Essays
Graphic Medicine: Comics Turn a Critical Eye on Health Care by sarah glazer
A
patient arrives in the emergency room apparently in a comatose state. But is he really unconscious or just faking? The young doctors on duty are skeptical. Failing to get a reaction with a chest rub, they try a variety of methods that become increasingly sadistic—pressing on the patient’s fingernail with a ballpoint pen, spraying his testicles with a skin-freezing compound, announcing an imminent eye injection to scare the patient awake. I first encountered those chilling pen-and-ink images in a 2012 comic book, Disrepute, authored by Thom Ferrier, the nom de plume for British general practitioner Ian Williams.1 Although the panels are simply drawn, almost schematic, the images of those leering doctors have stayed with me. (For other panels from Disrepute, see figure 1.) When I met Williams in London to interview him about his work, he told me, “I think the act of making comics forces you to reflect on your own experience.” Disrepute is part of a young but growing genre that Williams helped dub “graphic medicine” when he founded a website by that name in 2007.2 Using the graphic novel form, doctors, nurses, and patients are producing accounts that often reveal the dark underbelly of the world of medicine. From patients and their families, these include portraits of imperious and insensitive physicians or nurses; from doctors, explorations of the doubt that racks them when their treatment ends in a mistake or a patient’s death. While the form is also referred to as “comics,” the work, as in Williams’s strip, is bleak just as often as it is humorous. Sometimes it’s both, with the humor taking on a darkly savage or rueful tone. The most popular and numerous of these works are unsparing autobiographical accounts by patients or their family members about coming to grips with serious illness, Sarah Glazer, “Graphic Medicine: Comics Turn a Critical Eye on Health Care,” Hastings Center Report 45, no. 3 (2015): 15-19. DOI: 10.1002/hast.445 May-June 2015
sometimes called “pathographies.”3 In many of these accounts, the medical establishment comes off as insensitive, incomprehensible, or dictatorial. Encounters with soulless medical staff or with frightening treatments like chemotherapy can appear as daunting as the patient’s illness itself. A recent example is the best-selling graphic novel by New Yorker cartoonist Roz Chast about the agony of dealing with the aging and the increasing infirmity of her parents, Can’t We Talk about Something More PLEASANT? Her first hospital encounter is with a yelling nurse who pulls Chast’s chair away and tries to eject her from the emergency room, where she has brought her sick mother and is enduring a twentytwo–hour wait for a hospital room with her mentally fragile father.4 In Mom’s Cancer, author Brian Fies illustrates his mother’s chemotherapy for brain cancer as a dangerous balancing act that seeks to kill all the bad cells while sparing the good. Fies shows his mother walking a tightrope as a vulture tries to throw her off balance and an open-jawed crocodile waits in the void below.5 As I learned at the fifth annual Comics & Medicine Conference: “From Private Lives to Public Health,” held at Johns Hopkins School of Medicine in June 2014, the term “graphic medicine” is also taking on a broader, more eclectic meaning. The 235 participants included doctors, nurses, patients, educators, and illustrators who are using the graphic form not just to document their experiences but also to educate medical students and patients.6 As a free-lance journalist who writes frequently about health, I was intrigued by some scathing first-person accounts I had encountered in the comics format and was covering the conference to learn more about what direction this genre was taking. Some think these portrayals of grueling encounters with doctors and nurses can transform the profession into a more humane one. Darren B. Taichman, executive deputy editor of the Annals of Internal Medicine, said that graphic H AS TI N GS C EN TE R RE P O RT
15
narratives tend to be harshly critical of the medical profession, often for treating the disease rather than the person. “There’s truth to that,” he acknowledged. But he told me such portrayals “can only help” doctors and nurses as well as patients “understand this world of health care and hopefully improve it.” He added, “This type of graphic novel might provide a safe place where people feel comfortable expressing those uncomfortable issues.” There’s a long tradition of confessional storytelling by physicians, and medical journals often include doctors’ reflections on dilemmas they’ve faced. But how does mainstream medicine view this kind of storytelling when it comes in the form of comics? One breakthrough came in 2013 when the Annals of Internal Medicine ran its first comic, “Missed It,” written by Michael J. Green, a physician, professor, and bioethicist at Pennsylvania State University’s Milton S. Hershey Medical Center.7 The Annals was the first mainstream peer-reviewed medical journal to publish a comic, although some comics have appeared in journals of medical humanities.8 The fivepage spread describes a medical mistake Green made as an intern when he accepted a senior doctor’s diagnosis and ignored his patient’s heart murmur, a mistake that he believes cost his patient’s life and that haunted him for years after. The comic appeared in a special supplement on medical error.9 The concept of running a comic initially got a skeptical reaction from University of California, San Francisco, professor of medicine Robert M. Wachter, coauthor of the issue’s lead editorial10 and author of the 2004 book Internal Bleeding: The Truth behind America’s Terrifying Epidemic of Medical Mistakes. “One of the things I worried about,” Wachter told me, “was, does this cheapen the subject or make it overly simplistic—or is the form not appropriate to the gravity of the problem?” Wachter changed his mind after he read Green’s piece. “I thought this was very well done, and I didn’t have that concern at all.” He even tweeted about it and said it received “a huge number” of retweets. “Medical mistakes are one of those things that are hard to describe: They’re scary, dramatic, and it’s not surprising that they’re the subject of movies and books,” he said. At last year’s Comics & Medicine Conference, Annals editor Taichman issued an open invitation to participants to submit more comic narratives to the journal, and he told me that the journal is open to such pieces from doctors or patients. From the email responses to Green’s comic, “it was clear,” Taichman said, that “we hit a chord that resonated with a lot of our readers.” For physicians, he said, “The story itself is something we are all terrified of; if we’re not terrified of making a mistake, we’ve lost touch with the seriousness of our work.” Readers also said, Taichman reported, that they found it refreshing to read something in a format other than straight prose. As for why the Annals is interested in publishing more graphic narratives, he told me, “Our readers have broad interests, and those include not only the science of medicine but the art of medicine. Medicine, if we’re doing it 16 HASTI N G S C E N T E R R E P ORT
Figure 1. ”Tough” from Disrepute. British physician Ian Williams (penname Thom Ferrier) illustrates the emotional seesaw experienced by a junior doctor during his hospital training.
