| The Funny Bone |
The Urge to Titter Church services are classically wrong time, wrong place. My sharpest early memory of uncontrollable and discreditable giggling comes from the time my Auntie Mame—her real name—hauled me, at the age of ten, to a small church north of Seattle. During the service Mamie suddenly nudged me, grinning, and pointed to a plaque on the wall. It paid tribute to the “pioneer women of Woodland,” which long before had been a settlement in the area. Mamie’s joke was at best a weak one. The community had since dwindled to a dilapidated roadside tavern, so the plaque now seemed to commemorate these spirited women’s founding of a disreputable bar. Had I not been surrounded by strangers engaged in holy behavior I would have barely glanced up from my sneaked-in book, shot Mamie a condescending smile, and returned to my surreptitious reading. But we were in a church—and the church was packed. I immediately began a series of small respiratory explosions that swiveled all praying heads toward my deliriously amused self. Only Mamie’s complicity protected me from the thin-lipped consequences of Lutheran disapproval. One’s psyche survives this sort of thing with relative ease and a clean conscience. No element of the personal had played a part—I was mocking nobody’s physical appearance or habits of speech, nobody’s taste in clothing or love. Unfortunately, a titter without a whiff of mockery is more the exception than the rule. Often when the urge wells up, it is precisely because someone else has tumbled into ridiculousness. To be human is, from time to time, to appear ridiculous. This sad axiom has an unhappy corollary: from time to time, someone else will notice. With any luck the person witnessing our descent into the ludicrous kindly empathizes with the gaffe, or has already achieved sainthood and is above it all, or has practiced yoga breathing for decades and can suppress laughter indefinitely. But none of these conditions is common, so the likelihood is high that one will eventually become the instigator or the recipient of an urge to titter. Another home truth is that intimacy and silliness go together like love and marriage. Indeed, the backbone of a solid relationship has to be the sheer willingness to tolerate a partner’s descent into ridiculousness. Absent such tolerance, a divorce court is the likely next stop. The patient–doctor relationship is a perfect setup for ill-timed laughter. The clinical encounter is intimate, so one party or the other is always at risk of getting caught in a moment of absurdity. (I exempt from this discussion the merely humiliating, which is never an occasion for laughter. A great deal of medical practice is humiliating for patients, and all involved must soldier on as though they hadn’t noticed. I remain astonished, for example, at the sangfroid of my gastroenterologist.) While the patient may be relatively uninhibited in expressing mirth, the physician had damned well better conceal all signs of amusement until the patient is safely out of earshot. Divorce courts are bad enough; malpractice litigation has to be worse. But this is also exactly the problem. What is forbidden, as Adam learned to our universal cost, is the most tempting. I first began to think about the vicissitudes of tittering over a decade ago, when I was locked in unintentional combat with a patient who had concluded, on a week’s acquaintance, that I was ruining her life in every possible way. We had been discussing whether I would issue her a pass to leave her psychiatric unit for a few hours, but our conversation rapidly devolved into her sermon on my resemblance to Cain, Esau, and Judas Iscariot. It was, in its way, a bullfight, with me as lumbering bull. Every time I thought it was over, there was another shake of the cape, another verdict, and always the glint of steel as she waited for me to make my misstep. The pressure was building, because the only resolution to our face-off I could imagine was that I would burst into helpless laughter, whereupon she would neatly clip off my ears and tail, and I would need, at the very least, another profession, if not reconstructive surgery. And all the while, I was baffled by my impulse to laugh, because on the surface our conversation was more exasperating than funny. Having matured a bit since Mamie had taken me to church, I held on during the harangue, although it was becoming ever less clear how I could both breathe and continue the conversation. Then, at the last possible moment, the patient stopped and drew herself back. She looked at me and then at her knees and said, “Now you’re going to laugh at me, just the way my father always did.” Nothing made me love her more than that magic moment when she dropped the cape, tossed the sword aside, and showed me the way back to the bullpen. Or, more accurately, she showed me her psychological script and pointed out the role in her internal drama that I had, both unwittingly and guiltily, taken up. So I got off easy. But this experience started me on a search in both the medical literature and real, honest-to-goodness literature for some guidance on the topic of physicians tittering out of turn. It was, as you might imagine, a nearly dry well. Almost everything else that a doctor can do badly or wrong is amply covered—largely in Madame Bovary, if you ignore the adultery and stay with the good parts. But I know of only one solid source on the problem. It