path: MEDICAL ANALOGIES
- analogies similes and metaphors – youre confusing me.docx
- anatomy of a good analogy.docx
- health literacy.docx
- practical tips on using analogies in medicine.docx
Some great books on explaining pain through metaphor:
- Explain Pain by Butler and Moseley
- Therapeutic Neuroscience Education by Louw and Puentedura.
The Theory behind Analogies
“Metaphors have a way of holding the most truth in the least space.” Orson Scott Card
This page is all about using medical analogies to help you explain things easier and better to patients. This form of using analogies to explain medical things is called “The Synectic Model of Teaching” – so called because synectic is a Greek work which means the joining of different ideas. Others might refer to it as “Reasoning by Analogy” but in our medical context, I prefer to simply call it “Medical Analogies”.
Please remember, not all medical analogies required an explanation. However, having said that, medical analogies are powerful tools for helping you explain things effortlessly. Why? Because with analogies you are trying to help a patient understand things by comparing whatever it is that you are explaining to something that they are more familiar with. In so doing, analogies help SIMPLIFY things.
For example, I think that whenever delivering a teaching session, setting aims and objectives are important. Why? Because it is a bit like driving from Leeds to Birmingham without a map. Yes, you can do it, but it will a) take a long time to get there, b) you may get lost along the way and c) you will feel uncomfortable throughout the journey because you’ll not know whether you are on track or not. In a similar way, if you don’t set the aims and objectives of an teaching session, it may become rather messy and unstructured, and this too will make you feel uncomfortable and the tutorial may not be effective nor efficient.
This is Dr Rahul Thakurr. He’s been asked to run a diabetes education day for patients. Look at the amazing way he uses the ‘lock and key’ mechanism to explain diabetes. And it makes instant sense to people. Notice the point where the lady in the audience speaks out and says that’s the best explanation she has ever heard. Like Orson Scott Card says… ‘Metaphors have a way of holding the most truth in the least space’ and Dr Thakurr provides a super example.
I wanted to share this with you – especially those of you who like some of my trainees say to me “but Ram, that’s what I said” and when I look at their video or their real-live performance, it is not exactly what they said – it was something vaguely similar but not the same – but in their head, they think it’s the same!
So, I am hoping this video will show how these similar “set of words” can have profoundly different effects on people. It starts with a blind man sat on the street needing money.
THE MEDICAL ANALOGIES DATABASE
Not all of these are perfect. Some still need modifying. But they all provide a starting point for you to tweak yourself. If you have any more or would like to suggest amendments, please write in the comments box below.
- An aneurysm is like the bulge you can get in a garden hose. The bigger the bulge, the weaker the wall and the likely it will burst.
- An aneurysm is like a balloon that has reached it’s maximum air capacity, after a while, the pressure becomes too much and it pops.
- An aneurysm is like a blister on a blood vessel, and like a blister it can burst or pop
- An aneurysm is a bit like a bulge on a weak part of a tyre. And like a tyre blowout, it too can pop and burst out blood.
- In many ways angina is like a muscle cramp in the arm or leg; which occurs when the working muscle does not get enough blood to match what it needs. In other words, the heart is doing fine when at rest, but doesn’t have the reserve required for exertion or stress. That’s because the blood vessels are either getting clogged up or are going into spasm. It’s not usually life threatening, but it’s a warning sign that you could be at risk of a heart attack or stroke if we do nothing. There are good medications and other treatments for angina. HOWEVER, if the angina symptoms are becoming more frequent or severe, or occur at rest, then you may have unstable angina which requires urgent attention.
- Have you got a suggestion? Post one in the comments box at the end of this page.
- Have you got a suggestion? Post one in the comments box at the end of this page.
Congential Heart Disease
- Congenital heart disease is like receiving a faulty pump from the manufacturer. That’s because congenital defects are those that are present at birth.
- Over time cholesterol builds up in your blood vessels just like rust builds up in the pipes of your central heating system. And then, the circulation doesn’t work very well.
- Over time cholesterol builds up in your blood vessels just like grime that builds up in the outflow pipe of your sink. And then, the circulation doesn’t work very well.
- An atheroma is a bit like a silently growing volcano. Many are stable and do nothing. Others can sometimes start to slow the circulation of blood. But in other cases, it can be serious – like a volcano, one day it might erupt and cause an awful lot of damage which could end up being fatal. The problem is that it is difficult to tell the stable safe ones from those that are dangerous.
- Cholesterol circulates around your body and then deposits itself your artery walls. And this produces a mild inflammation which results in little cholesterol bumps or pimples. These bumps are called atheroma – and most are stable and do nothing. But others can ‘pop’. When those atheroma pimples pop, they cause the blood in the arteries to clot at that site. If the clot closes off completely one of the arteries supplying the heart, that’s what causes a heart attack, and emergency medical treatment is required to remove the clot.
- Your heart is actually very similar to a small house in that it has four rooms, each of which has its walls, own doors (valves), electric and plumbing.
