 And we're going to start with Michael Green, who's a professor of medicine and humanities at Penn State College of Medicine. He's also chair of the Hospital Ethics Committee, vice chair for research in the Department of Humanities and director of the program in bioethics. He has published landmark articles about the use of comics in medical education and patient care, and has organized several international conferences on comics and medicine, and is a member of the editorial collective of a forthcoming book series on graphic medicine. The title of this talk today is the how and why of using comics to teach medical ethics. So we welcome Mike back. Thank you. Thank you. And as always, it's great to be here. I'm going to do something that's very different for this particular audience. I'm sure people don't normally talk about comics, but I found it to be a really interesting and novel way of getting at some of the issues that I like to talk about anyway. And just to begin with, I think when most people think about comics, I imagine something like this comes to mind, or maybe something like this. But then this book, Mouse by Art Spiegelman, was published. And this won a Pulitzer Prize for Literature, the first ever for a graphic depiction of art is a story, for those of you who don't know, it's a story of the author's parents' experience in Nazi concentration camps during World War II and his relationship with them. And it's an amazing book, and it just blew me away. And made me realize there's more to comics than just Superman and Archie. Then this book came out in 2006 called Fun Home by Alison Bechtel. And Time Magazine named this the best book of the year. Not the best comic of the year, the best graphic novel of the year, but the best book of the year period. And at this point, it seemed pretty clear that comics have really hit the mainstream. And they're widely acknowledged to address issues ranging from war and life and peace and death and medical issues and pretty much any topic you can think of it's been done and can be done with comics, including medicine and medical ethics kinds of topics. And I'm going to show and talk a little bit about how comics have relevance in medical education and medicine in general. I explored some of these issues along with my colleague, Kimberly Myers, in an article that we published in the British Medical Journal a couple of years ago. And to my delight, this actually was the cover of the British Medical Journal, probably the first and last time you'll ever see a comic on the front cover of the BMJ, but there it is. And you can look at it if you want to see some examples of things that I'm talking about. And for the past five years, I've taught a course on comics and medicine to fourth year medical students. And this course, we call Graphic Storytelling, and it's a seminar course for six to ten students a year who take it. We meet for two and a half hours at a time, twice a week for four weeks. And the students learn to do a variety of things. In particular, they spend some of their time reading, critically reading comics or graphic narratives that are medically themed. We engage in some in-class activities that help them stimulate the creativity and learn to draw themselves. And then the most innovative thing is actually have them create their own comics, take one of the stories from their experiences as medical students and turn it into a comic. There's very few prerequisites for this class, other than having a pet positive attitude and a willingness to try something new. And surprisingly, fourth year medical students, they'll do pretty much anything you ask them to do. And they're brainwashed or trained or I'm not sure what the right word is, but they're really enthusiastic about doing it. And I don't expect any prior experience with drawing or writing to take the class. We read a variety of books and these are all graphic novels or graphic narratives. And all of these are ones that are really quite interesting and I'd be happy to provide anyone who's interested with a reading list of medically themed graphic novels. Maybe even a better way of finding out about it is to look at our website. It's called graphicmedicine.org and we do book reviews of pretty much all the medically related comics that are out there, at least we try to, as well as it's sort of a clearinghouse for folks who are interested in this area. The things that I tend to focus on in the course are things that we call graphic pathographies, which tend to be illness narratives that are memoirs generally and they use the comic format to tell the story of somebody who has an illness. So why do I have medical students read comics and what relevance does this have? I'm going to give you a couple of reasons that we do it. The first is that comics can teach people about the patient's experience of illness. And I think this is really important for anyone who has an interest in ethics. You have to start with an understanding of what a patient is going through and comics just do a great job at depicting this. So here's an example from a wonderful book called Mom's Cancer written by Brian Fees and it's a story about his mother who develops lung cancer and the experience of the family really as she develops this and goes through the treatment. So this is an example of the patient's experience. It's called the usual unusual. At every visit the doctor always says, call immediately if you notice anything unusual. The simple order turns out to be surprisingly hard to follow. I have a headache. Yeah, don't worry about it. Okay, that's his mom who has cancer here. I have a deep cough. What? You should have called it once. Oh, I feel weird stingers in my head. That's normal with a brain tumor. Okay. I had a leg cramp. Well, that could be a deadly blood clot. Why didn't you call? Sorry. I can't breathe. So you have lung cancer. What did you expect? Right. She's wrong when she complains and wrong when she doesn't. Either way, she feels stupid. How am I supposed to know? And after a while she stops trying. It's a great description of what it feels like to be on that end of the table, so to speak. This is another one from a book called Marbles written by Ellen Forney. And she's a woman who, it's a graphic memoir about her experience with bipolar illness. And in this particular scene she describes, she really shows. It's not just a description. She