‘The most powerful vehicle communities have for transforming their conventions – their agreements on norms, values, policies, purposes, and ideologies – is through the act of dialogue made possible by language.’1
Context A study of medical students’ perspectives on derogatory and cynical humour was published in 2006. The current study examines residents’ and attending doctors’ perspectives on the same phenomenon in three clinical departments of psychiatry, internal medicine and surgery.
Methods Two focus groups were conducted in each of the three clinical departments, one with residents and one with attending doctors, during the 2006–07 academic year. Seventy doctors participated, including 49 residents and 21 attendings. The same semi-structured format was used in each group. Questions focused on characterisations of derogatory and cynical humour along with motives and rules for its use. All focus groups were audiotaped and the tapes transcribed. Each transcript was read independently by each researcher as part of an inductive process to discover the categories that describe and explain the uses, motives and effects of such humour.
Results Three categories that appeared in the first study with medical students – locations for humour, the humour game, and not-funny humour – emerged as virtually identical, whereas two others – objects of humour and motives for humour – were more fully elaborated.
Discussion Discussions of derogatory and cynical humour should occur in any department where teaching and role modelling are priorities. In addition, the tenets of appreciative inquiry and the complex responsive process, particularly as they are used at the Indiana University School of Medicine, offer medical educators valuable tools for addressing this phenomenon.
In May 2006 we published a study of medical students’ perceptions and use of derogatory and cynical humour directed towards patients.2 We were interested in students’ descriptions of this phenomenon, particularly the categories of patients to whom such humour is directed, their motives for using it and their speculations regarding why residents and attending doctors use it. The present study is built upon this earlier research combined with compelling evidence that students across time and educational environments become more cynical as they progress through medical school.3–10 In addition to and foundational to our work are the results of a single-site study of medical student perceptions of humour and slang in hospital settings.11
The results of our earlier study were disturbing on several levels, on which we elaborated extensively in our earlier report.2 In particular, students frequently cited residents’ and attendings’ attitudes and behaviours as they described clinical environments where derogatory and cynical humour towards patients was sometimes sanctioned and used by residents and attendings themselves. Thus, our next step was to compare the phenomenon medical students described with the perspectives of residents and attending doctors.
The culture shock medical students experience when they move from the pre-clinical to the clinical environment is profound. Even when students make consistent ventures into clinical settings during their first 2 years, nothing is quite like their first clinical rotations in hospital settings. Here they are immersed in a culture of which they all aspire to become members, and here they look to their teachers – the fully sanctioned residents and attendings – to tell them how to be.
Aspects of this culture evoke cynicism in trainees. In their perceptive article, ‘The natural history of cynicism in physicians’,9 Testerman et al. looked at the development of cynicism in medical students as part of the professional socialisation process where cynical attitudes develop when students experience abuse and powerlessness. These experiences then ‘create ethical dilemmas unique to the medical student’s role. Students have to grapple with the double messages of the overt versus the “hidden curriculum”, experiencing pressure to compromise their personal ethics to support the team.’9 Moreover, part of the socialisation process involves obtaining ‘cultural insider knowledge’,12 some of which involves uses of humour that ‘outsiders’ would probably find offensive.
Testerman et al. propose two models as explanatory frames for this shift from altruism to cynicism.9 The first is the professional identity model, which suggests that medical students’ cynicism – and, for the purposes of this discussion, their use of derogatory and cynical humour about patients – is temporary, a result of the ‘harsher’ aspects of their socialisation, which corresponds with their attempts to develop professional identities in a ‘complex and ambiguous ethical environment’. Once through their residencies, and after assuming some level of authority as attending doctors, they become less cynical. The second is the intergenerational transmission model, which explains the development of cynicism in students as a learned response to mistreatment by residents and attendings who themselves are cynical.9
The literature on the progression and regression of cynicism would suggest that the first model is a good explanatory fit. However, this model alone does not explain the fact that students do report the ill effects of attendings’ negative attitudes on their education, which leans more towards the intergenerational transmission model involving learned responses. Szauter and Turner13 found that third-year clerks in one location indicated that ‘the most common transgressions of faculty professional behaviour… were the use of derogatory commentary directed at other services, at patients, or toward a patient’s family’. Maheux et al. found that over 25% of all Year 2 students and 40% of Year 4 students at two medical schools did not believe their teachers behaved as ‘humanistic caregivers with patients or were good role models in teaching the doctor–patient relationship’.14 Beaudoin et al.15 similarly found that 50% of Year 4 students and 33% of Year 2 residents surveyed perceived that ‘most of their teachers did not display the humanistic characteristics that were examined in connection with their role as caregivers and teachers’.
