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 basic metaphors used in medicine that to a large extent generate the vocabulary of doctor-patient communication – but can also unintentionally objectify and dehumanize the patient.
Here are three of the most prominent metaphors you’re likely to encounter 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 now largely abandoned 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 – just as alarming! – the ER nurse who returned to my bedside and sternly 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!”
By the way, the question that initiated the nurse’s scolding? I’d had the temerity to ask the Emergency physician this understandable yet apparently unacceptable question while in mid-heart attack:
“But doc, what about this pain down my left arm?”
Biomedical ethics, Dr. Coulehan warns, teaches health care professionals to respect their patients as adult decision-makers. Some, however, continue to treat patients as ignorant and slightly annoying children.
He explains, however, that the relative demise of paternalism in medicine has been accompanied by the rapid advance of those engineering and war metaphors, both of which are particularly prone to objectifying and dehumanizing the patient. He adds:
“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 especially rampant when describing those with cancer. As retired cancer researcher Dr. Michael Wosnick observed in his Healthy Debate essay:
“For those who ultimately die from a cancer, the idea that they have ‘lost’ a battle implies to me that if they had just done SOMETHING else differently, then maybe they might have ‘won’. The use of the word ‘lose’ is like a zero-sum game to me: if someone or something ‘loses’, then that means that someone or something else ‘wins’. You can’t have a loser if you don’t have a winner.
“Why do so many deaths from cancer get reported as ‘after a long struggle/battle, so-and-so lost his/her battle with cancer’? It’s not quite ‘blaming the victim’, but it does have ring of placing the ultimate responsibility for having died in the hands of the deceased.”
I agree with breast cancer blogger Nancy Stordahl at Nancy’s Point who poses this blunt question:
“Why not just ditch the winner/loser messaging altogether?”
“Why not just say, ‘ _____ died from breast cancer, lung cancer, heart disease, injuries sustained in an accident’, or whatever the cause was? And yes, even when talking about suicide, I would say it’s okay to come out and state, ‘ _____died of suicide’, or self-inflicted wounds, or whatever a family feels most comfortable with. Being forthright might eventually help reduce the stigma that suicide so often brings to families.
“I find it fascinating that we use and reuse some words and phrases over and over, yet at the same time we work really hard at avoiding other words. We go to great lengths to avoid using the ‘d’ words: death, die, dying, dead.
“Maybe we shouldn’t work so hard at avoiding them. Maybe just stating the simple, clear and honest truth would be better.”
When I worked in hospice palliative care, it was widely observed among my colleagues that the oncologists who had been treating our patients before they were referred for end-of-life care were also often reluctant to use the ‘d’ word with their cancer patients and their families – even those patients for whom continuing curative treatment was futile, and who quite clearly qualified for end-of-life care. No wonder so many of their patients felt like they were “losing the battle” when they decided to reject yet another round of aggressive treatment – thus losing their doctor’s battle to avoid a patient’s death.
Heroic combat metaphors are also damaging for bigger reasons. As I wrote here about the trendy pop science concept known as Post-Traumatic Growth (what doesn’t kill you makes you stronger, blahblahblah):
“My concern with this Post-Traumatic Growth expectation for patients is that not only are we supposed to manage a serious health crisis, but we’d better do this recuperation thing correctly so that we can emerge triumphantly at the other end with heroic results.”.
So far, very little since my own heart attack and subsequent diagnosis of inoperable coronary microvascular disease (MVD) has felt to me like much of a “fight”. It’s not a particularly heroic response against a chronic and progressive illness – unless you count getting out of bed in the morning, or taking a fistful of daily cardiac meds, or showing up for hospital, lab or doctors’ appointments, or putting one foot in front of the other. MVD is a uniquely painful and debilitating condition, but I’d never describe my response to it as any kind of “battle”.
It just is what it is.
(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
NOTE FROM CAROLYN: I wrote much more about unhelpful metaphors in medicine in my book “A Woman’s Guide to Living With Heart Disease (Johns Hopkins University Press, November 2017)
- 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 experience?