Online only: Military metaphors upset some cancer patients
Well-meaning doctors seeking to explain treatment to cancer patients by comparing it to an “all-out war” might be wise to skip the military metaphors, University of Florida physicians caution.
Although metaphors help patients understand their disease, battlefield analogies can be upsetting, say the researchers, who have published a study on doctor/patient communication in the Journal of Clinical Oncology. Case in point: Cyclist and six-time Tour de France winner Lance Armstrong switched oncologists after the first doctor he saw told him he would hit him so hard with chemotherapy he would virtually kill him.
“Wars on drugs, poverty and illiteracy pervade our society, and war talk is easily adaptable to cancer,” said Gary M. Reisfield, MD, a professor of community health and family medicine at the University of Florida Health Science Center Jacksonville. “The enemy is cancer, the commander is the physician, the combatant is the patient, the allies are the health-care team and the weapons are chemical, biological and nuclear.”
Yet thinking of cancer in terms of war strikes some as masculine, power-based, paternalistic and violent, Reisfield said. And it suggests winning the war -- or defeating the cancer -- is only a matter of fighting hard enough, he added. It also forces patients to keep fighting so they don’t lose the battle, when opting out of treatment may be a better choice if little or no medical benefit is evident.
Reisfield and George R. Wilson, MD, associate chair of community health and family medicine at the University of Florida Jacksonville, analyzed dozens of illness narratives gleaned from books, newspaper accounts and Web logs and examined how patients used or felt about metaphors. The human brain is wired to operate in metaphors, the researchers said, processing abstract or complex concepts in part by thinking of analogies derived from more familiar experiences. But oncologists need to be sensitive to the language they -- and their patients -- use.
“I first realized the power of metaphors a few years ago when my Aunt Fran complained about an orthopedic surgeon she visited for her arthritic knee,” said Reisfield, who specializes in palliative care and pain management. “He compared my aunt to an old car and her knee to a part that had to be replaced. She was incensed by this comparison and refused to go back to him.”
From then on, Reisfield started paying attention to his own use of metaphors.
“We all think in metaphors, and carefully choosing our language is especially important in today’s medicine, when some office visits last only five minutes,” he said. “Metaphors are part of our (physicians’) bag of tricks -- some are enabling for our patients, and other are disabling.”
Metaphors can express understanding and empathy, but unfortunately practitioners don’t always use this powerful tool wisely, said Alan Rubin, MD, director of the doctoring skills program and a research associate professor of medicine at the University of Vermont College of Medicine in Burlington.
“I once saw a videotape of a doctor giving bad news to a breast cancer patient,” Rubin said. “He said he could liken breast cancer to dogs. Some cancers are poodles and some are Rottweilers. He needed to figure out which kind she had. I watched the patient cringe and felt myself cringe, too.”
About 90 million American adults -- roughly half the adult population -- have difficulty understanding basic medical information, according to an Institute of Medicine study published last year. Choosing metaphors wisely can increase patient satisfaction, improve health-care outcomes and reduce health-care costs, Wilson said. The figures of speech also “can impose order on a suddenly disordered world,” the researchers wrote in the journal, helping patients to “understand, communicate and thus symbolically control their illness.”
“Metaphors, analogies and comparisons give patients and physicians a context for understanding and discussing something highly technical, specialized and biologic -- a common scenario for newly diagnosed cancer patients,” Wilson said.
The University of Florida study does not identify metaphors as intrinsically good or bad, appropriate or inappropriate. Instead, it suggests that a metaphor’s usefulness depends on each individual’s value system. Finding the best metaphors for a patient’s situation and frame of reference is the goal, Reisfield said, adding that a journey metaphor may be especially relevant as an increasing number of cancer patients may live with the disease for years.
Source: University of Florida Health Science Center, Jan. 3, 2005
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