- In heart failure, the muscles of the heart don’t work very well which means it doesn’t pump as well as it used to. Now, if the pump in a water fountain started becoming faulty, the water wouldn’t flow so well and would start to stagnate in the pool. In a similar way, if the heart pumps less well, then the blood doesn’t flow well, and that means that it lacks oxygen and it too starts to stagnate – which then causes problems like swelling in the case of the limbs or shortness of breath in the the lungs.
- The heart is simply a muscle and a pump. When it is weak for any reason it just can’t keep up with the demands of the body. It gives out just like any muscle does if you over use it. When the heart is not pumping enough, the pressures inside the heart increase, fluid backs up in the system, and you get symptoms like shortness of breath and leg swelling.
- It’s worthwhile explaining to patients “not to be too worried by the term failure in heart failure. It doesn’t mean that your heart has completely given up. It’s just that your heart does not pump as well as it used to and therefore we need to make it easier for it to pump. Does that make sense?”
- In terms of treatment you might say… In Heart Failure your heart is working very hard – a bit like a horse pulling a cart full of sandbags. And of course, after a short while, the horse is going to get very tired and slow down, as will your heart. One of the ways to improve things with the horse is to reduce the number of sandbags on the cart – that will make the life of the tired horse a lot easier. Again, in a similar way, if control the amount of blood going into your heart, for example, the less it will become tired and exhausted and the better it will work.
- In cardiomegaly, the heart muscle is too thick. Now at first, you might think that was a good thing but it isn’t. Body builders for instance have lots of thick muscle too but we all know how stiff and inflexible they are. In the same way, a thickened heart will have lost its flexibility and can’t work well, even though the muscles are big.
- Your blood in your body circulates all around your body through pipes which we call blood vessels. Just like the pipes in your central heating system, if the pressure gets too high, the pipes and other organs become damaged. And like your central heating system, if the pressure is high, you won’t notice a thing until the system bursts – that’s why we call high blood pressure a silent killer. And what we are trying to stop is that damage.
- Your heart and circulation system is a bit like the local water works, with the heart being one main water pump just as at the local water works. If the pressure within the water works system piping became elevated, it would be likely for one of the pipes to break or burst. The pipe that would be most likely to burst would be the weakest. Relating that to the human body, high pressures within the blood vessels would put the weakest/smallest vessels at risk of a burst or a break. These weakest blood vessels are in the brain, the kidneys, the eyes, and in the heart. If the break or burst occurred in the brain, that would be a stroke. In the kidneys and in the eyes, the high pressures will cause slow damage over time. And the problem is, the damage happens so slowly and sneakily that you only notice it when too much damage has been done.
- There are valves in your heart which make sure that blood goes in one direction and not backwards. Sometimes, when those valves become a bit sticky, they don’t let the blood through as well. A bit like a blocked sink.
- A heart valve is like a check valve, directing blood in one direction and preventing back flow.
- A heart attack happens when there is a blockage in one of the arteries supplying blood to the heart muscle. A big heart attack is like the permanent closure of a large road, which you know is going to cause mayhem on the streets. In a similar way, the blockage of a large artery is going to cause damage to a large section of the heart – so much so that there is a significant risk of death.
- A heart attack is basically like a plumbing emergency where there is a serious and sudden clogging up of one of the pipes that supplies blood to your heart. If it is not unblocked, that part of the heart muscle it is supplying dies. Heart attacks are very serious and there is a significant risk of death.
- A mild heart attack is like the closure of a small side road. It’s not going to affect a lot of people. Like the closure of a small road, the blockage of a small artery supplying the heart will only affect a small part of the heart muscle. This means only a small amount of permanent damage will occur. However, a major heart attack is like closing a motorway – which you know is going to cause mayhem to lots of people and other roads. So, a major heart attack is the result of a blockage of a big artery supplying the heart and that will affect large parts of your heart. Because the heart is one of the most important organs in your body, a big heart attack could easily end your life.
SOME CARDIOLOGISTS SAY THE PLUMBING/ROADBLOCK/OBSTRUCTION MODEL IS INCORRECT TO USE AS AN ANALOGY… so they suggest this one…
- Cholesterol circulates around your body and then deposits itself your artery walls. And this produces a mild inflammation which results in little cholesterol bumps or pimples. Most of these bumps will be stable and do nothing. But others can ‘pop’. When those pimples pop, they cause the blood in the arteries to clot at that site. If the clot closes off completely one of the arteries supplying the heart, that’s what causes a heart attack, and emergency medical treatment is required to remove the clot.
- In terms of explanation for lifestyle changes, you could then say
- Thus, for patients who are already showing signs of heart disease, it is crucial to take steps to reduce the inflammation. And the way you can do this is through not smoking, exercising, stress reduction and a Mediterranean diet.
- You mustn’t wait if you think you are having a heart attack. Call 999. A heart attack is like a house fire – the longer it takes to put it out, the more structural damage will be done. That’s why you must seek medical attention as soon as possible – call 999 for an ambulance.
