Wednesday 14 September 2011

Social media, black humour and professionals...

Beware of slang
Last week I presented at #altc2011 (the Association for Learning Technology Conference). My topic was "On being public.... how social media reshapes professional identity". One of my main points was that social media almost necessitates a reflexivity which we can get by without in face to face encounters. The pace of interaction is fast, we're dealing with people we may not otherwise come across, and norms are still being established. In fact we may never even get to the stage of having 'social norms'. Probably the only way to operate in these spaces is by having internalised your own values, but also being able to step outside of those values and to see what has shaped who you are and what you think, and to afford the same courtesy to others.

A few days later I came across a discussion between several male doctors on twitter which caused me to reflect on this very topic. The doctors were using slang, which I have not come across before, to refer to the wards in which they might have been working. The terms used were 'labia ward' and 'birthing sheds' to refer to the delivery suite where women give birth, and "cabbage patch" to refer to the intensive care ward where many patients are unconscious. 

I was shocked at this and angry and did query the doctors about some of the other things they said, but I felt I couldn't challenge them directly at that time about this language. One of the doctors referred to midwifes as 'madwives' and was challenged by a medical student to justify this position. In the meantime I pulled together the tweets using a curation tool and informed the doctors involved that I had done this. I did not tweet the link publicly and did not endeavour to have a conversation in public about this. However I did feel the need to check with others how they felt about this exchange so I sent them a link to the collated tweets by private message. I wanted to find out if my own shock and revulsion was  typical and also to gain some advice on what to do about this.  

Almost all replies stated that they found the discussion insensitive. Doctors seemed to be as likely to be offended as non-doctors. Some thought that this was risky behaviour because regulators may take action. I personally think this is very unlikely and do not consider these tweets a disciplinary offence.

But what happened in public? A few others (mainly other doctors) did challenge the use of this language. The protagonists explained that they thought their tweets should be interpreted as a conversation between medical professionals. One expressed that he did not want to cause offence and that he perhaps had misjudged sending the tweet.

How did I feel?
I was surprised at the strength of my reaction to this. I wanted to let it pass but I also felt that this was not appropriate. I felt that the language objectified women and was misogynistic. I privately told one of the doctors this and asked that he removed the tweets but he refused to do so and suggested that my feelings of offence were my problem.

Some doctors have thought that I am concerned that this kind of talk will 'bring the profession into disrepute'.  But I am not. I believe that patients make assessments of us as individuals. I don't believe that the public will think less of doctors after this. As has been pointed out, programmes like "Cardiac Arrest" have portrayed doctors as cold and callous individuals. But there has been no corresponding fall in trust in the "profession". 

The doctors involved in the initial discussion have suggested that my views to their use of slang are atypical. Only a very small number of their followers have raised any kind of objection to their use of this language. Perhaps inside more women are offended but they feel that they can not speak up because to have your views dismissed publicly is humiliating. I don't know. But I don't think that this is an issue of numbers. 

My account of this episode, so far,  has been very personal. But I also want to place this story  in a wider context within the medical education literature on professionalism and black humour.  Is the use of derogatory humour or slang by medical professionals inappropriate? Berk thinks that ;
"Simply put, derogatory and cynical humour as displayed by medical personnel are forms of verbal abuse, disrespect and the dehumanisation of their patients and themselves. Those individuals who are the most vulnerable and powerlessin the clinical environment – students, patients and patients’ families – have become the targets of the abuse. Such humour is indefensible, whether the target is within hearing range or not; it cannot be justified as a socially acceptable release valve or as a coping mechanism for stress and exhaustion."

Berk was writing this in response to research by Wear and colleagues on medical students and residents attitudes to this kind of humour. It is interesting to note that usually  it is referred to as being performed behind closed doors. Some accounts suggest that it is about establishing insider and outsider groups if performed in public. 

Wear suggests that doctors "throughout academic medicine might begin candid discussions of derogatory and cynical humour in their particular cultures in order to become better aware of their participation in it and their responses to it when they overhear it from others". 

And so I am writing this. Social media- blogs and twitter- are my culture. I want to raise this topic here- in this public space- so that I can think about how I respond to it in the future when I 'overhear' it. The next time I may choose to ignore it. Despite Wear's suggestion that incidents like this  provide 'teachable moments', and should be challenged,  the spaces of social media are much more exposed than a hospital corridor. 

But at the same time my blog is also a relatively safe place for me. I await your thoughts. 


  1. Hi Anne-Marie, I am going to respond to your post because I have very definite opinions, but it's going to need a blog post. This also ties in with work I am about to do at a big midwifery conference in October about online professional identity, so it may just take a couple of days to put my thoughts together. cheers Sarah

  2. What a great post, and what a great topic. It feels that talking in slang like this is humorous. But if you think about it a bit more, it shows some prejudice. And if you work to identify and eliminate prejudice from your life, you have to try to avoid such talk.

    I was part of a group supporting preeclampsia patients. Some of them lost their infants and asked for their medical records in an attempt to have more successful pregnancies. Even terms like: the infant "expired" in the parents arms were offensive.

    We need to always be sensitive, to always talk as if we are in public, to fight our prejudices, to find other ways to have fun and fight burnout.

  3. Hi,
    I'm male, and not easily offended. *Personally* I am not offended by their childish slang (and yes, I am being judgemental there), and I agree with you Anne Marie that it probably doesn't bring the *profession* in to disrepute. However, I would think it brings the individuals in to disrepute, and I can certainly imagine individual institutions that the 'offenders' may want to work for might consider them relatively unemployable (certainly by contrast to others who have maintained a more sensible online presence).

    I think the response that they 'thought their tweets should be interpreted as a conversation between medical professionals' is troublesome. They think people should expect that sort of use of language by the medical profession? That surprises me. I am perfectly aware of the sort of black humour paramedics use to help them survive the traumas they witness, but I also know they try to keep that *within* the profession. This appears to be a case of misogynism, to me, which is something I would expect any professional (well, anyone at all, to be honest) to avoid, even if it represents their own failings.

    It is gratifying that one of them thought that he might have over-stepped the mark. It would be interesting to know how people would feel if it had been a mixed, or all-female group who had been using these terms. I used to know quite a few midwives, and socially they would occasionally use somewhat, erm, colourful language - but not *publically* and not where it was recorded and searchable.

