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Metaphors are figures of speech that use relatively concrete expressions to convey the meaning of an abstract concept. More than 3,800 metaphors are in current use. 1
Metaphors are not just a matter of language. We cannot think without metaphors, 2 and metaphorical thought can even shape cultural institutions. For example, the westernization of cultures around the world is in part a reflection of the introduction of the metaphor "time is money" into these cultures. 3 Changes in metaphorical thought can have harmful consequences to our health and our lives. Medicine, for example, was once seen as a calling or a vocation that, based on compassion, ministered to the sick. This ethical and religious metaphor is being replaced by a business metaphor, with results that have proved less than desirable. In this article, we discuss the metaphor of medicine as a factory and the practical consequences for medical culture of a business-oriented model of patient care.
HOW DID HEALTH CARE COME TO BE VIEWED AS A FACTORY?
The problems we can identify in complex and troubling societal situations basically epitomize how much sense we are able to make of those situations. The way problems are described changes with the passage of time, 4 and different eras define problems in different ways. For example, uneven access to medical care was initially perceived as the result of the monopolistic attitude of the American Medical Association. In the 1950s, it was attributed to an inadequate number of primary care physicians, whereas in the early 1960s, the problem was blamed on the runaway cost of health care delivery.
Aiming at controlling costs while extending access to medical care to the most vulnerable members of the population, the Medicare Act was enacted in 1965. 5 The act was a major venture by the government into unfamiliar territory. To initiate the program, the government needed to make use of the capability and experience that already existed in the nation's public and private health insurance organizations. 6 It assigned responsibility to these organizations for determining the amounts due and for making payment for services covered by Medicare.
Inevitably, the jargon of the insurance industry and of cost accountants thereafter was introduced in communications and enactments dealing with claims-paying mechanisms. As a...