Pleasing the patient vs. saying no

The patient in Dr. William P. Sullivan’s emergency room in suburban Chicago asked him to write a note excusing her from work because of an unsightly pimple on her nose. He said no, but later he wondered: Would the refusal, even if it were clinically and ethically appropriate, result in a ding to his department’s patient satisfaction rating?

“People get mad and you think, ‘Great. There goes another bad score,’” he said.

The anecdote is recounted in an American Medical News story that explores what seems to be a source of growing tension between doctors and patients: providing care that’s appropriate vs. pleasing the patient.

This is by no means a new issue. Doctors have always had to deal with patient expectations for care that are not necessarily warranted – antibiotics for a viral infection, for instance, or imaging tests with a low likelihood of yielding any useful information. What’s different these days is that physicians, and the organizations they work for, are increasingly being graded on patient satisfaction and paid accordingly.

From the American Medical News article:

Nearly two-thirds of hospitals, health systems and large physician groups have annual incentive plans for doctors, said an October 2011 report from the Hay Group, a Philadelphia-based management consulting firm. Sixty-two percent of those use patient-satisfaction metrics as a factor, up from 43% in 2010, said the survey of 182 health care organizations covering physicians in 144 medical specialties. Many set base pay lower and require doctors to meet performance metrics to earn hefty incentive pay.

“Bonuses of less than 5% don’t get anybody’s attention. Make it 5% or 10% or 15%, and that’s a sufficient financial opportunity to get your attention,” says Ron Seifert, vice president of the Hay Group. “We’re going to see more of this.”

To add to the motivation to get serious about patient satisfaction, Medicare also has begun paying for and publicly reporting performance measures. Patient satisfaction ratings account for 30 percent of the overall score; hospitals and physicians who fall short will see a percentage of their payments withheld. In other words, if patients are unhappy with the care they’re receiving, the penalty to providers will be a smaller paycheck.

Is patient satisfaction such a bad thing? It’s no secret that health care hasn’t always been well attuned to the patient’s perspective. In many ways, the emphasis on patient satisfaction is a long overdue effort to place the focus of health care where it belongs: on patients themselves. If providers consistently receive low scores from patients, it’s probably a sign that there are some issues in need of addressing. Tying it to financial incentives simply puts more skin in the game.

There’s valid debate, however, over the extent to which patient satisfaction ratings accurately reflect quality of care and how much they should influence the size of the provider’s paycheck. Are patients receiving quality care when the doctor agrees to their request for a CT scan for a headache, even though the imaging study is expensive, exposes the patient to radiation and is probably unnecessary? What about people who are likely to be unhappy regardless of the quality of the care they receive?

The connection between the doctor’s refusal of an inappropriate patient request and the likelihood of a low patient satisfaction score in fact is not entirely clear. That’s why a Wisconsin physician who specializes in addiction medicine is designing a study to examine this relationship more closely.

Dr. Aleksandra Zgierska, an assistant professor with the University of Wisconsin School of Medicine and Public Health, told American Medical News that decisions about prescribing narcotic pain medicine are a “day-to-day conundrum” in her practice. “The challenge is how do we discuss this with the patient so the patient doesn’t leave unhappy… Saying yes is easy. I know from firsthand experience that it’s very tempting,” she said.

Her study will look at the prescription of opioid pain medications and whether it correlates to patient satisfaction ratings.

Of the handful of other studies that have explored this issue, the one that has received the most attention appeared earlier this year in the Archives of Internal Medicine. It found that patients who gave the highest satisfaction ratings also had higher prescription drug costs, were more likely to be hospitalized and had worse outcomes – but the researchers could not definitively establish why this was the case. Although it might be assumed (and this indeed was the conclusion that many people seemed to draw from the study) that these patients were happier because they were receiving lots of prescriptions and hospital care, whether it was warranted or not, this remains just that: an assumption.

Turning down requests for inappropriate care may in fact not be the no-win situation that doctors fear, the American Medical News article suggests:

Experts agree that saying no does not have to mean an unhappy patient. They say that listening with empathy to a patient’s concerns, reviewing options in an evenhanded, nonjudgmental way, emphasizing the undue risks of nonbeneficial interventions, asking the patient to defer a decision, and even sitting down with the patient – instead of standing – can help.

It’s possible that many patients might actually welcome the discussion and ultimately leave the exam room feeling better informed about the decisions that were made.