    There is also the power issue you allude to - it does seem that there is a tendency for women to be less likely to complain about men behaving badly, and also the doctor-JoePublic relationship is one which leaves a lot of people feeling they shouldn't complain. Those two points themselves seem to me to indicate that male doctors should be a lot more careful about how they express themselves. I don't know if it was obvious in the tweets that they were joking around, or whether it seems that this was the sort of slang they use in everyday descriptions. If the former, I have more tolerance for it (after all, humour pushes boundaries of acceptability), but if it is their general practice, I think it is pretty disgusting.

  4. Anne Marie,
    Great points, especially the point about internalizing one's values (and thus not having to create a second persona to present to the public - my interpretation).
    Will follow this discussion with interest.

  5. I'm a GP who is also involved in helping 1st/2nd year med students think about such issues as social media. I am concerned that those who tweeted here seem to think their tweets are a private rather than public conversation. IMO this is clearly in the public domain and reflects badly on the individual rather than on the profession. As you say they may be seen as less employable as a result (many employers check FB and twitter for potential staff these days).
    Anne-Marie I think you have handled it well in challenging them privately, so avoiding spreading the offensive posts. Hopefully at least one might think again in future.

  6. I sent the link to this piece to my daughter (via FB! - she's not on Twitter). She is at the start of her 4th year as a medical student. Her reply:

    "Other than my confusion at the twitter jargon I definitely think the way they were speaking was out of order!

    If you're going to talk about professional stuff like that I can see that it might have a place as banter between the lads but not on a public forum on the internet!

    Definitely haven't come across those phrases before"

  7. “The Offensive Internet: Speech, Privacy, and Reputation” ( ) This book does not speak directly to issues for the medical profession, but it has many interesting chapters. In particular, Martha Nussbaum’s chapter: ‘Objectification and Internet Misogyny.’ Not sure I agree with her explanation: Men enjoy shaming women in public due to Nietzsche’s ‘ressentiment’ and undercurrent of primitive shame among men who can’t (for contemporary cultural reasons) live up to myth of what it means to be a ‘real man.’ A bit too psychoanalytic for my taste. But excellent illustration of what the problem is.

  8. Well-written, thought-provoking post.
    I understand humour as a stress release mechanism, and I do realise that medical humour will not always come across well to non-medics. However, what comes across to me from those examples tweeted was that these are somewhat immature young men who do not understand people well yet.
    Whether intended or not, it suggests a lack of respect for other people, and as a result I would trust their professional abilities less, because I would not trust them to listen properly to patients or colleagues.

  9. Anne Marie,
    Excellent post. I do hope you get many comments because it raises so many issues. One of the core issues has nothing to do with social media. It involves whether the derogatory comments made in the medical profession (not to patients but to each other) is still acceptable? I think your quote from Berk is spot on. These types of comments demean our profession, even if only heard by other health professionals such as students, residents or staff. Granted, this will require a major culture change at some institutions, but that change is needed.
    Another issue raised is regardless of one’s position on the appropriateness of the aforementioned dialogue how it affects public perception when social media takes it to public space. I am certain that many physicians who might be more tolerant of derogatory comments made “in the trenches” would be appalled if these comments were overheard by patients/the public. On occasion, I head to Sermo, a physician’s only social media site. Comments are often rude and crass, but since only licensed physicians can view these comments, the discourse does not seem inappropriate. Similarly, I wonder if you would have felt differently if the Twitter conversation you viewed was not on Twitter, but a physician’s only site. Thus, if social media is a tool to “vent” physicians (and likely other professionals) may need to find non-public or restricted space to make such comments.
    Finally, is the issue of behavior in public spaces for the professional, especially for a physician. A few of my favorite tweeples (many of them physicians) use “salty” language (not offensive or derogatory as in the example, but more off color and profane). I don’t consider that type of language to be professional , and therefore appropriate for a physician to use in a public space. Should physicians be held to a higher civility standards when using social media? I think we should, though maybe this is unfair.

  10. A very important post Anne Marie. I too have strong ideas about this topic, like Sarah and others. Great to see the depth of comment here.

    In my opinion, Berk is correct. Respect and kindness is core to optimal, conscious relationships with others. Social and emotional intelligence and competence are key to best practice and collaborative, patient centred care. Their behaviour says more about their characters than either their profession or the vulnerable people that rely on them. What a misguided bunch. I only hope they come to consciousness soon.

    I also caution about the word 'black' being used to label humour that is off beat and/or paradoxical - not that slurs or derogatory remarks can be classed as either off beat or paradoxical humour, the comments you mentioned are rude, not humour at all!

    My masters research was on the way that midwives and doctors interacted in delivery suite in the care of birthing women. When everyone is respectful of the woman and her wishes/needs, doctors and midwives behave in socially and emotionally intelligent/competent ways and everyone feels good about themselves
    Here are the links for those who are interested:

  11. Interesting article. I have a few comments to make, but perhaps I should declare my interests first.

    I am a woman, and a feminist
    I am an anaesthetic registrar
    I have a subspecialty interest in obstetric anaesthesia
    I believe I am the person who first coined the term “labia ward”.

    Banter between hospital staff has been around since the year dot. Some of this is indeed quite harsh and can be termed black or sick humour. We are constantly warned about it by well-meaning academics and educationalists but it still keeps going on. Why is this? Well, many reasons, but principally because the job is difficult, stressful, with high stakes and high levels of emotion. Humour is one form of “safety valve” and it's an important one – it allows a degree of bonding between staff who have been involved in stressful events, and it provides an almost secret code whereby the people who “get it” are the people who have direct experience of those stressors. My mother often tuts at me for my descriptions of work but put me in a room with an anaesthetic regsirar I have never met before and I promise you we'll be laughing at the same stories.

    Right, that tedious and oft-repeated discussion out of the way – onto the specific terms you take exception to. “Labia ward” is the one I termed and it's a simple play on words. Most places refer to it as Labour Ward, which is a misnomer – many of the women there do not labour. In fact both Labour Ward and Delivery Suite are misnomers, with their suggestion that this is where you come when you work/labour to deliver a child. As opposed to be treated for severe pre-eclampsia, be stepped down from intensive care, be counselled and cared for after an intra-uterine death, undergo a late termination of pregnancy...the list of things that happen there which are NOT labour or delivery goes on and on. At the very least all of our patients have labia – hence the joke. I have labia myself, being female. I thought it was funny. I am sorry you didn't, but I'm not going to stop. I'm on call for labia ward this weekend.

