Medical Metaphors: Increasing Clarity but at What Cost?

Document Type : RESEARCH PAPER


1 Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas at Austin, Austin, Texas

2 Department of Population Health, University of Texas at Austin, Austin, Texas


Background: Clinicians often use metaphors to explain complex ideas. Metaphors also have the potential to reinforce 
unhelpful thinking regarding symptoms. We surveyed musculoskeletal specialists regarding use of metaphors in their 
daily practice and then assessed the contexts in which they are used, the themes of metaphors, and potential for 
reinforcement of common misconceptions (unhelpful thinking). 
Two primary research questions were posed: 1- What are the common characteristics of the medical metaphors used in 
patient-clinician communication by musculoskeletal specialists? And, 2- What percentage of medical metaphors used 
in patient-clinician communication have potential to induce unhelpful thinking and what are the characteristics of those 
Methods: Eighty-one orthopedic and trauma specialists provided examples of metaphors they use in daily practice. 
Qualitative analysis of responses was performed through open coding of the data with the use of a constant-comparative 
technique involving several rounds of reading and rereading the data.
Results: The 157 metaphors were categorized into 15 different themes. The most common themes were mechanical, 
objects, and sports and leisure. We also classified metaphors as addressing the natural history of the disease, treatment, 
mechanism, anatomy, or other. Thirty-five metaphors (22%) were identified as having the potential to reinforce unhelpful 
thinking. The most common purpose of these metaphors was for explaining the mechanism or natural history of the 
Conclusion: Metaphors can either reinforce or reorient potentially unhealthy misconceptions. They can also reinforce 
despair and worry, or they can improve hope and sense of control. Orthopedic surgeons can be strategic and thoughtful 
in their use of metaphors, planning and practicing specific metaphors for optimal mental, social, and physical health. 
Level of evidence: N\A 


1. Beckman HB, Markakis KM, Suchman AL, Frankel 
RM. The doctor-patient relationship and malpractice. 
Lessons from plaintiff depositions. Arch Intern Med. 
2. Levinson W. Physician-Patient Communication: A Key 
to Malpractice Prevention. JAMA. 1994;272(20):1619–
3. Te A, Wh B, Jr BD, A O. The virtuous orthopaedist 
has fewer malpractice suits. Clin Orthop. 
4. Salis P, Ervas F. Evidence, defeasibility, and metaphors 
in diagnosis and diagnosis communication. Topoi. 
2021; 40(2):327-41.
5. Bowdle B, Gentner D. The Career of Metaphor. Psychol 
Rev. 2005;112:193–216. 
6. Barsky AJ. The Iatrogenic Potential of the Physician’s 
Words. JAMA. 2017; 318(24):2425–6. 
7. O’Connor AM. Effects of framing and level of 
probability on patients’ preferences for cancer 
chemotherapy. J Clin Epidemiol. 1989;42(2):119–26. 
8. O’Connor AM, Pennie RA, Dales RE. Framing effects on 
expectations, decisions, and side effects experienced: 
the case of influenza immunization. J Clin Epidemiol. 
9. Cormier O’Connor AM, Boyd NF, Tritchler DL, Kriukov 
Y, Sutherland H, Till JE. Eliciting Preferences for 
Alternative Cancer Drug Treatments: The Influence 
of Framing, Medium, and Rater Variables. Med Decis 
Mak. 1985;5(4):453-463.
10.McNeil BJ, Pauker SG, Sax HC Jr, Tversky A. On the 
elicitation of preferences for alternative therapies. N 
Engl J Med. 1982;306:1259–62. 
11.Marteau TM. Framing of information: its influence 
upon decisions of doctors and patients. Br J Soc 
Psychol. 1989;28 (Pt 1):89–94. 
12.Colloca L, Barsky AJ. Placebo and Nocebo Effects. N  Engl J Med. 2020;382(6):554–61. 
13.López-Rodrí�guez CI, Tercedor-Sánchez M. 
Identification and understanding of medical metaphors 
by non-experts. Metaphor in Communication, Science 
and Education. Berlí�n/Boston: De Gruyter Mouton. 
14.Á� lvarez I, Selva L, Medina JL, Sáez S. Using root 
metaphors to analyze communication between 
nurses and patients: a qualitative study. BMC Med 
Educ. 2017;17(1):216. 
15.Casarett D, Pickard A, Fishman JM, Alexander SC, 
Arnold RM, Pollak KI, et al. Can Metaphors and 
Analogies Improve Communication with Seriously Ill 
Patients? J Palliat Med. 2010;13(3):255–60. 
16.Littlemore J, Turner S. What Can Metaphor Tell Us 
About Experiences of Pregnancy Loss and How Are 
These Experiences Reflected in Midwife Practice? 
Front Commun. 2019;4(1); 42.
17.Semino E, Demjén Z, Demmen J, Koller V, Payne S, 
Hardie A, et al. The online use of Violence and Journey 
metaphors by patients with cancer, as compared with 
health professionals: a mixed methods study. BMJ 
Support Palliat Care. 2017;7(1):60–6. 
18.Vranceanu A-M, Safren S, Cowan J, Ring D. The 
Development of the Negative Pain Thoughts 
Questionnaire. Pain Pract. 2008;8(5):337–41. 
19.Nie J-B, Gilbertson AL, de Roubaix M, Staunton C, van 
Niekerk A, Tucker JD, et al. Healing Without Waging 
War: Beyond Military Metaphors in Medicine and HIV 
Cure Research. Am J Bioeth AJOB. 2016;16(10):3–11. 
20.Wiggins NM. Stop using military metaphors for 
disease. BMJ. 2012;345:e4706. 
21.Ring DC, Dobbs MB, Gioe TJ, Manner PA, Leopold SS. 
Editorial: How the Words We Use Affect the Care We 
Deliver. Clin Orthop. 2016;474(10):2079–80.