right, involves emotions. If it doesn’t, there’s probably something wrong with how we’re practicing.” Stories like this could improve patient care, Taichman suggested, if they touch off discussions among physicians and educators along the lines of “Gosh, what kind of supervision are we providing to our interns? Are they being asked to make decisions that they’re not yet not ready to make in the emergency room?” Comics have already made inroads in the humanities departments established at several medical schools. “It seems that each year more universities are using comics to share both health care worker and patient perspectives in a really intimate way,” according to conference organizer Lydia Gregg, instructor and medical illustrator in the Department of Art as Applied to Medicine and the Division of Interventional Neuroradiology at Hopkins’ medical school. A comic by Williams—about a doctor’s sense of guilt over the suicide of a patient with whom the doctor had talked about his own tendencies to depression—was included last year in Health Humanities Reader, published by Rutgers University Press.11 But comics are also being used more directly in medical education. Medical textbook editor Paul Mayhew described a twenty-volume series slated for 2015 from JP Medical that will introduce comics-style case studies. The comics remind May-June 2015
In one comic, as a doctor describes an impending biopsy to a bugeyed patient, his words disintegrate in the bubble over his head into meaningless scribbles, punctuated with isolated words like “cancer” and “lumpectomy.” medical students that the patient is “a real person”—illustrating aspects of the patient’s experience, presentation, and diagnosis as well as management of the condition, he said. An “intern survival” comic book to orient new doctors at a rural Australian hospital gives tips on how to overcome firstyear stresses like an intimidating interrogation from a senior physician or a difficult patient. With vivid facial expressions and thought bubbles, “comics are a good way of showing how things not talked about affect the patient-doctor relationship,” said Aaron Scott Humphrey, the manual’s creator.12 Dan Bustillos, assistant professor of health care ethics at St. Louis University’s Albert Gnaegi Center for Healthcare Ethics, uses graphic novels and superhero comics in his bioethics course aimed mostly at premed undergraduates. He pointed to the graphic novel Wrinkles, which opens with a bank manager telling a young couple he won’t give them a loan.13 The exasperated young man sitting across from the manager responds, “I don’t want a loan! . . . The only thing I want is for you to eat your dinner right now,” as the scene shifts to a hospital bed and you realize the manager’s “desk” is actually a hospital tray with a bowl of soup. “You have this moment of catharsis and recognition that resonates with students,” Bustillo told me, and that “helps destigmatize” the kind of dementia that the old man suffers from. A theme running through many first-person illness narratives and doctor narratives is the failure of doctors to find out what’s really troubling the patient. Muna Al-Jawad, a physician who specializes in geriatric medicine at Brighton and Sussex University Hospitals in England, organized the 2013 Comics & Medicine Conference: “Ethics under Cover: Comics, Medicine, and Society.” “The reason we chose ethics,” she told me, “is comics are particularly good at looking at things under the surface.” Jawad has created a comics superhero, a cape-wearing geriatric specialist, to teach her medical trainees about the ethics and values involved in treating the elderly—“the real-life stuff no one ever talks about.”14 In one of her comics, her superhero, framed by a jagged outline of light, comes to the rescue of an elderly patient, his face distended in distress after a hospital staffer tells him that he needs to go into an old-age home. “Not so fast! The team will get you home with some help,” the superhero exclaims, pointing to her team of occupational therapists and aides who will be able to care for the patient at home. In 2009, Green pioneered the study of comics for fourthyear medical students in his bioethics course at Penn State, May-June 2015
a practice that has since spread to a handful of other medical schools, he said. “I came across some graphic novels that had medical relevance and I thought, ‘Wow, this would be a really cool way to teach medical students about issues we’re already teaching in medical humanities and in medical ethics, focusing on the doctor-patient relationship and the patient’s experience of illness.’” Green uses Can’t We Talk about Something More PLEASANT? to discuss end-of-life directives like the do-not-resuscitate order, a subject that author Chast depicts in all its excruciating discomfort as one that she must broach with her parents. Cancer Vixen, a graphic novel by cartoonist Marisa Acocella Marchetto about her breast cancer, becomes a springboard to discuss informed consent. In one panel, Marisa and her mother are shown bug-eyed with dread as the doctor describes an impending biopsy.15 The physician’s words disintegrate into meaningless scribbles in the word bubble above his head, punctuated with isolated words like “cancer” and “lumpectomy.” That scene is a “great example” of how challenging it can be to obtain genuine informed consent, Green observed, when patients are too frightened to absorb the information even though the doctor thinks he’s fully disclosing what they need to know. In his course, Green also assigns students to write their own graphic narrative about an experience they’ve had as medical students. Because medical students have more time than harried senior hospital staff members, they’re often “the ones who can sit down with patients and discover important pieces of information that were missed by the hustle and bustle of the regular team,” Green noted. For example, in one comic, a medical student discovers that the reason an elderly patient feels too sick to be discharged from his hospital bed is that he doesn’t want to return to his senior-care home, where the staff has neglected him.16 Other student comics posted on the class website offer a fascinating window into how medical students’ instincts and compassion are often devalued in a hierarchical teaching structure. In one comic, a senior doctor imperiously stops a medical student who wants to investigate a woman’s complaints of chest pain. The supervising physician labels the woman a repeat nuisance patient; the patient later suffers a heart attack.17 In “Medical Ethics 101,” a student is faced with a dilemma when the senior surgeon instructs him to lie to a patient about altering a medical procedure with which the patient is familiar, saying the patient won’t understand the reasoning behind the changes.18 H AS TI N GS C EN TE R RE P O RT
