This week, Dr. Bradley Block and Dr. Andrea Austin return to discuss how physicians can use humor effectively and appropriately while treating patients.

Dr. Austin: Hi, I am Dr. Andrea Austin. I’m an emergency medicine physician and simulation director. I work at Southwest Healthcare and for the Navy.

Dr. Block: My name is Brad Block. I’m a private practice otolaryngologist on Long Island for ENT and Allergy Associates, and host of the Physician’s Guide to Doctoring podcast.

We’re going to talk about humor today. I wrote a blog post about it; you wrote a book chapter about it. There are some rules to being funny—things we’re allowed to do, and things that we tend to do that we maybe shouldn’t. Even if being funny doesn’t come naturally to us, there are clearly some benefits to it.

When I read your chapter, Andrea, about being funny, one of the things that stood out to me was your mention of gallows humor. We use it all the time as a coping mechanism. But the thing that you said about it really stuck with me. Could you tell our listeners about that?

Dr. Austin: It’s interesting. When we think back to when we’re medical students, most of us can probably remember maybe feeling a little bit taken aback by hearing a joke that was mean-spirited. I’ve heard jokes about suicide: “If somebody meant to do it, they would’ve gotten it right the first time.”

We channel that feeling we had when we were a medical student, and then over time we got hardened into believing that this is part of the culture of medicine. As I went through my own softening process that I talk about in my book, I recognized that gallows humor is a maladaptive coping mechanism. I think there are a lot better ways that we can use humor. A term that I like is adaptive humor.

So when we hear gallows humor, I don’t think we should ever shame anybody that says something like that, but it may be an opportunity to check in on them. A lot of times, that gallows humor comes with cynicism. Cynicism is very common in burnout, and it is a form of distancing ourselves from patients and difficult situations.

Dr. Block: So it’s a coping mechanism. They’re using it to cope with something, so then it’s an opportunity for us to check in with them because clearly there’s something they’re needing to cope with. Maybe we can help them find adaptive ways to do that. That’s what you’re saying?

Dr. Austin: Exactly. When we come back to the rules of comedy—I loved your blog post, and it was very similar—to anybody who looks up the rules of comedy, the number one rule is to not punch down. That essentially means that you’re making a joke at the expense of somebody who is less powerful than you.

When we look at who tends to be on the receiving end of gallows humor, it’s patients. Inevitably, when we look at the healthcare system, physicians are in a hierarchy and patients oftentimes don’t have as much power as we’d hope they would have. Taking a step back, using the rules of comedy, gallows humor is punching down. Can we find a more adaptive way? So we can still have a good time at work but leave out the meanness and cynicism that is so prevalent in medical culture.

Dr. Block: If we can’t punch down, where is there left to go but up? That’s where my rule comes from. I didn’t make this up, I got it from Scott Dikkers, who founded The Onion. He says the role of comedy is to afflict the comfortable while comforting the afflicted. Our patients are literally afflicted when they come to see us. They’re afflicted with something. If we’re afflicting the comfortable, we have to decide who “the comfortable” is. That’s punching up.

You can make fun of the establishment, the hospital, the EMR. You can make fun of yourself. I just leave the caveat that you don’t want to take a dig at your competency at all. You don’t want to give them anything that makes them lose faith in your abilities. But other things about you that aren’t related are definitely fair game. Self-deprecation is a pretty easy one. Anything where you’re punching up is totally acceptable. If you want to make some jokes, and you’re thinking about who’s fair game, that’s fair game: the comfortable.

Dr. Austin: Yeah. I’m curious, I know you’ve been interviewing some comedians for a piece that you’re working on. What have you learned from talking to comedians that has surprised you or been super valuable as you’ve tried to incorporate more humor?

Dr. Block: One valuable thing is that the expectation of how funny a doctor needs to be in order to be considered funny is so low. The bar is so low for us. We’re not professional comedians, so any attempt that you make is going to be appreciated because, ultimately, you’re trying to break the ice. Even if you get a little chortle or a chuckle. You’re not really going for belly laughs here. But just something like those corny dad jokes is totally fine—referring to the internet as “the interwebs” or something like that.

Then there’s the fact that we do the same things over and over. You can make a joke over and over again. It’s like you’re doing a comedy set in Detroit and then three weeks later in Minneapolis. It’s not the same audience. It’s a different audience every time.

Another thing is that contrast is one of the places where you can find humor, and there are a lot of contrasts because everything in medicine is really dry. Now, we don’t want to joke about something that’s grave. If you’re giving someone terrible news, that’s not the time to do it. But because medicine is so dry, anything that you do that’s lighthearted and silly is going to be a great contrast. Think about Abbott and Costello, these classic comedy duos where you’ve got the serious person and the silly person. That contrast is where the comedy is. There is a lot of fodder there in medicine.

