My patient was struggling to describe his problem. “I have been having some trouble with…I mean, it’s just been a little different lately,” he said. While it was not immediately clear what “it” was, he mentioned it at the very end of his appointment and he was sweating.
“It’s not really a problem. Things are okay,” he added, reassuring himself as much as me. “But not like when I was younger.” His voice trailed off.
He couldn’t quite bring himself to say it, so I helped him.
“You don’t need to go from zero to sixty. You’re looking to go from thirty to sixty and stay on cruise control a little longer. Is that it?”
Relief washed over his face and he sat back in his chair.
“Yes,” he exhaled.
This was not the first time I had used an automobile metaphor to initiate a difficult conversation. Framing sensitive topics as maintenance and repair of the human machine can make medicine more accessible, less threatening. And while this approach is not for every patient, I am surprised how often I shift into car talk. Some days my office sounds like an auto shop.
Another patient was having trouble getting his blood pressure under control despite taking multiple medications. He drank six cups of coffee a day and was not inclined to cut down. Reluctant to add another antihypertensive, I explained that drinking all that caffeine while taking blood pressure meds was like having one foot on the gas and the other on the brakes.
“You’re going to wear out the engine,” I told him. He got it.
Automobile metaphors are perhaps most effective when used with car guys. However, there is no consensus on the definition of a car guy and their prevalence is unclear. Many patients—men and women—have a passion for automobiles, so in selected populations car talk can translate the language of medicine and ease their anxiety about health concerns. A physical exam may be less intimidating as a “tune-up.” Men who are stressed about getting a prostate exam sometimes breathe easier with the idea that we need to “check under the hood.” And young moms, so often focused on their families to the exclusion of self-care, sometimes need to hear that it is okay to “put the top down” and do something just for themselves.
Car talk is particularly applicable to cardiovascular issues. Patients with heart failure may better understand it when they hear that their heart is like an engine that has gone from six cylinders to four. For patients who do not exercise, I suggest that they are like a V8 engine sitting in the garage all day—the car needs to get out on the highway and blow the carbon out. And for 50-year-olds who lament the minor aches and pains of normal aging, I reassure them and encourage them to keep exercising: “The car has 50,000 miles on the frame. It’s going to creak a little.”
There are benefits to using metaphors in medicine, but there are also risks.1,2 To be sure, car metaphors sometimes backfire. I had a patient who objected to my use of the saying “blow the carbon out” and then took our medical discussion on an abrupt detour into the topic of global warming. And as patients increasingly favor alternative forms of transportation, car metaphors sometimes do not resonate, and may even have unintended cultural, socioeconomic or political undertones (in fairness, I should probably develop a series of bike and bus metaphors). Ultimately, car metaphors can go flat because a holistic approach to medicine is more complex than auto repair. But I find that, even when I get it wrong, patients appreciate my effort to help them understand their health. They recognize that I care, which is the heart of developing a therapeutic relationship.
One of the joys of being a doctor is getting to know our patients, but these relationships are mostly one-way. Car talk enables me to develop connections with patients without getting too personal. We talk about road trips, dream cars, and some encourage me to finally break down and get a city car. Friendly moments like these—ordinary in any other context—are powerful in clinical medicine. They build trust, give deeper meaning to our work and make medicine fun.
Serious car guys would not consider me to be among their ranks. I ride my bike to work and have never owned a car (I live in downtown Chicago where cars are often a hindrance). But I grew up outside Detroit and the first journal I read regularly was Car and Driver. I am fluent in the language of car guys and gladly return to my roots if it can improve my patients’ experiences and perhaps improve their health.
One patient named Walter had 90,000 miles on his frame when I met him. At the end of his visits he would sometimes ask me to come down to the parking lot to see his 1988 Chevy Caprice.
“This car still runs great and the engine can take any of those new cars on the road,” he would say. It was true. The car ran beautifully, unlike its owner who had a lot of wear and tear and needed frequent maintenance.
We both looked forward to his appointments and as the years passed these office visits were among the few reasons he actually drove. I would worry about him in traffic, but he loved the route up Lake Shore Drive and never missed an appointment.
Walter’s wife had died young and they did not have children. He had had a successful career and was still social with friends. When we talked about end-of-life issues he said he was not afraid to die. He was ready. Though he added, lightheartedly, that he wouldn’t mind “going a few more miles before my engine wears out.”
He did. When his engine wore out, his odometer had almost made it to 100,000.
