AMA Journal of Ethics^®

Abstract

Abundant evidence documents positive physical and psychological health benefits of humor. Humor and laughter researchers at the Association for Applied and Therapeutic Humor (yep, that’s a real thing) not only study why humor helps, but also how it can be applied in health professions settings where patients are ill, injured, or otherwise vulnerable. Along with briefly outlining some health benefits of humor and pitfalls to avoid when using humor, this article provides actionable strategies for enhancing one’s humor skill set and applying humor deftly (without doing harm) in clinical settings.

Benefits of Humor

My being kicked out of my philosophy 101 ethics course in college taught me a lesson about humor. The professor asked, “What is philosophy?” I said, “A bunch of old white guys arguing about things that don’t matter and nobody understands.” He forcefully replied, “Do you not understand because it doesn’t matter? Or does it not matter because you don’t understand? You can leave this class until you have an answer!” In addition to ethics, he also taught me a great lesson about the application of humor. Before you can be a smart ass, you first must be smart.

In the 25 years since my philosophical funny fail, I began to see the power of humor not only to get a laugh, but also to connect with people and even enhance health and well-being. We know that humor and laughter are shown to decrease levels of stress hormones,^1,2 lower blood pressure,³ strengthen the immune system,^4,5,6 decrease pain,^7,8,9 and decrease inflammation.¹⁰ Laughter is an excellent addition to treating almost any condition—with the exception, perhaps, of urinary incontinence.

Today, as president of the Association for Applied and Therapeutic Humor (AATH),¹¹ I study and apply humor to enhance health and human performance. At AATH, we define therapeutic humor as an intervention that promotes health and wellness by stimulating playful discovery, expression, or appreciation of the absurdity or incongruity of life’s situations.¹¹ It can enhance health or be used as a complement to treatment to facilitate healing or coping. This article discusses strategies for implementing humor in clinical settings, including how to develop humor habits, use improvisation as a tool, be intentional about using humor, avoid common pitfalls, and assess risks and rewards of using humor.

Humor Is a Habit

You might be thinking, “This is great, but I’m just not that funny.” If you’re thinking that to yourself, you’re probably right. You might not be that funny, but you are self-aware and modest, both of which are important parts of becoming funny.

A great thing is that you don’t have to be naturally funny to get good at using humor. A first step is to train your brain to have a funny focus. You can develop this mindset by incorporating humor habits in your life, including those discussed below.

• Comedy commute. Listen to comedy or humorous podcasts on your commute rather than news. Listening to more comedy on your commute will expose you to a variety of types of humor, which will help you learn more about what types you enjoy. You might not know that you like funny stories, observational humor, satire, slapstick, or impersonations until you give humor programs a try.

• Three funny things intervention. Each day write down 3 things that happened that you found funny, amusing, or humorous. One of our AATH researchers found that people who daily wrote down 3 funny things that happened for only one week increased their overall happiness and decreased depressive symptoms for up to 6 months!¹²

• Play the “what I could’ve said” game. If you’re the type of person who always thinks of the funny thing you could have done or said after the moment has passed, that’s okay! Go with it. Come up with various humorous ways that you could have handled a situation or greeted a patient. The more often you do this, the more quickly your brain will start making these connections.

• Five-minute funny. Set an alarm to take a break to watch a funny video. Not only will this keep your brain in funny-focus training, it will keep you sharper and more productive for the rest of the day. In fact, people who take a break and watch a funny video are twice as productive when returning to work as those who took a break with no humor.¹³ Humor has also been found to be one factor that can mitigate and counteract the effects of mental depletion.¹⁴

• Follow funny. Like and follow funny pages on social media. This practice will increase the amount of humor that organically appears in your feeds, thus increasing your exposure to humorous triggers.

Sharpening your funny focus by developing humor habits follows Hebbian theory that “neurons that fire together, wire together.”¹⁵ In fact, the findings of one study suggest that the more experience people have using humor, the more they will shift from relying on prefrontal cortex executive functioning to guide searches for humorous associations to relying on the temporal lobe, which facilitates spontaneous and remote or abstract associations.¹⁶ Training your brain to have more of a funny focus is about being intentional and not simply hoping for but harnessing humor. It’s okay if you aren’t naturally funny. Humor is not a talent. Humor is a habit.