- Have you got a suggestion? Post one in the comments box at the end of this page.
- Have you got a suggestion? Post one in the comments box at the end of this page.
- The skin is like a rubber band. Initially, when it’s new, is very elastic. It then becomes less elastic with age. And when exposed to the sun, it deteriorates even further.
- Did you know that some trees (eg Redwoods) make seeds that fall to the ground and lie there doing nothing for 10-50 years, only to sprout when the conditions are just right? Well, your cold sore is caused by the Herpes virus. When your cold sore settles, the virus never actually goes away. Like the tree seeds, the herpes virus goes to sleep only to wake up again when the conditions are right to cause another cold sore. And the right sort of conditions are when you’re not eating well, you’re run down or feeling stressed out. Even smoking can trigger it.
- A cyst is like a balloon with watery gunge in it. Most of the time they don’t cause any problems. And they aren’t anything serious.
- You’ve got something called seborrheic keratoses. Don’t worry, they are not serious and usually happen because of ageing. They are a bit like a barnacles on rock, except in your case they are stuck on the skin.
Tinea versicolor/pedis (Athletes foot)
- Tinea versicolor/pedis is bit like moss growing on trees, except it’s on your skin. So you have to continue treatment even when you can’t see it so that you kill the roots and stop it growing again.
- Unfortunately, you have a condition called diabetes. In diabetes, there is a problem with the way your body controls sugar. Normally, your body keeps a very strict level of sugar in your blood – because too much or too little can cause a lot of damage over time. The way it does that is with a chemical called insulin. Insulin is the key that opens and closes the door to how much sugar is released into the blood. In diabetes, there is a fault with this insulin-door system. It’s a bit like the key becoming rusty which therefore means the door doesn’t always open and close well. So, we need to do something to lubricate that key to make it work better and we can do that either through diet or medication.
- Unfortunately, you have a condition called diabetes. In people who don’t have diabetes what happens is that there is a certain amount of sugar in your blood. These sugar molecules are like cars on a motorway (American – freeway). And there is this chemical called insulin which opens various slip roads so that this sugar can come off the motorway and feed parts of your body. But in diabetes, this insulin system becomes faulty which means the sugars in your blood are sometimes very high or very low. This will not only make you feel unwell but start causing damage to your body over time.
- Imagine your body’s sugar stores like rows of houses with locked doors, and insulin is the key that opens the lock. In type I you don’t have they key, so you can’t open the doors to let the sugar in. In type II, you have the key but someone put gum in the keyhole so the key doesn’t work very well.
- When diabetes is uncontrolled, it can slowly damage your blood vessels over time. Just like a poorly maintained central heating system slowly builds up rust over time which then damages the inner pipes and radiators, the same sort of thing happens in diabetes. The high sugar circulating in the blood damages the blood vessels. For example, if those vessels supply the legs, you end up with poor circulation and possibly gangrene. In the heart it would lead to heart attacks, to the brain it would result in strokes, in the eyes it could lead to blindness and the kidneys to kidney failure. Does that make sense? Having heard all of that, would you mind telling me what you're thinking?
- We all have little blood cells called red blood cells circulating around our body. They are the things that make our blood look red when we bleed. There’s billions of them in your blood and they are shaped like donuts. In a bakery, some donuts have a lot of icing on them and others have little. In a similar way, those of us who aren’t diabetic don’t have much of a dusting of sugar on our donut-shaped red bloods cells but in diabetics there is. The amount of sugar dusting on your red blood cells tells us how bad your diabetes is. The more, the worse it is. And that’s what HBA1C measures – the amount of sugar dusting on your donut-shaped red blood cells. Does that make sense?
- HypOthyroidism: The thyroid is a gland that sits in your neck. It makes a chemical called thyroxine which gives you a bit of energy and ‘get up and go’. Your thyroid gland is unfortunately a bit lazy and doesn’t make much of that energy chemical. And that’s why your body feels tired all the time. It is a bit like running a factory without an adequate power supply. So, one of the ways to get that power back inside you is to give you that energy chemical in the form of a tablet.
- HypERthyroidism: The thyroid is a gland that sits in your neck. It makes a chemical called thyroxine which gives you a bit of energy and ‘get up and go’. Your thyroid gland is unfortunately a bit overactive and is making too much of that energy chemical. And that’s why you feel agitated all the time and can’t sleep. It is a bit like revving the accelerator too much on a speedy car. So, we need to slow you down a bit and the way we can do that is either with a tablet or iodine which will work against your thyroid so it makes less of that energy chemical.
- 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.
- The thyroid is like the thermostat for the body.
- The thyroid is like a music conductor and the body is the symphony.
Cleaning your ears
- Never put anything in your ear smaller than your elbow. That’s to say, don’t put stuff in there! Did you know your ears have a self-cleaning mechanism? Yes, that’s how good our body is. But if you start interfering, you start messing that system up. If you need to itch, rub here (rub your own tragus).
- Clean your ears out with cotton-tips as often as you polish the TV antenna on the roof of your house!
