|Year : 2020 | Volume
| Issue : 1 | Page : 74-77
Analogies in clinical practice: Seven steps in doctor-patient communication
Raviteja Innamuri, Deepa Ramaswamy
Department of Psychiatry, Christian Medical College, Vellore, Tamil Nadu, India
|Date of Submission||02-Nov-2019|
|Date of Decision||08-Nov-2019|
|Date of Acceptance||14-Nov-2019|
|Date of Web Publication||13-Jan-2020|
Dr. Raviteja Innamuri
Department of Psychiatry, Christian Medical College, Vellore - 632 002, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Some of the biggest challenges in clinical practice remain in understanding all aspects that affect the person presenting in ill-health. One of the challenges is in explaining medical concepts to patients. Analogies can be an effective tool of the therapeutic armamentarium. This article elucidates a theory of analogies, principles of effective analogies in clinical practice, steps in discussing analogies, examples, and implications in clinical practice.
Keywords: Analogies, explaining difficult concepts, patient education
|How to cite this article:|
Innamuri R, Ramaswamy D. Analogies in clinical practice: Seven steps in doctor-patient communication. Int J Health Allied Sci 2020;9:74-7
|How to cite this URL:|
Innamuri R, Ramaswamy D. Analogies in clinical practice: Seven steps in doctor-patient communication. Int J Health Allied Sci [serial online] 2020 [cited 2020 Feb 25];9:74-7. Available from: http://www.ijhas.in/text.asp?2020/9/1/74/275644
| Introduction|| |
It is understood that despite the technological breakthroughs in the field of medical sciences, the biggest challenges faced by medical fraternity are with regard to effective doctor–patient communication. Complicating this scenario is the increasing prevalence of noncommunicable diseases and poor adherence to treatment, behavior-related diseases such as exercise and diet related and digital doctoring. In this context, analogies are useful in communicating difficult concepts to patients and can be a part of the clinical and therapeutic armamentarium of health professionals.
In English literature, an analogy is a rhetorical device, where two things, alike in several respects, are compared, for the purpose of explaining or clarifying some unfamiliar or difficult idea by showing how it is similar to a more familiar one (e.g., “the heart is like a pump”). Simile and analogy overlap, the simile is more often an artistic likening, done briefly for effect and emphasis (e.g., “her hair is as dark as the night”). A metaphor uses a phrase normally designating one idea to designate another to make an implicit comparison (e.g., “her hair is the night”).
Of the three, the analogy is usually used to serve the more practical end of explaining a thought process or a line of reasoning or the abstract in terms of the concrete. Using effective analogies in clinical practice result in a better understanding of the patients about their illness and treatment decisions improve the therapeutic relationship and compliance. This article aims to elucidate the theory and practice of using analogies and lists some common examples that can be used in daily practice.
| Principles of Effective Analogies in Clinical Practice|| |
Analogies need to be carefully chosen to be effective and also to not confuse the listener. The user must first abstract the principle to be communicated. The chosen analogy must be familiar to the listener. The analogy should contain the same abstraction, both in full and without any additional confusing or contradictory principles.
The context and method of communication are also important. Before offering a new concept, the present understanding needs to be identified, and any misconceptions must be clarified. Communication is effective in the context of a trusting relationship, and if the method involves active participation and interest on the part of the receiver. It is also important to avoid jargon and to use only lay terms or common words as far as possible.
Therefore, the principles of effective analogies include:
- The target concept is complex
- The target concept is novel to the patient, in the context of medical knowledge
- The analogy is well known to the patient
- The analogy and the target concept are parallel in important ways
- The similarities between the analogy and the target concept are clearly explained
- The analogy should not further cause misconceptions.
| Steps in Discussing Analogies|| |
In this article, based on the above-mentioned principles, we propose a 7-step method to discuss analogies based on the principles of communication. The steps, the sequence, and their rationale are briefly described below assisted with an example.
Step 1: Confirm that the target concept is complex and also that the patient has difficulty in grasping the concept.
