Robert Buckman, M.D., Ph.D.
Medical Oncologist
Princess Margaret Hospital
Professor
University of Toronto
Dr. Baile: Welcome to the lecture. This lecture, the lecture series, Achieving Communication Excellence (ACE), is sponsored by the program in Interpersonal Communication and Relationship Enhancement, which is part of the department of Faculty Development. I'm Walter Bale the program director and I'd just like to make a few introductory remarks. I invite everyone to visit our I*CARE Web site at www.mdanderson.org/icare where you'll find a number of tools to illustrate and enhance communication skills in different situations with patients such as breaking bad news, error disclosure and a number of other challenging communications which we find ourselves dealing with patients over time. All of the lectures from our ACE series are online. I think there are five of them that will be online soon, including error disclosure, dealing with accrual to clinical trials and cultural issues and cancer care. So, if you have a chance to visit our site, please do so. This lecture is certified for continuing medical education and risk management credits and all the lectures online are certified for that. You'll also find CME, free CME credits online.
Today we're pleased to have a lecturer who is known nationally, internationally for his reputation on communication skills, especially "breaking bad news," Dr. Rob Buckman who is Professor of Medical Oncology at the Princess Margaret Cancer Center at the University of Toronto in Canada. Dr. Buckman received his medical degree from Cambridge University in 1972 and his PhD. at the University at London in Cancer Research. He's practiced medical oncology since 1985 with a specialty in breast cancer. Rob is a prolific writer. He's published 14 books and he has one in the works now, including one textbook on oncology and very patient friendly books on how to talk to your doctor about cancer and similar topics.
Rob is also well known for his interactions, in promoting interactions and information to patients and families and actually had a TV show in Canada on this topic which won the equivalent of an Emmy Award. I think the topic that he is going to talk today about humor and coping is particularly appropriate because when Rob was a resident in London, studying medicine; he had a TV show that was called the Pink Medicine Show which was watched by 10 million people every week. So, without further ado, I will introduce my good friend and prolific author for I hope a very interesting talk he's going to give us. Thank you Rob.
Dr. Buckman: Thank you. Thank you very much indeed Walter. It's... with that I want to make this slightly serious point. I hope this won't be a totally serious lecture. I will, as it were, you sprinkle it with a bit of humor just to illustrate I was going on. But the important point Walter is making is absolutely right that humor is part of the things that we can use to enhance excellence, enhance excellence in communication. Its basically what I'm proposing to you, is basically a strategy that we can use that we can use, safely as clinicians to, as you were, build and reinforce the patient's ability to cope with a diagnosis. And the first point I want to make, is humor, is wait a minute, if I got the placebo responder here, here we go, ah there we go... humor is almost universal. It's almost universal but not everybody finds things funny.
And I would like to propose, I don't have any data for this, its basically a normal distribution curve, basically at least two thirds of the population... two, excuse me, within 2 standard deviations there are 94 percent of the general population so most people have a bit of a sense of humor. And there are some people at the top end, as it were, who find everything funny and cannot take anything seriously, they are extremely irritating people I would imagine. And at the bottom end there are people who find nothing funny. They do not find... you know even on a good day, even on a Friday, they do not find anything funny at all. And psychiatrists correct me if I am wrong Walter, but psychiatrists have a special name for these people. These people who have no sense of humor at all. And in the very complex jargon of interpersonal social psychodynamics, psychiatrists call these people who have no sense of humor at all, they call them Scottish people. Good thank you. That was fine.
That was a... with the exception of course of Scottish people who have immigrated to Canada. But the important point I want to make is that humor, and there is, as always, when I make a joke, there is a serious point behind it. And the serious point behind that is that not everybody actually has an intrinsic sense of humor. And a vast number of people, all probably almost all of our patients even if they have a sense of humor, lose it at times of serious threat. It's not possible not to. They are bound to lose their sense of humor at moments of severe threat or challenge. So I want to make that point. That it is not universal and everywhere. And I'm going to build up to that. In the conclusion of my talk, I think I'm going to build it into a nice set of rules by which you and I can use humor safely in the clinic. And to build that up I want to propose to you, that humor has actually got a structure and a function. And I know its extremely brave, not to say fool hardy, of medical oncologists to try and say, what the structure of humor is, but I actually believe that it has one. And I would like to say, that humor is a deliberate and knowing diversion from an expected sequence.
