Practicing Medicine Turns One

As I look back on the first year of this blog and reflect on my four years of medical school, I am amazed at how much I have learned and how much
I have seen. All of it has informed what I have written about here on Practicing Medicine. And many of the issues I have raised remain vital to my experience within the hospital.
Medicine forces physicians to ask questions; questions beyond which IV fluids to give or which antibiotic to use. Medicine demands that we ask the same
questions that any student of human history might ask: What makes us human? What is so humorous about human suffering and pain? Why
do we become numb to human forms of sufferingWhat is the process by which we die? And is it dignified?

How should we view the place of the mentally ill in our society
?

I have also made other, perhaps less broad and less grand, attempts at explicating the practice of medicine. My first post explained why I decided to blog and the awkward place
of medical students within the medical field. This piece
discussed the potent smells of the hospital — they are unavoidable and yet we adjust to them. Stepping into the ED for the very first time, I
explained how a trauma code works and the horrors that
trauma patients face. The kidney-failure patient also faces difficulties,
but they are of a chronic nature due to dialysis, a miracle of modern science with its own drawbacks.

I compared
George Orwell’s experiences in a French hospital in the early twentieth century to my own experiences in a hospital in the early twenty-first; yes, there are major differences, but there are also similarities. This is a pragmatic post on how we ought to think about
scientific studies and evidence-based medicine. I have written about depression and schizophrenia. And, in a more recent post that would have
pleased me greatly as a younger reader, I wrote about Sir Arthur Conan Doyle’s eponymous detective, Sherlock Holmes — it turns out his methods are relevant to physicians today.

Over the next year I hope to continue to write about the big questions and bring up others in relation to what I see and do. I also have a few bigger writing projects in the works, which I will mention here on the blog. If you have suggestions or
comments, please feel free to send them my way. My e-mail address and Twitter handle can be found at the right.

Finding Humor in Medicine

Dmitrijs Bindemanis via Shutterstock

One morning, I checked in on an 82-year-old female who was admitted overnight after falling in her home. She looked like any other elderly woman: gray
hair, thin legs and arms, and wrinkled skin. Yet she lacked the frailty and exhaustion that sick older people often exhibit and wore a faint smirk — the
angles of her lips curved upwards just enough to discern an optimistic disposition. As I knocked and entered she startled and pulled the covers up to her
chin.

I asked the woman how she felt, if there was anything she needed
and, in turn, she answered and asked me how I was doing. She seemed, in other words, to be skillfully participating in the sort of anodyne introductory conversation that people have when they first meet in such settings. But when I asked her if she knew where she was, she replied “no.” It turns out she had dementia, a slow and progressive deterioration of
mental function, and could tell me almost nothing about life at home. In response to more detailed questions I only received a nod or a barely audible
“yes.” Even when I kneeled close and raised my voice, assuming she was hard of hearing, I received similar responses. Disease had mangled her memory and
her ability to socialize appropriately.

When we rounded, I presented her to the medical team and
entered the room to examine and speak with her. Our attending physician asked the patient how she was feeling. Frustrated by her inability to answer my
questions, the patient replied “sad” and exclaimed “I could really use a joke to lift my spirits!” It’s a request that we so rarely hear in a hospital;
everyone wants food, or drink, or medicine, but few people request a joke. The attending asked me to tell the patient a good joke after rounds.

I’m not skilled at the art of joke-telling — it requires the appropriate joke at the appropriate time with the appropriate delivery. And this particular
situation did not lend itself to a complex yarn with a long backstory. It needed to be simple. So I thought a knock-knock joke would do the trick; after all, everyone knows how knock-knock jokes work. Here’s the one I planned to use:

Knock, knock
Who’s there?
Rufus
Rufus, who?
Rufus the highest part of the house.

Granted, it is corny, but I was sure it would elicit a chuckle from an old lady with dementia. Then I told her the joke:

Me: Knock, knock
Her: Knock, knock
Me (jokingly): Who’s there?
Her: Who’s there?
Me (attempting to start over again): Knock, knock
Her: Knock, knock

She wasn’t doing this playfully; she did it because she could not understand or remember how knock-knock jokes work. When we all got back to the
physician workroom, I told the medical team about this encounter and we had a good laugh. Indeed, dementia is the theme of many jokes in medicine. Have you heard the one about the doctor and the Alzheimer’s patient?

“I’m sorry to tell you this but you have cancer,” the doctor told her patient.
“I do?”
“Yes, but that’s not all… you also have Alzheimer’s disease,” said the doctor.
“I do?”
“Yes,” nodded the physician.
The patient beamed and said: “Oh well, at least I don’t have cancer.”

Or, maybe you’ve heard this other good joke about dementia:

The doctor tells his patient: “Well I have good news and bad news…”
The patient says, “Lay it on me Doc. What’s the bad news?”
“You have Alzheimer’s disease.”
“Good heavens! What’s the good news?”
“You can go home and forget about it!”

But what is so funny about these jokes? Aren’t we laughing about a debilitating disease that tears apart lives? In that room I entered was a woman who
could not participate in a joke that even the youngest and simplest child could understand. Why is some part of this funny?

