Drafted into Your Metaphor: Encounters with Language
Notes from a Family Meeting, Vol. 3, No. 11
“Art doesn’t have to solve problems, it only has to formulate them correctly.”
Anton Chekhov
“To the typical physician, my illness is a routine incident in his rounds, while for me its the crisis of my life. I would feel better if I had a doctor who at least perceived this incongruity.”
Anatole Broyard, Intoxicated by My Illness
“This disease has really blown him away,” Mrs. Smith lamented, speaking to his new doctor while looking at her husband. “He’s been fighting and fighting and fighting.”
The intern nodded, briefly looking at her pager before returning most of her attention to Mr. and Mrs. Smith.
“The last doctor said they pulled out the big gun antibiotics. But he’s not getting any better. What are we going to do?” Mrs. Smith implored the intern. The intern wished she had someone else in the room to implore.
“Well,” the intern began. She knew what the team had discussed outside the room, and wanted to keep it outside for now. She licked her lips. “Well… we’ll take it one day a time.”
Mrs. Smith sensed the hesitation. “You’re not going to give up on him, are you? You need to keep fighting!”
The intern nodded, perhaps more enthusiastically than she should have. “Oh, yes. Yes, of course.” As soon as she could, she retreated back to the workroom.
Think of how difficult communication would be if we got rid of metaphors. Sure, we’d miss out on some fun colloquial idioms. Where I come from, folks sometimes say they “fought witches” after a sleepless night. But more than the idioms, we’d also lose an important tool that helps us grasp the ineffability of human experience - I can’t even write about it without metaphors. When a father says his daughter is a “ray of sunshine,” we see so many things about her that a mere list wouldn’t quite show: she’s lively, she’s joyful, she cheers him up, she buoys the mood of a room, she’s illuminating.
Metaphors are such a big part of communication they’re surely a core component of medical education, right? Alas, they’re not. As much as I now appreciate what Rita Charon has called “narrative competence,” it wasn’t something that came naturally to me. The hidden curriculum didn’t help and medical education was too effective in conforming me to the rote “history and physical.” I’ve spent a fair amount of time trying to relearn how to talk with, think about, and see my patients.
Thankfully, there’s plenty published even if it’s slow to make its way into the classroom.1 For example, Monica Bodd and colleagues recently examined the use of war metaphor in medicine. They interviewed a small number of patients with metastatic and non-metastatic cancer, discovering that the majority used war metaphor for meaning-making by “promoting positivity and situating their cancer within a larger life story.” They conclude “that the war metaphor should remain an integral part of cancer care, as not doing so could discount a framework that brings strength, continuity, and resilience to patients…”
Bodd and colleagues are speaking into a conversation fraught with controversy. Some clinicians wish we’d never associate medicine with war. Jing-Bao Nie and colleagues previously asked, “Why is it that healers, clinical doctors, and researchers committed to improving health continue to utilize violent metaphors when doing so runs the risk of devaluing human life?” They continue:
“[The use of war metaphor] is ironic because the respective aims of the arts of healing and war are in conflict - to save lives versus to kill and destroy. It is unfortunate because military metaphors can inadvertently further stigmatize patients, inflict additional suffering on them, and endorse the legitimacy of war and violence in social and political life.”
Paul Hodgkin also described some of the reasons why war metaphor might make clinicians uncomfortable:
“The ‘medicine is war’ metaphor also has more serious implications as it emphasises that taking action is a virtue, patients are passive, the main protagonists in this drama are doctors and diseases (patients are not the ‘real’ focus), technologies are weapons (and thus, implicitly, the more the better), and we doctors know best as we are the ones in control. These attitudes clearly have some advantages - for example, it is easier for doctors to bear the failures of medicine if the ‘real’ enemy is construed to be the disease. For many specialties, however, including geriatrics, psychiatry, and general practice, using the ‘medicine is war’ metaphor can be counterproductive. In addition, the doctor’s self image of battling against disease may not be in the patient’s best interest.”
Who knows whether the use of war metaphor in the clinical encounter actually contributes to any kind of bad outcome. Nie’s first two assertions are empirical and could be studied; the third is an ethical question. The work of Bodd and colleagues doesn’t address this either; just because something is endorsed by patients doesn’t necessarily mean it’s helpful or good.
But let’s head off in another direction. It starts with a simple enough question: what about clinicians?
To Render the Lives of Doctors
The focus on caring for patients - promoting their health and avoiding their harm - albeit essential, makes it easy to overlook this question. It’s a question with consequences for the clinicians who are, lest we forget, people too. People with stories of their own.
