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Making Fun of Patients: Medical Students' Perceptions and Use of Derogatory and Cynical Humor in Clinical Settings. Wear D, Aultman JM, Varley JD, Zarconi J. Academic Medicine 2006; 81: 454-462. Reviewed by Sherilyn Smith, University of Washington


Making Fun of Patients: Medical Students' Perceptions and Use of Derogatory and Cynical Humor in Clinical Settings. Wear D, Aultman JM, Varley JD, Zarconi J. Academic Medicine 2006; 81: 454-462.

Reviewed by Sherilyn Smith, University of Washington

What is the problem (issue) and what is known about it so far?
Medical students acquire cynical behavior as they progress in their clinical training. Two models have been proposed to explain this phenomenon: 1) intergenerational transmission model (e.g. students develop habits modeled by their superiors) and 2) professional identity model (e.g. cynicism is a by-product of the difficulties students face during training, a defense mechanism).

Why did the researchers do this particular study?
These authors observed students "making fun" of certain patients during a psychiatry rotation and wanted to explore the causes of these behaviors.

Who was studied?
58 clinical medical students (42 3rd year and 16 4th year) at a single institution volunteered to participate. Most were on their psychiatry rotation. The demographics of the study population roughly paralleled that of the institution.

How was the study done?
Non-clinical researchers using qualitative methods conducted five focus groups. They first asked open-ended questions requesting students to describe types of derogatory humor they witnessed during their rotations. There were a series of follow up questions designed to find out the students' responses to these scenarios, who initiated the humor, why they thought the humor happened and if there were rules about the humor. Researchers analyzed the responses and placed them in categories and gave examples from the transcripts to support their findings.

What did the researchers find?
Making fun of patients is a well-recognized behavior in clinical medicine. Students observe both residents and attendings participating in the humor but generally feel uncomfortable when attendings participate in the humor. Certain types of patients are often made fun of. Those with "preventable/self-inflicted" illnesses are most commonly targeted and obese people were the most commonly identified group. Students explained the behavior as a mechanism for putting distance between patients so not to "feel too much" or as a coping mechanism for stress. The researchers went on to make recommendations about how to face and modify this behavior for future students.

What were the limitations of the study?
This was a single institution study (not a problem for a qualitative study) and the students were all volunteers, thus perhaps more willing to talk about what they saw/heard. The researchers didn't explore whether the students thought patients who were the subject of the humor received inferior care.

What were the implications of the study?
Making fun of patients is common and there are specific types of patients who are made fun of. Both residents and attendings model this behavior. This paper clearly identified and discussed one modifiable threat to professional behavior in medicine. Perhaps, once we recognize the behavior, we can change it and provide other "coping mechanisms" for our learners and ourselves. On a personal note, this article made me very sad and I reflected on what I had seen as a student and vowed to work on this at "home."

(Comment: I agree with Sherilyn; this article makes me sad, but I'm sure none of us are surprised at the results. The article didn't address differences across specialties. I wonder how pediatrics stacks up to other disciplines in making fun of our patients, or patient's parents? I'd like to think we'd do better than most, but I fear that may be wishful thinking. More importantly, what can we do to immunize our learners against cynicism and negative stress? How do we protect ourselves, and our colleagues? - Leslie Fall)

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