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Monkey Business
When someone slips on a banana peel, why do we sometimes laugh—and sometimes call the doctor?
by Alice Flaherty

I was funny once. At least, I once made Tommy Smothers laugh. I was tagging along with a college friend to a party at the great comedian’s house in Los Angeles. When Smothers asked me what I did, I told him I was a monkey vivisectionist. He was so delighted that he gave me a bottle of cabernet sauvignon from the Smothers Brothers Vineyard. Sadly, though, I had not intended to be funny: my doctorate was in primate electrophysiology. I had made Smothers laugh merely because he had expected to be bored, and I had caught him by surprise.

While I spent college low on the evolutionary ladder, vivisecting slugs, that same college friend, Rob LaZebnik, was slaving over spoofs for the Harvard Lampoon. Most evenings found me on Premed Parkway, an infinite row of science library carrels whose monastic underground cement walls magnified every cough and crunch, while Rob more religiously spent his evenings watching Johnny Carson and David Letterman. Taking notes. While Rob and his Lampoon friends like Conan O’Brien struggled to wedge themselves inside the door of such shows as Saturday Night Live, my premed friends and I went on to medical school as passively as cattle on a conveyer belt.

From Rob I learned that although laughter may well be the best medicine, prescribing Lipitor is much easier. Even now, when Rob is a well-established writer and producer of sitcoms, the strain he feels from having to be funny ten hours a day makes me grateful for my hospital’s cheering atmosphere. This feeling—which comes from being surrounded by people whose problems dwarf mine—borders on schadenfreude.

We can perhaps make a case that the wall dividing comedy writers from doctors—masters of tragedy and propriety—is not that thick. Comedians and doctors often emerge from similar backgrounds—the great physician William Osler and the rubber-faced comic Jim Carrey grew up in neighboring small towns in Ontario, and the Brooklyn immigrant community that produced Nobel-Prize–winning neurologist Eric Kandel also gave us Woody Allen.

An even thinner wall separates Conan O’Brien, renowned for his comic genius, from doctors. He spent the first 18 years of his life in the Brookline home of his father, Thomas O’Brien ’54, a Harvard Medical School microbiology professor. Conan’s personal story would seem to control for both environmental and genetic influences.

But comic and medical phenotypes remain distinct: Conan once told me how, during high school, his father had shepherded him into a summer job caring for mice in a Brigham and Women’s Hospital laboratory. One slow day Conan put his murine charges on a tray, tied helium balloons to the corners, and sent it wafting down the corridor. Fifteen minutes later the tray floated back with a note: “Please return these mice to their cages.” That was the end of Conan’s medical career.

It’s not that doctors are never funny. There is The House of God, for example, the blackly comic bildungsroman that Stephen Bergman ’73 wrote under the pseudonym Samuel Shem. Generations of premeds, and even normal people, have laughed out loud reading it—although, after residency, the book seems less like satire and more like simple reportage.

We doctors could perhaps argue that we’re not funny because our work is so bound up with tragedy. Comedy is not the opposite of tragedy, though. The two are enmeshed; they are both the opposite of flatness. Comedian Mel Brooks argues that what separates comedy from tragedy is simply one’s perspective: “Tragedy is if I cut my finger. Comedy is if you walk into an open sewer and die.”

Larry David, co-creator of Seinfeld, believes that comedy is related to tragedy because in comedy, as in Olympic diving, you get points for difficulty. Making jokes about death becomes funnier because of its sheer riskiness—it provides your audience with an extra frisson from the likelihood that you will hit your head on the diving board on your way down.

The neurologist V. S. Ramachandran draws his metaphor not from athletes, but from apes. He proposes amused laughter as a primate false-alarm call, a revocation of the need for help. If someone in your tribe slips on a banana peel and breaks his leg, you don’t laugh—you call the doctor. But if he slips and gets up immediately, you laugh—at least if you’re a monkey, or a human with a taste for slapstick.