A couple other things. Laughter is a communal experience. If you’re upbeat and smiling and laughing, it’s more likely to raise the mood. Another thing is to remember you’re not the star of the show. As much as the doctor loves to be the star of the show, you’re not. The patient is. So if they make a joke, be a good audience and laugh at their joke. And then another thing is the energy that you bring to the room. If you walk into the room and you’ve got this positive energy about you, that’s going to feed into a positive experience.

Now, if you make a joke and it bombs, you can still save it. You can say, “Oh, don’t forget to tip your server. I’ll be here all week.” “Don’t worry. I’ll still be there to do your surgery because clearly, I’m not going on any comedy tours.” “It’s a good thing I’m practicing medicine and I’m not a professional comedian.” And then you just move on. You can save a bad joke easily, which gives you the ability to try and make some jokes, see what works, see what lands, and experiment a little bit.

I know you use improv yourself, right? You’ve taken some improv classes and use some of the principles in your exams, which is also like a foot in the door for comedy. Tell us how you use improv.

Dr. Austin: Yes, I attended an improv workshop at the last simulation conference I went to. I’d been to an improv workshop years ago. The classic rule of improv is the “yes, and” rule, which, for our listeners, you can imagine two people up on an improv stage. One person says, “Boy, it’s a really hard life here at the rodeo.” And the response should be, “Oh yeah, the rodeo, man. It’s my second week here.” You add on to that. You never say, “Well, no, it’s not.”

Beyond trying to be funny, it’s a great principle in general with medicine because many times our patients ask us for things that we actually can’t give them. For me, working in the emergency department, it’s “I want morphine for this.” If I take the “yes, and” approach, I say, “Yes, I hear that you’re in so much pain, and I would recommend that we try this medication first.” That is such a better response than “No, I’m not doing that.”

Dr. Block: I was wondering how you were going to add “yes, and” to that. So, “I found that morphine really works for me.” “Yes, and Dilaudid.” Okay, so yes, I hear you, and this is what we’re going to try first.

Dr. Austin: With “no,” you can think to your own personal life, maybe with a romantic partner, if you hear those words, they’re confrontational. Whereas “yes, and” just lands easier for people. That’s one you can take from the comedy book, but you don’t even have to make into a joke.

Dr. Block: Yeah, that’s interesting. In my practice, a lot of what I have to do is untangle this knot of what they believe to be the cause of their symptoms and inform that the diagnosis is something completely different from what they thought. So “no, but” is typically how we approach that. But it sounds like a better way is “yes, I hear you, that you’re having these symptoms, and we have a way to get you some control of those symptoms by opening the possibility to a different diagnosis.”

There was a point where you felt you couldn’t be funny, which was a different experience for me. Humor’s always been my coping mechanism, to the point where my wife sometimes says, “Can you just answer the question? Instead of trying to make a joke out of everything.” It’s clearly a little bit of a problem.

But you felt like medicine was so serious that you couldn’t joke. What changed that? How did you arrive there, and then what changed it?

Dr. Austin: I’m thinking back to one of the first jobs I had out of residency, and I worked in a shop that was very busy, like many of ours. There were a few toxic personalities, and they were just mean and constantly cranking on seeing more patients. I felt myself hardening, like I couldn’t be this more lighthearted person.

I’m thinking back to something you said earlier in the interview, about how if a patient shares a joke, you should just go with it. One of the jokes that patients say most often to me is when I roll the ultrasound in, they’ll say, “Are you going to look for a baby?” This will be a man saying it. I had gotten to the point where I’d think, “Oh my God, I hate that joke, and you’re wasting my time, or maybe you’re not taking me seriously.”

When patients say things like that, even though it’s the thousandth time you’ve heard that joke or you don’t find it particularly funny on that particular day, there’s this concept from the relationship world called a bid for affection. That’s what they’re asking for in that moment. They’re probably scared and they’re checking in: “Is this a good human? I’m kind of scared right now. I hope they are they going to reply in a humanlike way.” Even if they’re not fully processing it, that is what phrases like that are.

Looking back on that, I should have left that job earlier for a million different reasons, and one of them was I couldn’t be authentic. When I’m in my authentic self, even though I’ve been a little bit serious talking about comedy, I am a lighthearted person and I should be able to bring that to work.

Dr. Block: I should take my own advice because the joke that we get all the time being ear, nose and throat doctors is, “So how’s your hearing?” “… What?” Yeah, that’s great. I fell for that the first 100 times someone said it. I’m not falling for that anymore, but I can pretend like it is the first time I’ve heard that and say, “Oh, you almost got me. You almost got me.”

