On Metaphor in American Healthcare

By Marc-David Munk, MD

I’ve long been a passive observer of language in healthcare. So I was excited to stumble across a 2009 TED talk given by journalist James Geary who made a few intelligent points about metaphor (his blog has many more). Geary noted:

Metaphor matters because it’s around us every day, all the time. Metaphor matters because it creates expectations. Pay careful attention the next time you read the financial news. Agent metaphors describe price movements as the deliberate action of a living thing, as in, “The NASDAQ climbed higher.” Object metaphors describe price movements as non-living things, as in, “The Dow fell like a brick.” Researchers asked a group of people to read a clutch of market commentaries, and then predict the next day’s price trend. Those exposed to agent metaphors had higher expectations that price trends would continue…this is how metaphor misleads.

There are certainly a lot of metaphors in healthcare. On the heels of Obama’s “Moonshot” campaign to cure cancer, I found a nice piece in Johns Hopkins Magazine that illustrates how often metaphor is used to describe healthcare initiatives:

We have become so used to the language, we no longer notice it: “The war on drugs.” “The war on cancer.” “Battling” the spread of AIDS. Martial metaphors have become so ingrained in our discussion of disease and public health, it’s all but impossible not to use them. Try to write a paragraph about research against AIDS, for example, and avoid words like campaign, target, weapon, battle, fight, or crusade.

Geary, I’d suspect, would warn us about “the war on cancer.” The problem, of course, is that thinking of the disease in this way sets everyone up for therapy after therapy, battle after battle– when many patients may have other ideas about how they want to spend their final months. The metaphor creates expectations and sets the course.

Outside of clinical medicine I’m increasingly tuned to the metaphors that get used repeatedly in healthcare management. Here is a convenience sample: I just scrolled through LinkedIn and a couple of of health industry sites and in a few minutes compiled this shortlist of article titles:

• Medicare Proposal Takes Aim at Diabetes: NYT
• What’s really going on with our dying healthcare system? [LinkedIn Commentator]
• Startups using diabetes prevention program score big win with Medicare reimbursement. [Medcitynews.com]
• UPMC gets green light to acquire Jameson Health System [Beckers]
• 4 Ways to Prevent Healthcare Leakage [Fierce Healthcare]
• Partners HealthCare, an 800-pound gorilla, hopes to grow [Boston Globe]

The metaphors we use to describe our work in healthcare matter. One, because they reveal a lot about how we look at the current state of the healthcare industry: It sometimes seems to all be about aiming and big wins and gorillas these days.

But, two, the metaphors are important because they keep us from considering alternatives. So, in an era where we casually discuss healthcare “leakage” we also implicitly frame the solution as a tighter corral around our patients. As Geary notes, metaphor creates expectations.

I can imagine any number of non-FFS healthcare futures where the concept of patients “leaking” from a system makes no sense, and where scale has nothing to do with profitability. Green lights to acquire hospital beds may seem silly.

If you think I’m a Pollyanna, consider the degree to which our metaphors reflect our existing fee-for-service paradigm. Does the concept of “leakage” outside your system matter much when you take capitated payments? Look at the photo above and give “leakage” some thought. Is this the right way to think about patient flows and preferences in a complex human system?

And, when simple legislative change can force price transparency and standardization, does worrying about fat gorillas make sense? When intelligent payer/provider integrations evolve, does the idea of providers and payers “taking aim” and “scoring big” against one another seem stupid? Yet, the more we are exposed to the metaphor, the harder it becomes to imagine an alternative.

LinkedIn and the industry press have never been known for their counter-cultural viewpoints. But I challenge the thoughtful healthcare leader to be more careful about how we describe our environment. We create the future we imagine.

Marc-David Munk is a physician executive who works for a healthcare startup in Boston. This post originally appeared on Dr. Munk’s blog, American Healthcare.