How do residents and attending doctors respond to these and other observations about their use of derogatory and cynical humour directed towards patients? Would they cite the same motives for these attitudes and behaviours as students did and denote the same categories of patients about whom such humour was extended? Would they be aware of the same rules of ‘play’ that students observed? More importantly for this study, what insights might they offer as teachers regarding this phenomenon and its effect on learners, patients and themselves?
Authors DW and JA, both of whom are full-time, non-clinical faculty members, conducted six focus groups in three clinical departments – surgery, internal medicine, and psychiatry – during the 2006–07 academic year. We contacted the department chairs and residency directors of these three departments and asked for volunteers for focus groups at designated times and places before, during or after regularly scheduled meetings when time was already blocked out. Each focus group lasted approximately 1 hour. We selected the focus group method for several reasons. Firstly, it characteristically promotes interaction among participants and provides a forum for addressing sensitive topics. Secondly, it is the most practical method of bringing together groups of extremely busy individuals. In these settings individuals can use the method itself to interact with one another by way of questioning and challenging one another’s opinions, exchanging stories, and thinking out loud with a group of individuals who have similar experiences.
We conducted focus groups for residents and attending doctors separately and by department. Seventy doctors participated, including 49 residents and 21 attendings. The focus groups took place in conference rooms in each department. Each participant received and signed an informed consent document. We used a semi-structured format for the questions we posed in each group, identical to that used with medical students in our previous study. Questions focused on characterisations of derogatory and cynical humour along with motives and ‘rules’ for its use. Because residents and attendings are the primary teachers of medical students, we were most interested in their answers to the final question: ‘What are some of the possible ill effects of this kind of humour?’
The focus groups were audiotaped and the tapes transcribed by the two faculty who interviewed. Once all personal descriptors had been removed, the other two authors (JZ and JV) participated in the data analysis. We made the decision to wait until identifiers were removed because one of the two clinicians (JZ) holds an administrative position in the hospital where the research took place and the other (JV) is the chair of its Department of Psychiatry, which was one of the departments studied.
The four researchers read each transcript independently as an inductive process to discover categories that describe and explain the social phenomena under study. Each read and reread the data, focusing on phrases, explanations, observations, incidents or types of behaviour. We then compared our results and agreed the categories that frame the discussion below. All the text expressed below in quotation marks represents the language a resident or attending doctor actually used. It should be noted, however, that we make no claims for generalisability in this study, but we do provide a snapshot of several groups of residents and attending doctors in one Midwestern teaching hospital health system, along with our interpretive efforts.
Because we used the same questions with residents and attendings that we had used with medical students in our previous study, most of the categories of derogatory and cynical humour re-emerged. Students, it seemed, had been accurate in their assessments of this phenomenon in their learning environment. Three categories that appeared in the first study (locations for humour, the humour game and not-funny humour) emerged in virtually identical formats, whereas two others, objects of humour and motives for humour were more fully elaborated.
In short, we found that attendings and residents reported that the locations for derogatory humour were generally hallways outside patient rooms during rounds, conference settings or areas where residents congregate, or within private conversations.
Attendings and residents agreed that the rules for the humour ‘game’ were such that the person or group with the least authority, particularly students, almost never initiated derogatory and cynical humour directed at patients. However, they noticed that some lessening of this rule occurred when students became more familiar with the styles and values of the attendings and residents in any given clerkship. Residents may initiate derogatory and cynical humour around attendings but only after they have ‘watched’ the attendings with whom they are working and noted their attitudes towards such humour.
