May 4, 2023 – In the hospital is a girl of 5 or 6 named Cindi.
Dr. Graves enters her room. He’s very busy.
Cindi is afraid that she’ll get sicker.
Then a clown appears with Winnie the Pooh stickers!
Cindi smiles. Her red-nosed friend puts a finger to her lips.
She’s telling Cindi, “Be quiet, I’m going to do a trick.”
She sneaks behind Dr. Graves and puts a sticker on his shoe.
He’s so intent on Cindi, he has no clue!
Cindi starts giggling.
Dr. Graves says, “Stop jiggling.”
The examination ends.
Dr. Graves looks grim.
But as he turns to leave and continue his rounds,
Cindi hears “Excuse me, sir!” coming from the clown.
“I’m not sure how to say this, but I think it’s best I tell you,
Dr. Graves, you’ve got Pooh on your shoe!”
“The kid was in stitches,” recalls Mollypenny, a clown at the Children’s Hospital of Eastern Ontario -- commonly called CHEO -- in Ottawa, Canada. “And when the doctor realized what was going on, he started laughing too. I never thought he had a sense of humor, but he left that sticker on his shoe the entire day.”
This is just one of many heart-warming stories from the 21-year career of Ruth Cull, aka Mollypenny. (She officially retired last month, having passed the ceremonial rubber chicken – literally – to her successor, Zedd.) Originally an operating room nurse, she traded her stethoscope and scrubs for a banana phone and blue wig because “clowning makes a bigger difference,” she said.
That’s no joke: Growing evidence reveals that hospital clowns, also called medical clowns, therapeutic clowns, or clown doctors, can be incredibly valuable in clinical care. In one study published this year, researchers at Tel Aviv University and the Israel Center for Medical Simulation identified 40 skills used by hospital clowns. They concluded that these clowns “help patients, their parents, the medical team, and the achievement of therapeutic goals. In fact, through various communication skills, clowns enable patients to overcome crises and move towards healing.”
Among the skills the study called out:
Distraction: Mollypenny’s Pooh stickers illustrate this. “Diverting a patient’s attention from a negative emotion” or situation changes the atmosphere, the researchers explained. It “breaks the [patient’s] cycle of negativity,” even when it’s something as small as making a serious doctor laugh. Mollypenny calls this “distraction medicine.”
Anchoring: Clowns look for objects in a patient’s room that can be used as icebreakers to make a connection. Mollypenny once noticed a bottle of pink nail polish on a child’s nightstand and suggested they paint her dad’s toenails while he was napping in an adjacent bed. He woke up before they could do it, but whenever Mollypenny saw the child on the ward, she’d whisper “Code Pink” to make her laugh. That bottle of polish became their private joke, and they bonded over it, helping the child feel less alone.
Empowerment: Patients can feel powerless. Clowns help restore a sense of control and autonomy by providing them with choices. “The first question we ask is, ‘Can we come in?’” said Zachary Steel, program director for the University of Southern California’s Comic+Care, which trains medical clowns. “If the patient says no, we go away. That’s not happening with doctors and nurses. Empowerment is at the center of our work.”
Empathy: While hospitals provide care, the pace and atmosphere can often suck the warmth out of the word. While medical personnel are pressed for time, clowns don’t have a schedule. While doctors and nurses do most of the talking, clowns excel at listening. While hospitals are designed to move patients along, clowns try to be fully present. Amid everything a patient is going through, clowns provide understanding. One way they do this is by using the first-person plural. By acknowledging patient emotions without judgment and including themselves in their experience (“We’re in this together, and we’ll get through it!”), clowns provide validation, support, and relief.
Exaggeration: It’s easy to lose perspective in a hospital and adopt a woe-is-me attitude that can hamper treatment and recovery. Clowns counteract this by taking negative feelings to the extreme: “You’re right! We shouldn’t have to do these stupid exercises. I’ll tell them we’re on a general strike, and that you’re never going to move again!” According to the Israeli researchers, exaggerating patient frustrations invites them to laugh and reexamine the situation from a different perspective.
Partnership: To make patients feel heard, clowns become their advocate. If a child admits she can’t do any more chemotherapy, a clown might say, “I will come with you and tell them how much it hurts. We will tell them to try it themselves!” By taking the patient’s side, legitimizing the difficulty, and becoming their partner, clowns give children the strength to endure. Once, Mollypenny helped a little boy send his cancer into outer space by launching it in a balloon. “He’s healthy and 25 years old now,” she said.
Laughter: This is the skill for which clowns are renowned. Indeed, laughter has been scientifically shown to reduce stress hormones, increase oxygen uptake, improve immune function, raise pain thresholds, and activate areas of the brain that produce feelings of connection and joy. Most of these benefits result from the release of opioid neuropeptides and beta-endorphins. These have many feel-good effects. The act of laughing itself also physically stimulates the heart, lungs, and muscles, which reduces tension and makes breathing easier.
But clowns don’t have to be stand-up comedians. “It’s not a matter of being funny, but of having fun,” Mollypenny said.
Here's an example: Mollypenny is pushing a boy in a wheelchair around the hospital. They’re checking people for “freckle-itis,” a highly contagious made-up condition for which Mollypenny has appointed him “chief inspector.” They come across some med students who are anxiously awaiting internship interviews. The boy asks one of them if he would mind being screened for freckle-itis. He agrees, the boy inspects him, and then applies a green sticker to his suit to signal he’s passed. But the boy doesn’t stop there. He puts 15 to 20 stickers all over the guy. When he gets called for his interview, he looks ridiculous, and he must explain to the review board that “I got attacked by a kid and a clown out there.”
“He ended up getting the internship,” Mollypenny said.
