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?

2 thoughts on “Tragedy, black humor and coping

  1. Hi,
    I’m a little surprised that there haven’t been more comments on this topic. EVERYONE in healthcare is involved, and that’s lots of us.
    Your basic question is when it it okay and when is it not — you correctly judge that it’s essentially ubiquitous. I overhear more than I want to sometimes, but my strategy is to chastise anyone who goes “over the line”.
    Where is that line? Anything derogatory is off limits. Period. I’ve stopped plenty of conversations over the years that were getting out of control. But, at least to me, that’s different than “irreverent” — your example of “acute lead poisoning” is pretty common. And it’s actually a reasonable description. It’s more a play on words than an insult — and insults are not appropriate in any way or situation.
    I’m involved in medicine because of a desire to help. Inappropriate comments hurt, so participating in them is not in my nature. Or, hopefully, my colleagues’ nature. The more of us who are willing to keep each other in check, the better off we all are.
    This is directly related to your post about teamwork not long ago. If the team is strong, any member will be enabled to point out error or indiscretion in any other member. That’s what makes health care fun — and safe.

    • I think it’s hard to know where to draw the line between what’s appropriate and what isn’t, because we all have differing thresholds for what we might regard as inappropriate. But when you’re dealing with patients who are sick and vulnerable and frightened, it seems better to err on the side of being sensitive. Comments that are meant to be humorous or to lighten a bad situation can easily come across as flippant. Patients can end up feeling their concerns are being trivialized, they might start doubting whether they’re receiving good care, and it can end up damaging their trust.

      It’s not too hard to find examples online of genuinely derogatory and insulting talk about patients. The Internet has allowed laypeople to eavesdrop on how some health care professionals really feel about patients, and at times it’s very unsettling. Although most of the individuals who engage in this kind of behavior probably see themselves as good clinicians who would never allow it to get in the way of caring for their patients, it makes you wonder whether they’re really being honest with themselves. At some point, does derogatory talk in the break room or the doctors’ lounge spill over into how they view their patients and how they interact with them?

      I think you’re right that this is at least partially the result of organizational culture and the example that is set. It’s hard to imagine that any health care organization would actively encourage flippant or unfeeling comments about patients, but not speaking up when it occurs can inadvertently send the message that it’s OK. As the saying goes, “What you permit, you promote.”

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