Adv in Health Sci Educ (2010) 15:609–619

DOI 10.1007/s10459-008-9126-2

REFLECTIONS

Analogies in medicine: valuable for learning, reasoning,

remembering and naming

Gil Patrus Pena Æ José de Souza Andrade-Filho

Received: 2 February 2008 / Accepted: 13 May 2008 / Published online: 5 June 2008
 Springer Science+Business Media B.V. 2008

Abstract Analogies are important tools in human reasoning and learning, for resolving
problems and providing arguments, and are extensively used in medicine. Analogy and
similarity involve a structural alignment or mapping between domains. This cognitive
mechanism can be used to make inferences and learn new abstractions. Through analogies,
we try to explain a knowledge to be achieved (the target), with pieces of information
already familiar to the learner (the source), keeping in mind the constraints of similarity,
structure and purpose. The purpose of this essay is to examine the use of analogies in
medicine. We provide a brief review of the theoretical basis of analogical reasoning. This
theoretical background is discussed in the light of actual examples of analogies retrieved
from medical literature. In medicine, analogies have long been used to explain several
physiologic and pathologic processes. Besides deeper structural relations, superficial
attribute similarity is extensively used in many medical specialties. These attribute simi-
larities are important in naming, categorizing and classifying, and play a role as learning
and memorizing tools. Analogies also serve as basis for medical nomenclature. The choice
of the source of analogies is highly dependent on cultural background, and may derive
from ancient or diverse cultures. Learning by analogies may thus require research on
culture diversity in order to establish an adequate justification and to comprehend the
purpose of an analogy.

Keywords Education
Medical
Analogy
Metaphor

Introduction

Analogies are extensively used in our culture and are considered to be very important in all
aspects of human life. As far as we perceive structural or relational similarities between
two given domains, we are able to transpose knowledge from one to another. Harvey, for

G. P. Pena (&)
J. de Souza Andrade-Filho

Serviço de Anatomia Patológica, Hospital Felı́cio Rocho, Rua Uberaba, 418 Sala 102, Belo Horizonte,
MG 30180-080, Brazil
e-mail: gilpena@gold.com.br

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example, stated that the motions and action of the heart ‘‘constitute a kind of deglutition’’,
a transfusion of the blood from the veins to the arteries, as when a horse drinks, the water is
drawn in and transmitted to the stomach, at each movement of the throat (Harvey 1952, p.
279). Harvey decided to employ other already known physiologic mechanism—the
deglutition—as a means of describing the action of the heart, propelling the blood from
veins to arteries. Harvey’s choice is related to his time, when horses could be easily seen
even in urban landscapes. Presently, the action of the heart is more commonly likened to
that of a pump. Such mechanical and hydraulic analogies for the circulation are so common
nowadays, that it may be surprising to notice how sparsely they are found in Harvey’s own
writings (Burchell 1981).
As another example, we may say ‘‘the brain is like a computer’’ and employ compu-
tational programs as cognitive models, by means of relating, for example, input, processing
and output. As we align the structure of these different domains, however, besides
similarities, we may perceive invaluable contradictions. Bruner (1990, p. 4) stated, for
example, that the introduction of computability as a ruling metaphor in cognitive sciences
was the key factor in the shift of emphasis from ‘‘meaning’’ to ‘‘information’’, from
construction of meaning to processing of information. As we use such analogies, we can
enhance our knowledge and even discover or create new structural relations, not primarily
drawn from the isolated attributes of each domain.
Analogies are said to contain two main components: the target, which is the problem or
issue that one wishes to explain, and the source, which is the familiar piece of information
that is used to understand the issue (Dunbar and Blanchette 2001). As one checks for
similarities between source and target, knowledge can be imported from the familiar
situation and applied to the new one. Similarities may be readily apparent in superficial
features of both target and source, or they may reside more deeply, in the underlying
structure, despite differences in the superficial features.
Analogy has three basic constraints: similarity, structure and purpose (Holyoak and
Thaghard 1997). These constraints do not operate like rigid rules. Instead, they can be very
flexible, as subjected to different pressures, either converging or opposing forces, in a
constant interplay to achieve an internally satisfactory and coherent compromise. Con-
straint contradictions can be resolved by a process of constraint satisfaction. In Harvey’s
example, the purpose is to explain the action of the heart as a propeller of blood, from veins
to arteries, as the process of deglutition, in which the ingest is propelled from the mouth to
the stomach by the action of swelling. The heart and the throat share structural and
physiologic properties, as both are made of muscular walls, whose coordinated contraction
and relaxing allow empting and filling of their cavities, with an unidirectional ejection of
their contents.
Subtle distinctions have been proposed to the concepts of analogy, similarity, mere-
appearance and metaphors (Gentner and Markman 1997). Analogies involve cognitive
association between two different domains, sharing variable degrees of relation and
attributes. Similarity, in a sense, is like analogy, as both involve an alignment of relational
structure. However, in analogy only relational predicates are shared, whereas in literal
similarity both relational predicates and object attributes are shared. This contrast however
is a continuum, not a dichotomy. Similarity comparisons are far easier to notice and map,
than pure analogical (strictly relational) comparisons. In this last situation, comparisons
exhibit a high degree of relational similarity and little structural similarity. As more
similarities between attributes are shared, the comparison shifts toward literal similarity.
As explained by means of an analogy: ‘‘Analogies are like comets, flashing through our
awareness and riveting our attention. Literal similarity is like planetary motion: steady,