is a luminous episode in Woody Allen’s otherwise puerile 1972 film Everything You Always Wanted to Know About Sex (But Were Afraid to Ask). My movie guide gives EYAWTKAS (BWATA) three stars, which can only be explained by the segment starring Gene Wilder as Doug Ross, a mild-mannered physician. The doctor is in his office when a shepherd walks in, insisting on an appointment. The shepherd gradually makes clear to the doctor that he has succumbed to one of the hazards of his profession, falling madly in love with a sheep. We watch as Dr. Ross absorbs what he has been told and then, for 23 seconds (I’ve counted), keeps himself from bursting into laughter. The camera remains on Wilder’s face as the actor puts in a half minute that transcends his entire performance in Willy Wonka and the Chocolate Factory. Dr. Ross successfully keeps himself from tittering, but he wants to titter, and the rest of Allen’s tiny masterpiece—approaching Madame Bovary in subject matter and intensity—hinges on this terrible fact. Confident of his ability to resist her charms, Ross meets the ewe. He soon succumbs and then risks—and loses—everything for her. In Allen’s later doctor movie, Crimes and Misdemeanors, an ophthalmologist has his mistress rubbed out, but he gets off relatively easily compared with Dr. Ross, whose far graver crime was, after all, that he condescended to the shepherd’s desire and felt like snickering. We must not imagine, however, that condescension is only the doctor’s risk, whereas ridiculousness is only the patient’s. Like Falstaff, I have been dumped more than once into the laundry hamper of a patient’s amusement and have learned that horror and humor surreptitiously hold hands. Not long after I stopped myself from chuckling at one patient’s accusations of sabotaging her life, I was treating another, much older woman, who was confined to a dilapidated psychiatric ward against her will. Her state of mind was such that she would exchange few words with her captors, me the chief among them. She would sit erect in the day room of the ward and provide only her name (a false one), rank (fanciful), and serial number (which did not correspond with the medical record, but who was I to quibble?). This patient knew me as the archfiend, but every day I would saunter by and ask how she was doing as though I were utterly ignorant of my status in her cosmology. One morning I found her in her usual spot sitting near half a dozen other patients, all of them quietly preoccupied with their own thoughts. I went through my routine, asking her how she was. “You’re asking me how I am,” she said. “Why are you asking me how I am?” Delighted at the opening, I rushed in. “Well, I’m your doctor,” I said brightly, “so it’s good for me to know how you are.” I thought the patients nearby smiled slightly, approving of my good humor and good faith. She waited a beat. “You say you are a doctor,” she answered, sitting ever so slightly more upright. “I do not think you are a doctor. I think you are a shoe salesman, and I do not need any shoes today, thank you.” Although my patient was in the midst of an episode of mental illness, from which she soon recovered to display an infinitely sweet nature, that morning she nailed me neatly in front of a small but appreciative audience, none of whom laughed out loud. Too callow and embarrassed to do the right thing, I muttered something and strode off, as though I had a purpose. Only later did I realize what would have been the proper response: sit right down and have a good guffaw with her and our audience. But perhaps the most ridiculous I’ve ever felt as a physician was some 35 years ago, at the beginning of my career, when I was supposed to be caring for an elderly woman who had entered the last days of her life. Mrs. Edel, as I’ll call her, lay in a hospital bed, in considerable pain and barely able to move, but utterly without complaint and with a continuing lively interest in the events around her. Her heart had reached the end of its useful life. Her circulation had slowed to the point that in places the blood was simply turning solid; her legs were so deprived of blood that they had become practically inert. For some insane reason, I believed it was my obligation to come to her bedside each day and ask her to wiggle her toes. Whenever I did this, she lay there unmoving—because she couldn’t move. Yet my neurology professors had often stressed the importance of motivating patients to do such things as touching their noses accurately, arm wrestling with me, or reciting the names of U.S. presidents. The motivational technique they imparted, at least to me, was to shout. So I repeated my instruction several times, louder and louder: “Wiggle your toes, Mrs. Edel!” My telling her to do this was pointless, and if anything could be beyond pointless, it was my habit of shouting the command. On the next-to-last day of her life, as my voice rose once again, Mrs. Edel gazed up at me from her bed, and a positively impish smile came to her face. She looked me straight in the eye and said, with something just short of a titter, “By me, dat’s viggling.” William Ira Bennett ’68, who practices psychiatry in Cambridge, Massachusetts, is editor-in-chief of the Harvard Medical Alumni Bulletin. This article appeared in the Autumn 2004 issue of the Harvard Medical Alumni Bulletin. Photo: Nicholas Veasey/Stone/Getty Images |
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