Robert Buckman, M.D., Ph.D.
Princess Margaret Hospital
University of Toronto
Dr. Baile: Welcome to this I*CARE podcast. We're visiting today Dr. Rob Buckman. Rob is Professor of Medical Oncology and Specialist in Breast Cancer at the University of Toronto, Princess Margaret Cancer Center in Toronto, Canada. Rob is nationally and internationally known for his work on clinician-patient communication and is author of a classical text on breaking bad news. He's also the developer and principal character in the video scenarios of difficult communications on our I*CARE Web site. Today we're going to talk to him about the use of humor in medicine and later about his new book on cancer for patients and families. Rob, welcome.
Dr. Buckman: Nice to be here Walter.
Dr. Baile: So tell us a little bit about how you became interested in this topic of humor and its relationship to medicine.
Dr. Buckman: Well it was always, as it were, a part time activity, something like a hobby, something to do in the evenings. I mean in university, like many universities, there were societies, evening activities for people who did comedy and in Cambridge it was the Footlights, you know, which was John Cleese and Peter Cooke years before.
Dr. Baile: So this was came Cambridge in England?
Dr. Buckman: Cambridge, England yes. I keep on forgetting there are other Cambridges, yes, yes, yes. Yes, but in those days it was completely legitimate to be an English student or a medical student or an archeology student, or something in the mornings and then in the evenings, do comedy in the Footlights. So, I always regard it as absolutely fabulous thing to be able to make a room full of people laugh. But, I always regarded it as a hobby and it was only many years later that I realized, probably only in the last 15, 20 years that I realized it does actually have a serious and helpful role in supporting the doctor-patient relationship.
Dr. Baile: So you've worked with some pretty famous comedians?
Dr. Buckman: Yes, I have. You know, seriously, I mean John Cleese and I did a series of actually 50 videos on various medical topics, each of which began with a funny sketch in which he was a perplexed patient and I was the doctor [inaudible] and gave sort of terribly unintelligible jargonese statements without caring what happened to the patient and the patient played by Cleese just fell to pieces. I have to tell you he's amazingly funny, he is amazingly funny. And it was very difficult for me to keep a straight face especially since I wasn't allowed to look into his eyes. We each looked at the teleprompter over each other person's shoulders as it were,. So I was staring into the teleprompter over his shoulder aware of the fact that he was doing a million dollars worth of gagging and funny faces and I couldn't laugh.
Dr. Baile: Yes we have that clip on the Web site where he plays someone with I think, is it epilepsy?
Dr. Buckman: Yes.
Dr. Baile: And he goes to his whole entire repertoire of funny faces. So, if anyone wants to see that it's on the I*CARE Web site. That was really a great piece. So, let me ask you I think an important question. Do you think the ability to be humorous or have a sense of humor is something that people learn is it innate or how should we think about that?
Dr. Buckman: I mean I think mostly it's in there innate. I mean I think there are people, rare, but there are people who are sort of born and have brought up. They've been brought up with no humor. And I think actually your parents do actually bring your humor out. I mean if you see your dad making jokes and everyone laughing around the dinner table. Your mom making jokes and everyone laughing at the dinner table, then you kind of stretch those bits of your psyche. I think somehow you need probably to be born with a bit of it but 98 percent of the world is born with a bit of it but it develops and I think you can only develop, and there is evidence for this, in sort of times of relative serenity that when things are going reasonably well, we can laugh and are encouraged to do so. It's basically a sign of good prosperous times you know psychologically and civilization. And I think that we learn how to be funny on a background that's probably innate of being funny.
Dr. Baile: So you--one might be born with an ability but never develop it because the circumstances weren't quite right or they weren't encouraged or they came from a family that was very strict and severe and perhaps didn't encourage the development of a sense of humor.
Dr. Buckman: Oh, absolutely that. I mean actually if you examine like Angela's Ashes, you get the impression that somebody, you know the author could really go through these terrible times of real misery and pestilence in Ireland in the 1940s and so on and yet still keep alive a little bit of wit and as he tells his autobiography it sort of comes alive in it.
Dr. Baile: In that sense humor can be life saving as--
Dr. Buckman: I actually agree with that. I agree and myself this is the number 1 rule of humor is that humor is only permissible, acceptable, useful and helpful after you have taken the serious stuff seriously. So, rule number 1 is take the serious stuff seriously and this particularly goes with the doctor and patient. You cannot come in and make jokes and expect to cheer up the patient. Cheer up, you'll be dead next week but I won't. That's absolutely awful, awful thing to do. Take seriously what they take seriously. And after that, humor is one of the things that can go between the two of you and be, as it were, a bonding and coping strategy for the patient.
Dr. Baile: You know, I'm thinking about a very famous example of that and that was when Norman Cousins was hospitalized and he made a deliberate attempt to bring in I think it was Laurel and Hardy movies.