Jacob Blythe and Farr Curlin have sounded an alarm about how the market metaphor, with all its bureaucratic strings, can do immense damage to medicine. We are, in this model of healthcare, expected to do what patients want us to do. Are we also expected to be who patients want us to be? Blythe and Curlin warn of how the market metaphor turns clinicians into functionaries. In war metaphor, must we allow ourselves to be drafted into patients’ battles and serve as… whatever they want: soldiers, generals, armament technicians, and the like?
“Of course,” we say, charged with decades of respect for autonomy, “If that serves the patient’s good.” But let’s slow down and consider this question a little more closely.
Howard Brody, reflecting on the unique nature of the clinical encounter, wrote:
“The physician who takes stories seriously will, in any case where there is any mystery about the patient’s reason for seeking help, adopt as a working hypothesis that the patient is asking a question like the following: ‘Something is happening to me that seems abnormal, and either I cannot think of a story that will explain it, or the only story I can think of is very frightening. Can you help me tell a better story, one that will cause me less distress, about this experience?’ If this formulation seems overly wordy, a shorter form of the patient’s possible plea to the physician might be, ‘My story is broken; can you help me fix it?’
…
…this question has the virtue of clarifying an important task that the physician and patient must engage in together.”
That task as Brody names it is the “joint construction of narrative.” A simpler way to put it is, clinicians become co-authors of the patient’s story. I’ve written about the hopes and perils of this co-authorship: “If clinicians are historians, then they’re responsible for telling a story - indeed, a good story. The mark of a good story in this case isn’t that it’s entertaining or even educational, but that the story makes sense of what’s going on in this person’s life. That’s a responsibility clinicians share with their patients.”
We’re also characters in their story. Sometimes we’re just the doctor or nurse or social worker. Sometimes we’re good, sometimes we’re evil. Sometimes we’re the bureaucrat, the charlatan, the fool - cast in roles even if we don’t want them. We inhabit their metaphors.
Just like we’re co-authors of and characters in our patients’ stories, clinicians inhabit and write our own stories. We are ourselves growing and adding new pages to the books of our lives. To say that our patients’ metaphors should dictate our own self-understanding would be to abdicate the responsibility of that authorship. Despite the power differential in this relationship, it would be naive or arrogant to believe that clinicians could insulate themselves against the metaphorical and existential influence of their day-to-day work and the relationships they cultivate there. Clinician stories matter too.
For as much work as has been done looking at metaphor in the clinical encounter, far less has been done on the use of metaphor in clinician self-understanding. Are medical residents, for example, “parents” who have an unflagging duty to care for their “children,” i.e., patients? Are they “airline pilots” with immense technical tasks before them that require them to be well-rested? Daniel Shalev writes about the use of metaphor in his own training experience:
“One of my earliest memories of intern year was transferring a patient to my infectious disease list from the cardiology service. Along with my senior resident, we called the admitting coordinators to get the contact information for the trans- ferring team. As soon as we got the information, my resident perked up, ‘This is Carol’s cardiology patient. She’ll have him packaged up with a detailed transfer summary for us to copy and paste. She was my co-intern; she’s a total machine.’ In those early days of intern year, I was not feeling very machine-like. Constantly overwhelmed by the chaos around me and still inefficient in my inchoate routines, I was about as imperfectly human as one could be. What I did pick up immediately, though, was my immersion in a culture in which the ideal participant was efficient and stalwart. The goal was to control one’s reactions and focus them outwardly into one’s work, rather than inwardly: to turn the pain of witnessing suffering and death into impetus for technical improvement, or to morph the longing to go home into more efficient workflow. From early on, I realized that our directive as interns was to become machines and that machine-hood was the metaphorical description of turning emotion into productivity for the sake of being a good doctor.”
He goes on to describe all the many ways the machine metaphor both reflects the reality of being a physician as well as displays the (dehumanizing) aspirations of the field, reminding me of that terrible uncanny valley. For Shalev, the machine-maker was too strong to resist; he eventually became like Carol, though not entirely. He did write this reflection after all.
Or consider the metaphor of healer. To even conceive of clinicians as healers is a stretch. We, ourselves, never do the healing.2 Our medications hold things at bay and sometimes give the body time to heal itself. Even when we’re able to cure something like an infection, it’s only through the power of chemistry and microbiology that we’re able to do so. In surgery, it’s not the surgeon’s bare hands that do the healing. Healing is a team sport, and the clinician is drained of their technical power without the boons of modern science and the support of many other people. Nevertheless, the metaphor of healer remains alluring, both in how people choose medicine as a career and in the expectations patients have for their clinicians.