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predictable, and prosaic. But the planets are central to the behavior of the solar system, and
(like literal similarity comparisons) they are always with us. Finally, both planets and
comets are governed by the same fundamental laws’’ (Gentner and Markman 1997).
Another situation within this continuum space of possible comparisons has been described
as mere appearance matches, when objects share a high grade of attribute similarity and
only minor relational correspondence. As far as this continuum is concerned, analogy and
mere appearance matches are situated at opposed extremes. Mere appearance matches are
limited in their predictive or explanatory utility. They are, however, important to consider
as they may interfere with learning processes (Gentner and Markman 1997). The role and
importance of mere appearance matches have been limitedly explored in the literature on
analogy. Similarity and mere appearance matches are extensively used in medicine, par-
ticularly in specialties dealing with high amounts of image information, in which they have
an important role, not only in learning, but also describing, naming and retrieving pieces of
information (Andrade Filho and Pena 2001). In this paper, we use the term analogy to
encompass similarity and mere-appearance matches.
As one establishes an analogy, he or she can choose a representational approach, in
which both target and source are entities whose attributes are defined prior to the estab-
lishment of their relationship. In a nonrepresentational strategy, we first draw the
relationship, and only then examine the similarities that emerge from its use (Neuman
2005).
An interesting relationship was found between Ausubel’s propositions and the educa-
tional use of analogies. Meaningful learning is an active process and requires some
reconciliation with existing ideas in cognitive structure. The learner has to map similarities
and differences and also resolve real or apparent contradictions, between previously
existing knowledge and the knowledge to be learned. Analogies may be used as strategies
bridging the gap between what the learner already knows and what he is to learn, in a
manner analogous to the advance organizer. The advance organizer is a pedagogic device
that is presented at a higher level of abstraction, generality and inclusiveness than the
material to be learned (Ausubel 2000, p. 11). It serves as a mediating device, related both
to existing knowledge and new instructional material, preparing the existing cognitive
structure to receive the new information that is to be presented. As similar ideas exist in
learner’s cognitive structure, new ideas or propositions may be anchored in already
existing knowledge, thus facilitating assimilation and retention. The learning through
analogies can be considered a meaningful learning, clearly contrasted from rope learning.
The analogical reasoning is a strategy to solve problems, as general principles learned in
the context of one problem might be recognized as useful in the solution of similar
problems. The analogical transfer refers to the ability to access and apply concepts and
facts learned in one situation, to the solution of new problems. In this process, the solver
must retrieve a source problem for the target one, then map their structures and finally
adapt the solution procedures previously made to the needs of the target problem. The
target and source problems may share similarities in different dimensions: the context (the
physical context, implied goals and tasks); the content, comprising the semantic domain
(discipline, organ or system involved) and the surface elements (demographic data, clinical
presentation); and the schema or deep structure (underlying principle or concept).
Although problems may share similarities at any level, an adequate solution usually
depends on the alignment of their deep structure. The challenge to transpose knowledge
from one situation to another requires strategies to recognize and achieve the core of the
problem, despite differences in its context, content and/or surface elements (Eva et al.
1998).

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In the perspective of Vygotsky’s zone of proximal development (Vygostsky 1978, pp.

