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Can Metaphors and Analogies Improve Communication with Seriously Ill Patients?

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Abstract

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. Cross-sectional observational study of audio-recorded conversations between patients and physicians. Three outpatient oncology practices. Ninety-four patients with advanced cancer and 52 physicians. None. 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. In a sample of 101 conversations, coders identified 193 metaphors and 75 analogies. Metaphors appeared 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 (rho = 0.27; p = 0.006), as did physicians who used more analogies (Spearman rho = 0.34; p < 0.001). The use of metaphors and analogies may enhance physicians' ability to communicate.
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.
... Health providers, doctors, and medical staff often use metaphors to illustrate medical topics to patients (22,23). Using metaphors mediates difficult experiences of uncertainty, anxiety, and fear of death. ...
... Using metaphors mediates difficult experiences of uncertainty, anxiety, and fear of death. Doctors' use of metaphors has been linked to better relations between doctors and patients (22). Patients diagnosed with various types of cancer have bridged the gaps in understanding and communication by means of metaphors (24), and using metaphors has enabled patients to create order and logic in their world, which had suddenly become chaotic (22,25). ...
... Doctors' use of metaphors has been linked to better relations between doctors and patients (22). Patients diagnosed with various types of cancer have bridged the gaps in understanding and communication by means of metaphors (24), and using metaphors has enabled patients to create order and logic in their world, which had suddenly become chaotic (22,25). Militaristic metaphors are widely used in the field of medicine by both medical staff and patients (5,7,26,27). ...
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The COVID-19 pandemic has challenged medical professionals worldwide with an unprecedented need to provide care under conditions of complexity, uncertainty, and danger. These conditions, coupled with the unrelenting stress of overwhelming workloads, exhaustion, and decision-making fatigue, have forced clinicians to generate coping mechanisms. This qualitative study explored the use of metaphors as a coping mechanism by clinical directors of COVID-19 wards in Israeli public general hospitals while they were exposed to death and trauma throughout the pandemic's first wave in Israel (March to June 2020). The study employs discourse methodology and metaphor mapping analysis to capture the personal, organizational, and social dimensions of effective and ineffective processes of coping with an extreme health crisis. Analysis revealed that the metaphors that clinical directors used reflect a dual process of mediating and generating the social construction of meaning and facilitating effective and ineffective coping. Effective coping was facilitated by war metaphors that created a sense of mission and meaningfulness at both the organizational and the individual levels. War metaphors that generated a sense of isolation and sacrifice intensified helplessness and fear, which undermined coping. We propose actionable recommendations to enhance effective coping for individuals and organizations in this ongoing pandemic.
... An analogy extends understanding of a concept via comparison (Arroliga et al., 2002), and is an indirect comparison using words such as "like" or "as." Research examining provider use of metaphors and analogies tends to treat metaphors and analogies the same because of how they function to enhance patient understanding (Arroliga et al., 2002;Casarett et al., 2010). Thus, metaphors and analogies will be discussed interchangeably. ...
... For instance, interventions have used analogies such as farming a crop to explain the production of hookworm vaccines (Gazzinelli et al., 2010), and a weather forecast analogy to explain blood sugar levels for individuals with Type 2 diabetes (Naik, Teal, Rodriguez, & Haidet, 2011). Patients have higher ratings of physician communication when physicians use metaphors and analogies (Casarett et al., 2010). Analogies help people with varying levels of numeracy understand health risks (Galesic & Garcia-Retamero, 2013), and metaphors have influenced patients' intentions to participate in a randomized clinical trial (Krieger et al., 2011). ...
... Regarding the categories of analogies, machine metaphors were most recalled, followed by act/feeling/experience, random object, structure, food, nature, war/battle, and medical/body. Categories discovered in this study somewhat align with provider analogies in previous literature, such as battle, sports, puzzle, agriculture, and machine (Casarett et al., 2010;Periyakoil, 2019;Skelton et al., 2002), or bodily sensations, environment, and color (Spall et al., 2001). However, some of the metaphor categories were novel, such as random object, structure, or food. ...
