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Can Metaphors and Analogies Improve Communication
with Seriously Ill Patients?
David Casarett, M.D., M.A.,
1
Amy Pickard, B.A.,
2
Jessica M. Fishman, Ph.D.,
3
Stewart C. Alexander, Ph.D.,
Robert M. Arnold, M.D.,
5
Kathryn I. Pollak, Ph.D.,
6
and James A. Tulsky, M.D.
4,7
Abstract
Objective: It is not known how often physicians use metaphors and analogies, or whether they improve patients’
perceptions of their physicians’ ability to communicate effectively. Therefore, the objective of this study was to
determine whether the use of metaphors and analogies in difficult conversations is associated with better patient
ratings of their physicians’ communication skills.
Design: Cross-sectional observational study of audio-recorded conversations between patients and physicians.
Setting: Three outpatient oncology practices.
Patients: Ninety-four patients with advanced cancer and 52 physicians.
Intervention: None.
Main outcome measures: Conversations were reviewed and coded for the presence of metaphors and analogies.
Patients also completed a 6-item rating of their physician’s ability to communicate.
Results: In a sample of 101 conversations, coders identified 193 metaphors and 75 analogies. Metaphors ap-
peared in approximately twice as many conversations as analogies did (65=101, 64% versus 31=101, 31%; sign
test p<0.001). Conversations also contained more metaphors than analogies (mean 1.6, range 0–11 versus mean
0.6, range 0–5; sign rank test p<0.001). Physicians who used more metaphors elicited better patient ratings of
communication (r¼0.27; p¼0.006), as did physicians who used more analogies (Spearman r¼0.34; p<0.001).
Conclusions: The use of metaphors and analogies may enhance physicians’ ability to communicate.
Introduction
Physicians who provide care to patients with serious
illness face daunting challenges of communication. For
instance, physicians often need to deliver painful news
about a new diagnosis, relapse, or worsening prognosis.
Patients also look to their physicians for help with com-
plicated health care choices about treatment options. In
these conversations, physicians should provide information
empathically and openly, while supporting patients’ and
families choices under difficult and emotionally trying cir-
cumstances.
1,2
Previous studies have documented numerous problems
with communication in this setting. For instance, physicians
are often unaware of patients’ preferences for life-sustaining
treatment,
3
and patients and families may feel they do not
receive enough information about the patient’s illness and
treatment options.
4–6
Together, these problems are often re-
flected in families’ unfavorable recollections of their com-
munication with health care providers.
4,6–8
In other health-related conversations, physicians and pa-
tients may use metaphors and analogies to enhance theirability
to communicate effectively.
9–17
However, it is not known how
often physicians use metaphors and analogies to enhance
communication with patients who are seriously ill. Nor is it
known whether metaphors and analogies improve patients’
perceptions of a physician’s communication. Therefore, the
goals of this study were to describe how metaphors and anal-
ogies are used in conversations between physicians and pa-
tients with advanced cancer and to determine whether they are
1
Center for Health Equity Research and Promotion at the Philadelphia Veterans Affairs Medical Center,
2
the Division of Geriatric
Medicine,
3
Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania.
4
Center for Palliative Care, Duke University Medical Center, Durham, North Carolina.
5
Section of Palliative Care and Medical Ethics, University of Pittsburgh School of Medicine), Pittsburgh, Pennsylvania.
6
Duke Comprehensive Cancer Center, Duke Department of Family and Community Medicine, Durham, North Carolina.
7
Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, North Carolina.
Accepted September 23, 2009.
JOURNAL OF PALLIATIVE MEDICINE
Volume 13, Number 3, 2010
ªMary Ann Liebert, Inc.
DOI: 10.1089=jpm.2009.0221
255
associated with more favorable patient perceptions of physi-
cians’ communication.
Methods
This report presents data from the Studying Communication
in Oncologist-Patient Encounters (SCOPE) project, a three-site
study from Duke University, the Durham Veterans Affairs
Medical Center, and the University of Pittsburgh. Details of the
study have been previously reported.
18
This protocol was ap-
proved by each institution’s Institutional Review Board.