79–91), analogies can be understood as elements that can be used by the tutor, helping the
apprentice to manage a new task with some sort of assistance. This help may be, for
instance, a hint for the retrieval of a previous learned analog problem, clues to enhance
structure mapping with such a previous learned problem, as well as a more directive help in
achieving congruent adaptation between structure of both source and target problems
(Novick and Holyoak 1991). Analogies may act thus as a scaffolding, to employ Bruner’s
analogy, allowing the learner to cope with the problem, comprehending its solution as a
whole. Comprehension of the solution must precede production: ‘‘the learner must rec-
ognize a solution to a particular class of problems, before he is himself able to produce the
steps leading to it without assistance’’ (Wood et al. 1974).
Cerebral circuits and neuronal connections have been identified, that intercept the
incoming information, allowing interactions with pre-existing associations. Such circuits
modify the way the incoming signal is relayed and thus how the world is perceived: ‘‘we
see the world in terms of what we have seen already’’ (Greenfield 2000, p. 65). These
cerebral circuits underlie the importance of analogies in education, as far as ‘‘new’’
information is assimilated in terms of already is known.
The analogical reasoning requires the participation of different areas of the prefrontal
cortex, in contrast with simple semantic tasks. In the study of Bunge et al. (2005) pre-
frontal cortex regions were mapped, while subjects were confronted to analogical and
semantic retrieval. Verbal analogical reasoning depends on integration across multiple
retrieval relations, and has been shown to depend on multiple prefrontal cortex compu-
tations. Parenthetically, semantic retrieval can be contrasted to analogical reasoning, as
rope learning can be contrasted to meaningful learning.
Analogical thinking is probably related to association by similarity, as discussed by
James (1952):
Take a present case A, with character m in it. The mind may fail at first to notice this
character m at all. But, if A calls up C, D, E and F – these being phenomena which
resemble A in possessing m (…) such association (…) may lead to the noticing of m
in an abstract way. (…) Our chief help towards noticing those special characters of
phenomena, which when possessed and named, are used as reasons, class names,
essences or middle terms, is this association by similarity (p. 678)
The character m can be either an attribute and/or a relation, and as long as we are able to
map m in A, C, D, E and F, it is possible to establish an analogy between them. As James
has stated, analogies, once established, are relevant in explaining, naming and mediating
knowledge.
As A, C, D, E and F are similar cases, one can also infer that if one case is held to have a
certain property, then the other cases, it is concluded, also have the same property. This
inference is the basis of the argument from analogy. The argument from analogy can be
structured as follows (Walton 2006, p. 96):
Similarity premise: Generally, case C1 is similar to case C2.
Base premise: A is true (false) in case C1.
Conclusion: A is true (false) in case C2.
The similarity in cases C1 and C2 must reside in the deeper structure, in order to warrant
more consistently an argument (Pena 2007). Inferences based on superficial similarity or
mere appearance matches can be ultimately proved to be false. As an example, cases of

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breast carcinoma similar to the tall cell variant of papillary carcinoma of the thyroid have
been described. Characteristically, RET/PTC oncogene activation occurs in papillary
carcinoma of the thyroid, and one might argue this could also be true for breast cases.
Contrary to this expectation, Eusebi et al. (2004) found no evidence of RET/PTC acti-
vation in breast cases, demonstrating that although histologically similar, their subjacent
molecular pathways are different.
Association by similarity, as presented by James, may also trigger the process of
hypothesis creation in non-analytical diagnostic reasoning. It has been suggested that
similar features are matched between the case requiring a diagnosis and cases stored as
exemplars of each diagnostic category. As this matching process may run unconsciously,
the diagnostician may use either a specific feature of the case, as well as an irrelevant
aspect of the context (Norman et al. 2007). The constraints of similarity, structure, and
purpose also operate in this setting: a process of constraint satisfaction may take place, as
the findings of the case may be reinterpreted, in order to coincide with diagnosis being
entertained.
The analogical reasoning also underlies modeling strategies, as long as we test a
hypothesis in a model, and then try to extrapolate the results to other analog situations. The
relation between the model and the ‘‘real’’ situation should operate within the same con-
straints of similarity, structure and purpose, proposed for an analogy. Guiot et al. (2007), for
example, found that the analogy between cancer invasion and a ‘splashing water drop’ leads
to an understanding of tumor invasion as controlled by a parameter that is proportional to
confining pressure and tumor radius and inversely proportional to its surface tension.
In medicine, many different conditions are described or explained in terms alien to
medicine itself. Although important in learning and practice, analogies are only occa-
sionally dealt with in medical literature. Analogies may ‘‘serve to translate microscopic
images into memorable catch-phrases, enhancing the learning experience and alleviating
its tedium’’ (Hoda and Hoda 2004). Kunter (1997) proposed an alimentary metaphor–
learning as ingestion–in medical education: ‘‘students are spoonfed, forcefed; they cram,
digest, and metabolize information; and they regurgitate it on tests’’. Batistatou et al.
(2000) noted a plethora of alimentary images as means of description. Frienden and Doley
(2005) provided examples of the use of analogies in explaining medical situations to the
patient. As long as practicing physicians are concerned, analogy may act as mediator
between a clinical, radiological or pathological finding and a diagnostic category (Pena and
Andrade Filho 2006). Ahmed et al. (1992) postulated that the use of analogies is con-
strained by terms derived from completely different cultures, as when culinary analogies
are transposed to students from other countries.
In the last years, one of the authors (JSAF) has been collecting examples of analogies
from the medical literature (mainly medical textbooks in pathology and related areas). As
they were collected, an effort has been made to establish their purpose and to conceive
them in its medical (target) as well as its original meaning (source). In this essay, mean-
ingful examples were selected in order to illustrate the use of analogies in medicine.