Dr. Buckman: It was worse. It was the Three Stooges. He went into a hospital room and for something like 2 weeks he had possibly ankylosing spondylitis which may actually have been on a remitting course anyway he thought that by laughing uproariously at these Three Stooges which I would say, if anyone laughs at the Three Stooges I think I would immediately demand a CT scan of their brain. But anyway that's my own personal opinion. And he sat there laughing and laughing and laughing for 2 weeks and claimed that it cured his ankylosing spondylitis disputed by most rheumatologists. I do not think that. It may have helped him cope but it certainly didn't change the disease.
Dr. Baile: Well, after we leave here I'll go right for my CT because the Three Stooges are one of my favorites.
Dr. Buckman: Is that really the case? You're a psychiatrist, aren't you?
Dr. Baile: I'm a psychiatrist. Yes, you put me really on the spot now.
[ Laughter ]
Dr. Baile: So, this is very interesting. So from, so patient-generated humor might really, really be helpful. But I wanted to ask you what makes something funny?
Dr. Buckman: I actually think, I'm very old now, but after all these years I think I've come up with a formula of what actually makes something funny. It doesn't tell you how to make something funny. But it tells you what all humorous things have in common which is a deviation from an expected sequence. So you have to have an A, B, C, D, but instead of going A, B, C, D the joker goes A, B, C banana. Now A, B, C banana is not funny, but my favorite one just as an example of this. If a man speaks alone in a forest and there is no woman there to hear him is he still wrong. Now the point is that that, you know, that's a diversion from an expected sequence which is going to be really rather dull and the diversion is what makes us feel ah, this is a joke and it also establishes a sense of perspective between the joker and the jokee.
Dr. Baile: So, it's really an ending or something about it that seems to be normal or usual but has a twist to it.
Dr. Buckman: It has got to be unexpected. It has got to be, to use your phrase, it's going to be abnormal if you see what I mean. It is [inaudible] socially accepted abnormality. It's got to be okay to make a joke like the joke I made was a joke with men as the expense--is he still wrong? Is a joke at the expense of males? I'm allowed to make that joke because I'm a male. It wouldn't necessarily be as funny if that particular joke was told by a female. But it's perfectly safe for a male to make that joke because the butt of that joke is a male. So it's alright. And so in some respects it's got to be a socially acceptable abnormality that's the punch line of the joke.
Dr. Baile: Interesting. So, why can humor of this type be beneficial to patients?
Dr. Buckman: It can be beneficial because basically it reminds them of two things at the same time. It reminds them of the humanity on both sides of the desk. I am human as a patient. You are human as a doctor. And it also reinforces the communality, the bond between the patient and the doctor. So if the doctor is able to make a joke after, and I say after, after, after not instead of taking seriously what the patient takes seriously, it basically says to the patient, we are both humans. We both have functioning outside the role of, in this case you patient and me doctor. We both exist as human beings, as it were, when we're not playing the role of doctor or patient. And look, those communalities can be bonds between us and of course the beauty is if the patient, as it were, gets the joke then what you've actually done is subsumed over things that you got, the A and the B and the C in common in leading up to that diversion of the punch line of D, as it were. So you're telling the patient, "Hey, isn't it wonderful we both have the expectancy with this?" This we share as communality and we both can recognize that the end of that is a diversion from the expected sequence.
Dr. Baile: So, for people who are concerned about the relationship with the patient and supposing someone said well, isn't this being overly friendly?
Dr. Buckman: I would strongly disagree with that because I would say this is my idea. Humor is a communication technique and in some respects the key to a technique is, as it were, administering the appropriate technique at the appropriate interval. In other words it is a professional intervention. So, I would say that my use of humor in my relationship with my patients is a professional intervention. It is certainly based on a desire to make them feel better but I wouldn't say that it is friendly in the sense of a preexisting friendly relationship between me and the patient. What is it? You are my patient, you are suffering, this is a bad time, I have acknowledged empathically all the bad things. Now, having acknowledged those things I'm going to make a little joke because I want you to feel better. The patient doesn't say that Dr. Buckman is a friend of mine, he says or she says isn't that Dr. Buckman trying to make me feel better and appreciates that.
Dr. Baile: So, let me get back to Norman Cousins and the article of the New England Journal that I respect your opinion that probably didn't cure his ankylosing spondylitis but I wonder if we know anything about what it does do.
Dr. Buckman: Yes, we actually know that it doesn't because there were a whole lot of people who slavishly followed on Norman Cousins even in Canada and there were these laughter rooms in hospitals. There was one actually in a hospital where I worked and they had a little room with a video recorder and library and the idea was you go in there and you laugh and if you come out and nothing has changed it's because you didn't try hard enough. But I do believe that humor and I don't--laughing, excuse me. I don't know the real evidence of this but probably does put out a little surge of endorphins. Actually you know more about this than I do. It does have, we do know that a functional MRI scanning does show that little areas, various areas of the brain light up and by and large good areas of the brain, if you see what I mean, by and large the appearance of the fMRI after or during laughter is actually more likely to be helpful to the customer than not.
