Is There a Role for Humour in Medicine? If so, what is...

Is There a Role for Humour in Medicine? If so, what is it?

Original illustration for Healthcare-Arena by Fran Orford

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For centuries, the medical profession and nursing profession have used humour as a way to communicate with patients, with each other, and as a way to reduce stress at work (1). For doctors and nurses, having a ‘sense of humour’ is an important quality and is regarded as part of being an effective and caring professional (2).

The use of humour, mirth, and laughter as a means of communication between healthcare professionals and patients is often recommended. However, population-based health improvements resulting from the use of humour as a form of treatment lack evidence-based research.

In some parts of the world ‘therapeutic laughter’ and ‘laughter wellness’ are accepted new forms of complementary lifestyle medicine (3). These are new approaches that use the aerobic energy of laughter to promote health and well-being in body and mind and to lessen the impact of illness (4). It is possible to imagine that these approaches could become part of the ‘social prescribing’ strategy within the NHS, as humour costs nothing and has few if any reported side effects (5).

Humour can be defined as an external stimulus that helps people to feel happy and to laugh. Psychologists recognise that humour has cognitive, emotional, psychological, behavioural, physiological and social aspects (4).

What Happens When You Laugh?
There is at least one identifiable anatomical location for the neurological response to humorous stimuli. In humans, the anterior part of the supplementary motor area (SMA) in the brain has developed to accommodate the specialised functions of manual dexterity, speech and laughter (6). It is now understood how brain abnormalities involving the SMA, including tumours, can result in abnormalities of laughter (’pathological laughter’).

In one controlled study, a ‘mirthful laughter’ experience was shown to reduce serum levels of cortisol, adrenaline, and growth hormone (7). These physiological changes have been proposed to be the basis for some of the reported physical benefits of humour.

Humour and the Cardiovascular System
In 2006, a study examined the effect of humour on endothelial cell function and peripheral blood pressure (8). Subjects were asked to view an example of a movie causing mental stress; the opening scene of ‘Saving Private Ryan‘ (DreamWorks, 1998). Subjects were then asked to view selected scenes of a comedy movie such as ‘Kingpin‘ (MGM, 1996) or ‘There’s Something About Mary’ (20th Century Fox, 1998) (8). Brachial artery blood flow was impaired as a consequence of viewing a movie that induced mental stress; it was improved following laughter (8). It is possible that mental stress impairs nitric oxide-mediated vasodilatation, whereas laughter facilitates nitric oxide-mediated vasodilatation and lowers blood pressure (9).

Psychological Benefits of Humour
As a personality characteristic, a sense of humour, as measured by different self-reporting methods, is correlated with an increase in self-esteem and a decrease in depressive personality attributes. The influence of a sense of humour on clinical depression is not as clear (10). Some studies on humour as a treatment for depression have shown that humour acts only as a moderator of life events, rather than having a direct effect.

‘Mindfulness-based cognitive behavioral therapy’ (MBCBT) is a treatment that combines CBT with meditation techniques (11). MBCBT has been shown to reduce the risk of relapse or recurrence of anxiety/depression when compared with usual care. In 2015, the results of a clinical trial PREVENT, compared MBCBT with maintenance antidepressant treatment (11). MBCBT was developed to help people with repeated bouts of depression. Patients were taught to recognise symptoms likely to cause relapse and respond using humour. In future, MBCBT could provide an alternative, non-drug based treatment for people who do not wish to continue long-term antidepressants (11)

‘Humorous Coping’
In 2014, Samson and colleagues at Stanford University published a review of the literature on the use of humour to alleviate the stress and even the symptoms of serious physical disease (12). These authors used the term ‘humorous coping’ to describe the approach used by patients, doctors, and nurses, to thinking about and discussing a range of physical diseases (12). This study found that the use of humour was an effective short-term strategy to down-regulate negative thoughts and to up-regulate positive emotions.