17
Several members of the audience at the June 2014 conference in Baltimore asked how to overcome the skepticism of university curriculum committees toward introducing courses based on comics in medicine and bioethics. “I had to prove to them this wasn’t frivolous and these materials were worth reading,” Bustillos said, noting he had paired Watchmen comics with an essay by John Stuart Mill to illustrate principles of utilitarianism. Still, many unanswered questions remain. Green has argued that reading a comic, which requires making inferences and filling in the mental gaps from one frame to another, requires skills analogous to making a diagnosis, since the bits and pieces of a medical history the doctor gets from a patient are often amorphous, requiring the doctor to weave a coherent narrative.19 But he acknowledges, “There’s not a ton of data yet” on whether comics improve diagnostic skills or foster empathy among medical students. Similarly, there’s not much research on whether comics are a more effective way of informing patients about their medical conditions than straight prose or other forms of media, according to Gregg. Fies, who began to record his mother’s metastatic brain cancer online with comics in 2004, “was astonished by how many readers saw their own story in ours.”20 An Australian nursing instructor told him she was recommending the comic to nurses in the outback to pass on to patients and their families, Fies told the Baltimore conference. Green has proposed that a physician might suggest Cancer Vixen to a patient newly diagnosed with breast cancer to prompt questions she might not have considered discussing with her doctor and to make her feel “less isolated.”21 Yet some graphic novels paint such a dark and frightening vision of disease that it’s not clear such accounts would be helpful for every patient. For example, the autobiographical Epileptic, by French author David B., about growing up with an epileptic brother, is illustrated with his nightmarish visions of the disease. It “is not a feel-good story about how to overcome epilepsy; it’s a dark, harsh, challenging story about the real challenges this poses in this family’s life,” Green stated.22 But Taichman says it depends on the patient. “Learning about the bad experiences and knowing what might come, that’s an important part of our job of informing our patients,” he told me. Knowing you’re not alone in feeling anger or fear can be comforting, he added. The graphic medicine movement can be viewed as part of a larger trend toward giving patients more of a voice in narrative medicine accounts. But to Susan M. Squier, professor of English and women’s studies at Pennsylvania State University and coeditor of a new series on graphic medicine for Penn State University Press, the visually accessible and iconoclastic nature of graphic accounts is unique: “Narrative medicine gives you a platform to talk back to the assumption that the doctor knows everything; a comic brings it out of the university or library,” she told me. “Comics create a richer and more resistant voice to speak back to the dominant medical discourse.” Graphic medicine has historically been a subversive underground culture, Squier points out, going back at 18 HASTI N G S C E N T E R R E P ORT
least to the 1973 comic Abortion Eve, by two counselors at a women’s free clinic. That tradition continues to be played out in Not Your Mother’s Meatloaf, a sex education book that started out as an online zine for accounts by young women about their personal struggles with sexual relations and using contraception.23 Several conference speakers tried to articulate what’s so special about this medium. Some noted that comics are good at depicting visually the moments when emotions are at variance with spoken words. Arthur Frank, author of The Wounded Storyteller, pointed out that the idea of an event so horrible that words cannot describe it is expressed visually in the eighteenth-century novel Tristram Shandy, where Lawrence Sterne inserted an entirely black page upon the death of one of his characters. Similarly, Frank observed, in Cancer Vixen, when Marisa learns of her first positive test result indicating cancer, she illustrates her shock and sense of falling into a void with a black panel—although in this case, two terrified eyes peer out of the emptiness.24 As a journalist, I am steeped in the world of prose, and I confess that at first I had trouble getting into graphic novels about illness. They didn’t allow for the kind of skimming that I’m accustomed to with straight text—or even the feeling of being completely absorbed by a flow of words. I complained about this to Nancy K. Miller, a memoirist and professor of English at City University of New York Graduate Center, who recently began recording her own experience of lung cancer through comics. She explained to me that you have to slow down to read a graphic novel. You have to focus on each picture, each panel before you can move on. Similarly, graphic medicine seems to be asking medical professionals to slow their frantic pace: Look at the patient; try to read the body language; take the time to ask more questions. You might be surprised at what you discover. 1. T. Ferrier, “Cruel to Be Kind,” in Disrepute by T. Ferrier (Hafoty LWYD, Wales: Graphic Medicine, 2012); Disrepute, in which the panels in figure 1 appear, is available at http://www.thomferrier.com/#/ strips/4526268949, accessed March 16, 2015. 2. See http://www.graphicmedicine.org/. 3. M. Vaccarella, “Exploring Graphic Pathographies in the Medical Humanities,” Medical Humanities 39 (2013): 70-71. 4. R. Chast, Can’t We Talk about Something More PLEASANT? (New York: Bloomsbury USA, 2014), 62-63. 5. B. Fies, Mom’s Cancer (New York: Abrams ComicArts, 2006), 60-61. 6. “Comics & Medicine: From Private Lives to Public Health,” June 26-28, 2014, Johns Hopkins Medical Campus, Baltimore, MD; see http://www.graphicmedicine.org/ comics-and-medicine-conferences/2014-baltimore-conference/. 7. M. J. Green and R. Rieck, “Missed It,” Annals of Internal Medicine 158, no. 5 (2013): 357-61. 8. See cover of Ars Medica 8, no. 1 (2011), by I. Williams, http://www. ars-medica.ca/index.php/journal/issue/view/15/showToc. Also see M. Al-Jawad, “Comics Are Research: Graphic Narratives as a New Way of Seeing Clinical Practice,” Journal of Medical Humanities, published online February 2, 2013, http://link.springer.com/article/10.1007/ s10912-013-9205-0. 9. Green et al., “Missed It.”
