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

Juxtaposing text and image

Although graphic pathographies are often thematically similar to standard textual accounts of illness, their powerful visual messages convey immediate visceral understanding in ways that conventional texts cannot. An excellent example 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 characters’ text bubble dialogue. Here, the lower text box explains an important milestone 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 narrative 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 explanation of the upcoming procedure. Anxiety ridden, neither hears much of what the doctor says. Marchetto conveys this with scribbles punctuated by isolated words and phrases that do register consciously: “cancer,” “lumpectomy,” “may not be invasive,” and “lymph nodes.”

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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 technical 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 something 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⇓).

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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 experiencing 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 daughter’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 economy.

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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 doctor, 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 nevertheless 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 anxiety about issues the doctor might not find as relevant to the clinical encounter. Such depictions implicitly offer important social critiques of the medical profession.

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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 ethics,9 creative writing and composition,10 11 12 literature,13 and physics.14 Graphic stories—like film, fiction, poetry, and visual art, which have already been integrated into medical curriculums—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 illness 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 comics, like doctors in the exam room, must determine 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.

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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 interpretive 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 public awareness and enhance patient care for various problems including substance abuse, HIV, diabetes, and mental illness.20 21 22 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, aeroplane 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 experience of anguish (fig 6⇓).

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Research has shown how combining pictures and text enhances understanding, as the activities of reading and viewing activate different information processing systems within the brain.24 This combination also fosters connections 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 explanatory, 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 prognosis and to elicit the patient’s treatment preferences. Reading a graphic pathography also gives the patient something concrete on which 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.