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Healthcare providers must explain medical information to patients in a way that patients can understand. Provider use of analogies is one strategy that may help patients better understand medical information. The present study, guided by a memorable message framework, investigated whether participants remembered any analogies used by their healthcare providers, and included a content analysis of the function the analogies served, the types of analogies participants remembered, and the body systems associated with the health issues that were described. Almost one-quarter of participants recalled an analogy used by a provider. The most frequently recalled analogies functioned to describe health conditions or phenomena, followed by elements of the body, and treatments or something external to the body. Analogies were most frequently used to describe health issues associated with the cardiovascular system, musculoskeletal system, digestive system, dental, eye, or skin issues, or the nervous system. The analogies were categorized as mechanical, a feeling or experience, random object, structure, food, nature, war/battle, or medical/body. Provider analogies may be a type of memorable message for some patients. Providers could consider using suitable analogies to explain health issues when communicating with patients, and be trained in effective use of analogies.
... Metaphors are found to be used by both "patients and clinicians" when "communicating about grave illness" (Periyakoil 2008, 842). Indeed, metaphors pervade communication between clinicians and cancer patients to the extent that one survey found that oncologists used metaphors in roughly two thirds of their conversations with patients (Casarett et al. 2010). Metaphors are "used to communicate otherwise inexpressible experiences" (Skott 2002, 231), and "can be more than mere rhetorical flourishes; they can have a powerful influence on the practice of medicine and the experience of illness" (Reisfield and Wilson 2004, 4024). ...
... There are a number of studies that have focused on metaphor in the English-language discourse of cancer patients (e.g. Casarett et al. 2010, Clow 2001, Demmen et al. 2015, Fillion 2013, Gibbs and Franks 2002, Hendricks et al. 2018, Penson et al. 2004, Reisfield and Wilson 2004, Semino and Demjen 2017, Skott 2002, Sontag 1979. ...
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This study explores the use of metaphors in the narratives of breast cancer patients in online magazine websites in the Arabic language. It aims to find similarities and/or differences between English and Arabic in respect of the metaphorical constructions of cancer experiences. The corpus of the study consists of 13,705 words in 19 narratives in Arabic. We used the metaphor identification procedure of Pragglejaz Group (2007) to detect the metaphors in the corpus. We focused on the role of metaphor in constructing our experience of cancer, and examined which metaphors are more frequent in the construction of the cancer experience. The results of the study revealed that there is a great similarity between Arabic and English in respect of the metaphors used to construct the cancer experience; the patients have framed their cancer situation via WAR and/or JOURNEY metaphors, with War metaphors more frequently used than Journey Metaphors. The findings also indicate that the Arabic narratives tended to include a stronger religious framework, constructing cancer as a kind of Trial by Ordeal in which one proves one’s firm faith through patience and acceptance of fate.
... 1,3 Physicians' use of metaphors in difficult conversations has been reported to be associated with better patient ratings of their communication skills. 4 Metaphors are also present in dream reports. Dreams can be a source of personal insight and it has been proposed that waking life concerns are represented metaphorically in dreams, with the function of ameliorating recent distressing emotions. ...
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Background: Metaphors are used by patients and professionals in the discourse of disease and can facilitate conversations about difficult topics. There is little information about metaphors present in patients' end-of-life dreams. Objective: Identify and interpret metaphors in end-of-life dreams, directly reported by patients in palliative care. Design: A qualitative study with a secondary analysis of transcribed face-to-face interviews with patients. Setting/Participants: The study includes 25 patients with end-stage disease receiving advanced end-of-life palliative care. In total, 41 interviews were performed. Results: Metaphors applicable to 3 themes were found: the journey toward death, the inevitability of death and death itself. The underlying meaning of the metaphors is often related to topics and emotions commonly relevant in dialogue with patients near death. Patients, however, often seemed unaware of the meaning of their dream metaphors. Conclusion: Metaphors pertaining to death are present in end-of-life dreams in patients with end-stage disease. We hypothesize that encouraging patients to talk about their dreams can expose metaphors that could facilitate end-of-life discussions.
