Between attending lectures and dissecting cadavers, first-year medical student Ryan Ziltzer volunteers as a medical clown. Several times a month, he pops on a red nose, grabs some wacky props and arrives at L.A.-area hospitals, ready to entertain patients and inject some levity into otherwise sterile environments.
Medical clowning isn’t the newest trend among future physicians. Ziltzer stumbled into it as an undergrad at the University of Southern California, the only school in the country to offer accredited medical clowning courses. Now at the Keck School of Medicine at USC, Ziltzer sees his clowning background as a boon to his medical education: “I learned how to read a room, make eye contact and allow myself an emotional response to something heavy that a patient says.”
Medical clowning boasts ancient roots, global acclaim and well-documented health benefits for patients of all ages. In the U.S., formal troupes have been around for decades — the Big Apple Circus Clown Care Unit started performing in New York City children’s hospitals back in 1986. And the hit 1998 movie Patch Adams brought medical clowning to the big screen. Even so, it remains a little-known and misunderstood service. Those in the community, however, say it’s time for medical clowning to gain recognition as a valid form of art therapy. Introducing clowning into higher education just might accelerate the process.
Ziltzer initially thought the listing for Introduction to Medical Clowning was a joke. This was two years ago, when Ziltzer was browsing the USC course catalog before his senior year of college. The class, run by the USC School of Dramatic Arts, was part of a medical clowning program, created in 2016 and offered to all undergraduate students. He was intrigued enough to sign up.
The following semester, Ziltzer spent three hours a week playing theater games and honing his improv skills alongside 16 other clowns-in-training, mostly pre-med and theater students. They studied the theories behind medical clowning and spent hours in the studio learning important clowning things, like scarf-juggling and turning everyday hospital objects into puppets. Ziltzer loved every minute of it. The following semester, in Advanced Medical Clowning, his class started working in the field, test-driving their clown personas at nearby hospitals.
Part of learning the craft is looking the part: Ziltzer wears a small white hat, perched jauntily on his dark hair, along with a plaid shirt, a bowtie, blue shorts, striped knee-high socks and brown sneakers. To finish off the ensemble, he strings a ukulele around his chest and fastens a pink fanny pack — which might, on any given day, contain silk scarves, a pocket-sized trumpet or a squeaky chew-toy — around his waist.
Unlike Ziltzer, most medical clowns have backgrounds in theater or other performing arts. But it makes sense for those in the healthcare industry to take up clowning, according to Zachary Steel, USC dramatic arts professor and clowning program founder. Steel sees accredited, university-level courses as a step towards medical clowning becoming a “legitimate profession in line with the art therapies.”
After all, the therapeutic value of clowning is backed by medical journals. In studies on children, the presence of clowns has been associated with reduced distress over blood draws, reduced anxiety over painful emergency-room procedures and decreased crying and anxiety during the anesthesia process. Parents of kids in the intensive care unit, one study found, overwhelmingly felt that clowns had a positive effect on both them and their children; most parents even deemed clown care “necessary.”
Outside the pediatric ward, research supports wide-ranging benefits for adult patients too, including enhanced well-being, reduced emotional reactivity and decreased negative emotions such as anxiety and stress. Different studies have linked clown interventions to reduced fighting among adult psychiatric patients, reduced agitation among elderly patients and boosted pregnancy rates for women who’d undergone IVF.
Steel performs and teaches alongside his longtime partner, Caitlyn Conlin. He instructs students to couple up as well, since it’s industry standard for medical clowns to work in pairs. One clown, for instance, might play an instrument while the other croons. Patients connect more easily with clowns when there’s music around, Steel says, so students often port along ukuleles and harmonicas, whistles and even Bluetooth speakers clipped onto their suspenders.
Sometimes, clown pairs move from room to room, visiting patients individually. Other times, they’ll stage group performances or work with multiple patients in a common area, like a chemotherapy room. It all depends on the facility and audience; flexibility is crucial in medical clowning.
Steel described a typical medical clowning scenario: A frightened child requires a blood draw. In the waiting room, she’s greeted by a nurse and a clown duo. The clowns play and joke around with the patient for a little while, then stay with the patient throughout the procedure — no theatrics or zany props; just support, reassurance and empathy. “The clown enters alongside the patient as an ally,” Steel said, “and the primary event is no longer an anxiety-producing blood draw, but a positive, humorous experience.”
