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Employing Humor in the Radiology Workplace

By: John M. Holbert, MD, FACR

Background

Benjamin Felson, MD, was perhaps the best-known humorist in radiology. Dr. Felson was a popular lecturer and the well-known editor of Seminars in Roentgenology. People came to his lectures because of his humorous approach to lecturing and his “Letters from the Editor” but stayed to listen and learn.

Two of the basic operating principles of Dale Carnegie’s book, How to Win Friends and Influence People, are (a) smile and (b) start in a friendly way (1). It seems that Dr. Felson understood these principles intuitively and used them effectively. In addition, he exhibited his understanding and experience in his articles. His collected writings appeared in a book entitled, Humor in Medicine and Other Topics (2). His inclusive, self-deprecating style should be an exemplar for anyone trying to incorporate humor into his or her leadership technique. Among Dr. Felson’s writings are two of the funniest radiology stories of all time: “The Cow in the X-ray Room” and “Arms and the Doctor.”

Before Dr. Felson became a world-renowned radiologist, he experienced anti-Semitism while growing up and in the early phase of his professional career. He used engaging humor to address religious and racial discrimination (as displayed in his story, “Pride and Prejudice”). Eventually, Dr. Felson was able to employ his prestige to combat the injustices he saw. Dr. Felson had no use for malicious humor. He said, “Racial, religious, sexist, nationalistic, or political anecdotes often sound as flat as a bassoonist with a hernia, and are best avoided” (2).

Dr. Felson’s popularity as a lecturer led to invitations throughout nearly all of the United States and “half the countries of the world” (“A Traveling Radiologist”). He was an effective ambassador and teacher during his travels, while chance encounters and incidental events served as fertile objects of his wit. Dr. Felson also included research among his many interests. The title of his Eugene W. Caldwell Memorial Lecture before the American Roentgen Ray Society was “Armchair Research and the Practicing Radiologist.”

As Dr. Felson grew older, he suffered the degradations we all are heir to, as he lamented the decline in his tennis game (described in “Doctor with a Racket”), the indignities of being a patient (as shown in “Doctors Are Such Bad Patients”), and the poignant loss of some of his closest friends, including Richard H. Marshak, MD, and Harold G. Jacobson, MD. Finally, upon reaching the status of emeritus professor (as discussed in “Emeritus”), this change was immediately noted by one of his friends, because “they’ve turned off the heat in your office.”

If you want to look to the paragon of how to employ humor in the radiology workplace, then you need look no further than Benjamin Felson, MD. Teacher, researcher, writer, lecturer, and leader—he did it all, and he made sure others laughed heartily while he did it.

Scenario one

Dr. Kern is an academic medical physicist who is blessed with an uncontrollable mop of frizzy hair, a distinctive regional accent, and an infectious laugh. Dr. Kern has embraced these qualities and used her natural gift as a cartoonist to make herself a memorable lecturer on topics that often could be considered to be quite dry. Her talks are sprinkled throughout with her comic self-caricatures, which typically illustrate what not to do and what lessons she learned. Whether in one-on-one sessions or in small groups, she regales her students with embarrassing memories of her faux pas and hilarious stories about the people she has known. Students love her; she has won numerous teaching awards and is a popular choice as a visiting professor.


Dr. Kern’s teaching style stands in stark contrast to other members of the department—some of whom are prone to sarcastic put-downs of their students’ ignorance, often leading to public embarrassment. These other lecturers spend considerable time preparing their talks and objectively include all of the pertinent material, but they consistently receive poor evaluations from their students.


As a teaching function, Dr. Kern’s use of humor serves to do all of the following except ______.

A) Help develop curriculum.
Correct. 

Dr Kern’s use of humor has no role in the development of curriculum; therefore, answer A is correct. Her humor is designed to support an established curriculum and could be adapted to curriculum changes. The other three answers are incorrect. Robinson (3) noted that the use of humor in education can build rapport between teacher and student; thus, answer B is incorrect. Felson (2) promoted humor for its effects on reducing boredom; thus, answer C is incorrect. Ziv (4) acknowledged the role of humor in improving retention; thus, answer D is incorrect. However, Ziv (4) observed that sarcasm had a negative impact when students were the object.
 
B) Improve rapport.
This is incorrect. Try another answer.
C) Decrease boredom.
This is incorrect. Try another answer.
D) Aid retention.
This is incorrect. Try another answer.

