AMA Journal of Ethics^®

Abstract

Physicians who recommend patient education comics should consider that some patients might question the appropriateness of this format, especially in the US, where a dominant cultural view of comics is that they are juvenile and intended to be funny. In this case, Dr. S might have approached communication with Mrs. T differently, even without knowing her attitude toward comics as a format for delivering health information. Dr. S could acknowledge that though some people might not expect useful medical information in a comic format, it has unique aspects and new research on patient education comics shows that even adults are finding this medium to be effective, educational, and engaging. Offering comics to patients, however, does potentially require patient educators to invest additional time to review and assess their accuracy and relevance.

Case

Dr. S is a psychiatrist who is seeing Mrs. T, a 45-year-old woman, in his clinic. She was referred for difficulty sleeping and anxiety following a massive car accident two months ago. Mrs. T also has been having panic attacks and is now afraid to drive on the highway. After telling her story to Dr. S, she asks for his opinion. Dr. S explains he believes she is experiencing posttraumatic stress. He further explains that there is a diagnosis called posttraumatic stress disorder (PTSD); he suggests some interventions for helping her manage her symptoms.

On her way out of the exam room, Dr. S pulls a booklet from a display on the wall. Dr. S is aware of the growing literature that supports comics as an effective patient education tool and has stocked several educational comics in his office on a variety of psychiatric disorders. Patients have told him that this booklet in particular resonated with them in describing what it is like to suffer posttraumatic stress.

“Here,” he says, handing her the booklet. “Some patients find this helpful.” Mrs. T looks down at a comic book titled “Trauma and You.” She is surprised to see posttraumatic stress represented in comic form. Not wanting to be rude, she just thanks him and quietly leaves the clinic.

Walking out of the clinic, she hurriedly flips through the pages. Using cartoon images and text, the book details a man’s experience with PTSD. Mrs. T stops and calls her husband. “I can’t believe he gave me a comic book!? The accident isn’t funny, it’s serious! What is Dr. S thinking!?” She throws the comic in the garbage outside the clinic door and begins to walk home. She wonders, “Does Dr. S think I’m stupid or something? Why does he think I need a children’s book? Why would he think I’d find this helpful?” Mrs. T did not return to Dr. S for further care.

Commentary

The American Medical Association Code of Medical Ethics states that physicians should “present relevant information accurately and sensitively, in keeping with the patient’s preferences for receiving medical information” [1]. As such, it is important for Dr. S to ask himself these questions: (1) Does the comic book given to Mrs. T convey relevant, accurate health information? (2) Have Mrs. T’s views about the appropriateness of comics and her broader preferences about how to receive information been solicited by Dr. S? (3) If Mrs. T’s views comics as inappropriate or does not want to see health information conveyed this way, how should Dr. S respond?

In the following commentary, we will address the above questions by considering the similarities and differences between comics and other types of patient education materials and by examining the formal aspects of comics that could be beneficial for patient education within two categories of health-focused comics. Additionally, we will suggest possible strategies for presenting comics to patients who might be unfamiliar with this type of format in patient education materials.

Comics versus Other Patient Education Formats

To provide relevant and accurate information, clinicians can choose to give or recommend to patients additional educational materials to supplement any verbal medical information they communicate during an appointment. These materials can be in the form of handouts, videos, websites, comics, or other media types. All formats have potential to contain relevant and accurate information. Similarly, any format can also be poorly written, out-of-date, medically inaccurate, or irrelevant.

Comics are similar to other patient education formats in that clinicians should consider their own confidence in the content. Even clinicians who choose to use comics might have additional concerns, including how adult patients might react to receiving a comic about a serious medical topic. In contrast to Mrs. T’s opinion of comic books as “funny,” examples of comic books addressing serious health topics abound: Marbles: Mania, Depression, Michelangelo, and Me: A Graphic Memoir [2], The White Donkey: Terminal Lance [3], Taking Turns: Stories from HIV/AIDS Care Unit 371 [4], and so on. Nevertheless, most adult patients in the US are unlikely to have received a comic book from a doctor and might need to be reassured that comics can indeed communicate relevant and accurate information. Furthermore, a clinician in Dr. S’s position might also want to explain why he or she recommends a specific comic for a specific patient. This explanation might differ depending on the type of health-focused comic offered to the patient.

Types of Health-Focused Comics

In recent years, a growing body of research has demonstrated the potential effectiveness of comics as a patient education tool [5-7]. Broadly, there are two categories of health-focused comics that appear in this graphic medicine literature: (1) memoirs about a personal health, medical, or illness experience; and (2) instructional content designed to educate patients. This case does not specify the precise category to which Trauma and Youbelongs—and it could possibly combine features of both categories. Accordingly, this section will discuss both categories as well as unique aspects of comics that enable the format to provide accurate and relevant health information.

