(Originally Published in the: Journal of the Kentucky Medical Association.  1995 Feb;93(2):59-61)

Diagnosis/Treatment

AFTER being repeatedly savaged by ruthless heckling, I dropped the passive, avant-garde comedy material. Instead, I elected to assume a more finger-poppin', New York attitude, confrontational style. Armed with the confidence of several successful performances, I entered into hostile comedy environments with confidence.

On a cold February evening, shortly after Operation Desert Storm, I attacked the comedy stage with material on the ironies of war in America. I addressed the silliness of the contrived television quotes during the Iraq invasion ("Well Jim, we are in downtown Baghdad covering the war - live! As you can see, the sky is lit up like a fireworks display - live! In fact, my right foot appears to have just been hit by a Toe Missile - live! This is a night like my podiatrist will never forget.")

However, a large number of the audience were members of a World War II airborne division. As I ranted and raved, I became aware that my new-found style elicited not laughter, but fear in these older veterans. To them, I was little less like Jay Leno and Jerry Seinfeld, and a little more like Abbie Hoffman and Jerry Rubin.

I frightened these people. I realize now that I was blinded by the spotlight. If I had evaluated the whole audience, perhaps I would have been less aggressive in my approach.

*****

AFTER being repeatedly grilled by attending physicians, fellows, and senior residents, I elected to assume a more academic style. Armed with the confidence of successful deflections of practical, patient care questions concerning the incidence of babesiosis in Uganda, and the bedside determination of insulin's molecular structure, I entered the second year as an Internal Medicine resident with confidence.

On a cold February day, I met MK who was a 24-year-old woman who I inherited in internal medicine clinic. She had several recent ER visits for frantic complaints of palpitations and shortness of breath. With the helpful guidance of the academic attending physician, I obtained a 24­hour cardiac monitor (episodic sinus tachycardia), that prompted a 24-hour urine for metanephrines and catecholamines and thyroid blood tests (normal values), that prompted an echocardiogram ("questionable mass in the atrium"), that prompted a magnetic resonance imaging study of the heart (no diagnosis), that prompted cardiac catheterization, that demonstrated a normal heart in this 24-year-old woman.

Within a short period after the cardiac catheterization, I saw MK's brother as a patient. His medical history included a scar of the left periorbital region due to a rat-bite wound as a child, and a severed right arm related to a bus ride, a concrete tunnel, and an open window. He also had complaints of palpitations and shortness of breath diagnosed as an anxiety disorder that was well controlled with benzodiazepines. I suddenly felt a little less like Sir William Osler and little more like Sir Idont Havaclue.

Ms MK suffered from panic attacks. I realize now that I was blinded by the technology. If I had evaluated the whole patient, perhaps I would have been less aggressive in my approach.

The Art of the Craft: Medical Procedures, Magic, Guitars, and Juggling

Pure stand up comedy is an art form. But many stand-up comics choose comedy as their vocation, not to advance the art of comedy. Despite the cry for "clean" comedy by club owners and patrons, comics soon learn that offensive language and risqué material is rarely criticized as long as the comic elicits an audience response. It would be useful if all comedy clubs would inform audiences of potentially offensive comics prior to a performance.

Some comics are mostly magicians, jugglers, musicians, and/or "prop acts." Although most use these talents to enhance their comedy, some of these comics forgo comedy and perform primarily as entertainers. Audiences and club owners are often more impressed with and will pay more for the comic who can entertain than for the pure stand up comic.

*****

Pure bedside diagnosis and treatment is an art form. But many physicians choose the practice of medicine as their vocation, not to advance the art of medicine. Despite the cry for cost-containment by academic centers, doctors in training soon learn that ordering excessive laboratory is rarely criticized in the academic setting. When presenting the patient who presents with fever, cough, and infiltrate on chest X-ray, it is not unusual for residents to be hounded as to how they leaped to the diagnosis of "pneumonia" without the confirmatory Technetium Gerbil Scan recently described in the Annals of Obscure and Billable Technology. It would be useful if all medical journal articles on "How `Real World' Physicians Should Improve Their Medical Cost Effectiveness" were accompanied by a rating as to how the author's academic center compared to the "real world" in cost effectiveness.

Some physicians' practices consist mostly of procedures. Although most physicians utilize these technical skills to enhance patient care, some forgo cognitive effort and function primarily as technicians. Patients and insurance companies are often more impressed with and reimburse more for the doctor trained in a procedural skill than for the pure diagnostician.

Racism

TS is an innovative, introspective, and very talented African-American comic. On the last show Saturday, another African-American comic (who frequently appeared on a popular African-American stand up comedy cable program) requested to perform a "guest spot." The club agreed and TS wisely chose to go on before this "guest" comic. The show was extensively advertised by black radio stations. With the exception of a Caucasian couple in the front row (i.e. a very surprised and confused Caucasian couple). I was the only white person in the club. I had not experienced such a minority feeling since my medical training at the old General Hospital. Nevertheless, the audience was gracious and I experienced one of the more enjoyable performances of my comedy career. It has been my observation that African-Americans are especially attuned to political issues.

TS, adorned in an impeccably tailored suit, then followed with 40 minutes of brilliant comedy. He illuminated America's social landscape - not as a member of the black race, but as a member of the human race. The chic audience applauded with their approval. It was glorious.