In other words you have to have some expectations. I know where I'm going with this, don't panic. You have to have some expectations of the outcome of a sequence and then to realize, oh that's not what I was expecting. So, as it were, I say A, B, C, D and because you all know the alphabet you know that E comes after, so if I do the equivalent of A, B, C, D, banana, I mean I'm not saying A, B, C, D banana, as a joke, but you know its that kind of a thing. It's a diversion, a dog leg, wait I'll do one very, very quick. This is printed on the front page of the Global Mail in Toronto in a little proverb section and now it's very, very popular. If a man speaks alone in a forest and there is no woman there to hear him is he still wrong? Now, I must say. You see the point. You know I made my face serious, I'm... if a man, and you, Oh, God, its going to be some you know, some sort of quasi philosophical, what is the sound of one hand clapping in order to step forward you must step backward or you know garbage like that. And you were very relieved at the end that it wasn't... I must tell you this, my wife is a diagnostic oncologist, that's the correct word for pathologist, and particularly she is a major person in cancer of the ovary. And she's also, as you might expect, has an amazing sense of humor, and I actually read that to her. And I'm really serious, you know three or four years ago I read a Global Mail, and I always [inaudible] if a man speaks [inaudible] is he still wrong and without batting an eyelid, she says... I said, is he still wrong, and she said, of course he's still wrong... he just doesn't know it till he gets home and his wife tells him. Which I thought was absolutely brilliant.
But the point I am making is that, and this is very relevant to the clinical use of humor that humor is a deliberate and knowing diversion from what is expected so that the other person is expecting response A, but actually you give response B and that makes him, that makes him laugh. That is the humor. The structure of humor is a deviation from what is expected and that tells us something as I'm going to build up to in a moment or two. I would like to propose to you that humor almost always decreases stress. And therefore it is a coping strategy. That in some respect what humor does is to basically tell the jokee, the receiver of the joke and the joker that it is A, B, C, D, E, but look, look outside the box and you could see A, B, C, D, banana or whatever it is. It is looking outside the box that tells both the person who makes the joke and the recipient of that joke that there is a world outside the box.
A very, very important point. It establishes a sense of perspective, that all humor, by its very definition, by going outside the expected sequence actually establishes a sense of perspective. And it therefore, to some extent, if it reduces stress it can be categorized as a coping strategy. To support that evidence, to support that hypothesis, I would like to suggest to you, this is very relevant to this audience; there are a lot of subjects of jokes dealing with things that intrinsically have nothing funny about them at all. I am reliably assured by stand up comedians in England with whom I still communicate, that most, something like you know whatever it is, 91% of all jokes are about health, sex, mothers-in-law, airline travel, I can't remember the other subject, but it was very, very difficult for me in my first marriage, because my mother-in-law lived in South Africa, so when we went out to visit you know airline travel, mothers-in-law, never mind all the other stuff. Difficult enough. But the point is, that none of those, and this is a really important point, none of those are intrinsically funny.
There is nothing... I mean if you're having an argument for example with an in-law the spouse is caught in a real conflict of loyalty, a division of loyalty between the family of origin and the family of choice and in many respects that conflict is extremely unpleasant. So, it is not likely, that say, if I was having a row with my mother-in-law, which is actually very rare, because I'm away a lot, it would be unusual, if not impossible, for my wife to say, when she is caught in a conflict of loyalty, Oh, this is going to be hilarious, we're going to laugh about this in a few years time. Not possible. She is not going to do that. I'm not going to do that. My mother-in-law is not going to do that. My mother-in-law's lawyer is not going to do that. Whatever you know. Its not going to happen. So, one of the points I am making is that we make jokes about things that are threatening, this is the important part, we make jokes about things that are threatening in order to establish that sense of perspective. In order to draw the box at it and say look, we can see outside the box, we can think outside the box.
The point I'm making, which is a very important one, is that what's inside the box, sex, mothers-in-law, airline travel, sickness and so on are not intrinsically funny. There is nothing intrinsically funny. And I'm going to, I'm going to... when I get to the end of my talk I'm going to illustrate that with an incident that happened about four years ago. Which absolutely, absolutely I'm going to tell the truth about it, I think demonstrates that point. There is nothing intrinsically funny and I would also add, that therefore there's nothing intrinsically forbidden. There are very few, if any subjects, that you cannot make a joke about that about them in the right circumstances. That's the big thing. It's the right circumstances. And in a moment I ought to come on to what's, what those right circumstances are. So, the structure of humor as I defined it is a deviation from an expected sequence. And actually I think it's a damn good definition. It really, it really actually fits the bill. You have to have some expectations.
If there are people who have nothing in common, suppose, suppose there was, we suddenly found an island in the South Atlantic on which people have grown up speaking English but had no lets say, to make things easy, but had no contact with any culture of any of the cultural nuances of the let's say North America or something like that, it is possible that we might be able to communicate with them. But if they had no understanding of the nuances, because they had been you know, on this island in the South Atlantic and had no contact with the culture, it might be impossible to make jokes with them, even though we can speak the same language. Do you see what I mean? That in some respects humor demands communality. You've got to have a whole load of expectations in common in order to recognize a diversion from those expectations. I hope that doesn't sound too philosophical. But the important point is that humor depends on communality.