Otitis media (Glue Ear)
- Glue ear is a bit like having a drum that is full of water. When you hit it, it doesn’t vibrate well or make a noise. This is why you cannot hear very well. The good news is that most drain out over time – but in some cases it can take a while (months).
- The fluid in your inner ear infection is thick like ketchup in a bottle. We all know how difficult it is to sometimes get a new bottle to release the ketchup but If you can get a little air in there the ketchup will flow nicely. In a same way, by gently “popping” the ears and getting a little air drop in there, the fluid will run out out of your ear. But you have to do this very gently like the way I showed you. Never pop your ears hard. (Demonstrate Val-Salva manouvre).
- Your ear canal is a bit like conveyor belt in that as wax builds up, it will push it from the inside out – providing you leave it alone. However, if you use a cotton bud (or Q-tip for Americans), you will push the wax back up the belt and clog things up.
- The external ear canal is like a self-cleaning oven. If you try to clean it with chemicals you will damage the self-cleaning oven. In a similar way, if you try to clean your self-cleaning ear with things like cotton buds (Q-tips) you can damage it and clog things up.
- The eye is like a camera. The back of the eye is called the retina and is like the film in the old style of cameras. The front of the eye is called the cornea and is like the front glass on a camera. And then there is the lens of the eye which is like the lens of a camera.
- It is this lens that becomes cloudy and steamed up in cataracts and needs replacing with a clear one.
- The eye is like a camera. The back of the eye is called the retina and is like the film in the old style of cameras. In a detached retina, part of the back film lifts off and becomes all wrinkled. We need to do some laser therapy to glue it back down again.
- Unfortunately, as you’ve guessed, you are bunged up. I think you’re bunged up because you’re not getting enough fibre in your diet. You see fibre in your diet is like a sponge. It absorbs water and makes your poo nice and soft. So with fibre, you have to drink a lot of water too. Without fibre and without water, they will be hard.
- The gallbladder is like a little rugby shaped ball which pumps its juices into your bowel to help it digest the fat in food. Unfortunately, your gallbladder is full of stones which means every times the ball squeezes, it hurts as it squeezes onto those stones.
- You can also refer to the gall bladder as something that looks like the bladder of a sphygmomanometer. Hold up the BP cuff and show them.
- Hemorrhoids are like the varicose veins you see in your leg. When they get full of blood, they hurt because the blood doesn’t circulate through those varicose-type veins very well.
- A hernia is like an inner tube inside a tyre. If the tyre is cut, the inner tube bulges through. To repair it, we need to push that tube back in and strengthen the area where the tire is cut usually with something like mesh.
Irritable bowel syndrome
- Your bowels are like one big tube. And they’re normally very good at slowly pushing the poo along to the end in a regular fashion – so much so that you don’t even notice that they’re doing it. A bit like gently squeezing toothpaste out from one end to the other. But in irritable bowel syndrome, your bowels start behaving erratically. Imagine squeezing a toothpaste tube at several points at the same time – there would be a mess everywhere. And that’s what’s happening in irritable bowel syndrome. Don’t worry, it’s nothing serious, but it can be quite horrible.
IBS is a bit like leg cramps but in your tummy. Now, think about leg cramps for a moment. They are very real and very painful aren’t they? And although the muscle isn’t behaving properly, it doesn’t necessarily mean there is something seriously wrong with your legs. The same goes for your irritable bowel – which is why all the tests have come back normal but you are still experiencing quite bad discomfort. Does that make sense? We just need to find a way of managing it better.
- The bacteria that live in the normal vagina are like the little creatures that live in the woods in balance, like foxes and squirrels. If there are too many foxes (BV), you need to kill some off to restore the normal order and allow the squirrels (good bacteria) to flourish. [Comment: Remember BV is NOT an STD, just an imbalance of normal bacteria.]
- Mrx XXX, let me explain a bit about the different types of smear results. There are five types of results and it’s best to think of these as five cities in a line that goes outwards from your home. The first type of result is NORMAL – and that’s your home town – everything is good and safe. The second result is called CIN1 and thats the second city. CIN2 is the third. CIN 3 is the fourth and finally Cancer is the fifth. Now it’s important to remember that the CINs are not cancer, but the journey can lead to city number 5 – which is cancer. That’s why we keep a close eye on you and sometimes do surgery. But I have to stress again that CIN is not cancer, and it usually takes several years to get to city 2 to 5 (i.e. the cancer).
- Mrs XXX, you have this condition called Cervical Dysplasia. The first thing I want to say is don’t let yourself get too worried at this stage because it is not a cancer. Let me explain and by the end you’ll understand everything. The cervix is the lower part of your womb. Did you know that before cervix cancer happens, there are usually some cell changes that can be seen there. They do not indicate you have a cancer. But they do indicate we need to keep an eye on you otherwise it might progress to a cancer. But again, don’t worry too much because it often takes years for these cell changes to turn into a cancer. It does not happen overnight. These changes can be mild, moderate or severe. We keep an eye on the mild ones because most of those turn back to normal within 18 months. The moderate or severe ones may require a little bit of surgery or may be frozen off. [still need to think of an analogy for this one]
- Fibroids are like potatoes, buried in your womb. Some stick a little out of the ground. The more fibroids you have, the more blood you make and that’s why your periods are heavy and painful.
