teaching with comics: a course for fourth-year medical students

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Teaching with Comics: A Course for Fourth-Year Medical Students Michael J. Green Published online: 7 September 2013 # Springer Science+Business Media New York 2013 Abstract Though graphic narratives (or comics) now permeate popular culture, address every conceivable topic including illness and dying, and are used in educational settings from grade school through university, they have not typically been integrated into the medical school curriculum. This paper describes a popular and innovative course on comics and medicine for 4th-year medical students. In this course, students learn to critically read book length comics as well as create their own stories using the comics format. The rationale for the course, its general content and format, and methods for teaching are described. Finally, the author offers some reflections on why this medium resonates so powerfully with medical student learners. Keywords Medical education . Comics . Graphic narratives . Narrative medicine . Humanities For the past 5 years, I have taught an elective course on comics and medicine to fourth-year medical students at Penn State College of Medicine. The comics of which I speak are not New Yorker cartoons (though I like these very much) or Sunday funnies (which are sometimes quite entertaining) but rather something I will call graphic narrativesor graphic stories.The following describes the rationale and goals for the course, what is taught, and how I teach it, so others who are so-inclined can also integrate this medium into their teaching. Background In this paper, comicsrefers to a medium that combines images with text, in sequence, to tell a story where the images complement and/or enhance the text (McCloud 1994). Comics need not be funny or juvenile, nor do they require superheroes. Rather, comics can (and do) address every conceivable topic, serious or otherwise, can be delivered in a variety of formats (e.g. single panel cartoon, comic strip, graphic novel), and may be expressed via different genres (fiction/non-fiction, comedy, romance, memoir, etc.). In my class, we focus J Med Humanit (2013) 34:471476 DOI 10.1007/s10912-013-9245-5 M. J. Green (*) Departments of Humanities and Medicine, Penn State College of Medicine, C1743, 500 University Drive, Hershey, PA 17033, USA e-mail: [email protected]

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Teaching with Comics: A Course for Fourth-YearMedical Students

Michael J. Green

Published online: 7 September 2013# Springer Science+Business Media New York 2013

Abstract Though graphic narratives (or comics) now permeate popular culture, addressevery conceivable topic including illness and dying, and are used in educational settingsfrom grade school through university, they have not typically been integrated into themedical school curriculum. This paper describes a popular and innovative course on comicsand medicine for 4th-year medical students. In this course, students learn to critically readbook length comics as well as create their own stories using the comics format. The rationalefor the course, its general content and format, and methods for teaching are described.Finally, the author offers some reflections on why this medium resonates so powerfully withmedical student learners.

Keywords Medical education .Comics .Graphic narratives .Narrativemedicine .Humanities

For the past 5 years, I have taught an elective course on comics and medicine to fourth-yearmedical students at Penn State College of Medicine. The comics of which I speak are notNew Yorker cartoons (though I like these very much) or Sunday funnies (which aresometimes quite entertaining) but rather something I will call “graphic narratives” or“graphic stories.” The following describes the rationale and goals for the course, what istaught, and how I teach it, so others who are so-inclined can also integrate this medium intotheir teaching.

Background

In this paper, “comics” refers to a medium that combines images with text, in sequence, totell a story where the images complement and/or enhance the text (McCloud 1994). Comicsneed not be funny or juvenile, nor do they require superheroes. Rather, comics can (and do)address every conceivable topic, serious or otherwise, can be delivered in a variety offormats (e.g. single panel cartoon, comic strip, graphic novel), and may be expressed viadifferent genres (fiction/non-fiction, comedy, romance, memoir, etc.). In my class, we focus

J Med Humanit (2013) 34:471–476DOI 10.1007/s10912-013-9245-5

M. J. Green (*)Departments of Humanities and Medicine, Penn State College of Medicine, C1743, 500 University Drive,Hershey, PA 17033, USAe-mail: [email protected]

on memoirs about illness or “graphic pathographies,” (Green and Myers 2010) which areincreasing in number and have particular relevance for medicine.

Why comics

For students to develop into competent and caring professionals, it is crucial that they come tounderstand illness in all its complexity. This includes seeing illness not only through the lens ofbiology but also as a social, political, and narrative construct. The comics taught in my class areall associated in some way with sickness, portraying the experience from points of view thatdiffer from those typically found in medical textbooks. For example, some graphic narrativesdepict illness from the perspective of the patient (Dahl 2009; Marchetto 2006; Small 2009),others from the point of view of family members (B 2005; Fies 2006; Leavitt 2010), and stillothers from the vantage point of caregivers (Cunningham 2010; Ferrier 2010). Graphicnarratives address themes ranging from the patient’s experience of illness to caregiver burnout;from doctor-patient communication to the social context of illness (Table 1).

While comics are by no means the only medium for addressing such issues, they areparticularly effective at transporting readers into a story. Because they integrate images withtext, viewing and reading graphic narratives stimulates both analytic and creative activity inthe brain, a process that has been shown to enhance understanding (Mayer and Sims 1994).Not only can this process potentially augment learning, it can also facilitate empathybetween author and reader by offering a portal into the individual’s experience of illness(Williams 2011). Moreover, students typically find comics accessible and enjoyable to read.