... Among older women living with breast cancer, for example, religious/spiritual coping was commonly reported among African Americans and Latinas (Umezawa et al., 2012), whereas White Americans living with various forms of cancer commonly expressed beliefs related to fighting and their individual strength (Kagawa-Singer, 1993). Furthermore, since coping styles and cancer metaphors can affect patient-provider communication and both psychological and physiological cancer-related outcomes (Casarett et al., 2010;Greer et al., 2020;Gustafsson et al., 2020;Svensson et al., 2016), the recognition and careful consideration of cultural, racial, and ethnic differences in coping and metaphor use is increasingly recognized as a crucial step to reduce disparities in cancer outcomes (e.g., prevention, screening, and treatment) between patients from racial/ethnic minority groups and their Non-Hispanic White counterparts (Kagawa--Singer et al., 2010;McMullin et al., 2009). ...
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Metaphors are often used to describe cancer experiences (e.g., battle, journey). Few studies explore how social threats (e.g., discrimination) shape metaphor preferences. We examined the relationship between discrimination and preferences for cancer battle metaphors (i.e., concrete, action-based) versus journey metaphors (i.e., open-ended, reflective) and mediating effects of needs for personal significance and cognitive closure. We also stratified the analysis when discrimination was/was not attributed to race and by racial/ethnic group. Four-hundred twenty-seven U.S. participants completed an online survey. Items included everyday discrimination, need for personal significance, need for cognitive closure, and preference for cancer scenarios using battle or journey metaphors. Multigroup structural equation modeling examined: serial mediation (i.e., discrimination predicting metaphor preference via needs for personal significance and cognitive closure) stratified by discrimination attribution; and single mediation (i.e., discrimination predicting need for cognitive closure via need for personal significance) stratified by racial/ethnic group. Discrimination was associated with battle metaphors preferences through serial mediation when discrimination was not attributed to race (β = 0.02, 95% CI [0.01,0.05]). Discrimination was directly associated with journey metaphor preferences (β = −0.20, 95% CI [-0.37,-0.06]) and the serial mediation was nonsignificant when discrimination was attributed to race. The single mediation model varied across racial/ethnic groups and was strongest for Non-Hispanic White participants (β = 0.17, 95% CI [0.07,0.30]). Discrimination may shape cancer metaphor preferences through needs for personal significance and cognitive closure, yet these relationships differ based on whether discrimination is attributed to race and racial/ethnic group. Given that the U.S. health system often focuses on battle metaphors when framing cancer treatment and screenings, individuals who prefer journey metaphors (i.e., those who experienced more frequent racial discrimination in the present study) may experience a systematic disadvantage in cancer communication. A more careful consideration of cultural, racial, and ethnic differences in metaphor use may be a crucial step towards reducing cancer disparities.
... 64 percent of the conversation contains metaphor when a physician communicates with the patient with serious illness. Similarly, patients also use metaphors to discuss their illness with physician [44] [45]. The advertisements of sanitizers, personal hygiene and personal care materials against microbes in mass media will create an enmity among all microbes including the vast majority of human friendly ones [46]. ...
Conference Paper
War and military metaphors are commonly used in the situation where the government requires strong and strict decisions. Metaphors may play a crucial role in the healthcare domain when there is an emergency situation like COVID-19 pandemic. In the era of social media, the emergency communication can be disseminated in most efficient manner. This paper proposes and investigates the use of war and military metaphor in the Twitter and its impact on the citizen and the government machinery. We used data mining tools to extract data from the Twitter and subjected it for sentiment analysis. The metaphor perception in the healthcare context have different dimension. It will induce fear and insecurity in the citizen and more authoritative nature in the people in power. The use of war and military metaphors will have mixed responses depending the socio-economic and cultural background of the person. The war and military metaphor will prevail until the quest for power by the human being exists in nature. The war and military are the having different perceptions among the people lives in fear in the war hit region and the people never experienced the war situation.
