“Laughter is the best medicine.”

The comment is a cliché thought to have its origins in the Bible. Regardless of who first coined the phrase or when, humor shares a place with hope and sorrow in patient care. Hippocrates advised a balance between seriousness and wit because he asserted no one, healthy or ill, liked a dour face.¹

Much has been written about humor in medicine from the patient perspective. There are frequent references to Norman Cousins’ “Anatomy of an illness,” which was both an article and a book. Cousins describes the pain of ankylosing spondylitis and how watching funny movies (primarily Marx Brothers and sitcoms) and a good 10 minute laugh (along with mega doses of Vitamin C) allowed him two hours of sleep without pain and lowered his erythrocyte sedimentation rate. Despite his original dire prognosis, he recovered and credited laughing as the cure. ²

A small but interesting study looked at end-stage renal disease patients and found that a sense of humor appeared to lead to better coping with kidney disease. The study (less than 50 patients) relied on questionnaires to assess sense of humor-although an argument can be made that a sense of humor is too objective to be measured. The authors conclude that a sense of humor contributes to greater survival, although not necessarily a higher quality of life. ³

Can humor help the caregiver?

While there is considerable literature, much of it anecdotal, on humor’s healing powers, humor for the provider is relatively unexplored. Just as humor has the potential to alleviate suffering in patients, it can bond staff together and alleviate the stress of caring for ill patients and their families. No one would say professional education for physicians, nurse practitioners, or physician assistants is a cakewalk; it is serious, often grueling, and takes its toll on the students. Yet a tradition in many institutions is the “roast,” where students make fun of their instructors, themselves, and experiences over the past years.

Poking fun can also be on a small scale. At the end of a hospital ward rotation which had been particularly stressful—critically ill patients, unexpected deaths—the house staff team (medical students, residents and fellow) ordered various mustaches to emulate their attending physician. On the last morning, when the attending entered the report room, the group––men and women––met him each wearing a pasted-on mustache. A framed picture hangs in his office not as a memory of a horrendous month but of the lightheartedness found in the midst of stress.

Humor also has a dark side. Known as gallows humor, it often is used in a time of extreme stress and often has meaning to specific groups and cultures. Thus, what is extremely funny to those of us in nephrology might leave the dermatologists totally stone faced.

Humor and stress

The House of God, published in 1978, rocked the process of turning new medical school graduates into tough, capable physicians. Written by Stephen Bargman, MD, under the pseudonym of Samuel Shem, it drew back the curtain on the training and shaping of future physicians. It also exposed the often cruel humor and acronyms that allowed them to cope with the stress of training. Today the book is something of a novelty since positive changes have occurred in reducing resident duty hours. However, it remains popular and is often cited in classes and lectures.

Patients also use gallows humor to make light of the life-changing diagnosis of kidney disease. The most famous practitioner of patient-driven humor is Peter Quaife, former bassist for the English rock band The Kinks, who drew a series of comics called “The Lighter Side of Dialysis.” When his dialysis nurse saw Peter sketching humorous scenes with a dialysis theme, she talked him into posting them in the dialysis unit and eventually publishing a book on humor in dialysis. While Mr. Quaife has passed on, his humor is still with us, still topical and timely, and can still bring a smile to even the grumpiest patient.

Humor doesn’t come in a pill form and can’t be prescribed. But it has its place in the medicine bag of antidotes for you and your patients.    

[sidebar]

As with most ideas, there are two sides to humor and medicine. There are those who do not see where it has a place in patient care. If this is your opinion, quit reading now because what follows is a collection of real conversations with real patients and real practitioners. If you have your own stories to tell, drop us a line.

Jane Davis ( This e-mail address is being protected from spambots. You need JavaScript enabled to view it ) •  Kim Zuber ( This e-mail address is being protected from spambots. You need JavaScript enabled to view it )