The objects of humour included, as students suggested, primarily alcohol- and drug-abusing patients, obese patients and a large category of ‘difficult’ patients. With some notable differences among departments, attendings and residents in all three departments offered the same motives for the use of derogatory and cynical humour directed towards patients as did the medical students in our earlier study. Their list included the following: to relieve ‘frustration’, ‘stress’ and ‘anger’; ‘to make light of difficult work’; ‘to distance oneself’, and ‘to stay sane’. They used clinical terms such as ‘countertransference’ and ‘defence mechanism’; they also called the use of such humour a response to ‘increased demands’ in the care of patients, to fatigue and to ‘feeling too needed’. Finally, they spoke of the phenomenon as a means of promoting camaraderie and as a method of shorthand when communicating with peers.
The differences among departments concerned the depth of reflection and self-disclosure, which doctors working in psychiatry and medicine displayed more than those in surgery, particularly among attendings. This may be related to group size (doctors in surgery comprised the largest focus groups), stressors related to time on that particular day, personality differences associated with specialties, or the nature and amount of derogatory and cynical humour found in the respective departments.
Ill effects of humour
Attendings and residents had no trouble describing the potential ill effects of using derogatory and cynical humour directed at patients. One psychiatry resident believed that its widespread use can ‘perpetuate a culture’; another referred to a month she had spent in outpatient emergency services where she ‘burned out’ on the:
‘…negative energy of the people and the space there… The intensity of it there, the negative vibes coming from that place, was definitely an ill effect.’
Some believed that training in a culture where derogatory humour is widely sanctioned may have negative implications. A new psychiatry resident, noting that patients with borderline personality disorder were frequently the objects of derogatory and cynical humour, offered the following observation:
‘[Such humour] can affect people who are being trained. Like, I don’t have that borderline thing yet, but I keep hearing about it, and I’m waiting to have this whole reaction toward them and I’m trying not to.’
In fact, residents in all three departments believed that derogatory humour might lead to preconceived ideas about a patient that may not always be accurate or true. One medicine resident mentioned that such humour during a pager pass (shift change) may ‘give someone a very predetermined idea of this patient which may or may not be fair’; a psychiatry resident believed it could ‘cloud your judgement’.
In addition, there were more immediate reasons given for not using derogatory and cynical humour directed towards patients in clinical settings, particularly the chance that a patient or family member might overhear ‘humorous’ remarks being made nearby. One psychiatry attending said that several of his patients had reported overhearing someone making derogatory remarks and were ‘sure it was directed at them… and they were pretty upset about it’, prompting one of his peers to describe ‘the stray bullet effect – it’s not directed at them but they perceive it [to be]’. Another attending remarked:
‘…as a patient, it’s hard to hear laughter. The times I’ve been sick, or if you’re in the ER, or your doctor’s office and you hear people yukking it up outside the room and you’re like, I’m sitting here suffering… stop yakking and get in here.’
Teachable moments in instances of derogatory and cynical humour
Several attendings in each of the three departments described finding ‘teachable moments’ after a resident or student had used derogatory or cynical humour in reference to a patient. One surgery attending spoke at length about teaching opportunities in response to such humour. If one does not value human life, he maintained:
‘…you become incredibly distant and non-attached to taking care of patients in the most optimal way to assist their recovery. And so negative humour is actually discouraged in our rounding process… We turn it around and use a more positive approach to it. My classic line is, they’re all God’s children even if God might have some trouble recognising them from time to time… to turn them around so they don’t focus on the dehumanisation of the patient.’
This attending doctor did not browbeat residents and students in order to dissuade them from engaging in negative humour, but, rather, steered them in another direction which allowed them greater opportunity to evoke connections with patients.
Similarly, an attending in medicine spoke of his efforts to establish personal connections with each patient in order to ward off cynicism. He tried to get residents to ‘reframe’ a patient after a cynical comment is made:
‘So if [a resident] says this [patient] is such a dirtbag, or this person has no insight, or … everyone in his family is addicted, he says he doesn’t use cocaine but his tox screen is positive, hahaha, he’s lying, we all react to that. And my point then, at that time [is to say], “Well, how many of you have an addicted person in your family?” When I do that everybody stops, and they know where I’m going, and then I ask, “There are things that are happening that are difficult for this person and I want you to just enter into their world so you can understand.”’
This point – understanding patients as unique persons instead of members of categories – was discussed at some length among these attendings as representing a way to balance the effects of negative humour, similar to a point made about seeing patients in three rather than two dimensions.
