Simplify the message – Medical metaphors and Anecdotal analogies

Life is like a box of chocolates...

Life is like a box of chocolates…

“Metaphors have a way of holding the most truth in the least space.” Orson Scott Card


Have you ever tried to explain to a patient the basis behind why a patient has hypothyroidism from hashimoto’s and how to interpret their results?

“Well it’s quite straight forward really. Basically you have a endocrine gland just below the laryngeal prominence, which is controlled by the pituitary which is controlled by the hypothalamus. This hypothalamus released thyrotropin releasing hormone which acts upon the anterior pituitary to release thyroid stimulating hormone. This hormone then acts on the thyroid to have the follicular cells create thyroid hormones T3 and T4. We often only test the TSH because this is longer acting component however can measure T3 and T4 directly if we need to. Oh and no, if the TSH is low that means that your thyroid is working too well so we have to decrease your dose of thyroid hormone to 100mcg on weekdays and 150 on weekends. Yes, in Hashimotos the thyroid is being destroyed, and yes you used to have high thyroid, but now your autoimmune condition is damaging the thyroid and preventing it from making more hormone and it is running out of its stores in colloid. All makes sense really and is quite obvious.” Sometimes explaining things the long way doesn’t work.

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“The thyroid gland helps control our metabolism. When it is working too much it is like running our car running at high revolutions for too long – things could break down. However, if we run the car too slowly, you can feel horribly sluggish, not really get anywhere, and also things could break down. We need to get it running just right so you can do everything you want to do.”

We all have those moments where we would like to make a complicated concept simple. A way to break down the education and communication divide and bring a complicated concept from the medical world and make it beautifully simple in a lay person’s world.

So, I asked a group of experienced GPs (thank you GPs down under – Link) to share some of their best metaphors and analogies that they use to explain complex concepts to patients. There are a few pearls here so grab a cup of tea and have a bit of a chuckle at how GPs in Australia attempt to relate complex medical problems to day to day issues.

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XKCD

Vote for your favorite in the comments box below!


Glue ear:  It is like having a bass drum which is filled with water. When you hit it, it doesn’t vibrate or make a noise. This is why you cannot hear very well. It will drain out over time. (RP)

Reducing energy intake: Think of your fat stores like money in a bank. Food you eat right now is like cash in your pocket. If you’ve always got more than enough cash, you don’t have to go out of your way to get money out of the bank. You’ve got to make sure your body runs out of ready cash through the day, and force it to go and get some out of the bank. (CL)

Weight loss – alcohol There’s the same amount of calories in a bottle of red wine as there is in a Big Mac. That’s why you’re struggling to lose weight!  (PM)

Lifestyle modification I use the ‘learning how to ride a bike’ – so just because you fell a few times doesn’t mean you can’t get back up on it and try again until you succeed’ analogy for those who recount all their failed attempts at lifestyle changes ( smoking, weight loss (SD)

Smoking cessation There are two parts to smoking – the chemical addiction to the nicotine, and the psychological addiction which is your habit. The medication will stop the physical cravings but it’s still hard work from your side of things to break the habit, which have become part of your everyday life. Let’s look at your triggers and work out what new positive habit we can substitute for those times when a craving will hit. (LES)

Depression – CBT and medication – Depression is like being in a deep hole that is really hard to climb out of. Medication is kind of like a ladder. You still have to do the work to climb out (ie the talking/thinking therapy) but the medication helps to make that possible. (MS)

Depression – Taking medication – If you have a broken leg it will heal with time. But using a cast and crutches will help you to manage until it heals. (JD)800px-Bottle_of_Huxley's_'Ner-Vigor',_England,_1892-1943_Wellcome_L0058547

Depression – Taking medication Most people don’t like the idea of antidepressants, but if I told you, you had an iron deficiency you wouldn’t hesitate in taking supplements if it made you feel better. Look at depression as a deficiency in neurochemical transmitters, and this drug increases them and then allows you to be able to explore other ways of improving you mood (self care, CBT etc) (CL)

Depression – Type of medication – When prescribing antidepressants I talk about the fact that sometimes the first one we choose may not work so well. It’s likes shopping for a shirt; it may look great on the rack but fit terribly or look awful. Don’t worry there are other shirts to try on if needed. (TC)

Depression – Staying on medication Explaining why there is a need to stay on antidepressants for a certain amount of time: it’s like your depressed brain is unset jelly, and the antidepressant is the fridge. If you take it out too soon, it’ll turn back to liquid (depression). But if you leave it long enough it will “set” (euthymia) (CG)