- Unfortunately, you’re blood results show that you’re anaemic. What that means is that you don’t make enough blood. Your blood is a bit like a truck which carries food and oxygen to all parts of your body. If there isn’t enough blood, then there aren’t enough trucks to quickly carry all that food and oxygen around your body and that’s why you’re feeling so tired.
- Unfortunately, you’re blood results show that you’re anaemic. What that means is that you don’t make enough blood. Your blood is a bit like a river which has lots of little boats which carry food and oxygen to all parts of your body. If there isn’t enough blood, then there aren’t enough boats to quickly carry all that food and oxygen around your body and that’s why you’re feeling so tired.
- Your lymph nodes are like little filters in your body and you’ve got lots of them. Just like a water filter, they filter out all the nasties like bacteria and bugs that don’t belong in the body. Sometimes they swell up and feel sore especially when you have an infection – and especially when they are doing overtime!
- One of your blood tests came back as a bit high. The difficulty is that this particular blood tests only tells you that something might be going on but doesn’t tell you exactly what. For that, we have to dig deeper. It’s a bit like a dog who senses something is going on in the near by buses but cannot tell you whether it’s a cat, a mouse, a squirrel or a hedgehog. Does that make sense to you?
- One of your blood tests came back as a bit high. The difficulty is that this particular blood tests only tells you that something might be going on but doesn’t tell you exactly what. For that, we have to dig deeper. It’s a bit like finding a red stain on one of your shirts that have been taken out the laundry. You can see that something is up, but you wont be able to tell just by glancing whether it is a result of cherries, beetroot, cranberry juice, or something else. In fact, you may never know!
- When 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: Mrs X, I can see your going through a tough time at the moment. Sometimes we get thought viruses. Thats where we start thinking negatively about our condition. So we need to keep our thoughts in check and not allow negative ones the power to do this. To me it seems like your going through a temporary blip but that you’re going to come through just fine if you can keep these thoughts in check. I know you can do it. So let’s talk about how to get you thinking strong again…
- We all need time off from work to rest and recover – if we don’t, then we burn out. The liver is the same. You need to have those alcohol free days to allow it to still function. It’s a great organ but it can still burn out if not looked after properly. So, are you in a position where you might be able to give it a bit of break?
- Worry: Worrying about something that may not even happen is like paying interest on a loan you haven’t taken out.
- Stress: Having heard you, it sounds like your life is full of too much stuff. Would you agree? (nods). The thing is, stress is like a vase filled to the top with water – if you put a drop in it overflows. Would you say that’s the case with you? So, we need to have some way of controlling the water level?
- Life is a bit like a long distance race where you have to pace yourself. But some people don’t pace themselves and treat it like a sprint. And as you know, in a sprint your body exhausts itself very quickly as your ‘rip, bust and tear’ those muscles.
- 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, you got too many programs on the go. Perhaps if you could shut down some of the programs you and your life might be more at ease and work better? What do you think?
- 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, have you any thoughts about how we can juggle with less balls?
- 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? (Gently ask): So why is it okay to put to one side something which has an even bigger chance of bankrupting your life?
- 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 up the ladder – like working on your thoughts and counselling. How do you feel about this?
- Depression – mechanism of action: You’re brain produces a happy chemical called Serotonin. But the depressed mind is a bit like a bath without a plug hole. The serotonin leaks away and doesn’t stay in the brain long enough to keep you happy. Taking an antidepressant is a bit like the bath plug – which stops it from escaping.
- Trying to deal with depression just by fighting it is a bit like trying to settle an itch by scratching it. I wonder if it is now time to seek some help by the way of talking therapy with a counsellor or medication. What do you think?
- 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. In a similar way, would you be willing to take medication to aid your natural recovery?
- Taking medication – Most people don’t like the idea of antidepressants/anti-anxiety tablets, but if I told you that you had iron-deficiency you wouldn’t hesitate in taking supplements if you knew there was a good chance that they would make you feel better. So how about looking at depression as a deficiency in mood chemicals, and that taking this antidepressant may increase them and make you feel happier again? You might then even be able to explore other ways of improving you mood (like self-care and counselling)
- Type of medication – Hopefully this antidepressant will work. There is a small chance that it might not, but not to worry. It’s likes shopping for a shirt; there are loads of shirts in a shop and you need to try them on. Many will fit you and not fit others. Many will fit others and not fit you. But either way, hopefully we will find one that suits. Would you be willing to give it a try.
- Depression – staying on medication – It’s really important that you stay on your antidepressants for about 12 months. If we think of a depressed brain like an unset jelly, and the antidepressant as a fridge, then if you take it out too soon, it’ll turn back to liquid (depression). But if you leave it long enough it will “set”.