May-June 2015
10. R. M. Wachter et al., “Strategies to Improve Patient Safety,” Annals of Internal Medicine 158, no. 5 (2013): 350-52. 11. I. Williams, “Culpability,” in Health Humanities Reader, ed. T. Jones et al. (New Brunswick: Rutgers University Press, 2014), chapter 34. 12. A. S. Humphrey, Mackay Hospital and Health Service 2014 Intern Survival Comic Book, 2014, at www.aaronhumphrey.com. 13. P. Roca, Arrugas (Bilbao: Astiberri, 2014), 8; in translation as P. Roca, Wrinkles (London: Knockabout, 2015). 14. M. Al-Jawad, “Super-Geris: How Geriatricians Really See Themselves,” February 3, 2013, at http://oldpersonwhisperer.tumblr.com/ page/3. 15. M. A. Marchetto, Cancer Vixen (London: Fourth Estate, 2007), 89. 16. P. Adedayo, “Listen Up!,” Penn State Hershey College of Medicine, 2014, at http://www2.med.psu.edu/humanities/for-medical-students/ research-opportunities/graphic-storytelling-Medical-narratives/.
17. J. Monk, “A Ghost of an Idea,” Penn State Hershey College of Medicine, 2012, http://www2.med.psu.edu/ humanities/for-medical-students/research-oppor tunities/ graphic-storytelling-Medical-narratives/. 18. R. Svoboda, “Medical Ethics 101,” Penn State Hershey College of Medicine 2012, http://www2.med.psu.edu/ humanities/for-medical-students/research-oppor tunities/ graphic-storytelling-Medical-narratives/. 19. M. J. Green, “Teaching Comics: A Course for Fourth-Year Medical Students,” Journal of Medical Humanities, 34, no 4 (2013): 471-76. 20. Fies, Mom’s Cancer, preface. 21. M. J. Green and K.R. Myers, “Graphic Medicine: Use of Comics in Medical Education and Patient Care,” BMJ 340 (2010): c863. 22. David B., Epileptic (New York: Pantheon, 2006). 23. S. Miller and L. Bley, Not Your Mother’s Meatloaf: A Sex Education Comic Book (Berkeley, CA: Soft Skull Press, 2013); see http://notyourmothersmeatloafbook.com/. 24. See Marchetto, Cancer Vixen, 9.
Graphic Medicine in the University by susan m. squ ier
T
he spring I first offered a graphic medicine graduate seminar, I wasn’t sure what to expect of students so schooled in approaching their subjects from an academic perspective. Every class meeting included one hour in which the students, from fields that stress rigorous verbal and written achievement, were required to embrace the position of the amateur by learning to create comics. They experimented with putting images and words together in sequential drawn panels in order to tell a story of their own devising. Of course, they did more than draw; the other two hours of the seminar introduced them both to the medium of comics and to graphic medicine in particular.1 They read and discussed comics like Harvey Pekar and Joyce Brabner’s Our Cancer Year, John Porcellino’s Diary of a Mosquito Abatement Man and The Hospital Suite, Lynda Barry’s One Hundred Demons, and Kaisa Leka’s I Am Not These Feet. They also read secondary articles in comics studies and in literature and medicine. In addition to writing a conventional seminar paper, at the end of the semester they turned in the comic they had created about an experience of illness, disability, or medical treatment, whether their own or that of an acSusan M. Squier, “Graphic Medicine in the University,” Hastings Center Report 45, no. 3 (2015): 19-22. DOI: 10.1002/hast.446 May-June 2015
quaintance or family member. Although I had been teaching graphic narratives of other kinds to humanities graduate students for several years, what happened in this course on graphic medicine surprised me. Not only did the students, none of whom were medical students, explore illness, disability, and medical treatment in their comics, but they often articulated bioethics issues as well. Here is a partial list of the subjects their comics addressed: being treated for dengue fever in an upper New York State hospital where the patient had to teach his caregivers to pronounce the name of his disease; discovering after a year of depression that the birth control method prescribed by the university health center had been flagged by the Food and Drug Administration for its depression-related side effects, something the prescribing physician had never mentioned; improvising a method of teaching studio art to a student with a prosthetic arm; and finding a way to tolerate the pain of a younger sister’s chronic illness. Influenced by the experience of creating these comics, some of the students in this multidisciplinary group even changed the topic of their final seminar paper from a conventional critical reading of texts to a topic that brought their skills of literary and rhetorical analysis to bear on the bioethical issues the comics had illuminated for them. Thus, the H AS TI N GS C EN TE R RE P O RT
19
Graphic Medicine: Comics Turn a Critical Eye on Health Care by sarah glazer
A
patient arrives in the emergency room apparently in a comatose state. But is he really unconscious or just faking? The young doctors on duty are skeptical. Failing to get a reaction with a chest rub, they try a variety of methods that become increasingly sadistic—pressing on the patient’s fingernail with a ballpoint pen, spraying his testicles with a skin-freezing compound, announcing an imminent eye injection to scare the patient awake. I first encountered those chilling pen-and-ink images in a 2012 comic book, Disrepute, authored by Thom Ferrier, the nom de plume for British general practitioner Ian Williams.1 Although the panels are simply drawn, almost schematic, the images of those leering doctors have stayed with me. (For other panels from Disrepute, see figure 1.) When I met Williams in London to interview him about his work, he told me, “I think the act of making comics forces you to reflect on your own experience.” Disrepute is part of a young but growing genre that Williams helped dub “graphic medicine” when he founded a website by that name in 2007.2 Using the graphic novel form, doctors, nurses, and patients are producing accounts that often reveal the dark underbelly of the world of medicine. From patients and their families, these include portraits of imperious and insensitive physicians or nurses; from doctors, explorations of the doubt that racks them when their treatment ends in a mistake or a patient’s death. While the form is also referred to as “comics,” the work, as in Williams’s strip, is bleak just as often as it is humorous. Sometimes it’s both, with the humor taking on a darkly savage or rueful tone. The most popular and numerous of these works are unsparing autobiographical accounts by patients or their family members about coming to grips with serious illness, Sarah Glazer, “Graphic Medicine: Comics Turn a Critical Eye on Health Care,” Hastings Center Report 45, no. 3 (2015): 15-19. DOI: 10.1002/hast.445 May-June 2015