My chief exposure to primate humor—or, rather, nonhuman primate humor—came in graduate school. When bored, I would make rounds with the head vet in the animal facility, a huge underground zoo of frogs, mice, and primates. On those rounds the vet acted as simian play therapist, carrying a tin lunchbox of toys that he rotated with godlike impartiality through the cages to keep the monkeys from becoming bored. More successful than his slinkies and rubber balls, though, was the television set he kept tuned to reruns of Wild Kingdom and The Monkees. Keeping the primates amused was deemed to be good for their health—pant-hoots, the ape equivalent to laughter, as best medicine. The entertainment also kept the monkeys from masturbating all day, which was thought to be bad for graduate student morale.

Ramachandran’s false-alarm hypothesis fits with what little we know about how the brain controls humor perception. Of great importance are parts of the medial forebrain that help detect incongruity. Perceiving humor also activates the same centers for drive and pleasure that kick in during such wayward pastimes as gambling and cocaine use.

As for the notion that laughter is the best medicine for humans, too, several recent research papers show that watching comedies such as that Marx Brothers classic, Duck Soup, can decrease pain perception. Then again, so can watching tragedies like Hamlet. Or even watching something merely gory, like Night of the Living Dead. Apparently the primary factor is that the stimulus be distracting and arousing enough.

Control of the expression of humor is relatively well localized, much further back in the brainstem than is the perception of humor. Pseudobulbar affect, the uncontrolled release of laughter or tears without any experience of the appropriate triggering emotion, can occur when brainstem function is altered. One of my patients, after having a stimulator placed in her brain to control Parkinson’s disease, reported a new, involuntary giggle that embarrassed her at the golf club. When I changed the voltage on her stimulator, the giggle disappeared.

Other pseudobulbar patients weep when they should laugh. One construction worker with a brainstem stroke, who sobbed every time I made a mild witticism on rounds, would then sob for real because his tears mortified him.

Perhaps this anatomical link between laughter and tears could be used to argue, however fallaciously, that a little comedy should be added to the daily practice of a profession as tragic as medicine. Humor may be merely an inappropriate psychological defense against suffering, but even black humor is less corrosive than numbness. I learned this from a surgical chief resident who had one of the wickedest senses of medical humor I have ever encountered. On rounds, before we entered a patient’s room he would dissect that patient—and the rest of the team—more accurately than any scalpel could.

Yet as soon as he crossed the threshold, his bedside manner was unsurpassingly gentle. He never ignored the suffering of an opiate addict who was hypersensitive to minor pains, or the qualms of anxious patients with dozens of questions. Although his Janusian character troubled me, at least he was alive to his patients. And he brought them alive for the rest of us too, transforming the large-bowel obstruction in Room 818 into a character from Molière’s The Imaginary Invalid.

For most doctors, the preferred defense against patients’ suffering is to scrub it out of our minds. Nowhere is this avoidance more evident than in patient notes. These desiccated husks of patients’ lives are dry not only because we must write them quickly, but also because we intentionally strip everything tragic or comic from them. Whether our dryness stems from a desire to be polite, to avoid litigation, or to stand on a pedestal of ponderous scientific rhetoric aimed at rendering our pronouncements more authoritative, by writing dull notes we do our patients a disservice.

If our notes leave out everything that is human—such as the silk scarf an elderly Boston Brahmin has improbably found to coordinate with her johnny—we make our patients less memorable, and that makes it harder to treat them. Was the 83F w/ COPD, CAD s/p CABG, and CRI the one with ALL=PCN? If the note-writer had impolitely quoted the patient’s description of how taking penicillin “made me swole up,” you’d remember.

Wise families of ICU patients put up photos of the patients when they were young and healthy to appeal to our sense of tragedy and motivate our efforts to save what may otherwise look like shells of their former selves. Similarly, the patients who engage us with humor get more of our attention and therapeutic effort.

When we respond to our patients only in measured tones, our advice is less memorable and our patients are less compliant. Humorlessness deadens human communication, which is, after all, propelled by emotion. Rather than spending millions of dollars developing a new blood pressure medicine that is marginally more effective than last year’s model, we should communicate warmly and vividly enough to our patients so that they even bother to take the pesky pills in the first place.