- 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. Does that make sense?
- 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. It's actually a NORMAL reaction that we all have. 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 counselling does is NOT to get rid of it, but instead to help the brain stop reacting to everything like a bear running at you.
- When we are depressed, it's because of an imbalance in the chemicals in the brain. Some of these can leak out of the brain and affect other parts of the body - for example if it gets to the the tummy it might cause butterflies or tummy pains, in the chest it might cause chest pain, palpitations or shortness of breath, or in your muscles you might find tiredness or fatigue and in the head you can get headaches. (patient frantically nods as they identify with some of those symptoms).
- Refusing counselling: I know you’re not very keen on going to counselling and that’s okay if you really don’t want to. I would just like you to consider something for a moment. Answer me this if you will. If you had a broken leg would you be keen on mending it yourself? What about appendicitis – would you be happy removing your own appendix? You see, the reason why I am asking you all of this is that the discomfort you are experiencing in your mind is like physical discomfort in that it indicates something needs to be mended or the damage will worsen. Counsellors are health professionals who are very good at helping to heal your mind just like a surgeon is good at mending your leg. [I know you have found it hard in the past, and sometimes it is hard just like it is recovering from a fracture – the operation is the easy bit, the 6 week recovery after the hardest. ] Would you mind telling me your thoughts having heard what I’ve said?
- Refusing counselling: I know you’re not very keen on going to counselling and that’s okay if you really don’t want to. I would just like you to consider something for a moment. 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. Do you see where I am coming from? What’s your thoughts?
- I wonder how we can build up your strength and flexibility to cope with whatever is thrown at you? We call that resilience and building your resilience is a bit like building a dam. 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. Do you see what I mean? What are your thoughts?
- Having schizophrenia is like viewing life through a kaleidoscope. There’s all these colourful thoughts, ideas and behaviours and it is hard to put the pieces together and make sense of it all because things keep changing.
- When someone self-harms, it can be like lifting the lid of a boiling pot. There is a sudden release of pressure and a sense of release and a temporary feeling of calm. Is that how it is for you?
The thing is, the release is only temporary and I wonder if there are other equally good ways of release that is not so harmful to your body. Is that something you would like to talk about? (note, if patient says no or is unable to do so, NICE recommends talking to the patient about harm minimisation, whilst addressing the long-term underlying issues and finding more healthy coping strategies through therapy. Understand the WHY behind the behaviour, not just the WHAT.
PS In the case of overdose or chemicals, it is always important to explain that there is “no safe way to self-poison”.
Bursitis (e.g. olecranon, prepatella, trochanteric)
- Your joint has a sort of cushion filled with a thin layer of gel to protect it. Sometimes, in trying to protect the joint, it gets overworked and when that happens it becomes inflamed and swollen.
Cancer – recovery
- Patients are often overwhelmed by the uncertainty that the future holds after they have had cancer curative treatment.
- One method is to gently remind them that worrying about something that may not even happen is like paying interest on a loan you haven’t taken out.
- Another is to suggest they consider their past history of cancer 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.
- Now, let me explain something about exercise. “Exercise is Medicine”. Just like other medicines we need to think of dosing when it comes to our exercise. Too little and it won’t do much. Over do it and you can aggravate the problem. So what I suggest is that you do the exercise I’m going to give you 3 times a day. On each of those times, you need to do 10 repetitions. These exercises will only work if you do them every day and that’s the commonest reason why they fail – people sometimes just don’t do them or they do them half-heartedly. But just like the way we need to take our medicine regularly, the exercise needs to be done regularly too. Does that make sense?
- There is a fracture on your x-ray. The reason why it wasn’t picked up the first time when you had your injury is because it was a razor thin fracture which meant it couldn’t really be seen on the first x-ray. Those sorts of fractures are only picked up on x-ray pictures take 2 or more weeks down the line when a “bone scab” forms which is much easier to see.
- Basically, in gout you have too high a level of a chemical called uric acid. The problem which high level of uric acid is that it’s a bit like sugar or salt. If you put too much sugar say to your tea, it will crystallise on the bottom of your cup. And too much uric acid does the same – it crystallises in your joints. And as we all know, crystals have sharp edges and that’s why your joints are painful when you move them.
- Don’t use wear and tear…. wrong because it is not a true reflection of what goes on and also it gives patient a sense of helplessness (how would you feel if you were told your joints were ‘crumbling’? Instead, use wear and repair (gives a sense of hope).
- Can I take a moment to explain something about pain? We it goes something like this. Pain is very much like the volume dial on a radio. And right now it sounds like it's getting cranked up to a high level and everything is too loud. Am I right in thinking this? So, what we need to do is some how turn down the dial and get things back to a comfortable listening volume. How does that sound to you? Shall we talk about some of the ways to do that? [Could also suggested a realistic pain level eg 'can't turn the volume off but we can get it to a comfortable listening volume'].