We approached all (n¼110) medical, radiation, and gy-
necological oncologists who saw patients in the radiation
oncology, surgical and medical oncology, obstetrics and gy-
necology (OB-GYN), brain tumor, and bone marrow trans-
plant clinics to participate in the study. A faculty investigator
met with each oncologist to introduce the study. If oncologists
agreed to participate, they signed a consent form and com-
pleted a baseline survey. Participating oncologists were of-
fered $25 gift certificates on completion of the audio
recordings of their visits.
We asked oncologists or their midlevel provider staff to
identify patients with metastatic cancer whose death within
1 year would not be a surprise. These patients were sent an
introductory letter and brochure that included a toll-free
number that they could call to refuse participation. Patients
who did not call within 10 days were contacted by phone by
interviewers who described the study and requested patients’
permission to approach them at their next scheduled oncol-
ogy visit. Patients were eligible if they spoke English, received
primary oncology care at one of the three study sites and had
access to a telephone. Patients were excluded if they were
unable to provide informed consent as assessed by the inter-
viewer, if they were seen primarily by nonphysician providers
or medical residents, or if they were hearing impaired or had a
speech disorder. We asked all health care providers and
family members present to sign a consent form that allowed
their voices to be audio-recorded.
Within 1 week of the visit, patients completed a telephone
interview in which they evaluated their oncologist’s com-
munication using a six-item subscale adapted from the In-
terpersonal Processes of Care (IPC) instrument. This scale
consists of four items that assessed the physician’s ability to
communicate clearly, and two items that assessed the physi-
cian’s ability to listen. Each item has is scored from 1 to 5 and
the scale has demonstrated adequate homogeneity (Cronbach
a¼0.76).
19
We selected a random sample of approximately 25% of
conversations for coding. First, two coders reviewed record-
ings of each conversation. The goal of this stage of coding was
to identify all examples of physicians’ use of figurative lan-
guage, which we defined as an instance of communication in
which the physician intentionally illuminates the patient’s
experience by creating a picture, scenario or example different
than the patient’s actual experience.
20
An instance of the
physician’s speech was coded as figurative language if it was
identified by at least one of the two coders. In pilot testing
(n¼30), we found that this approach identified over 95% of
figurative language compared to review by three coders and
the lead author (D.C.).
Next, two investigators who were not involved in the first
phase of coding (D.C. and J.F.) reviewed transcripts of these
examples and eliminated those that involved figures of speech
or idioms. For instance, descriptions of a treatment option as a
‘‘silver bullet’’ or a ‘‘home run’’ were not coded. Similarly,
technical descriptions of radiographs or nuclear medicine
scans as ‘‘active’’ or ‘‘hot’’ were not coded. These phrases were
ubiquitous among these conversations, which made accurate
coding exceedingly difficult. Moreover, we reasoned that
their routine use in everyday conversation would make them
less likely to enhance communication.
Finally, the same two investigators classified each of the
remaining examples as either a metaphor or an analogy. We
distinguished between these two types of figurative language,
because we reasoned that analogies tend to be more direct,
whereas metaphors rely more on concepts and images.
Therefore, each might have a different effect on patients’
perceptions of communication.
We defined a metaphor as figurative language in which one
concept is described as being equivalent to another, often
imbuing the first with qualities that are difficult to describe in
other ways (‘‘Think of A as if A were B’’).
21
For instance, in-
fectious disease and the body’s immune response might be
described in terms of a war with attackers and defenders.
22
We defined an analogy as figurative language in which the
similarity between two things is described in terms of a
property they have in common (‘‘A and B are similar with
respect to C’’)
21
For instance, one might describe a lung mass
as being the size of a quarter, or a bile duct as having the shape
of a hollow straw. Disagreements were resolved by consensus
between these two investigators (D.C. and J.F.).
To evaluate the association between metaphor or analogy
use and patient ratings of communication, we assumed that
each physician’s communication style would determine his or
her use of metaphors and analogies. Therefore, we used the
physician rather than the patient as the unit of analysis. Each
physician’s use of metaphors or analogies was averaged
across his=her conversations, as were the patients’ ratings of
the physicians’ communication.
