Table 3.

Examples of Potentially Bias-enhancing Metaphors and Alternatives

Bias	Example Metaphors That May Reinforce Unhelpful Thinking	Alternative Metaphors
Containing extreme or negative connotations	A calcaneal fracture is like an egg crushed flat	A calcaneal fracture is like a cracked egg.
	Carpal tunnel syndrome is like “a rock crushing a hose,” or “Ziti being squished to linguini”	Carpal tunnel syndrome is like a hose that is under pressure and water flow is less than normal.
Invokes disease modification when only palliation is available	Gel injection for the knee is like getting an oil change for your car	Gel injection for knee arthritis may be like dying one’s hair—temporary at best
Out-of-date inaccuracies such as overuse or damage	You’re born with an empty bucket and if you only put one drop in it every day, it will overflow eventually (overuse)	It’s like exercise, you might feel sore during or after, but it’s definitely safe and healthy. Think of yourself as a keyboard athlete.
	Spontaneous long head of biceps rupture: “Like rubbing a rope on a rock - the rock eventually wins.”	Your hair doesn’t thin because of your hat or your pillow. It’s just age and genetics.
	Lumbar disc herniation: “Treatment is like repair of a flat tire”	Like a jelly donut, when you press on it, the jelly comes out the hole.
Invoking fear	Abdominal aortic aneurysm is like a ticking time bomb	Like an aging garden hose, it can work for some time, but not forever.
	Distal radius fracture is like a canary in the coal mine signaling fragile bones	A fracture like this after a simple fall can be like a signpost on your life journey, marking the next stage.
Hurt means harm	Just as with a car, the motor gets older (heart) and the bearings start to grind (osteoarthritis)	Osteoarthritis is like grey hair, everyone eventually gets it.
	Ankle fracture: the ankle joint is like a wheel bearing. If it is too loose it will wear out fast.	It’s like hanging a door, we want to line it up as well as possible for long-term function.
Nudging patients towards a specific treatment	A car with 100,000 miles will make noises, does not start on cold mornings, etc. You can either try to tune it up (NSAIDs, injections) or trade it in for a new one (TKA)	An old car can still get you where you want to go.
	If your car was running as rough as your knee you would take it in for service with the mechanic	Just like when you get your car checked, if there’s nothing specific to address, you can keep using it like normal.
Implying vulnerability and progression	A bone with osteoporosis is like a damaged road with many holes in constant maintenance.	Osteoporosis is like grey hair and presbyopia, an expected part of aging. There are treatments to be considered with care.
Using battle analogies	You will win this battle, because you are a fighter	Just as people live with diabetes or heart failure, I live with cancer.
	Use the weapons at your disposal