— But don’t forget to speak softly and tread carefully
by Arthur Lazarus, MD, MBA – MedPage Today
During a visit to our daughter and her family in Columbus, Ohio, my wife and I went grocery shopping. I noticed a dialysis center nearby and joked, “If we decide to settle in Columbus, I won’t have to go far if my kidneys fail,” given my stage 3b chronic kidney disease.
My wife didn’t appreciate the humor about my kidneys, despite their stability for the past 20 years. In general, she isn’t fond of dark humor, which has been a recurring point of contention in our marriage. I tend to use it frequently, while she finds it cruel and unkind. As we stood in the parking lot, I explained that I’ve relied on dark humor as a coping mechanism for my health and my patients’ health for over 40 years. She insisted it was insensitive and preferred to focus on the positive. I mentioned that medical school had shaped my perspective, but she urged me to change my ways or find healthier coping strategies.
Once in the car, Bob Dylan’s “Knockin’ On Heaven’s Door” played on the radio, and I couldn’t help but laugh at the irony. I saw it as a form of divine intervention in our discussion about health and mortality related to kidney disease. When I explained my laughter, my wife, initially confused, felt I was adding insult to injury.
“The House of God”
Dark humor, often characterized by its morbid, sardonic, and sometimes shocking nature, is ubiquitous in the field of medicine. It can be heard in the ICU, operating theatre, emergency department, and perhaps for the first time for many aspiring physicians, in anatomy lab. But while often serving as a coping mechanism for medical professionals, it can sometimes cross the line into inappropriateness, particularly when it is perceived as insensitive or disrespectful to the patient, acting as a barrier to compassion and empathy. (For example, a patient was the brunt of dehumanizing jokes — recorded on his smart phone while sedated — and received $500,000 for malpractice and defamation).
Samuel Shem’s novel, The House of God, which provides a satirical and often irreverent look at the lives of medical interns in the early 1970s, is filled with instances where dark humor is used to highlight the dehumanizing aspects of medical training and the coping strategies of young doctors. For example, the interns in the novel refer to certain patients in dismissive terms and use acronyms like GOMER (“Get Out of My Emergency Room”) to describe elderly patients with chronic conditions who frequently return to the hospital. While these terms reflect the interns’ frustration and emotional exhaustion, they also underscore the potential for dark humor to devalue patient experiences when used insensitively.
“M*A*S*H”
“M*A*S*H,” a novel by Richard Hooker and later a movie and television series, is a quintessential example of the use of dark humor in a medical setting. Set during the Korean War, “M*A*S*H” follows the lives of surgeons and staff at a Mobile Army Surgical Hospital. The series is renowned for its ability to blend comedy with the grim realities of war, using dark humor as a means for characters to cope with the stress and trauma of their environment.
In “M*A*S*H,” dark humor is frequently employed to highlight the absurdity and futility of war. Characters like Hawkeye Pierce and Trapper John McIntyre use wit and sarcasm to deal with the overwhelming challenges they face, such as the relentless influx of wounded soldiers and the constant threat of danger. Their humor often serves as a shield against the emotional toll of their work, allowing them to maintain a sense of humanity amid the chaos. The humor in “M*A*S*H” is not just for entertainment but serves as a commentary on the human condition, emphasizing the resilience and camaraderie that can emerge in adverse situations.
COVID-19
The unprecedented nature of the COVID-19 pandemic — characterized by widespread fear, uncertainty, and significant stress — led many to turn to dark humor as a way to manage their emotions and maintain morale.
Healthcare workers, in particular, faced extraordinary challenges, including high patient loads, resource shortages, and the emotional toll of treating severely ill patients. Dark humor provided a way for them to express their frustrations and fears in a manner that could help alleviate stress. Jokes and memes about the realities of working during the pandemic circulated widely among medical communities, often highlighting the absurdities and challenges of their daily experiences. This type of humor functioned as a form of coping and bonding, helping to build a sense of community and shared understanding among those on the front lines.
Preventing Overload
In the high-pressure environment of medical practice, where decisions can have life-altering consequences, dark humor can help in normalizing the abnormal, making the overwhelming seem more manageable. It offers a momentary escape from the seriousness of our duties, allowing healthcare workers to distance themselves emotionally, albeit temporarily, from the suffering they witness daily. This detachment is not indicative of a lack of empathy but rather a necessary strategy to prevent emotional overload and compassion fatigue.
However, the use of dark humor in medicine is not without its ethical legal and considerations. It is crucial that such humor remains within the confines of the medical community and is not expressed in front of patients or their families. Tread carefully. Speak softly when walls are thin. And don’t forget smartphones are everywhere. Additionally, it is important for medical practitioners to be mindful of the diverse backgrounds and sensitivities of their colleagues, ensuring that humor does not inadvertently contribute to a negative or hostile work environment.
While it is important to be mindful of context and audience, humor can be a powerful way to navigate difficult times, offering both psychological relief and a way to connect with others experiencing similar hardships.
I believe that dark humor allows us to see the “light” in medicine by capturing its dual role as both a coping mechanism and a means to illuminate the challenges within the medical field. However, my spouse remains unconvinced.
Arthur Lazarus, MD, MBA is a former Doximity Fellow, a member of the editorial board of the American Association for Physician Leadership, and an adjunct professor of psychiatry at the Lewis Katz School of Medicine at Temple University in Philadelphia. He is the author of several books on narrative medicine, including Medicine on Fire: A Narrative Travelogue and Story Treasures: Medical Essays and Insights in the Narrative Tradition.