The real issue seems to be one of balance. How can providers deliver quality care without compromising for the sake of a good patient satisfaction score? How can the patient experience be meaningfully valued without compromising other important measures for how providers ought to be paid? Regardless of the imperfect metrics that currently exist, these are questions that demand some thought.

The exercise conundrum

We all know physical activity is supposed to be good for us, yet approximately 40 percent of the American population reports not exercising at all. How come?

The New York Times reported a couple of days ago on some intriguing research that might shed a little light on this riddle: When people avoid exercise, maybe it’s because some forms of physical activity leave them feeling bad rather than good.

How this works seems to be complicated. In a series of studies, the researchers found that people had different reactions to the increasing intensity of exercise. Some felt better the harder they exercised; others felt worse. The majority of them felt bad when they surpassed their “ventilatory threshold,” or the point at which they were breathing too hard to talk – and this threshold was different for everyone.

In another study, volunteers were asked to exercise for 20 minutes at a level that felt unpleasant to them. In one session they were given a five-minute cool-down afterwards that restored their sense of well-being. In the other session, they were told to stop exercising without cooling down. When asked later which of the two workouts they preferred, most chose the one that left them feeling more pleasant.

In some ways this shouldn’t come as a surprise. People tend to pursue activities that make them feel good and avoid those that don’t.

The more intriguing part is that we seem to be learning that exercise, like weight management, may not be a one-size-fits-all matter of “just do it.”

While the vast majority of people derive health benefits from regular physical activity, there clearly are differences in how it’s perceived and experienced.

Some people seem wired to enjoy exercise more than others do, and research suggests there indeed may be individual variations in how the body responds physically and emotionally to exercise. Some runners, for instance, experience the fabled “runner’s high,” while others don’t. Then again, perhaps individual behavior is largely to blame for why so many people don’t engage in exercise.

Or is it more complicated than this? Reader responses to the New York Times article provide a wider perspective on what might be going on in people’s lives to make the recommended 30 minutes of daily physical activity so difficult for many of them.

One person lived in San Francisco for many years, didn’t own a car and walked everywhere. Then he moved to Florida, to a town where “a car is needed for even the smallest errand,” and watched his weight, cholesterol and blood pressure soar. Others described neighborhoods with no sidewalks, streets that are poorly lit at night, bike paths littered with glass, and gyms and fitness centers that are either unaffordable or only open during the day.

Some commenters wrote that for many non-exercisers, the problem is in getting started. What they need is help, patience and encouragement, one person wrote. “There is so much anxiety tied up in this issue for people who are out of shape, they don’t know where to start and the idea of exercise feels overwhelming and genuinely terrifying.”

And what about the tendency for issues such as arthritis, chronic insomnia, low-level depression or long, stressful work hours to undermine people’s willingness to be more physically active? One commenter, who had frequent severe migraines and also worked long hours, wondered, “How is one supposed to exercise?!?! and eat? and sleep? and be a person… of sorts?”

Several commenters also complained about the sniffy elitism that can pervade the conversation about exercise – for instance, value judgments about what constitutes “real exercise.” Don’t shame people for not being able to engage in a high-intensity workout, wrote one woman, who said she’s over the age of 60 and has painful arthritis. “Judging other people’s exercise habits doesn’t make them want to exercise more, it just makes them feel bad.”

Someone else pointed to the unrelenting hideousness of phys ed classes in junior high that were rigid and competitive rather than fun. “Maybe that is why I came to hate exercise and it still feels like punishment,” she wrote.

So what’s the answer? It seems to come down to making physical activity more rewarding and less of a struggle. How this is supposed to be accomplished might be different for everyone – and, as with the national effort to reduce the incidence of obesity, some of the solutions will likely have to take place in the environmental and policy sphere. Figuring out why some people genuinely enjoy exercise and find it pleasurable and why others don’t might be a good start, though, at understanding these differences and coming up with effective strategies to help.

Movember: just another gimmick?

Take a look at the guys around you this month and count how many of them are displaying more facial hair than usual.

Chalk it up to Movember, a global charity event that invites men to grow mustaches during November to raise awareness and money for men’s health. According to the website, the initiative had more than 854,000 participants – they’re known as “Mo Bros” – worldwide last year and raised $126 million on behalf of prostate and testicular cancer.

Well, fair enough. After all, the entire month of October is devoted to breast cancer awareness and fundraising and all things pink. Maybe it’s time men had their own health month.

But the critics are cautioning: Don’t be too quick to get behind this health campaign without asking more questions about what’s really being accomplished.