Analogy as a medical educational tool

Example 1: Sequestrum, sequestration

In common English usage, to sequester or sequestrate a property or an estate, is to take it
officially from someone who has debts, usually after a judgement in a court of law.

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In medicine, sequestrum may refer to the presence of a portion of dead bone tissue,
that in the course of inflammation and necrosis, becomes partially or totally detached
or isolated from sound bone: it is the bone sequestrum, seen most commonly in cases
of osteomyelitis due to Staphylococcus aureus. In tuberculosis of bone and joints,
foci of bone necrosis may occur in the opposed extremities of a joint, as in the distal
femur and proximal tibia. As these foci become isolated from adjacent alive tissue,
the radiological image of ‘‘kissing sequestrum’’ can be seen.
The pulmonary sequestration is defined as a mass of abnormal pulmonary tissue,
with no communication with the tracheobronchial tree, and receiving blood supply
from a systemic artery. It can be divided into two types: (1) the extralobar seques-
tration, considered a developmental defect, characterized by a mass of lung tissue
outside the boundaries of the visceral pleura, which can be both intra- or extra-
thoracic. It is more commonly seen in the first six months of life and is associated
with other malformations; and (2) the intralobar sequestration, which is confined
within the visceral pleura and is considered to be a post-infectious lesion.
In cases of hyperesplenism, one observes the splenic functions to be exacerbated,
with reduction of circulating blood elements, including platelets. Whereas one-third
of produced platelets are normally stored in the spleen, in cases of splenomegaly, up
to 90% of the total reservoir of platelets can be captured in this organ (platelet
sequestrum).
Also in the field of hematological disturbances, there is the so-called sequestration
crisis in falciform (sickle cell) anemia – a hereditary hemoglobinopathy, which
results in red blood cells with altered shape. The red blood cell sequestration crisis
occurs in children with intact spleen. When it is severe, one notes splenomegaly of
rapid onset, hypovolemia and shock, requiring blood transfusion.
Some authors describe the pagetic sequestrum in persons with Paget’s disease
(osteitis deformans), that occasionally present symptoms of dizziness, as the blood is
diverted from the internal carotid system to the bones, depriving the brain from
adequate blood supply. It is known that in this disease, there is significant increase in
the blood stream to the bones.
In pharmacology, a sequestrant is an agent that binds to some molecules, for
example, the cholestyramine resin, which binds bile acids in the intestine, preventing
their absorption.
In Example 1, an analogical concept is related to several situations, from different medical
specialties. This example is similar to what Ausubel described as an advance organizer. A
general idea, that finds resonance in the individual cognitive structure, is presented, pre-
paring the existing ideas to serve as efficient anchoring ideas for the new ones presented,
thus providing an ideational scaffolding (anchoring). The analogy (as an advance orga-
nizer) should be explicitly related to the learning passage and must also be relatable to and
take relevant ideas in cognitive structure into account (Ausubel 2000 p. 62).
Example 2
In a given disease, large potatoes are palpated or sometimes even visible in the neck.
They are enlarged lymph nodes, whose consistency is described as rubbery, but in
some cases can be petreous or hard as stone. Macroscopically, the cut surface of