    As for other terms referring to Labia Ward, like the birthing sheds or the raptor's nest (coined by an old senior registrar of mine) – these do somewhat give the impression that it's a hostile environment, don't they? Do you know why that is? Because for an anaesthetist, it can be. Any anaesthetist who has done their time on there can give you a host of stories – the nights when you just have to do cases back to back without even a loo break and then get screamed at because someone had to wait for an epidural, the times when “epidural, room 4” followed by the phone being slammed down is apparently an acceptable method of communication between professionals, the times when noone bothers to tell you about the woman with massive anaesthetic risks who has been admitted and then get cross when you cannot anaesthetise them at the drop of a hat without senior assistance or specialist equipment...I could go on. To say that grumbling about this is misogyny is simply rubbish and quite frankly offensive to women in itself – because it maintains an outdated stereotype that medicine is a male profession. Look around you sisters – we are not in a minority any more. The Early Learning Centre (with their boy doctor and girl nurse dolls) and those patients who cannot get it into their heads that I am not a nurse – they're the ones who have got it wrong. You perpetuate this myth of the male doctor oppressing the poor female patient every time you refer to this stuff as misogyny. This is an outdated sexist analysis which ignores the very real and important contribution made by women like myself at all levels in medicine, and I myself find that offensive.

    I am happy to disclose my identity to the blog author personally in order to continue debate if she wants to do so - just let me know on the blog and I'll email you. Best wishes all.

  12. Gosh where to start! Thanks for the post Anne-Marie. I saw the tweet exchanges un-folding myself and was taken aback also.

    Being from Northern Ireland and also being brought up during "The Troubles" I am very aware of power of black humour to actually help out in times of stress and to provide an outlet in extenuating circumstances. But the point is - useful in extenuating circumstances! Did these guys not have any other more appropriate outlet for their locker-room humour? My own view is that their actions were wholly inappropriate and they should have found a more appropriate forum for letting off steam, if that is what it was.

    Funny enough, as a fan of Liverpool FC, I just saw a report of one of their players making inappropriate comments about 9-11 on Twitter. That player is now subject to a formal investigation by the Club. So if we expect professional behaviour from sports people on open forums, then surely it is not too much of stretch to expect it from our Doctors?

    I am not sure I agree with you when you say that “I don't believe that the public will think less of doctors after this”. I think there is a fine line here. There does seem to a few open Forums where *some* doctors use this sort of black humour. For example - Facebook General Hospital /Medical Registrar/OutofHoursGP etc is one of these that I think can cause offence and often sees patients and doctors engaging in online heated discussion about respect and dignity. Yes some of it is funny too and helps us laugh at ourselves, but again where do we draw the line?

    For me, I do think I expect doctors to act with more respect and dignity. Perhaps that is wrong of me to do so – to hold Doctors to a higher level of accountability. No doubt many medics may get irritated by this view! The level of trust we have in the medical profession has a significant impact on patient outcomes. We know that from many studies on patient engagement and shared decision making for example. So while yes I do judge my doctors individually, say next time a I am faced with a new doctor or a locum for example, perhaps I may be thinking if he is a youngish male, his views and values may not allow for the build of necessary trust between us.

    I am reminded of a saying – “All that is necessary for the triumph of evil is that good men do nothing”

    OK maybe that is a little dramatic for Twitter exchanges but the point is that I am glad Anne-Marie that you saw fit to say something. I would want you to do the same again. However, I don’t think it is all your responsibility though. As in non-virtual society, I think we all have a responsibility to challenge behaviour that could impact the most vulnerable or a part of society where trust is important.


  14. I think that you handled the situation very well by taking the discussion off line. The slang terms for birth were offensive to me as a woman and a patient. As a nurse, I haven't heard those used before, but it in all honesty OB is not my specialty and we may have different slang in the states.

    I have heard the term cabbage patch before - but not for about 20 years.

    Like Fiona and others, I learned black humor as a coping mechanism in the ED. Betting on alcohol levels took away from the trauma of doing CPR on a 2 week old or taking care of whatever the knife and gun club had dropped off at the door. Part of the cause for this is that we never learned another way in nursing or med school.

    I think we are trying to do a better job in health professions education of teaching compassion. Organizations such as compassion4care are trying to encourage practitioners to feel the patient's pain without taking it on themselves.

    I watched some of the comments go by on twitter. I do agree that the hidden curriculum is a strong force. Teaching black humor as a coping mechanism, reinforcing lateral violence (eat your young mentality), and tacitly allowing disrespectful behavior as in your example.

    I work to try to change the experience for new nurses, med students, and residents. Changing the hidden curriculum is a much bigger challenge - but an important one.

  15. Oh my goodness me. I'm not a medic, I am a former barrister who is now in digital engagement (I make internet things and teach people how to engage on the net).

    I saw the conversation this post refers to, and can only look in wonderment at the responses this post has received so far. I can best summarise my view as 'much ado about nothing', whilst noting that thus far, those responses all appear to be from within the profession.

    If you are going to assume public offence, should you not be asking the public?

    Do you really think the public don't know about medical slang? Do you really think we are not amused by it? Can you not remember the various articles that did the rounds, including one years ago in the Mail about the abbreviations you guys allegedly use in our notes?

    My practise at the bar often required me to trawl through medical notes, and I was most disappointed to not find any frankly. At 3 am, they would have been a welcome diversion. I have read my own notes (yes, I am one of those PITA patients), and didn't find any there. Should I have done, I would have undoubtedly laughed.

    All professions have a language they think is secret. Part of humanising a profession is letting the public into a few 'secrets'. It does neither party any harm whatsoever.

    As an example, have you chaps heard of the Twitter case of @Baskers? Sarah Baskerville is a fairly senior civil servant, who tweets personally. Often her tweets are about which pub she is drunk in, or which meeting is boring her.

    The Mail took her to task, printing several of her tweets. No doubt the tut-tutters who read the Mail shook their collective heads in dismay. The service however, stood behind her, as did the politicians who work with her, and as did her Twitter followers. Overall, aside from the Mail readers, the view was a collective shrug and wonderment that anyone was surprised that a civil servant was a normal human being outside of her professional facade. I think you will find the reaction out there is pretty similar in this instance.