Course goals and methods

The main aims of the course are to: 1) expose students to a set of medically relevant graphicnarratives that provoke critical reflection about the experience of illness and the wayspatients and their families interface with the medical system; 2) equip students with criticalthinking skills for reading and understanding comics that are relevant to medical practice;and 3) nurture students’ creativity by helping them develop their own stories into originalgraphic narratives. I achieve these goals via a seminar-style course that meets twice weekly(2 ½ hours per session) for 4 weeks. During each session, students engage in three distinctactivities: discussion of readings; an in-class exercise; and sharing-progress on their finalprojects. Specific session topics include (but are limited to):

& Why comics are relevant to medicine& Elements of storytelling& The relationship between images and words& Exploring point of view& Drawing comics& Writing dialogue& Social context of medicine& Final presentations

Although the required course readings have varied over the years, we have read some orall of each of the graphic narratives listed in Table 1 as well as background readings on thecreation of comics such as Making Comics by Scott McCloud (McCloud 2006); The

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Complete Idiot’s Guide to Creating a Graphic Novel by Gertler and Lieber (2004); DrawingWords and Writing Pictures by Abel and Madden (2008). At the same time, a variety of in-class activities aim to stimulate students’ creativity and prepare them to create their owncomics. For instance, at the beginning of the course, I ask students to complete simple stemssuch as:

& One thing about being a medical student that my family doesn’t understand is…& My proudest moment as a medical student was when I …..

Table 1 Select graphic medicine texts

Title Author Medical topic Summary Year

Epileptic David B Seizure disorder A grim story about growing up withan older brother who has epilepsy,and the hope/despair the familygoes through as they try to cure it.

2006

Psychiatric tales:Eleven graphicstories aboutmental illness

Darryl Cunningham Mental illness A series of stories about psychiatricillnesses derived from the author’sexperience working on a psychiatricward. The stories both explain, andhumanize, mental illness.

2011

Monsters Ken Dahl Herpes A man is convinced he has herpes andis tortured by anxiety, isolation, andfear as he tries to deal with thisdisease.

2009

Cancer made mea shallowerperson

Miriam Engelberg Breast cancer The author’s brutally honest and oftenfunny account of her experiences afterdeveloping breast cancer at age 43.

2006

Special exits Joyce Farmer Aging/deathand dying

A memoir chronicling the declininghealth of the author’s parents, andthe challenges of coping with thefragility of life.

2010

Disrepute Thom Ferrier Medicine froma doctor’sperspective

A series of short graphic stories aboutthe dark thoughts, insecurities, andodd encounters that doctors have,but don’t usually talk about.

2012

Mom’s cancer Brian Fies Lung cancer The author’s account of the challengesof navigating the health care systemafter his mother develops lung cancer.

2006

Tangles Sarah Leavitt Alzheimer’sdisease

The author’s mother develops Alzheimer’sDisease, and the family is transformedas Sarah must figure out how to beengaged despite living far away.

2010

Years of theelephant

Willie Linthout Suicide, Grief The story of a grieving father’s attemptsto understand and cope with his son’ssuicide.

2010

Cancer vixen Marisa AcocellaMarchetto

Breast cancer A memoir of a hip, urban woman whodevelops breast cancer, and how shedeals with the effect on her love life,personal relationships, and self-image.

2006

Stitches David Small Childhoodcancer

The author’s recollection of hisdysfunctional childhood and whathappens when he develops neckcancer and loses the ability to speak.

2009

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& I was most disappointed in myself when I …..& The funniest thing that I experienced as a medical student was….& I was really impressed with a colleague when s/he….& One of the most troubling things I ever experienced in medicine was….& I really love my work when….& It was especially hard for me to deal with my patient when s/he…

After responding in writing to these stems, students break into groups of three to discusstheir responses and begin thinking about how they might transform their ideas into a graphicstory.

To give students practice writing dialogue, I “white out” (with correction fluid) the wordsin an edited version of a short comic (Harvey Pekar’s “The Day Before the Be In”) (1986)and have students fill in the speech bubbles with their own imagined dialogue. Studentsnever fail to surprise one another with their creative approaches and diverse interpretationsof these scenarios, demonstrating the myriad ways that a story can be told, depending onwho is interpreting it (Fig. 1).

A third exercise focuses on point of view. I provide students with the text of a story frommy own medical school experience (Green 2011) and have them break into small groups tocreate, in 15 min, an illustrated comic from three different perspectives – that of the medicalstudent, the attending physician and the patient. Their often-funny interpretations of the storyare not only nuanced but also reveal students’ understanding of their place in the medicalhierarchy and the complex culture of medicine.