How Humor Heals
Yipeng Ge, MD, is a third-year resident at the Harvard T.H. Chan School of Public Health in Boston. As a medical student at the University of Ottawa, he signed up for an elective where he got to dress up as a clown and shadow Mollypenny on her rounds, introducing himself as Dr. Yippy.
“I was way out of my comfort zone,” he said, “but I learned so much. In med school, you’re taught to diagnose, treat, and manage illness. Clowning taught me how to bring play and humanness into that space, along with the value of being present and connecting with patients. In that respect, Mollypenny is like an ER doctor, providing that important patchwork care within the system.”
Indeed, the Israeli study mentioned earlier also concluded that doctors and nurses could improve patient care and outcomes by adopting some of those clown skills. The researchers aren’t suggesting they wear oversize shoes and squirting lapel flowers, but rather that they simply be aware of the therapeutic effects of things like distraction, anchoring, and humor. “Doctors often think of clowns as just there to ‘cheer up’ patients, but it’s about much more than that,” lead study author Orit Karnieli-Miller, PhD, told The Times of Israel.
These skills can have dramatic effects. A 2015 study compared two groups of children (ages 2 to 16) having the same type of outpatient surgery. One operating room had a clown; the other did not. Kids who interacted with the clown had less anxiety before and after surgery, less time in the operating room, lower reported pain levels, and shorter times to discharge. Cost savings also resulted from less time in the operating and recovery rooms.
In more recent research, hospital clowns lowered anxiety and pain in children having catheter insertion as effectively as sedation. Their presence during an EEG (a test for epilepsy that involves placing electrodes on the scalp) led to better patient cooperation and higher-quality test data.
Among children getting cancer treatment, clowns enhanced short-term emotional well-being across all age groups, leading researchers to recommend clowns for all pediatric oncology wards. Indeed, a 2019 study determined that children having surgery reported lower levels of pain when admitted and when discharged, as well as 12 hours after their operation, than those who did not interact with a clown. There’s even preliminary research that therapeutic sessions with clowns can improve communication among children with autism.
Although hospital clowns have traditionally worked with children, that is changing. Research is finding that adults in a variety of health care settings can also benefit:
- Women entertained by a clown after in vitro fertilization have more successful fertility treatments and increased rates of pregnancy.
- Thirty minutes of clowning improved the lung function of COPD patients.
- Clowning enhances the quality of life of nursing home residents and promotes moments of connection with Alzheimer’s patients.
According to Steel, whose Comic+Care program has trained 50 to 60 clowns, there’s also a growing opportunity to reach people outside care facilities who may be struggling with mental health.
“During the pandemic, we created a virtual clowning program,” he explained. “We were concerned it wouldn’t be as impactful, but we were still able to make people smile and laugh. … The revelation came when a woman in Hungary signed up for a Zoom session. We assumed she was in the hospital, but she was quarantining in her home. She just needed some cheering up because she was feeling anxious and alone.”
Since then, Steel has opened USC’s free clowning consultations to “anyone who needs us.” He half-jokes that maybe one day, there will be a bank of clowns at a call center waiting to address everyone’s mental health needs.
That may be far-fetched, but clowns have been an increasing presence in hospitals ever since medical doctor Hunter “Patch” Adams – who was depicted by Robin Williams in the 1998 film Patch Adams – pioneered the trade in the 1970s. The first structured hospital clown program was established in New York City in the late 1980s. And dozens of medical clown training schools now exist around the world, serving hundreds of hospitals in many countries. In 2015, Argentina even legislated all of its hospitals must have a clown.
Joking Aside
Although there was little mention among the experts we spoke with of “coulrophobia,” or the fear of clowns, hospital clowns are certainly aware of it and avoid elaborate makeup to appear more relatable. Mollypenny says she occasionally meets parents who are a bit anxious but, like everything else, she uses humor to defuse it.
“I was alone in a hospital elevator once,” says Mollypenny. “On the second floor, five or six teenagers got in. The last guy pushed the button, turned around, and yelled ‘OMG! There’s a clown in here! I’m afraid of clowns!’”
To which Mollypenny replied: “OMG! I’m afraid of teenagers! I’m not looking at any of you!”
Hospital clowns face other, more serious challenges, however. Chief among these is the mental stress from dealing with sick children and other struggling patients. Sure, their smiles and laughter help, but their pain can become the clown’s pain too, if they’re not careful.
Marion Fauconnier, PhD, is the psychosocial director for the Dr. Clown Foundation in Montreal. As a licensed psychologist, she not only helps train therapeutic clowns but also supports them emotionally. “We talk through the difficult situations they’re dealing with as a group and individually,” she says.
“Clowning has given me new appreciation for how heroic the hospital staff really is,” says Steel. “Being so close to pain and tragedy, especially in a children’s hospital, can take a toll. We have monthly support group meetings for our clowns as well.”
Mollypenny and Ge are big believers in “lollipop moments” as a coping mechanism. Popularized by leadership expert Drew Dudley in a 2010 TEDx Talk, these are moments when something is said or done that makes someone’s life fundamentally better. Hospital clowns do this regularly. Their days are filled with lollipop bouquets.
“One of my favorite things to do is ask patients and staff if they’d like a brownie,” says Mollypenny. “Nobody ever says no to a brownie, so I’ll reach into my bag and give them a big brown letter E. Or sometimes I’ll just sit in the lobby with a wind-up fish in a plastic bag of water. Or I’ll have a sign on my lap that reads, ‘Bored Meeting in Progress.’”
Imagine going into a hospital, filled with apprehension or stress, and the first thing you see behind those sliding glass doors is a clown who offers you a brown E.
“All that research about medical clowning is nice,” says Mollypenny, “but I don’t need to read any of those studies to know that this works. We are all powerful beyond measure.”