Improv to Improve

While the purpose of improvisation (improv) isn’t necessarily to generate humor, it can be a joyful consequence of being present, listening, and building upon what others offer. “Yes, and” is commonly thought of as the first rule of improvisation.¹⁷ While “Yes, and” is a crucial part of doing improvisation well, one must first be present in the moment and listen. If you’re a clinician going through the motions, distant, and not listening, it’s very easy to miss opportunities for humor. Your patients might open the door for humorous interactions themselves. The question is whether you notice those open doors. One study found that patients initiate humor in a clinical setting at about the same rate as clinicians.¹⁸ The bad news, however, is that not all clinicians follow the first rule of improvisation as much as they could. In one study, clinicians only elicited the patients’ agenda 36% of the time, and, when they did, in 67% of those encounters the clinician interrupted the patient in a median time of 11 seconds.¹⁹

It’s okay if you aren’t naturally funny. Humor is not a talent. Humor is a habit. 

Humor can sneak its way into a clinical situation if you remain open to it. For example, Sarah Bryson, a licensed clinical social worker in Arkansas, was meeting with a client and talking about depression and suicide. When Sarah told her, “I’m concerned that you’ve been thinking about suicide,” they heard the deep sound of the tympany drums from a music therapy room down the hall (“Bum bum, bum bum, bum bum!”). The client began laughing hysterically, and Sarah followed suit. This spontaneous moment of humor led to the client opening up with Sarah. Now, any time their conversations take a more serious tone, one of them will say, “Bum bum, bum bum, bum bum!”(S.W. Bryson, oral communication, December 10, 2019). A key is to listen and follow patients’ lead. If they’re using humor with you, then it probably makes them more comfortable. Just like in improvisation comedy, you listen for opportunities and then proceed with positive intentions: “Yes, and!"

Humor by Choice, Not Chance

Now that you’ve got some humor habits and your improvisation listening skills are on point, here are some strategies to help those of you who are clinicians to intentionally incorporate humor in the clinical setting.

Prime the pump for positivity. In order to increase the chances of having a lighthearted and positive interaction with your patient, add humorous reading material to your waiting area, tune into funny shows on the TVs, display a funny photo of your pet or kids in your office that might spark conversation, or even place funny signs in public areas. For example, one doctor’s office had a small sign that read, “From ‘1 to stepping on a Lego,’ how much pain are you in?”²⁰ The signs don’t even need to be medically related to get a smile. Why not have the boring “Please wash your hands sign” in the restroom be a picture of Han Solo that says, “Wash Your Hans?” Anything that is a little funny or different could have a positive effect on the emotional state of your patients prior to them even seeing you.

Conversation starters. Try something different by creating a list of questions—or a stack of cards with questions on them—and having the nurse tell each patient to choose one question that the doctor will answer upon entering the room. The following questions might be helpful conversation starters: What’s the weirdest thing you’ve ever eaten? If you built a themed hotel, what would the theme be and what would the rooms look like? What would a world populated with clones of you be like? This quick dose of fun is sure to lead to some humor and easier dialogue. If it feels like the patient is comfortable with you, then you can ask the patient the question.

Find humor in pain points. Humorist Charlie Chaplin once said, “To truly laugh, you must be able to take your pain, and play with it.”²¹ Most comedians focus on the pain points in life to generate humor. Think about annoying things that are universal to your patients, such as long wait times, long lists of side effects, complicated insurance forms, or that loud crinkly paper covering the exam table. You might even draw some humor out of the patient’s pain by asking a slightly different question. After asking about symptoms or how they’re feeling, you could ask, “What’s been the most annoying thing about dealing with this condition so far?” Sure, the patient might share something that isn’t funny, but it could spark a humorous response that you can run with!

Exaggeration. This is a commonly used, simple tool of comedy. In fact, this year alone, use of exaggeration has gone up a million percent. (Sorry, I had to.) Anyway, all you do is take a concept and exaggerate it to a ridiculous level to make it funny. Let’s take one of the aforementioned pain points of long wait times. Rather than coming in and saying, “I’m sorry about the wait,” you could exaggerate it. “I’m sorry about the long wait. So, the chart says you’re 43…. Is that still the case or have you celebrated a birthday since you got here?”

Comic triple. This is another simple comedic technique. You just list 3 items in a row with the first two being serious and the last one being funny, surprising, or different. For example, if you just treated a broken leg and are telling the patient what to expect, you could say: “In the first week, you can expect some swelling, itching, and constantly being asked, ‘OMG what happened’!?”

