Through the looking glass: a different lens on medical education

Field: Health Professions (Health Sciences)

‘Alice laughed. “There's no use trying,” she said. “One can't believe impossible things.” “I daresay you haven't had much practice,” said the Queen. “When I was your age, I always did it for half-an-hour a day. Why, sometimes I've believed as many as six impossible things before breakfast.”’ (Lewis Carroll1) Although academics are usually serious people, it would be incorrect to say they do not sometimes engage in lighter takes on their view of life. Charles Dodgson, better known as Lewis Carroll, was a fellow and lecturer in mathematics at Christ Church College, Oxford, and although he wrote erudite books on mathematics and logic, it is for his fiction that he is best remembered. In both Alice in Wonderland2 and Through the Looking Glass and What Alice Found There,1 Alice is transported to a magical world where nothing is as it seems and where she is obliged to examine life in a completely different way. So in the course of discussions of how Medical Education might celebrate the publication of its 50th volume, the idea of something completely different, an edition looking at current issues within the discipline from a humorous viewpoint, was proposed. The word ‘humour’, the quality of being funny, originates from the Latin for liquid or fluid. Hippocrates (c. 460–370 BC) incorporated the four temperaments into his medical theories in line with the ancient medical concept of humourism, in which four bodily fluids were believed to affect human personality traits and behaviours. Hippocrates believed that human moods, emotions and behaviours were caused by an excess or lack of these bodily fluids, or the humours blood, yellow bile, black bile and phlegm. A humourist was an individual thought to have an excess of one of these humours. The remedy for this disordered temperament was said to be laughter. Thus, the aim of this humorous issue of Medical Education is to offer articles with well-grounded insights, presented in an entertaining way in order to encourage balanced temperaments in the journal's readers. The format of a spoof – an original work that copies the style of another work in a way that is meant to be ridiculous or humorous3 – was decided to represent the best intervention. All papers submitted to this special issue were treated in the usual way. Once the editor had agreed that the item met the remit, as above, it was sent to three reviewers for evaluation. Their reviews were collated and compared. Where there was a consensus to accept or reject, there was no problem. Feedback for the authors was sent out with the appropriate e-mail of celebration or commiseration. However, for a number of papers there was considerable disagreement and poor inter-rater reliability. The same submission might clearly reduce some reviewers to tears of laughter but fail to induce so much as a vague smirk in others. Why was this? Did our robust selection process for selecting reviewers for this special issue have poor predictive validity? Had a few humourless individuals been included in the referee panel by some mistake? There was no evidence of this for all the reviewers had indeed found something to tickle their funny bones – it was just that some seemed to have very different skeletons. We were intrigued by this difference, and by what might explain it. The reviewers panel had a good gender balance, which is important as several studies have demonstrated that there are gender differences in humour usage and appreciation.4, 5 A person's age can also influence how receptive he or she is to certain types of humour,6 but the lower end of the age range was poorly represented in our panel and thus it was unlikely that the differences in responses were attributable to generational factors. However, the reviewers were internationally diverse, a fact that caused us to wonder if these different reactions to submissions reflected variances in humour across different cultures. Although humour is used universally to ease social interactions, to make others feel happy, and to give a feeling of belonging to a particular social group,7, 8 there is burgeoning evidence that national and cultural differences exist: what's regarded as funny in one country may not go down well in another.9, 10 For example, Ruch and Forabosco11 compared the responses of 148 Italians with those of the same number of Germans to the same selection of jokes and cartoons. Their results showed that there were indeed differences in appreciation of sexual humour and nonsense humour between the two groups. This certainly chimes with our own experiences when travelling and working in different countries: our own (we believe) finely honed uses of caustic irony and self-deprecation are sometimes met with looks of puzzlement. It seems that many other cultures do not embrace these particular forms of humour quite as wholeheartedly as do the British.12 There is a massive amount of serious academic literature on humour, in which researchers take various theoretical and methodological approaches to systematically understanding humorous events, behaviours and situations. Theories vary from those of Freud, who believed that the process of humour represents a defence mechanism on the part of the ego and the superego,13 to those of cognitive psychologists, who postulate that the degree to which someone will enjoy humour is related to the level of difficulty of the humour and how much the recipient analyses it after the event.14 Approaches to exploring the underlying structures of humour range from investigations into genetics and individual differences (see earlier) to explorations in neurobiology. For example, Shammi and Stuss investigated which regions of the brain underlie the appreciation of humour and found that the right frontal lobe is most concerned with the ability to appreciate levity.15 Individuals with damage in this region also reacted less to humorous stimuli with diminished physical or emotional responses such as laughter or smiling.15 Is humour less about funny bones and more to do with our biology and neural structures and connections? No doubt different philosophical, theoretical and methodological approaches to understanding the nature of humour will appeal to different researchers, just as different approaches are apparent in medical education. Although we cannot comment on the robustness of the conceptual underpinning and empirical testing of humour as this is not our area of expertise, it is interesting nonetheless to realise that what might seem like a light-hearted area can be taken just as seriously as we take our own. ‘Men will confess to treason, murder, arson, false teeth, or a wig. How many of them will own up to a lack of humour?’ (Frank Moore Colby16) In compiling this special spoof issue, it is our hope that whatever your culture or background may be, you will find something to make you smile or even laugh out loud. It may be that by looking at medical education through a different lens, you, like the White Queen, will come to believe in six impossible things before breakfast.