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Views And Reviews Primary Colour

Helen Salisbury: Careless communication costs lives

BMJ 2020; 371 doi: (Published 24 November 2020) Cite this as: BMJ 2020;371:m4383

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  1. Helen Salisbury, GP
  1. Oxford
  1. helen.salisbury{at}
    Follow Helen on Twitter: @HelenRSalisbury

Most patients want to know “What have I got? Why? What next?”—and doctors spend a lot of time explaining diagnosis, cause, treatment, and prognosis. An important part of our medical training is learning to translate our technical knowledge into everyday language that will mean something to our patient. One tool we use is analogy—comparing atherosclerotic arteries to furred-up pipes, or conjuring images of battles between immune defences and invading pathogens.

Analogies are useful, but we should be wary of stretching them too far. Comparing statins to limescale remover, or antimicrobial drugs to cleaning products, can lead to dangerous misunderstandings.1 Some analogies have unfortunate associations, and many people find the preponderance of military metaphors unhelpful in descriptions of illness and healthcare.23

This pandemic has been marked by poor communication from our government and its spokespeople.4 At one stage Boris Johnson, the UK prime minister, talked about local lockdowns as a “whack-a-mole” strategy. Quite apart from the bizarre levity of comparing control of a lethal infection to a children’s game, this implied that suppressing the virus in one place means it will inevitably pop up elsewhere.5

More helpfully, the Welsh government has implemented a metaphorical “fire break” to reduce transmission.6 This is apt, because if we’d managed to put out the embers smouldering over the summer by using an adequate test, track, and trace system, the fire wouldn’t be raging now. As it stands, with so many people infected, we have to take drastic measures to prevent new fires and hope that limited interactions mean the sparks die out before new flames are kindled. (As a side note, the impossibility of allowing the general population to carry on as normal while shielding only vulnerable people is like trying to keep fluids apart in a public recreation facility: “There’s no piss-free lane in the swimming pool.”)

Given that the government has reportedly spent huge sums on consultancy during the pandemic, it’s surprising that its communication with the public remains poor.7 Its address to the nation announcing the second lockdown involved graphs that were complex and illegible (particularly for anyone who was colour blind). The lockdown rules are often so complicated that ministers contradict each other or can’t explain them.8

We face many obstacles in this struggle, and a vital first step is convincing people that restrictions are necessary. A basic understanding of exponential growth is helpful: it may not look like a problem if two patients are in our intensive care unit with covid-19 in early November, but if the number doubles every two weeks, we’ll run out of space before Christmas (aside from all the other conditions we won’t be able to treat).

To establish trust, we need transparency around the data behind these decisions—and we need translations into easily understood language and images, so that people know what they need to do, and why.