What is the substance behind the “awareness” the Movember campaign says it promotes? Take a look at the list of Movember health tips, which include a recommendation to get an annual physical: “Getting annual checkups, preventative screening tests and immunizations are among the most important things you can do to stay healthy.” Nary a mention is made of the debate surrounding the value of the yearly physical exam. Nor is there discussion about the risks vs. the benefits of prostate cancer screening, an issue that’s of considerable controversy amongst the medical and scientific community, or how men can weigh the evidence to make appropriate, informed decisions.

Another health checklist on the website advises men 40 and older to talk to their doctor about the use of aspirin and statins to lower their risk of heart disease, even though the preventive benefit of these two therapies has not been clearly established in people who don’t have existing heart disease.

Most would agree men are well served by education that gives them accurate, realistic information about their health. Are they served as well by information that’s overly simplified or that fails to adequately convey evidence-based pros and cons? Or by messages that confuse screening with prevention?

Perhaps the bigger issue is whether Movember, which started out with good intentions, is turning into a gimmick that allows people to feel good about a cause merely by growing a mustache and donating a few dollars.

Blogger Ashley Ashbee calls it “a type of slacktivism.”

“Does your moustache share information about the importance of screening, or where to get screened?” she wrote last year. “Does it tell you how you can prevent prostate cancer (if you even can)? Does it tell you the symptoms? Does it tell you who’s affected?”

Moreover, critics say one of the flaws of catchy public awareness campaigns, whether they’re exemplified by mustaches or by pink ribbons, is that they can skew the public’s perspective about risk and disease and lead to inaccurate or exaggerated beliefs that sometimes spill over into health-related behaviors. Although prostate cancer is far and away the most commonly diagnosed type of cancer among men in the United States, it’s actually lung cancer that is responsible for the most cancer deaths in men. Heart disease continues to be a significant health risk for men and, many would say, is the leading male health issue. Men also outnumber women when it comes to alcoholism, fatal traffic crashes and suicide.

To their credit, the Movember organizers added men’s mental health this year to their list of causes. But whether this helps improve the public’s understanding about male health remains to be seen.

The Toronto Globe and Mail spoke last week to medical ethicist Kerry Bowman of the University of Toronto, who lamented, “There’s not a direct relationship between the diseases we hear most about and either their occurrence in society or the lethality and the amount of suffering they create.”

Ideally, there should be a form of “ethical triage” that helps the public be better informed about the most widespread and urgent health care needs before donating their money to a cause, Bowman said. But for most fundraising campaigns, this kind of analysis is “very much lost,” he said.

Tobacco use: still a problem

It’s safe to say that over the past few decades, billions of dollars have been spent in the United States on reducing tobacco use.

It has had an impact. The number of adults who smoke has declined steadily, from about 43 percent in 1965 to the current rate of approximately 20 percent. Among high school students, the age group in which tobacco use most often starts, the smoking rate has fallen as well. Smoke-free workplaces and eating establishments are widespread.

This should be reason to reflect on the progress that has been made. But to those who work in the field of tobacco control, it isn’t enough.

ClearWay Minnesota launched a new campaign this week whose title conveys a blunt message: “Still a Problem.”

Some facts from the website:

- Smoking is linked to health problems that range from coronary artery disease and high blood pressure to lung cancer, oral and neck cancer, chronic bronchitis and increased risk of type 2 diabetes.

- More than a quarter-million children in Minnesota are exposed to secondhand smoke at home.

- Almost half of the adults who responded to the 2010 Minnesota Adult Tobacco Survey said they were exposed to secondhand smoke within the past week.

- Progress in reducing tobacco use among adolescents in Minnesota appears to have stalled. According to the 2011 Minnesota Youth Tobacco and Asthma Survey, 77,000 middle school and high school students are current tobacco users; collectively they will buy or smoke 13.4 million packs of cigarettes this year – enough when stacked sideways to span the entire state from north to south.

- Smoking costs $3 billion in excess health costs annually in Minnesota. This works out to $554 per individual Minnesotan.

None of this information should come as a surprise. The American public has been exposed to public health messages about the physical and economic toll of tobacco use for decades, perhaps to the point of tuning it out.

Tobacco control efforts can be at odds with individual rights and interests, as any smoker forced to huddle outside the company loading dock for a cigarette break might tell you. When a federal appeals court struck down the U.S. Food and Drug Administration’s graphic new warnings for cigarette labels earlier this year, the decision came down to free speech protection.

