Metaphorical Medicine: Using Metaphors To Enhance Communication with Patients Who Have Pulmonary Disease

Although the importance of enhancing communication with patients has been emphasized and is the subject of recent editorial reminders (1), little formal attention has been given to the way pulmonary physicians speak with patients regarding the underlying nature of their chest illnesses or the rationale, risks, or benefits of treatment. In many forums, including business (2, 3), education (4, 5), politics (6), and medicine (7-15), using metaphors has been advocated as a way to enhance teaching and communication and as a means to achieve better insight into institutional character. Derived from the Greek root metapheiren meaning willing to transfer and defined as a figure of speech in which a word or phrase literally denoting one kind of object or idea is used in place of another to suggest a likeness or analogy between them (16), metaphors can facilitate communication because they render new concepts in familiar terms. On the basis of our impression that using metaphors to explain pulmonary illness can enhance communication with patients, we conducted the current study with two goals in mind: 1) To describe the frequency with which pulmonary and critical care physicians use metaphors in explaining diagnosis or treatment to their patients, and 2) to begin to assemble a catalog of metaphors for a variety of pulmonary issues that may be useful to colleagues seeking new communicative strategies. Methods To ascertain whether physicians in our department use metaphors and to record their metaphors, we administered a survey to all 22 members of the Department of Pulmonary and Critical Care Medicine at the Cleveland Clinic Foundation, Cleveland, Ohio (11 staff physicians, 11 fellows). Using a brief questionnaire instrument, we asked colleagues whether they ever use metaphors or similes in communicating with patients regarding diagnosis or therapy. In the case of an affirmative answer, the respondent was asked to indicate for which types of pulmonary illness the metaphor or simile is used. Finally, using an open-ended format, respondents were asked to describe the metaphor or simile they use. The study was conducted with approval of the Cleveland Clinic Foundation Institutional Review Board. Metaphors were classified according to the well-accepted contemporary theory pioneered by Lakoff and Johnson (17). As discussed and applied by Johnson (18), Honeck (19), and Ortony (20), the contemporary theory holds that metaphors define and reflect deeply entrenched cultural understandings. In contrast to the traditional theory of metaphors, in which metaphors are regarded as mere figures of speech that compare words to ornament their presentation rather than to enhance their meaning (for example, my love is a rose expresses a relationship that is both beautiful and thorny but does not suggest that love is a plant), the contemporary theory understands metaphors as conceptual entities that are based in the shared experiences of a given group of people and that structure the language that these individuals speak. According to the contemporary theory, a metaphor associates two mental concepts or domains, the first of which is understood and experienced in terms of the second (21). For example, in the conceptual metaphor ARGUMENT IS WAR (capital letters indicate that the metaphors are conceptual), the first domain, ARGUMENT and its attendant attributes, is understood and experienced in terms of the second domain and attributes, WAR. WAR ARGUMENT emerges from the association as a kind of verbal battle, a conceptualization that is then articulated in such familiar expressions as you attacked my point and she defended her thesis (17). Seen this way, metaphors construct meaning rather than merely embellishing it, often within everyday language. This feature distinguishes true metaphors from analogies, which simply expand common concepts through comparison. The analysis that follows recognizes this distinction between analogies and metaphors. Results Responses were elicited from all 22 members of the department, including 11 staff physicians (9 men, 2 women; mean age, 42.5 years [range, 34 to 51 years]; mean years in practice, 10.1 [range, 3 to 18 years]) and 11 fellows (4 third-year, 3 second-year, and 4 first-year). Ten of the 11 staff physicians expressed the belief that metaphors enhance communication with patients, and 8 provided examples of metaphors from their practices. One staff physician felt that using metaphoric language could be confusing to the patient. All 11 fellows thought that the use of metaphors enhanced communication with patients, but only 4 could provide examples of metaphors they used. Altogether, a total of 19 metaphors were offered, addressing 8 separate topics in pulmonary disease (Table): chronic obstructive pulmonary disease, 1-antitrypsin deficiency, emphysema, airflow obstruction, asthma, interstitial lung disease, restrictive chest disease, pleural