In an education experience in 2018 with three hundred participants (including pulmonologists, internal physicians, cardiologists, and general practitioners) we focused on the topic of communication with patients who are either suffering from the chronic obstructive pulmonary disease (COPD) or asthma.

The aim was to reflect together on the words and expressions they use every day to communicate with their patients, including metaphors that help to carry and explain messages to the patient, without distressing them too much, and at the same time to protect the doctor from equivocal situations and distance from the patient.

The proposed practice required participants to write down the metaphors (words and/or whole expressions) they use daily to explain COPD and asthma, to allow patients understanding what happens in the physiopathology of the lung, and empowering them in knowing the meaning of therapies, in a process of sharing with patients. Then we also dwelt, this time not on the metaphors, but on the terms “not to be used” with patients with ASMA or COPD, and reading them we can realize that in reality, they are terms that would be better avoided in different processes of care.

The doctors first carried out individually the exercise and then shared within their working team of choosing the metaphors and words.



–        It is as having a dry meadow, and every external factor (smoke or virus…) burns it; the aim of the therapy is to make the meadow as the English one

–        A squeezed water pipe

–        It is as a fire in the fireplace: therapy is the water to extinguished it, external factors (as fuel) light it

–        It is an upside-down tree: closed branches because of inflammation (the sap goes to the leaves) then the air flow is stopped

–        The pathway of disease: daily training to participate to Olympics, so the need to have an appropriate therapy and to be adherent to it (a positive perception of the time, adds vitality)

–        roller coaster

–        It is a bunch of grapes, with grape berries as pulmonary cavities

–        If you don’t adhere to therapy, bronchi will begin to close as water pipes with limestone or rust; conversely, with the therapy, they are opened

–        Pressure Pot

–        As you have a balloon in your chest

–        Spirometry: blow the candles



–        Healing

–        Technical words (bronchospasm, eosinophilia, methacholine): try to ‘translate’ them for patients

–        English words, as ‘device’ (for Italians)

–        “Fight the crisis”

–         Avoid difficult concept but with a strong impact, as ‘chronic disease with paroxysmal trend’

–        ‘irreversible disease’ is too negative, it affects patients’ vitality

–        Relapse

–        Dry and bare tree (it makes them sad)

–        Obstructed bronchus

–        sibilant breath

–        Vellichi

–        Sibelius

–        Tractive pain

–        Obstruction

–        The excitement in the course of spirometry

–        Dyspnea

–        Breathing fatigue

–        Chronic Asthma

–        Smoking abolition

–        Using the device (the English word)

–        You must begin a diet



–         “Lace” and “lace break.”

–        Car tires (inner tube not functioning);

–        Balloon: fills up but doesn’t deflate;

–        Lung remodelling = description and similarity with hive;

–        Image of the blackened lung compared to the normal clean lung;

–        Engine “blown out”;

–        Blocked pipes, air conditioning (hydraulic);

–        Worn  out athlete (100 m-marathon);

–        Smoke is like fire under the ashes

–        Bronchi are like a chimney encrusted with smut

–        Its pipes/channels have shrunk and it passes less air

–        Emphysema: they are like pantyhose that stretch out

–        The lungs are like bellows: the air enters but has difficulty in exiting

–        The alveoli are like plastic for packaging (pluriball), emphysema is like bubbles that burst

–        It’s like filling a tank with an open cap.

–        Your illness is like a breastplate, an armour that tightens your chest and prevents you from breathing


–        Acronyms (BPCO, COPD);

–        Emphysema

–        English terms (for Italian patients)

–        Alarmism (adherence to the “here and now” of the patient and not to envisage a possible “catastrophic” future);

–        Technical terms (FEV1-VC);

–        Healing

–        “If you don’t stop smoking, don’t come back.”

–        Suffocation or strangulation;

–        You don’t take care of yourself/ you are not  adherent/ death/ incurable/ Englishes (e.g. device, puff)/patient’s fault

Do not compare inflammation to a fire that burns inside you because it greatly scares the patient

If most used symbols to explain the disease in Asthma were the trees to be bloomed again, the tubes to be unwound, the fires to be tamed, the words not to be said were those that spoke of the miracle of healing and the adjective “chronic”, because the word chronic becomes a ” forever sentence “.  Other forbidden expressions were Englishism’s (device, puff, compliance), no to technical terms such as dyspnoea, spirometry tests, not to mention FEV1.

In COPD the most common metaphors to explain what happens to the lung apparatus were the worn-out lace, the deflated tires or wheels of the bicycle, the hive to be cleaned, and the black of tar and smoke, towards the white of cleanliness. The words not to be said belonged to a similar kind to those of asthma: English outside the door, I welcome the Italian with all its dialect, the technical terms, if they are to be said, should be explained well, perhaps even using a metaphor, and since the person with COPD is generally old, the doctor should be understood in his age, without putting a  fine on smoking, without blackmail if he/she does not stop smoking. Rather, it is appropriate to use the positive energies of the present. It is interesting that the participants did not find a consensus on the word “incurable”: for some it was not to be said, for others, however, when they say that the word prohibited is “healing”, this is what tacitly manifests the impossibility of healing, with a patient “bearer for life of an illness”.

In short, another evidence that language requires a great deal of customization. Sometimes the sound of a whistle, a hissing or a cough, for respiratory diseases is much more worth than symbolic images or long technical explanations.

Useful reflection on the words commented the participants “we should do it more often“.

Maria Giulia Marini

Epidemiologist and counselor in transactional analysis, thirty years of professional life in health care. I have a classic humanistic background, including the knowledge of Ancient Greek and Latin, which opened me to study languages and arts, becoming an Art Coach. I followed afterward scientific academic studies, in clinical pharmacology with an academic specialization in Epidemiology (University of Milan and Pavia). Past international experiences at the Harvard Medical School and in a pharma company at Mainz in Germany. Currently Director of Innovation in the Health Care Area of Fondazione ISTUD a center for educational and social and health care research. I'm serving as president of EUNAMES- European Narrative Medicine Society, on the board of Italian Society of Narrative Medicine, a tenured professor of Narrative Medicine at La Sapienza, Roma, and teaching narrative medicine in other universities and institutions at a national and international level. In 2016 I was a referee for the World Health Organization- Europen for “Narrative Method of Research in Public Health.” Writer of the books; “Narrative medicine: Bridging the gap between Evidence-Based care and Medical Humanities,” and "Languages of care in Narrative Medicine" edited with Springer, and since 2021 main editor for Springer of the new series "New Paradigms in Health Care."

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