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these nodules can be white and homogenous, like raw fish flesh. When there is
necrosis, however, it can have irregular boundaries, as those seen in a geographic
map. Microscopically, there are large cells, whose nuclei are just like beans with
convexity mirrored one to another. The large nucleoli within the nuclei compound
the figure of an owl-eye. As long as particular forms of the disease are concerned,
‘‘C-like’’ bands of fibrosis can be seen, and there are lacunas where those peculiar
cells reside. The popcorn cell is also a variant of these cells. Mummified cells can
result from necrobiosis. As this disease evolves to compromise other organs, one can
see the porphyre-spleen and the ivory vertebra.
In Example 2, Hodgkin’s disease is presented with the aid of different analogies. Many
aspects of the disease can be explored with the aid of analogies. Issues like clinical
presentation (palpation, ectoscopy), radiological and pathological findings (macroscopy,
microscopy), classification and staging, can be further stressed in more depth. As a theme
is introduced with elements already known to the students, new concepts can be more
easily assimilated.
In many occasions, students cannot confront what they read in textbooks in a real patient,
as when one deals with tactile sensations. Analogies are very important in this setting.
Students can be trained to make injection in oranges, feel the catareous fremitus in a cat, and
can be told that the sensation of palpating the intestines in cases of Crohn’s disease is just like
palpating eels in rigor mortis (Rosai 2004, p. 721), or that the macroscopy of breast carcinoma
‘‘has the uncanny resemblance to an unripe pear, further accentuated by the consistency and
the sensation one has while cutting it’’ (Rosai 2004, p. 1802). These strategies have an
anticipatory role, which is very important in education, as it allows learners to become skilled
before a real situation has been experienced (Andrade-Filho and Pena 2001).
Analogies have a role in illustrating physiologic mechanisms such as the mucocilliary
escalator in the tracheobronchial tree. Also, different aspects of blood pressure and flow
have been compared to river streams or home plumbing system (Carroll 2001).
Analogies in medicine have been used in questions in self-assessment reviews (and may
occasionally be found in quizzes, finals or boards) as in the following example (Compton
1995, p. 4):
Pathology lesions produced by vascular congestion include all of the following,
EXCEPT:
A. Nutmeg liver
B. Brown induration of the lung
C. Gandy-Gamna bodies in the spleen
D. Strawberry gallbladder
E. Stasis dermatitis of the legs

Analogy as a mnemonic mediator

Memory is the human ability to retrieve facts or thoughts from earlier times. As culture
became a tool mastered by human brain, memory has gained mediated auxiliary elements
(Vygotsky, 1978 p. 39). We can consult repeatedly a book, in order to retrieve a piece of
information. We can mark our appointments in an agenda. These elements act as mediators
between ourselves and what we should remember. Analogies in medicine can have a similar
role, as they can direct our attention to certain elements or categories (Pena and Andrade-
Filho 2006). Thus, when a radiologist recognizes in an X-ray of the skull the image of a ‘‘hole

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within a hole’’, he will certainly remember at once that one of the conditions responsible for
this image is the Langerhans cell histiocytosis. Once a pathologist sees a degeneration of
dermal collagen and this elicits the mental image of a flame, he may come to evaluate the
diagnostic possibility of Wells’ syndrome. The starry sky pattern in some lymphomas
certainly leads the pathologist to think about the possibility of Burkitt’s lymphoma.
The use of language codes is of foremost importance in producing such association
matrices, participating in the cognitive processes of perception, classification and
retrieving (Pena and Andrade-Filho 2006). When dealing with cyto-histological mor-
phology, a single structure, such as a nucleus, may assume different morphological
patterns. Perception and recognition of these different patterns are enhanced when we are
able to name them. In Table 1 we show how analogical terms are important in naming and
categorizing such findings.