Now what does it do? I, I basically, I mean its very difficult to define what it actually does, but I'm going to just very quickly discuss four major categories, as it were, of what humor actually does. I think first of all it changes the subject and very often in medicine, without actually, once the subject has been grappled with, once we've actually talked about the subject, we and they, our patients are actually looking for something to, as it were, lighten up. Actually change the subject from the threat of the embarrassment or whatever it is, or from a, from the grief which can be self directed of course, their own [inaudible] or loss of future potential from the sadness and of course from the overwhelming stress. In all of those circumstances, humor after the serious stuff has been taken seriously, can provide a change of subject and can be a useful way of temporarily escaping from the actual impact of the bad news itself.
Humor also, as it were, brings along with it a change in the emotional climate. Now, I would like to propose to you, that in order to do that, the patient, you know I'm talking about in the clinic, the patient has to trust you. They have to know that you know that, you know you're stuff, you know their situation, that you will do the correct and appropriate thing for their particular crisis, you know, whatever it is, metastatic disease, or whatever you know primary surgery, whatever it is, doesn't matter, that you know you're on it. You know what it is that you're doing, after you have shown that you can be trusted with the serious stuff, it may well be possible that they are looking for an emotional break, a holiday as it were, a brief emotional break, but in order for that joke and for the humor to actually do that, they need to trust you.
So the important point I'm making is that you have to establish your street credit as it were. You have to establish your credibility as a physician before you go on to do the jokes and to some extent, the jokee, the receiver of the joke, part of them must actually want to change their mood. In this I am a total opponent. I differ totally from what I would call the Patch Adams approach. Now I don't know very much about Patch Adams, probably you know more about Patch Adams and the Gesundheit clinic. But I saw the movie, in which Robin Williams is Patch Adams and in that movie I had really serious criticisms about the use of humor as portrayed by the character, Patch Adams played by Robin Williams in the movie. I don't know whether the real Patch Adams actually does this, but in the movie he definitely inflicted humor on people. So he came into the ward with you know a clown's outfit, and a wig and a red nose and big floppy shoes. In the film he dressed himself up as an angel of death which I didn't think was a very good idea. You know, he wasn't an oncologist of course, but you know I don't think it was a good idea to come into a miserable patient, who was very depressed and dress as the angel of death. And somehow... make a joke about you know you've died and you are in heaven. It can't be real heaven because I'm here too, etcetera, whatever... Actually that was a better joke than he made, anyway, doesn't matter.
The important point is that Patch Adams inflicted humor in the movie; I don't know whether he does in real life. But I believe that is totally wrong. I don't think you should ever, ever inflict humor. And actually, personally I find it repellant. If people... I happen to be really miserable or worried or stressed or something and somebody comes in and says, this will cheer you up. You know, and they go, I'll tell you a joke... its doomed to failure and I find it very insulting that they are actually telling you that they will manipulate my emotional state by humor. I do not believe that that is actually possible.
I think that as it were, that good clinical effective use of humor, what you're actually doing is responding to what it says there. The part of the jokee, the receiver, the recipient of the joke that actually wants a change. Then it can actually produce a change but not otherwise. This perhaps is the most important slide of all, perhaps, maybe. Maybe not. But this is where I want to propose to you that humor does enhance the excellence of communication and the interpersonal relationship because humor reinforces the communality. It reinforces the bonding between you, the joker, and him, or her, the jokee. In some respects the moment I say, take that example, if a man, if a man speaks alone in the forest. That is such a good example... that when I... I made a slightly serious face, I said, if a man, probably didn't ring any bell... forest and you thought you know... forest. You know it vaguely reminded you of something you know if a tree falls in the forest and there is no ear to hear it does it make a sound. You may have been thinking that, you may not. But it has given you something quasi philosophical.
The moment I said... is he still wrong, you realized that number one that it was a deviation from the expected sequence, if a man... forest, it usually ends up with something serious down here. But look its there, it goes is he still wrong. And at that moment I would like to propose to you that you laughed for at least two different reasons. Number 1, there was the relief from the quasi philosophy... someone would say the humor of that remark was derived from the deviation of the expected sequence. But I would also propose to you, in this auditorium, at that moment, we all laughed. [inaudible] I hope I wasn't laughing too much. But you all laughed partly, even unconsciously, you may not realize this, to show other people that you understood the joke. You are actually saying, whether you realize it or not, I'm okay. I understand that. The kind of sentence that begins, if a something, something, something forest, something, something, something, usually ends up with a serious quasi philosophical saying and here it ended up with something that was funny.