In estimating sample size, we used a conservative estimate
of power for a Pearson correlation coefficient (1-b>0.90),
anticipating that the nonparametric alternative (Spearman
correlation coefficient) would be required. We estimated that
a sample of at least 52 physicians would ensure adequate
power to detect a strong association (correlation coeffi-
cient >0.50) between the number of metaphors or analogies
each physician used and the patient’s perception of his=her
communication ( p¼0.025 adjusted for multiple compari-
sons).
23
Stata (version 8.0, StataCorp, College Station, TX) was
used for all quantitative analysis.
Results
Of 110 oncologists, 21 (19%) were ineligible because they
did not see enough patients. An additional 15 (14%) refused,
and 74 (67%) consented, contributing between one and four
conversations (mean: 2.1). There were no differences in de-
mographic or practice characteristics between those who
consented and those who did not.
A total of 101 conversations were selected at random from
the entire set of 398 conversations. These conversations in-
volved 94 patients and 52 oncologists (Table 1). There were no
significant differences in demographic characteristics between
those patients who were selected and those who were not.
256 CASARETT ET AL.
A total of 361 examples of figurative language were iden-
tified in the first stage of coding. In the second stage, 93 (26%)
were excluded as figures of speech or idioms (e.g., a ‘‘home
run,’’ a ‘‘hot’’ nuclear medicine scan). Of the remaining 268
examples, 193 (72%) were coded as a metaphor and 75 (28%)
were coded as an analogy. Interrater agreement between the
two investigators (D.C. and J.F.) was high for both metaphors
(k¼0.88) and analogies (k¼0.84).
Metaphors appeared in approximately twice as many
conversations as analogies (65=101, 64% versus 31=101, 31%
sign test p<0.001). Conversations also contained more met-
aphors than analogies (mean 1.6, range 0–11 versus mean 0.6,
range 0–5; sign rank test p<0.001). However, both the inci-
dence (w
2
p<0.001) and the number (Spearman r¼0.50;
p<0.001) of metaphors and analogies were highly associated.
No associations were found between the use of metaphors or
analogies and patient or oncologist characteristics.
Analogies
Analogies (n ¼75) generally incorporated everyday con-
cepts with which patients were likely to be familiar (Table 2).
Most (48=75; 64%) used nonmedical examples. For instance,
one oncologist explained that the rash produced by a che-
motherapy drug typically looked like a sunburn. Another
described a nodule as having the size and shape of a pea.
Close to one third of these nonmedical analogies were ex-
amples that may have been outside the patient’s experience
(15=48; 31%). For instance, one oncologist warned that after a
bone marrow biopsy the patient would feel like he had been
‘‘kicked by a horse.’’ Another explained that a patient’s par-
ticipation in an early phase trial was ‘‘like being a pioneer.’’
But analogies also made use of medical concepts with which
the patient was familiar (27=75; 36%; e.g., radiation therapy
was like a diagnostic radiograph, or the experience of re-
ceiving one biologic agent was like that of receiving another).
Most analogies were brief and were described in a few
seconds. But some were more extended. For instance, one
oncologist used the example of pain to convince a patient that
depression should be treated even when it is an understand-
able response to a serious diagnosis. Another compared the
long-term treatment strategy for ovarian cancer to that of
other chronic diseases in which a cure was also impossible,
such as diabetes or hypertension. These extended analogies
typically took more than a minute to communicate.
Metaphors
Most of the metaphors that were identified (157=193; 83%)
fell into one of four categories. Many, for instance, followed
agricultural themes (e.g., a description of stem cells as ‘‘seeds’’;
61; 32%). Others were overtly militaristic (e.g., a description of
the host’s immune system as a defending army; 42; 22%).
Mechanical metaphors, too, were common (36; 19%). For in-
stance, one physician described a cell receptor as the ‘‘on’’
switch, and another described two possible treatment regi-
mens as being in ‘‘high’’ versus ‘‘low’’ gear. Sports metaphors
were also common (18; 9%). For instance, one physician de-
scribed a patient’s treatment regimen as a marathon, rather
than a sprint. The remaining metaphors (n¼36) were either
unique, or fell into multiple categories.
