Is Gallows Humor Ever Appropriate?

An Early and Late Career Collaboration with Hans Duvefelt, MD of A Country Doctor Writes

“If physicians practiced in more humane work environments, I don’t think gallows humor would exist.”

This was the beginning of a great discussion with a medical student (now physician! Congratulations Olivia!).

So, is gallows humor ever appropriate?

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Certainly the ubiquitousness of gallows humor cannot be denied.

For those not familiar with the term, gallows humor is defined by Webster as “humor that makes fun of a life-threatening, disastrous or terrifying situation.” Intense circumstances may result in intense or aggressive humor. And, if overheard by the patient, it would likely be hurtful or quite insulting.

As a medical student during my initial clinical rotations, I remember being shocked at the way patients were the subject of jokes behind closed doors. I admired many of the resident physicians I worked with as a student, but I had a hard time reconciling this intense, often grim humor about suffering patients with the caring hearts of these physicians. I vowed I would be a physician who wouldn’t use gallows humor. I viewed physicians as “helpers of healing” and the rhetoric of gallows humor felt incongruent with that role. How could we help people heal and then turn around and joke about them?

The Oxford Languages defines gallows humor as “grim and ironic humor in a desperate or hopeless situation” and hints more at the use of gallows humor as a method of coping.

It wasn’t until I was a resident myself that I began to recognize this more and more. Not uncommonly, my co-residents and I would use gallows humor as a way to blow off steam at the end of a long call or work day. After joking around, it allowed us to return to our work a little more lighthearted and continue caring for patients. It was a way of coping with the desperate situation that is residency training in our country.

However, I can still vividly recall the first day I used gallows humor to cope in residency. I promptly came home and cried to a friend about what I had said. I felt like a terrible person, a terrible doctor. A hypocrite.

Thankfully, my friend was compassionate and kind and reminded me that I’m only human. And sometimes coping in a tough situation looks a bit messy.

So is gallows humor ever appropriate?

I’m not sure.

Is it ideal?

I think not.

Is it inevitable?

Let’s dive a little deeper.

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The unfortunate truth is that while I and a growing number of doctors are choosing to practice medicine on our own terms, many physicians still find themselves in work environments not unlike residency. The coping and the gallows humor often continue as a result (I suspect) of these unhealthy situations.

But would gallows humor go away if all physicians had humane and supportive working conditions?

I’m not sure it would go extinct, but I’m inclined to think it would diminish markedly.

I’ve witnessed this myself in the direct primary care community. Gallows humor is not absent. Physicians - whatever their practice setting - are often still coping with difficult situations with very ill patients and ill healthcare system at large, even if their personal office environment is one of their own design. Part of this may be the ingrained gallows humor response from medical training. At the end of the day, we are all human and taking care of other humans can be challenging and require some sort of coping or way of addressing that tension.

However, I have witnessed in myself (and somewhat in the DPC community) that gallows humor is much less prevalent now that I’m spending more time in my own practice. The relationships I have with my patients are more personal, respectful and caring. Reciprocally. Gallows humor directed toward one of my patients tends to feel wrong - like talking poorly behind a friend’s back. And I have the time, space and energy to recharge my internal battery more often, making that method of coping less needed or unnecessary. But my work environment is pretty ideal, so I’m not coping with that factor.

So is gallows humor inevitable?

I think, to some degree, yes - as long as we are human we are somewhat bound to make mistakes or say things we regret. But as we continue to advocate for more humane working environments for physicians, I hope that it will continue to fade.

And who knows? Maybe one day gallows humor will disappear altogether as physicians take back medicine.

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Late Career Perspective By Hans Duvefelt, MD of A Country Doctor Writes

On our way home from Friday’s housecalls I had to swerve for two dead ravens in the road. I don’t usually joke about death, dying or dead bodies, but suddenly found myself blurting out “two birds with one stone”. My assistant, who was a firefighter before entering the medical field, broke out in near-hysterical laughter.

“Gallows humor”, I said calmly.

“Exactly the word I was about to say”, she responded. “You don’t hear that word very often.”

Originally, the expression referred to when those convicted to public hanging at the gallows tried to be funny to relieve their own fear of dying. But now any joke about life or death situations can be called gallows humor.

We spent the last mile or two of our trip talking about how medical people and emergency workers seem to be able, or even have some sort of need, to make fun of situations that don’t seem funny to lay people.

In some ways, finding something comical in situations that involve death or disaster is a way of distancing ourselves from the tragedy of what we are witnessing. And at the same time, sharing a joke about it is a way for us to bond with other people who also must deal with tragedy on a regular basis in their work.

Of course, any public sharing of these macabre coping mechanisms of us life-or-death workers would be offensive or hurtful in most situations. But privately, between colleagues, I think it can be valuable in helping us carry on, no matter what.

As physicians or any other worker in this field of helping the sick and tending to the dying, we must live up to the expectations our patients have of our demeanor. Just like clergy, we have roles to play in people’s lives that are incompatible with lightheartedness or flippancy. This goes back thousands of years, to Hippocrates and beyond. Gallows humor is our secret little safety valve when the pressure of living up to these ancient standards threatens to be too high.