And in some respects what you were doing was to tell everybody else here, that's why you laughed out loud, that you actually are part of the same group. Hey, I understand this cultural comment. I understand the basic culture background that actually goes behind it. And I would like to propose to you that laughing out loud as you did, thank you, by the way, I'll give you the money afterwards, that laughing out loud is partly an intrinsically bonding experience, a behavior. What it actually does is to show all the other people around you that you are with it. That you are in the joke. I think that sometimes, I am getting a bit Jonathan Miller here, but sometimes Miller often points out that people sometimes make laughing behavior and make a loud ha, ha, ha, ha, as he describes it you know slap their thigh, for something they don't actually find funny. And he demonstrates that very important point that Miller made, that you see that kind of behavior particularly in for example, soldiers, and he sort of traveled I think a couple of times you know in where there were soldiers flying to somewhere.
This is always a very tense situation. And they made jokes which were not intrinsically funny, but when anyone got to the point which could be deemed a punch line, everyone went ha, ha, ha yeah and slapped their thigh. It was laughing behavior without true humor and he was making the point that what they were doing in there, I agree with him here, I'd be mad not to, that what they were actually doing was establishing bonding. But what they actually did at that moment, I will agree that you told me a joke or [inaudible] joke; I will agree that's funny even though it isn't and I will slap my thigh ha, ha, ha, ha, ha, and that will show you that I want to be a member of the same group as you. So in fact one could call it almost pseudo bonding. It, as it were, no it's a real bonding but it's a pseudo relationship.
They don't actually think the same thing is funny, but they are actually establishing that they are members of the same group. The corollary effect is that jokes are easier the closer you are and the more common stems, as it were, you share with the other person. Basically if you come from the same culture, you're imbued with the same kind of pop culture, music, comments, radio, television, whatever it is, films and so on. Its easier to make jokes because its easier to see the expectations from which the joke is an actual deviation. The more shared events you have, it is easier. Now this must be an experience of your own too. There is, as it were, those strange situations, that you all must have seen, in your residency here, there is nothing more, there is nothing funnier, as it were, than the cardiac arrest team, the crash team after the emergency has been dealt with, particularly if it's successful.
When the patient is now in the ICU and is hooked up... at that moment when the emergency has passed, you all feel very, very close to each other and you do make jokes... people laugh at things which are not particularly funny, because of their relief, because they have just lived through a shared experience. Now the psychiatrists actually have a word for that. It's called imprinting. And imprinting, and this may be very relevant, in the clinic, imprinting is a demonstrable decrease in threshold to other people's stimuli, from other people as a result of stress. Actually one of the television programs that Walter also mentioned, we actually did a demonstration of stress. We filmed people at a fairground, and we actually had one of these. Those were the days where monitors for chests hadn't been invented but we had telemetry with, I had to go with them in a Ferris wheel. Now I happen to hate Ferris wheels and I hate the sort of drop of the... and so we were filming these people, and you know their pulse rates were going up to like 130, 140 and I can't remember whether they actually had their diastolic, I've got a feeling their diastolics were around 95 plus for that moment and systolics were about 160. At that moment. And at that moment of terror in the Ferris wheel safe terror in the Ferris wheel, their sensory thresholds go down so that they are extremely sensitive to the other person.
So, it is not surprising that young men and young women go to the fairground together and go on the Ferris wheel or go watch scary movies or whatever. Because at the moment of terror when you are next to the other person, your threshold goes down and you're inclined to, as it were, note them, notice them much more. It is my theory that is why so many, I'm talking about England particularly, so many surgeons, in England particularly, end up marrying the OR nurse, I think its very likely that the shared experience has made them increasingly sensitive to the other person's input or stimuli. And therefore, wait a minute, the computer... the computer; excuse me I just got to talk to it for a moment. Move forward now. Wait a minute, did I do that? Hang on a second. Walter you're a psychiatrist save me here. Doctor I need help. Thank you.
What did I do there? How did I do that? Okay.
