By stealth and by design…Using graphic medicine as a teaching tool in the medical school

In this post, Liz Brewster shares material from her recent talk on integrating graphic narratives into medical education at Curating Health: Graphic Medicine and Visual Representations of Illness hosted by Nordic Network Gender, Body and Health (Stockholm, December 2018). 

If there is one thing that is agreed about medical education, it is that there is more to teach students than ever. As technology advances and we understand more about the human body, what makes it ill and how to keep it well, the medical curriculum keeps expanding. Alongside genetics and genomics, there are also calls for medicine to remember its humanity; that clinicians treat people and not just symptoms. In particular, I am interested in how we teach students to engage with the complexities of topics that affect patient experience and engagement with treatment including stigma and health inequalities.

As we move towards a more population-based approach to thinking about health and illness, it is with an awareness that keeping people well is as, if not more, important than treating them when they are ill. While medical students often love to learn about pathologies, one of the challenges is to help them to think about how to help patients to live healthily and well, and not just to treat sickness.

Narrative medicine is a well-established field, which helps to tell stories of illness, but still sometimes seems marginal to the everyday teaching that UK medical schools deliver to their students in practice. Textbooks and peer-reviewed journal articles still form the majority of resources recommended to students to support their learning. There could be a greater diversity of sources, particularly those that encompass story-telling about health and illness; if medicine is an art as well as a science then perhaps this could be reflected in the way that medicine is taught.

Looking at the history of medicine reveals that it is a history of medical illustration. Images of medical education highlight the sharing of images to learn more about the human body. The juxtaposition of text and images is clear, and both contribute, though there has been little exploration of the form in which they are communicated, as discussed by Kat Rawling, Harriet Palfreyman, and Beatriz Pichel in their piece ‘Picturing medicine: visual and material culture as historical source.’

Scholarship around graphic medicine – the use of comics to communicate narratives of health and illness, particularly around experiences of illness – has grown during the past decade. I am a firm believer in the fact that graphic narratives can be a powerful communication tool. Using graphic narratives in my work as a medical educator? More difficult.

In the Graphic Medicine manifesto, Michael Green describes medical school as “a mind-numbingly fallow environment.”[1] Given that there is so much content to convey in the curriculum, there is little, if any, room for creativity.  But this is not how I want to teach medical students; I want my future doctor to be trained in what Baruch referred to as an educational environment that is “committed to fostering creative and critical thinkers.”[2]

Two graphic narrative resources inspired me to try to integrate graphic medicine into my everyday practice. The first was the Act With Love Collaboration, with illustrator Jade Sarson, representing Oli Williams and Ellen Annandale’s research onto obesity and stigma in comic form. The resulting The Weight of Expectation demonstrates the difficulties experienced at the intersection of low socio-economic status and obesity. It helps to illustrate the embodied nature of stigma and the intractable relationship between inequalities and healthy lifestyles. Healthy choices are not accessible to everyone and by creating a comic that draws on sociological research, Williams and Sarson have clearly and accessibly represented an issue that medical students often find difficult to engage with.

The second resource, created by Emma Halliday, Natasha Lackovic and Joe Decie, in collaboration with the Communities in Control project, is another graphic narrative that presents stories about health inequalities in northern England. Community-led stories of experiences of poverty and the effect of poverty on health, powerfully illustrated, form an engaging resource that makes complex issues easier to absorb.

One issue with graphic medicine is the physical availability of the resources themselves. I enjoy comics most when I have a hard copy of them in my hands, but providing copies of resources amongst large groups of medical students is always an issue. By sharing digital comics, something may be lost in the reading process, but it may be a necessary sacrifice in order to get students interacting with the form at all.

Credit: Robyn Mclean, year 2 medical student at Lancaster Medical School, taken from ‘Sam’s adventures in epilepsy’.

Sharing these resources with students, and using images from graphic medicine texts in lectures to communicate experiences of health and illness, feels like a good starting point to helping them to think differently – creatively as well as clinically – about medicine. When I was thinking about my pedagogical practice, I considered how sometimes it seems right to introduce such changes by stealth. Adding graphic medicine resources to a reading list and encouraging the university library to buy copies is hardly a radical act but contributes to a shift in medical educational practice that does acknowledge that graphic medicine is valuable.

Designing projects that overtly promote the value of graphic medicine to students is an obvious next step. One of the small spaces in the medical curriculum for doing something different is a curated collection of four week projects that the students take on as part of their assessed work in years two and three. This year, for the first time, I ran a graphic medicine module in which students engage with the principles and practice of graphic medicine as a topic, and created a resource based on patient stories. Using healthtalkonline, which collects information about illnesses and patient experiences, students learned about how graphic medicine can be a useful communication tool which goes beyond textual narrative to connect and share. However, getting them to move away from comics-as-educational-and-informational to telling a patient’s story was trickier than expected. One of the things I value about graphic resources is their ability to represent emotion vividly, and trying to help students to understand the role of emotion in medicine is an ongoing challenge.

Seeing Ainna P. Randhawa and Paivi M. Miettunen’s presentation at Curating Health reminded me why. Ainna, a medical student in Canada, shared her images of patients whose stories had moved her, and explained how clinical culture can discourage the consideration of the patient as a whole person. The hidden curriculum, in which students are sometimes inculcated into medicine through demonstration of knowledge rather than through an ethic of care, is still a powerful model of medical teaching (though not one I support, obviously). Isabel Hanson and Safdar Ahmed’s recent exposition of the relationship between patients and knowledge in a US context in The Guardian presents this particularly powerfully.

Despite a shift towards medical humanities and narrative medicine, thinking about someone’s story represents a very different way of thinking about symptoms for many medical students. I guess for me, that’s what makes the graphic medicine community so valuable – a reminder that people use, think differently about image and narrative, and that bringing that into medical education will help to improve healthcare.

[1] Michael Green, “Graphic Storytelling and Medical Narrative: The Uses of Comics in Medical Education,” in Graphic Medicine Manifesto, ed. by MK Czerwiec and others (Pennsylvania: The Pennsylvania State University Press, 2015), 67-86.

[2] Jay M Baruch, “Doctors as Makers.” Academic Medicine 92, no 1. (January 2017): 40-44.


Liz Brewster is a Lecturer in Medical Education and health sociologist at Lancaster University. She is on Twitter @LizBrewster

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