- Imagine a big organisation where you have the top boss underneath whom are lots of vice presidents who report to him. Now, if those vice presidents report too many matters to the top boss, for example, even trivial matters, then that top boss is going to end up overloaded, feeling like they can't cope and a massive headache. All these reports will make the top boss feel overwhelemed and even anxious as he or she analyses the reports in more and more detail. And they'll be on the look out in case even more new reports come through. If they do, they'll get even more anxious. In your body, you have a top boss too - which is your brain. Different parts of your body report back to the brain just like the vice presidents do in the organisation. But in persistent pain, the brain gets too many pain inputs from different parts of the body. As a result, your brain (and you), feel overwhelmed, feel you can't cope and you end up being more sensitive to any new pain signals that come your way. This makes you more aware of the painful body part. So what we need to do is be able to not only calm those signals down, but also retune the brain to get it back to its more calmful state.
- Your sensory system is an alarm system. Sometimes it is too sensitive and we need to calm it down.
- Your brain is like an orchestra. Now, an orchestra can play many tunes, but you brain is currently overplaying the same tune - the pain tune. We need to find a way to retrain the brain so that it doesn't play the pain tune as often and plays other more pleasant tunes instead.
- When our nerves are damaged they release a soup of inflammatory pain producing chemicals. These tablets will hopefully reduce the amount of that inflammatory soup.
- Sometimes we get thought viruses. Thats where we start thinking negatively about our condition. The research shows that these thought viruses can actually play havoc with our nerves and make them feel even more sick. So we need to keep our thoughts in check and not allow negative ones the power to do this. Let me show you a little 2 minute video giving examples of thought viruses: www.youtube.com/watch?v=7eQpRZxXv2g. So, tell me about the kinds of thoughts you've been having at home. (gradually move the patient into positive thinking)
Tennis (or Golfers) Elbow
- The brain is a bit like a set of filing cabinets. In dementia, some of these filing cabinets start becoming sticky and are difficult to open. As time goes on, unfortunately more and more drawers start getting stuck. The medication for dementia tries to open some of these again but I’m sorry to say it’s not always successful.
- Normally the brain fires little electrical signals in a controlled way. But when a fit happens it’s a bit like electrical signals going off all over the place. And then it spreads all over the brain. We need to put you on medication to calm those signals down.
- Normally, the brain fires electrical signals in a controlled way. When a fit happens, the brain cells are a bit like people at a rock concert. One person starts screaming and dancing, then those nearby do so too. And before you know it, it spreads all over and everyone is dancing and screaming chaotically. We need to put you on medication to tone down the troublemakers.
- Epilepsy can be thought of as a short circuit in the brain, where the electrical impulses go round and round.
- In Multiple Sclerosis unfortunately your immune system starts to MISTAKENLY attack the outer insulation covering of your own nerve cells. Just like a frayed electrical wire which would then short circuit and misfire, the damaged nerve cells do the same thing – they start to misfire. This can lead to a wide range of symptoms from extreme tiredness to balance and walking problems.
- The headache you’re getting is a called a tension headache and you’ve already said how much tension there is in your life both at work and at home. The thing I’m worried about is the amount of paracetamol you’re taking. I don’t think it is the answer. Let’s say a friend of yours had a headache because they were punching themselves in the head all the time. What would you advise? Would you tell them to take some paracetamol or tell them to stop punching themselves? So, can you see what I am saying? Paracetamol is not the answer… we need to work on the tensions in your life. Have you any thoughts?
- What is Cancer? Every cell tries to repair or replenish it cell. Every cell in our body has a program. When the program is faulty and bad cell is made. Like a washing machine programme going wrong half way in a cycle.
- The lungs are like a set of tubes. And the big tubes split into smaller tubes and those tubes split into more smaller tubes and so on. These tubes are normally elastic and flexible but in asthma, something triggers them to go into spasm which mean they go all small and don’t open up. And that’s why asthmatics find it hard to breathe. Imagine trying to breathe through a straw quite hard – it would not only be difficult, but it would produce a whistling wheezy noise too. And that’s exactly what happens in asthmatics. So, we need to give a medication like an inhaler to open those airways back up again. It can be a very serious condition and an asthmatic should keep their inhalers with them at all times.
Blue and Brown Inhalers (Treatment, Preventative)
- The inhalers are like the safety devices in your car. The brown one is the preventer and its job is to stop the asthma flaring up in the first place. So, you take it every day without fail – just like the way you wear a seat belt in your car every time you get in. The blue inhaler is to treat any asthma symptoms that breaks through. You only use it when the asthma flares up. A bit like the airbags in the car – they only come out once you actually have a crash.
- A lung with emphysema is like having blebs or blisters on the lung. These blebs or blisters have a habit of trapping air once they get in them and so a patient will always be breathless because the oxygen can’t move in and out. It’s often related to smoking. And occasionally, a bleb/blister can break and if that happens air gets out of the lung, causing a collapsed lung.
