Is It Ever Okay For Healthcare Students To Laugh About A Patient?

Humour is an element of communication that has evolved over many thousands of years to convey complex concepts and emotions in a succinct and efficient way. The transmission of "positive emotion and playfulness" by laughter is well recognised and it is relatively commonplace in clinical environments. However, clinical environments are, at varying times, places of stress, fear and power differentials and where healthcare practitioners, students and patients all come together and use humour for a range of purposes. This paper considers some of the boundaries to be respected when using humour in the clinical environment and whether it is ever okay for healthcare students to laugh about a patient.


What Is Humour?
Humour is communication which induces amusement, with or without laughing or smiling. Both smiling and laughing in humans are now considered to be signals of "good will". However, smiling is believed to have once been an aggressive gesture involving the bearing of teeth and has over time evolved through an expression of submission and appeasement (Preuschoft, 2010) into a demonstration of a safe message to others. Laughter in comparison is thought to be "a medium for emotional contagion, a mechanism for transmitting positive emotion and playfulness" (Gervais, 2005) whose origins possibly lie in the pant -like vocalisations of the great apes during tickling and chasing (Darwin, 1872;Caron, 2002); and it is perhaps also worth remembering that smiling can be easily faked (Gunnery, 2012) but laughter less so.
Humour is an icebreaker; a bonding instrument; good bedside practice and a stress reliever (Dziegielewski, 2003). Several brain components are exploited to comprehend humorous situations -cognitive, muscle movement and areas responsible for emotion perception (Takeda et al., 2010). Respectively, these are used to understand, translate this Asif A, Gay S MedEdPublish https://doi.org/10.15694/mep.2020.000229.1 Page | 2 information to a physical manifestation of appreciating (or not) the humour underlying the situation, and to feel either positive or negative emotions.
Humour and laughter are invaluable to medicine. Physiological responses to humour and laughter include increased respiration and exercise of the muscles associated with it, improved immune responses, better treatment responses, endorphin production, raised pain thresholds and tension release mediated through the autonomic nervous system (Fry, 1994). And regardless of whether patients use this ancient communication tool to brighten up a tough consultation with their doctor or other healthcare professionals use it to comfort their teams on a day-to-day basis, it can serve to build connections amongst all parties -the patient, the clinician, the patient's family and the wider healthcare team.

What Do Guidelines Say?
Showing patients respect, treating them without discrimination and acting honestly are all clearly emphasised in Maintaining Trust, Domain 4 of the UK General Medical Council (GMC) document Good Medical Practice (2013). However, if patient dignity and their trust in healthcare professionals and the wider NHS is to be maintained as highlighted a number of questions need to be answered: How far can healthcare practitioners and their students take their jokes within either their school or the clinical workplace? What is 'gallows humour'? And is any use of humour ever really appropriate?

What Is Gallows Humour?
Gallows humour, also known as "dark humour", is frequently encountered in medicine. Being able to laugh or find humour in hopeless, dark situations, which are sometimes life-threatening or worrying, is an integral part of healthcare.
Indeed, Freud stated that humour is an essential protective shield from life's harsh realities (Freud, 1963) and in palliative care, for example, humour plays an enormous role in the coping mechanisms of both healthcare professionals and the patients themselves (Collicutt and Gray, 2012). Furthermore, such gallows humour is also sometimes adopted by both patients and clinicians as a strategy for managing uncertainty (Bosk, 1980) when clinicians are unsure about a diagnosis or treatment.

Humour In The Workplace
Humour is regarded as highly social and even "infectious". A problem or diagnosis becomes less threatening when the team can laugh through it, along with the patient. For a team to be effective and efficient it must have a strong sense of cohesion. Just as "shared understanding" is deemed as a positive trait in a "good" doctor-patient consultation, "shared laughter" is important and treasured in the workplace.
"Humour is not a substitute for clinically competent care -but it can be a powerful adjunct to therapy." (Goodman, 1992) Laughter encourages teambuilding and provides all healthcare professionals with a sense of belonging through insider jokes or humorous comments said during common experiences. This shared laughter is a well-recognised stress reliever (Martin et al., 1993).

Humour In Schools Of Healthcare
Whilst ideally 'teachers should aim to be stimulating rather than entertaining' (Preston-Whyte and Fraser, 1999), humour has been documented to promote a positive environment for learning (Ziegler, 1998). Humour injects desire and curiosity to learn through thought-provoking material. Upon listening to a joke, the student's arousal levels rise until the tutor's punchline is delivered, ensuring that the educator has the learner's attention. In this way, fictional characters or anonymised patients can be employed to aid the learning of medical students as long as the raconteur is careful to avoid such tales being received in a "Barnum statement" (Meehl, 1956) like way where the learners believe they know the patient or perceive the tutor as behaving in an unprofessional manner.

What About Negative Aspects Of Humour In Healthcare?
A clinical environment is vulnerable and sensitive. It depends and thrives on teamwork, trust and integrity. Most patients in critical conditions are in fear for their health and some are left in less than favourable states. Cynical, degrading humour in these circumstances is not acceptable and cannot be justified (Berk, 2009). Degrading humour can cause real harm, especially when it disrespects people according to race, nationality, disability, sexual orientation or some other personalising characteristic. In a place where we are expected to heal, treat and lift people's spirits we can easily crumble their self-esteem and even induce anxiety or depression (Borins, 2003). Patients are less likely to comply with treatment or speak openly about what is bothering them if they do not trust healthcare professionals after previous negative experiences. Nobody should be humiliated, embarrassed or disrespected when their weaknesses are "out in the open" and sometimes patients who find themselves in this situation act strangely and express their deep mental insecurities, concerns and frustrations via heightened and exaggerated physical responses, which occasionally escalate demonstrative anger or physical violence. Even so, despite their immediate tribulations some patients also provide open invitations to subtle humour if they utter witty sentences or nuances themselves, further demonstrating the use of humour as a valid, 'socially acceptable' defence system.

Take Home Messages
Ultimately, abusing a patient, their trust and a healthcare professional's power is where humour becomes inappropriate and unethical. We should never take pleasure in our patients' suffering. Humour should be used in a just, "innocent" manner that would not harm or abuse a patient or a colleague. We can simultaneously take our work seriously whilst taking ourselves lightly (Goodman, 1992). Humour is a vehicle of positive human interaction amidst the stresses of medical practice. Humour is an important bridge that allows us to show patients that we are as human as they are and have their best interests in mind.

Notes On Contributors
Aqua Asif is a 3rd year medical student and course representative at the University of Leicester School of Medicine in the UK. Her interests include medical education, surgery, social prescribing and diabetes mellitus. ORCID ID: https://orcid.org/0000-0003-3233-7428 Simon Gay is a General Practitioner and Professor of Medical Education (Primary Care) at the University of Asif A, Gay S MedEdPublish https://doi.org/10.15694/mep.2020.000229.1 Page | 4 Leicester School of Medicine in the UK. His current interests include clinical reasoning, consultation skills development, reflection and professionalism. ORCID ID: https://orcid.org/0000-0002-1743-9824