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Graphic medicine: Use of comics in medical education and patient care

Authors:
  • Pennsylvania State College of Medicine

Abstract and Figures

Graphic stories, or adult themed comics, are a popular new cultural trend. Michael J Green and Kimberly R Myers argue that they are also a valuable tool for medicine
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574 BMJ | 13 MARCH 2010 | VOLUME 340
ANALYSIS
Some healthcare professionals—especially
those working in public health, with young
people, or with non-native speakers—have
begun to use graphic stories for patient care
and education.
1-3
One reason this practice is not
more widespread is probably because most doc-
tors have not considered its merits. We believe
that graphic stories have an important role in
patient care, medical education, and the social
critique of the medical profession. What follows
is an introduction to graphic stories, with some
examples of what they are, how and why they
work, and how they can enhance teaching and
patient care.
Evolution of a medium
Comics have evolved over the past 100 years4
and are now viewed as a legitimate form of lit-
erature. Graphic stories are prominent in book-
stores, film, and television, having expanded
their audience beyond young people to include
serious minded adults keen to learn more about
myriad weighty issues ranging from philosophy
5
to political revolutions.6
Recently, a distinctive sub-genre of graphic
stories that we call graphic pathographies— ill-
ness narratives in graphic form—has emerged
to fill a niche for patients and doctors. These
graphic pathographies can be helpful to patients
wanting to learn more about their illness and
find a community of similarly affected people.
Graphic pathographies also provide doctors
with new insights into the personal experience
of illness (especially regarding concerns patients
might not mention in a clinical setting) and mis-
conceptions about disease and treatment that
could affect compliance and prognosis.
Graphic pathographies depicting cancer
Among the most compelling examples of graphic
pathography in the past few years are Cancer
Vixen7 and Mom’s Cancer.8 Though both chroni-
cle real people’s experiences, they have different
intended audiences and publication history.
Cancer Vixen is the story of the cartoonist
Marisa Acocella Marchetto’s personal experi-
ence with breast cancer. Editors at Glamour
commissioned Cancer Vixen and promoted it as
a bestseller with “attitude,” targeting a specific
readership of fashion conscious, affluent, female
urbanites in early to mid-adulthood. M om’s
Cancer, by Brian Fies, had a more modest begin-
ning. Written from the caregiver’s point of view
and serialised on the internet, it documents his
mother’s metastatic lung cancer. The story was
so popular that it won an Eisner award for best
digital comic in 2005 and was published as a
book in 2006.
Juxtaposing text and image
Although graphic pathographies are often the-
matically similar to standard textual accounts of
illness, their powerful visual messages convey
immediate visceral understanding in ways that
conventional texts cannot. An excellent exam-
ple of this advantage is evident when Marchetto
and her mother visit her doctor just before he
does a biopsy on the mass in her breast (fig 1).
Throughout the book Marchetto provides context
in lime green narrative boxes that supplement
the ch aracters’ text bubble dialogue. Here, the
lower text box explains an important milestone
Graphic medicine:
use of comics in medical
education and patient care
Graphic stories, or adult themed comics, are a popular new
cultural trend. Michael J Green and Kimberly R Myers argue
that they are also a valuable tool for medicine
Fig 1 |
Cancer Vixen: a p erson al stor y of br east c ancer
Fig 2 |
In Mom’s Cancer the reader simult aneous ly has a ccess to wor ds and thought s of the charac ters, ill ustrating th at what we say is not alw ays wha t we mea n
BMJ | 13 MARCH 2010 | VOLUME 340 575
ANALYSIS
in her process for office visits: Marchetto had
used a tape recorder sporadically before, but
she now realises it should become a constant
fixture in such meetings. While Marchetto’s nar-
rative clues are helpful, it is the visual centre
of the panel that imparts pithy truth. Marchetto
and her mother are depicted bug eyed and rigid
with fear as they listen to the doctor’s explana-
tion of the upcoming procedure. Anxiety ridden,
neither hears much of what the doctor says.