    Do I think that a doctor calling intensive care the 'cabbage patch' is an insensitive bastard? No. Do I think that it means his care of those patients is in someway compromised? No. Do I think that he's just a professional, on Twitter, nattering to his mates? Yup. A human, in other words, who just happens to be a doctor.

    Come on guys, there are enough people out there who want to criticise your profession for various things. Don't start doing it to each other, and especially not over something as unimportant as Twitter.

  16. Funny video from anonymous, but there is a difference between political correctness (being careful not to offend anyone) and a culture/hidden curriculum in medical institutions that uses language which is in conflict with the goals of the profession. In addition, as healing professionals, I think there is a difference when a physician is offensive.

  17. Thanks to everyone who has commented. The discussion is just as rich as I hoped it would be. I especially want to thank the anaesthetic reg who coined the term 'labia ward' . You have written a very clear and heartfelt account for why you started using this expression. And it took a lot of words for you to do that and I am very grateful. If any of the doctors initially involved in this discussion had chosen to try and explain to those of us who were taken aback then this blog post would probably not have been written. But they didn't. That's a pity but at least the conversation is moving on now.
    Each of us has our own story and our own truths. I wrote here about my experience and you have been very kind in telling yours. This is the only way that we can make any progress in learning and I am very grateful to you for that.

  18. After a recent medical emergency with my daughter I am looking to return to work hopefully in the healthcare sector. I have been following medics, nurses RT to get a feel for how that type if work affects individuals. I saw the initial convocation and just thought it was banter between online 'friend's'. I think the public realise that 'black' humour if often a coping mechanism in stressful situations whatever the profession. I personally wasn't offended by 'labia ward' or 'birthing sheds' I think they are actually funny names. Even the term 'cabbage patch' didn't offend me but it I may have done if I had read it on twitter when my daughter was in ICU. I would definitely have been upset if I had overheard it said in the hospital. I think that is the thing with social networking, especially twitter, we often overhear 140 characters that weren't really meant for our ears. It is very easy to take things out of context or read more meaning into them than is actually there. At the end of the day we do not have to read anything we do not want to. There is always the option of unfollowing. As a patient I would be more concerned with how a medic relates to me on a personal level rather than the banter he/she has with friends. I have already said that I admire you for bringing this subject up though as anything that makes us question ourselves is a worthwhile experience.

  19. I’m acutely aware of these issues. I’ve set up a website as part of launching the Lincoln First5 Group. First5 is an RCGP initiative to improve support for newly qualified GPs in the first 5 years post qualification. As part of this, I have been asked by members to provide a discussion forum, to exchange ideas and tips and ask for help if needed.

    This has led to multiple potential risks, including but not limited to: breaching patient confidentiality, employment law, financial services law as well as libel. As the ‘owner’ of the forum I fear I would be held jointly liable.

    Therefore, I’ve locked the forum down, insisting on being able to approve individual members, and I will be heavily monitoring the posts, and have made clear my right to edit posts if needs be.

    I think it’s a very close line between protecting yourself legally and censorship.

    As for how to interact on FB and twitter: I favour the bus rule. If you wouldn't shout it out at the top of your voice on a crowded public bus, then you shouldn’t post it online. Simples.

  20. I'm a bit shocked by some of the comments. As a taxpayer, healthcare patient and woman I am sickened by this language, and it has definitely brought the medical profession down in my eyes, particularly all the justification and minimizing going on after the fact. Respect for your fellow humans, people. If your profession is dehumanising you to the extent that you think language like this is OK, do something about the working conditions of your profession.

  21. It's exactly 20 years since I started training as a med student and I've used most of the abusive terms that most doctors and medical students used. I even used to use the example of the 'pumpkin sign' (when the patient's head lights up when you shine the torch in their mouth) during lectures. But I've also been a frightened, acutely unwell patient in a busy hospital with a gown and a curtain bewteen myself and medical professionals making inappropriate comments. As a patient my experience (and sense of humour) cannot in any way be compared with the confidence I have when I'm on the doctor's end of the stethoscope. In fact, as a patient I am a completely different person, my need to be treated with care and consideration is altogether entirely different from what it is as a confident, experienced doctor. This extends to the difficulty we have in defining what it is to be a patient. To be afraid that you have a serious illness, that you might die or be parted from a once vital part of your anatomy, to be on the cusp of losing your independence, continence or breast, means having to put your trust completely in another person (or rather a team) I would almost certainly have more trust in someone who has the humanity of humour and even the gallows humour the profession is renown for might well endear me to them. But ... the humour that demeans patients or belittles other team-members would (and has had) quite the opposite effect. In fact I suspect that it might damage team working and by making the team dysfunctional.
    I believe that there is good and bad humour (and it's not black and white)

  22. I am a woman.
    I am a feminist.
    I am a doctor.
    I have been an inpatient on a number of occasions.

    Come on, get real. Please. Medicine is an incredibly stressful occupation. It isn't just the responsibility for people's health, and indeed lives, it is also trying to cope with this whilst tired, hungry, stressed, dying to get to the toilet, and having to do all this in an overstretched and understaffed service. Black humour is a stress release valve, and a survival mechanism. But there is more to it than that. The forms of language used are one of the last vestiges of the tools of camaraderie that have traditionally helped to keep junior doctors sane. The New Deal and EWTD may have reduced hours (yes, I've worked the old 72 hours plus long shifts), but they also broke up the old firm system, trying to turn doctors into little cogs in a wheel rather than members of a team. MMC and run through training, and the deliberate deterioration of hospital accommodation, means that junior doctors are no longer living together. Doctors' messes still persist, but are often now multidisciplinary, and with shorter hours doctors work harder within those years, so never really get that chance to socialise and destress. Doctors' dining rooms are long gone, with people being disciplined for talking shop in the canteen, even though the work must be discussed and if they don't do it over food they won't have time to eat. The insiders' language, and the in-house jokes, are about the only glue left to gel us together. And we need to gel together. Of course the nurses, pharmacists, HCAs, porters, physios, radiographers, lab techs, paramedics and everyone else are vital. But the buck still ultimately stops with us. And for some of these young kids coming out of university, they must face that without the support mechanisms that used to make the intolerable pressure more bearable.

