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Friday Reflection 33: Making Your Doctor Laugh
RF is a 74-year-old man with multiple, progressive medical problems. He sees his doctor frequently and often needs his assistance to arrange home care and other services so that he might maintain his independence despite his increasing disability.
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I appreciate humor in medicine. I am certainly not talking about the Patch Adams, laughter is the best medicine, trope. I think that humor is an important part of the socialization of doctors. I also love it when my patients and I can laugh together. I know that sometimes their humor is defensive, or a technique for avoiding uncomfortable topics, but mostly I think it signifies a comfortable relationship. If my patients can make us laugh, we have succeeded, at least to some extent, in creating a mature, equitable relationship.
There is actually evidence that humor during visits is a marker of productive doctor-patient relationships. In a famous study that used audio recordings of visits, primary care doctors who had not had malpractice claims against them laughed and used humor more than those doctors subject to claims.
For years, I’ve kept a notebook of interactions that led to a good, shared laugh in the exam room. I chose a few that I thought might translate well to writing, and whose authors, at some point, said they were OK with me sharing them. As I read the entries, I recognize three types of humor. Some are spontaneous exchanges striking enough for me to record. Others are times that a patient said, or did, something not intended to be funny but which we both spontaneously realized was. The last two recounted here (one that happened to me and one that I prevented from happening to a colleague) were jokes that took planning.
Patient: Can you believe I made it to 89?
Me: It is amazing, right? Congratulations! Any advice on how you did it?
Pt: I didn't die.
Pt. How old are you?
Me. Old enough.
Pt. No really.
Me. Why do you want to know?
Pt. I always want a doctor who is younger than me and a barber who is older.
Patient: How old are your kids these days?
Me: Both my kids are in college now.
Pt: Dr. Cifu, you are getting old.
Me: You’re the 90-year-old! Isn’t that the pot calling the kettle black?
Pt: Yes, but I am a spry and handsome pot.
And then, because so many conversations these days are electronic, a recent email exchange:
Pt. I think I might have an umbilical hernia. I googled it and that seems to be the diagnosis. Can you refer me to a surgeon without seeing me?
Me. Happy to refer you, but I’d like to make sure it is what you think it is. We can probably avoid a visit if you can send me a picture – if you feel comfortable with that.
Here is a picture. Is it good enough for a referral?
RF was a patient I saw for years. He was not healthy when we first met and his health continued to decline under my care. There were a couple of months, about a year before he died, that I was always doing something for him. There were letters he needed written, forms to be filled out for handicapped parking placards and durable medical equipment, and seemingly endless documentation for homecare services.
At a scheduled visit he said, “Dr. Cifu, I know I’ve been asking a lot of you lately, so I just wanted to give you something.” With that, he handed me a sealed, greeting card sized envelope. I figured it was a thank you note so I thanked him, dropped it in the pocket of my white coat, and proceeded to end the visit, rushing to get to my next patient.
He immediately said, “Wait, wait, why don’t you open that now?” I paused, sat back down, opened the envelope, and a crisp $100 bill fell out onto my lap.
“Thank you so much, Mr. F, but I can’t possibly take this. I really appreciate the thought but everything I have done for you is part of my job.” I handed the bill to him.
Without missing a beat, RF just said, “OK” and slipped the bill back into his pocket.
I paused, a little surprised that the exchange had ended so abruptly. RF then started laughing, self-consciously at first and then heartily.
“I guess I should have given more of a convincing act that I wanted you to keep the money, huh? I am not much of an actor. I knew there was no way you’d take it.”
At that point his wife, also at the appointment, and I joined in his laughter.
I had cared for HB and his wife Grace for a few years when HB came to me with unmistakable symptoms and signs of gonorrhea. I told him I would send a test to verify the diagnosis but that we would start treatment immediately. I told him that when the test came back positive, he would need to tell Grace so that she too could be tested and treated if necessary.
What followed was the uncomfortable silence that I’ve grown accustomed to after dozens of these conversations. I added, “If you don’t tell her, I will have to.”
After the briefest pause, HB replied, “How about this. I know that I didn’t get the infection from Grace. I also know that I haven’t slept with her since I got it so I am sure she does not have it. Let’s do this. You treat me. I sleep with Grace. If I don’t get reinfected, then we know she doesn’t have it and we don’t need to tell her. If I do get the infection then I’ll have to come clean. What do you think?”
I remember sitting, staring at him, dumbfounded by the flawless reasoning – he had restated Koch’s Postulates – and amoral plan.
Seeing that I was not buying into it, and that he had left me speechless, HB started laughing. “Yeah, I am a total dog. Give me the test and the antibiotics. I’ll talk to my wife, suffer the consequences, and have her call you to come in for the test.”
The memory that still leaves me shaking my head was a gag that took some effort and an absolute shamelessness. The episode started with a call from a patient of mine who thought he had body lice (Pediculus humanus humanus). He reported the classic “wandering freckles” in his pubic region. I had him come in, verified his accurate diagnosis, and tested him for other sexually transmitted infections. I called him the next day to let him know that he also had chlamydia.
Two days later there was a knock on the door. Standing outside was a man with overnight delivery of Maryland Blue Crabs. I was confused and protested that the delivery must be a mistake.
And then I found the card. “Dr. Cifu, thanks for all your help. I would have sent you a box of chlamydia too but I could not find anyone to ship them.”
The last piece of humor was an equally elaborate gag that I thwarted. A long-term patient of mine was seeing me the day before he was scheduled for a colonoscopy. He told me that he liked the gastroenterologist who would do the procedure and thought he had a good sense of humor. To give the doctor a chuckle during a long day of procedures, he planned to write on his bottom, in Sharpie, “Remember, anything you find up there is mine!”
I let him know that there’d be other people in the room and maybe the joke wouldn’t go over so well. He agreed it might be in bad taste and decided not to go through with it.
He has since had second thoughts and tells me that he is definitely going to do it for his next one.