M archetto conveys this with scribbles punc-
tuated by isolated words and phrases that do
register consciously: “cancer,” “lumpectomy,”
“may not be invasive,” and “lymph nodes.”
This single panel is an important reminder
to doctors that patients rarely absorb much of
what doctors try to explain, and it conveys to
patients the all too familiar feeling of being
overwhelmed by a diagnosis and the techni-
cal details of treatment. The panel also shows
how complex information can be efficiently
and effectively communicated using the comic
form: just consider the amount of space and
time required to communicate this information
with written words (that is, the two paragraphs
you just read) versus the single 50 mm×50 mm
frame.
Mom’s Cancer similarly accomplishes some-
thing that is almost impossible to do with pure
text: the representation of a conversation along
with the hidden, unspoken meaning behind
the words. Depicting a telephone call between
himself and his stepfather, Fies reveals in each
of eight panels both the spoken conversation
and the unspoken subtext of what those words
really mean (told in separate boxes below each
illustration). In this ingenious way, the reader
simultaneously has access to both words and
thoughts of the characters, illustrating that what
we say is not always what we mean (fig 2).
Manipulating the image
The impact of graphic stories comes not just
from juxtaposing text and images but from
manipulating images themselves. Fies uses this
technique in 10 panels in which he illustrates
his mother having what seems to be an absence
seizure (fig 3). In the first panel, his mother and
sister are having a conversation. In subsequent
panels, the mother assumes an unchanged
pose while her eyes fade from black to white,
depicting the vacant stare of someone experi-
encing a lapse in consciousness. In each panel,
the “lens” zooms from a three quarter body
shot to a tight head and shoulder shot, while
the background changes from grey to black.
This ominous darkening simulates the daugh-
ter’s growing anxiety as everything except her
mother’s vacancy recedes into the background.
These powerful images illustrate the patient’s
and family member’s experience in a way that
standard clinical reportage could never achieve
with such ec onomy.
Fig 3 |
Ten panels in which Fies illustrates his mother having what seems to be an absence seizure
Fig 4 |
Use of fo nt style and s ize and p ositio n to indi cate que stion s’ import ance
576 BMJ | 13 MARCH 2010 | VOLUME 340
ANALYSIS
Visually altering the text
Extending the manipulation of visual images,
Marchetto manipulates the appearance of text
in ways that are unusual for conventional books.
At various points in her treatment, Marchetto
records the questions she needs to ask her doc-
tor, and they dominate the page. In a traditional
book, the questions would appear as a list; and
to convey the relative urgency of each, the author
would have to stipulate that hierarchy overtly. In
contrast, Marchetto conveys what are, to her, the
most crucial questions by the style and size of the
font, as well as where she positions the questions
on the page (fig 4). Early on, during a visit when
she needs to ask basic questions like “How long
will I be in the hospital?” Marchetto is neverthe-
less most concerned about how she will pay, a
central preoccupation throughout the story. Most
of the questions are presented in roughly 16 or
20 point font, but Marchetto uses 30 point bold
font to ask, “Does Saint Vincents take Amex?”
Marchetto reminds doctors that patients often
don’t—or can’t—convey the depth of their anxi-
ety about issues the doctor might not find as rel-
evant to the clinical encounter. Such depictions
implicitly offer important social critiques of the
medical profession.
Using graphic stories in teaching and
patient care
Medical education
Although graphic texts are not yet widely
integrated into medical education, educators
in other fields have successfully used them
to teach topics as diverse as professional eth-
ics,
9
creative writing and composition,
10-12
lit-
erature,
13
and physics.