Peak flow meter
- Please can you monitor your lungs for me using this device. It is called a Peak Flow Meter and it tells me how quickly air can move in and out of your lungs. It’s a bit like the speedometer on a car. If a car is coughing and spluttering and failing to speed up – you can easily pick that up through its speedometer. In a similar fashion, when your asthma is playing up and you are coughing and spluttering – your Peak Flow Meter tells me how bad things are.
- Antibiotics: You've got a viral infection. And for those type of infections, antibiotics don't work. They only work against bacteria. It's a bit like using bug spray to kill the weeds on your lawn. You know it won't work because it's designed to kill bugs not weeds.
- Antibiotics: Let's say you had ants in your house. Would you use rat killer on them to get rid of them? No, because you know it's for rats and not ants. And the same goes for antibiotics - they are good for bacteria but not viruses. And what you have is a virus. But the good thing about viruses unlike rats and ants is that they end up killing themselves off after about 5-7 days.
- Antibiotics: We're not going to give you antibotics for this for the same reason we wouldn't give you an allergy pill for a broken arm. Do you see what I mean?
- AntibioticsUsing antibiotics for viruses is a bit like putting more fuel in the tank of your car when actually it's the battery that's dead.
- Reassurance: 'yes, it's doing the rounds - theres a lot of it going around' is a very reassuring and therapeutic statement.
Chronic Renal Failure
- The kidney is like a filter, taking bad things out of the blood. Unfortunately, your kidney filter is not working as good as it used to. It’s still doing an okay job but we need to keep a close eye on it.
Chronic Kidney Disease
- The kidney is like a filter, taking bad things out of the blood. Unfortunately, your kidney filter is not working as good as it used to do when you was younger. However, I don’t want you to worry because the level at which it is working is okay for your age. So, it’s still doing an okay job but we need to keep an eye on it.
Benign Prostatic Hypertrophy (BPH)
- The prostate is shaped like a donut and the tube that you pee out of goes through the centre of the donut. Over the years, your donut-shaped prostate has got bigger and bigger and the central hole has got smaller and smaller. This means the big prostate then starts tightening around your peeing tube and hence the reason why you have the water trouble you are describing.
- Examining the testicle is like squeezing a peach. It should be soft. If you feel something hard, like the pit, call your doctor.
- Your body is like a bank account. It stores fat instead of money. When you've got too much money, you put it into your bank account and as a result it becomes fatter. In a similar way, if you eat way too much, your body becomes fatter. Now, if you want your body bank account to get slimmer, you have to eat less so that it forces your body to withdraw the fatty cash from its storage areas.
- I know you've tried to change your eating habits in the past a few times and you feel you have failed. If you were teaching someone to ride a bike and they fell off a few times, would you tell them that they shouldn't bother to get back up on it and try again until they succeed? Do we all fall off a few times in the beginning?
- Your body has actually done an amazing job of getting rid of that awful virus you had. But in order to do that, it's used up all the energy in your energy stores. So much so that there's little energy left for you and hence why you're so exhausted. But it will build it all back up again, it just needs a few more weeks.
- 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.
“God will heal me”
- Sometimes patients resist medical help because "God will heal them". There’s no need to contradict them, their belief is as valid as yours. Your aim should be to get them to see the whole story and to do so you can tell this story…
- I am so impressed by your strong faith in God and I would like to tell you a very short story and then see what you think. Okay, so the story goes like this. There were some floods in a small village, and they were getting worse. A police car came to evacuate a man, but he refused saying "No, God will help me." Later his house was surrounded by water and this time a boat came to rescue him. He gave the same response to them. Later, the floods got worse and he is now on his roof and a helicopter comes but again he refuses but this time he drowns. In heaven he says, "God, I had such faith, why didn't you save me?" God says, "I sent a police car, a boat and a helicopter. What more did you want?" So, the reason why I told you that story is because a lot of people believe that God performs miracles through people too. What are your thoughts having heard that story?
- Taking medicines on a regular basis is like watering a garden. If you wait until the plants are a little wilted, it's too late. Water every day.
Preventive care/Well-Woman/Well-Man checks
- Taking care of your health is like doing maintenance on your car. You don’t wait until you blow your engine before you change the oil.
Screening for Cancer
- Cancer screening is basically a test is designed to find diseases that can then be stopped or slowed down. It is hoped we pick them up early, but that isn’t always the case. It’s a bit similar to a car mechanic who puts one of those diagnostic machines on your car to see if anything playing up.
Sleeping tablet request
- Patient asking for benzo to sleep/anxiety: I know you’d like some sleeping tablets because your sleep is so bad and that’s completely understandable. The thing about sleeping tablets is that it’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. Do you see where I am coming from?
- I know you’ve tried to stop smoking in the past a few times and you feel you have failed. If you were teaching someone to ride a bike and they fell off a few times, would you tell them that they shouldn’t bother to get back up on it and try again until they succeed? Do we all fall off a few times in the beginning?
Your life, your goals
- Life is like a car. A driver decides where they want to go where as a passengers lets things be done to them. Do you want to be the driver or the passenger?