“She’s a fighter!” and other metaphors in medicine

12 Feb

by Carolyn Thomas   @HeartSisters

Are you “battling” heart disease”? Have you “beaten” cancer? Are you “fighting” a chronic illness? These wartime references are metaphors as described by Dr. Jack Coulehan, a physician, an award-winning poet, and editor of the 5th edition of The Medical Interview: Mastering Skills for Clinical Practice, a best-selling textbook on the doctor-patient relationship. Dr. C explains that there are several of these basic metaphors used in medicine that to a large extent generate the vocabulary of doctor-patient communication.

Here are three of the most prominent metaphors encountered in health care: 

Parental (paternalistic) metaphor    

Disease is a threat or danger  (“She’s too sick to know the truth”)

Physician is a loving parent/ patient is a child  (“We don’t want him to lose hope”)

Engineering metaphor   

Disease is malfunction   (“He’s in for a tune-up”)

Physician is an engineer or technician  (“Something’s wrong, doc – you fix it”)

Patient is a machine  (“We need to ream out your plumbing”)

War metaphor     

Disease is the enemy  (“I treat all my patients aggressively”)

Physician is a warrior captain  (“She’s a good fighter”)

Patient is a battleground  (“The war on cancer”)

Dr. Coulehan believes that contemporary medicine has officially disavowed the parental (or paternalistic) metaphor, perhaps the most prevalent way of thinking about the patient-physician relationship in the good old days.

But try breaking that news to the Emergency Department physician who misdiagnosed me despite my textbook heart attack symptoms in 2008, and – worse! – his nurse who warned me after the doc had left my cubicle:

“You’ll have to stop questioning the doctor. He is a very good doctor and he does not like to be questioned.”

That paternalistic tone is pretty darned close to my own parents’ simple yet effective conversation stopper when I was a small child:

“Because I said so, that’s why!”

Biomedical ethics, Dr. Coulehan warns, teaches physicians to respect their patients as adult decision-makers. Some, however, continue to treat patients as ignorant and slightly annoying children.

Dr. C explains, however, that the relative demise of paternalism in medicine (which at least somehow implied a human, caring interaction) has been accompanied by the rapid advance of those engineering and war metaphors, both of which tend to objectify and dehumanize the patient. He adds:

“Of course, each of these metaphors is true in a sense.

“Each sheds some light on the patient-physician relationship, but also casts a shadow. While capturing one characteristic of illness or healing, each one downplays or ignores certain other features.

“There are also other, more humane, metaphors for medicine; for example, physician-as-teacher, or physician-as-reader or editor.

“Obviously, we need many such images to capture the truth, but we must understand that none are exclusive, and some are more useful in healing than others.”

.

* Coulehan J. “Metaphor and Medicine: Narrative In Clinical Practice”. Perspectives in Biology and Medicine, volume 52, number 4 (autumn 2009):585–603 © 2009 The Johns Hopkins University Press

 

See also:

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Q: what metaphors have you used to describe your health care journey?

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18 Responses to ““She’s a fighter!” and other metaphors in medicine”

  1. Jen Thorson February 19, 2013 at 8:07 am #

    When I was in hospital while waiting for surgery with first heart attack, my husband kept saying “You have such a strong heart” over and over until I snapped and told him to knock it off.

    I know he was saying it for himself, not me, but it drove me crazy. Something akin to men’s supportive words while in labor – they are eventually going to get you smacked.

    I most obviously did not have a strong heart and the cheeriness was driving me batty. I had enough to think about just then. Being a “fighter” or “winning” was not one of them.

    People need to know that sometimes the best support is presence and silence.

    Like

    • Carolyn Thomas February 19, 2013 at 8:34 am #

      Hello Jen – that labour analogy is a good one. Hubbies are often in danger of grave personal injury in the delivery room because of those empty reassurances about how “great” we’re doing! During illness, I suspect this urge to say something, anything to buoy us up might be also related to the invisible-ness of our conditions (no neck braces or leg casts, so no visible sign about how ill we actually might be feeling).

      Like

  2. Nancy's Point February 19, 2013 at 7:41 am #

    So happy to have finally made my way to your blog. I will be back.

    We think alike on this one. I am so tired of all the war metaphors, among other things in cancer land.

    Thanks for writing about this.

    Like

  3. The Accidental Amazon February 14, 2013 at 5:48 am #

    One of the things that always gets to me about this sort of thing is, what choice do we have?

    With cancer (in my case) and heart disease in yours, what else were we going to do but put one foot in front of the other and endure our treatment? Most of us want to go on living.