14
Graphic stories—like
film, fiction, poetry, and visual art, which have
already been integrated into medical curricu-
lums—are engaging ways to enhance medical
education. For example, to foster empathy, you
might assign and discuss graphic pathographies
that give insights into different aspects of the ill-
ness experience. During preclinical years, such
stories remind students that the vast body of
scientific knowledge they are trying to master
will one day help real people. During clinical
and residency years, graphic pathographies
can reinforce that healing a patient entails
more than treating a body. When assigning
book length works is not viable, students can
consider smaller segments (like those above) in
greater detail to understand discrete elements of
a medical encounter. The use of images with text
universalises the illness experience, facilitating
a greater connection with characters.15
Graphic stories can also be used to teach
observational skills. To read a comic effectively,
you must understand not only what is overtly
seen and said but also what is implied. This is
because much of the action takes place outside
the boundaries of comic panels in the blank
space known as the gutter. Thus, readers of com-
ics, like doctors in the exam room, must deter-
mine meaning by inferring what happens out of
sight and without words. For example, in figure
5 Marchetto writes only: “Don’t be scared.” Yet
these panels communicate much information:
that the patient has something to be scared
about, that she is isolated and guarded, that
her interaction with the healthcare provider is
mediated via technology, and so on. Notably, it
is the reader, not the artist, who must fill in the
blanks and complete the narrative.
Such skills parallel those used for diagnostic
reasoning, where a doctor typically has access
to incomplete information but must deduce
a diagnosis from available data.16 In keeping
with research in medical education showing
that visual art improves students’ diagnostic
skills,
17 18
reading graphic stories may likewise
enhance students’ observational and interpre-
tive abilities. Reading a range of such stories
could cultivate awareness of the broader social
and political issues germane to medicine and
thus further students’ cultural competence. One
of us (MJG) explored these potentials in a course
on comics and medicine for fourth year medical
students.19
Patient care
Graphic stories have been used to promote pub-
lic awareness and enhance patient care for vari-
ous problems including substance abuse, HIV,
diabetes, and mental illness.20-23 The medium is
particularly appropriate for educating patients,
since an increasingly diverse population poses
challenges to effective verbal communication.
Visual understanding is intuitive in ways that
verbal understanding may not be. Consider
how our increasingly globalised world relies
on iconographic meaning in, for example, aero-
plane safety instructions, street signs, iPhones,
advertising campaigns, and pain rating scales.
Fies needs nothing more than the image of his
mother’s face to convey the universal experi-
ence of anguish (fig 6).
Research has shown how combining pic-
tures and text enhances understanding, as the
activities of reading and viewing activate dif-
ferent information processing systems within
the brain.
24
This combination also fosters con-
nections between new information and existing
knowledge, thereby increasing recall of health
information, especially among those with low
literacy.25 This process is even more effective
when pictures overlap with text, are explana-
tory, and are engaging.26
Graphic pathographies can also help patients
and their families better understand what
to expect of a certain disease. For example, a
doctor might suggest that a woman with newly
diagnosed breast cancer read Cancer Vixen. This
approach accomplishes several things. On the
most basic level, the doctor could use portions
of the book to describe the diagnosis and prog-
nosis and to elicit the patient’s treatment pref-
erences. Reading a graphic pathography also
gives the patient something concrete on which
Fig 5 |
The reader, not the a rtis t, must fill in the blank s and comple te the na rrati ve
Fig 6 |
The face of Fies’s mother
BMJ | 13 MARCH 2010 | VOLUME 340 577
ANALYSIS
to focus, thereby diverting her attention and
potentially lessening anxiety. The book might
also evoke questions that the patient could
discuss with her doctor—questions she might
never have considered otherwise. Armed in this
way with specific questions, a patient might feel
more focused and in control as she plans follow-
up visits with her doctor. She might also feel
less isolated and more hopeful, realising that
another person has had similar experiences
and lived to tell them. Although these ideas
have not yet been systematically evaluated, they
raise several interesting hypotheses that could
be empirically tested.
Next steps
Integration of graphic stories into medical educa-
tion and practice is not without challenges. The
first is to contest doctors’ and patients’ biases
against graphic stories—including the mispercep-
tion that they are juvenile, simplistic, or frivolous.