demonstrates through her drawing and her words what it's like to have a manic episode. And you see the racing thoughts and the rapid speech and the euphoria and the impulsiveness that accompanies having that diagnosis. And you get this sense in a very literal way that there would be much more difficult to get from a sort of clinical description that you see in a textbook. And then she does the opposite here in describing what it feels like to be depressed. And then what she does is shows using this visual metaphor of a carousel of what it's like to go through the ups and downs of having these mood swings that accompany bipolar illness. And it's something that you just sort of can't do without these pictures. I mean there's something about when you put the words and the pictures together that you get meaning that is hard to reproduce using other kinds of media. Another thing that comics can do is teach people about suffering and empathy and sort of non-spoken realities. So this is again from mom's cancer. And this is his mom after she is receiving some bad news. And it's a universal feeling. I think everybody who sees this knows immediately that she's suffering and she's sad and she's grieving. And you don't need an explanation. It just speaks for itself. It's very powerful. This is an example from a book called Cancer Vixen, which is another great memoir about breast cancer in this case. And this is a depiction of what it's like to live with a particular diagnosis. And so it says at the top, although we made small talk, you see the words written all the way in the background, the cancer, cancer, cancer, cancer. It's an elephant that's in the room, which may be unspoken, but it never really goes away. And what I think is remarkable about this is the way she uses graphic elements, in this case the words, cancer, to evoke what cancer cells look like and feel like. And if you look under a microscope, you see that they're out of control and spread out much like cancer acts in reality as well. Biotics can also teach about communication and informed consent, which I think is particularly relevant for us in bioethics. So this is a scene where Marissa receives bad news about a recent breast biopsy and it begins, she's sitting at her drafting table when the phone rings and she gets up and leaves her table and then she sees on her phone that it's Dr. Mills calling. And on the fourth panel, we witness this remarkable depiction of what it feels like to receive bad news. She covers her eyes, her mouth is a gape with horror, her hair stands on end and then she recalls the moment of this phone call, 10, 12 a.m. exactly. It's like the time JFK was shot or 9-11, she remembers exact moment when this happened as something that was imprinted on her forever. And it may have well been a routine conversation from the point of view of the doctor, from the patient's point of view, this is something that is far from routine. This is also from mom's cancer, I'm sorry, from cancer vixen. And this is one of the best depictions that I've seen of the challenges of informed consent in clinical practice. And this is a scene where the doctor is explaining about the upcoming biopsy that she's going to get for her breasts and Marissa is sitting with her mother, the mother's got the neck braced. And he's doing what a doctor is supposed to do in these circumstances, is likely having a conversation about informed consent and talking about what is the nature of the procedure and what are the risks and what are the benefits and what are the alternatives and what can you expect and so on. But what you see here is that it doesn't matter what he's saying, what she remembers about this conversation is very little. She hears a couple of words only because she's scared like patients get and the information doesn't sink in. And then she makes the insightful comment that it's the last visit she's going to make without a tape recorder, which I think is really interesting, so she can record these conversations and listen to them at a later date. But it's, you know, you can talk and explain and describe the challenges of informed consent in many, many different ways, but the economy of this is remarkable. All this information is contained in a panel that's two inches by two inches in size. It's really a lot going on. Reading comics can help students think critically and deductively, which I think is really interesting for teaching about diagnostic reasoning. This is from Scott McCloud's book called Understanding Comics. And so you look at this and then you look at this. What happened here? The axe murderer chopped his head or did something violent, but you know, the only way you know what happened here is by making inferences. The reader has to work to read and understand a comic. And what happens between these panels, it's called the gutter, that's where the magic happens and that's where the reader actually has to figure out the connections between one scene and the next. It's very much like what we do when making diagnoses in medicine. You're given incomplete information and often in a disorganized way and you have to take that information and make inferences and make conclusions based on the limited information that you have to figure out what's really going on. And reading comics engages students in a similar sort of process. In a medical context, here's an example. So you have these two panels, she says don't be scared. But there's so much more going on here. You have to observe the nonverbal communication and behavior. You have to understand that there's something to be scared about and you have to understand what the body language means that she's upset and worried and then what's happening with the doctor who's got her back turned to the patient and what does that say about what may be contributing to her fear or dissipating it or the way they interact. There's a lot of interpretation that takes place in reading these visual sorts of messages. So I have them read comics. Another thing I do though that's more challenging for the students is have them make comics. And I do this for a few reasons. For one, creating comics can provide students with an outlet for creative expression. Anyone who's been to medical school knows that there's very few opportunities for creativity. And many of the students who come to medical school are very creative people who have all sorts of