Medical clowning is no laughing matter (or at least it’s not only that).
With some 5,000 trained professionals with red noses, funny hats, floppy shoes,
stethoscopes, makeup and outlandish hairdos working in hospitals around the
world, enough scientific evidence has accumulated to prove that they benefit
patients, both young and old.
Serious studies have shown that such
programs reduce pain and anxiety in both children and adults, increase the
success rate of in-vitro fertilization, lower blood pressure and pulse rates in
patients undergoing cataract surgery, facilitate examination of sexually abused
kids and improve the care of elderly suffering from dementia. Even the IDF has
appointed its first reserve-duty medical clown to visit ill and wounded soldiers
in hospitals.
Israel boasts 90 medical clowns in 22 hospitals, and many
of them earned bachelor’s degrees from the University in Haifa’s theater
department, while others have taken special courses. A master’s degree in
“clowning therapy” at the university will soon offer even more advanced
training.
The country has become so prominent and innovative in the field
that the world’s first International Conference on Medicine and Medical Clowning
was held recently over three days at the Kibbutz Ma’aleh Hahamisha Guest House,
attracting some 200 professional clowns and some 15 physicians from 25
countries. Even a Bethlehem nurse, one of six medical clowns at the Inad
Theater’s Dr. Clown Project in the Palestinian Authority, made sure to
attend.
Health Ministry associate director-general Dr. Boaz Lev came to
greet the conference, saying, “You squeeze out laughter from moments of pain and
show compassion and understanding. We hope one day to define medical clowning as
part of the basket of medical technologies like any other
treatment.
Thank you for what you are doing!” Philippe Nordmann and Henri
Klein of Geneva served as honorary presidents of the conference, while
Yaacov Shriqui was head of the organizing committee. A former Jewish Agency
emissary, Shriqui fell in love with the idea launched in the US and Switzerland,
and in 2002 he established with Nordmann the Dream Doctors project
(www.dreamdoctors.org.il/eng) . Funded by private donations from Israel and
abroad, it reached some 176,000 Israeli patients last year.
The chairman
of the conference’s scientific committee was Prof. Arthur Eidelman, who retired
a few years ago as chief of pediatrics Jerusalem’s Shaare Zedek Medical Center
and continues to teach pediatrics at the Ben-Gurion University of the Negev in
Beersheba and the Hebrew University-Hadassah Medical School in
Jerusalem.
WHAT DOES humor have to do with medicine? asked Laura
Fernandez of CliniClowns in Germany.
“Over two millennia ago, the Greek
physician Hippocrates – father of modern medicine – developed the concept of the
Four Humors. The doctrine... maintained that just as the natural universe
is comprised of four elements – earth, water, air and fire – humans are also
made of these elements. These corresponding elemental forces were known
as bodily ‘humors,’ meaning fluids,” she said.
The balancing
of these humors – melancholy, phlegm, blood and choler – became the basis of
medical diagnosis until the Age of Enlightenment.
In 1705, the word
“humor” first appeared in the Oxford English Dictionary with a new meaning – it
meant “funny, witty, laughable.”
So with medical clowning, real humor and
Greek-style “humors” are combined.
Michael Christensen of the Big Apple
Circus Clown Care Program in Brooklyn, New York, was one of the early pioneers
of professional medical clowning.
“In 1985, I lost my brother to
pancreatic cancer. Before he died, he gave me a medical bag, and I made a
commitment to serving patients using it, even though I’m not a
physician.”
“Hospital clowning is multidisciplinary,” he said in his
lecture, which he began wearing an ordinary outfit with a red bow tie and ended
after suddenly changing, behind a screen, into a red nose, black hat and red
polka-dot stockings up to his knees.
“Parody is a very strong aspect of
the Big Apple Circus. For example, one of our performers uses whiteface
and wears a white lab coat. She introduces herself as Dr. Ginger Snaps; instead
of listening to a child’s heart with her stethoscope, she blows bubbles through
it. The other member of the team plays a naive role. The clowning
material is based on what doctors do in the hospital, such as eye and hearing
tests, but with a twist.”
To do an eye test, for example, Christensen
pulls from his pocket a large, realistic plastic chicken and then replaces it
with increasingly smaller ones to examine the patient’s vision. A young
heart-transplant patient is amused by Christensen transplanting red
noses.
Unlike the volunteer clowning projects of American physician and
activist Dr. Hunter “Patch” Adams, the Dream Doctors and similar groups stress
specially trained clowns paid to work as an integral part of the medical
team.
“We are the clownical part of the clinical team,” joked
Christensen. “The clowns study theater skills such as
improvisation. I myself studied acting at the University of
Washington. The subject curriculum is complex, with issues of medical
confidentiality, hygiene and treatment protocols.”
As is inevitable, some
patients die, and the clowns meet with a professional facilitator to cope with
loss, grief and anger, he continued.
SHRIQUI NOTED in his lecture that
Dream Doctors began as an experiment with only three medical clowns, who were
painstakingly selected and integrated into the pediatric departments. Shriqui
started with the Hadassah Medical Organization’s Hadassah University Medical
Center in Jerusalem’s Ein Kerem because HMO director-general Prof. Shlomo
Mor-Yosef (who just ended an 11-year term) was very enthusiastic. All the
participating hospitals participate in costs, covering half, with the rest being
covered by donations.
Shriqui, who is head of the Magi Foundation through
which the Dream Doctors are supported, said its vision is to expand the number
of patients benefiting from medical clowning and transform the therapy into an
officially recognized and firmly established paramedical profession acquired
through a specialized academic training program.