sometimes called “pathographies.”3 In many of these accounts, the medical establishment comes off as insensitive, incomprehensible, or dictatorial. Encounters with soulless medical staff or with frightening treatments like chemotherapy can appear as daunting as the patient’s illness itself. A recent example is the best-selling graphic novel by New Yorker cartoonist Roz Chast about the agony of dealing with the aging and the increasing infirmity of her parents, Can’t We Talk about Something More PLEASANT? Her first hospital encounter is with a yelling nurse who pulls Chast’s chair away and tries to eject her from the emergency room, where she has brought her sick mother and is enduring a twentytwo–hour wait for a hospital room with her mentally fragile father.4 In Mom’s Cancer, author Brian Fies illustrates his mother’s chemotherapy for brain cancer as a dangerous balancing act that seeks to kill all the bad cells while sparing the good. Fies shows his mother walking a tightrope as a vulture tries to throw her off balance and an open-jawed crocodile waits in the void below.5 As I learned at the fifth annual Comics & Medicine Conference: “From Private Lives to Public Health,” held at Johns Hopkins School of Medicine in June 2014, the term “graphic medicine” is also taking on a broader, more eclectic meaning. The 235 participants included doctors, nurses, patients, educators, and illustrators who are using the graphic form not just to document their experiences but also to educate medical students and patients.6 As a free-lance journalist who writes frequently about health, I was intrigued by some scathing first-person accounts I had encountered in the comics format and was covering the conference to learn more about what direction this genre was taking. Some think these portrayals of grueling encounters with doctors and nurses can transform the profession into a more humane one. Darren B. Taichman, executive deputy editor of the Annals of Internal Medicine, said that graphic H AS TI N GS C EN TE R RE P O RT
15
narratives tend to be harshly critical of the medical profession, often for treating the disease rather than the person. “There’s truth to that,” he acknowledged. But he told me such portrayals “can only help” doctors and nurses as well as patients “understand this world of health care and hopefully improve it.” He added, “This type of graphic novel might provide a safe place where people feel comfortable expressing those uncomfortable issues.” There’s a long tradition of confessional storytelling by physicians, and medical journals often include doctors’ reflections on dilemmas they’ve faced. But how does mainstream medicine view this kind of storytelling when it comes in the form of comics? One breakthrough came in 2013 when the Annals of Internal Medicine ran its first comic, “Missed It,” written by Michael J. Green, a physician, professor, and bioethicist at Pennsylvania State University’s Milton S. Hershey Medical Center.7 The Annals was the first mainstream peer-reviewed medical journal to publish a comic, although some comics have appeared in journals of medical humanities.8 The fivepage spread describes a medical mistake Green made as an intern when he accepted a senior doctor’s diagnosis and ignored his patient’s heart murmur, a mistake that he believes cost his patient’s life and that haunted him for years after. The comic appeared in a special supplement on medical error.9 The concept of running a comic initially got a skeptical reaction from University of California, San Francisco, professor of medicine Robert M. Wachter, coauthor of the issue’s lead editorial10 and author of the 2004 book Internal Bleeding: The Truth behind America’s Terrifying Epidemic of Medical Mistakes. “One of the things I worried about,” Wachter told me, “was, does this cheapen the subject or make it overly simplistic—or is the form not appropriate to the gravity of the problem?” Wachter changed his mind after he read Green’s piece. “I thought this was very well done, and I didn’t have that concern at all.” He even tweeted about it and said it received “a huge number” of retweets. “Medical mistakes are one of those things that are hard to describe: They’re scary, dramatic, and it’s not surprising that they’re the subject of movies and books,” he said. At last year’s Comics & Medicine Conference, Annals editor Taichman issued an open invitation to participants to submit more comic narratives to the journal, and he told me that the journal is open to such pieces from doctors or patients. From the email responses to Green’s comic, “it was clear,” Taichman said, that “we hit a chord that resonated with a lot of our readers.” For physicians, he said, “The story itself is something we are all terrified of; if we’re not terrified of making a mistake, we’ve lost touch with the seriousness of our work.” Readers also said, Taichman reported, that they found it refreshing to read something in a format other than straight prose. As for why the Annals is interested in publishing more graphic narratives, he told me, “Our readers have broad interests, and those include not only the science of medicine but the art of medicine. Medicine, if we’re doing it 16 HASTI N G S C E N T E R R E P ORT
Figure 1. ”Tough” from Disrepute. British physician Ian Williams (penname Thom Ferrier) illustrates the emotional seesaw experienced by a junior doctor during his hospital training.