None of this is necessarily bad. We look at life through the lens of metaphors. We conceive of ourselves and others through that same lens. So how do we negotiate metaphor in the clinical encounter, recognizing this is a meeting of two stories?
Clinicians as Story-Jumpers
I wonder if part of the resistance to the use of war metaphor in medicine is that there’s an implication that the metaphor means something war-like for the clinicians themselves. Clinicians are drafted into patients’ war metaphors. Since some clinicians don’t consider their work in terms of war metaphor, they try to dodge the draft.
But we’re not about to start regulating our patients’ speech. “No war metaphors here,” reads no poster in a doctor’s waiting room. Nor can we sway how the public might cast medicine in whatever metaphorical light they wish in news media, social media, art, cinema, and elsewhere. So, what then?
I wonder if a nidus of miscommunication in the clinical encounter is metaphorical mismatch. If that’s the case, we’d do well to notice it when it happens. For example, the patient may view the oncologist as healer, but the oncologist, in this case, views herself as a mere guide. Or the patient may view the surgeon as a general in an army, but the surgeon may view the patient as the general. A patient may want a soldier and get a coach out of their primary care physician. The clinician may still attempt to use their technical expertise as best they can to meet certain metrics (improved creatinine, blood pressure, or progression-free survival, for example), but the story is written in two different languages. If it were a real book, you’d sit it down and walk away. Since it’s life (both for the clinician and the patient), frustration or confusion might ensue. Jay Baruch put it this way:
“Disorganized stories are more than an academic concern in clinical practice because they can lead to disorganized responses. The best medicine will not work on the wrong story. So we must remain open to problems, to those elements that do not make sense, and it begins on the platform of story. At its fundamental core, the doctor-patient relationship involves the sharing of stories. Story is not a vehicle used in the service of reaching a diagnosis. Story should be the destination. Sometimes the best way to care for patients is to care for the stories they are sharing.”
Thinking about sitting down a story, though, makes me think about the many things we might do with stories. If you’re reading this, you’ve probably given this more thought than the vast majority of your patients. In that sense, then, we have the narrative advantage and should be mindful of that. A clinician with narrative competence will usually have more capacity than their patient to move among metaphors, reconsider how metaphors apply in certain circumstances, and even choose metaphors. The best case scenario is one in which clinicians can:
Reflect on how the patient’s use of metaphor, particularly in how it casts the clinician. This can help to broaden the clinician’s experience of the human condition. There are ineffable aspects of health, illness, and suffering that will only be captured metaphorically. What would it mean to step into that metaphor and look around to see the world the patient is building? It could mean that in this encounter, you’re drafted as a war photographer. An hour later, you’re packing up to accompany a patient on a journey. An hour after that, you’re reviewing the playbook to coach a patient through a game. The next day, you’re running the water stand in the patient’s marathon. This provides an opportunity for the clinician to…
Transcend narrow-mindedness and reductionism about health, healing, illness, and suffering. Listening to patients can do this, as can reading stories of fiction and non-fiction. I can use the metaphorical worlds patients and I create together as starting points on which to build some measure of “symbolic healing,” as Brody called it; a route toward health even if cure isn’t forthcoming. I can also use those same metaphorical worlds to deepen my own self-understanding, both as a clinician and as a person (himself subject to illness, suffering, and death). I’m not caring for patients so that I can better understand myself. Even if reflection isn’t the point of the work, though, it’s nevertheless a critical part of the work.
Cultivate spaces of creative reflection. Someone once wrote that suffering either expands to fill someone’s world, or else collapses their world to the locale of the suffering itself. Suffering makes us inflexible. Clinicians are at risk of becoming inflexible, too, as they tread the same ground year after year: this disease or that, over and again for thirty years, with occasional changes in treatment patterns. In a certain sense, it’s good to have a map and follow it closely. But the map isn’t the territory, and sometimes a tree is down across the path or the creek’s flooded. That calls for technical creativity: how are we going to get a patient what they need in the face of this change in their health? These situations also call for existential creativity. How do we conceive of our work together from this angle - the angle of the patient as a soldier at war? Or the angle of the patient as on a journey? Or in a race? Or hiding from a monster? The only way to consider any of this is to have a space - literally, time - to reflect on it. Failing to reflect doesn’t mean we evade the formative influence of language and suffering; it just means those things shape us without our intention. And they will no matter what, to some extent. Reflection deepens and directs the process to cultivate both technical and existential creativity, also known as wisdom.
