Humor Appears in Anatomy Labs as a Means of Coping
Our study confirmed the presence of humor in anatomy labs and highlights some explanations of how and why it is used. This aligns with previously discussed anatomy studies that demonstrated humor to be a means of coping with lab associated distresses [20,21,22]. Our findings go a step further, by highlighting the use of humor as a coping mechanism for specifically the surreal or morbid acts of dissection. Such findings are supported by broader humor theory. As far back as Freud, humor was theorized to be a mature defense mechanism, to express the feelings of unconscious discomfort . Jokes and laughter are considered by some to provide psychological and physical health benefits [35,36,37]. And it is theorized that in intense situations, laughter can prove a better means of catharsis than say screaming or breaking down . While anatomy labs are certainly not regarded as emergency scenarios, and the majority of our participants did not report high frequencies of experience or witnessed distress in labs, the same theories might still apply, just on a less extreme scale.
The presence of humor as a means of coping and team bonding is also documented in the clinical components of healthcare and medical education, which aligns better with the educational considerations of anatomy labs [25, 38, 39]. Wear and colleagues provided some more in-depth evidence of how and why dark humor is used, particularly from a medical training standpoint, in a set of focus-group studies with medical students, residents, and attending physicians [23, 24]. Of particular interest to the findings in our study, Wear and colleagues  highlight the presence of “unspoken rules” that guide humor in the healthcare setting. These rules include the hierarchy for initiation of humor (i.e., always started by the more senior practitioner), patient populations considered “fair game” (i.e., difficult or non-compliant patients), and limitations to humor. Such limitations included the importance of tone and delivery, as well as respecting “off-limits” patients, such as those with a terminal illness.
Our findings support the presence of similar “rules” in anatomy labs. Whether directly communicated, or an unspoken value, our study indicated that one of the biggest determinants in the importance of humor is regard for the donor. As our illustrative quotes exemplify, anatomical donation being regarded as a true “gift” implies that there is a responsibility of respect towards the donor that might be considered an important “rule” of the anatomy lab. This may be related to the increasingly standardized practice in anatomy education of referring to donors in a more humanistic fashion [4, 5].
Differences in Opinions
Our results also highlight that there is a subset of individuals who believe that maintaining “professional behavior” in labs means that humor is never appropriate to use. In our open-closed coding question, 20% of respondents put they had never heard or used dark humor in the lab. Our frequency statement analysis revealed that 12% of participants put they had “Never” experienced the use of black (cynical) humor in the lab.
The differences in these responses may be explained by the wording of the question, with a greater percentage denying humor when asked to elaborate on their views. However, if the range can be considered 12–20% of individuals who believe that this type of humor simply does not exist, it begs the question as to why they are at odds with the majority. Upon examining these response rates compared with demographic information provided, there appeared to be no significant trends in any particular group and the comments that humor is considered “inappropriate.” Therefore, our study does not indicate what the implications from such stark differences in professional opinions may be. However, we hypothesize that such strong professional stances may also shade teaching and learning opinions.
For example, when asked about views on “dirty mnemonics,” a humorous approach to learning/recalling information, participants were split in responses. A review of the literature suggests that this concern is related to the pervasive use of acronyms in healthcare as a whole [40, 41], since a widespread reliance on potentially confusing acronyms has been identified as inherently problematic . Such rapid and voluminous recall has an especially rich tradition in the classical study of anatomy . But this very tradition points to the even greater need for future physicians to build a deeper fundament of long-term understanding of medical and anatomical concepts, rather than mere rote recall of data encoded in letters that could all too easily be accidentally interchanged (with disastrous results). Such depth is key to related issues of professionalism .
Less than 2% of respondents denied knowledge of the existence of mnemonics in the anatomy lab. The data showed almost all respondents (nearly 99%) were aware of the use of mnemonics in the anatomy lab. There is a common theme in the belief among respondents that mnemonics are in general, dirty or otherwise, an effective albeit lower-level learning tool that should not feature as a planned teaching device. Polarity appears in how much “ownership” they are prepared to take in the dissemination/tolerance of their use in professional practice, which points back to the internal and external barometer. Many respondents indicated that mnemonics ought to be left to students to discover on their own (as part of the “hidden curriculum”). Other respondents reflected on their own use of mnemonics to memorize structural anatomy, and 12% responded with an unprompted mention of the “cranial nerves mnemonic” as an example. Smith and Border  point out that mnemonics “build a construct for subsequent deeper layers of knowledge.” In our study, the difference of opinion on the use of dirty mnemonics in the anatomy lab reflects on issues of identity in professional practice.