    Slang terminology like "Labia Ward", or "Madwife" isn't about insulting anyone. It is about coping, and still caring, without either going insane or crying at work (try to avoid that - wait until I'm at home). Because we can't fall apart. We have to be able to come out of resus, where we've just been unable to save a baby from cotdeath, and cope with being shouted and sworn at be someone cross at being kept waiting to be seen about a cut finger. To our patients we must be cool, calm professionals. But to our friends, and colleagues, we will joke about things that others would recoil from in horror. Because it beats rocking backwards and forwards in the country.

    Of course, I may be biased. I once had a madwife complain about me. I was a very junior doctor, and a baby was unexpectedly born very flat. Thankfully CPR was successful, and by the time my backup arrived I'd got them breathing. In the lift on the way to SCBU, I said to the midwife "Shit, that was scary". And she complained about it. Maybe I should have put in a formal complaint that when I was doing CPR and asking her to crash bleep my registrar, she actually was more interested in checking the placenta. And yes, for the record, it is occasions like that which cause some of us to use the term "madwives"...but I suspect most good midwives would not wish to be associated with such a nitwit.

  23. As a medical student, I don't think any less of the doctors in question. I realise the intention was not to hurt anybody and that the comments should just be taken as "having a laugh". As a student and a doctor, if something doesn't affect a doctor's clinical judgement (and this doesn't), I'm not that bothered.
    However, as a patient, it would bother me. Doctors are expected to adhere to different standards to others whether they like it or not. Patients no doubt know that their doctors engage in so called "black humour". But that's no reason to demonstrate it to them in public. I, as a patient, wouldn't like to hear my doctor make potentially derogatory comments in the same way that I wouldn't like to know that my doctor was racist or engaged in potentially incriminating drunken antics as a student. It would make me think less of them as a person and, thus, as a doctor.
    Furthermore, we have to remember that patients often feel extremely vulnerable. Making comments such as these (however jovial they may be) may make them feel ridiculed, enhancing this vulnerability.
    The important thing to take from this, as far as I'm concerned, is that, if you wouldn't feel happy saying something when a patient and their family are in earshot, don't say it on the internet. This arena is about as public as it gets so save anything potentially controversial for private conversations.

  24. I had the privilege of viewing the original tweets a few days ago. My first thought was "Is Ann-Marie doing a social media experiment here?". As a woman and an O&G trainee, the tweets made me smile. However, I was surprised that they were posted in the public domain by a couple of not-so-junior male colleagues.

    But then, would I have intervened? Probably not. My bottom-line is that these comments only reflect these individual thoughts and mannerism, and it has little to do with public safety. Was it misogynistic? Perhaps, but women can take little silly comments by men (in general- can't speak for all).

    People use twitter differently, some use it as a mean to communicate with friends and family. Other use it as a campaign tool, networking, building a public identity and, in extreme cases, to start revolutions. Then I guess perhaps there are different self-regulated standards- e.g. you wouldn't expect Sarah Brown to use such language on twitter?

    A few things stuck into my mind after reading the tweets, blog and FB messages:
    1. "liberal" use of SM is not just restricted to junior staff.
    2. Can't help but wonder what the difference between writing such things on twitter and speaking out loud in L/W with those comment? (Readers: try to imagine that in your mind- makes me giggle).
    3. As a medic from a non-medical family (echoes with "Milly"'s post above)- I really don't think patients care too much as long as they are treated professionally, effectively and in a timely manner. One of my consultants used similar terms to patients but never received any complaints (she is a female). In fact, patients fall into similar categories- some were shocked, others just took it as harmless jokes.

    Take home message: Twitter is public domain. Think what it reflects when you post.

  25. There are several valid points in the post.

    Some of mine: it continually amazes me the extent to which people who may not be doctors themselves hold doctors to a higher standard of public discourse than others in the community. Recent murmurings by a GMC liaison official about the political views he would prefer his doctor to hold attest to this.

    I don't agree with profanity in doctor slang such as "labia ward" (in 19 years I never heard that one). Terms like "expensive care" for ICU/ITU are acceptable in my view. Anyone who has experienced the demanding demeanour of some midwives who act as if theirs is the only ward in the building, coupled with attempts to undermine anaesthetists. will understand where "madwives" comes from.

    I would comment more but my two year-old has just woken up.

  26. I've cross posted some of this from Facebook as I have a feeling that this blog attracts a different audience from the Medical Registrar's homepage. I haven't seen the exchange that Anne Marie refers to (has anybody commenting here seen it?)

    I often wonder whether the burgeoning rant levels on medically slanted social media have anything to do with the pervasive social atmosphere in the NHS that a junior doctor's place is in the wrong. It has become increasingly difficult for itinerant junior doctors to in any way challenge the behaviour of permanently employed colleagues in other professions directly, which can only increase the need to let off steam in other ways. Indeed., it is becoming apparent to me that it can be quite difficult for senior doctors to take these people on! From an anaesthetist's point of view, Midwives and ITU nurses are key culprits here.

    Perhaps we are seeing a group of people who don't have a voice finding a way to speak out courtesy of new media.

  27. I think it's important to see Twitter comments in context and not as something that impacts on patient care.

    In the real world we cannot be "friends" with our doctors and rarely have anything to do with them outside of their professional practice, even our GPs (unless you live in a particularly small town) so we don't know them as a "person" only as "our doctor". Yet on twitter those who are not medical doctors can follow random medics and see their comments...even those that show they are also humans. If you chose to follow a doctor on twitter, surely you have to be prepared for them to be just people and so not base your views on the medical profession as a whole on thier comments on there?!

    In my experience working on acute psychiatric wards with children, adolescents and adults going through countless SHOs and SpRs (or whatever their new letter/number combinations are) there are doctors, nurses and psychologists who will use gallows humour and those who think it is distasteful. As long as it is done behind the office door and not within earshot of patients or their carers/family it does not hurt patients - may even help them having professionals with effective coping strategies.

    Just a view from a patient of medical doctors, a fairly prolific twitter follwer/facebook liker of medical professionals and a clinical psychologist within the NHS...

  28. 1. Great thread
    2. Am ashamed that some of today's trainees are so insensitive
    3. Educational supervisors in hospital spcialties must bear some responsibility for the attitude of their trainees
    4. Reassured that people will speak up;racism may be natural progression such professional attitudes unless challenged
    5.I am a survivor of ITU - let me persuade the protagonists that I am no cabbage.
    6. "Labia ward" is brilliant play on words in 'House of God' tradition
    7. Keep up the discussion

  29. To Morag Eyrie, I would challenge you to shadow a doctor on either the labour ward or ITU and not come away affected by the experience. The senseless, unfair, horrible things that mean people need Intensive Care or the not-so-happy outcomes from pregnancy that seem to happen all too often. I would then challenge you to go back and do it all over again. And again, and again.