Yet the other side of this is that for every smoker who doesn’t wish to quit, there’s someone else who does. Last year the U.S. Centers for Disease Control and Prevention analyzed data from the 2010 National Health Interview Survey involving more than 27,000 adults over the age of 18. Among those who smoked, seven out of 10 said they wanted to quit, and half had attempted to quit during the previous year.

Despite long-standing anti-tobacco campaigns, it’s somewhat startling to realize how pervasive tobacco use still is. A new small-scale study, to be published in the upcoming issue of the Pediatrics journal, found that many parents who smoke do so in their car in the presence of their children, and only a minority had a smoke-free policy for the family vehicle.

In another recently published study, researchers observed patients at a large urban hospital and found that among those who smoked, nearly one in five continued to light up during their hospital stay – even though the hospital had a smoke-free policy.

Tobacco smuggling also remains a significant global issue that robs Third-World governments of tax revenue and is thought to contribute to the funding of organized crime. An in-depth report developed by an international team of journalists concluded that the illicit tobacco trade is so widespread and so lucrative that tobacco has become “the world’s most widely smuggled legal substance.”

So is tobacco use “still a problem”? Let the public look at the evidence and judge for themselves.

Demolishing assumptions about patients and the PHR

When a medical practice in Florida decided to survey its patients about whether they’d be willing to use a personal health record offered by the practice, the doctors figured those most likely to say yes would be younger, well-educated and higher-income. They also hypothesized that the likely users would be more health-literate.

As it turned out, they were right – but only by half.

Income and schooling made no difference and neither did age. What seemed to matter most was the patient’s health literacy (or, to be more accurate, the patient’s perception of his or her level of health literacy). Among the patients in the survey who said they were willing to use a personal health record, 65 percent self-reported high health literacy. For those who weren’t willing to use a PHR, only 38 percent estimated their health literacy as high.

Overall, three out of four who responded to the survey said they’d be willing to adopt a personal health record if the medical practice made this service available to them.

The results of the survey appear in a recent edition of the Perspectives in Health Information Management journal, and they raise some interesting questions about the assumptions that often are made regarding patients and information technology – e.g. that older adults don’t go online or less-educated individuals aren’t very interested in a personal health record.

Even the researchers were a bit taken aback by their findings. Alice Noblin, Ph.D., an assistant professor and program director for the Health Informatics and Information Management Program at the University of Central Florida, told the AMA’s Medical News Today, “I knew going in that it was a high Medicaid population, so the demographics didn’t surprise me. But how they felt about the PHRs, yes, I thought they would be a lot more unwilling to get involved with it, but definitely, most of them were interested.”

To be sure, this was a small survey, involving only 562 patients at just one medical practice. Nor was it able to predict whether these patients would translate their willingness into action if an online personal health record became available to them.

One of the lessons, however, seems to be that the medical community shouldn’t take for granted that most of their patients are indifferent to technology – and they shouldn’t underestimate patient interest in PHRs either.

A couple of the more intriguing findings from the survey: More than half of the patients who participated in the survey had a high school education or less, yet 71 percent in this group said they were willing to use a personal health record. And although nearly 60 percent of the respondents were in the lowest income category ($20,000 a year or less), three-fourths of them were interested in using a PHR. Most of the survey participants also were middle-aged and older.

Now for another statistic: Nationally, use of personal health records has been placed at around 7 percent of the total patient population – a very low figure when you consider the extent to which people are using information technology in other areas of their lives.

It’s not clear why there hasn’t been more uptake. Some of this can be traced to people’s concerns about privacy and security; unlike the electronic medical records maintained by hospitals and medical practices, the personal health record is maintained by patients themselves. Some of it could be due to the amount of hunting and gathering often required for consumers to create a PHR that’s complete and accurate. Actual use also somewhat depends on the PHR’s design and whether it’s easy or cumbersome.

But much of it simply might be a result of a general lack of awareness and patient education. Would it help if medical practices took a greater lead in discussing and promoting the PHR with their patients?

This particular survey was commissioned by a medical practice that wanted to offer a PHR and wanted to gather some data before making a final decision. Although many health care professionals remain ambivalent about how much information should be placed in the hands of patients, this small study suggests patients are more receptive than providers might think – and furthermore, that patient interest cuts across the demographics of age, income and education. It remains to be seen how the gap between what patients say they want and what providers assume they want can somehow be narrowed.

Holiday food guilt? Not on the menu

Writer Ragen Chastain can think of several things that would be more fun than being under holiday surveillance by what she calls “the Friends and Family Food Police”: a root canal, a fishhook in the eye… you get the picture.