right, involves emotions. If it doesn’t, there’s probably something wrong with how we’re practicing.” Stories like this could improve patient care, Taichman suggested, if they touch off discussions among physicians and educators along the lines of “Gosh, what kind of supervision are we providing to our interns? Are they being asked to make decisions that they’re not yet not ready to make in the emergency room?” Comics have already made inroads in the humanities departments established at several medical schools. “It seems that each year more universities are using comics to share both health care worker and patient perspectives in a really intimate way,” according to conference organizer Lydia Gregg, instructor and medical illustrator in the Department of Art as Applied to Medicine and the Division of Interventional Neuroradiology at Hopkins’ medical school. A comic by Williams—about a doctor’s sense of guilt over the suicide of a patient with whom the doctor had talked about his own tendencies to depression—was included last year in Health Humanities Reader, published by Rutgers University Press.11 But comics are also being used more directly in medical education. Medical textbook editor Paul Mayhew described a twenty-volume series slated for 2015 from JP Medical that will introduce comics-style case studies. The comics remind May-June 2015
In one comic, as a doctor describes an impending biopsy to a bugeyed patient, his words disintegrate in the bubble over his head into meaningless scribbles, punctuated with isolated words like “cancer” and “lumpectomy.” medical students that the patient is “a real person”—illustrating aspects of the patient’s experience, presentation, and diagnosis as well as management of the condition, he said. An “intern survival” comic book to orient new doctors at a rural Australian hospital gives tips on how to overcome firstyear stresses like an intimidating interrogation from a senior physician or a difficult patient. With vivid facial expressions and thought bubbles, “comics are a good way of showing how things not talked about affect the patient-doctor relationship,” said Aaron Scott Humphrey, the manual’s creator.12 Dan Bustillos, assistant professor of health care ethics at St. Louis University’s Albert Gnaegi Center for Healthcare Ethics, uses graphic novels and superhero comics in his bioethics course aimed mostly at premed undergraduates. He pointed to the graphic novel Wrinkles, which opens with a bank manager telling a young couple he won’t give them a loan.13 The exasperated young man sitting across from the manager responds, “I don’t want a loan! . . . The only thing I want is for you to eat your dinner right now,” as the scene shifts to a hospital bed and you realize the manager’s “desk” is actually a hospital tray with a bowl of soup. “You have this moment of catharsis and recognition that resonates with students,” Bustillo told me, and that “helps destigmatize” the kind of dementia that the old man suffers from. A theme running through many first-person illness narratives and doctor narratives is the failure of doctors to find out what’s really troubling the patient. Muna Al-Jawad, a physician who specializes in geriatric medicine at Brighton and Sussex University Hospitals in England, organized the 2013 Comics & Medicine Conference: “Ethics under Cover: Comics, Medicine, and Society.” “The reason we chose ethics,” she told me, “is comics are particularly good at looking at things under the surface.” Jawad has created a comics superhero, a cape-wearing geriatric specialist, to teach her medical trainees about the ethics and values involved in treating the elderly—“the real-life stuff no one ever talks about.”14 In one of her comics, her superhero, framed by a jagged outline of light, comes to the rescue of an elderly patient, his face distended in distress after a hospital staffer tells him that he needs to go into an old-age home. “Not so fast! The team will get you home with some help,” the superhero exclaims, pointing to her team of occupational therapists and aides who will be able to care for the patient at home. In 2009, Green pioneered the study of comics for fourthyear medical students in his bioethics course at Penn State, May-June 2015
a practice that has since spread to a handful of other medical schools, he said. “I came across some graphic novels that had medical relevance and I thought, ‘Wow, this would be a really cool way to teach medical students about issues we’re already teaching in medical humanities and in medical ethics, focusing on the doctor-patient relationship and the patient’s experience of illness.’” Green uses Can’t We Talk about Something More PLEASANT? to discuss end-of-life directives like the do-not-resuscitate order, a subject that author Chast depicts in all its excruciating discomfort as one that she must broach with her parents. Cancer Vixen, a graphic novel by cartoonist Marisa Acocella Marchetto about her breast cancer, becomes a springboard to discuss informed consent. In one panel, Marisa and her mother are shown bug-eyed with dread as the doctor describes an impending biopsy.15 The physician’s words disintegrate into meaningless scribbles in the word bubble above his head, punctuated with isolated words like “cancer” and “lumpectomy.” That scene is a “great example” of how challenging it can be to obtain genuine informed consent, Green observed, when patients are too frightened to absorb the information even though the doctor thinks he’s fully disclosing what they need to know. In his course, Green also assigns students to write their own graphic narrative about an experience they’ve had as medical students. Because medical students have more time than harried senior hospital staff members, they’re often “the ones who can sit down with patients and discover important pieces of information that were missed by the hustle and bustle of the regular team,” Green noted. For example, in one comic, a medical student discovers that the reason an elderly patient feels too sick to be discharged from his hospital bed is that he doesn’t want to return to his senior-care home, where the staff has neglected him.16 Other student comics posted on the class website offer a fascinating window into how medical students’ instincts and compassion are often devalued in a hierarchical teaching structure. In one comic, a senior doctor imperiously stops a medical student who wants to investigate a woman’s complaints of chest pain. The supervising physician labels the woman a repeat nuisance patient; the patient later suffers a heart attack.17 In “Medical Ethics 101,” a student is faced with a dilemma when the senior surgeon instructs him to lie to a patient about altering a medical procedure with which the patient is familiar, saying the patient won’t understand the reasoning behind the changes.18 H AS TI N GS C EN TE R RE P O RT