pre-existing competencies in many areas and they have stories. They accumulate stories during the course of medical school and by the time the fourth year comes, they've got these stories and they don't have anything to do with it and so this provides an outlet for them to creatively share some of the stories that they've had that have been very impactful. Creating comics also helps students improve communication skills. It's very difficult to take the story and communicate it visually in an effective and efficient manner and it forces people to figure out what is the best way to tell the story in a way that other people can understand. And I also use this exercise in creating comics to help facilitate team learning because so much of medicine is a team sport, so to speak and you can't do it on your own and it's the same thing with comics. Some people are good writers but they can't draw and some people are good storytellers but they can't write and so when I have them make these comics together I say, look, you're going to be great and not that they care so much about the grade but I say you're going to be evaluated not only on how well you do on your own comic but how good a colleague you are and how you help other people make their work the best that they can so they really do work together and that's one of my goals in teaching this course. So I want to show an example of a comic that was created by one of the medical students in my course. Her name is Taylor Olmsted and she's now a pediatric resident but she was a fourth year med student when she did this and she calls it the taming of Tina and it's the story of a belligerent young girl who's admitted to the hospital and the challenge of taking care of her and so it starts out and I'm not going to read the whole thing but I'll sort of summarize it. Here is Tina, she's coming into the hospital and that strikes horror into the nurses and the doctors and they find out she's going to be admitted and they do their best to try to make nice to Tina and they get this kind of response which is predictable for her as well as get away from me so she alienates everybody and that prompts one of the nurses to say there's no way I'm going to take care of that girl and then comes Taylor and she's going to save the day and what's interesting about what Taylor does is she depicts herself in various and evolving ways. First she's going to be the superhero who swoops in and sort of saves the day and then she's sort of the eager beaver, she'll do anything she can to please the attending physicians then she becomes like a sleuth, she's the detective, she's going to get to the bottom of the mystery of Tina and solve the dilemma and these are excerpts, it's not the entire comic but as she does this comic she matures and evolves and eventually she comes to some understanding that the reason that Tina's so ornery is because she has a painful rash from the patch that she's being given to treat her pain and that's one of the reasons why she's really the way she is and so Tina, Taylor becomes an empathic healer and she surprises the nurses when she gives Tina a hug goodbye and a pat on the shoulder and it's a great way of showing not only the power of comics for depicting a personal transformation but also complex emotions that go into doctoring. Now I've taught this course for a number of years, I've got some data about it and some of the things that we found is that the course from at the baseline compared to afterwards people's attitudes change, they see comics is relevant to the medical education and creating a graphic story can help make them a better doctor, significantly improve and people have significant improvements in their attitudes. Well the percent of people who agree with that creating comics can improve a variety of skills goes up as well and so this is sort of pre to post data for five years of data that they think that making comics can improve their empathy, their communication, clinical reasoning, communication, writing skills, awareness of bias, verbal communication skills, diagnostic skills, nonverbal communication, all the stuff that I've listed here improve. Got some interesting comments from students, made me more aware of the role body language plays and physician-patient interactions. I gained a better appreciation of the patient's perspective of dealing with chronic illness. I'm better at reading nonverbal cues particularly from patients but also have increased awareness of physicians' nonverbal communication. I was really struck by how physicians were portrayed in the different stories we read, made me more aware of how I come off to patients. So all the students' comics that they've created are posted online and probably enough time to write this down but I'd be happy to share the website with anyone who's interested. And after I've taught this course for a couple of years I realized that I should walk the walk not just talk the talk and so I worked with a talented graphic illustrator to create my own comic and this was published in the Annals of Internal Medicine just this last March and it tells the story of a mistake I made when I was an intern here in Chicago actually and a patient died. And I got a, this was published I think it was the first time they ever published a comic like this and I got all sorts of interesting comments after this was published, not only about the content of it but the process and the medium as well, people really liked it. And I've found that people are using this to teach all over the country on topics ranging from medical mistakes to diagnostic reasoning to all sorts of things that never would have even occurred to me. And in closing we've had four international conferences on comics and medicine and these are some of the posters from those conferences. They've been in the states, they've been in England and the next one is going to be held at Johns Hopkins in Baltimore this upcoming June and we just released a call for paper. So if anyone's interested in this area and has something to say about comics and they want to submit a paper, this is how you do it. And the conference is going to be June 26th through 28th and it's really fun. I mean these are very interdisciplinary conferences and you're all welcome to come and I think it would be great to have a bunch of ethicists attend these conferences as well. So thank you and I will stop there.