Scenario two

Dr. Wilmont is a private practice radiologist with a large stock of standard gags that he continuously recycles. Most of them are mildly funny—at least the first time you hear them. He says things such as, “Just because I said it yesterday doesn’t mean that I agree with it today”; “I came in late so I have to leave early”; and “Leave it for the guy on call to read. Who’s on call? Me.”

He’s at his funniest when the chips are down and the examinations are coming so fast that no one can keep up. It’s not so much what he says, but his friendly, bantering humor style that keeps people chuckling. He makes it seem as if everyone is in it together even though there’s no way out.

Dr. Wilmont’s use of humor as a coping mechanism in a highly stressful situation is considered to be all of the following except ______.

A) Immature.
Correct.

Humor is a mature coping mechanism, one of the highest and best defense mechanisms (5); thus, answer A is correct. Humor is a very useful way of adapting to and managing life stresses, because it has a calming and protective effect. Therefore, answers B to D are incorrect. As Sigmund Freud suggested, “Humor can be regarded as the highest of these defensive processes” (6).

Humor can be viewed in different ways. Martin et al (7) divided humor into four main styles, according to how people used humor daily: (a) affiliative, (b) self-enhancing, (c) aggressive, and (d) self-defeating.

One of the healthier forms of humor is affiliative humor, which is Dr Wilmont’s style. People who employ this style use witticisms, jokes, funny stories, and playful humor to validate themselves and others. Nearly everyone enjoys being around someone who uses this style. Gentle, self-deprecating humor naturally improves interpersonal relationships and fellowship and is included in this style. Affiliative humor is not aggressive toward others. It enhances group bonding and relationships with a warm, happy feeling of intimacy and positivity.

Self-enhancing humor is the ability to laugh at yourself and your situation. It is a healthy coping mechanism that focuses on the brighter side of any situation. A positive benefit is that it helps you regulate your emotions without harming others.

Aggressive humor is a negative humor style directed toward others. Insulting techniques such as sarcasm and ridicule allow the humorist and those within their group to feel better at another’s expense. This kind of unfeeling humor includes racist and sexist humor.

Self-defeating humor is a negative humor style that is self-directed. This is self-destructive humor with the intent of making others feel better about themselves by having them feel superior to someone else. A clown is the classic example. If he is used to being bullied, he can gain control by disrespecting himself before others do.
B) Adaptive.
This is incorrect. Try another answer.
C) Calming.
This is incorrect. Try another answer.
D) Protective.

This is incorrect. Try another answer.

Scenario three

Drs. Johnson and James have been making fun of other people’s names for years. They greet Alison from the film library with, “Hello, Miss Wonderland!” Two people in the department are named José, so Drs. Johnson and James have taken to calling them “José” and “Hose B.” They enjoy pointing out unusual names from patients outside their own cultural group, and they try to outdo each other with snide remarks.


Typical comments include the following: “Get a load of this last name. He needs to buy a vowel!”; “OK. Try pronouncing this!”; or, “Can you believe anyone would name their kid this?” In particular, they find it amusing to make fun of unusual names, especially if the name can be twisted into something suggestive or humorous in English. Names with atypical spellings or names obviously originating from another country, culture, or religion are recurrent objects of their derision.


However, the doctors’ mockery does not stop with patients. If Drs. Johnson and James find out that a coworker is using her middle name because she dislikes her first name or if someone has an unusual middle name, the doctors go out of their way to call them by the name they are avoiding. A name doesn’t even have to be unusual for Drs. Johnson and James to make it an object of their humor. They gleefully change the name to rhyme with something they find humorous or evocative of a body characteristic or tic. Any nickname that makes someone sound ridiculous will do.


Drs. Johnson and James consider their patient name game to be a harmless form of playful humor, because the patients cannot hear them joking. If their coworkers protest about being the butt of their jokes or nicknames, Drs. Johnson and James label them as humorless stuffy people who cannot take a joke. They see comedians making fun of people’s names all the time. For Drs. Johnson and James, it is just a lighthearted way to pass the time.


Making jokes about another person’s name is a form of what type of humor?

A) Affiliative humor.
This is incorrect. Try another answer.
B) Self-enhancing humor.
This is incorrect. Try another answer.
C) Aggressive humor.
Correct.