Cultivate communities of creative reflection. You don’t need to be alone in that space. What would it be like to gather with other clinicians and share who you became today in the eyes of your patients? How did that resonate and how didn’t it? How do your colleagues see you? I’ve been a part of narrative medicine groups that do this. It can be both playful and deeply meaningful (as the best play is).
With all this in mind, it’s not about whether we should or shouldn’t use war metaphor. It’s about what war metaphor, or any metaphor, might show us about the nature of human frailty, vulnerability, and mortality. Our patients didn’t choose their affliction, and as they scramble for words, they often don’t choose the metaphor that fits. It takes trust and humility to walk into an unfamiliar story, not sure of what you might see or learn there. You might even find yourself changed. But you can’t know that at the beginning. At the beginning, you only know you’re setting off somewhere else. Although our patients often come to us, we’d do well to recognize that whenever we meet them, we are always setting off somewhere else: into their story for a few moments.
Trajectories
Following a meandering reading-path, sharing some brief commentary along the way.
“The rise and fall of peer review”
A hard conversation for anyone who publishes (or reviews for) peer reviewed journals. I’m not a researcher, but I’ve tried, with variable success, to publish pieces op-ed type pieces in PR-journals, as well as other pieces in humanities and ethics. Reason 1 why I choose to write Notes from a Family Meeting is that I want to reach a wider audience (patients, clinicians, people without money for subscriptions) that PR-journals screen out, and engage them in what I think are important conversations. I’m also suspicious of PR for the genre of material I’m writing. That might sound like sour grapes (I have had pieces rejected) or pride, but I think PR can stymie productive, timely conversations. The drawback is that the material is unedited. I mean, I edit it, of course, but no one else looks at it beforehand, so the only way it’s refined is through discourse I encounter I have with you all in email, comments, and social media. Which is a pretty good way to go about it, for my purposes. It’s also how a lot of medical podcasts go about it too; they’re not being peer reviewed, though they are rigorously produced (more so than my little newsletter). PR adds a veneer of scientific rigor that probably isn’t appropriate for these pieces and, as Experimental History argues, not great to begin with. So, it’s helpful he also published the piece on Substack, and continues the conversation here.
Wes Ely has a wonderful framework of thinking about periods of latent professional productivity: it’s called a meanwhile. These come in three varieties: meanwhiles of unknowing, of uneventful occurrences, and of not yet. As Ely writes, “Meanwhiles are like a garden. After planting seeds, you see dirt for a long time, yet there’s a LOT of activity going on. When green sprouts show, a foundation of roots has been established to allow the plant to endure harsh weather & grow in stature. Patience, Grasshopper!”
Part of my work as a physician is putting tools in the hands of my patients to have challenging conversations with other clinicians when I’m not there. Matthew Tyler does this by producing these wonderful videos.
“Pain Talk: Beyond Epistemic Injustice with Jada Wiggleton-Little”
A helpful conversation in which Dr. Wiggleton-Little surveys the many barriers people face to adequate acknowledgment and management of their pain. For example, epistemic injustice can occur when we downgrade someone’s testimony based on irrelevant factors about who they are (e.g., this person is black so they must experience less pain than others). Dr. Wiggleton-Little goes a step further and identifies “motivational deficits” in which someone’s pain is acknowledged (there’s no apparent credibility deficit) but it fails to motivate clinicians to do something about it, like when some women complain of severe menstrual pain but are disregarded because the pain is “normal.” There’s a lot more here and anyone caring for patients in pain would do well to listen.
Closing Thoughts
The Road goes ever on and on Down from the door where it began. Now far ahead the Road has gone, And I must follow, if I can, Pursuing it with weary feet, Until it joins some larger way Where many paths and errands meet.
J.R.R. Tolkien, The Fellowship of the Ring.
I’m grateful to spaces like the Duke Trent Center which have offered me a reflective community and mentorship through residency, fellowship, and beyond.
In the colloquial, physiologic sense of the term akin to curing. Clinicians can be direct instruments of healing in the way Howard Brody describes, and in other ways (e.g., psychotherapy).
Great post! I'm reading "Metaphors We Live By" by George Lakoff and Mark Johnson these days and I can't help but see metaphors everywhere!