Chapter
Discussion of the value of image, metaphor and creative principles to good consulting skill and patient education within the Primary Care setting is important in enhancing improved patient-physician interactions. A broad-based view of the techniques used in undergraduate and postgraduate teaching within Medical Education in the UK and US are canvassed to establish the best practices and efficacy of using drawings and images as communication tools between physicians and patients. A descriptive analysis of the author's use of image and metaphor is analysed to assess how such convey medical information and help in the improvement of consultation and patient understanding.
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Background Establishing trust and effective communication can be challenging in the emergency department, where a prior relationship between patient and provider is lacking and decisions have to be made rapidly. Venous thromboembolism (VTE) represents an emergent condition that requires immediate decision making. Objective The aim of this paper was to document the experiences, perceptions, and the overall impact of health care provider communication on patients during the diagnosis of VTE in the emergency department. Methods This was a qualitative method study using semistructured interviews to increase understanding of the patient experience during the diagnosis of VTE and impact of the health care provider communication on subsequent patient perceptions. Results A total of 24 interviews were conducted. Content analysis revealed that certain aspects of health care providers’ communication—namely, word choice, incomplete information, imbalance between fear over reassurance and nonverbal behavior—used to deliver and explain VTE diagnosis, treatment, and prognosis increases patients’ fears. Conclusion These interviews elucidate areas for improvement of communication in the emergency care setting for acute VTE.
Thesis
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Die Palliativmedizin hat sich über die letzten 20 Jahre zu einem eigenständigen Teilgebiet der Medizin entwickelt. In der vorliegenden diachronen Studie wird die sich vollziehende Institutionalisierung der Palliativmedizin unter Einsatz korpuslinguistischer Methoden nachgezeichnet. Die schrittweise Etablierung des neuen Forschungs- und Behandlungsbereiches wird durch die Analyse eines mehr als 60 Millionen Wörter umfassenden Fachtextkorpus nachvollziehbar gemacht. Gleichzeitig werden im Rahmen der Untersuchung neue Verfahren der diachronen Analyse großer Korpora exploriert. Ein multiperspektivisches Korpusdesign ermöglicht einerseits einen detaillierteren Einblick in die einzelnen Phasen der Entwicklungsgeschichte der modernen Palliativmedizin, andererseits eine konzise Beschreibung von Schlüsselbegriffen, -werten und -haltungen der Palliativversorgung.
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Background: Alleviating the problems faced by dying persons and their families has drawn substantial public attention, but little is known about the experience of dying. Objective: To characterize the experience of dying from the perspective of surrogate decision makers, usually close family members (89%). Design: Prospective cohort study. Setting: Five teaching hospitals. Patients: Persons who had one of nine serious medical conditions or were 80 years of age or older who died and for whom a surrogate decision maker completed an interview about the death. Measurements: Medical records were reviewed and surrogate decision makers were interviewed. Results: 4124 of 9105 seriously ill patients died (46%); 408 of 1176 elderly patients died (35%). The patients' family members were interviewed after 3357 persons (73%) had died. Of 1541 patients who survived the enrollment hospitalization, 46% died during a later hospitalization. In the last 3 days of life, 55% of patients were conscious. Among these patients, pain, dyspnea, and fatigue were prevalent. Four in 10 patients had severe pain most of the time. Severe fatigue affected almost 8 in 10 patients. More than 1 in 4 patients had moderate dysphoria. Sixty-three percent of patients had difficulty tolerating physical or emotional symptoms. Overall, 11% of patients had a final resuscitation attempt. A ventilator was used in one fourth of patients, and a feeding tube was used in four tenths of patients. Most patients (59%) were reported to prefer a treatment plan that focused on comfort, but care was reported to be contrary to the preferred approach in 10% of cases. Conclusions: Most elderly and seriously ill patients died in acute care hospitals. Pain and other symptoms were commonplace and troubling to patients. Family members believed that patients preferred comfort, but life-sustaining treatments were often used. These findings indicate important opportunities to improve the care of dying patients.