    Couple this with the widening gulf in the public's expectations of the NHS and what is actually possible in the real world.

    You would very quickly find that without some means of distancing yourself from the emotional horror, you would burn out, or maybe worse.

    One thing I know for certain is that, as a taxpayer, the changes you propose to the working conditions would end up with you paying a hell of a lot more tax!

    If this post has affected your perception of the medical perception, then it was probably your perception that was flawed in the first place. Doctors are people, just like everyone else. Except they are people who have to witness some pretty awful things and then find a way to cope so that they can still turn up for work the next day.

    And MaturinUK, to equate some fairly innocuous slang (that you yourself call a brilliant play on words) to racism is simply absurd! While we're at it, we may as well get Godwin's Law out of the way and say it's just a few short steps from here to Nazism!

  30. That was of course supposed to read 'medical profession' not 'medical perception'. Too many perceptions in one sentence!

  31. I've only got bandwidth for a skim and a brief reply. Having said that:

    I say, one is responsible for one's public statements. Cussing to one's buddies on a tram is not the same as cussing in a corner booth at the pub. If you want to use venting vocabulary in a circle, use email with CC's, or a Google+ Circle.

    One may claim - ONCE - ignorance, as in, "Oh, others could see that??" It must, I say, then be accompanied by an earnest "Oh crap!!" Beyond that, it's as rude as cussing in a streetcorner crowd.

  32. I agree e-Patient Dave, well said indeed - it is as rude as cussing in the street. I also like what was written by the woman who coined the 'labia ward' phrase.

    This is an excellent post Anne-Marie. Thank you for sticking your neck right out and writing it.

    I didn't see the tweets but I am glad they were in the public domain for public scrutiny and reaction.

    It may be possible to hide prejudice or ill-informed phrases about parts of society behind the closed walls of a profession but they will not often stand up to scrutiny when they are in open view.

    The Medical profession is a stressful one. So are many others. Humour is important, but humour can be expressed in better ways than some of the terms bandied about here.

  33. Good thought provoking post Anne-Marie but I agree with Anonymous. Nothing here to offend. Many individuals who are in professions that are very stressful use humour to release some of that stress and the humour is, to my knowledge, always questionable. It's funny. I'm not a professional but since childhood, I've spent a lot of time in hospital and I've overheard many comments that would nowadays be regarded as derogatory, however, I always found them funny. People take things too personally and are preoccupied with being politically correct which, quite frankly, annoys me. Time to lighten up and use your energies on matters that really need your attention. Just saying...!! :D

  34. As someone who was a junior doctor in a variety of challenging acute specialties for many years, I am surprised at some of the things being said here. To my mind its fairly straight forward: there's nothing wrong with using these terms in private, but its out of order in public. That's the point, and its nothing to do with how difficult the job is, or how unpleasant other healthcare professionals can be to you while you are doing it (as they undoubtedly are sometimes).

    The fact that 'anonymous' is still 'anonymous' on this thread says it all - don't you find it anomalous that you are prepared to stand up for using these terms in public, but insist on remaining nameless? Come on.

    Thanks again to Anne Marie for getting the debate going.

  35. Interesting remarks.

    Last week an incident arose which you may have seen in the press. It was also remarked upon on the Today programme...

    A hospital manager emailed their HR team to post a job ad on NHS jobs. At the bottom of their message they added a comment about adding the "usual rubbish" about equal opps. Unfortunately, the HR department, who handle the job ads, posted the whole text to the NHS jobs system, where it was spotted and complained about by potential applicants who read it. From evidence we know that the applicants were likely to be precisely the kind of NHS professionals who really do suffer disproportionate discrimination, and for whom equal opportunities statements actually mean something.

    The manager who originated the ad was naturally embarrassed and their Chief Executive has had to deal with the fallout. But what does this tell us?

    When people are in normal social situations their guard is up, they will police their language, and we are unlikely to be able to gain an honest assessment of what they really think.

    In online social media, the speed and apparent isolation mean that people are likely to forget such caution ... and then we gain some insight into what they really think.

    I have a lot of sympathy for people working in stressful situations. It's not just clinicians ... many professions have evolved black humour and slang as ways to desensitise themselves from the horrors they deal with.

    That's not to excuse such language though, especially as it inevitably leaks into the public domain like this, where it is held up for scrutiny in a different context and may be considered in a different way to which the people uttering it probably meant.

    All of this suggests that the people using this language should examine their motives. It takes no more effort to say "Labour ward" than "Labia ward". ICU is even quicker to say than cabbage patch. So we are not looking at necessary jargon and brevity here. It means someone took the effort to think of such terms and their colleagues shared some kind of belief system which encouraged it to gain currency.

    Rather than defensively dismiss people calling them out on this, therefore, I think it behoves professionals to step back and analyse what they are doing and why. What does it tell them about themselves?

    Young people have slang too. Some of them might describe these clinicians' wives, sisters and mothers as 'slags'. Would they be so relaxed? Would they consider that a part of a group culture? Would they want to call it out?

  36. Some thoughts here, after looking over at the Facebook conversation about this:

  37. While I feel that some of these terms were derogatory in a way that communicates contempt and distaste without any value added, I can say from a more personal perspective with many years of ICU behind me that the black humor employed by many in critical care is simply a (rather crass, but effective) coping mechanism. Where there is humor, there is pain.

    No coincidence that staff and physicians have employed black humor in a setting where our emotional needs are rarely accounted for. I worked in an ICU in one of the best hospitals, period, in the world, and was at the morgue regularly. I had no outlet or support system for being slapped with death besides frequent vacations, then resigning upon full burn-out.

  38. Another thoughtful post, Anne-Marie, and as can be seen from the response this is very much a live issue that we should all be mindful of.

    I've blogged my response to this, because it just was too long to post as a comment. Please see

    Essentially, I agree with some of the posters above; we have to have a congruent identity, online and offline. We must maintain professional demeanour at all times, and what we assume is private may, in fact, become public.