Laughter yoga. Incorporate laughter exercises in your practice. At AATH, many of our members are certified in leading laughter yoga, which consists of a version of yoga breathing exercises (pranayama) done in the form of laughter. The laughter leader could have participants breathe in deeply and breathe out with guided “ha, ha, ha’s” or “hee, hee’s” with movement. Designed to help people reap therapeutic benefits of laughter and humor, laughter yoga is being practiced at some senior living facilities, workplaces, and hospitals.^{22,23,24,25,26,27} One study suggests that laughter yoga is a promising addition to the hemodialysis regimen and might enhance some dialysis patients’ quality of life.⁹

Avoiding Pitfalls

We know that humor builds trust and that when 2 people (even strangers) laugh together, they are far more likely to like one another,²⁸ so humor is a great way to get those patient satisfaction survey scores up! Keep in mind, however, that people may not be looking for humor in their health care experience. That`s why, as a clinician, the most important thing you can do is listen, connect with a patient, and follow their lead. One of the best ways to avoid pitfalls with humor is to start with yourself and your own experiences rather than trying to focus the humor on a patient or their situation. And be careful when using self-deprecating humor. A self-deprecating joke can be a way to reduce social distance between you and a patient, but be sure it isn’t about skills necessary to do the job well. For example, you might tell your patient about dropping your jelly donut on your white shirt this morning, which could get a chuckle. What you don`t want to do is to add, “I can be so clumsy sometimes” or “talk about butterfingers!” The last thing a patient wants is to picture their clumsy clinician not being able to hold a jelly donut right before their vasectomy.

Another way to avoid pitfalls is to remain positive and inclusive. Aiming humor at common human annoyances is a much safer bet than aiming at specific people or groups of people. For instance, if you know that parking at your facility is difficult, parts of the building are under construction, traffic nearby is brutal, or the rain has caused a bad hair day for you, those are all common annoyances that most people relate to. Before using humor, you can always ask yourself the question, “What’s the risk?” If there is a reasonable risk of someone taking offense, then in a professional setting the cost is too high. When in doubt, leave it out. Remember, if you have to say, “It was just a joke,” then you haven`t told one.

Risk vs Reward

Using humor is not a requisite qualification for being a good clinician. I`m a humor advocate, and even I don’t want my clinicians spending more time trying to figure out how to make me laugh than staying current on best practices in their field. Intentional, strategic use of humor in a clinical setting need not be for every clinician in every circumstance and is a skill carefully and deliberately learned and enhanced over time. As with many things in life, using humor with an intention to connect with patients, decrease their stress, or provide a moment of relief from their concerns does not come without risk.

If I want to run a marathon, I incur risk of injury, and I greatly reduce that risk by training properly, taking things slowly, and getting better at the craft. If using humor in the clinical setting is something you would like to try, but it isn`t a natural part of your repertoire, then begin with easy, low-risk strategies. For instance, as mentioned, having a funny photo on the wall or funny reading material in the lobby are low-risk ways to begin to see whether patients engage with it and comment on it. You might decide you`re simply going to try to intentionally notice and listen for moments when patients are attempting to use humor and give them an encouraging smile or laugh. The “what I should have said” or “3 funny things” interventions described above are personal exercises nobody needs to know you’re doing, but they might lead to your sharing a humorous anecdote or two from your week with a patient.

Starting with the lowest risk strategies that feel comfortable for you can result in the humor you use being more reflective of your own personality and engagement style. Perhaps that is why one study published in JAMA (albeit a study published when the Backstreet Boys were topping the charts) found that primary care physicians who had zero malpractice claims against them used more statements of orientation with patients, laughed more, and used more humor than primary care physicians who had a history of malpractice suits.²⁹ When used in combination with professional empathy, compassion, and knowledge, humor can be a low-risk way to positively influence some patients’ experiences.

In Conclusion

By using some humor habits, you can train your brain to have more of a funny focus and then begin to intentionally, deliberately create humor—not by chance but by choice. At AATH, we believe in humor’s power to compliment clinical practice and aid physical and psychological healing and recovery processes. Whether you think you’re the clinic comedian or a humor novice, incorporating humor in your life and practice is a skill that can be learned and leveraged.