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Rapid response to:


Peaches and cream in a multi-ethnic society

BMJ 2017; 357 doi: (Published 10 April 2017) Cite this as: BMJ 2017;357:j1752

Rapid Response:

Medical education, Metaphors, and Analogies in a multi-ethnic society

Gwinyai Masukume (a,b,c), Euphemia W. Mu (d), Brit Trogen (e), Nicholas M. Mark (f), Alimuddin Zumla (g)

a. Irish Centre for Fetal and Neonatal Translational Research (INFANT), Department of Obstetrics and Gynaecology, University College Cork, Cork, Ireland
b. Gravida: National Centre for Growth and Development, University of Auckland, Auckland, New Zealand
c. Division of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
d. The Ronald O. Perelman Department of Dermatology, New York University School of Medicine, 240 E 38th St, Floor 11, New York, NY 100165, United States of America
e .New York University School of Medicine, New York, NY, United States of America
f. Division of Pulmonary Critical Care Medicine, University of Washington, Seattle, WA, United States of America
g. Division of Infection and Immunity, University College London and NIHR Biomedical Research Centre, UCL Hospitals NHS Foundation Trust, London, United Kingdom

We were delighted to read Dr. Fisher’s article on whether analogies and metaphors describing clinical signs and presentations ‘written by white doctors working with white patients’ stand up in a multi-ethnic society [1]. She raises very important questions using the facial ‘peaches and cream’ complexion, a not uncommon feature of hypothyroidism in fair-skinned individuals.

This contributes further to our ongoing debate on the relevance of metaphors and eponyms in medical textbooks and educational material written by western authors being currently used in African and Asian medical schools as standard texts where these terms may not be culturally or educationally appropriate [2].

Hundreds of food-related and other metaphors have become deeply entrenched in journals [3], medical schools [4], and hospitals, and are used for teaching, learning and in exams [2].
Although blood tests are the basis of diagnosing most thyroid disease, performing these tests is driven by a patient’s history and physical examination findings. Culinary metaphors like ‘peaches and cream’ complexion [3,4,5] thus remain useful in maintaining a high index of suspicion for thyroid disease. Despite some misgivings, medical metaphors permit rapid diagnosis of classic presentations [6].

Rather than move away from their usage, it might be advisable to develop metaphors that are appropriate locally and are culturally relevant. A multi-ethnic society is precisely where a diverse set of old and new metaphors is most useful. Such an approach would also help to ‘close the gap’ in medical education in which students are taught to recognize dermatologic signs of disease using metaphors that are primarily applicable in fair-skinned populations; not only the ‘peaches and cream’ of hypothyroidism, but the ‘slapped cheek’ appearance of parvovirus, the ‘bulls-eye rash’ of Lyme disease, and many more [7].

More research is needed in developing a culturally relevant and evidence-based approach, because medical metaphors are also a critical aspect of communicating with patients and the public [8].

Competing interests
All authors have read and understood BMJ policy on declaration of interests and declare that they have a personal academic interest in eponyms, synonyms and cultural aspects of medical education. GM is a member of GRAPE (Group for Research and Advancement of Palatable Eponyms).

1. Fisher P. Peaches and cream in a multi-ethnic society. BMJ. 2017. 357:j1752.
2. Masukume G, Zumla A. Analogies and metaphors in clinical medicine. Clin Med (Lond). 2012. 12(1):55-6.
3. O'Callaghan JM, Bewick J, Paice A, Ng P. Stabbing? Cause. BMJ Case Rep. 2009. pii: bcr12.2008.1312.
4. Milam EC, Mu EW, Orlow SJ. Culinary Metaphors in Dermatology: Eating Our Words. JAMA Dermatol. 2015. 151(8):912.
5. Mark NM, Lessing JN, Buckley SA, Tierney LM Jr. Diagnostic Utility of Food Terminology: Culinary Clues for the Astute Diagnostician. Am J Med. 2015. 128(9):933-5.
6. Kipersztok L, Masukume G. Food for thought: Palatable eponyms from Pediatrics. Malta Medical Journal. 2014. 26(4):46-50.
7. Fix AD, Peña CA, Strickland GT. Racial differences in reported Lyme disease incidence. Am J Epidemiol. 2000. 152(8):756-9.
8. Trogen B. The Evidence-Based Metaphor. JAMA. 2017. 317(14):1411-1412.

Competing interests: No competing interests

18 April 2017
Gwinyai Masukume
Research Fellow
Euphemia W. Mu, Brit Trogen, Nicholas M. Mark, Alimuddin Zumla
Irish Centre for Fetal and Neonatal Translational Research (INFANT), Department of Obstetrics and Gynaecology, University College Cork, Cork, Ireland
5th Floor, Cork University Maternity Hospital, Wilton, Cork, Ireland