Medicine is war: and other medical metaphors PAUL HODGKIN When I worked in a paediatric casualty department children were forever being told that after being stitched, x rayed, or covered in plaster they would be "bionic." The desire to be more machine like is apparently widespread-inevitably perhaps, in an age when technology is both idolised and feared. Medicine is strewn with mechanistic language and concepts, and the metaphor "the body is a machine" suffuses much of the language of pathology and physiology. I write here about some of the linguistic forms that underlie the way we talk about medicine and the way that they limit as well as advance our thinking.Examining the metaphors behind language is worth while because it clarifies our assumptions. Seeing the body as a machine, for example, has been useful-the heart, after all, is much like a pump and treating it as one has provided many insights. The success of the mechanistic approach, however, has meant that we have often imbued the body with other machine like attributes. All too easily patients become-like machines identical, passive and "fixable." Medicine, as has often been pointed out, has become dominated by a mechanistic hubris, which sees machines and engineered solutions to ill health as the favourite way forward.All this, of course, begs the question of the relation between the language we use and the things it describes. Some have felt that any language may actually prevent its native speakers from perceiving the world in ways that are quite "normal" in other tongues.' According to this view, language more or less deterrmines reality. A more orthodox position is that language and our perception of the world evolve together, both influencing each other. The particular vocabulary and syntax of any given language "do not make it impossible to express certain things, they merely make it more difficult to express them.'"

The discussion suggests that strategies based on educating or punishing defaulters in order to change their behaviour may be of limited effectiveness.

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There is widespread recognition that simply publishing research findings is not enough to ensure that they are carried into clinical practice. One response to this has been the burgeoning "guidelines movement" of recent years, which has now reached the stage of generating guidelines for the production of guidelines. Argues that guidelines, and other forms of intervention to change clinical practice in an evidence-based direction, will succeed only to the extent that they engage actively with the real world of clinical decision making. This world is more complex than guidelines writers acknowledge, and includes economic, administrative, professional and personal incentives as well as those provided by research evidence. Engaging with this real world may be difficult, but it opens up new possibilities for understanding how clinicians act and how evidence may be used to inform clinical practice. Such possibilities include social influences, educational outreach, providing information to patients, negotiating local coalitions on specific issues and changing the administrative environment.

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