effusion, obstructive sleep apnea, lung cancer treatment, transtracheal oxygen therapy, bronchoscopy, and hemostasis. The percentage of physicians who used metaphors when discussing specific topics varied from 55% for emphysema and chronic obstructive pulmonary disease to 0% for pulmonary vascular disease and pulmonary hypertension. Table. Metaphors for Lung Issues Classification of the types of images (18, 19) used in these 19 metaphors showed four basic types: 1. Container images (that is, lungs or aspects of them as a balloon, paper bag, white coat, balloon in a balloon, coffee cup in a coffee cup, and collapsed straw); 2. Natural images (that is, lung or aspects of them as a small child, Swiss cheese, a mosquito bite, an upside down tree, killing/roping a beast); 3. Mechanical images (that is, lungs or aspects of them as monkey bars, a plumbing system, clogged drainpipe, compressed rubber tube, trash compactor, band around the chest, punctured tie, collapsed straw, rope around a beast, piercing an ear, and a clogged freeway), and 4. Somatic images (that is, lungs or aspects of them as twitching back muscle, cut and scar on arm, and pierced ear). In addition, the 19 metaphors used by physicians in this series vary from more limited, prosaic figures of speech that may be best categorized as analogies (for example, the bronchi are to the trachea as branches are to a tree trunk) and similes (for example, the lung is like a jungle gym) to the more imaginative, poetic figures that are true metaphors because they construct fresh meaning by relating two domains with unexpected and new connections (for example, the windpipe is like a small child in that the slightest insult can cause it to spasm). While most of the 19 figures assembled here are best characterized as analogies or similes, the spectrum is broad and reflects the continuum that physicians in this series have found useful as they communicate with patients. Discussion The results of this survey show that for almost all pulmonary and critical care physicians at the Cleveland Clinic Foundation, metaphors were considered helpful and were actually used in communicating with patients about diagnostic or treatment issues. Our simple survey generated a total of 19 different metaphors from 12 physicians who offered examples from their experiences. The figures of speech assembled cover a spectrum from analogies and similes, in which the lung is likened to other objects with common features, and true metaphors, in which new meanings are constructed by imaginative and even poetic associations (for example, the windpipe as a small child). This range defies simple classification and establishes the continuum of figures of speech that physicians in this series used in talking with patients. In this study, metaphors were valued by physicians at all levels of experience, from new fellows to the most senior practitioners in our group. The use of metaphors varied by topic. For example, more than half of physicians surveyed used metaphors in their discussions of emphysema and chronic obstructive pulmonary disease with patients. However, for other topics, such as pulmonary hypertension and vascular disease, metaphors were never used. We speculate that physicians did not use metaphors because they could not identify a suitable analogy rather than because of bias against the potential value or harm of these linguistic devices. Our observations also suggest that certain medical content areas are amenable to metaphoric communication, while others are less so. Physicians' frequent use of metaphors in this survey bespeaks the widespread endorsement of metaphors as communication aids in our department. Although not formally studied here, physicians' rationales for using metaphors reflect two goals: 1) to transform a complex, clinical concept into a simple explanation for lay persons, and 2) by enhancing the comprehensibility of clinical explanations, to accelerate communication. Participating physicians commonly felt that patients achieved understanding faster when metaphors were used, thereby helping communication by allowing more time for follow-up questions and interaction. While the current report is, to our knowledge, the first full description of metaphor use in pulmonary and critical care medicine, earlier reports have described the value of metaphors in other medical contexts (7-15). For example, Olweny (7) presented an inventory of metaphors used by oncologists in speaking with patients about the diagnosis and treatment of cancer. As an example, Olweny likened the bone marrow to a factory whose three main products are the three blood components: erythrocytes, leukocytes, and platelets. Also, in explaining the role of receptors in treating breast cancer, Olweny likened the breast cancer to a house with many open windows and doorsthe receptors. The more windows and doors that are open (that is, the greater the receptor positivity), the better the chance that closing them with receptor antagonists (for example, tamoxifen) will