Several psychiatry attendings elaborated on similar efforts they made with residents and students. When one attending doctor saw students looking at patients as ‘bizarre or weird or to be made fun of’, she asked them questions:
‘[they] may not have thought of… Can you imagine being this person? How would you have developed a coping style for this? How does anyone cope with this? And I think that really decreases – hopefully – making fun of patients, or laughing at them.’
Another psychiatrist described frequently using students’ nervousness or giggling about patients during case conferences:
‘We talk about it and I really encourage them to talk about it. I don’t stifle that because it’s their feelings… they just are… [it’s] better to talk about and figure out where it’s coming from rather than [say] “Don’t be doing that,” [which] doesn’t help them learn anything.’
Derogatory and cynical humour directed at patients is a well-documented and ubiquitous phenomenon in medical education. Our previous study and the present report confirm that such humour exists, persists, and is justified by its practitioners as a way of coping with the stress, exhaustion and emotional difficulties of caring for persons who are ill or dying, patients who are demanding or manipulative, and patients who can’t or won’t follow medical advice. In addition, some theorists contend that using such humour is like sharing a secret code and that it represents a form of cultural-insider knowledge that may or may not convey the actual feelings of those who use it.12
This study suggests that residents and attendings make assessments of this phenomenon that are remarkably similar to those made by medical students. All three groups articulate with great precision the same categories of patients as targets for such humour and identify the deeply ingrained but unwritten rules or hidden curriculum for its expression. Everyone who chooses to participate plays by the same ‘rules’; they focus on the same categories; they know where the phenomenon is enacted and sanctioned; they rationalise why they participate; and many recognise potential ill effects on themselves and others from participation. Firm assertions were made in all three groups that the practice of derogatory and cynical humour is never a mean-spirited diatribe directed towards individual patients; the practice is, rather, about the frustration and stress that patients’ addictions, disorders, behaviours, values and attitudes evoke in those who are trying to care for them. This is an area that requires further study, particularly surrounding the disagreement about the use of such humour illustrated in the remarks of several attendings cited above: does using derogatory and cynical humour about patients as a stress reliever ward off or lead to burnout? A longitudinal or ethnographic study of this phenomenon could yield rich insight into the long-term effects on individuals who use or repeatedly witness such humour, particularly during students’ and residents’ professional socialisation. A limitation of this study was that not all the attendings who were present in each focus group participated, and those who did may not speak for their peers, who also have contact with trainees yet may have different perspectives on the uses, motives and effects of humour about patients. A more comprehensive ethnographic study of the wide and diverse landscape of hospital culture may add new dimensions to our understanding of this phenomenon.
One of the attending doctors we interviewed in internal medicine provided another intriguing angle from which to study this phenomenon further. He made the distinction between gallows humour and derogatory humour, which he likened to ‘the difference between whistling as you go through the graveyard and kicking over the gravestones’. Gallows humour is practised ‘just to survive’, he said, but derogatory humour relates more to specific ‘classes’ of people, such as addicted persons:
‘Sometimes we spill over into derogatory humour and that’s wrong and we try to catch ourselves… [yet if we] took everything we saw seriously every day we couldn’t make it through the day emotionally.’
A greater analysis of the nuances of humour directed towards patients in clinical settings might yield deeper understanding of how it is used, the stated motives for its use, and its effects on those who use it. That is, we cast a very wide net for derogatory humour, and the distinctions this doctor suggested – that there are ethical dimensions of humour – may be an important direction for further study. For example, in her recent article, ‘Does Laughter Make Good Medicine?’, Sobel suggests that it may be more acceptable – and more humane – if joking about patients occurs ‘at a distance – both spatial and temporal – from patients’.16
This study also points to the need to examine far more closely the deep and lasting impact residents may have upon medical students’ professional development and identity. Despite their vast teaching responsibilities, residents in this study did not address the teaching implications arising from the use of derogatory and cynical humour the way attendings did, particularly attendings working in medicine and psychiatry. However, it is residents who spend the most time with students and who thus may have more opportunities to role model than attendings do. A recent study of medical students’ perceptions of effective teachers found that resident teaching effectiveness correlated most strongly with providing a role model, being available to students, promoting confidence in their knowledge and skills, and exhibiting enthusiasm.17 Another recent study examining surgery residents as role models found that students scored residents higher than attendings in 12 of 14 qualities describing outstanding clinical mentors.18 Although department leadership and teaching faculty must always assume responsibility for the clinical education of trainees, residents should be brought into all conversations surrounding the learning environment early and consistently and be provided with appropriate faculty development support to address any issues with which they may be struggling.