Depression – Mechanism of action – Your mind is like a bath running but with the plug out. You’re making Serotonin, it’s just being absorbed quickly. An SSRI is like a plug but it will take time for that bath to fill. (PM)

Depression – seeing a psychologist When a pt says – A counsellor can’t change my problems doc. I talk about how we can change the way patients perceive things. For example, if you walk around a corner and a dog jumps at you and you are scared of dogs, you may have a panic attack. However, if you love dogs you might pat it. The situation hasn’t changed but the way you handle it can change. (JM)

Depression – treating early – (Similar to the above jelly analogy) “Setting” is the depression and I explain the longer we leave the jelly in the fridge (ie the brain in a depressed state), the harder its going to be to “unset”. (I just have to make sure I don’t use these on the same patient or could get very confusing…!)

Treat the cause – Taking paracetamol for a headache while hitting yourself on the head with a hammer will not stop the headache – stop hitting yourself on the head with a hammer. (Find and treat the cause, not just the symptom – especially useful in the context of an issue that requires lifestyle changes) (JD)

Where babies come from…… For some of my patients “well, when a daddy loves a mummy very very much…” (TL)

Pap smear results – I describe Pap smear results like a train trip. Normal is your home town, atypia – the next town, LSIL/CIN 1 a town one third the way along, HSIL/CIN 2-3, two thirds along and finally cancer at the end of the line. But it takes years to get to the final destination. In my case the state capital city is the cancer! [not a FOAM4GP belief – just used by Ri P…] (Ri P)

Epilepsy – Epilepsy can be thought of as a short circuit in the brain, where the electrical impulses go round and round (KA)Muu

Hypertension – Describing the effects of hypertension: it’s like running a pump at full throttle 24/7. It wears out or damages the pump (heart), pipes (blood vessels) and the filter (kidneys). Sometimes the pipes burst from the pressure (stroke, aneurysm). Treatment (lifestyle +/- medication) means the system works better and lasts longer. (WS)

Ear cleaning – (More general advice really but) Never put anything in your ear smaller than your elbow. That’s to say, don’t put stuff in there! (JK)

Ear cleaning – Clean your ears out with cotton-tips as often as you polish the TV antenna on the roof of your house. (NG)

Sciatica –  If I try to call a friend in Brisbane, and there is no dial tone, I don’t know if the damage is outside my front door, halfway between here and Brisbane, or outside my mates front door. Your sciatic nerve is the same. If it is damaged, our brain doesn’t know where the damage is so it can tell us that it is in different spots, such as foot, calf, knee, thigh. (RP)

Managing expectations Unfortunately I was given neither a crystal ball nor a magic wand at medical school. All I can do is offer my best possible advice. (MC)

Regular check ups I liken these visits to servicing your car. If you don’t do it regularly, things break down much sooner. (JK)

Burnout risk Life is a long distance race, not a sprint”. This is for people who want to go “rip, bust, tear”, ie not pacing themselves. (JK)

Burnout risk For the chronically tired overworked person approaching burnout : Do you use a computer? (usual answer – yes). What happens when you have too many programs running concurrently? (It slows down or sometimes freezes). Well you are just like a computer. Perhaps if you could shut down the programs and work on one thing at a time….? (EF)

Burnout risk – For the businessman who is too busy to look after his health: If you identified a threat to your business which carried a 30% chance of bankrupting your business, what lengths would you go to to address that threat? (NG)

Burnout risk When busy people are having trouble managing things, I liken it to juggling. The more balls that are in the air, the greater the chance of dropping one or more of them. So juggle fewer balls for a while. (JK)Nervous

Resilience –  I talk about dam walls being your resilience. By building up the dam walls – making them higher and stronger (improving resilience) – when the flooding rains (stressful life events) come along, the dam walls won’t burst and there is less likely to be damaging overflow. (GY)

Sleeping tablets Patient asking for benzo to sleep/anxiety…that’s like me using an Elastoplast to treat a massive boil that needs drainage or a bandage to treat a fracture…it’s not dealing with the underlying issue… (CL)

Weaning off addictive medications- When I’m trying to wean people off sleepers/bzd/opiates and they come in saying they can’t handle the symptoms and need to go back up a dose I say “the only way is through”. Seems to stop them struggling and accept the pain of it better (JP)