During clinical practice, we often note that patients express difficulty in understanding the concepts explained to them. The doctor, then, has to encourage and involve the patient to help understand the concept. Few examples of such concepts include:
- Lag in therapeutic effect (“no immediate relief”)
- Concept of control versus cure (“I have had no attacks for several months, maybe I do not need medicines any more”)
- Fear that treatment for a bout of illness makes the latter a lifelong one (“Will I get addicted to this medicine”).
Each of these is complex and contains many elements. For example, with regard to “lag in therapeutic effect,” the concept is that many treatments do not provide significant relief immediately, but they must be continued to gradually provide relief. In the meantime, the patient may be distressed about side effects, expenditure on medicines, etc., which can result in the discontinuation of medication.
Step 2: Assess baseline understanding of the concept and assess if an analogy would help in better understanding.
Before proceeding further, it is important to elicit what the patient already understands the concept as the old Chinese saying goes, “empty your cup.” For example, “lag in therapeutic effect” is linked to an understanding of concepts of absorption, first-pass metabolism, synaptic receptors, up- or down-regulation, and downstream changes. Even for the well-educated, this information can be very difficult to follow; retention of detail can be poor, resulting in the all too familiar experience for a clinician – having explained something in detail, and the patient or family member looking quite blank about the topic in subsequent visits. Here, an analogy can help in the understanding of the principle of “regular investment with benefits reaped later.”
Step 3: Initially, it is recommended to have a list of analogies that one would be comfortable using. With practice, one is able to frame relevant analogies from observations in their environment. Choose an analogy appropriate to patient's background knowledge, age, gender, religion, and ethnicity. For example, the example given under step 5 can be used for a farmer; while the example “myopia and spectacles” given below can be used for someone wearing spectacles. Some of the resources for analogies are available online.,,
Step 4: Enquire if the patient understands the analogy used and is familiar with the situation you are comparing in the analogy.
Unless the patient can make parallel connections with the analogy and the concept being explained, the efforts will be in vain. For example, “lag in therapeutic effect” can be compared with the idea that a plant or tree requires time and care before it yields fruit. Comparing treatment to this process communicates all the elements – that time and attention have to be paid (visiting the doctor), there are expenses such as fertilizer (purchasing drugs), regular care must be given (daily meds), and that fruit appears later (response). It can also be expanded to explain how noncompliance (stopping watering) will not cause immediate relapse (the plant will not die immediately) and that once relapse occurs (plant dies), the treatment will go back to the first step (start with a new sapling).
Step 5: Explain the analogy preferably using question and answer/active communication eliciting the similarities that explain the target concept.
This is an extension of step 4 where a question-answer format, rather than a didactic explanation can be utilized, to makes the process active. Arousal of emotions through introducing a whimsical note, or humor, can make the process more efficient and promote long-term retention.
For example, in the case of lag in therapeutic effect, begin by saying, “medical treatment is similar to farmer's work”. Or to arouse, say, “A doctor is a like a farmer or gardener. Do you think that is true?” Said with a smile (to prevent any anxiety), it can induce a sense of puzzlement or curiosity.
Continue by saying, “One has to dig the mud, remove the weeds, then plant the seed, water, and fertilize it. When will you see any growth?”
Elicit the answer “Several days.”
Then enquire “When will you get any fruit?”
The usual response is “Several months later.”
Say, “Treating illness is similar. The medicines go into the stomach, get absorbed into the blood, reach the brain (or whichever organ is being targeted), and then begin their action.
Hence, you may not begin feeling well immediately. There is no need to be disheartened. Do continue taking the medicines/following the diet/doing the exercises regularly.”
Step 6: Point out the limitations and identify ways the analogy could be confusing through questions.
This is a challenging but important part of the discussion. In the given example, the patient can be confused with medication that can give immediate relief (e.g., relief of headache immediately with paracetamol). This can be explained as there are different types of harvest and only a particular one is being referred to improve understanding and maintain effective communication.
Step 7: Confirm understanding of the patient by asking for conclusions based on the analogy. Can recheck for misconceptions and summarize.