    I refrained from getting into whether or not some of the debate has been unfortunately personalised and sexist- which itself doesn't present medical professionals is a great light!

    Thanks again for raising this issue, Anne-Marie.

  39. Very interesting blog, and also comments. Thanks for raising this, Anne-Marie.

    (I posted a comment earlier but it seems to have gone astray- apologies if this is repeating myself).

    Social Media is breaking down the barriers between us: what may have been acceptable in a Doctor's room 30 years ago is simply not acceptable today, in full public view.

    But I wonder, was misogyny, or derogatory commenting about patients *ever* acceptable? or did the culture of the Doctor's room impede the expressions of discomfort of people who recognized the anti-social nature of such discourse?

    I blogged a fuller response to this, linking to some bits of evidence in support of using and analyzing social media use for healthcare professionals.

    Thanks, Anne-Marie, for sticking your head above the parapet.

  40. Madwife and proud of it17 September 2011 at 10:35

    I think the term 'labia Ward" is brilliant and for all the reasons the anaesthetic reg listed - I just wish I'd thought of it first. It's completely the right name for the place I work - the place I like to refer to as either "the gulag" or "the factory". I do this with blatant disregard for the positive marketing/spin that the administrators are attempting by calling the place " the birth centre". Sure, births do take place there, but a high tech, high security, 16 room ward that pushes women through as if on a production line to facilitae 20 births a day is not the family-freindly, intimate and shanti space that comes to mind when I think of a birth centre. I like to call things as they are, and like MaturinUK, I was a huge fan of Shem's "House of God" and actually think those plays on words are funny.

    I think a much greater risk to our profssional reputation is the increasing obesity levels among (so-called) health professionals - particualrly the 20-somethings, and the multitude of staff who smoke and insist on doing it IN UNIFORM and out the front of hospitals (invariably RIGHT UNDER the "this is a smoke free facility" sign.

  41. It's a truism that most humour can be regarded as being offensive - to someone, somehwere.
    Subgroups of society develop their own form of humour - in-jokes that help establish group identity. When you become a member of such a group, it can be difficult to avoid joining in and using such humour. You can end up feeling like an out-sider if you don't join in the banter. So there is peer group pressure to conform; something we learnt in our playgrounds. This humour can be either offensive or difficult to understand for outsiders. It probably has to be to provide the group's need for cohesion.
    We all subject ourselves to potentially offensive humour every day on television and the radio. If one scrupulously censored programmes such as "Have I Got News for You", "Mock the Week", with reference to anybody who could potentially be thought of as experiencing offence, there would be nothing left to put on air. Yet most of us love these programmes and the world would be a worse place without them.
    The important thing is that potentially offensive humour works if it is clever, and delivered with wit and style. It often helps if there is a dollop of self-deprecation to hurry it along. So, a joke that would be homophobic can be really funny told by a gay comedian. "Queer" is offensive coming from a straight mouth.
    However, Jeremy Clarkson's recent recent attempts at humour, proposing the abolition of the Welsh language were crass and offensive as they lacked style and wit, coming across as rants from a boorish bully.
    The series of tweets I saw, in general, seemed to fail the style, wit and cleverness test, and I think did have the potential to offend - something that would be extremely difficult to get right in 140 characters anyway.

  42. I find the attitude of the blogger and most of her sycophants on this blog to be unsettling. People have the right to express themselves as they wish. It's called freedom of speech. Stasi PC bigots like Cunningham who avoid patients by becoming "academics" and start telling people (who do the real work) what to do make me sick. The tide is hopefully turning though, and soon Cunningham's brand of PC scapegoating, thought-control and vilification will be out.

  43. I found this a fascinating discussion. I remember when I was a junior doctor patients being termed ‘rubbish’ because their case didn’t have any interesting or unusual features, and the use of ‘plumbus oscillans’ etc. in the writing of notes in patient records.

    I had hoped that the widening of entry to medicine, the change in gender balance and the gradual development of modern ethical codes would have changed things so that in wasn’t acceptable to refer to patients in disrespectful terms.

    Having been brought up in the Catholic community in the North of Ireland, one learnt all about discriminatory and derogatory language. I was however surprised on moving to England to find that it was acceptable in the most surprising of quarters to make fun of ‘thick Paddies’ and use terms like ‘bog wog’. Of course if I criticised such language I was always told that it was just a bit of fun and not to be taken seriously.

    The use of terms that people would find insulting and offensive is always unacceptable and should be particularly unacceptable in the exercise of a profession that holds such power over vulnerable people. I understand that many doctors and nurses have stressful lives and that humour is an escape valve. But it is not humour about and between equals if it is insulting to patients. It is both unethical and unprofessional. Those that indulge in insulting patients (whether the patients hears or not) demean themselves and us all.

  44. i generally avoid internet debates, but i just have to jump in here.

    to all the people who argue this is harmless humour or are comparing dr. cunningham to the thought police, consider that language has a strong impact on the way we think (check out if doctors use disrespectful, dehumanizing language to describe their patients, it could very likely impact their care. it doesn't take a genius to realise that if you think of someone as less than human, you're not going to be as compassionate or careful as you would otherwise be.

    doctors do certainly have a right to free speech, but they are in a huge position of power over their patients both rhetorically and practically. doctors are are trusted and held in high esteem more than any other profession. many patients will ever question what their doctor tells them what to do. and, it goes without saying that doctors make life and death decisions for patients. such a role comes with huge responsibility. so, doctors should know better than to make disrespectful comments about patients and colleagues on twitter.

    thank you dr. cunningham for bringing this to public attention. as a patient, i would not feel comfortable knowing my doctor was thinking about me in such dehumanizing terms.

  45. Stasi PC bigots like Cunningham who avoid patients by becoming "academics" and start telling people (who do the real work) what to do make me sick.

    Well said.

    The day I stop using black humour to get through my days is the day I resign (which won't be a minute too soon).

    The NHS, pre-MMC/MTAS/EWTD bollocks, cultivated and supported a team culture in hospital medicine. One was part of a firm, 'brought up' by the bosses, supported by peers... working longer hours with more on-calls and less 'shift' work. It was a healthier working environment than today's NHS. Junior doctors were much happier and perhaps more inclined to keep their black humour within the profession.

    Now all juniors do shifts, they treat the job as a 'job' instead of a profession (one can hardly be surprised - it's how their work is treated). It is no surprise to me that those who are still working hard and dealing, daily, with situations which would leave many people claiming benefit through post-traumatic stress, find an outlet in humour which some don't like.