Some patients want to interact with the person behind the red nose. That’s fine, Steel says: “We never say you must stay in character. The clown doesn’t have an agenda. If a patient really wants to talk to the clown as a person, we don’t say, ‘No no, we are clowns, you must clown along with us.’”
As director of the Therapy Program at the Circus Arts Conservatory in Sarasota, Florida, Karen Bell trains clowns to perform for elderly patients at long-term nursing facilities. Bell, a professional clown and former performer with the Ringling Brothers and Barnum & Bailey Circus, leans on advice from social workers and professional healthcare providers to prepare clowns for the specific challenges of entertaining older audiences. Because abstract thought is often lost in middle- to- late-stage dementia, older patients tend to appreciate slapstick physical humor more than magic tricks or wordplay.
Cognitive limitations prevent some patients from getting all the jokes, but that’s OK. “While we take their mental capacity into account,” Bell said, “we’re performing for the person, not the disease.”
In the Netherlands, there’s a nationwide clowning program, called miMakkus, developed specifically for dementia patients. Since 2002, the program has trained performing arts professionals, or “miMakkers,” in the practice of largely nonverbal clowning that transcends dementia’s limitations.
At this point, medical clowning is more popular abroad than in the U.S. Steel himself discovered medical clowning in Israel, where a graduate program at the University of Haifa helped turn the craft into a well-regarded career. One Israeli group called Dream Doctors began in 2002 with three medical clowns working in a single hospital. Now, dozens of Dream Doctor clowns are working in 29 hospitals and 30 different departments, including emergency and oncology departments, autism clinics and maternity wards.
In the U.S., Steel says, medical clowning still isn’t taken as seriously as other emotional support services for patients, like art therapy or music therapy, possibly because performers are working against negative stereotypes. “Hollywood has a depiction of clowns that doesn’t correlate with how we see clowns,” Steel said.
Historically, face paint has been used to amplify clowns’ facial features, so that even the nosebleed section can see their exaggerated expressions.
Famous clowns in American pop culture include Pennywise, the homicidal clown from Stephen King’s book It; the Joker, one of Batman’s most iconic foes; and down-and-out Krusty the Clown from The Simpsons. It’s a motley crew, and probably not one you’d want gathered around your hospital bed. Even so, the notion that clowns are a common phobia appears to be overblown. In one study involving 1,160 hospitalized children, only about 1 percent of participants exhibited coulrophobia, meaning an irrational fear of clowns.
Medical clowns don’t even look like prototypical Hollywood clowns. For one thing, they rarely wear full faces of white paint. Bell used to, when she was performing with the Ringling Brothers. Historically, face paint has been used to amplify clowns’ facial features, so that even the nosebleed section can see their exaggerated expressions. But medical clowns aren’t performing at Madison Square Garden, so face paint doesn’t serve much of a purpose. “Our costumes are simple,” Bell said, “because we want patients to see the person underneath, and the heart that’s inside.”
Sweat and tears of a clown
Clown care is, quite literally, fun and games, but it’s still physically draining. “The most difficult aspect is the amount of energy needed to do this kind of work,” said Calvin Kai Ku, who performs with an 11-member troupe called the Medical Clown Project at pediatric hospital units, acute care facilities and assisted living centers in the San Francisco Bay Area. “We perform four to five hours a day without turning it off,” with the exception of short breaks for documenting sessions.
Clowns are also inevitably affected by the illness and grief they witness. “When we leave those rooms,” Steel said, “Caitlyn and I look at each other, take a deep breath, and say, ‘Wow, that was heavy.’”
To deal with those heavy moments, Steel encourages what he calls “emotional hygiene”: “We should feel like we have the space to let these feelings out after the fact, and be there for each other,” he said. “We talk through these things so we’re not absorbing the despair of the room, but it’s the most gratifying thing I’ve ever done in my life.”
Ziltzer has taken it upon himself to get his classmates hooked on clowning. He even started a formal medical clowning club at Keck earlier this year. Future MDs, as well as practicing healthcare providers, Ziltzer says, would benefit from learning the therapeutic artform: “It’s a great way to practice empathy and build a rapport with patients.”
He also visits hospitals with his partner whenever he can. When making time to perform seems like an impossible scheduling feat, he thinks of the patients he’s met during clown rounds, like the 5-year-old twins, hooked up to IV bags, who lit up when they laid eyes on Ziltzer and his partner. For 20 minutes, the four of them played catch with silk scarves. “When they caught one, I’d say, ‘Whoaaa,’ and then they’d start giggling and throw it back to me, usually with terrible aim,”’ Ziltzer said. “They were just so happy.”