Metaphor as a comprehension increasing device in medical consultation: the benefits and risks Simone Wolfswinkel 11925345 Dr. Jean Wagemans 9/2/2018 1. Introduction
Medical consultation is a complex form of communication in which a lot of factors must be taken into account. A doctor must not only be clear in his explanation, he must also guard the patients’ freedom of choice. A doctor must be neutral, but advice giving. He has to be professional and thorough, but empathizing. The doctor is walking a tightrope, in limited time.
A review of empirical studies showed that, amongst other factors, time limitations and unease caused by not understanding medical terms are two important causes of negative experiences for patients in a medical consultation. The study reported ‘providing information in a manner understandable to the patient’ as one of the most important issues that need improvement in medical consultation (Marcinowicz & Górski, 2016). The informational imbalance between a patient and a doctor is the cause of this incomprehension. When a doctor is informing a patient, he might make use of rather technical terms to explain complex medical processes. A patient, however, is to a certain extent a layman when it comes to medical background information. Therefore, in this type of communication, there is need for a tool that can both have a positive effect on comprehension, and is efficient to use.
A device that fits these needs, is metaphor. Metaphor is a rhetorical device that is known to have a positive effect on persuasiveness (Sophory et al, 2002). It is a figure of speech in which two concepts from a different domain are being implicitly or explicitly compared (Steen, 2011), like in the following example: Taking Prednisone as a cancer patient is like putting rotten meat in the freezer: it will still be rotten, but you will not smell it anymore. Here, the effect of the use of Prednisone on a body is compared to the effect of refrigeration on rotten meat. Besides for persuasion, metaphor is adequately equipped for explanation. When using metaphor as a device to explain a feature of something abstract, the relation between a concrete object and its feature, is used to explain the relation between the abstract object and its feature. The concrete object is often from an everyday domain that anyone comes in contact with. In the example above an everyday topic as refrigerating rotten meat is compared to a for a layman more abstract object, the effects of Prednisone.
Despite metaphor’s potentially beneficial effects, the conscious use of metaphor has never been introduced to the field of medical consultation. This paper aims to inventory the potential benefits and risks of metaphor use in medical consultation. To investigate whether metaphor is suitable for medical consultation, I will firstly take a closer look at medical consultation as a communicative activity type. In the second section, I will explain the concept of a communicative activity type and why medical consultation should be considered as one. I will determine whether metaphor fits the goals that are associated to medical consultation. Then in the third section, I will investigate how metaphor is currently being used in other communicative activity types within the health domain, to be able to assess whether the explanatory ability of metaphor is used to its full potential in these types of communication. In the conclusion section, I will combine the gained insights and come to a conclusion to the research question: what are the potential benefits and risks of metaphor in medical consultation?
2. Medical consultation as a communicative activity type
By medical consultation I mean the advice-seeking interaction between a doctor and a patient, about a health-related problem, in an assigned place such as the GP’s office, or the hospital. It is clear that communication plays a big role in these interactions. Therefore, analysis and evaluation of medical consultation can provide important insights that can be interesting for discourse analysts as well as medical professionals. In these analyses, investigating how the institutionalized context shapes the manner of communication is important. To be able to analyze communicative aspects of medical consultation, it is important to consider it as a communicative activity type. After analyses of the communicative practices, it is worth the effort to apply insights from linguistics into the field of medical communication.
A communicative activity type is seen as culturally established communicative practices that have become conventionalized, because they are to a certain degree institutionalized. The activity type’s rules and conventions are what shape the communication that takes place in these activity types (Pilgram, 2009, p.155). Medical consultation can be seen as an institutionalized communicative practice because it only takes place in assigned places, is regulated by institutions, and is conducted in a conventionalized fashion and order. Therefore, one can speak of a communicative activity type of medical consultation. The institutional point of medical consultation is giving advice to patients for health-related problems. The informational exchange is a stage that facilitates the discussion and is therefore of great importance or the communicative activity type of medical consultation.
The distribution of information in medical consultation is and has been a cornerstone in the past decennia. A shift of models has taken place: until the 1980s, the default model for medical consultation has been the paternalistic model, meaning the doctor had prevalence and authority caused by the informational asymmetry between doctor and patient. The patient accepted the fact that a doctor had the knowledge and power to make decisions concerning the patient’s health issues. Fully informing the patient was therefore not always necessary as the doctor thrived on the principles of doing no harm to the patient. From the 1980s onwards, the informational model was the default model, as informed consent became an important principle in medical consultation. At this point, the doctor is no longer the decisive party, and leaves the patient with almost full autonomy, as a result of an increased feeling of dignity, freedom and agency at the side of the patient. This model however left the advice-giving role of the doctor disregarded. The doctors were strictly there to inform (Stiggelbout e.a., 2015, p.1173).