For their final project, students produce their own original graphic narrative based on apersonal experience from medical school. Despite the fact that most of the students have littleconfidence or experience drawing comics at the outset of class, these learners consistentlyproduce outstanding works that reveal their wry humor and personal transformations as wellas observations about modern medicine. These works can be viewed at: www2.med.psu.edu/humanities/for-medical-students/research-opportunities/graphic-storytelling-Medical-narratives/

Conclusions

Reading and creating comics may at first seem like an unusual activity for medical students, but itis of great value. By critically reading visual texts, students become more careful observers, aphenomenon that has been demonstrated in other contexts as well (Naghshineh et al. 2008).Reading medically-themed comics provides an opportunity for reflection—about the practice ofmedicine, the pressures faced by patients, their families, and their doctors, and even about theinner experiences of the students themselves. Furthermore, appraising comics prompts students toengage activelywithmedical stories, thereby improving their narrative and visual literacy. As theyinterpret the incomplete visual data inherent to comics and transform this into a coherent story,they mimic the diagnostic process in medicine—where the physician is supplied with amorphousinformation, and must make inferences and draw conclusions to produce an accuratediagnosis.

By creating comics, students have an opportunity to express their varied and deeply feltexperiences. By the time they reach their fourth year of training, students have accumulateda wealth of stories and experiences and have often undergone dramatic personal changes butlack opportunities within the traditional medical curriculum to express themselves creatively.The talents and skills that students bring to medical school are largely disregarded aseducators attempt to fill their brains with information (the empty vessel theory of learning)

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(Gunderman 2011). This course offers the space, context, and instruction to turn theirexperiences and ideas into works of art. Doing so not only stimulates alternative ways to

THE DAY BEFORE THE BE IN, BY HARVEY PEKAR, GREG BUDGETT AND GARY DUMM

Fig. 1 Fill in the dialogue exercise

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see the medical world but also creates a shared connection among students who see theirown experiences expressed in a classmate’s comic. This universality is validating and helpsstudents feel less alone. Creating comics also allows students to expose aspects of the“hidden curriculum” in medical education while simultaneously supporting values thatmatter—such as the importance of communicating clearly, working collaboratively, devel-oping creative solutions to challenging problems, tolerating and embracing ambiguity,avoiding preconceptions, and recognizing the shared humanity between doctors andpatients.

On the walls of a busy corridor at Penn State College of Medicine, enlarged and mattedversions of students’ comics are prominently displayed. More often than not, students,faculty, and visitors can be seen standing before these comics, reading carefully, chucklingoften, and nodding their heads in knowing appreciation. Recently, an individual chargedwith the allocation of wall space suggested that these comics be replaced by more traditionalart reproductions. A department chair protested, and the comics remain.

References

Abel, Jessica, and Matt Madden. 2008. Drawing Words&Writing Pictures: Making Comics: Manga, GraphicNovels, and Beyond. New York: First Second.

B, David. 2005. Epileptic. New York: Pantheon Books.Cunningham, Darryl. 2010. Psychiatric Tales. London: Blank Slate Books.Dahl, Ken. 2009. Monsters. Jackson Heights, NY: Secret Acres.Ferrier, Thom. 2010. Fear of Failure: Episode #1. Jafoty Lwyd: Graphic Medicine.Fies, Brian. 2006. Mom’s Cancer. New York: Abrams Image.Gertler, Nat, and Steve Lieber. 2004. The Complete Idiot’s Guide to Creating a Graphic Novel. New York:

Alpha Books.Green, Michael J. 2011. “Teaching and Learning Moments: Comeuppance.” Academic Medicine 86 (8):981.Green, Michael J., and Kimberly R. Myers. 2010. “Graphic Medicine: Use of Comics in Medical Education

and Patient Care. BMJ 340:c863. doi:10.1136/bmj.c863.Gunderman, Richard B. 2011. Achieving Excellence in Medical Education. New York: Springer.Leavitt, Sarah. 2010. Tangles: A Story About Alzheimer’s, My Mother, and Me. Calgary: Freehand Books.Marchetto, Marisa Acocella. 2006. Cancer Vixen: A True Story. New York: Alfred A. Knopf.Mayer, Richard E., and Valerie K. Sims. 1994. “For Whom is a Picture Worth a Thousand Words? Extensions

of a Dual-coding Theory of Multimedia Learning. Journal of Educational Psychology 86 (3): 389–401.McCloud, Scott. 1994. Understanding Comics: The Invisible Art. New York: HarperPerennial.McCloud, Scott. 2006. Making Comics: Storytelling Secrets of Comics, Manga and Graphic Novels. New

York: Harper.Naghshineh, Sheila, Janet P. Hafler, Alexa R. Miller, Maria A. Blanco, Stuart R. Lipsitz, Rachel P. Dubroff,

Shahram Khoshbin, and Joel T. Katz. 2008. “Formal Art Observation Training Improves MedicalStudents’ Visual Diagnostic Skills. Journal of General Internal Medicine 23 (7): 991–997.doi:10.1007/s11606-008-0667-0.

Pekar, Harvey. 1986. American Splendor: The Life and Times of Harvey Pekar: Stories. Garden City, N.Y.:Doubleday.

Small, David. 2009. Stitches: A Memoir. New York: W.W. Norton & Co.Williams, Ian. 2011. “Autography as Auto-therapy: Psychic Pain and the Graphic Memoir. Journal of Medical

Humanities 32 (4): 353–366. doi:10.1007/s10912-011-9158-0.

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