Hospitals: Send in the clowns

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.