Chastain, who blogs at “Dances With Fat,” tackled the subject last year of holiday eating and the well-meaning individuals who comment, nag or react in other ways to someone else’s food choices, particularly if that someone is overweight.

She clearly hit a nerve, because the comment section quickly filled with stories about people’s experiences at the holiday dinner table.

One woman was scolded by a cousin for eating high-carb carrots. Someone else was told “You don’t need that!” when she reached for the bread.

For others, the guilt tactics were more subtle – for instance, people asking them if they’d lost weight, or commenting, “I’m really being bad, I shouldn’t be eating this” while downing a sliver of pie.

Maybe it’s the food, maybe it’s the family dynamics, maybe it’s the emotional expectations we have for Thanksgiving and Christmas. Whatever the reason, there’s something about the holidays that can bring out the worst in people’s guilt and disordered attitudes about eating. When I Googled the words “holiday food and guilt,” there were 7.9 million results.

If you’re on the receiving end of the guilt tactics, how do you cope?

Chastain, who teaches workshops on self-esteem and the Health at Every Size approach and has written a book, “Fat! The Owner’s Manual,” advises deciding where the boundaries lie and what the consequences are for those who overstep them.

She writes, “I give people clear information, and several chances, but I don’t keep anybody in my life who consistently fails to treat me with the level of respect that I require.”

This might mean, for instance, simply saying “yes” or “no” if someone asks whether you really need that second helping of mashed potatoes – and then proceeding to eat it. Or it might mean giving a pointed response when someone gets too persistent: “I have absolutely no interest in discussing my food intake with you.”

Although much of the food guilt is aimed at obesity, it’s a minefield for other people as well. Thin people can be equally likely to have their weight commented on at the dinner table, or urged to eat more. And for those dealing with or recovering from eating disorders, holiday meals can be doubly difficult. Not only must they cope with food, and lots of it, but they may also be subjected to intense scrutiny over how much, or how little, they’re eating and whether they’re sticking to their prescribed meal plan.

This isn’t to say people shouldn’t try to eat sensibly for the holidays. The amped-up food choices can be difficult for those who have diabetes, need to limit their sodium or cholesterol intake, or simply want to watch calories.

Some tips from the Duke University Health System: Sample a little of everything but balance it with more fruits and vegetables. Stock up on healthy snacks for when temptation hits. Eat before a party to avoid overdoing it. Drink moderately. Don’t be afraid to say no if someone applies pressure to eat more.

The real question about food guilt is whether it actually works. According to a new study by the Rudd Center for Food Policy and Obesity at Yale University, the answer is no.

Researchers asked 1,000 study participants to evaluate several public health obesity campaigns by rating how positive or negative the campaign messages were and whether they were motivating or stigmatizing.

The best ratings went to campaigns that promoted specific health behaviors, such as eating more fruits and vegetables, and campaigns that encouraged people to become confident and empowered. Those that ranked the highest didn’t even mention the word “obesity.”

The least motivating? Messages that promoted shame, blame and stigmatizing.

Someone who truly cares about a friend’s or relative’s health should discuss it alone, at an appropriate time and in a way that invites dialogue, rather than shaming him or her at the dinner table, says Chastain. “Guilt is not good for your health. So I hope that if you choose to eat it, you also choose to enjoy it.”

The financial wallop of surviving a heart attack

Surviving a heart attack comes with a considerable price tag to patients as well as to their employers.

In a new study presented this week at the American Heart Association’s Scientific Sessions 2012, researchers tallied up the direct and indirect costs of treating a heart attack and other forms of acute coronary syndrome.

Here’s what they found:

- The  average person had $8,170 in health care costs, including out-of-pocket expenses. Although most of the money was spent on hospitalization and medical care, a sizable chunk – $625 – was for pharmacy costs.

- Workers lost 60.2 days of work in the short term and 397 days of work in the longer term.

- The cost to employers of losing the worker’s productivity was $7,943 per claim for short-term disability and $52,473 per claim for long-term disability.

- Hospitalization accounted for three out of every four dollars spent annually on acute coronary syndrome.

What makes this study somewhat unusual is that it focuses almost exclusively on working-age adults under age 65, a population that accounts for just under half (47 percent, to be exact) of all coronary patients yet often is statistically lumped in with older people.