Stress and Worry – Worrying about something that may not even happen is like paying interest on a loan you haven’t taken out. (EF)

Stress and Worry Stress is like a vase filled to the top with water – if you put a drop in it overflows so need to have some way of controlling the water level. (RS)

Panic disorder – I read an analogy once of an anxiety/panic disorder being like a smoke alarm. When a smoke alarm detects smoke it doesn’t stop to work out whether it’s from burnt toast or a fire, it just goes off. A panic disorder is like that too. Your brain perceives a threat and doesn’t stop to work out whether it’s a real threat or not and you just go straight into fight or flight mode. So just because you feel panicked doesn’t mean something bad is happening, it’s just an overly sensitive smoke detector. (HJ)

Panic disorder Panic is where the brain says “It’s a bear!!! Run!!!” So you body hears that and prepares for fight/flight with lots of adrenaline. All of those symptoms you have are usually an excellent response to this situation – the heart races, the breathing is faster, you feel fidgety, your gut wants to empty itself, you are initially very alert then later exhausted. The problem is when it starts having that reaction to something that isn’t life-threatening like going to the shops or when you see your ex. What psychology does is helps the brain stop reacting to everything like a bear running at you.

Alcohol reduction The liver is like dealing with life, we all need time off from work to rest and recover. The liver is the same. You need to have those alcohol free days to allow it to still function. I mean hey it’s a great organ. You can cut a bit off it and it will grow back. But give it a break sometimes too. (CL)

Post viral fatigue – Having a bad virus is like having an injury to your leg from a knife. Just because the knife (or virus) has gone away, doesn’t mean the wound is fixed. It still takes some time for everything to return to normal and healing to occur (RP)

Dementia – I explain dementia as having a series of filing cabinets and the newer ones have sticky drawers. So these are much harder to  open. (KA)File:Prescription medication being dispensed.tiff

Asthma prevention Asthma is like a freight train, if it’s already going fast (poor control) it’s easier for it to speed up (flare up). If it is stopped (good control), it makes it easier to prevent it starting. (MB)

URTI Antibiotics – When antibiotics are requested by a patient, “you can take them now and you will be better in seven days. If you don’t have them, it will take a week”. (JK)

URTI reassurance “there’s a lot of it going around” is a very reassuring and therapeutic statement (JK)

Solar keratosis / efudix Efudix is like lawn weed killer. It kills both the lesions you can see and those that you can’t. (PM)

Irritable bowel syndrome Gut symptoms (especially IBS) and psych link – Serotonin is the chemical in our brain that we use for things like emotions and making decisions. There’s actually more Serotonin in the gut that in our brains. During stress/anxiety the levels are out of whack in our brains, and so too in our our gut – hence phraces like “worried sick”. If we can help your head space, your gut will settle down too. (LES)

Irritable bowel syndrome / Funtional disorders I like comparing functional disorders like IBS to leg cramps when patients get frustrated that tests are normal (or who want more tests than they need). I say that leg cramps are very real and painful, that the muscle isn’t behaving properly, but that doesn’t mean that there is something necessarily “wrong” with your legs. Yes, it can sometimes caused by electrolyte imbalance or something, but usually no cause is found but this doesn’t make them any less real. (GY)

Medication refusal All drugs, whether synthetic or natural, are potential poisons. If the poison works for you its great! (EA)

Treatment without evidence Its your right and perogative to [insert anything/action] … but I should tell you that there’s unfortunately no evidence it will help you either. (EA)

Allowing time I often say to patients that Time and Nature will fix most things, but if they want to give me the credit, that’s OK. (JK)

Recovering from cancer I run breast cancer follow up clinics and patients are often overwhelmed by the uncertainty that the future holds. I suggest they consider their cancer (history) as a balloon that is tied to their wrist. It is with them forever, but while they’re moving forward, that little balloon will always be behind them (NO)


Thanks everyone! Tell us your favorite. Do you have any you use? Please share them below and I will add them to the post! Hope one or two may stick in your head and come in handy next time you’re stuck.

Cheers, Doc Rob. @Robapark.

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5 thoughts on “Simplify the message – Medical metaphors and Anecdotal analogies

  1. I find pts get confused that everything affecting their heart is a heart attack. To differentiate arrhythmias, valve issue I talk about the heart as a house. It has plumbing (coronary artery disease), electricity (arrhythmias), walls (hypertensive hypertrophy) and doors that don’t shut properly.

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