Metaphors and analogies are favored tools of poets — and doctors.
They invite us to see a person, idea, or object differently, by inviting comparisons. Providers use them often, to explain complex physiological phenomena to patients. They may even improve physicians’ communication.
So what’s the problem? 
Sometimes they don’t work. They can even give patients the wrong impression. And you usually can’t tell if this is happening. If you’re in academic medicine, you have even more to think about: are your students getting it? And will their future patients?
But there are things you can do to increase your chances of getting across the message you’ve worked so hard to craft.
Why you’re taking your metaphors for granted
Metaphors and analogies are powerful language tools. They’re even important to the way we think.
Nearly 40 years ago, linguists Lakoff and Johnson wrote Metaphors We Live By, explaining how metaphors structure the ways we think about the world—not only the ways we speak about it.
The authors write about the many metaphors comparing argument to war. We talk about argument in terms of defense, tactics, destroying opponents, and so on. We see argument as a kind of war or battle.
Then they ask us to imagine a society where argument was not seen as a war, but more like a dance. It’s possible that if we were to witness an argument in such a society, we might not recognize what we were seeing. Because it did not look like an argument—a war—to us.
We live by metaphors. We’re surrounded by them. But this almost invisible nature of metaphors can work against you when you’re creating a metaphor or analogy for patients. This is because it can be hard to step back and notice what we’re taking for granted when we use them.
But that’s just what I’m going to help you do.
Know what’s under the hood of your metaphor
A recent JAMA editorial asks physicians to be thoughtful about metaphors, as you use them often. The author, Brit Trogen, remarks on physician’s practice of ‘drawing on the commonplace to express the complex.’ This itself is an elegant definition of a metaphor.
What are you considering ‘commonplace’?
Your metaphor hinges on what you assume is common between you and your patient audience. Being aware of your metaphors is important because comparisons only work if the audience knows at least one of the items being compared.
You know that a metaphor (and an analogy) is a comparison. Rhetorician I.A. Richards famously gave names to the two halves of the metaphor: the tenor and the vehicle. In the argument as war example from earlier, the tenor is argument, and the vehicle is war.
The tenor, in your case, is the medical information. The vehicle is what you are borrowing the traits from, the ‘commonplace.’ In one of the most recognizable medical metaphors, the tenor is cancer, the vehicle is a battle.
This is where it gets tricky, because what counts as “common” is specific to communities and social groups. What is normal, natural, or common also varies by race, class, gender, and more.
These are vehicles you’ll want to watch out for. These can unintentionally require knowledge or experiences that are specific to a social or cultural group.
Another editorial from BMJ points out the dangers of overgeneralizing across populations, and the importance of culturally relevant metaphors. They caution against the use of food-based metaphors, because food is so culturally specific.
Food metaphors are the most common in medicine, for example, peaches-and-cream complexion, port-wine stains, and sausage digits. I’m not sure I could tell you the color of a port-wine stain. And I drink wine!
Why do you want to get rid of these vehicles? Because you want people to understand your metaphors’ meaning.
But also because cultural mismatches in speech and language patterns in institutions are a source of negative outcomes, as found in research based on culturally-relevant, culturally-sustaining pedagogy over the last 30 years. (This theory informs these recommendations.)
Steer clear of:
- Holidays
- Celebrities
- Music, movies, tv
- History, geography
- Vacations and other leisure-time activities or hobbies
- Jokes or figurative language
Some of this may sound like I’m splitting hairs, so let’s give an example.
Vacations. Seems innocent enough, right?
I grew up in a large working class family. When I was a teen, if you had asked me what a vacation was, I certainly could’ve told you. But they were not part of my life. My family took day trips. So the idea of getting away – by plane perhaps – and staying a few days, in a hotel, was not part of my experience until I was an adult. And yet this is what is implied by ‘vacation.’
It’s not that I wouldn’t have understood the analogy or metaphor, but it would have a different meaning to me than perhaps you were counting on. Also, I likely would have spent some time figuring out what I might be missing in your point because I was not a vacation-taker (and meanwhile, not hearing some of your explanation).
Holidays are similar. It’s not hard for someone to know what a Christmas tree looks like, and picture one, even if they don’t celebrate Christmas. Could you use a Christmas tree analogy? Sure, but your meaning can be obscured or dulled, based on a patient’s experience.
I recommend caution building metaphors around topics that are emotionally charged, such as sex, politics, and religion. They’re not necessarily cultural mismatches, though they can be. These topics tend to elicit strong feelings. The strong feelings, and any conversation on the topic, can powerfully illuminate—or entirely overshadow–your metaphor.
Watch your handling
There’s caveats for each of the above suggestions. Above all, be careful the assumptions you’re making. If you must use a food metaphor, consider, for instance, what you assume about the kinds and quantities of food people eat, have access to, prepare, and enjoy.
In this way, using effective metaphors also let your patients know you see and hear them as people and as members of communities.
When in doubt, use the concrete
Figurative language is beautiful and powerful when it works, but it is tricky and culture-specific.
You don’t want your metaphors or analogies to disadvantage some patients, just by virtue of who they are. (If you’re interested in quizzing yourself to learn more about how bias can be difficult to detect, try Harvard’s Implicit Bias project.)
When in doubt, focus on explaining things in concrete, simple terms.
If you are interested in taking your metaphor use seriously, this workshop shows you how to break down the metaphors you use, understand their cognitive and affective aspects, and evaluate them in use. On demand, right on this site.