The "guest" comic then followed. I knew what to expect. His material would consist of excessive use of obscene language, graphic description of sexual acts, unmerciful belittling of whites, and would generally help to promote unfavorable misconceptions of African-American culture. ("It's great to see y'all here to­night. I guess yo' is glad to see me here too. `Cause if'n I'm here, that means I ain't out in the parkin' lot stealin' yo' car.")

After witnessing to the intelligent comedy of TS, I was convinced that this educated and uptown crowd was going to reject "street comedy" as demeaning, discriminatory, prejudice, and not in the best interest of furthering the advancement of this proud people. It was clear to me the "guest comic" would die a most painful comedy death. But rather than die as I expected, he killed. The audience roared with appreciation.

Blacks and whites are not equal with respect to discrimination. Is my attitude racist, naive, or just snobbish? If I object to white comics whose comedy material heavily relies on foul language, sex, and body excrement, is it racist to be critical of blacks who do the same? After all, not having been a member of an African American family, I may not fully appreciate the culture.

*****

It has been suggested that much of the increased health risk of African Americans, such as high blood pressure, may be due to suppressed anger and anxiety from repetitive encounters with racism. Initially, I found this a medical stretch at best. Because it is the 1990s, surely racism is no longer a major factor for most blacks. Clearly, it seemed, the increased risk of such problems as high blood pressure, heart disease, and stroke is simply that too many African-American foods (and therefore too many African-American persons) contain too much fat and salt.

Shortly afterward, a friend from a progressive city in the Midwest told me of how she and her coworkers were recently invited by one of her colleagues to go out to lunch. She was astounded to discover that the leader of the group had first called the "club" to ask permission to bring SQ, who was an African-American woman professional. During our conversation, my friend and I both wondered if SQ knew that she was the only black person in the club, except for the servers and cleaning staff. We both wondered if SQ knew that the club had to give "permission" in order for her to join her friends for lunch. We both wondered if SQ knew her blood pressure.

Blacks and whites are not equal with respect to the risks of many medical conditions such as diabetes, hypertension, kidney and heart disease. But how much of attributable risk is due to genetic predisposition, how much is due to social issues, and how much is due to the high intake of fat and salt of many African Americans? If I object to obese white patients with high cholesterol blood levels who eat cow brains (that are very high in cholesterol), is it racist to be critical of obese, adult onset diabetic, hypertensive black patients who eat cow feet, salt pork, and fatback? After all, not having been a member of an African-American family, I may not fully appreciate the culture.

After all, not having been a member of a cow brain-consuming white family, I may not fully appreciate my own culture.

Road Comedy, Research and Family

"Road comics" travel from town to town, spending days in hotel rooms or comedy housing provided by the comedy club. The typical features of "road comedy" housing include mismatched furniture and dishes, worn-through carpet, and numerous crusted, once opened mustard and mayonnaise jars in the refrigerator. And there is the "information wall." This is the area above the phone with handwritten comments of previous comics, as well as vital phone numbers of the comedy club, calling card operators, and various pizza delivery services.

Early in their careers, the success of road comics is highlighted by noting the success of other comics he/she has worked with in the past. Progressively, the success of road comics becomes more dependent on the status of the clubs they have worked, the articles they have had written about them, and the number of TV performances they have made. In addition to monetary and professional success, many road comics find a major appeal of stand up comedy is the concept of family.

Because so many road comics work so many clubs with so many other comics, a comedy "family" is created. Comics can spend a large part of their day in the condo critiquing the accomplishments and comedy bits of their colleagues, as well as espousing their esoteric theories of comedy and the comedy industry. And if a road comic does happen to obtain success through a TV spot, their colleagues soon assimilate this information into their comedy collective and the event becomes a benchmark for future discussions. Every success and failure of a stand up comic enhances and solidifies the comedy family.

*****

Medical "bench" researchers often train and work from one academic center to another, spending days in the lab provided by the academic institution. The typical features of a research laboratory include mismatched beakers and test tubes, worn-through tile over concrete floors, culture plates and blood samples of unclear origin and purpose, and numerous crusted, once opened mustard and mayonnaise jars in the refrigerator. And there is the "information wall." This is the area above the phone with handwritten comments of previous researchers, clinical coordinators, and lab techs, as well as the vital phone numbers of the reference laboratories, study monitors, and various pizza delivery services.

Early in their careers, the success of the researcher is highlighted by noting the success of other researchers he/she has worked with in the past. Progressively, the success of researchers becomes more dependent on the status of the academic institution they have worked, the articles they have published, and the number of grants obtained or the number of drug trials they have performed. 

In addition to monetary and professional success, many researchers find a major appeal of research is the concept of family. Because so many researchers go to so many meetings attended by so many other researchers, a research "family" is created. Research investigators can spend a large part of their evenings at meetings critiquing the accomplishments and research of their colleagues and espousing their esoteric theories of medical pathophysiology and the medical research industry. And if a researcher does happen to become published in a major journal, the other researchers will soon assimilate this information into their academic collective, and the publication becomes a benchmark for future discussions. Every success and failure of a medical researcher enhances and solidifies the research family.

Conclusion

Comedy can sometimes be medicine; medicine can sometimes be comical. Although we may fancy our experiences as unique, we all follow the same path, but in different forests. Sometimes it's just hard to see above the trees.

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