Dr. Baile: Very, very interesting. So, let me ask you, you know I've seen occasions where physicians try to make jokes with patients and they just backfire.
Dr. Buckman: Yes.
Dr. Baile: I mean why does that happen?
Dr. Buckman: Well, important point. I mean I do think that laughter, that humor is kind of a high hazard, zero risk of zero margin of tolerance. It's like landing an airplane on an aircraft carrier. I mean you got to get it right to make it right and you--it can backfire. And it is much more likely to backfire if there are cultural differences and I don't necessarily mean that you know, the patients comes from Japan and I come from London or something like that. It might be cultural within the same city. I mean Toronto for example is a very multicultural city and we all live there, but it might easily be that the way this particular patient has grown up to regard what is funny is not the same way as I have so there might indeed be misfires. In the event of a misfire, acknowledge it and say I'm sorry, that obviously didn't get the effect I was hoping for. And by acknowledging it, what you're then doing is acknowledging a shared experience anyway. So you'd actually made an empathic response on both of your feelings.
Dr. Baile: So, if I walk into a patient's room with a good lawyer joke only to find out that the patient is a lawyer they might, that might not go very well.
Dr. Buckman: I'm terribly sorry. Are you trying to imply that there is such thing as a good lawyer because I was told there wasn't? I'm sorry. It's the joke that was okay, right, okay, ha-ha-ha-ha. Yes, you're absolutely right. You might, that's a very good example because you might think yeah, and you and I are both doctors, so we might think any joke about lawyers is completely safe so you make a joke about a lawyer 'cause there are some things even lawyers won't eat or whatever it is. And then it's "Oh, my goodness this person is a lawyer." And the lawyer looks at you straight in the eye and say, I'm terribly sorry, we're you trying to be funny, you know or something like that, you know, and very important point you didn't realize and you've missed the aircraft carrier. You've landed in the sea. The important thing is to acknowledge it and the moment you fess up and say I'm really sorry, I did think that I was going to make us laugh. I realize now it was not a good idea. Please accept my apologies and patients do, they love it.
Dr. Baile: , if we could sum this up, I think that the important point that you mentioned about humor is it actually creates a bond between the clinician and the patient but we really need to be careful and select our moments.
Dr. Buckman: Yes.
Dr. Baile: And also the type of humor that we want to make a joke about.
Dr. Buckman: Yes, absolutely right. And always show that you are aware of their feelings first. I mean you take them through it and then also show that you've got somehow to have good credibility. Now, it might be the good credibility at a previous visit when you're planning the adjuvant treatment or whatever it was. In some respects you've got to be trusted before you can be trusted to make a joke and then you can.
Dr. Baile: Thank you that was very illuminating and hopefully it will provide some guidelines for our listeners about a more rational approach to using humor in a clinical setting. Tell us what other projects that you have on the burner now?
Dr. Buckman: I'm glad you asked me that, Doctor. I'm now putting together, it's going to be published in October 2009, a book which is like a handy guide to all strategies for communications like breaking bad news, error disclosure, conflict resolution, information giving which I have to tell you us doctors we are not good at how do you make it interesting when you're explaining a clinical trial to a patient and you know that you got to explain 16 or 18 or 20 points and you're, oh my gosh, it gets worse. How do you make it interesting to yourself so that you're good at it?
And then also how do you, as it were, prepare? How do you get yourself into the right frame of mind for an interview? And this book which has a little sort of pocket guide which you can put in your upper pocket of your white coat with all those acronyms. It's basically, if I dare I say it, that dummies guide to communication, reminding you when you are panicked and stressed and hurried and hurried and hassled and high emotions and high stakes about how you can actually, as it were, prepare yourself in order to get the best and give the best during the moment between the doctor and patient.
Dr. Baile: And so this book will be coming out in October?
Dr. Buckman: October, It's called Practical Plans for Difficult Conversations in Medicine by John and it's published by Johns Hopkins University press. I'm allowed to mention that even though they're not actually affiliated with M.D. Anderson and nice people even though they're not in Texas.
Dr. Baile: Yes, I did my residency there, so--
Dr. Buckman: They still speak of it. It is a plaque up right there, you know.
Dr. Baile: Well, thank you very much, Rob for joining us today and you can see a full lecture on this topic of humor as a coping strategy by Rob as well as video illustrations of key communications skills on our Web site www.mdanderson.org/icare. Thanks for listening and thank you again, Rob.
Dr. Buckman: Thank you Walter.
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