Another task is to identify appropriate graphic
stories and get into the hands of those patients
who are most able to benefit from them. In doing
so, doctors should ensure that patients do not feel
“brushed off” when given a book about a disease
or condition; a graphic pathography is obviously
no substitute for a substantive conversation and
caring relationship.
Research can help to dispel doctors’ scepticism
about the use of graphic stories. Recent publica-
tions have featured graphic stories as a topic of
historical analysis
27
and disability studies,
28
and
as a method for combating illiteracy,29 but few
empirical studies exist on their effect in medicine.
Future research from a wide range of disciplines
might focus on ways to show the effectiveness of
this tool in medicine. Some questions to consider
include:
Does the use of graphic stories in medical
education improve students’ observational
and diagnostic skills, and does it aect
empathy?
How might graphic stories enable the
emergence of multiple voices and thereby
cultivate broader awareness of relevant
issues?
Do patients like reading graphic
pathographies and find them helpful?
Can graphic pathographies enable patients to
ask more informed questions or improve their
understanding of diagnosis and prognosis?
Does the use of graphic pathographies aect
the doctor-patient relationship?
Conclusions
Graphic stories are a novel and creative way to
learn and teach about illness, and we believe the
themes and structure of this medium will reso-
nate with an increasingly large number of medi-
cal professionals. We have offered some examples
of how this medium works and ways it might be
integrated into medical education and practice,
but this is only the beginning. We look forward
to the ideas and experiences of others, and to a
robust research agenda that rigorously evaluates
the impact of graphic stories on educational and
clinical outcomes.
Michael J Green professor, Department of Humanities and
Medicine, Penn State College of Medicine, 500 Universit y Drive,
Hershey, PA 17033, USA
Ki mbe rly R My ers as soc iat e pr ofe sso r, De pa rtm ent of
Humanities and Medicine, Penn State College of Medicine, 500
University Drive , Hershey, PA 17033, USA
Correspondence to:
M J Green mjg15@psu.edu
Accepted:
1 February 2010
We thank Susan M Squier, Maria Vaccarella, J T Waldman, and Ian
Williams for their valuable insights. We also acknowledge Ian Williams
for the term “graphic medicine” (http:
//graphicmedicine.org).
Contributors and sources:
Both authors teach ethics and
humanities to medical students. MJG has a life long interest in
comics and visual art and in using these media for improving
communication and learning. KRM became interested in the
potential for graphic pathographies while researching various
forms of health self help books. Both authors contributed equally
to the manuscript and will act as guarantors.
Competing interests:
None declared
Provenance and peer review:
Not commissioned; externally peer
reviewed.
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Cite this as: BMJ 2010;340:c863
See REVIEWS, p 600
FURTHER READING
Some graphic stories with themes relevant to medicine
Harvey Pekar, Joyce Brabner. • Our Cancer Year. Four Walls Eight Windows, 1994
David Small. • Stitches. WW Norton, 2009
David B. • Epileptic. Pantheon Press, 2006
Brian K Vaughan, Pia Guerra. • Y: The Last Man. DC Comics, 2008
Apostolos Doxiadis, Christos Papadimitriou. • Logicomix: An Epic Search for Truth. Bloomsbury, 2009
Mark Schultz, Zander Cannon, Kevin Cannon. • The Stuff of Life: A Graphic Guide to Genetics and DNA.
Hill and Wang, 2009
Resources for understanding and using comics
Scott McCloud. • Understanding Comics the Invisible Art. HarperPerenial, 1994
Will Eisner. • Comics and Sequential Art. WW Norton, 2008
Jessica Abel, Matt Madden. • Drawing Words and Writing Pictures. First Second, 2008
Could graphic medicine work in
medical education? To follow the
discussion on doc2doc, the
BMJ
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visit http://tinyurl.com/ydldu5g
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