Could you just excuse me a moment. I'm sorry; I'm very Canadian aren't I? So, the important point is that humor is a bonding. That humor forms a serious bonding capacity. A bonding role between you and your patient and therefore it actually has an additional function. Now I'm not going to make a big deal of this, but I'll just mention it. Physiologically there are probably a whole lot of parameters that follow when people laugh out loud. We don't know, studies have actually been done, but it may well be that humor decreases pain by the endorphins. I'm going to tell you one, it is a serious and true story, and I mean I'm not playing for sympathy but it's true. I have a condition called dermatomyacitis, its very similar to lupus, but less so in various stages, particularly in late 1970's, it was really it was nasty and I had a lot of bad arthritis, muscle wasting and so on, I was a crock as we say./p>
And I remember this very, very distinctly; I walked into the cinema to see a movie called Bread and Chocolate. Which was an Italian comedian called Nino Manfredi, in fact, I'm not saying it's the best movie in the world, its good though, its very good, and I remember very distinctly hobbling into the cinema, my feet, most of my joints were in real pain and I remember very distinctly lowering myself into the chair, actually hurting. Sat down and I remember also then laughing for about the next 70 or 80 minutes at the movie. It was a very, very good movie. And I really laughed myself sick, and you know at the end of the movie, the lights came up and I remember this very distinctly, to my own astonishment, I basically stood up without any pain at all and I walked out of the cinema and the pain didn't start rolling in for about another I would say 10 minutes. Which is a little bit short for endorphins or maybe short for endorphins but I had totally unexpectedly 10 minutes completely free of pain. And I remember that very distinctly at that particular point and I'm not even sure that endorphins had been discovered but certainly that incident of basically getting laughter for about 70 minutes and then getting 10 minutes of pure relief, of sheer relief from the pain was probably mediated by endorphins which actually probably decreased the pain.
Probably also they may have, made be feel euphoric, I would like to say Nino Manfredi did it without the use of endorphins but maybe that he did it, but maybe that he used them. But it may well be that laughter to this extent not necessarily a cause of feeling better, in that sense, but a symptom of feeling better. The point I'm making is that if people are able to laugh and if that laughter does produce a flood of endorphins into the CSF it may well be, one of the effects of endorphins which of course, is feeling good. Maybe produced by that. And I'm not getting too philosophical about that but I'm making the point that there are physiological reasons above, alongside the psychological reasons for humor making you feel, making you feel good.
Therefore, this is the slide for clinical use. I would like to make the point that in order to use humor in the clinic you have to demonstrate that you know what it is you're about as a clinician, and you absolutely, must do this. Absolute rule, you have to take seriously what they take seriously first. You cannot ever make a joke instead of grappling, making an empathic response to an emotion that they are experiencing. If you do that, if you make a joke, if a patient says, "Oh, my God, the tumor has progressed, nothing could be worse." And if you say something asinine like, "Oh, it could be worse, it could be happening to me." Or something stupid like that. If you do that, I think it's a very good example, in that instant of making that awful joke, what you are actually doing is marginalizing the patient. You're actually saying you are suffering but I don't care about you, and you're trivializing them which is a very bad mistake.
Actually, trivializing anything they see as important, even if medically speaking you actually think it may be trivial, you have to acknowledge the trivial first with an empathic response then make a comment later. But if you make an asinine joke like... instead of taking them seriously you trivialize them and you marginalize them and you basically say, you're taking it seriously but I'm not going to, and I would say, that is rule one of humor. Never, ever, ever, do it instead of taking seriously what the patient takes seriously. After you have taken it seriously then you can make a joke, as I would demonstrate at the end of this. But after it's perfectly okay.
I would secondly, rule 2, and this may not even be so important, if you have some little hint that the patient is likely to be, as it were, in the market for humor, and then be even more encouraged. But, and this my important point, I think humor is like garlic. I mean I don't know how you feel about garlic. I mean I personally think garlic is fabulous. I think it's absolutely terrific in meat and vegetables and so on but you don't like a meal that is sort of soaked in garlic, from the soup to the dessert. I mean if they bring you a peach melba at the end and that's full of garlic too, you're being poisoned. That's what actually happened. It's a bad mistake. But strong spices are very, very good if they are used appropriately and occasionally. And I think garlic is actually a very good example. That garlic is fabulous if used appropriately on the meat but not on the dessert, and occasionally. not actually, the food isn't actually soaked in it. And I would say the same is true of humor. That humor is very powerful, as it were, an adjunct as a spice to difficult communications, but not as a substitute. Here are the hazards, I guess rule three.
Rule three is if you use rule 1 and rule 2, take seriously the serious stuff first and number 2 appropriately and sparingly, you will avoid the potential hazards. Trivializing I've mentioned. Changing the focus, demeaning and belittling are all hazards of humor. And here's the important point. This slide, which is if you misfire, if you misfire acknowledge the misfire. So suppose you are diseased in your brain enough to think that that joke, you know it could be worse if it happens to me. It could be happening to me. Suppose you thought that was a joke, and then went into see the patient, oh my God, this is absolutely dreadful and you say, "Cheer up it could be worse, it could be happening to me," and you thought that was going to be very funny and the patient says this is awful. Immediately you realize that your joke has failed, acknowledge it.
