The Art of Analogies in the Clinic

Translating medical nomenclature into language that is easily understood by patients can be difficult: how do you explain the pathology of cancer or the benefits of myeloablative chemotherapy in patient-friendly terms? Your ability to do so, however, can impact treatment adherence, health outcomes, and the perception of physician empathy during a patient’s bleakest moment. The use of analogies, long recognized in medicine as a way to facilitate physician-patient communication, can help get your message across.

I still vividly recall the elderly Vietnamese male patient in the busy emergency room of Harborview Medical Center. He seemed to be dazed at the frenetic pace of activity around him as he laid on a gurney in a room created by curtains, grimacing in pain. Family members spanning four generations surrounded him and looked up at me as I approached and gently bowed in respect. There I was, a busy hematology/oncology consult fellow, who had to announce his diagnosis of metastatic pancreatic cancer and answer a multitude of questions that would likely make no sense to anyone. I’m certain that many of my peers have been in a similar situation countless times, in which translating clinical information into “human” terms proves difficult. In my experience, the effective use of analogies when communicating with patients has been an invaluable tool that is often met with a sigh of relief and a nod of understanding.

While I have improvised analogies to cater to the educational background of patients and family members, I prefer to use basic analogies, as rudimentary explanations are best for even the most educated of individuals when it pertains to issues of life and death. Most patients appreciate this sort of explanation, and more often than not, the analogies generate a smile during even bleakest situations.

Some of my most useful analogies have been as follows:

Chemotherapy: I often explain to new patients who are about to start the first of many chemotherapy regimens that they are embarking on a marathon; the physician is the coach and the health care team, composed of the nursing staff and pharmacists, are track coordinators monitoring their well-being. Many patients ask about nail changes with chemotherapy. I often tell them that just like the annual circles in the cores of trees that demonstrate their age and reflect the harsh times they have experienced, each hyperpigmented nail line indicates the chemotherapy insult that they have received, and that normal nail usually develops once they discontinue chemotherapy.

Blood counts: I communicate the importance of blood cell counts by telling patients that white blood cells, red blood cells, and platelets represent the armed forces, the Navy, and the Air Force. All three are needed to fight disease and stay in homeostasis; inadequate levels of any of them can render the patient’s health in major jeopardy.

Neutrophils: Mostly needed to prevent infection, they are like policemen that curtail offenders (ie, microbial pathogens). When there is unrest (ie, infection) there is always an increased number of troopers (ie, leucocytosis); neutropenic patients are therefore vulnerable to infection due to less policing.

Lymph nodes and metastasis: Lymph nodes are like security guards at multiple checkpoints or roadblocks in the body. When there is disorder and mayhem, the security guards radio for backup to swell their numbers. Similarly, lymph nodes enlarge when they become involved in an irregularity upstream, thus preventing it from dissipating downstream. If they are overwhelmed, metastases occurs.

Myeloablative chemotherapy: This is like winter, in which the cold weather causes the grass to die and take on a pale hue. When new growth appears in small pockets during the spring, it is difficult to ascertain if it is fresh grass or tainted with weeds (ie, disease). Oftentimes in patients with leukemia who have undergone induction chemotherapy, a day 14 marrow aspiration is performed to identify the persistence of blasts (ie, weeds), and another marrow aspiration and biopsy is performed on day 28 to identify if the new growth is devoid of blasts (ie, weeds in the grass). Another similar analogy is the effect of a powerful weed killer on grass.

GI malignancies: Using the analogy of drilling though a timber frame wall is helpful to explain the stage of disease. If the cancer has penetrated most of the muscularis mucosa and serosa (ie, the insulation and sheathing of the home’s wall), its chance of metastasizing is high (ie, through the outside brick). The more the cancer has spread through its confining walls, the greater the chance that the cancer will disseminate.

Proper hydration: Although need for proper hydration in patients with cancer is essential, many do not consume enough fluids due to chemotherapy-associated nausea, anorexia, and changes in taste. Such patients often have dark-colored urine indicating high urinary concentration and poor oral fluid intake. I use the analogy of a few drops of a blue coloring agent changing the color of water in a small glass, but not of a tub of water. Volume does matter. After hearing this analogy, they often return to tell me that their urine is mostly clear now, which is very gratifying!

Non-malignant hematology patients: In patients who are mostly well, I cannot over-emphasize that the need for regular medical follow-ups is imperative for their well-being. Many patients do not keep their appointments or do so only when they need medication refills. I ask these patients how often they change the oil in their cars. It is like a light bulb turning on when patients see the connection between the maintenance of their vehicle and their body.

Analogies are extremely useful when used in the proper way. If they are misused and misunderstood by the patient, it could lead to confusion and discontent. The central message is to use familiar concepts to help patients understand unfamiliar or complex issues to help ease their anxiety. One must always gauge the level of understanding of the patient and avoid overusing analogies. Always bear in mind the rule that analogies are like cars—if driven too far, they will inevitably break down!

Jaideep Shenoi, MD, is a third-year senior hematology/oncology fellow at the University of Washington/Fred Hutchinson Cancer Research Center in Seattle, Washington.

This edition of Oncology Fellows is supported by Genentech, a member of the Roche Group.