Of course, it’s not fair to say that all doctors are white-coated pillars of grimness. At Massachusetts General Hospital, where I work, psychiatrists seem to be the best at putting humor to use. George Murray, for example, has earned renown for progress notes that will burn a patient into the reader’s memory forever. Unfortunately, the best are too scatological to repeat in an alumni publication.

In the psychiatric interview, humor can open patients up—or intentionally close them down. Once I watched John Herman, director of clinical services in the hospital’s psychiatry department, interviewing a depressed woman who had never seen a psychiatrist before. Although she was ashamed to be there, and guarded, his humor relaxed her. She was soon describing her feelings so openly that she was on the point of tears. He quickly made a joke, and she collected herself. Afterward he asked me why I thought he had cracked the joke.

“Because you’re a guy! Guys hate to see people cry,” I replied, with all the psychiatric insight that comes from being a neurologist.

“No!” he exclaimed, delighted that I had fallen into his pedagogical trap. “Some patients like to cry; they find it cathartic. But not this one. Self-control was very important to her. If she had cried, she would have been so embarrassed that she would never have returned for her follow-up appointment.”

The king of psychiatric humor at our hospital may be Ned Cassem ’66, the former department chief. Cassem, a Jesuit priest, does much of his work in end-of-life issues; he even heads the hospital’s Optimum Care Committee, usually called the God Squad. Is his ability to be funnier than usual in a role that is gloomier than usual simply one more piece of evidence for the link between comedy and tragedy?

Cassem uses humor to make teaching points memorable to residents, as when he reminds them, with an aphorism, that a family history of suicide escalates a patient’s suicide risk: “Suicide is putting your skeleton in other people’s closets.” He makes his advice memorable to patients in similar ways. Once, for example, he was asked to speak to a family who, for religious reasons, wanted medical treatment withheld from a relative.

“We know that Jesus is watching over her,” the son told Cassem.

“I’m sure He is,” Cassem replied, “but I’ve checked, and He’s not leaving notes in the chart. So for day-to-day management, I think He’s leaving decisions to us.”

Non-psychiatrists sometimes dismiss humor, along with the other emotions, as psychiatric turf. Studies have shown, though, that even pathologists and neurologists can be funny on occasion. On rounds when I was a resident, I used to copy down the clinical pearls the neurology attendings uttered. Soon I had a spin-off column in which I was recording the funny things they muttered. The first column became a handbook of neurology; the second would have to be published under a pseudonym. Nonetheless, funny bits from the second column kept trying to creep into the first. My editors rooted out most of them. One fragment that escaped the censors into the handbook, though, was the jingle Michael Schwarzschild ’85 composed for the Movement Disorders Consult Service:

            Trouble with tone?
            Just pick up the phone.
            Jerky or stiff?
            We’re there in a jiff.

Unfortunately, when the jingle hit the Spanish edition it was translated literally, as straightforward clinical advice: “If you are experiencing muscular rigidity, utilize the telephone, please.” I have not yet had the nerve to find out what happened to the poem in the Japanese edition; I hope it became haiku.

Later, when giving talks about a second book, I was pleased that the audience generally laughed much harder than the jokes deserved, but I was taken aback to find that their laughter was so tinged with relief. “Thank you so much for being funny,” one woman said after one of my talks. “When I saw you were a doctor I was sure this would be boring.”

I found that the tighter I rolled my bun and the duller I dressed, the more my humor caught the audience off guard. An advantage that doctors have over comedians, then—besides better job security—is the element of surprise. Because no one expects doctors to be funny, our patients are grateful for even the mildest joke. And, although stress-related illnesses and depression are higher in both comedians and doctors than in the general population, at least we doctors know better how to work the medical system to get ourselves treated.

Then again, we never get invited to host the Oscars.

Alice Flaherty ’94, PhD, a neurologist at Massachusetts General Hospital, is author of The Massachusetts General Hospital Handbook of Neurology and The Midnight Disease: The Drive to Write, Writer’s Block, and the Creative Brain.

This article appeared in the Autumn 2004 issue of the Harvard Medical Alumni Bulletin.

Photo: Ray Massey/Stone/Getty Images