of Utah Family Medicine Residency Program in Salt Lake City. He is the director of primary care at the Neurobehavior HOME Program, a patient-centered medical home for those with developmental disabilities. You can follow him on Twitter @kbjones11(twitter.com).

Posted at 04:02PM Dec 02, 2016 by Kyle Jones, M.D.

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