In this example, ideally, the patient should be able to conclude that these medicines reach the stomach, they have to be digested, get into the bloodstream, and then reach the nerves to correct the chemical imbalance inside the nerves. Hence, the relief I will get is just like the fruit on the tree, which will be much later. In the meantime, I have to spend money on the medicines, maybe bear with some side effects on the body, but be regular with taking the medicines.
| Some Useful Analogies and Conversations (D: Doctor, P: Patient)|| |
Myopia and spectacles
Patients usually report seeking a cure from the illness. Once free of symptoms, patients are keen to stop their medicines. In reality, apart from few infectious illnesses, and a few simple surgical conditions (e.g., hernia or appendicitis), most conditions (metabolic, endocrine, autoimmune, and allergic) require long-term treatment, although one can hope for good symptom relief.
Relief from a complaint is not the same as cure.
D: Look at me; I have an illness, can you see any sign of it? (This is often met with an uneasy shifting in the chair or an embarrassed smile, and a shake of the head). I wear glasses (relief from the patient). Why do I wear them?
P: Because you have weak eyes.
D: Correct. Do you know, I have such high power, that I cannot recognize my own brother/sister (I choose according to the gender of the person) sitting there without them? But, with them on, I can see everything as clearly as someone whose eyes are normal (look for agreement – usually a nod). So tell me, can these glasses make my eyes normal again?
D: It can correct my vision, but my eyes will always stay weak, is that right?
D: So, if I go to the eye doctor and say, “I can see everything now, can I throw away my spectacles,” what will I be told?
P: No, don't do that. You can see clearly only because you are wearing them.
D: Correct. In the same way, you have a condition that we cannot repair or make new again. But the function can be restored as long as you continue the advice.
P: How long do I need to take it?
D: How long do I need to wear my glasses?
D: Same answer!
The patient may understand “control versus cure.”
Lock house and thief
Many illnesses are intermittent or episodic in nature, but the treatment is continuous. Bipolar affective disorder in psychiatry is a classic example. Others are asthma and migraine. Patients discontinue medicines, get relieved from side effects (hence feel better), and may have long periods of wellness before the next attack. Their subjective experience of feeling better without medicines for months at a time makes it difficult to understand the benefits of continuous treatment.
Intermittent risk but constant protection.
D: I want to tell you a story (piques interest). When I come to work, my house is empty. What do I put on the door for safety?
D: Correct! I always put a strong lock. Let us say that I was late 1 day, and forgot to do it. When I return in the evening can we say for sure that a thief would have taken everything?
P: I guess so.
D: Guaranteed? Is it possible that my luck is good that day, and no one notices that the door is unlocked?
P: Yes, that is possible.
D: So I return, and find all is well. Then, I say to myself, “I didn't lock the door, nothing bad happened; this means that I can leave it unlocked sometimes.” What do you think of that?
P: That would be wrong thinking. Eventually, you will get burgled.
D (smiling): You are being polite, that would be a fool's conclusion (pause). The house is your body, the thief is the illness, and the medicine is the lock (pause). No one can tell when the thief will come; he may come after a month, or after a year, but the lock needs to be used every single day.
The patient may understand the need for prophylactic medication.
Analogies need not be compulsively used whenever a complex concept is encountered during patient education. It must be borne in mind that unnecessary use of analogies might further confuse a patient, if not well explained. At times, analogies might consume more time than otherwise anticipated. The use of multiple analogies in a single session to drive home the concept is not recommended. At times, patients may take home only the analogies used and forget about the concept. This may be prevented by allowing adequate time for comparison and explanation. Another associated limitation is that patients from different cultures or socioeconomic backgrounds may be unfamiliar with the usual analogies used in one's clinical practice.
| Conclusion|| |
Using analogies in doctor–patient interaction are a relatively quick and effective way to communicate important abstract concepts. This could not only improve patient satisfaction and treatment adherence but also doctors' sense of accomplishment. Their use needs to be encouraged to become an integral part of medical education and in regular clinical practice.
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Conflicts of interest
There are no conflicts of interest.
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