17
Several members of the audience at the June 2014 conference in Baltimore asked how to overcome the skepticism of university curriculum committees toward introducing courses based on comics in medicine and bioethics. “I had to prove to them this wasn’t frivolous and these materials were worth reading,” Bustillos said, noting he had paired Watchmen comics with an essay by John Stuart Mill to illustrate principles of utilitarianism. Still, many unanswered questions remain. Green has argued that reading a comic, which requires making inferences and filling in the mental gaps from one frame to another, requires skills analogous to making a diagnosis, since the bits and pieces of a medical history the doctor gets from a patient are often amorphous, requiring the doctor to weave a coherent narrative.19 But he acknowledges, “There’s not a ton of data yet” on whether comics improve diagnostic skills or foster empathy among medical students. Similarly, there’s not much research on whether comics are a more effective way of informing patients about their medical conditions than straight prose or other forms of media, according to Gregg. Fies, who began to record his mother’s metastatic brain cancer online with comics in 2004, “was astonished by how many readers saw their own story in ours.”20 An Australian nursing instructor told him she was recommending the comic to nurses in the outback to pass on to patients and their families, Fies told the Baltimore conference. Green has proposed that a physician might suggest Cancer Vixen to a patient newly diagnosed with breast cancer to prompt questions she might not have considered discussing with her doctor and to make her feel “less isolated.”21 Yet some graphic novels paint such a dark and frightening vision of disease that it’s not clear such accounts would be helpful for every patient. For example, the autobiographical Epileptic, by French author David B., about growing up with an epileptic brother, is illustrated with his nightmarish visions of the disease. It “is not a feel-good story about how to overcome epilepsy; it’s a dark, harsh, challenging story about the real challenges this poses in this family’s life,” Green stated.22 But Taichman says it depends on the patient. “Learning about the bad experiences and knowing what might come, that’s an important part of our job of informing our patients,” he told me. Knowing you’re not alone in feeling anger or fear can be comforting, he added. The graphic medicine movement can be viewed as part of a larger trend toward giving patients more of a voice in narrative medicine accounts. But to Susan M. Squier, professor of English and women’s studies at Pennsylvania State University and coeditor of a new series on graphic medicine for Penn State University Press, the visually accessible and iconoclastic nature of graphic accounts is unique: “Narrative medicine gives you a platform to talk back to the assumption that the doctor knows everything; a comic brings it out of the university or library,” she told me. “Comics create a richer and more resistant voice to speak back to the dominant medical discourse.” Graphic medicine has historically been a subversive underground culture, Squier points out, going back at 18 HASTI N G S C E N T E R R E P ORT
least to the 1973 comic Abortion Eve, by two counselors at a women’s free clinic. That tradition continues to be played out in Not Your Mother’s Meatloaf, a sex education book that started out as an online zine for accounts by young women about their personal struggles with sexual relations and using contraception.23 Several conference speakers tried to articulate what’s so special about this medium. Some noted that comics are good at depicting visually the moments when emotions are at variance with spoken words. Arthur Frank, author of The Wounded Storyteller, pointed out that the idea of an event so horrible that words cannot describe it is expressed visually in the eighteenth-century novel Tristram Shandy, where Lawrence Sterne inserted an entirely black page upon the death of one of his characters. Similarly, Frank observed, in Cancer Vixen, when Marisa learns of her first positive test result indicating cancer, she illustrates her shock and sense of falling into a void with a black panel—although in this case, two terrified eyes peer out of the emptiness.24 As a journalist, I am steeped in the world of prose, and I confess that at first I had trouble getting into graphic novels about illness. They didn’t allow for the kind of skimming that I’m accustomed to with straight text—or even the feeling of being completely absorbed by a flow of words. I complained about this to Nancy K. Miller, a memoirist and professor of English at City University of New York Graduate Center, who recently began recording her own experience of lung cancer through comics. She explained to me that you have to slow down to read a graphic novel. You have to focus on each picture, each panel before you can move on. Similarly, graphic medicine seems to be asking medical professionals to slow their frantic pace: Look at the patient; try to read the body language; take the time to ask more questions. You might be surprised at what you discover. 1. T. Ferrier, “Cruel to Be Kind,” in Disrepute by T. Ferrier (Hafoty LWYD, Wales: Graphic Medicine, 2012); Disrepute, in which the panels in figure 1 appear, is available at http://www.thomferrier.com/#/ strips/4526268949, accessed March 16, 2015. 2. See http://www.graphicmedicine.org/. 3. M. Vaccarella, “Exploring Graphic Pathographies in the Medical Humanities,” Medical Humanities 39 (2013): 70-71. 4. R. Chast, Can’t We Talk about Something More PLEASANT? (New York: Bloomsbury USA, 2014), 62-63. 5. B. Fies, Mom’s Cancer (New York: Abrams ComicArts, 2006), 60-61. 6. “Comics & Medicine: From Private Lives to Public Health,” June 26-28, 2014, Johns Hopkins Medical Campus, Baltimore, MD; see http://www.graphicmedicine.org/ comics-and-medicine-conferences/2014-baltimore-conference/. 7. M. J. Green and R. Rieck, “Missed It,” Annals of Internal Medicine 158, no. 5 (2013): 357-61. 8. See cover of Ars Medica 8, no. 1 (2011), by I. Williams, http://www. ars-medica.ca/index.php/journal/issue/view/15/showToc. Also see M. Al-Jawad, “Comics Are Research: Graphic Narratives as a New Way of Seeing Clinical Practice,” Journal of Medical Humanities, published online February 2, 2013, http://link.springer.com/article/10.1007/ s10912-013-9205-0. 9. Green et al., “Missed It.”