Analogies and medical nomenclature

The following passage from James (1952) may give some insight on how words are
originated:
The first words are probably always names of entire things and entire actions, of
extensive coherent groups. A new experience in the primitive man can only be talked
about by him in terms of old experiences which have received names. It reminds him
of certain ones from among them, but the points in which it agrees with them are
neither named nor dissociated. (…) The first adjectives will therefore probably be
total nouns embodying the striking character. The primeval man will say, not ‘‘the
bread is hard’’ but ‘‘the bread is stone’’, not ‘‘the face is round’’, but ‘‘the face is
moon’’ (…). The first words are neither particular, nor general, but vaguely concrete;
just as we speak of an ‘‘oval’’ face, a ‘‘velvet’’ skin, or an ‘‘iron’’ will, without
meaning to connote any other attributes of the adjective-noun than those in which it
does resemble the noun it is used to qualify (p. 689)
Many medical terms have been devised by similarity, but elegantly employing terms from
Latin or Greek, most frequently. As these terms are translated to current language,
underlying analogies become apparent. For example, placenta, from Greek, means flat cake
(Skinner 1961). Thyroid is something shield-like (the name was given first to the cartilage,
and then to the gland). Duodenum derives from 12-finger-long intestine. Mast cells were
named so, because they were initially interpreted as cells capable of nurturing other cells.
Vomer comes from the Latin word for plowshare. Many newly described entities are
still named from analogies: spindle cell hemangioma, tufted angioma, targetoid hemosi-
derinotic hemangioma (also known as hobnail hemangioma) and retiform
hemangioendothelioma (by resemblance to the rete testis), just to cite a few vascular
neoplasms. As James (1952) further states, ‘‘after a while, certain of these adjectively used
nouns come only to signify the particular quality for those sake they are oftenest used (…)
they become true abstract and general terms’’.

Analogies as an instrument to increase general and diversity culture

An accessory gain of the study of analogies in medicine is undoubtedly an increase in our

knowledge about the source of the analogy, not the target itself. For example, eosin is the

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Table 1 Analogical terms used in the characterization of nuclei

Descriptive term Description Pathological situation

Owl’s eye A large nucleolus within a large Reed-Sternberg cells (Hodgkin’s

nucleus lymphoma);
cross-section of Anitschkow cell nucleus
in rheumatic Aschoff’s node
Mirrored Binucleated cells with nuclei Reed-Sternberg cells (Hodgkin’s
facing one another lymphoma)
Slender Fusiform, elongated, thin nuclei Fibromatosis cells
Plump Fusiform, with wider transversal Fibrous histiocytoma cells
diameter
Carrot Elongated nuclei with blunt ends Medulloblastoma
Cigar Elongated nuclei with relatively blunt Leiomyocyte
ends
Tapered Elongated nuclei which becomes Schwannoma
thinner at the ends
Oval Egg-shaped Columnar epithelial cells and many others
Wavy With a wavy profile Neurofibroma
Coffee bean With longitudinal sulcus Granulosa cell tumor
Beans With a concavity in one of its sides Histiocyte nucleus
Reniform Shape of a kidney. Like beans
(see this)
Cerebriform An exaggeration of a cleaved nucleus, Mycosis fungoides
with convoluted contour
Sanded Chromatin of homogenous texture, Hepatitis due to virus B (indicates presence
with different affinity for of hepatitis B core antigen)
hematoxilin
Raisinoid Chromatin condensation and irregular Koilocyte; chromophobe renal carcinoma
nuclear membrane cell
Ground glass Optically clear, homogenous Thyroid papillary carcinoma; Herpes
chromatin infected
cells in vaginal smears
Cartwheel Radiating chromatin Plasma cell
Salt and pepper Finely granular chromatin Neuroendocrine tumors, neurocytoma
Orphan Annie Clear nuclei Thyroid papillary carcinoma
eye (see Ground glass)

dye responsible for the pink coloration of the acidophilic structures in the Hematoxylin and
Eosin (H&E) stained histological section. The eosin was named after the Goddess Eos (the
Dawn) (Skinner 1961). Whether it was named so because of the color of this dye was
likened to the beautiful image of a rosy morning or because of the rosy fingers of the
technician, just as Homer described the Dawn (‘‘Now when the child of morning, rosy-
fingered Dawn, appeared…’’) is a question to be answered.
The choice of the source of an analogy rests upon previous experience and cultural
background (Andrade-Filho and Pena 2001). This is considered a difficulty in the use of
analogies, when such concepts are to be transferred to different points, in space and time,
where people may have different experiences and culture (Ahmed et al. 1992). Nonethe-
less, these difficulties may represent opportunities for the increasing of both general and
diversity culture of medical students. Finding out what sort of toy was the water-hammer,

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to which the pulse in aortic insufficiency was likened, may serve as an example of such
situation.

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