"And would you like the forceps now, doctor?" It's an innocent-sounding phrase, but that simple question has the power to bring one surgical team I know to tears with laughter, every time it's uttered. Understanding exactly why those words are so funny has proven elusive. Ask though I might, all that is shared is a tale of a tough shift, with a difficult patient, needless delays and a surgeon who'd had enough of everything going wrong — and no compunction about letting everyone in earshot know of his dissatisfaction. There was something about the question, delivered immediately after the tirade was finished, that punctured the tension of the moment, brought some fresh perspective to the problem and left everyone laughing. To understand it further, I'm assured, "You had to be there."

Inclusive humor has its drawbacks
That "You had to be there" aspect is such a defining mark of medical humor. This is especially true when we talk about surgical teams. Surgical humor can be some of the darkest humor out there, not surprising considering the intense, intimate environment of the OR . Humor is a powerful tool to build team identity and cohesion. "You had to be there" moments create what is known as inclusive humor. If you get the joke, if you know why the mere mention of forceps is enough to provoke sidesplitting laughter, then you were there. You were part of the group then, and you're part of it now. Your laughter marks you as an insider.

Being recognized as part of the group provides tremendous social benefits. Increased security regarding one's position boosts confidence and morale. Laughing with colleagues builds bonds, fostering those points of personal connection that lead directly to increased team efficacy and efficiency.

Members only
But what happens if you're not in on the joke? There's no answer to "You had to be there." Either you were part of the experience, or you weren't. Insider humor, so inclusive if you're part of the group, can be tremendously exclusionary if you're not. That's why we hear about surgical teams (or departments) being cliquish, unwelcoming and difficult to join.

Eliminating inclusive, insider humor is not the answer. (And that's a good thing, because I'm not sure that's even possible. Humor is the natural human response to high-stress, high-pressure environments...you know, places like operating rooms!) Being more mindful of the boundaries we create with laughter — and taking steps to expand the community of people we laugh with — is.

To do this, we have to move past "You had to be there." We need to take responsibility for and ownership of our insider humor. If your team has its own version of "Would you like the forceps now, doctor?" (and most do!), take the time to explain the story to new staff as they come on board. This can minimize feelings of alienation and resentment.