The researchers conducted their analysis using data from Integrated Benefits Institutes’ Health and Productivity Benchmarking Databases and IMS Lifelink. They looked at medical, pharmacy and short-term and long-term disability claims to calculate both the direct and indirect costs for more than 37,000 employees and their dependents from 2007 to 2010. About three-fourths were men, and 95 percent were under age 65.

There’s much that the analysis doesn’t tell us, of course. Women were underrepresented, and it would be interesting to know how they fare. Is it more costly for women to be treated for a heart attack, and do they sustain more or fewer disability-related costs? What about younger heart attack survivors – those under age 55, for instance?

It’s also notoriously difficult to reckon up the emotional cost, both to patients and to their families, during the immediate crisis and lingering aftermath.

But it’s clear from the American Heart Association report that having a heart attack comes with a price that’s steeper than many of us realize.

I was curious to know how the cost of treating a heart attack stacks up against other situations – for instance, cancer or traumatic injury. According to a statistical comparison developed by the National Heart, Lung and Blood Institute (you’ll have to scroll down to the bottom of the linked page to find it), cardiovascular disease accounts for the greatest share, far and away, of annual health care costs in the U.S. It outstripped even cancer and diabetes.

Not every heart attack can be prevented. It’s thought that a large percentage of heart attacks are avoidable, however, and many of the most common risk factors – smoking, sedentary lifestyle, elevated blood pressure and/or cholesterol levels that are poorly controlled – can be modified.

If the impact of a heart attack on their overall health is too hazy or theoretical to motivate people, perhaps the practical implications for their wallet might send a stronger message about the value of doing what they can to reduce their risk.

Tragedy, black humor and coping

A seemingly frivolous tweet about superstorm Sandy drew a sharp rebuke this week from the Michigan Nurses Association.

The offending tweet came from the Detroit News and actually was a retweet of what another Twitter user (a civilian, apparently) said about the storm: “BREAKING: Frankenstorm upgraded to Count Stormula.”

The nurses’ association tweeted back:

The organization’s communications director, Dawn Kettinger, then contacted media uberblogger Jim Romenesko to further press home the point. “People are hungry for information and connection right now,” she wrote. “Moments of misjudgment are understandable, but perhaps it is worth another discussion of how media use their resources and power.”

Is it ever OK to use dark humor when confronted with tragedy, whether it’s death, life-threatening illness or injury, or natural disaster?

It’s a little ironic that the “Count Stormula” criticism would come from someone in the health professions, a demographic that’s well known to engage in black humor to cope with the illness, injury, tragedy and stress they encounter on a daily basis.

There’s been little formal research on the use or frequency of black humor among health care professionals. The use of this type of humor seems to be most common in the higher-stress specialties: emergency medicine, critical care and surgery.

A small-scale study several years ago, involving 608 paramedics in New Hampshire and Vermont, as well as members of the National Flight Paramedics Association, found that almost 90 percent used gallows humor as a coping mechanism. In fact, it was their most frequent method of de-stressing, even more than venting with colleagues or spending time with family and friends.

The use of irreverent terms such as “acute lead poisoning” to refer to a gunshot wound or “celestial transfer” to describe patients who have died is so widespread that several online dictionaries have been compiled to list all of them.

Some studies even have found that black humor can benefit clinicians and patients by reducing tension and allowing the clinician to focus on the situation at hand.

But there seems to be a growing consensus that it’s not acceptable to resort to black humor within earshot of patients and families, or to frame the joke at someone else’s expense (and I daresay this applies to the media as well).

A group of Canadian researchers who explored the issue agreed that although laughter is often therapeutic, cynical humor that’s directed toward patients “can be seen as unprofessional, disrespectful and dehumanizing.”

Furthermore, the use of black humor to cope is frequently a learned behavior that medical educators need to address, they wrote:

“There is disturbing but compelling evidence that medical education and acculturation are partly to blame, by tolerating and even fostering a certain detachment and cynicism. Recent moves to encourage the development and evaluation of professionalism in medicine embrace concerns about this issue and the distinction between dark humor about the human condition and the particular observations of those who style themselves as healers.”

At its worst, black humor can stereotype or dehumanize the patient and make it harder to be objective or empathetic, wrote a nurse at Those Emergency Blues, a group blog of Toronto ER nurses. When this happens, doctors and nurses can end up providing poor care, she wrote. “The wisdom is having the insight to understand the sources of black humour in our own relative helplessness, and to recognize it, first, as an inevitable part of our practice, and secondly, as having a time and place.”

Readers, what do you think? When is black humor appropriate and when is it unacceptable?