Finally, this study also points to the need to instigate discussions of derogatory and cynical humour in any academic department where teaching and role modelling are serious priorities. Such discussions may occur in grand rounds, noon seminars, journal clubs or other forums for faculty development. Many of the attending doctors who elected to participate in these focus groups offered thoughtful reflections on this phenomenon and how they respond to it. That said, and despite their apparent frankness, it is possible that the focus group format may have prevented others from honest disclosure if their attitudes and behaviours would have positioned them negatively in the eyes of their peers. The format may also have prevented some faculty from expressing disapproval of their colleagues’ attitudes and behaviours. Nonetheless, attendings and residents throughout academic medicine might begin candid discussions of derogatory and cynical humour in their particular cultures in order to become better aware of their participation in it and their responses to it when they overhear it from others, particularly trainees. Our experience here using focus groups prompted extensive, lively and frank discussion in most settings and we believe that such discussions may prove to be even more open without the presence of a tape-recorder.
As medical educators committed to developing and sustaining humane environments for both patients and trainees, we could all learn much from the ground-breaking work currently going on in this arena at the Indiana University School of Medicine. Using the tenets of appreciative inquiry (AI) and complex responsive process (CRP), a group of medical educators is seeking to transform the organisational culture. In spaces throughout the 4-year curriculum, they are attempting to focus attention on what is positive, right and good in the environment, what is working, and how to create circumstances for more of it. Using this orientation, ‘expectations and behaviour thus organise around a core perception of capability and hopefulness rather than deficit’.19 Some of the faculty cited above who spoke of ‘teachable moments’ are actually using aspects of AI when they redirect trainees’ attention towards positive possibilities in the denigrated patient’s life rather than surface features that cause negative knee-jerk responses such as derogatory or cynical humour. Instead of silently sanctioning negative comments or, worse, participating in them, faculty can direct attention to the life world of suffering patients during those ‘teachable moments’ described above.
Inui and colleagues have also adopted CRP, a theory that works concurrently with AI, in their efforts to change the organisational culture at Indiana University School of Medicine. Like AI, CRP theory focuses on conversation and how meaning arises and evolves at each moment of interaction. It asks us to concentrate and reflect on the here and now, on what is actually happening in order to see how ‘patterns of relating… are being re-enacted in each moment’.20 Faculty development in CRP would orient those in leadership positions in clerkship cohorts, residency programmes and other interdisciplinary or administrative teams to how small actions can ‘sometimes, unpredictably, amplify into transformational patterns. It shows how we influence each other by how we show up to each other.’21
Relationships matter, whether they are relationships between doctors and patients, doctors and peers, or medical students and their teachers. As Haidet and Stein persuasively write, ‘…medical educators may be able to harness the power of relationships to modify students’ adoption of the prevailing premises of the medical culture.’22 Individually and in small groups, we can all ‘foster a new way of being together – a new way of relating’20 that leaves behind derogatory and cynical humour directed towards patients. We contribute to medical students’ distress or acquiescence by ignoring the problem;2 at the same time we fail residents and young faculty embarking on a life in medicine. Evidence from the job satisfaction literature indicates that doctors find the interpersonal aspects of care the most satisfying;23–26 evidence from the burn-out literature indicates the opposite, with depersonalisation a significant aspect of that phenomenon.27,28 Helping to launch young trainees into rich and meaningful lives in medicine is surely one of our most sacred duties. To do so, we must help them – and, indeed, ourselves – envisage a healing environment that fosters positive relationships everywhere.
Contributors: all authors participated equally in the conception and design of this project. DW and JA collected the data. All authors participated in data analysis and writing, editing and revising this manuscript.
Conflicts of interest: none.
Ethical approval: this study was approved by the Institutional Review Board of Summa Health System, Akron, Ohio, USA.