To some extent what you need to do is tell the person that you have noticed that you have misfired. I was giving this talk a few months ago in Northern Ontario, wonderful physician, whose name will come to me in a moment, but I couldn't mention it anyway, because I can pretend it has come to me. But he said, in the question and answer, he said, he made a joke once to, I think she's in her early 70s or so, he made a joke which just failed and he did a brilliant, his comeback was actually very good. He said, that joke failed didn't it? Which was a great start, he acknowledged it, he said, I tell you what, I will type out the letter of complaint to the college all you need do is sign it, and she thought that was wonderful. And the fact that he acknowledged and then basically told her that she had every right to feel unhappy with this made him even more huggable than he is. It was actually quite clear this particular guy is a really superb internal medicine physician and it was quite obvious. But the fact that he did that when he had misfired with a joke and my analogy, I hope you'll forgive me is, humor is like landing an aero plane on an aircraft carrier. Not that I've ever done that, but I'm reliably assured, that landing an aero plane on an aircraft carrier at sea is quite difficult. I am reliably sure. Boats going up and down, planes going up and down, and you've got to line up and you've got to land. You've got to make your approach at exactly right down the middle of the runway or the deck and so, and then you've got to basically drop at a very, you've got to really forcibly drop onto the deck. And at that point if you do, the hook on the back of the aero plane will catch on to the lines which you hope somebody has tied up and will slow down the plane before it falls off the edge. So your margin of error is basically zero. Now obviously people are trained in it and they are extremely good at it.
The point I am making is that humor is a bit like that. That humor has a very slender or absent margin of error. Its like landing an aero plane on an aircraft carrier. If you do it right the hook will bite on the lines and you will have an increased bonding between you and the patient. If you do it wrong and even if you are only 50 feet to the right or to the left, you are going to end up in the water, which is a total catastrophe. And what I am saying is that humor is something you can do if you feel, as it were, equipped to do so, but be aware that, as it were, has a very small margin of error. And this being M. D. Anderson, I of course, have an equation. I don't think anything can actually function without an equation. And to some extent its true. I'm not making a big deal about it, but I make the point that the amount of humor the quantum of humor depends on the gap between the observed and the expected. That's very good. That's a statistical thing. The O minus E multiplied by the huggability of the joker and all multiplied by the amount of trust.
Now, actually, I sort of believe that huggability and trust actually overlap. I'm not actually sure they are. They really are separate components. I don't think that you can think of the joker as huggable if you don't trust them. Very important point that trust actually builds huggability. It's a very important point. Somehow trust which is something to do to with expectations maybe partly be the creator of huggability. And then the point the next point is that the closer the gap between the culture of the joker and the culture of the audience, the closer to zero the CJ minus CA is, of course the bigger the amount of humor. This is why jokes in the family are always so funny. I mean why is it that we always find family jokes amazing... suppose you have a great uncle Fred and he comes down every Christmas and he falls asleep in the chair after the Christmas meal and always, while he is asleep, breaks wind. I have got several uncles called Fred who are just like that which of course is why I immigrated to Canada.
But suppose you've got that Uncle Fred. Uncle Fred can become, as it were, a trigger for that kind of situation and you could probably use it as a euphemism for breaking wind. And you say, Oh I'm sorry, I just Uncle Freddied or something like that. And we haven't even had Christmas dinner yet. Or something like that. In some respect the closer, oh wait a minute, it moved, it ganged up on me. The closer CJ and CA are to each other, the funnier the amount of humor because of the shared experiences I think. So, the point I want to make is, the closer you are the easier it is to make jokes. Humor is not cheap in terms of labor and effort. I am really serious about this too. It is impossible and strongly to be discouraged to, as it were, to have a load of ready made lines which you will inflict on your patients. I think highly inappropriate. Highly dangerous to the doctor-patient relationship. It requires effort.
You really have to listen and you have to, as it were, concentrate on what is appropriate, and I think those three rules I propose to you, take the serious stuff seriously first, then you know what was the second rule? I knew it was something very important anyway. And the third rule was avoid trivializing and so on. Oh yeah, be aware that they might be in the market for humor and so on. Those rules, concentrating on them, requires a great deal of effort. And I would like to propose to you that doing that amount of effort is a really, really good demonstration, I made this point many times, that communication skills, including humor are like good table manners.
