Psst. I have a secret to tell you. Lean in closer in case my stethoscope is bugged. You’re not going to believe this, but medical students, residents and attending doctors use derogatory and cynical humour with their patients and with one another. Yup, that’s what I said. Where’s the professionalism and appropriate role modelling for the next generation of doctors in that?
The research that undergirds this secret is described next, along with some reflections on what can be done to change that behaviour.
Negative humour exists, persists and is justified as a way of coping with stress, exhaustion and emotional difficulties
In 2006, Wear et al.1 reported a study of medical students’ perceptions and use of derogatory and cynical humour directed at patients. They found that students frequently cited residents’ and attending doctors’ attitudes and behaviours that indicated the sanctioning and use of these forms of humour. A follow-up investigation by the same researchers,2 published in this issue, sought to investigate these behaviours by residents and attending physicians and to examine their effects on students, patients and themselves. The results are confirmatory. Negative humour exists, persists, and is justified 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.
Other studies cited by Wear and colleagues2 also furnish evidence that these practices exist among medical personnel in the clinical teaching context. Why are derogatory and cynical humour most prevalent? No explanation is given for the derogatory humour observed on rounds, outside patients’ rooms, in conference settings and in private conversations. It’s possible that, as the culture at large condones put-down humour by persons in highly ranked positions over those in more lowly and, typically, vulnerable positions, doctors can get away with that type of humour in the workplace. It’s even part of our entertainment: put-downs are a key ingredient in performances by stand-up comedians and actors in TV sitcoms and comedy movies. It’s so easy to put people down.
Moreover, Wear et al.2 argue that the development of cynicism in medical students is part of the professional socialisation process they undergo as they seek to establish their professional identities. Once they reach the rank of attending physician in the medical food chain, they become less cynical. However, the preceding studies report cynicism at all levels, from student through to attending physician.
Derogatory and cynical humour on the part of medical personnel are forms of verbal abuse, disrespect and the dehumanisation of their patients and themselves
As Wear and colleagues2 conclude, derogatory and cynical humour as exhibited by students, residents and attendings is ubiquitous and well documented. What would it be like to work with or learn under doctors who exhibit this behaviour? Would you like to learn medicine from the type of doctor portrayed on TV as Dr Gregory House? Probably not, unless you land a part in the popular drama bearing his name.
Simply put, derogatory and cynical humour as displayed by medical personnel are forms of verbal abuse, disrespect and the dehumanisation of their patients and themselves. Those individuals who are the most vulnerable and powerless in the clinical environment – students, patients and patients’ families – have become the targets of the abuse. Such humour is indefensible, whether the target is within hearing range or not; it cannot be justified as a socially acceptable release valve or as a coping mechanism for stress and exhaustion. Worse, it seems to have metastasised throughout the medical staff at several teaching hospitals. It erodes any sense of professionalism and civility in the clinical workplace. Absolutely no one deserves to be humiliated, embarrassed, undermined, insulted, belittled, put down, shunned or marginalised by a resident or attending.
These negative behaviours in medical training can be viewed in the context of a national negative trend in higher education. Numerous instances of inappropriate office behaviours on the part of faculty have been documented, including shouting, harsh words, rudeness, ridicule, mean and nasty comments, or underhand, passive-aggressive or bullying behaviours. These behaviours have been lumped together under the label of ‘faculty incivility’.3
How can we begin to change these behaviours in students as well as in senior medical staff? Definite action can be taken in medical schools and in clinical settings to provide the essential interventions. Two key areas that must be addressed are professionalism and use of humour. Suggestions for implementing these interventions are described next.
Regular, standardised assessment of professional behaviours of all medical personnel in academic and clinical settings is necessary to correct inappropriate behaviours
The most obvious starting point is in medical education. Negativism needs to be nipped in the bud. Professionalism should take a prominent position early in the medical school curriculum. Further, follow-up processes should ensure that desirable interpersonal behaviours are practised as students move through the various clinical rotations and clerkships. Regular, standardised assessment of professional behaviours of all medical personnel in both academic and clinical settings can provide the accountability and evidence necessary to correct inappropriate behaviours.
The US National Board of Medical Examiners has developed a list of 59 behaviours (http://professionalbehaviors.nbme.org/2008listofbehaviors.pdf) and is in the process of conducting field trials in collaboration with medical schools and residency programmes to test its instrument in the context of a multi-source feedback (MSF) programme (http://professionalbehaviors.nbme.org/guide.pdf). Measures of professionalism have been included in many 360-degree MSF clinical assessments of medical students, interns, residents and licensed doctors.4 That same model has been extended to professional behaviours of medical school faculty staff.5,6
In this formative decision application, the doctor as clinician or professor represents the hub of the rating wheel. A large sample of raters is chosen by the faculty and department chair. Categories of behaviour might include the emotional intelligences displayed in intrapersonal and interpersonal skills, teamwork, communication, accessibility, responsibility, altruism, honour, integrity, respect, caring and compassion. These behaviours can set standards for all students and doctors, which hold the latter accountable so the former will have appropriate role models to emulate.
Once ratings have been reported to the department chair, meetings with individual students, residents and attendings should be scheduled to provide prompt face-to-face formative feedback on positive and negative behaviours. These ratings can also be contrasted with self-ratings and the department chair’s ratings to pinpoint discrepancies in expectations. An action plan should then be developed to address negative behaviours and track improvements over the months that follow until the next assessment.
Using humour to manage or cope with stress, anxiety, tension, depression, self-esteem and other psychological states is not new.7,8 A large body of research evidence supports its effectiveness and there have been several studies of its use in medicine,9,10 especially in intensive care and emergency departments. But the forms of humour used are critical. Clearly, negative forms, such as derogatory remarks, cynicism, sarcasm and ridicule, which are intended to put down, discourage, embarrass and humiliate students, patients and employees, are inappropriate in teaching and the workplace.7 There are other forms of humour that build people up rather than tearing them down, such as harmless banter or self-deprecation.
Effective teaching and a positive work environment hinge on trust, respect, honesty, understanding, encouragement and open communication.11 A work environment built on fear, intimidation and stress caused by put-down humour and cynicism is not conducive to either learning or effective job performance. A 2006 survey of health care workers indicated that 55% of primary care doctors under the age of 45 years planned to leave their practice within 4 years. Dissatisfaction and disappointment in the profession on the part of medical directors, nursing executives and other clinical professionals are spreading.
Department chairs should communicate the ‘rules of conduct’ regarding appropriate forms of humour and model by example
Decades of research by the Great Place to Work® Institute and its surveys of thousands of employees across a wide range of industries, including high tech, health care, financial services and manufacturing, yielded Fortune’s‘100 Best Companies to Work For’ list. Employees at the best companies have a high level of trust and say they are working in a ‘fun’ environment. Those companies have higher productivity, better recruiting, reduced staff turnover and greater camaraderie than companies outwith the list.
What can be gleaned from those results that could benefit medical education? The process of defining how humour is used starts at the top. The department chair should communicate the ‘rules of conduct’ regarding appropriate and inappropriate forms of humour in the classroom and clinical environment and then model by example in practice.7 This sets the tone for everyone else.
Despite the natural seriousness and intensity of medical school and practice, humour can serve as that necessary coping tool to manage stress and tension. There are numerous appropriate techniques students, residents and attendings can use.11 These techniques should be integrated into professionalism courses in medical school and in faculty development programmes at various clinical sites. This strategy will hopefully improve attitudes and interpersonal skills to create academic and clinical environments where trust, respect and the positive use of humour can grow.