Drs Johnson and James are using a form of aggressive humor when they are making fun of other people’s names or using demeaning nicknames; thus, answer C is correct. Aggressive humor is malicious and hurtful, notwithstanding the protests of Drs Johnson and James to the contrary. The net effect is to alienate others from you and those in your group affiliation. If you are unwilling to have patients hear your comments, you should not make them.

Affiliative humor is a sort of communal joking that creates a sense of fellowship and common experience. Self-enhancing humor pokes fun at our own frailties and trials in a self-affirming, forgiving way. Affiliative humor and self-enhancing humor are healthy and should be encouraged. Self-defeating humor is an aggressive form of self-directed humor that is harshly self-critical. Self-defeating humor and aggressive humor are unhealthy and should be discouraged.

The humor standards for a professional comedian and a professional radiologist are not equivalent.

“Remember that a person’s name is to that person the sweetest and most important sound in any language,” as Dale Carnegie observed (1).
D) Self-defeating humor.
This is incorrect. Try another answer.

Scenario four

Three members of a medium-size private practice group, Dr. Green, Dr. White, and Dr. Brown (the president of the group) are crossing a busy street from the hospital to their office building at noon for a group meeting. They are running late. Dr. Brown trips on the curb as he steps into the street and nearly falls. Traffic doesn’t even slow down. Dr. White, who has been Dr. Brown’s friend for a couple of decades, sees him trip and narrowly catches him before he falls, pulls him up, and yanks him to safety before traffic whizzes by. Shaken but unhurt, Dr. Brown composes himself, and the three head on into the medical office building.


As the three of them breeze into the meeting, someone says, “Hey, where have you guys been?”

Dr. Brown replies, deadpan, “I was trying to cross the street, and Dr. White tripped me and tried to push me into traffic.” (This is a brazen lie, as everyone immediately knows from the half-smiles on all three of the doctors’ faces.)


“Yeah, he got away this time,” said Dr. White. “Next time, I’ll push harder.”


Dr. Brown then tells the group the real story and sincerely says to the entire group, “He saved me. I owe him big time.”


As a leadership function, Dr. Brown’s use of humor serves to do all of the following except ______.

A) Strengthen friendships and group rapport.
This is incorrect. Try another answer.
B) Deal with embarrassment.
This is incorrect. Try another answer.
C) Give public thanks for another’s actions.
This is incorrect. Try another answer.
D) Control someone.
Correct. 

In this scenario, Dr Brown uses humor, but not to control someone; thus, answer D is correct. Dr Brown uses a spontaneous jest that he was tripped and pushed into traffic to accomplish multiple leadership objectives simultaneously: to strengthen friendships and group rapport, to deal with embarrassment, and to give public thanks for another’s actions. Therefore, answers A to C are incorrect.

Dr Brown quickly diverts discussion from his late arrival, which could potentially reflect poorly on him. To deal with an embarrassing stumble and near-death experience, Dr Brown makes a laughable claim that his longtime friend, Dr White, would openly try to endanger him. Having long engaged in this sort of banter, Dr Brown can rely on his friend to come back with the equally outlandish observation that Dr Brown got away this time and next time he’ll push harder. These sorts of scripts develop over years. The players clearly understand their roles in what is, in effect, a polished comedy routine. Everyone knows that something serious occurred, and this is a helpful way to defuse tension.

It is risky to try joking with someone without knowing them well. Some people don’t understand the process and may be offended. Drs Brown and White rely on years of building rapport and trust to slip into this spontaneous, unrehearsed back-and-forth without misreading the other’s intent. The net effect is to pique everyone’s interest in the real details. Dr Brown caps the discussion by publicly thanking Dr White for saving him.

As Dwight D. Eisenhower observed, “A sense of humor is part of the art of leadership, of getting along with people, of getting things done” (8). One of the best ways to get people to do what you want is to have them like you. Humor is such an essential part of human interaction that it is often the best pathway to accomplish your objective, whether positive or negative. “Leaders must understand the functional nature of humor not only so that they may use it effectively, but also so that they may use it appropriately” (9).
 

Scenario five

Radiology residency has been tough on Dr. Grassley. Her husband left her halfway through her 1st year. When she first arrived, she seemed kind and caring, but now she is known for her sarcastic humor. Although she has been progressing, her performance has been uneven. Nevertheless, she has been cleared to take overnight call, which is notoriously challenging. The cases often come through at an overwhelming pace. She gets through the 1st week okay, but it was really tough.

