A Pediatrician, a Resident, and a Medical Student Walk Into a Clinic: The Role of Humor in Clinical Teaching

Humor is defined as a funny or amusing quality, whereas a sense of humor is defined as the ability to be funny or to be amused by things that are funny. Despite the seemingly innocuous nature of humor, historically humor has generally received a bad reputation in professional settings.⁴ 

Humor can increase group cohesion, bring individuals together, and alleviate tension. On the other hand, it can disparage others, create misunderstandings, or foster isolation and division and thus hinder the learning environment. So how is it that sometimes humor is amusing and other times it is offensive? Two frameworks can help to explain the double-edged sword nature of humor.

The first framework (Fig 1) describes 4 styles of humor.⁵  The styles cross 2 dimensions: positive versus negative and self versus others. The positive versus negative distinction indicates whether humor is used to support (positive) or denigrate (negative). The self versus others delineation identifies the intended target of humor. This humor style framework is valuable in understanding why some forms of humor are interpreted as good, whereas others are deemed bad. For example, humor that reduces tension within a group, fosters relationships, and is intended to amuse hits on the dimensions of positive and others. This style of humor is described as affiliative and may be highly effective at building teams. In contrast, humor that mocks, ridicules, or isolates leaners hits on dimensions of negative and others. This style is described as aggressive and is harmful to relationships and the learning environment.^5,6 

A second major framework identifies 3 theoretical purposes of humor: superiority, incongruity, and relief.⁴  The superiority theory suggests that the purpose of humor is to be viewed more favorably by putting others down. An example of this was shared by a medical student who stated, “People on the team use humor to make fun of other people on the team, especially medical students.… A lot of times people are laughing at you and you don’t know why.”⁷  Similarly, humor that ridicules on the basis of race, ethnicity, or sex is another example of using humor to inappropriately suggest superiority. Humor used for any of these purposes is especially inappropriate in the learning environment, and clinical teachers have a responsibility to confront and address it immediately. Although these jokes might appear innocuous to some, they are actually microaggressions, which marginalize others and harm the entire team.⁸ 

By comparison, incongruity theory posits that the purpose of humor is to provide contradiction. What was expected is contrasted by what is provided. Similarly, humor used for the purpose of relief is generally used in a positive sense; it relieves strain from a situation.⁴  An example is the joke provided in the introduction, which could serve either purpose. The play on the words “patients” and “patience” serves as an incongruity, whereas the use of a joke in a published article is unexpected and serves to (hopefully) offset the seriousness of academic writing, thus also offering relief.

Some forms of humor may fall into a particular classification depending on the context or purpose of the speaker or the perception of the recipient. For example, irony and sarcasm may be used for relief or they may be used to demonstrate superiority. In these situations, the purpose may be demonstrated more so by the intent rather than the content alone. These types of humor may be perceived differently depending on sex, race, ethnicity, or life experiences and are never appropriate in the learning environment.

After recognizing the differences in style and purpose, clinical teachers can then consider the benefits of humor. These include those for the learner and those for the overall learning environment.

Humor has been shown to have positive effects on stress and cortisol levels in pediatric patients and increase activation of the brain’s reward system.⁹  For medical education, its study for use as a specific tool in education has been limited; however, humor theory suggests that causing a learner to smile or laugh provides evidence of engagement.¹⁰  Furthermore, clinical teaching is a relationship-driven process, and humor can help lessen the social distance between teacher and student.⁶  Finally, humor may remove some of the barriers of the hierarchical structure of medicine and improve the rapport between instructor and learner.¹¹ 

A positive learning climate is critically important, and many strategies exist to create and support such an environment.¹²  Humor and laughter are a way to capture attention, increase enjoyment, and increase participation.¹  Humor can reduce anxiety, tension, and stress, thus serving as a tool to create an environment that facilitates a student’s receptivity to feedback.^6,13 

However, humor can influence the environment in negative ways too. Most notably, derogatory and cynical humor is often role modeled as part of the “hidden curriculum,” and is an unfortunate factor in the development of students’ professional identities.¹⁴  Hostile humor can marginalize and isolate trainees, perpetuate a threatening environment, manifest as microaggressions, and make the entire team feel uncomfortable.⁸ 

It is important to recognize that humor is fundamentally subjective. Not everyone is funny, and it can be uncomfortable to watch an unfunny person try to be funny. Great clinical teachers who choose to be humorous know how to select humor at appropriate times, for the right purpose, and with the right audience. They acknowledge that humor can contribute to the strong socializing forces of the hidden curriculum.¹⁵  Their humor may include the telling of funny stories, using body language, smiling, and laughing. They never make fun of others and avoid humor that addresses sensitive issues. They know that forced humor is easily recognized and may be perceived as more awkward than funny.

Overall, it is important to realize that not all teachers are comfortable with humor, and there are many other methods for promoting effective learning. Humor is one tool in the clinician-educators toolbox and like all tools should be handled appropriately.

Humor in educational settings serves many purposes. If implemented with a positive viewpoint and for developing camaraderie, humor can foster a comfortable learning environment and increase enjoyment. Humor can also have the opposite effect. The great clinical teacher may or may not be funny but is observant of the role that humor plays in influencing the learning environment and choses to implement humor in a sensitive way and confront inappropriate humor. Through careful consideration of the pros and cons of humor, pediatricians may consider the best way to implement (or not implement) humor in their interactions with students and their patience…er, patients.