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