I am reliably assured by behavioral scientists that when we eat spaghetti for example, what we really want to do is pick up. I don't, but they say we do, what we want to do is pick it up and smear it all over our face and apparently this, apparently this is what we like to do with spaghetti, whether we are children or in Canada after the age of 30 but you know whatever it is. You know twirling your spaghetti on a fork, if you are a fork and spoon twirler, some people can actually twirl with a fork. Pat can actually twirl with a fork, well I don't know how she does it, she does it with her fork alone but even twirling is apparently quite an effort compared to what you want to do. The point I want to make is that when you twirl your spaghetti what you are saying is look, however inept I am at twirling, I am trying to twirl. I am trying to be a member of the group of which you also are a member. I am trying to show communality. I am trying to show I understand the rules. You can't eat spaghetti like that; you've got to eat it like that. And in doing so good table manners include you in that group and I would like to say that humor is the same thing. It requires effort, just like spaghetti twirling, it's an effort. But it shows the other person that you want to be an accepted member of this group, the good table manners people. And I think that humor is the same thing. I am going to end then I'm going to open this to questions. I am just on time. I'm amazed at myself. But of course I am amazed at myself; I am an oncologist aren't I.
I'm going to end up with a story which actually happened four years ago. As I said there is nothing intrinsically funny about any cancer or any treatment. There is nothing intrinsically amusing about them. I'm, as you gathered, I'm a breast medical oncologist so a lot of the times I am giving adjuvant chemotherapy for example to patients. I am talking about you know for the next however many days, you know, 18 weeks of them being really unhappy and tired and fatigued and nausea and hair loss and whatever it is, and so on. So what I always do routinely, I tell them and this was a patient with her husband in the clinic, and I said we're going to start you on I think whatever it was, FEC 100 I think it was, and I said these are the main side effects of FEC 100 and I went into the side the effects and I said as I always do, we'll start the treatment next week so if there are any more questions jot them down on a bit of paper and if you want to I will answer them before the treatment actually starts.
So the following Thursday she and her husband came in and the husband had a clipboard with about 30 sheets of paper. I'm going... here we are. And they were there... they obviously they've been thinking about this very seriously and he was quite serious, and he said doctor, there are a few questions I want to ask. "Number 1, how about diet?". Very common question. I said "No problem at all, you Mrs. Anderson," her name was Anderson, actually mustn't say that, her name wasn't Anderson actually, I said, "You know you can eat anything you like but don't eat your favorite foods in the 48 hours after chemo, because that gets scapegoated and induces a feeling of nausea." And so you'll find that there's actual data on that. They did the experiments with halva, I was very impressed. Personally I find halva causes more vomiting than chemotherapy but anyway, that's not the point, that's not the point so he said, "Yes." Then he said," I meant about strengthening the immune system. Have you heard of that one... strengthening the immune systems with food." I said "Well there's lot of talk about it but actually there's no evidence that any food actually strengthens the immune system," which is true. There is no evidence. He said, "Oh, well okay." Then he said, then he got even tenser and he said "Doctor, how about alcohol?" And I said "No problems with alcohol, if at any stage during the next few months Mrs. Anderson you're on antibiotics, some people say that when you're on antibiotics there's a bit of a psychological interaction anyways that you feel actually drunker than you are, than you would normally be for that amount of alcohol," so I said, "You know you'll be a cheaper date than usual."You know she shared a little bit of smile. And then he got really tense and this is obviously something that they'd been talking about and he leaned forward and she leaned in very, very closely, and he said, "Doctor, how about sex?" And I leaned very close to him and I said "That's the best offer I've had all day actually. But shouldn't we wait till your wife leaves the room?"
You know, I said also, "I want you to take me out to dinner first, because you know I'm not that kind of a guy normally." And they loved it. They absolutely loved it. They both laughed themselves sick and I tell you that several times, they're both alive and well right now, but several times I saw them in the waiting room when I was... and you know he would wave at me from across the waiting room you know. "Oh, doctor, how about sex?" Not a very good thing to hear across the waiting room, you know. So I said, "You don't write, you don't phone, you don't send flowers, forget it," you know.
The point I am making and then I'll open this for questions, the point I am making is that even in very unforgiving circumstances like adjuvant chemo for breast cancer; it is possible to make a joke after you have taken the serious stuff seriously. Like this diet and like the alcohol and so on, if you think there is an inclination that they are in the market for humor as she slightly smiled when I said cheaper date, and I go, okay, okay, I'm alright. And then you could make a joke after you've taken something seriously. And it will strengthen and enhance the communication and the bond between you. So what I'm really saying is that in the right circumstances, appropriately and in low doses, humor is a strategy that we can use clinically after we've taken the serious stuff seriously to enhance the relationship between doctor and patient. Thank you very much indeed. Thank you.