Dr. Grassley’s best friend is one of the other residents, Dr. Jackson, who is next up to take overnight call in the queue. On Dr Grassley’s last night of call, Dr Jackson stops by to beg her to trade call weeks with her so that she can visit with her parents, who are flying into town on short notice from overseas. Reluctantly, Dr Grassley agrees.

Dr. Grassley hasn’t been sleeping well while on call, and the pace of the overnight call and the constant demands start to get her down. Her fellow residents notice it first when she begins saying dismissive things such as, “This patient has chronic biscuit toxicity” and talking about a “GOMER with belly pain.” Things come to a head when she writes, “one toke over the line” on the history section of the preliminary report for a patient with lung cancer and leaves it for faculty review the next morning.

Dr. Grassley has been called in to see the residency director.

All of the following statements characterize Dr. Grassley’s use of humor except ______.
A) It is a healthy defensive form of humor.
Correct. 

It is not true that Dr Grassley’s use of humor in this scenario is a healthy defense; thus, answer A is correct. Saying unprofessional, uncaring things such as an overweight patient has “chronic biscuit toxicity” or that a patient with lung cancer is “one toke over the line” is deplorable and intolerable. Thus, answer B is incorrect. However, there is a clue to the pathway that got Dr Grassley to this point.

When Dr Grassley refers to a “GOMER with belly pain,” she is using a term that was popularized by a book, The House of God, by Samuel Shem, which was published in 1978 (10). The House of God is a biting, satirical novel that has sold well over 2 million copies and has been published in over 50 countries (11). The House of God details the stressful, exhausting experiences of Ray Basch during his internship. Unfortunately, this kind of dispiriting, depressing experience persists in medical education in some institutions to this day, leading to the sort of dehumanizing sarcastic epithets, such as GOMER (Get Out of My Emergency Room), that were popularized by this book. Therefore, answer D is incorrect.

Fellow residents and faculty should be aware of the warning signs of stress in residents, including cynicism, divorce, and depression (12). Dr Grassley is exhibiting classic signs of burnout, and she should be considered at risk. Thus, answer C is incorrect.
B) It is unprofessional.
This is incorrect. Try another answer.
C) It is a sign of burnout.
This is incorrect. Try another answer.
D) It may be a reflection of more widespread problems in the education of radiology residents and the treatment of patients.
This is incorrect. Try another answer.

References

  1. Carnegie D. How to win friends and influence people. New York, NY: Simon and Schuster, 2009.
  2. Felson B. Humor in medicine and other topics. Cincinnati, Ohio: RHA, 1989.
  3. Robinson VM. Humor and the health professions. 2nd ed. Thorofare, NJ: Charles B. Slack, 1991.
  4. Ziv A. Teaching and learning with humor: experiment and replication. J Exp Educ 1988;57(1):5–15. https://www.jstor.org/stable/20151750.
  5. Vaillant GE. Involuntary coping mechanisms: a psychodynamic perspective. Dialogues Clin Neurosci 2011;13(3):366–370.
  6. Freud S. The standard edition of the complete works of Sigmund Freud. Vol 8, Jokes and their relation to the unconscious. London: Hogarth, 1960; 225–233.
  7. Martin RA, Puhlik-Doris P, Larsen G, Gray G, Weir K. Individual differences in uses of humor and their relation to psychological well-being: development of the humor styles questionnaire. J Res Personality 2003;37(1):48–75. https://www.sciencedirect.com/science/article/pii/S0092656602005342.
  8. Bacharach S. Leadership without presumption: lessons from Eisenhower. Inc. website. https://www.inc.com/samuel-bacharach/leadership-without-presumption-lessons-from-eisenhower.html. Published June 26, 2013.
  9. Brooks GB. Humor in leadership: state of the art in theory and practice. Presented at the annual meeting of the Mid-Western Education Research Association, Chicago, Ill, October 1992. ERIC website. https://eric.ed.gov/?id=ED417113
  10.  Shem S. The house of God. New York, NY: Richard Marek, 1978.
  11. Wear D. The house of God: another look. Acad Med 2002;77(6):496–501.
  12. Hochberg MS, Berman RS, Kalet AL, Zabar SR, Gillespie C, Pachter HL. The stress of residency: recognizing the signs of depression and suicide in you and your fellow residents. Am J Surg 2013;205(2):141–146.