Although metaphors were usually brief, taking up only a
few seconds of the conversation, some required more time to
communicate. For instance, in reassuring a patient about the
implications of a positive bone scan, one oncologist used the
metaphor of a building’s structural supports, explaining that a
positive result only indicated that there was some tumor in-
volvement in that bone but that most of the bone was unaf-
fected (‘‘ ...the end has the breast cancer but the middle is
fine’’; Table 2).
In another extended example, the oncologist described
dysplastic cells as weeds that have overgrown a garden. This
metaphor was used, first, to explain the patient’s pancytope-
nia (‘‘[The dysplastic cell line] chokes everything else out’’).
Next, the oncologist extended the metaphor to explain the
Table 1. Patient and Oncologist Characteristics
Patient characteristics (n¼94)
Age: mean (range) 58 (23–86)
Gender=male: n(%) 51 (54%)
Race: n(%)
White 76 (81%)
Black=African American 15 (16%)
American Indian or Alaskan native 1 (1%)
Asian=Pacific Islander 1 (1%)
Other 1 (1%)
Education: n(%)
Eighth grade or less 2 (2%)
Some high school 4 (4%)
Completed high school or GED 22 (23%)
Some college 29 (31%)
Completed college 24 (26%)
Graduate school 13 (14%)
Marital status: n(%)
Married 77 (82%)
Divorced or Separated 8 (8%)
Widowed 4 (4%)
Never married 5 (5%)
Length of relationship with oncologist: n(%)
Less than 6 months 32 (34%)
6 to 12 months 24 (26%)
1 to 3 years 26 (28%)
More than 3 years 12 (13%)
Previous visits to this oncologist: n(%)
0–2 23 (24%)
3–5 15 (16%)
6 or more 55 (58%)
Don’t know 1 (1%)
Oncologist characteristics (n¼52)
Specialty: n(%)
Medical oncology—solid tumor 20 (38%)
Hematology oncology—liquid tumor 11 (21%)
Medical oncology—general, solid,
and liquid tumor
15 (29%)
Gynecological oncology 2 (4%)
Radiation 4 (8%)
Age: mean (range) 48 (33–64)
Gender=male: n(%) 39 (75%)
Race: n(%)
White 43 (83%)
Black=African American 1 (2%)
American Indian or Alaskan native 0 (0%)
Asian=Pacific Islander 5 (10%)
Other 3 (6%)
Patient hours=week: mean (range) 31 (4–130)
Years of practice in oncology: mean (range) 19 (5–35)
CAN METAPHORS IMPROVE COMMUNICATION WITH PATIENTS? 257
treatment plan of intensive chemotherapy (‘‘And so the way
to treat it is to use a weed killer ...’’; Table 2)
Metaphors, analogies, and patients’ ratings
of communication
Physicians who used more analogies elicited higher (better)
patient ratings of communication on the IPC (N¼52; Spear-
man r¼0.34; p<0.001). Similarly, physicians who used more
metaphors also received higher ratings of their communica-
tion (r¼0.27; p¼0.006). The size of the sample was not large
enough to construct a multivariable model that would elim-
inate potential confounders that might explain this relation-
ship. However, we found no such associations between
ratings of communication and the patient’s age, ethnicity,
education, or length of relationship with the oncologist. Nor
was there any association between ratings of communication
and the oncologist’s age, ethnicity, type of practice, time since
entering fellowship, gender, site, or clinical hours per week.
Finally, there was no association between ratings of commu-
nication and the length (in minutes) of the recorded conver-
sation.
We also examined items individually and found that pa-
tients reported less trouble understanding physicians who
used more metaphors (Spearman r¼0.22; p¼0.028) and
analogies (r¼0.29; p¼0.003). Patients were also more likely
to report that their physician made sure they understood their
health problems when the physician used more metaphors
(r¼0.24; p¼0.017) and analogies (r¼0.25; p¼0.010).