Nowadays, the model of Shared Decision Making is the default model used in medical consultation. In the previous two models either the doctor decided what was best for the patient and the patient is encouraged to consent to this decision, or the patient takes a decision after having been given the needed medical information and thus gives “informed consent” (Charles et al 1997, p.684). This is different from the Shared Decision Making model in the sense that it combines both: the patient is been given all the medical information that is needed, and the doctor as well as the patient take on a participating role in the decision making process. The SDM-model entails a distribution of information by the doctor, in which he informs the patient about his or her diagnosis, prospects, treatment options and chances. Then, the patient is advised with the doctor’s treatment preference and he or she is asked to share their preferred treatment option. Ideally, they jointly come to a shared decision (Frosh and Kaplan, 1999, p.287).
Snoeck Henkemans and Mohammed (2012) argue that even though a doctor’s role is limited in the Shared Decision Making model, he or she will still try to steer a patient towards what they think is the best solution. They do not openly do so, but make use of strategic maneuvering. Strategic maneuvering is reasonably, in accordance with institutional norms, trying to reach the dialectical goal, which is in this case convincing the patient that the option they favor is medically speaking the best (Snoeck Henkemans and Mohammed, 2012). The institutional preconditions that are part of the activity type make it harder to maneuver strategically without derailing, because there is less space to maneuver (Van Eemeren and Houtlosser, 2006, p.385).
Summarizing, we can conclude from this section that even though medical consultation does not seem argumentative, but merely informative at first sight, it is both. The informational stage precedes and serves the argumentative stage, because it is eases the reach of an agreement.
Informing a patient thoroughly is a doctor’s duty, as well as giving an advice and jointly coming to a decision. A doctor does this following the Shared Decision Making-model’s conventions and he may also maneuver strategically, to jointly decide that the option the doctor favors is the preferred option, while staying within the boundaries of the communicative type.
3. Metaphor use in health-related discourse
This section of the paper will focus on how metaphor is already used in health care or health care related fields to investigate whether comprehension increase is one of the functions it is currently used for.
Beger (2015) has found that metaphors are frequently being used in psychologic counseling. She used the target domains LOVE and ANGER to investigate metaphor use of psychologists talking to their patients. What she found is that most of the metaphors used were indirect, conventionalized or both, such as ‘falling in love’ [Love = container], ‘building a relationship’ [Love = building] or ‘it tore us apart’ [Love = unity of parts]. However, particularly the examples she gave for anger-metaphors, contained metaphors that seem to be consciously used to make clients visualize their anger and to be able to offer a concrete solution. Beger (2015, p.62) mentions a fragment of a counselling session where a psychologist tells her client to look at anger as a filling up barrel.
Think about this tank of water as the reservoir within your soul, that aggressive impulses are dripping into. And as this tank fills up, the pressure of the weight of these impulses become stronger and they push on this plug that keeps it bottled up. [..] you don’t behave aggressively until all of this stuff kind of explodes and comes pouring out of you. (p. 62)
The difference between the types of metaphors that occurred could be explained by the subject. Love is commonly talked about and is often conceptualized. This may lead to conventionalized conceptions and visualizations. Anger, however, may not be discussed as frequently and therefore is less often conceptualized. An explanation could also lie in the universality of the feeling: love may feel very similar for every individual, while anger may
be an emotion that is experienced in different ways and is therefore metaphorically expressed in different ways. What this article shows us, is that whenever metaphors have more characteristics that comprehension increasing metaphors should have, they are likely to be used as such. The metaphors used for anger such as a hot fluid in a container, a weapon, heat, a cover, insanity and an explosive are not nearly as conventional as the source domains used to metaphorically express love, such as a container, a structured object, a living organism, a unity of parts and a business transaction.
The difference in directness however is harder to explain. Social science has a relatively high proportion of indirect metaphor and a relatively low proportion of direct metaphor, as reported by Herrmann (2015). She explains these proportions of direct and indirect metaphor use by the tradition of the social science of not wanting to overtly evaluate social facts and structures, because some disciplines make observations to these.
