Abstract
Objective: Little is known about humor's use in clinical encounters, despite its many potential benefits. We aimed to describe humor during clinical encounters.
Design: We analyzed 112 recorded clinical encounters. Two reviewers working independently identified instances of humor, as well as information surrounding the logistics of its use.
Results: Of the 112 encounters, 66 (59%) contained 131 instances of humor. Humor was similarly frequent in primary care (36/61, 59%) and in specialty care (30/51, 59%), was more common in gender-concordant interactions (43/63, 68%), and was most common during counseling (81/112, 62%). Patients and clinicians introduced humor similarly (63 vs 66 instances). Typically, humor was about the patient's medical condition (40/131, 31%).
Discussion and Conclusion: Humor is used commonly during counseling to discuss the patient's medical condition and to relate to general life events bringing warmth to the medical encounter. The timing and topic of humor and its use by all parties suggests humor plays a role in the social connection between patients and physicians and allows easier discussion of difficult topics. Further research is necessary to establish its impact on clinicians, patients, and outcomes.
- Humor
- Patient-Centered Care
- Primary Health Care
- Physician-Patient Relations
- Patient-Physician Communication
Adequate and open communication between patients and clinicians can have a positive effect on the outcomes of care.1 Positive interactions between patients and physicians in the medical encounter helps build a relationship, establish trust, and support the exchange of accurate and relevant information, all of which may contribute to achieving favorable health outcomes.2 In fact, the Accreditation Counsel of Graduate Medical Education considers interpersonal and communication skills to be one of the core competencies to be taught to physicians in training.3 Although many strategies exist to bolster physician-patient communication, humor is particularly interesting due to its utility in navigating difficult topics and potential to bridge gaps between patients and clinicians.4,5
Humor is one of many verbal and nonverbal strategies used by patients and physicians to connect in the medical encounters. In 1996 Wender6 and in 1999 Frances and colleagues7 discussed the role of humor in clinical practice. Humor, they posited, could reduce anxiety, demonstrate connectedness, and invite warmth into an interaction that is otherwise formal, cold, and distant. Humor can be a mean for physicians to surface difficult or uncomfortable topics, subtly express dissatisfaction with the patient's behavior, provide reassurance, or get the patient's attention. In addition, it can invite patients to comfortably express anxiety or discuss frustration with their diagnosis, treatments, or with the medical system. Humor has the potential to decrease power imbalance and cultural differences between patients and physicians, which can otherwise hinder open communication.6,7 Humor has also been correlated with positive outcomes such as improved satisfaction, fewer malpractice claims, and increased patient enablement.8⇓⇓–11
Although humor may serve numerous beneficial functions in clinical encounters, there is no standard definition of humor for research purposes and the logistics of humor's use in clinical encounters (eg, frequency, who introduces it, what is it about) has not been well studied. Where it has been studied, its prevalence varies widely across settings (inpatient rounds, emergency department, hospice; Table 1).8⇓⇓⇓⇓⇓⇓⇓–16
Studies Evaluating Frequency, Features, and Outcomes of Humor during Medical Encounters
To further characterize the logistics of humor in medical encounters, we analyzed audio/video-recorded clinical encounters to describe the frequency and other features of humor in outpatient primary and specialty care visits.
Methods
We analyzed clinical encounters recorded as part of practice-based randomized trials conducted to examine the effect of decision aids on shared decision making (published between 2009 and 2015).17⇓⇓⇓⇓⇓–23 Recordings were audiovisual or audio-only based on the preferences of the patients and their clinicians at the time of enrollment. Of the 272 complete videos available for analyses from these trials, we included all the videos that were recorded in specialty care (51) and selected a random sample of 61 videos from the 221 remaining primary care videos stratified by treatment arm (decision aid use) to complete a sample of 112 videos.24
Our primary objective was to quantify and evaluate the use of humor; however, the concept of humor is subjective and lacks a standardized definition. Thus, 12 recordings were analyzed by 4 experienced independent reviewers (all with medical training) to define what constitutes an instance of humor, calibrate the coding, and identify variables to be collected. Humor was defined as a statement made with the intent to make others in the room laugh or react positively (ie, deemed humorous by reviewers) and to which a positive response was elicited. Therefore, unacknowledged humorous comments or statements that were not intended to be funny (ie, deemed not humorous by reviewers) but were laughed at nonetheless were not included (eg, nervous laughter within a generic conversation). Once calibration was achieved, 2 reviewers working independently analyzed each one of the remaining recordings. Humor was considered present when both reviewers identified the instance as humorous.
Coding was completed using Noldus XT25 software. For all videos, reviewers recorded how many physicians interviewed the patient, the gender of the patient, and senior clinician, the setting (primary care, specialty care), whether a decision aid was used, the duration of the encounter, and whether a physical examination was performed. Use of humor was coded as a binary (humor present or absent during the whole visit) and quantitative variable (how many times humor was noted in the visit). For each instance of humor within the encounter, reviewers recorded who introduced humor (patient, provider or guest), timing (introduction, history taking, physical examination, or counseling), subject, apparent function of the humor, and whether the instance was a single statement (“dead end”) or resulted in a string of humorous back-and-forth comments. These data were collected using Research Electronic Data Capture (REDCap), a data collection and management program.26 Contextual clues were used by reviewers to determine the subject and function of humor, and disagreements were resolved by consensus. We compared the proportion of encounters with humor by setting, decision aid use, and participant gender. Hypotheses testing of differences between groups was performed using the χ2 statistic and adjusted χ2, where the clustering was within study. This method accounted for any intraclustering effect across studies.27 All statistical analyses were performed using JMP28 and Stata Statistical Software.24
Results
Of the 112 medical encounters, 87 (78%) were audiovisual recordings and 25 (22%) were audio only. Most video recordings took place in primary care clinics (61; 54%), with 51 (46%) taking place in specialty care clinics. The median encounter duration was 30 minutes (range, 4 to 80 minutes). Humor was present in 66/112 (59%) of these encounters. A total of 131 instances of humor were identified with a median of 2 humorous instances per humor-containing encounter (interquartile range, 1 to 2; range, 1 to 5).
