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.”
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?
* 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
- 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
Q: what metaphors have you heard to describe your health care journey?