05/22/2014 08:49 EDT | Updated 07/22/2014 05:59 EDT

How Doctors Use Dark Humour to Keep Ourselves Going

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I can remember my first night on call as a newly minted resident at Toronto's Hospital for Sick Kids like it was yesterday. I admitted three infants in respiratory distress, took blood samples on two more and started intravenous drips on three more. I can remember the excitement of being the first line of defense for the little ones under my care.

Still, as I look back, it's another memory that makes that first night on call at the hospital stand out. The next morning, my senior resident arrived on the ward, saw my haggard appearance, and walked over to the wall that I was leaning against to try and stay awake.

"So, Brian," he said, putting a reassuring hand on my shoulder, "how many babies did you box last night?" Box, as in coffin. He wanted to know how many patients I'd killed! For a half-second, he kept a perfectly deadpan look on his face, then broke into a big grin.

He was kidding, of course. My resident had enough confidence in my ability to keep the little ones alive that he could get away with the joke.

That was my personal introduction to hospital slang. Right away, I could see one of the key purposes of slang -- which is known to experts in linguistics as argot or cant. My senior resident used the slang to break the tension I was feeling. I was quite nervous that first night on call, and Rutherford's slang told me that I wasn't alone in that feeling. Not only that, he was letting me in on the secret handshake. Sharing slang is a ritual that binds young doctors to their band of brothers and sisters.

I'm amazed that there are those who are surprised that doctors keep and pass along a secret stash of slang terms -- as if doing so is highly unusual.

For those who work in high stress professions, dishing slang is pretty normal. The military have invented hundreds of such terms to describe their work. 'SNAFU', 'FUBAR,' and 'BOHICA' are just three terms in common use that started off as military slang. Police, firefighters and paramedics have their own unique slang. So do teachers, lawyers, stockbrokers and car salesmen.

True, it may be that doctors have invented more slang than most other kinds of professionals. But that's because as doctors they encounter more situations that generate strong emotional reactions than most other professions.

Another important purpose of hospital slang is to help health professionals cope with patients who are in pain and suffering as well as those who die on their watch.

What do the phrases "circling the drain," "discharged up," and "hanging crepe" have in common? They are just three of many phrases used by doctors that refer to patients who died or are in the process of dying. There are many more where those came from. There are probably more words and phrases used to talk about patients at or near death than almost any other clinical condition or situation.

Dark humour has been part of the culture of modern medicine for at least 70 years. In the 1950s, Dr. Renee Fox, one of the pioneers of medical sociology, observed second-year medical students at Columbia University Medical College as they attended their first autopsies. In her research from the 1950s, Fox noted that gallows humour flourished in the anatomy laboratory.

That gallows humour existed back then and still exists today does not in any way suggest or imply that doctors are unfeeling about their patients. The humour and the slang are coping skills for a profession increasingly stressed not only by the suffering of their patients but also by the futility of their efforts to ease it.

As physicians, none of this is supposed to affect us. That's because physicians have long been taught to remain emotionally detached from patients. We have a venerable Canadian physician named Sir William Osler to thank for that. Osler, who taught at McGill University, was one of the founders of modern medical education. In a famous essay entitled Aequanimitas, Osler admonished MDs to maintain an attitude of unflappability that he referred to as "imperturbability," which to me means never letting patients and their families see physicians sweat.

Today, we call that emotional detachment. Today, patients and their families want doctors to show concern for the situations that cause patients and their families emotional distress. Finding the balance between emotional detachment and concern for the patient is the great challenge of modern medicine.

As a veteran ER physician, I don't see how it's possible to observe the horrific traumas that befall our patients from a position of complete emotional safety. Given the rising rates of compassion fatigue, moral distress and burnout among health professionals, I doubt that detachment is as desirable as it may have been in Osler's day.

Given that, I believe that slang terms like "circling the drain" and "discharged up" help doctors acknowledge and reflect upon the death or the impending death of their patients. In that sense, using slang to vent strong feelings is better than bottling them up behind a mask of imperturbability that is increasingly harder to maintain.

If I were a patient or a the family member of a patient, I'd worry more about the emotional state of the doctor who refuses steadfastly to utter a word of slang than one who does.


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