Humor was similarly present regardless of participant gender, setting (primary or specialty care), and in encounters with and without shared decision-making tools. However, there was significantly more humor used when the senior clinician and patient were of the same gender (43 of 63 encounters; 68%) than when they were not (23 of 49 encounters; 47%; P = .02; Table 2).
Distribution of the Use of Humor According to Setting, Decision Aid Use, and Gender of the Patient and Senior Clinician
Humor was used most commonly during the counseling of the medical encounter (62% of the encounters; Table 3). Representative examples of humor are presented in Table 4.
Proportion of Humor Use by Portion of the Encounter, by Subject and by Purpose
Examples of Humor by Subject, Time, and Type
Discussion
In this study, we found that humor was present in approximately 60% of encounters at an average rate of 2 instances per encounter. Humor was most commonly used in the counseling portion of the encounter and was introduced by the patient and physician almost equally. The most common subject of humor was the patient's medical condition. The function of humor was most often to relate to general life or to discuss adherence and other difficult topics. Humor was often limited to one-line exchanges (“dead end”).
There was no difference in the use of humor between primary- and specialty-care settings, nor was there a difference based on the gender of the clinician or patient or any effect from the use of a decision aid. However, when the patient and the senior clinician were of the same gender, humor was used more often. This phenomenon was noted by Roter et al16 in the obstetrics setting as well. Though a reason for this phenomenon has not been proposed or explored, we hypothesize 2 possible causes for this finding. First, it may be due to an increased level of comfort sensed between individuals of a similar gender. In addition, those of concordant gender tend to have more similar senses of humor, thus may feel more comfortable introducing humor into an interaction. Finally, although we did not have access to data to verify this, it is plausible that more gender-concordant pairs were those of primary-care provider and patient. The familiarity in these relationships may allow for easier use of humor.
Based on our observational findings, it is difficult to draw concrete conclusions about the benefits of humor in these encounters. However, based on the data we gathered, we can infer agreement with previously published literature regarding the uses of humor in clinical encounters (Table 1).
The counseling portion of the medical encounter is commonly when discussions of diagnosis, treatment, adherence, and other potentially difficult topics surface, thus necessitating some of the key functions of humor. Humor was most often seen in this portion of the interview, suggesting it is being used in these discussions. It is possible that humor allows patients and physicians to more openly broach these otherwise-uncomfortable topics and helps maintain a productive interaction.6,7
The fact that humor was used to relate to general life events and circumstances provides further evidence that humor can be used to promote connectedness and warmth, as previously stated by Wender and Frances.6,7 Patients and physicians experience a network of roadblocks that can ruin efforts of communication. Power imbalance, gender differences, age discrepancy, and varied cultural and socioeconomic backgrounds can all lead to hindered communication. In turn, this can affect the patient experience and the efficacy of the clinical encounter.29,30 Humor may help to overcome those roadblocks by connecting people on common ground.7 As an example, it was noted that patients and physicians commonly discussed pets or spouses in humorous ways. This allowed for connection on a simple level, which could serve as a launching point for more serious and intimate conversations. An improved personal connection may explain the increased patient satisfaction noted in visits with more humor.11
Our study cannot make concrete conclusions nor suggest recommendations for medical education or clinical practice. However, it quantifies the use of humor in the clinical encounter, and it suggests agreement with previously published literature regarding the uses and benefits of humor.
In this study, we evaluated the use of humor in medical encounters. All videos were reviewed in duplicate to increase reliability. This is important when characterizing a subjective construct like humor. In seeking rigor, we may have underestimated the use of humor, as we required agreement between 2 reviewers to adjudicate an instance as humorous. A limitation of our study is that we did not confirm our judgments regarding the humorous intent of each statement with the participants nor did we obtain judgments from observers with nonmedical backgrounds. In addition, our assessment of available videos is convenient and not necessarily representative. Our medical encounters were collected within a health system with longer than average appointment times in both primary and specialty and were recorded as part of clinical trials assessing the efficacy of decision aids. Thus the data may not be widely representative.
A few studies have sought to identify and explore the impact of humor in the medical encounter, but few identify its frequency and none explore other logistic aspects of its use in clinical encounters. Our study contributes to reduce this knowledge gap. Future studies may need to apply video-reflexivity techniques to capture participant views of humor use in encounters. Additional research may need to characterize how humor use can facilitate or hinder partnership, communication, and conflict resolution and contribute to improve the experience of care for clinicians and patients and the usefulness of the encounter. Finally, while focusing on humor, we noticed in some recordings that patients or clinicians would laugh or chuckle when nothing funny was said. Often this went unacknowledged by the other party. The significance of this sign, for example, as a marker of unstated anxiety or discomfort, deserves further exploration.
Conclusion
The use of humor during medical encounters is common, occurring in about 6 of 10 encounters. It seems to be introduced equally by patients and clinicians in both primary- and specialty-care settings. Studies have demonstrated a positive impact of humor on a number of outcomes8⇓⇓–11. Our study serves to describe in detail how humor is used in clinical encounters and to support humor as a tool used to discuss difficult topics and bring warmth into the medical encounter.
Notes
This article was externally peer reviewed.
Funding: none.
Conflict of interest: none declared.
To see this article online, please go to: http://jabfm.org/content/31/2/270.full.
- Received for publication July 21, 2017.
- Revision received November 17, 2017.
- Accepted for publication November 28, 2017.