*   *   *

In another medical unit, we took care of an 80-year-old with metastatic cancer nearing the end of his life. He needed a breathing machine to pump air into
his lungs and was being fed through a tube which connected his stomach to a container of liquid nutrients. He lay in bed without moving, occasionally
blinking his eyes. Because he lay in bed all day he developed pressure ulcers. The pressure from
an immobile person’s weight on the bed causes skin breakdown. This leads to serious and life-threatening infections as well as terrible pain. In order to
slow the breakdown process, nurses constantly change the position of the immobile patient, rolling him or her every few hours and putting creams and
ointments on the sores.

During rounds, I helped the nurses and the attending physician to examine the patient’s pressure sores. When we turned the patient, his hospital
gown opened exposing his bare derrière. I bent down to look closely at his sacrum, an anatomical spot above his anal opening, which contained multiple
ulcers. As I got close, the patient let out a huge fart. I almost burst out laughing but abruptly held myself back when I saw the attending physician,
staid and focused on the ulcer. Why did I nearly laugh at flatulence from a patient who was so close to death that he could not control his bowels? Should
I laugh at that?

Irreverent, dark, depressing, and, yes, immature humor pervades the medical profession. We all tell each other funny stories like these when we get
together. I remember one resident telling me a knee-slapper about a demented patient throwing feces at her. It’s funny, in an upsetting way.

Multiple days a week, physicians witness some of the darkest moments that human beings experience in their lives: cancer diagnoses, deathalcoholismdrug overdoseschild abuse, neglect and abandonment, depression, horrific trauma, progressive physical and mental
disease, stillbirths, strokes, and more. Humor is one of the ways physicians deal with this barrage of depressing encounters.

But why? Perhaps to understand this response in the relatively mild context of the hospital, we can examine the most extreme example of humor in the face
of suffering — the Jewish experience before and during the Holocaust.

Ruth Wisse, the Martin Peretz Professor of Yiddish Literature and Professor of Comparative Literature at Harvard University, wrestles with the idea of tragic humor
in No Joke, her wonderful 2013 book on Jewish humor. Professor Wisse
notes that during tumultuous times, Jewish humor flourished because of “an increased need for entertainment that would distract or temporarily release the
tension, and offer consolation.” One Jewish comedian in particular, Shimon Dzigan, exemplified
this concept during the early twentieth century in Eastern Europe, playing characters on stage in sketches which poked fun at local Polish political
figures and even German leaders. In explaining why he sought humor in dark times, Dzigan explained, “I have no answer. I can only say that perhaps
because we subconsciously felt that our verdict was sealed and our fate unavoidable, we consciously wished to shout it down and drown it out. With
effervescent joy we wanted to drive off the gnawing sadness, the dread and fear that nested deep inside us.” Indeed, there is a gaping chasm between how
those who joke about serious matters actually feel and what they laugh about. The laughing isn’t merely a cover for their feelings but a way of making
those feelings less unpleasant and less controlling. Wisse eloquently observes: “If cognitive dissonance is caused by a divergence between convictions and
actuality, and if humor attempts to exploit that discomfort, no one was ever so perfectly placed to joke as were Jews under Hitler and Stalin.” Wisse also
provides an entertaining example of a joke during the Holocaust:

Two acquaintances meet on the street. “It’s good to see you back,” says the first.

“I hear that conditions in the concentration camp are horrible.” “Not at all,” replies the second. “They wake us at 7:30. Breakfast with choice of coffee
or cocoa is followed by sports or free time for reading. Then a plentiful lunch, rest period, games, a stroll, and conversation until dinner, the main meal
of the day. This is followed by entertainment, usually a movie…”

The first man is incredulous. “Really! The lies they spread about the place! I recently ran into Klein, who told me horror stories.”

“That’s why he’s back there,” nods the second.

Doctors, to be sure, are not in a position that even closely resembles the position of Jews during the dark days of the twentieth century. But the
humor that physicians use to deal with the things that they see is similar. There is a pit of Weltschmerz in medicine as well; a divergence between
convictions and actuality. Most doctors enter medicine with a desire to help and to heal. But medicine necessarily deals with death and failure and all the
emotions that come with them. To exploit and, at the same time, cloak that discomfort we resort to laughing at the actions of demented patients or inappropriately
commenting about a patient’s impending death. Whether right or wrong, laughter transiently drives out the gnawing sadness, the dread, and the fear that,
perhaps, one day we will be that patient.

Open mic night at H+ Summit

Up next is Brian Malow (bio), self-described “transhumorist.” I think that means he transcends the boundaries of what’s humorous, because yowza:

— “We are going to die, and that is a spoiler.”
 
— (after a joke bombs) “That was an endothermic joke. It required the addition of a little energy from you.”
 
— “I’m not saying I don’t have hair, it’s just outside the visible spectrum.”

Brian MalowThis guy just flew in, and boy are his surgically-implanted wings tired. But it’s okay, I think the guy is sort of an entertainer first, informer second, like the transhumanist version of Michael Scott.

Sorry, I’m obliged to heckle. The bestiality-and-transhumanism jokes actually weren’t bad. Well, you know, they were bad, but they weren’t bad. Don’t forget to tip your waiters, folks.