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BACKGROUND Communication between physicians and advanced cancer patients is frequently difficult. Patients often report poor levels of satisfaction with communication. The purpose of this study was to assess the impact on patients' recall of and overall satisfaction with their consultation by the addition of an audiocassette recording of a consultation to written recommendations.METHODS Sixty patients with advanced cancer were randomized to either receive a tape recording of their consultation or receive no tape in addition to written recommendations in this randomized, double-blind trial. Patients gave their global ratings of the clinic, were tested for their recall of information given, and responded to questions about the utilization and role of the cassette in influencing family communication.RESULTSThe addition of the audiocassette to written communications significantly increased patient satisfaction with the clinic (8.7 ± 1.7 vs. 7.7 ± 2.0 on a scale of 0–10; P = 0.04) and significantly improved recall of the information given during the consultation (88% ± 8.7% vs. 80% ± 15.5%; P = 0.02). Patients expressed a high level of satisfaction with the audiocassette. Patients listened to the tape a median of 2 (range 1–4) times, whereas family members and friends listened to the cassette a median of 2 (range 1–3) times.CONCLUSIONS The addition of an audiocassette recording of an outpatient consultation to written recommendations for patients with advanced cancer is capable of increasing both the overall patient recall of the visit and satisfaction with the outpatient clinical setting. Patients expressed a high level of satisfaction with the audiocassette. Cancer 1999;86:2420–5. © 1999 American Cancer Society.
Article
Persons of lower socioeconomic status and members of racial and ethnic minority groups experience poorer health and increased health risk factors. A framework of interpersonal processes of care specifies distinct components and incorporates the perspective of diverse racial and ethnic or socioeconomic groups. Its dimensions, each with several domains, are communication (general clarity, elicitation of and responsiveness to patient concerns, explanations, empowerment), decision making (responsiveness to patient preferences, consideration of ability and desire to comply), and interpersonal style (friendliness, respectfulness, discrimination, cultural sensitivity, support). All the domains, except cultural sensitivity, were validated through a survey of 603 ethnically diverse, low-income adults. Confirmation of the framework's usefulness should enable researchers to explore how interpersonal processes might account for observed ethnic and social class differences in health care and health.
Article
OBJECTIVE: To describe the association between hospital resource utilization and physicians’ knowledge of patient preferences for cardiopulmonary resuscitation (CPR) among seriously ill hospitalized adult patients. DESIGN: Prospective cohort study. SETTING: Five U.S. academic medical centers, 1989–1991. PATIENTS: A sample of 2,636 patients with self- or surrogate interviews and matching physician interviews describing patient preferences for CPR, from a cohort of 4,301 patients with life-threatening illnesses enrolled in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT). MEASURES: Patient, surrogate, and physician reports of preferences for resuscitation, and resource use derived from the Therapeutic Intensity Scoring System and hospital length of stay, converted into 1990 dollars. RESULTS: Nearly one-third of the patients preferred to forge resuscitation. Of the 2,636 paired physician—patient answers, nearly one-third did not agree about preferences for resuscitation. The physicians’ views of the patients’ preferences and those preferences themselves were both associated with resource use. Standardized adjusted hospital resource consumption, expressed as average cost in dollars during the enrollment hospitalization, was lowest when the physician agreed with the patient preference for a do-not-resuscitate order ($20,527), and highest when the patient did not have a preference and the physician believed the patient wanted resuscitation in the case of a cardiopulmonary arrest ($34,829) Hospital resource use was intermediate when patient—physician pairs evidenced either lack of agreement or communication, or awareness of options about resuscitation. CONCLUSIONS: Both physician and patient preferences for CPR influence total hospital resource consumption. Physician misunderstanding of patient preferences to forgo CPR was associated with increased use of hospital resources, and could have led to a course of care at odds with patients’ expressed preferences in the event of cardiac arrest. Increasing physicians’ knowledge of patient preferences, and increasing communication to help patients understand that options foi medical care that include forgoing resuscitation efforts, might reduce hospital expenditures for the seriously ill.