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

~ Carolyn Thomas

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.(1)  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: 

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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”)

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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.”

To me, the most cringe-worthy aspect of using such unhelpful metaphors (particularly combat comparisons) to describe patients and/or their conditions is the implication that those who “lose the battle” against their diagnoses somehow just haven’t fought as bravely as those who win that battle.

This is both hurtful and ignorant – and rampant when describing those with cancer. As retired cancer researcher Dr. Michael Wosnick observed in his Healthy Debate essay, “it’s not quite ‘blaming the victim’ but it does have a ring of placing the ultimate responsibility for having died in the hands of the deceased.”

“What other diseases or condition do we cede this kind of power to? My mother died a few years ago from acute respiratory distress brought on by the H1N1 virus.  Did anyone say that she ‘lost her battle to a virus’? No, she died from a respiratory infection. If someone suffers lifelong hypertension and eventually dies from a heart attack, do we ever say in the obituary that he/she ‘lost his/her battle’ with high blood pressure?

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1. 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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NOTE FROM CAROLYN:   I wrote more about the language used to describe patient experiences in my book, “A Woman’s Guide to Living with Heart Disease”. You can ask for it at your local bookshop, or order it online (paperback, hardcover or e-book) at Amazon  –  or order it directly from my publisher, Johns Hopkins University Press (use their code HTWN to save 30% off the list price).

See also:

When you fear being labelled a “difficult” patient

How can we get heart patients past the E.R. gatekeepers?

Six rules for navigating your next doctor’s appointment

Does surviving a heart attack make you a better person?

Why we keep telling – and re-telling – our heart attack stories

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

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Published by Carolyn Thomas

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

  1. 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.

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    1. 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).

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  3. 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

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    1. 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! 🙂

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  5. 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.

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    1. Thank you so much, 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.”)

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      1. 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.

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        1. 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! 😉

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          1. 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.

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            1. 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? 😉

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  6. 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.

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