Associations with other items were heterogeneous. For
instance, when physicians used more analogies, patients re-
ported less trouble understanding the words the physician
used (r¼0.35; p<0.001). But there was no association be-
tween responses to this question and metaphor use (r¼0.12;
p¼0.223). Conversely, when physicians used more meta-
phors, patients were more likely to report that they received
enough information (r¼0.32; p¼0.001). However, there was
no relationship between responses to this question and the
number of analogies that physicians used (r¼0.12; p¼0.209).
As expected, there were no associations between either
metaphor or analogy use and the two items that were unre-
lated to the provision of information. For instance, there was
no association with patients’ perceptions of how well the
oncologist listened to them (metaphor r¼0.11, p¼0.272;
analogy r¼0.04, p¼0.683). Nor was there any association
with whether the oncologist gave them enough time to say
what they thought was important (metaphor r¼0.15,
p¼0.133; analogy r¼0.11, p¼0.267).
Table 2. Examples of Metaphors and Analogies
Analogies Metaphors
The daily treatments are only about 15–20 minutes. You
know, it’s pretty much just like getting an x-ray.
A spindle is a kind of highway that moves the
chromosomes apart.
The rash will look just like a sunburn. Your bone marrow is an elephant. It has a long memory.
It remembers everything it has ever seen before.
You won’t feel anything. The energy goes right through
you—like getting an x-ray.
What we’re doing, in essence, is to give you an entirely
new immune system.
It’s like saying you have a little bit of cancer or a lot of
cancer, you know, it’s not very helpful. It’s helpful
sometimes for us to decide who to treat or who not to
treat, but it’s kind of like being a little bit pregnant,
having a little bit of cancer.
The stem cells we have are like tomato seeds, and think of
the tomato fruit as the cells that circulate in the blood.
So the stem cells are like seeds we take out of you so we
can give very high doses of chemotherapy that can
damage what’s left in you and then we give you back
those seeds so it can regrow.
Interleukin is like the IL-2 you’ve already taken. [A cell signaling pathway] is the ‘‘on’’ switch for growth.
[Having a bone marrow biopsy] feels like you’ve been
kicked by a horse.
[Your treatment regimen] isn’t a sprint. It’s more like a
long run. A marathon. You have to pace yourself.
You’ll feel as though you have the flu. [The treatment] is the bullet, or missile, that we’ll aim at
that target.
But like ...pain, [your depression] still hurts, even though
there’s a reason for it. It still interferes with your
functioning. So we can treat your depression. We can
help you.
[A dysplastic cell-line’s] like weeds in your garden that
take over a garden, it chokes everything else out. And
so the way to treat it is to use a weed killer, so you get
rid of all that bad stuff. And slowly, the good stuff
comes back.
It’s like a little pea. The dendritic cells are the script writers of your immune
system.
You know you can live with [ovarian cancer] for a long
time. I mean, you can live with diabetes for 50 years.
There’s a lot of diseases that we don’t cure, we just
manage. Hypertension, right? We don’t cure it, we just
give you a pill to take every day that keeps it under
control.
A wall in your house has many studs. So one stud in the
middle of it has cancer, but the ends are fine. Or in
another bone, the end has the breast cancer, but the
middle is fine. It’s not that it just goes (whistle) through
the entire stud.
Participating in an experimental trial is like being a
pioneer, of sorts.
[Regarding your disease-free survival] you’re in the top
20% of your class.
[A nutritional supplement] is just like a milkshake. If it’s anything bacterial (the antibiotic) will kill it with
a...mallet. Not a mallet, what am I thinking of, that
word, like, a sledgehammer.
258 CASARETT ET AL.
Discussion
This study found that oncologists frequently use both
metaphors and analogies. These examples of figurative lan-
guage appeared in a wide range of conversations and covered
a wide range of concepts. Moreover, they were used by a
diverse group of oncologists, in three distinct clinical settings.
Together, these results suggest that metaphors and analogies
may be a common communication technique.