You’re right. It’s that bid for affection. They’re trying to connect with you. They’re trying to joke, and usually they’re nervous. They are the star of the show. So do your best to laugh at the jokes—as long as they’re appropriate, right? They are sometimes inappropriate jokes, and that’s an excellent opportunity to draw a boundary, say that’s not how we do things here, and move on or react accordingly.

There’s another joke that I got from one of my interviews where we mentioned Dr. Google. Everyone comes in with their Dr. Google, and you don’t want to take anything away from the patient having done research, but you can still make a joke and say, “Oh, you know what? I went to med school with Dr. Google and he’s got a big online presence, spreading a lot of misinformation, and tells everyone they have cancer. He might have some valuable information, but it’s hard to tease apart from the misinformation. So why don’t we start from there?” That was a little more long-winded than I usually say it, but just, “Oh yeah, I went to med school with Dr. Google. I’m pretty sure he just tells everyone they have cancer.”

Dr. Austin: Yeah, and I love what you did there because you’ve found, frankly, a trigger when somebody starts to go down the Dr. Google rabbit hole. It’s annoying sometimes. Didn’t you come here to talk to me?

In those moments, maybe without the proper amount of caffeine or whatever I needed that day, a sarcastic response can come out and it never lands well. It’s not funny and it doesn’t make the patient want to take your advice. This is a great moment to reflect on what is a lighthearted authentic response that would let the steam off of me and help us move forward in that interaction.

Dr. Block: I have another joke that you might want to use, especially in the emergency department, because you might be done with the patient, but they’ve still got to get their plan together, their chart together, the nurse needs to see them, their discharge paperwork, all that stuff needs to happen. I think in that place, you might say, “Listen, I know we’ve come to a conclusion on how we’re going to treat this, and you’re going to be discharged or admitted soon. But just so you know, this hospital runs on dial-up. I think someone’s using the phone right now, and we don’t have access to the modem. It’s going to be a little while, so please be patient with us.”

Again, it’s punching up because you’re taking a dig at the hospital and making a joke about the fact that they’re going to have to wait long. You’re being apologetic about it but still making a joke. That goes back to, what are the things that happen over and over again that you can make a joke about and have it still be punching up?

Dr. Austin: I love that. The administrative process is so painful, and we know we have to ask some of the same questions, but I try to use humor in those moments. “I know you just told your story to three different people, and this time you’ve got your story down. With feeling, tell me what brought you to the emergency room today.”

Dr. Block: Or, “Alright, since you’ve said it three or four times, you’re going to be pretty good at it. Now let’s see how fast you can tell me that story.”

Dr. Austin: If you find out somebody’s in healthcare, and, again, if they open the door and they start cracking jokes, you have to make sure they’re not making anything inappropriate. But I do love to follow their lead. You mentioned during grave situations to not use humor, but the person may open the door. I’ve had some patients with stage four cancer that are very, very sick, and they use humor as an adaptive strategy. I’m sure you’ve seen it; I’m sure you see a fair number of patients with cancer as well. A lot of times, they’re great at using adaptive humor. I have to meet them if they’re ready to use that coping mechanism. Even though I might be feeling a little bit sad, I try to follow their lead.

Not that the audience can see us right now, but we’re at least mid-career. I like to round up. If you’ve been doing this for a while, you need to figure out ways to keep it interesting. I’ve enjoyed our interaction because you’re challenging me to come up with some better material. Hey, if you’re getting a little bored with the ultrasound joke, how could you change it up a little bit?

Dr. Block: “We could find a cheeseburger in there. I don’t think we’re going to find a baby, but we might find a cheeseburger.” Although, you don’t want to make fun of someone who’s got a weight problem, but maybe in the other direction, you find someone who’s super skinny and you can say, “Oh, maybe we found a burger and fries in there.”

But you’re right, that’s something they don’t tell us. You get far enough into your career, you see the same things over and over and over, and it stops being as intellectually stimulating as it once was. You need to find ways to make it intellectually stimulating. By making jokes, it makes it more fun for you and the patient. Then everyone’s having a good time.

The benefits to humor: it’s going to lower their cortisol level. Patients are going to be more open to new information. They’re going to be more receptive. They’re going to remember more of the information that you give them. There are so many reasons. It’ll certainly going to help your patient satisfaction scores. Then you’re going to enjoy it more because you’re just having fun with this. It’s just another way to stimulate yourself intellectually. How am I going to make this person laugh at the right times?

So yeah, they don’t tell us that when we’re starting our careers, that in a couple of years this is going to stop being as stimulating as it once was, and you’re going to have to find ways to make it more stimulating. You wrote a book and are doing coaching. What are some of the other ways that you’re finding to make it more stimulating?