• While rounding, a PA was beckoned over by a long time dialysis patient to his chair. “You know,” he said, “I have given it a lot of thought and I have decided to be a kidney donor.”
• A mildly demented patient kept driving herself to the clinic although we felt it was unsafe. One day, she lost control of her car and ran through the wall of the dialysis clinic, ‘parking’ in the employee lounge. She calmly got out of car and walked into clinic (no, not through the hole in the wall, which she seemed not to notice). I could not let her drive any more. The clinic is on a street with two elementary schools. So I called the state Division of Motor Vehicles and told them she was unsafe to drive. They called her in for driving test, she failed and had her license revoked. She blamed me and reminded me every time she came in for treatment. Fast forward two years. She is now completely confused, does not remember her family, or her name. She has been transferred to another one of my clinics, and one day sees me (after 2 years) and shouts,  “You took away my driver’s license...”
• A 70-something happily demented dialysis patient with chronic hyperkalemia is sitting on the dialysis chair eating a banana. The dietitian asks if her hyperkalemia could be from her diet. She says no. Then the dietitian asks if she ever eats bananas, and she says no. The dietitian mentions there is a banana in her hand right now. The patient was stunned to find that out.
• Ms. Smith is a 66-year-old female with end-stage renal disease and has been on hemodialysis for eight years. She has a long history of hyperkalemia despite repeated weekly visits with members of the dialysis team. Last week while rounding, she asks me, “Why is my potassium always high?” In my non-irritated voice, I respond with, “Ms. Smith, remember as we have discussed in the past, since your kidneys stopped working, your diet is the main reason why your potassium is always high.” In a loud shrill voice, Ms. Smith gasps/screams, ‘My kidneys stopped working?!!!  When did this happen?  Why didn’t anyone tell me?’ This conversation took place while she was receiving hemodialysis.
• A favorite hemodialysis patient had a wife who was a saint. Every month or so, he would become agitated about waiting, medications, the patient next to him, or just the phase of the moon. Then he would cuss at the staff. We had a monthly meeting with him, his wife, the social worker, and the clinic manager. We went through the fact that he could not cuss at the staff. He said: “Damn it, I don't cuss.”  I pointed out that many people consider “damn it” cussing. He responds, “Hell, then I can't even talk.”  His wife just rolled her eyes and mouthed an apology to us as we tried to keep our giggling under control. When he died, we all admitted that we missed these monthly meetings for their comedic value.
• A patient came to the CKD clinic with a GFR of 15. She had been coming to a nephrologist for four years and CKD clinic for two. I moved my chair close to her, looked her in the eye, and said, “We really need to talk about what you want to do when your kidneys fail.”  She looked at me in horror and said, “What? Is something wrong with my kidneys?” Gently, I said, “Yes, your kidneys are not working well.” She stood up, grabbed her coat, and said “So you waited to tell me when it is too late?”  I said we had been talking about it for two years and her nephrologist had been seeing her for four years. She looked me straight in the eye and said, “No one ever told me there was something wrong with my kidneys,” stormed out, and has not been seen again.
• I once had a patient who had a paper pica. He would eat anything remotely close to paper. Most egregious would be when he visited other sites of care and would eat whatever information was given to him: ER visit paperwork, lab requisitions, etc. When it was clear that he was going to die soon (he lived years longer than any of us thought possible), I thought how much he would have loved to be in a room with his medical records (all paper) and could pick and choose what he wanted to eat. Imagine the variety.
• Three police cars came screeching up to my dialysis unit this evening....lights flashing, guns pulled, covering the front/back entrance of the unit. Four police officers got out and came in asking about a grey Honda. It was reported as stolen. The police activated the 'Lo-Jack' device and it led the police to the dialysis unit. Turned out the husband of the dialysis technician forgot she had taken his car to work.
• A diabetic was excited to get a new prosthesis for his below-knee amputation. His NP asked what he would do with the old one. “That's easy,” he said. “I’m gonna turn it into a planter and grow flowers. I’ve got several at home and they make great planters.”
• One patient had a habit of not coming to dialysis for at least one of her thrice-weekly dialysis sessions. A fellow dialysis patient called her once and asked if this person was coming to dialysis today. “No,” was the response. “The snow is piled up a foot high outside my house and I can't get out.”  “Funny,” said the fellow patient. “We're in your driveway right now and there is no snow.”  She still didn't make it to dialysis.
• We have a patient who is major fluid abuser despite many talks, much counseling, many care plans, interventions, discussion with social worker, etc., and the dietitian did everything but stand on her head. He comes in today at 15 kg over, but it is OK. He has decided that for Lent, he will watch his fluid and only (!!) gain 5 kg between treatments. All I have to do, he tells me, is to be patient and wait five weeks for Lent to start.

References

1.     Berger JT, Coulehan J, Belling C. Humor in the physician-patient encounter. Arch Intern Med.2004. 164 (8): 825-839.

2.     Bennett HJ. Humor in medicine. Southern Medical Journal.2003; 96 (12) 1257-1261).

3.     Syebak S, Kristoffersen B, Assergd K. Sense of humor and survival among a country cohort of patients with end-stage renal failure: A two-year prospective study. Int, J Psychiatry Med.2006; 36 (3): 269-281.

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