[ Applause ]
Dr. Baile: Thank you Rob. We have time for a few questions. In the meantime, could you guys please fill out your evaluation because we really would like to have some feedback in order to support the lecture series? So, any one have a question they'd like to ask? So may be I can ask you for those people, for example, you mentioned at the beginning the people way on the end of the normal curve who don't have a sense of humor, like do you have a summer camp? Or something? Is it teachable?
Dr. Buckman: This is something that you psychiatrists wouldn't understand at all. Medication. There is nothing else, medication. No, stay away from Scottish people. No, you can't actually teach humor and to some extent you shouldn't. It's like teaching any sort of subject, its like teaching beauty or... you can't, you can't tell people what is funny. You can only find out what they think is funny. To take your question seriously Walter, to some extent humor is a central philosophy. Its part of the filtrum shaum the view of the world. And if they have it you can respond to it. You can constantly be surprised. Somebody you thought was a humorless Scottish bastard or something like that makes a joke and then you can respond to it. But I don't think ever you can actually, you can actually teach it or inculcate it. And you shouldn't.
Dr. Baile: Other, Dr. Gritz.
Dr. Buckman: Oh, there you are. Hi.
Dr. Gritz: Maybe I think its part of a relationship bond with a patient that you start to get insights into the patient's mode of thinking and empathic responses and that you can find that people will respond with humor to things or that you can assess what would be humorous to them and capitalize on that. I'm not making the point very well but...
Dr. Buckman: I would agree with you totally in fact, I want to go back to that slide because I think you're absolutely right. And I... would slightly modify that. I think you're talking about the T for trust, and I'm very serious I think and it doesn't say that I just thought of it but I think that you're absolutely right. That empathic responses build T, build trust and the trust is there for time or rather process dependent. That when I first meet the patient, when I first met Mrs. Anderson, she might have thought, you know, who's he? But after I continue making empathic responses about her and her husband's anxiety, the T for trust enlarged greatly. Which probably, is probably, you're probably right that if I'd have tried that joke about you know how about sex the first time that Mr. and Mrs. Anderson came into the clinic, it would have died the death. But the second time after the empathic response what had probably happened, you are right, that the trust had actually built and so empathic responses are part of, as it were, laying the foundation for trust in which they feel safe to share their sense of humor with you. So, just as Walter said, you might not have thought they had a sense of humor but it might have been hibernating because of the trust.
Dr. Gritz: And as a practitioner, people can identify that in themselves, when they first say how could I turn this into a humorous situation but as they relax themselves and identify the [inaudible]...
Dr. Buckman: I agree with you also that actually ones own relaxation, actually there is a fabulous book called Evolution for Everyone, by David Sloan Wilson. And he proposes and there's good behavioral data for animals too, that relaxation, activities that occur in relaxation, humor is not exclusive to the humans. It is shared you know bonobos and certain other primates and so on, and he makes that point that under threat nobody does humor activities but when we are reasonably safe we do these building activities which include humor so we feel safe. You're absolutely right. I never tried telling a joke to a bonobo ape but I will.
Dr. Baile:Danny.
Dr. Epner: Is the probability factor completely genetically determined or are there ways to make one more huggable?
Dr. Buckman: The latter, I actually seriously believe that. And here I reference a major academic journal which probably you don't read but I read regularly, called People Magazine. But I absolutely believe when you look at the people who are huggable and you see their photos, you wouldn't think that they were huggable at all, maybe sculpted looking or very good or something. But I think huggability does actually develop in shared relationship between, as it were, the therapist and the patient. And many psychiatrists have said to me for example, in the same morning, one... I'll never forget this when I was an intern, a woman psychiatrist said that one patient had said to her that he thought she was the ugliest woman he'd ever seen and the next patient that she saw that morning had said she was the most beautiful woman he'd ever seen. So, I would think that huggability is context dependent. And therefore establishing a good relationship, as I was saying to Ellen, with the empathic responses will actually enhance your huggability. So its not genetic at all. I would say.
Dr. Baile:Anyone else?
Question: In the last series situation, in the clinical one, and if your joke misfires, isn't it appropriate to explain it if you know that the person will understand it? After acknowledging that it misfired.
Dr. Buckman: I love that. Should you explain the joke? I mean true comedians would say never. Never, ever, ever. Terrible thing is I have incredible scotomas, blank spaces when I missed the joke entirely... I don't get it. And when somebody has tried to explain it to me, I still don't get it. And a week later, I suddenly get it. So I would say, absolutely don't explain it, do acknowledge but don't try to explain it... don't say, you see the joke was... when I say it could be happening to me, I would no... I think I like your question.
Dr. Baile:Well thank you very much for coming today, and a grand applause for Dr. Buckman. Please don't forget to hand in your evaluations. Place it on the desk on your way out and swipe your card if you haven't.
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