Doctors love using 'fighter' metaphors. Should they?

Military metaphors may make patients 'soldier on' when they cannot

Editor's note: This popular story from the Daily Briefing's archives was republished on Aug. 27, 2018.

Among outpouring of support for Sen. John McCain (R-Ariz.) following his passing from brain cancer on Saturday, many well-wishers have characterized the senator as a "fighter"—a well-intentioned, but potentially "counterproductive and unhelpful" way to support "those faced with a horrible disease," Philip Klein writes for the Washington Examiner.

Don't speak your patient's language? Here's your cheat sheet.

As Massachusetts General Hospital internist Dhruv Khullar explores in The Atlantic, the use of military language in medicine—i.e., "you're a fighter"—may actually hurt patient care, particularly when perpetuated by medical professionals.

A ritual as old as Western medicine

Physician Thomas Sydenham in the mid-17th century is often credited with introducing military lingo into Western medicine, writing that a "murderous array of disease has to be fought against."

Sydenham was far from alone to use such language. Poet John Donne wrote in 1624 that illness is a "siege…a rebellious heat, [that] will blow up the heart, like a [mine]," overthrowing all and demolishing all. About 150 years later, scientist Louis Pasteur used imagery of invaders to explain his germ theory in the 1860s. In 1971, President Richard Nixon declared a "War on Cancer."

Modern physicians have adopted these phrases, often calling patients "fighters" in a "battle" against an illness. In 1970, Polish physician Zbigniew Lipowski introduced a framework for doctors to use when they characterize medical conditions, such as a challenge, enemy, or loss.

A 2010 study found physicians use metaphors in nearly two-thirds of their conversations with seriously ill patients. Their patients, in turn, reported that they viewed the physicians who used the most metaphors as the best communicators.

But should doctors use such language?

Khullar reflects on a patient he used such language with, writing, "Did she, on some level, feel she lost the battle because she didn't fight hard enough? Might she have suffered less at the end if she hadn't felt compelled to try one more drug, determined to soldier on?"

Khullar is not alone in his concern. Some health experts say calling cancer a "fight" can lead patients to use maladaptive coping mechanisms and suppress some of their emotions.

A few studies have found cancer patients who perceive their disease as an "enemy" also tend to have higher rates of anxiety, depression, and a poorer quality of life than patients who use a more positive characterization. Those "positive" patients also tend to have higher pain thresholds and better coping scores.

"[A]ny metaphor—military or otherwise—is not inherently good or bad," Khullar writes, adding that using them depends on "a patient's culture, values, experiences, and preferences."

Ultimately, physicians use metaphors to "develop a common language with patients, and offer patients an avenue to express their emotions and exert agency over their conditions... [but patients] deserve to be the keepers of the lens through which they view their illness" (Khullar, The Atlantic, 8/7; Klein, Washington Examiner, 7/20).

Navigating a doctor-patient relationship

Excellent patient experience is a critical piece of modern medicine, reflected clearly in outcomes. And more than amenities, clean rooms, or quiet during night, the factors that most inflect patient experience all relate to communication and coordination among the care team—factors that physicians are in a unique position to influence.

Clinician-patient communication, leadership of the care team, and support and empathy for the patient across the unit are the most important factors for success, and they’re all driven by the physician as the “Influencer in Chief.”

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