Humor as a Hidden Curriculum of Anatomy Labs
Given our findings in the variability of humor experiences and questions that arise from such diversity, our study confirms that humor is a facet of the hidden curriculum of anatomy labs. It also highlights the need for more recognition of the hidden curriculum in anatomy. As Hafferty and Finn  highlight, the anatomy lab, in particular, can be considered a space for professional formation, related to hidden curriculum. As they describe it, the hidden curriculum can be considered the differences in what an organization says and what it actually does, as well as the non-formal aspects of organizational function. In considering the anatomy lab as an “organization,” the hidden curriculum is demonstrated by the presence of humor in this study. Many participants noted that while humor was not often directly and openly recognized, it still persisted, as a facet of organizational structure. The power of humor within the anatomy lab, whether it be positive or negative, stems from its often-tacit nature.
The hidden curriculum is often linked to implications for professional practice. As Escobar-Poni and Poni  highlight, there is an opportunity for the gross anatomy curriculum to play a major role in professionalism-related training for medical students. Their article highlights particular curricular learning activities which may facilitate professional development in gross anatomy, while also emphasizing the need for peer review evaluations of such activities. Swick  also highlights some professionalism aspects of anatomy experiences, such as adherence to ethical and moral standards, demonstrating humanistic values, and dealing with complexity/uncertainty that might be considered more hidden rather than formal curriculum. Both of these articles make excellent arguments for more professionalism-focused research and evaluation in the anatomical sciences. And as our study highlights, there may be interesting findings for those who instruct the anatomical and basic sciences, such as the argument for more direct discussions of the hidden curriculum.
Limitations, Considerations, and Future Directions
While our study highlights that humor is widely used by many individuals in anatomy labs, there are several considerations that should be recognized as limitations of our findings.
First, while our study attempted to recruit a wide scope of international participants, it should be noted that it was written in British English. Only approximately 3% of participants reported their country of residence to be a country where English is not the predominant language used in higher education institutes. Language and cultural differences can be considered a limitation of this study from a truly international perspective. Even the concept of humor is a complex cognitive process that can be influenced by an individuals’ culture . This thus limits a true cross-cultural understanding of humor utilization in anatomy labs, particularly when considering the native language and cultures (American and British) of the research team. Future directions for similar studies might include international collaboration or use of formal translation services for recruitment and data collection. Language variances could also have inadvertently resulted in a conflation of humor with jokes and laughter, as humor can be a nuanced concept. This could be mediated and better understood in future studies by asking individuals to also self-report their definition of “humor,” and subsequently black/dark humor, in order to better identify potential discrepancies in communication.
The limitations of recruitment methods should also be considered in our comparison of international and age groups. The sampling methods used let to a wide demographic range, which made in-group comparisons difficult. Our findings suggest that the presence of humor was reported to be roughly the same across our top three countries of responses, as well as across age groups. However, given recruitment tactics for our study, the resulting participant totals displayed homogeneity in age and country of residence. An additional future direction would be to use more purposeful sampling methods, instead of snowball recruitment, to see if the similarity in responses is still apparent when the overall sample is more heterogeneous in its demographics.
Another couple of considerations we wish to note were related to the occasional ambiguity of our study design. First, we did not require participants to specifically define their individual definitions of terms such as “stress,” “distress,” or even “black humor.” This flaw in survey design may explain subtle differences in reports of the use of humor or even stress experienced in the lab, as we see between our frequency statements and open-ended responses. In the absence of shared understanding, it could be argued that the minutia of stress and humor views cannot be concluded from the present study. However, we do believe that the general views and trends are well enough reported to be considered supportive evidence on broad views of humor and stress in anatomy labs.
Second, as highlighted in our survey details and results, frequency statements were based on numeric values determined by the research team to provide some context, but not limit participation. This presents the limitation of the possible confounding factors related to time that may be reflected in our data. For example, to a participant who has been teaching anatomy for 15+ years (reported by numerous respondents), hearing something “Often,” or more than 10 times, may be interpreted quite differently than an “Often” rating reported by a year 1 health professions student with limited lab experiences. While it is exponentially challenging to attempt to account for such considerations without limiting inclusion criteria, we do not think these discounts our results.
Our results provide strong evidence to confirm the presence of hidden curriculum in anatomy labs  and encourages more specific research into subdivisions of this curriculum, often related to the emotional, professional, and ethical considerations of anatomy. We suggest and encourage more specified work be targeted at these potential curricular components, to best understand how curricula are being implemented, and the benefits. It may also be key to investigate the curricular decisions to not include more humanistic aspects. For example, our results highlight that about 12% of respondents stated that they never have experienced discussion or reflections about the emotional aspects of anatomy. Could this be due to the documented restraints of contact hours in many anatomy courses [50,51,52,53] or is this a personal decision made by these individuals? Perhaps, while there has been an increase in donor-focused activities [54,55,56], not all institutions host or focus on such humanistic activities or do not require them to be mandatory for students and staff. Further research might allow us to better understand the breadth and differences we as anatomy educators certainly possess.