Humour and Healthcare Professionals
Sir William Osler (1849-1919), an eminent 19th-century physician, was a proponent of the use of humour in teaching medical students and doctors (13). Many of the teaching recommendations that Osler established continue to be used today.

Most physicians use humour in lectures and do not think that humour is distracting or unprofessional or that it trivialises the education process. For these medical professionals, humour seems to work best in small doses of four or five jokes or cartoons per lecture, as long as it is relevant to the material being presented.

The publication of humorous medical literature has been usual practice for more than 100 years (14). The most common roles for humour include medical school education and reviews, as part of specialist training, in writing and publishing, in research, and in clinical practice.

The New England Journal of Medicine is known for publishing case reports that describe unusual and entertaining maladies (15). In the UK, the British Medical Journal has an annual Christmas edition that includes unusual case reports and studies. As an example, one of the most highly cited of these ‘Christmas BMJ’ studies is from 2013 and is titled: ‘The survival time of chocolates on hospital wards: a covert observational study’ (16).

Humour can help doctors and nurses to deal with the demands of work, foster good working relationships with colleagues and improve morale. Medical students often cope with the stress of their training by making fun of their courses, their professors, and colleagues. In 1989, Keller and Koenig examined the strategies that emergency room physicians use to manage stress and prevent ‘burnout’ and found that humour was used almost universally (17).

In 1996, a review of the role of humour in primary care showed that humour was an important way of communicating empathy by doctors (18). Humour was used by patients to relieve stress and anxiety associated with medical treatment (18). This study also established that patients often use humour to express frustration with their health problems and with their interactions with the medical establishment (18). In 2014, in a study of patients’ perspectives on the use of humour in health care, patients expressed a wish for healthcare staff to initiate and reciprocate humour (19)

In the modern evidence-based NHS, more controlled clinical studies are required before humour and laughter become an accepted form of complementary therapy (20). But even without this evidence, the medical profession is likely to ‘carry on’ in their usual and often humorous way (21).

If you would like to comment on any of the issues raised by this article, particularly from your own experience or insight, Healthcare-Arena would welcome your views.