Herrmann (2015) has also investigated the humanities and arts, politics, law and education, and natural sciences apart from social sciences. Natural sciences however, were the least indirect sub-register she has researched. It had a significantly low proportion of indirect metaphors and a proportion of direct metaphor that is significantly higher than what was expected on the basis of statistical chance. An explanation lies in the highly exact and explicit style of the natural sciences. It seems to comply well with the strictly scientific ideals of precision and logic, because language should accommodate the values by being as specific, unambiguous and thus as literal as possible. The use of direct metaphor is well attested and proven to be effective, because metaphorization invites new and sometimes unexpected perspectives by redescribing and reframing a given phenomenon to create new hypotheses, explanations and predictions. Metaphors do not only communicate established knowledge, but are capable of generating new knowledge as well (Knudsen, 2015 p. 192). Berger (2013, p.149) argues that it is not necessarily new information that has been provided to the reader, but the reader is enabled to perceive and interpret existing information in another way. It is not new content, it is a new perspective that creates a new understanding.
However, the fear in some scientific fields is that metaphor, while highlighting important certain structural similarities, ignores other characteristics, that may not be as essential, but are of importance. Knudsen (2015) has investigated several scientific biological domains by doing journal research: ecology and environmental studies, microbiology and genetics, neuroscience and cognitive science, and health and society. In all of these domains, metaphor was looked at in four different ways. She lists the following four ranked from most common to least common: (1) metaphor as inferior and commonsensical knowledge, (2)
metaphor as a visualization tool, (3) metaphor as communicators of complex ideas outside of scientific discourses, and (4) metaphor as pre-theoretical, heuristic devices. From these results, we can tell that metaphor as a generator of new information is the perspective on metaphor that is least adhered to. It needs to be stressed that this perspective on metaphor use is when it is implemented in expert-to-expert communication.
Concluding from this section, we can tell that metaphor is not a new device in sciences. In social sciences, it is being used, for instance in psychologic counseling. However, it’s use does not always happen consciously, but because it is conventionalized. In natural sciences, in for instance education, metaphor is used as a tool to increase understanding. A hesitance to use metaphor in expert to expert communication exists because while highlighting one characteristic, it may leave out information that is important too. There has not been reported a lot of studies on metaphor use between an expert and a layman in the health domain.
4. Conclusion
In this paper, I have examined if metaphor could be a tool to provide information and increase understanding in medical consultation. I have approached the research question ‘What are the potential benefits and risks of metaphor use in medical consultation?’ by first analyzing medical consultation as a communicative activity type. It is necessary to classify medical consultation as such, because besides informational exchange, argumentation is a central element. Informational exchange is necessary for a fruitful discussion and thus for a quicker reaching of agreement. Besides this, providing enough information is a doctor’s duty, and in line with the Shared Decision Making model.
In other communicative activity types within the health domain, metaphor is already being used. In social sciences as psychology, metaphor is used to visualize abstract or otherwise indescribable feelings. In natural science education, it is used to explain complex phenomena to students. Of all the functions of metaphor Knudsen (2015) examined, metaphor as communicator of complex ideas outside of scientific discourses, is the category medical consultation belongs to. In this function, metaphor is defined as highly pedagogical, explanatory, and persuasive device that can serve as a bridge between science and the (layman) public. However, this function is listed as the second-last frequent of the four functions Knudsen (2015) investigated. This is a result of skepticism toward metaphor as a tool to adequately explain. The underlying fear is that metaphor cannot fully grasp the concept
of what one is trying to explain, because it only highlights a certain feature of it, while blurring other characteristics.
However, in medical consultation, an expert to layman context, metaphor could be of use. In medical consultation, it is not necessary to explain every detail of a medical process. Providing sufficient information is needed, but an overshare of information is not, and is inefficient. Only the features that need elaboration, should be highlighted. Metaphor is a tool that can provide this highlight.
Interesting to further investigate may be how different features of metaphor might affect the ability of metaphor to increase comprehension. It is to think that novelty of metaphor, deliberateness, and directness might all have a positive effect on its comprehension increasing ability. Furthermore, the valence of the source domain might be of an influence. All these variables have not been tested for a possible relation to comprehension increase, as well as linguistic variables such as implicitness and location in the sentence or message. It could be very fruitful to investigate the effects of this experimentally, to be able to maximally exploit metaphor as a way to generate understanding between a doctor and a patient.
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