In addition, these results suggest that metaphors and
analogies may be associated with better patient perceptions of
communication. In this study, both metaphors and analogies
were associated with patients’ perceptions of their oncolo-
gist’s communication overall, and particularly with their
perceptions of their oncologist’s ability to present information
in an understandable way. This finding is important because
it suggests that metaphors and analogies may offer a simple
and relatively easy way to improve communication. This
would be an extension of previous work in the area of cancer
communication in which the communication styles of ‘‘ex-
perts’’ have been used to build a toolkit of effective commu-
nication practices,
24
which have been incorporated into
training programs and curricula.
25
Figurative language cannot take the place of good com-
munication skills that are acquired through experience, role-
modeling, and formal training. Indeed, these methods should
be essential in helping physicians and other health care pro-
viders communicate more effectively.
25–27
Nevertheless, these
results suggest that metaphors and analogies may offer a
valuable supplemental strategy that physicians could use to
enhance communication.
However, these results also suggest ways in which figu-
rative language could impair honest communication and re-
duce understanding. For instance, an analogy (Table 2)
between ovarian cancer and diabetes might lead a patient to
conclude that her prognosis is better than it is. Indeed, it seems
likely that figurative language could be used not only to im-
prove understanding, but also to reassure or encourage or
convince patients. Thus figurative speech might produce
substantial harms if it is used to minimize or obscure im-
portant information about a patient’s illness trajectory or
prognosis.
This study has several limitations. First, because these on-
cologists agreed to participate in this study, their communi-
cation styles may be somewhat atypical of oncologists in
general. However, the results reported here constitute a sec-
ondary analysis of existing data. Therefore, none of the on-
cologists in this sample knew that their conversations would
be examined to assess the use of metaphors or analogies and
there is no reason to believe that these conversations have an
atypical incidence of figurative language.
Second, we cannot determine whether the use of figurative
language has an independent effect on patients’ perceptions
of the oncologist’s communication skills. Instead, it is possible
that oncologists who are more skilled at communicating also
tend to use figurative language. However, we did not find an
association between the use of metaphors or analogies and the
two scale items that assessed the oncologists’ ability to listen.
If oncologists who used figurative language also had better
overall communication skills, one would expect those items to
be associated with the use of metaphors and analogies.
Nevertheless, given the modest associations described here
(correlation coefficients less than 0.40), it is likely that figu-
rative language is only one factor that contributes to effective
communication. Further research is needed, with larger
sample sizes that permit multivariable modeling, to define the
independent effect of figurative language on patients’ per-
ceptions of communication.
Third, we did not use a pvalue adjusted for multiple
comparisons in evaluating associations between the use of
figurative language and individual items. Although we did
use an adjusted pvalue (0.025) for the main outcome of in-
terest, doing so for all comparisons would not have been
feasible for such a small sample. Therefore, the associations
with the items reported here are exploratory and should be
interpreted with caution.
Fourth, this study did not include objective measures of the
outcomes of communication. For instance, we could not de-
termine whether metaphors and analogies improve under-
standing or reduce decisional conflict. This is particularly
important in light of the possibility that figurative language
may be used to reassure or convince, rather than to improve
understanding.
17
However, randomized controlled trials of
communication interventions in advanced cancer often rely
on patients’ perceptions as a primary or secondary end
point.
25,28–30
Nevertheless, further research should focus on
these and other objective outcomes.
Although conversations near the end of life can pose
daunting challenges to physicians, these results suggest that
oncologists frequently use figurative language in conversations
that they perceive to be difficult. Moreover, the creative use of
figurative language may offer an innovative way to improve
communication in this setting. Therefore, in addition to formal
efforts of physician education, metaphors and analogies might
offer additional opportunities to enhance physicians’ commu-
nication skills, if they are used honestly and accurately, with
the intention of improving understanding.
Acknowledgments
This work was funded by grants from the Greenwall
Foundation (Casarett) and from the National Cancer Institute
(R01-CA100387-01) (Tulsky).
Author Disclosure Statement
No competing financial interests exist.
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Address correspondence to:
David Casarett, M.D., M.A.
3615 Chestnut Street
Philadelphia, PA 19104
E-mail: Casarett@mail.med.upenn.edu
260 CASARETT ET AL.
