I recently came across an obscure compact disc (CD) from the equally obscure progressive rock band Caravan. The CD was titled "Blind Dog at St. Dunstans." At the end of the seventh song, "Jack and Jill," two voices can be heard amid music and barking dogs. The first voice asks, "What are those two doggies doing over there?" The second voice answers, "Well, the doggie in front is blind and his friend behind is pushing him all the way to St. Dunstans." ( was founded in 1914 as a charity and rehabilitation center for British soldiers who were blinded during World War I.)
My laughter yielded to somewhat serious contemplation. How often do we use -- stories in general -- to explain complicated medical concepts to patients? Probably not often enough. But , "collectively, physicians' stories become ... shared awakenings to the importance of humanities in medicine."
One of the most pristine examples is the use of war as an allegory for medical intervention. Colleen Bell, PhD, a professor of political science, : "... metaphors of illness, patient, and physician -- constituting a strategic allegory of medical intervention -- have appeared as characters in the narrative of modern counterinsurgency." Bell notes that physicians have a tendency to view cancer and infectious diseases as "threats" that must be evaded. Upon successful treatment, the patient has "beaten the enemy" and "won the battle."
Plato's has frequently been used as a teaching tool in medicine. The Allegory of the Cave describes a group of imprisoned individuals forced to live in a cave their entire lives. The prisoners can only see shadows of objects moving near a fire, but they cannot see the objects casting these shadows. The prisoners, Plato argues, are us: human beings trapped by the limitations of our senses.
Plato's cave embodies the uncertainty embedded in humans' perception of the world and the objects it contains, contrasting reality with our interpretation of it. It is a lesson in humility to know that physicians will never have perfect or complete understanding of a patient's disease. Living and working with uncertainty is why practicing medicine is considered both an art and a science.
I used many allegories with my patients. I viewed storytelling as a way to bridge the divide that separates us from human frailty. Some of my favorite allegories were based on books and movies that, in themselves, were loosely based on Plato's Cave.
For example, I treated a patient with a severe narcissistic personality disorder. He only saw the world one way -- his way. I used Ray Bradbury's 1953 novel Fahrenheit 451 to urge him to consider other viewpoints. In this famous dystopian novel, fireman Guy Montag burns books for a living, until an eccentric young neighbor forces him to reconsider his worldview.
I've treated several medical professionals for depression related to . In this context, the 1998 movie The Truman Show was a useful allegory. Unbeknown to Truman Burbank (Jim Carrey), he lives a faux life used purely for television entertainment. Slowly, he begins to chip away at the facade and breaks free, discovering his true identity.
When my patients with schizophrenia and bipolar disorder were in remission, many of them related to the classic 1966 French film King of Hearts. The inmates from the asylum literally escaped and took control over an abandoned town ravaged by war. The psychiatric patients assumed the role of shopkeepers, like "normal" people.
The most frightening and dangerous patient I ever treated was a pyromaniac. Anger and rage were at the root of his impulse disorder, and I suggested a metaphor for his anger -- that it was like gasoline and he could use it in one of two ways: he could set the gasoline on fire with a lighted match, or he could put the gasoline in his car for extra mileage. "There is nothing wrong with being angry," I told him, "It just depends on how you use it."
My favorite allegory is the starfish story. Many of us have heard it before. In short, a little boy at the beach returns stranded starfish to the ocean. An old man asks the boy, "Do you really think you're making any difference?" The boy holds aloft one of the starfish and replies, "It makes a difference to this one," and hurls it back into the sea. The starfish allegory resonates most with patients who have given up on themselves and question why we work so diligently to save them.
During my residency, I recounted to my supervisor how I planned to selectively use the starfish story. He said I had a "" "Art," he commented in the same vein as the older man to the child, "you can't save them all," reminding me that psychiatry, like other specialties, has a mortality rate -- from suicide and homicide. Still, I tried.
Understanding allegories requires abstract reasoning. Therefore, children and individuals with cognitive deficits, poor comprehension, or limited English proficiency may not be appropriate candidates, because the allegory may be misunderstood or misleading.
Case in point: I was required to deliver bad news to a gay man I had been treating in psychotherapy. His comprehension was below average, and to make matters worse, AIDS was new on the horizon (circa 1983). He handed me a health department letter that read "HTLV III positive" (the term "HIV" had not yet been coined).
I thought if I explained the allegory behind Nathaniel Hawthorne's The Scarlet Letter -- that "A" stood for adultery (among other possible meanings) and that shaming tactics do more to alienate than they do to heal -- that it would affirm my patient's choice of lifestyle and lessen the blow of bad news. But the message never registered. Sensing his bewilderment, I advised my patient to discuss the lab result with his primary care physician.
I have since learned more appropriate ways and how to temper my storytelling so that I can be certain to reach and join patients rather than confuse them or come across as disingenuous.
So, if you choose to use allegories in practice, make sure they are understood and paint a complete and accurate picture of the reality of the situation. After all, the dog from behind is not really guiding the dog in front!
Arthur Lazarus, MD, MBA, is a member of the Physician Leadership Journal editorial board and an adjunct professor of psychiatry at the Lewis Katz School of Medicine at Temple University in Philadelphia.