    Happy Valentine’s Day, Heart Sister.
    Kathi

    Like

    • Carolyn Thomas February 14, 2013 at 12:48 pm #

      You are so right, Kathi. Just putting one foot in front of the other is often all we are capable of doing in the midst of an overwhelming diagnosis. I wrote about a similar theme in “Does Surviving a Heart Attack Make You a Better Person?” in which I quote Dr. Jessie Gruman who wrote:

      “The belief is that sickness ennobles us; that there is good to be found in the experience of illness; while diseases are bad, they teach life lessons that are good – but this belief can inadvertently hurt sick people and those who love them.”

      Happy Valentine’s Day to you, too! :-)

      Like

      • The Accidental Amazon February 15, 2013 at 9:24 am #

        Carolyn, we are on the same wavelength in this, as in so many things. Here’s one of my early rants on this subject, and there have been several.

        Like

  4. Kathleen February 12, 2013 at 8:41 pm #

    A very long term cancer survivor, I get very sick of the “battle” and “fighter” metaphor, not that I minded back when I was 21.

    After differing degrees of “fighting” and “thinking positively” several family members have died of cancer in recent years.

    Oh, she’s so positive!”
    “She’s so confident.
    “I just know that she’s going to beat it.”

    Sometimes this is positively chirpy. And they didn’t. So were their deaths because of insufficient “fight”? or “negative thinking”? To follow the implications of some, one would think so.

    In any case, my body is a living record of treatment decisions that nobody would do today, and at this point I’m likely to die of what is called secondary cancer from my treatments. While one never knows what one will do, I will at least seriously consider living as well as I can and then going as quickly and painlessly as possible.

    Like

    • Carolyn Thomas February 12, 2013 at 8:59 pm #

      Thank you Kathleen. There’s actually been lots written lately about this unwavering demand for positivity and the ‘right’ attitude (I’m thinking for example of Barbara Ehrenreich’s “Bright-Sided: How the Relentless Promotion of Positive Thinking Has Undermined America” in which she wonders why “negative thoughts somehow produce negative outcomes, while positive thoughts realize themselves in the form of health, prosperity, and success.”)

      Like

      • Kathleen February 13, 2013 at 7:00 pm #

        I love Barbara Ehrenreich’s book, highly recommend it, and am so glad you’ve read it.

        Two years ago I actually decided to stay home from a 60th birthday party. I was in a sling from recent (and hard-fought-for shoulder surgery – after another HMO surgeon’s disastrous outcome) and knew that the majority of attendees would be doctors (some from that very HMO) who would ask detailed questions, would not be deflected, but, in fact, would not like my answers, if I said anything close to the truth.

        I decided that it was simply too much emotional work at that point to anticipate what may be acceptable under those circumstances, and it was easier to stay home.

        Like

        • Carolyn Thomas February 13, 2013 at 7:12 pm #

          Fantastic example of good self-care, Kathleen! Way to go! My therapist says that the first rule of mental health is “protect yourself”. I take her words to heart frequently when deciding on a social outing that includes a possibility that the life might be sucked right out of me by guests like your doctor friends! ;-)

          Like

          • Kathleen February 14, 2013 at 12:33 pm #

            It’s a relief to hear that others consider self-protection a factor in social gatherings. No survey data available, not even my own informal ones, but I suspect that few people appreciate how draining a party can be. After several hosted by this particular couple, in which I was shocked by the insular world in which many doctors live and by outright denial of other experience/perspectives, I have learned to assess how hard I’m prepared to work at being a guest.

            Like

            • Carolyn Thomas February 14, 2013 at 12:42 pm #

              I’ve gone from being an outgoing extrovert who loved to ‘work the room’ at parties (before heart attack) to one who now finds making small talk with people I may never see again to be utterly exhausting. Hmmmm…. There just may be a future blog post on the self-protection value of declining party invitations! What do you think? ;-)

              Like

  5. Ashley February 12, 2013 at 10:08 am #

    Thank you for writing this! I would argue that paternalism is alive and well. Doctors still have all the power in deciding if an illness experience is valid or not. Patients give doctors that power, as does society.

    I have noticed that war metaphors are especially prevalent in pink breast cancer culture. Participants feel they are empowering themselves, but I believe it’s the opposite. The language is as disempowering as pink breast cancer culture is. People will take issue with criticism of these metaphors, accuse critics of being nitpicky and sensitive. Really, this language is a symptom of greater problems.

    Like

  6. Mary February 12, 2013 at 9:01 am #

    Don’t forget the TEAM…the Sports metaphor!

    Like

    • Carolyn Thomas February 12, 2013 at 11:28 am #

      Good one, Mary! Although I used to hear this far more from staff when I worked in the hospital system than I do now as a patient ‘outsider’ . . .

      Like

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