As Israeli hospitals are
a melting pot of both patients and medical staffers from many backgrounds,
faiths, observances and cultures, as well as new immigrants and veteran
residents, Shriqui understood that the clowns must be able to relate to everyone
and use a universal language.
“Dream Doctors play a unique role in
facilitating cross-cultural liaisons mediating across religious, ethnic and
national lines. Their expressive abilities enable them to bridge between
opposites, calm fears, elicit smiles and inspire trust in the medical team and
the treatment process,” he said.
Some clowns also use puppets effectively
to represent children’s inner worlds.
Eidelman, a graduate of Yeshiva
University’s Albert Einstein College of Medicine who came on aliya as a
pediatrician 33 years ago, told The Jerusalem Post in an interview during the
conference that it contained seven evidence-based presentations of the benefits
of medical clowning.
“This was unheard-of not too long ago. We knew the
benefits to patients must be documented if it was to be taken seriously. We have
an animal therapist at Shaare Zedek to help patients, so why not clowning?”
Eidelman, an expert in infant feeding and interaction between mother and baby,
recalled that he was head of the Jerusalem hospital’s neonatal intensive care
unit and had just been appointed as chairman of pediatrics in 2003 when he
learned about Dream Doctors. Shaare Zedek, with enthusiastic support from
hospital director-general Prof. Jonathan Halevy, was the third or fourth
Israeli medical center to introduce medical clowning. Today, the hospital
has four professionals in the wards.
Eidelman noted that both women and
men are equally represented in the profession and the specially trained clowns
are paid good salaries.
“More and more, people are interested in doing
it. I’m not referring to volunteers who come to the hospital unasked and
entertain patients for Purim. I’m talking about professionals who are integral
parts of the medical team.”
Medical clowning today has expanded not only
to various pediatric departments but also to adults in oncology departments and
dialysis units. It could even be used in dentistry.
“I have not heard any
opposition from physicians. Clowns don’t interfere with them, they help them,”
the senior pediatrician concluded. But as yet, no Israeli medical faculty has
included the topic of medical clowning in its curriculum, he said.
DR.
HILA Ben-Pazi, a Shaare Zedek pediatric neurologist who treats children with
movement disorders and cerebral palsy, said her young patients suffer not only
from physical, cognitive and emotional disabilities but also chronic
pain.
“We offer them injections of botulinum – Botox – toxin which
reduces spasticity as it is a muscle relaxant and improves their quality of
life.
But the effects fade away every few months, so the shots have to be
repeated. They are best performed without general anesthesia. We treated an
eight-year-old girl with so much anxiety that we thought either to postpone the
procedure or put her under general anesthesia,” Ben-Pazi
recalled.
Instead, the team decided to do it with clown care; they gave
her five injections, but she didn’t cry even once. “In fact, she laughed during
the whole procedure.”
The neurologist works with medical clown Avi Cohen,
who also addressed the conference.
“I was asked to give Botox injections
to a little girl who had to lie in bed on her stomach. I tried to
distract her, but it is hard in such a position,” he said.
By clowning,
Cohen finally got her attention, and she calmed down. Their recent study of 19
boys and six girls randomly assigned to a control or treatment group registered
the children’s pain assessment using Smiley symbols before and after injections.
The children reported suffering much less pain when they underwent clown
therapy.
“It’s easier to target the right muscles,” said Cohen. “They
smile afterwards as if nothing happened and go home without trauma, feeling
empowered and ready to have shots again.”
Prof. Yaacov Gozal, chief of
anesthesiology at Shaare Zedek, said many children suffer from pre-operation
anxiety and distress.
“It can even lead to delirium and more
post-operative pain. If reduced, it can reduce the need for painkillers
and result in faster recovery,” he noted. A syrup named midazolam is routinely
given to reduce anxiety in children, but it has a bitter taste and may cause
dizziness. Gozal looked for other solutions to reduce presurgery anxiety. “We
decided to see if clowns can do it better than syrup.”
The children’s
blood levels of cortisol [a sign of anxiety] were tested. Forty children
undergoing inguinal hernia repair, removal of the adenoids and insertion of
ventilation tubes into the eardrum were divided into two groups. Parents were
much more satisfied with the reduction of anxiety with medical clowning than
with taking the syrup, he reported.
Dr. Liat Maimon of the
hemato-oncology department at Soroka University Medical Center in Beersheba also
found in her study that medical clowning reduced anxiety among young patients.
Afula’s Emek Medical Center, among the first group of hospitals here to use a
medical clowning team, found it can be used in many cases instead of medical
sedation when children have to undergo kidney imaging after urinary tract
infection.
Dr. Shevach Friedler and colleagues from Assaf Harofeh Medical
Center in Tzrifin reported on a study showing that medical clowning raised the
IVF pregnancy rate to 36 percent, compared to only 20.2% in women not exposed to
it. Thus, they concluded, “medical clowning as an adjunct to IVF and embryo
transfer may have a beneficial effect on pregnancy rates and deserves further
investigation.”
Caroline Simonds, founder and creative director of Le
Rire Medicin in France, reported that not only conventional clowning works, but
also dance and song when used by a properly trained clown.
But don’t stop
at treatment in general hospitals, advised Dr. Peter Spitzer, medical director
and co-founder of the Humor Foundation in Australia. Use it in geriatric
hospitals as well, he said.
Medical clowning can raise moods and reduce
behavioral disturbance among the demented. Since 150,000 Australians live in
care facilities for the aged, costing the government $7.5 billion a year, and in
light of the challenge for facilities to improve quality of life while operating
within their budgets, he recommended the consideration of clown therapy to help
them as well.