    Don't read it if you don't like it.

  46. so if you dont like the way that junior doctors are expressng themselves, then could it be a failure of the educational process and those who are being paid to teach them ?
    A better way of influencing the might be to come down from your Ivory tower of Excellence and be a role model that they can work alongside at the coalface.
    Whilst you may think yourself a success as you go to meetings and hob-nob with like-minded people it seems you are failing in your task of educating the next generation of doctors if they arent behaving as you wish. Have you considered resigning , as you seem to be useless?

  47. As a member of a multidisciplinary healthcare team, egalitarian and respectful relationships should be the order of the day. Of course these professional courtesies translate into every dimension of practice and to the central focus of care, that being the client.
    Have a read about the principle of Subtle Elegance of Birthing Women which contradicts any crudity about Mothers.

  48. Alot of discussion about this between the docs. Here is my perspective as a patient.

  49. Are these comments effective as humor or stress reducers only if they target individuals or classes of people whom the speaker perceives to be "less"--patient, underling, female, cognitively injured, aged, disabled? I've been concerned about the power of this language to decrease empathy and its potential effect on patient care, but never expected to hear an open discussion about it. Social media has unexpected ways!

  50. Anne Marie, You raise some under-discussed points here. The implications extend well beyond social media.

  51. Bravo for shining light on this. Everyone needs to remember that twitter is a public space, so what you're not prepared to say to your mum, you should not tweet about. Totally agree with your stance on this and am glad that not all doctors, especially newly trained ones, agree with this use of language.

  52. I find it a bit ironic that the much criticism of the doctors who posted these tweets was that they posted in the public domain, yet the only reason most people are aware of the tweets is because Dr Cunningham made it public and the story ended up in national newspapers as a result. I do agree that the comments should have been kept private, but I think that was their only error.

    Comments are being made about how this behaviour impacts on patient care; that if we, as doctors, will somehow care less about patients if we use these jokes to help lighten a stressful day at work. What a load of rubbish, I may make comments such as these myself, but it in no way impacts on how I deliver care.

    Many surgeons are criticised for their attitude and relationships with patients, but from my perspective as an anaesthetist who works with many different types of surgeon, is that how well they perform surgery is by far the most important part of their job. I work with surgeons who are crass and could appear uncaring but who are excellent at the skill that truly matters, the surgery. I also work with surgeons who are very friendly and great with their patients, but who lack the skill to make them a good surgeon. Academics and communication experts like Dr Cunningham would no doubt come along to observe these guys at work and praise the lovely guy whose a rubbish surgeon, and criticise the brilliant surgeon for his inability to communicate. The difference is, you don't see the nice surgeon's patient die on ITU a few weeks later from an anastamotic breakdown, I do.

    Whilst in the ideal world, every surgeon would be technically brilliant and a good communicator, but for now, if I need surgery I know who I would want to do my operation.

    I realise that I have gone a bit off topic, but my point is that there are much greater things to be worried about than this petty banter that seems to be blown way out of proportion. Technically poor doctors who are good communicators and 'nice guys' are much more dangerous to our patients than doctors who aren't as PC as you'd like them to be.

    Perhaps if Dr Cunningham had any idea what it was like as an anaesthetist to deal with obstetric emergencies in the 'birthing shed' and critically I'll patients on the 'cabbage patch' (I do find this one slightly offensive!), she could sympathise with us

  53. Come on, get real. Please. Medicine is an incredibly stressful occupation. It isn't just the responsibility for people's health, and indeed lives, it is also trying to cope with this whilst tired, hungry, stressed, dying to get to the toilet, and having to do all this in an overstretched and understaffed service. Black humour is a stress release valve, and a survival mechanism. But there is more to it than that. The forms of language used are one of the last vestiges of the tools of camaraderie that have traditionally helped to keep junior doctors sane. The New Deal and EWTD may have reduced hours (yes, I've worked the old 72 hours plus long shifts), but they also broke up the old firm system

    *raises eyebrow* I think you miss (an important part of the) point, signalled by **the very title of this post**. This is not about medics slagging off patients in their own private boozer, or wherever, it's about them using these terms *in public*. The word "unprofessional" springs to mind.

  54. I was drawn to this on reading a thread on a doctors' group that you yourself subscribe to. All fascinating stuff. Demonstrates a need for constant circumspection. Best not to say anything in these discussion groups that you wouldn't be happy saying to your own grandmother, I think.

  55. I think everyone realises that comments such as those cited are used for stress relief and while we may not like the particulars of that, it is the reality. I think many people have missed the point, though, that to make such comments in a public forum is taking it to another level. To assume that it is OK does say something about the attitudes of the people willing to do that, I think, and that they are perhaps ignoring the potential hurt and disrespect that such language can carry. I'm sure that all of us have said things in the privacy of our own homes or under stress at work that we wouldn't say to the people or groups of people directly. It is not 'banter' if people are deeply hurt by it. I suspect that people said the same things about ethnic jokes in the past that would be seen as completely unacceptable now in a public forum. As several people have said, it is about being aware how it might come across if you are choosing to put it out for everyone to see.

    I also find the attack on Ann-Marie by other doctors rather astounding. If she found the comment misogynistic, then that is her opinion. You may not, but to directly attack her post as 'rubbish' I find quite dismissive. I didn't see it as implying that medicine is a mostly male profession at all. However, there are many aspects of the profession of medicine that are still stacked against women and I think these attitudes can be held by females as well as males. Just declaring your "feminism" doesn't change anything.

  56. As long as my doctor is doing his/her job well, I don't need him/her to act good. Humans are horrible, anyway. I would prefer a doctor who is an A-Hole but is really great than one who is goody-goody but is not competitive. It would be a bonus if the doctor is nice and skillful at the same time, but I put higher priority on his/her skills. Be a jerk all he/she wants, as long as he/she does his/her job, I don't care.

  57. Well, those really look offensive at a glance. But black humor is apparently not that bad. A study by Medical Humanities and Bioethics at Northwestern University, Illinois shows that "treating serious and painful subjects in a light, satirical way, improves the doctor’s surgery performance and the patient’s treatment and recovery." So there, but we must remember that every patient is different and that the joke should not have the patient as its butt. Rather, it should be "death". More of this study here:

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