References

  1. Freud S. Humour. The International Journal of Psychoanalysis, 1928;9:1-6. http://psycnet.apa.org/psycinfo/1928-01858-001 Accessed July 13, 2015
  2. Fry W. The biology of humor. Int J Humor Res. 1994; 7:111–126. http://www.degruyter.com/view/j/humr Accessed July 13, 2015
  3. Laughter Therapy. The Guardian. July 6, 2008. http://www.theguardian.com/lifeandstyle/2008/jul/06/healthandwellbeing4 Accessed July 13, 2015
  4. Martin R. Humor, laughter, and physical health: methodological issues and research findings. Psychol Bull. 2001. 127:504-19 http://www.ncbi.nlm.nih.gov/pubmed/11439709 Accessed July 13, 2015
  5. Parums D. Social Prescribing. Healthcare-Arena. July 14, 2015. https://healthcare-arena.co.uk/social-prescribing Accessed July, 2015
  6. Picard N, Strick PL. Motor areas of the medial wall: a review of their location and functional activation. Cereb Cortex. 1996. 6:342–53 http://cercor.oxfordjournals.org/content/6/3/342.long Accessed July 13, 2015
  7. Berk L, Tan S, Fry W, et al. Neuroendocrine and stress hormone changes during mirthful laughter. Am J Med Sci. 1989. 298:391-6 http://www.ncbi.nlm.nih.gov/pubmed/2556917 Accessed July 13, 2015
  8. Miller M, Mangano C, Park Y, Goel R, Plotnick GD, Vogel RA. Impact of cinematic viewing on endothelial function. Heart 2006. 92; 2:261-2 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1860773/ Accessed July 13, 2015
  9. Miller M, Fry WF. The Effect of Mirthful Laughter on the Human Cardiovascular System. Medical Hypotheses. 2009. 73; 5:636 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2814549/ Accessed July 13, 2015
  10. Kuiper N, Martin R, Dance K. Sense of humor and enhanced quality of life. Pers Individ Diff. 1992;13:1273–83. http://psycnet.apa.org/psycinfo/1993-21538-001 Accessed July 13, 2015
  11. Kuyken W, Hayes R, Barrett B, et al. Effectiveness and cost-effectiveness of mindfulness-based cognitive therapy compared with maintenance antidepressant treatment in the prevention of depressive relapse or recurrence (PREVENT): a randomised controlled trial. Lancet. 2015 Apr 20.pii: S0140-6736; 14:62222-4 http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)62222-4/fulltext Accessed July 13, 2015
  12. Samson AC, Glassco AL, Lee IA, Gross JJ. Humorous Coping and Serious Reappraisal: Short-Term and Longer-Term Effects. Europe‘s Journal of Psychology, 2014, 10; 3:571–581. http://ejop.psychopen.eu/article/view/730/pdf Accessed July 13, 2015
  13. Obituary. Sir William Osler. BMJ Jan 3rd. 1920. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2337064/pdf/brmedj06750-0071.pdf Accessed July 13, 2015
  14. Bennett HJ. Humor in the medical literature. J Fam Pract 1995. 40:334-336. http://www.ncbi.nlm.nih.gov/pubmed/?term=Bennett+HJ+1995 Accessed July 13, 2015
  15. Hunter KM.An N of one.Syndrome letters in The New England Journal of Medicine. Perspect Biol Med 1990. 33:237-251. http://www.ncbi.nlm.nih.gov/pubmed/2304823 Accessed July 13, 2015
  16. Gajendragadkar PR, Moualed DJ, Nicolson PLR, et al. The survival time of chocolates on hospital wards: a covert observational study BMJ 347:7198. http://www.bmj.com/content/347/bmj.f7198 Accessed July 13, 2015
  17. Keller KL, Koenig WJ. Management of stress and prevention of burnout in emergency physicians. Ann Emerg Med 1989. 18:42-47. http://www.ncbi.nlm.nih.gov/pubmed/2783361 Accessed July 13, 2015
  18. Wender RC. Humor in medicine. Prim Care 1996. 23:141-154. http://www.ncbi.nlm.nih.gov/pubmed/8900512 Accessed July 13, 2015
  19. McCreaddie M, Payne M. Humour in health-care interactions: a risk worth taking. Health Expect 2014. 17; 3:332-44 http://www.ncbi.nlm.nih.gov/pubmed/22212380Accessed July 13, 2015
  20. MacDonald C. A chuckle a day keeps the doctor away: therapeutic humor and laughter. J PsychosocNursMent Health Serv. 2004. 42:18–25.http://www.ncbi.nlm.nih.gov/pubmed/15068163 Accessed July 13, 2015
  21. ‘Carry On Doctor.’ 1968. British Comedy Guide. http://www.comedy.co.uk/guide/film/carry_on_doctor/ Accessed July 13, 2015

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1 COMMENT

  1. An intensive-care paramedic father ensured my formative years were spent absorbing the idea of gallows humour as a PTSD preventative. Outside the clinical setting the patient exerts the major influence over outcome, this being tested on an infarct in a remote location. With the hypertensive patient’s BP dropped to under 100systolic and the ambulance lost, cracking jokes was the last resort. After surviving to the cath lab, I was googled and sought out – but not to receive complaints for inappropriate lack of professionalism! Equanimity over imminent death is probably the best preventative (well, in the absence of GTN).
    The risk for doctors is that they’re taken too seriously, more oracle than teacher. Humourist drjustincoleman.com/2015/02 suggesting gabapentin/Neurontin for backpain was a satirical suggestion (as his friends would know), but appears as a product endorsement. Physician wit cannot be delivered deadpan.

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