May-June 2015
10. R. M. Wachter et al., “Strategies to Improve Patient Safety,” Annals of Internal Medicine 158, no. 5 (2013): 350-52. 11. I. Williams, “Culpability,” in Health Humanities Reader, ed. T. Jones et al. (New Brunswick: Rutgers University Press, 2014), chapter 34. 12. A. S. Humphrey, Mackay Hospital and Health Service 2014 Intern Survival Comic Book, 2014, at www.aaronhumphrey.com. 13. P. Roca, Arrugas (Bilbao: Astiberri, 2014), 8; in translation as P. Roca, Wrinkles (London: Knockabout, 2015). 14. M. Al-Jawad, “Super-Geris: How Geriatricians Really See Themselves,” February 3, 2013, at http://oldpersonwhisperer.tumblr.com/ page/3. 15. M. A. Marchetto, Cancer Vixen (London: Fourth Estate, 2007), 89. 16. P. Adedayo, “Listen Up!,” Penn State Hershey College of Medicine, 2014, at http://www2.med.psu.edu/humanities/for-medical-students/ research-opportunities/graphic-storytelling-Medical-narratives/.
17. J. Monk, “A Ghost of an Idea,” Penn State Hershey College of Medicine, 2012, http://www2.med.psu.edu/ humanities/for-medical-students/research-oppor tunities/ graphic-storytelling-Medical-narratives/. 18. R. Svoboda, “Medical Ethics 101,” Penn State Hershey College of Medicine 2012, http://www2.med.psu.edu/ humanities/for-medical-students/research-oppor tunities/ graphic-storytelling-Medical-narratives/. 19. M. J. Green, “Teaching Comics: A Course for Fourth-Year Medical Students,” Journal of Medical Humanities, 34, no 4 (2013): 471-76. 20. Fies, Mom’s Cancer, preface. 21. M. J. Green and K.R. Myers, “Graphic Medicine: Use of Comics in Medical Education and Patient Care,” BMJ 340 (2010): c863. 22. David B., Epileptic (New York: Pantheon, 2006). 23. S. Miller and L. Bley, Not Your Mother’s Meatloaf: A Sex Education Comic Book (Berkeley, CA: Soft Skull Press, 2013); see http://notyourmothersmeatloafbook.com/. 24. See Marchetto, Cancer Vixen, 9.
Graphic Medicine in the University by susan m. squ ier
T
he spring I first offered a graphic medicine graduate seminar, I wasn’t sure what to expect of students so schooled in approaching their subjects from an academic perspective. Every class meeting included one hour in which the students, from fields that stress rigorous verbal and written achievement, were required to embrace the position of the amateur by learning to create comics. They experimented with putting images and words together in sequential drawn panels in order to tell a story of their own devising. Of course, they did more than draw; the other two hours of the seminar introduced them both to the medium of comics and to graphic medicine in particular.1 They read and discussed comics like Harvey Pekar and Joyce Brabner’s Our Cancer Year, John Porcellino’s Diary of a Mosquito Abatement Man and The Hospital Suite, Lynda Barry’s One Hundred Demons, and Kaisa Leka’s I Am Not These Feet. They also read secondary articles in comics studies and in literature and medicine. In addition to writing a conventional seminar paper, at the end of the semester they turned in the comic they had created about an experience of illness, disability, or medical treatment, whether their own or that of an acSusan M. Squier, “Graphic Medicine in the University,” Hastings Center Report 45, no. 3 (2015): 19-22. DOI: 10.1002/hast.446 May-June 2015
quaintance or family member. Although I had been teaching graphic narratives of other kinds to humanities graduate students for several years, what happened in this course on graphic medicine surprised me. Not only did the students, none of whom were medical students, explore illness, disability, and medical treatment in their comics, but they often articulated bioethics issues as well. Here is a partial list of the subjects their comics addressed: being treated for dengue fever in an upper New York State hospital where the patient had to teach his caregivers to pronounce the name of his disease; discovering after a year of depression that the birth control method prescribed by the university health center had been flagged by the Food and Drug Administration for its depression-related side effects, something the prescribing physician had never mentioned; improvising a method of teaching studio art to a student with a prosthetic arm; and finding a way to tolerate the pain of a younger sister’s chronic illness. Influenced by the experience of creating these comics, some of the students in this multidisciplinary group even changed the topic of their final seminar paper from a conventional critical reading of texts to a topic that brought their skills of literary and rhetorical analysis to bear on the bioethical issues the comics had illuminated for them. Thus, the H AS TI N GS C EN TE R RE P O RT
19
