Teaching the Humor Curriculum We Already Have

One of the more uncomfortable findings in the medical education literature is that students enter training optimistic, idealistic, and disposed toward affiliative humor, and graduate four to seven years later with a measurable shift toward cynical and derogatory humor (Wear et al., 2006). The shift is not incidental. It is one of the visible markers of the broader empathy decline that CompassionSolution.Org's other writing has documented.

Educators who care about compassion in their graduates have to take this seriously, because humor is not just a social ornament that students pick up around the edges of training. Humor is a core practice that shapes the practitioner who delivers it. The students we are training will use humor every day of their careers, with patients, with families, with colleagues, and with themselves. The question is not whether they will have a humor practice. The question is which one we are teaching them to have.

This post is for faculty and program directors who want to teach humor deliberately rather than leave it to the hidden curriculum.

What the hidden curriculum is teaching

Wear and colleagues' 2006 study of medical students' perceptions of derogatory and cynical humor in clinical settings is the foundational document in this area. They interviewed students at four U.S. medical schools and documented a consistent pattern. Students enter clinical rotations expecting to encounter difficult patient situations and quickly discover that the residents and attendings around them have a humor culture for managing those situations. The culture is rarely taught explicitly. It is modeled. Students absorb it because they want to belong, because the humor offers a kind of relief, and because explicit refusal is socially costly.

The targets of the hidden-curriculum humor are predictable. Patients perceived as difficult, non-adherent, undeserving, or unsympathetic become the focus. Patients with substance use disorders, obesity, mental illness, low health literacy, or social marginalization are particularly common targets. Students described being uncomfortable when they first encountered this humor and finding themselves participating in it within months. By the end of clinical rotations, many had developed their own derogatory vocabulary.

The students in Wear's study were honest about this. They knew the humor was a coping mechanism. They also knew it was changing them, and they were not sure how to stop.

The case for taking this seriously

A reasonable response from a busy program director might be that this is a feature of training, not a bug. The reasoning would be that humor is how students manage the hard parts of clinical work, and trying to suppress it will either fail or create worse problems. The literature does not support that reasoning, for three reasons.

First, the humor that the hidden curriculum teaches is not the only humor available. The Martin humor styles taxonomy, developed in 2003 and now extensively validated, distinguishes four functionally distinct styles: affiliative (other-oriented and benign), self-enhancing (self-oriented and benign), aggressive (other-oriented and harmful), and self-defeating (self-oriented and harmful). Affiliative and self-enhancing humor produce all the team-cohesion, stress-relief, and resilience benefits that the apologists for derogatory humor want to claim. Aggressive and self-defeating humor produce the opposite. The choice is not between humor and no humor. The choice is between two humor practices with very different effects on the practitioner.

Second, the corrosion is documented. Aultman (2009) and the broader medical ethics literature have shown that derogatory humor changes the joker. Even when the patient never hears it. The repeated practice of reframing patients as objects of contempt produces measurable shifts in clinical reasoning, biased attention to vital signs and history, and what Aultman calls moral erosion. This is not a benign coping mechanism. It is a practice with cumulative effects on the practitioner's character, and through the practitioner, on the patient care that follows.

Third, the alternative is teachable. Compassionate humor is a learnable practice, and the evidence base for teaching it is at least as strong as the evidence base for teaching the empathy and compassion fundamentals that already appear in many curricula. The Berk physiology lab work on the neuroendocrinology of laughter, the Sun and colleagues 2023 integrative review of humor therapy outcomes, and the Martin humor styles framework together provide a teachable scientific foundation. The Watson distinction between humor that targets the situation and humor that targets the person provides a teachable ethical framework. Compassionate humor delivery can be taught the same way the GRACE pause and the Compassionate Breathing Space are taught: as a practice, not a personality trait.

What a compassionate humor module would cover

A compassionate humor curriculum module, designed for clinical rotations or as part of a foundational professional formation course, would cover four content areas.

The first area is the science. Students need to know that humor is biologically active. The Berk laboratory's documentation of cortisol reduction, endorphin elevation, and immune modulation following mirthful laughter is concrete enough to dignify humor as a clinical variable rather than a soft skill. The Sun integrative review on humor therapy outcomes connects laboratory findings to patient-level effects on depression and anxiety. This content does the same work that the Singer and Klimecki neuroscience does for the empathy-compassion distinction: it gives students permission to take seriously something they have been treating as decorative.

The second area is the taxonomy. Students need a structural framework for distinguishing humor styles. The Martin four-styles model is the most useful pedagogical tool here because it is intuitive, it maps onto familiar examples, and it produces immediate self-recognition in learners. A simple exercise asking students to identify which style was modeled in a series of brief case vignettes produces engagement that lecture-based content rarely achieves.

The third area is the ethics. The Watson distinction between humor that targets the situation and humor that targets the person is the operational rule, and it deserves protected curriculum time. The earshot principle, the corrosion concern, and the difference between team-room gallows humor and bedside derogatory humor are all teachable through case analysis.

The fourth area is the delivery practice. Like any clinical skill, compassionate humor requires modeled examples, supervised practice, and feedback. Students can learn the seven principles of compassionate delivery (target the situation not the person, let the patient set the temperature first, test small, use yourself as the target if needed, audit your motivation, treat the earshot principle as inviolable, and notice the corrosion). They can rehearse them in standardized patient encounters. They can debrief on how it went.

The faculty problem

There is a complication that has to be named directly. Faculty cannot teach a humor practice they have not adopted themselves. The transmission belt does not skip the teacher. A program that wants its graduates to use compassionate humor needs faculty who model compassionate humor, in clinic, in didactic settings, in interactions with one another, and in their own self-talk. The hidden curriculum will continue to teach whatever the faculty actually do, regardless of what the explicit curriculum says.

This is one of the reasons faculty wellbeing and faculty professional development on compassion practices are not optional. They are infrastructure. Faculty who are themselves operating from depleted, egosystem-oriented, end-of-day fatigue will reach for the same derogatory humor that the literature documents. Faculty who have built their own compassionate humor practice will model something else, and their students will notice.

This connects to CompassionSolution.Org's broader argument that compassion training cannot be limited to credentialed clinicians and cannot be one-time. It is sustained practice in a sustained culture. The same is true for compassionate humor.

Where to start

A program that wants to take this seriously can start in three places.

The first is faculty development. A 90-minute faculty workshop covering the Martin taxonomy, the Watson distinction, and the seven delivery principles, paired with structured reflection on the program's own current humor culture, is a reasonable starting point. The Baylor workshop methodology that CompassionSolution.Org has documented elsewhere is adaptable for this content.

The second is curriculum integration. A compassionate humor module added to an existing professional formation course, ideally before clinical rotations begin, gives students the framework they need to recognize what they are about to encounter and the language to discuss it. This works best when paired with structured debrief sessions during clinical rotations themselves, where students can name what they are seeing without indicting individual preceptors.

The third is culture work. The slow work of shifting a program's actual humor culture happens through what gets laughed at in faculty meetings, what gets named in clinical debriefs, and what gets modeled at every level of the organization. This is the longest-cycle and highest-leverage intervention. It is also the one most often skipped because it cannot be measured in a single semester.

The opportunity is real. Compassion in healthcare can be taught, and humor is one of the practices through which compassion either gets sustained or gets eroded across a career. Students will learn one humor culture or the other during training. Educators get to decide which one.

Care differently, not less.