Dr. Austin: One of the things I would recommend is trying to use humor to connect with other staff members. We’ve talked a lot about patients. I try to use humor when I’m calling consults. It can be a rough one, but sometimes you can say, “I can’t even believe this,” and then whatever comes next.

In the emergency department, certainly, there are plenty of funny moments. There are natural breaks built in. Thinking about times that everybody has to run out of the room to take the X-ray. That can be a great moment, especially if things seem tense, to throw in a little levity to this situation

Dr. Block: We’re leaving the room, everybody make sure you keep your clothes on. Not that time, that’s not what we’re doing here.

Dr. Austin: Or right before EMS comes in, everyone’s huddled, and maybe you’ve already decided what you’re going to do for this case. Especially if the team’s pretty comfortable, you can throw in something to break the mood as everyone’s waiting for the ambulance to come in. What joke? Do you have anything off the top of your head?

Dr. Block: Oh, no. I mean, haven’t been in that experience. I’ve certainly had to leave the room plenty of times. Anyone who’s been in a hospital has done that. But I’m sorry, I can’t put myself in that situation to try and think of one.

Dr. Austin: All right. That’s my challenge to myself.

When we look at stress responses, we’re trying to find more adaptive ways to do this job, and tend and befriend is one of those ways to lower cortisol levels. Humor is a great way to tend and befriend. When you feel yourself in that heightened state, where maybe you would lean into saying something sarcastic or snarky, maybe take a breath and figure out a way that you can say that differently. It’s good to have some go-to phrases or jokes because it’s really hard to come up with something in the moment. Listening to you, I can tell that you’ve rehearsed some of these and you have some go-to lines.

Dr. Block: So many, so many. I see a lot of pediatric patients, so I refer to them as Mr. and Mrs. or Sir and Ma’am, and I shake their hand. Hyperbole is another device for humor. You can use hyperbole in that situation.

If you’re like, listen, I’ve got this thing that I want to make a joke about. How am I going to do it? Scott Dikkers has these things called funny filters. You run information through the funny filter to try and come up with something funny. Contrast is one of them. Hyperbole. I can’t recall if these are the ones from the book, but that’s the idea. What’s something that I encounter all the time, and what’s a comedic device that I can use, this funny filter?

In thinking of your situation when you’re in the huddle, is there something that you can do to contrast with the seriousness? You’ve got paramedics coming in. They’re not there yet, so you’re not taking anything away from the patient, but something that you can say or do that’s completely silly in contrast to the situation that people might laugh at, or at least break the mood a little bit. That would be something to think about.

Dr. Austin: Yeah. And I’m wondering too, have you experimented at all with ChatGPT giving you any jokes?

Dr. Block: With the way that ChatGPT writes in general, I never would’ve considered it for joke writing, but that seems a reasonable thing. Great. It’s going to take art from us, and now humor. It’s a tool.

Dr. Austin: I’m playing with it for titles, that type of thing. It’s a great place to get the wheels turning. Probably, a few people listening are like, “I don’t even know where I’d start with this. Are you guys asking me to get a MadLibs book?” Throw it in ChatGPT. I am an X type of doctor. What are three dad jokes that I could use at work tomorrow? They might be terrible, but they might get you thinking. If one wasn’t terrible, you can tweak it.

Dr. Block: And it doesn’t matter if they’re terrible because you’re making an effort, and the bar is so low for what your patients expect from you. Even if you’re making these attempts at humor and they’re not that funny, they appreciate the effort as long as you’re punching in the right direction. That’s the key here.

Another thing, if you’re like, “I’m not even funny, I don’t even know where to start,” just think about what you find funny. What movies do you watch? What comedies, sitcoms, movies, and jokes do you like? Because that’s the lens through which you see the world, and that’s where you can start.

Dr. Austin:

Yeah, maybe that is a call to action. I would just recommend to our listeners to listen to and watch comedy. Our jobs are really hard right now, so I’m very conscientious when I’m going through a rough patch that dramas go down in my life, and comedies go up. There are tons of great podcasts out there, too, that can scratch the funny bone.

Well, it has been wonderful getting to chat with you, Dr. Block. For any of listeners that want to get more tips on humor, you can check out my book, Revitalized: A Guidebook to Following Your Healing Heartline.

Dr. Block: Dr. Austin, it was a pleasure speaking with you. I really enjoyed what I’ve learned from you about humor. I can definitely apply that to my practice as well. I appreciate the advice. You all can find me at physiciansguidetodoctoring.com. You can find me on all podcast platforms and on all the socials @PhysiciansGuide. I’ll be here all week. Don’t forget to tip your server.

This transcript has been edited for readability.