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We're not trying to pull your leg -- using laughter as a technique to improve office morale, productivity and patient relations is no joke.

Two decades of peer-reviewed research on the benefits of laughter and humor in the workplace bear out the conclusion that there are positive effects of injecting levity into the day.

In the office, laughter can foment increased creativity, productivity and teamwork, even if not every comic remark draws a giggle. Merely an attempt at humor, even if unsuccessful, can carry the same benefits. Laughter helps people feel more in control of their situations, even if those situations seem out of control. Laughing with patients can get them to open up about their conditions, establish yourself as a good listener, and reduce the risk of getting sued.

Don't laugh. Actually, you're probably not laughing. Doug Farrago, MD, a family physician in Auburn, Maine, who runs a humor magazine and blog called Placebo Journal, measures the level of laughter in doctors' offices as: "Not much."

Insurance hassles, declining pay, more patients, staff conflicts, everyday tragedies experienced by patients -- no wonder there is a dearth of mirth. But experts say all those problems make it more essential for leaders in a physician office to make people smile.

"People are more likely to be satisfied with their job, less likely to burn out, which is a particular problem in the medical profession," said Chris Robert, PhD, a University of Missouri business professor who researches humor in the workplace.

"In a medical context, interactions between workers, but also between patients and caregivers, is likely to be better when people are in a better mood," Robert said. "It's not to say you always want to be cracking jokes. But well-timed humor can spill over into other aspects of people's relationships and their attitudes toward their job. Humor has an important function of forming relationships in society. It turns out we really like the sounds of other people's laughter."

Added Dr. Farrago: "If you can't smile during the day, man, you're done."

Laughter in the office

Pulitzer Prize-winning humorist Dave Barry, challenged by his editor at the Miami Herald to define a sense of humor, came up with this: "A sense of humor is a measurement of the extent to which we realize that we are trapped in a world almost totally devoid of reason. Laughter is how we express the anxiety we feel at this knowledge."

However, even the staunchest advocates of humor in the workplace understand why laughter often is not the desired means to express the anxieties of the physician office.

Humor gone wrong can have bad consequences. Look at the terms for failing at comedy: Laughter can be a minefield. In the wrong hands and used the wrong way, humor can bomb. Jokes that die can result in sexual harassment or discrimination lawsuits.

Before getting to what kind of humor kills (even terms for succeeding in comedy are severe) in the office, experts want to take the comedic pressure off.

Getting staff to laugh isn't just about telling jokes. It's about creating an environment in which people are comfortable enough to share and chuckle, with laughter rolling out of natural patterns of communication.

"Frankly, I think it's very difficult for an organization to go from zero to 60 in terms of humor," Robert said. "You can't go from a serious environment where humor is frowned upon to a fun-loving organization where humor happens all the time. Interventions to introduce humor are not going to be successful."

A doctor doesn't have to "enact Jerry Seinfeld-esque behavior," said Melissa Wanzer, EdD, a communications professor at Canisius College in New York who has researched humor and laughter in the medical and nonmedical workplace.

You can find people online who will come to your office, clown nose and all, to teach your office how to lighten up. But experts say there is one thing any physician can do, very easily, for free, to make the office a little funnier, and send a signal that it's OK to laugh: self-deprecation.

"Talk about your receding hairline, your gut, your tie," Dr. Farrago said. A physician who laughs at himself or herself about innocuous things can loosen up a tight environment.

Wanzer said there are many ways to defuse the everyday tension -- staff sharing funny stories about their kids, giving humorous asides, telling dumb jokes.

"Why did the cyclops quit teaching? He had only pupil," Wanzer said. "People like that. It's silly. It doesn't offend anyone. Except cyclops."

Spending time together outside work helps build a comfort level that encourages humor, but shared work experiences can help develop material to blow off steam with a few laughs. The material doesn't need to be in the form of traditional jokes; in one nonmedical office, Wanzer saw humor and bonding grow out of staff taking turns dressing up a stuffed bear.

The one absolute no-no, on the other hand, is humor directed at others' expense, including making fun of patients with fellow staff members. "Humor that targets others based on race, religion, political affiliation, sexuality -- all of those things, that's risky," Wanzer said. "There is a very good chance that humor is going to be perceived as inappropriate."

Peer-reviewed research shows that although laughter can help people open up, an office where jokes are made to be mean, to point out divisions or to make underlings laugh at whatever the boss says, has the opposite effect. People shut down or are less creative and more stressed.

However, experts say the fear of humor that bombs is no reason to deny the sound of laughter to everyone. "I'm a little less concerned about people using inappropriate humor and it being an unmitigated disaster," Robert said. "But even when people attempt to use humor that others don't find very funny, I think, socially, that someone attempting to use humor and attempting to lighten the mood has benefits in and of itself."

Laughing with patients

Even many practices where laughter abounds among the staff would never dream of joking in front of patients. Ken Jeong, MD, now a comedy star on TV (NBC's "Community") and in movies (memorable turns as a naked guy leaping out of a car in "The Hangover" and a cranky ob-gyn in "Knocked Up"), has said in various interviews that he kept the humor out of his interactions with patients while he worked as an internist.

However, experts say a well-timed joke or remark can be a great tool when dealing with patients, making them more at ease and relaxed.

Experts often use Southwest Airlines as an example of an organization that successfully made humor a part of its culture.

Southwest eases the minds of its passengers who are nervous fliers and opens the ears of passengers who normally would ignore pre-flight safety announcements, making for a more productive encounter. A typical safety announcement joke: "Should the cabin lose pressure, oxygen masks will drop from the overhead area. Please place the bag over your own mouth and nose before assisting children or adults acting like children."

In the same vein, a physician can use humor to ease the mind of a nervous patient, or open the ears of a patient who is not fully engaged, making for a more productive encounter.

"I think in health care, where there is such anxiety and [patients] are unhappy to be there, even small doses of humor are appreciated," Wanzer said.

Even better, she said, is when the staff and physicians appreciate the patient's humor -- it tells the patient that he or she is being listened to. "If a patient initiates humor, it's great if the staff laughs," she said.

Kelly Haskard-Zolnierek, PhD, an assistant professor of psychology at Texas State University, has helped develop something called the "Patient-Physician Humor Rating Scale."

The spreadsheet-style statistical analysis of patient-physician interaction is about as funny as dry toast.

But the analysis, based on hearing tapes of patient-physician interactions, provide evidence that light humor and banter between doctors and patients is positive, she said.

It's not that patients wanted to roll down the aisles after an office visit. The use of humor was a sign that the physician was "being warm, being friendly and things of that nature," Haskard-Zolnierek said.

Various studies note that well-timed, light humor with patients can make life less stressful for physicians and staff -- especially if it makes patients open up about what's bothering them and place more trust in their physicians.

Like with staff, humor that is mean, racist, sexist, homophobic, overly sarcastic or inappropriate turns off patients. Also, if patients joke in that way to doctors and staff, it only adds stress, and experts say physicians should feel free to tell a patient that sort of humor doesn't play in that room.

But seriously, folks. Laughter in the office, with staff and patients, isn't about making sure everyone has a smile at all times. It's about using a positive, physical reaction to help release stress and improve morale, experts say. Nothing but laughter is as bad as nothing but a straight face.

After all, Dr. Farrago, the physician who makes a sideline of being funny, said: "You have to know when it's time to get serious."

The print version of this content appeared in the July 5 issue of American Medical News.

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