Personal memoir comics. The first category—personal memoir comics—is sometimes called graphic pathography and is often created by an individual writer-illustrator who tells the story of his or her own health care experience. These comics can range from a realistic, documentary-like style (e.g., Mom’s Cancer [8] and Our Cancer Year [9]) to more metaphorical representations (e.g., Spot 12: Five Months in the Neonatal ICU [10] and Hyperbole and a Half: Unfortunate Situations, Flawed Coping Mechanisms, Mayhem, and Other Things That Happened [11]). By definition, this genre of comics focuses on the experience of a particular person, which might factually differ from that of other patients or caregivers. Therefore, clinicians should keep in mind that the value for patient education may be more in the author’s depictions of relevant concepts and accurate representations of potentially relevant emotions than in the author’s communicating detailed and comprehensive medical information.

Suppose that the comic book Trauma and You that Dr. S hands to Mrs. T is a personal memoir. If this is the case, Dr. S should first be confident that its content might be something Mrs. T would find relevant to her own situation. For example, what if the comic book was about experiences of someone with PTSD after a military trauma, not a car accident? To bridge this difference, Dr. S could explain to Mrs. T how the experiences, symptoms, and treatment of PTSD can be similar even when stemming from two very different traumas. Additionally, comics are notable for their ability to invite a broad spectrum of readers to identify with unique characters, because the visual representation of characters can be more abstract and symbolic than photorealistic representations [12]. As such, comics have the power to invite the reader to relate to the characters more easily, which could allow Mrs. T to relate to a comic book character whose experience does not align exactly with her own experience of PTSD. Dr. S could even point out this idea to Mrs. T as a possible reason why his other patients had found the comic helpful.

Health education comics. The second category—health educational comics—is more like the type of patient education format that straightforwardly explains medical information. However, instructional comics are very different from handouts that use bullet-point lists or brochures that use photographs. Comics have a unique grammar that McCloud defines as “juxtaposed pictorial and other images in a deliberate sequence, intended to convey information and/or to produce an aesthetic response in the viewer” [13]. Comics have been used to communicate accurate and relevant information on serious and technical topics over many decades and across cultures [14]. Instructional comics can use narrative (e.g., “Sophie’s Science Project: What Is Medical Research?” [15] and Forgotten Memories [16]) or be more didactic (e.g., Trauma Is Really Strange [17] and “Let Me Tell You How Dad Got Sick!” [18]).

The grammar of comics might be able to facilitate comprehension to a greater degree than other patient education formats. One well-known feature of comics is the carefully designed interplay of words and pictures, which can help improve health literacy. For example, sequences of action can be depicted visually that might otherwise take many paragraphs of written text to explain in equivalent detail, and the sequence itself could contain concise speech bubbles or captions that complement or clarify the visual information. In addition, spatial relationships between illustrations can create a dynamic depiction of time, which could be used to help explain cause-and-effect information related to certain medications or health behaviors. Another graphic technique of comics is the juxtaposition of differing images on the page. This technique can be useful to contrast healthy and unhealthy or disease states (e.g., normal vs. asthmatic airways) or to compare observable external symptoms and internal physiological processes (e.g., wheezing vs. bronchoconstriction) [19]. Taken together, these features give comic readers a multilayered experience, encouraging repeated reading that could continue to reinforce educational concepts well after the patient visit. If Trauma and You is a health educational comic book, Dr. S could point out to Mrs. T why he feels this unique format presents this medical topic more clearly than other materials he has reviewed.

Presenting Patients with Comics

In the case, Mrs. T believes that comics are only for children and that the medium is not an appropriate format for serious subject matter. Physicians who recommend patient education comics should address possible patient attitudes questioning the appropriateness of this format, especially in the US where the dominant cultural view of comics is that they are juvenile and intended to be funny.

It is important that Dr. S present this information sensitively, in keeping with Mrs. T’s preferences. It is not clear if Dr. S specifically solicited Mrs. T’s broader preferences about receiving medical information or her specific feelings about comic books. However, Dr. S might have approached communication with Mrs. T more sensitively, even without knowing her personal preferences for patient education format.

Dr. S could have acknowledged that some people might not expect useful medical information to be presented in a comic format. He might have also chosen to mention that new research published in medical and health journals demonstrates this medium to be an effective and engaging educational tool for both children and adults [5-7]. In providing context that comics can address serious topics, he could have referenced famous comics that have become mainstream hits, even if these are not specifically health related, such as Maus: A Survivor’s Tale [20], Persepolis [21], and Fun Home: A Family Tragicomic [22]. To better assure Mrs. T of the relevance of the comic to her medical issues, Dr. S could have pointed out a few specific details about how and why he feels this specific comic book, story, or character might relate to her. Most importantly, Dr. S might have affirmed to Mrs. T that many comics he offers to patients meet the same standards (e.g., accuracy, readability, up-to-date information) of other patient education content in other media formats that might be more familiar to her.

If Mrs. T indicates that she views comics as inappropriate, and if additional information does not persuade her, Dr. S could potentially choose to offer her the comic book anyway but also convey that she need not read it. If Dr. S adamantly feels this particular comic is the best version of PTSD patient education he can provide, it might be worth taking the chance that Mrs. T is simply expressing a negative viewpoint because she feels it would be inappropriate for her to accept the comic but that she might potentially still read it later. At the same time, Dr. S could also accommodate Mrs. T’s stated preferences for more serious-appearing information and refer her to reputable websites or other materials that he might have available.

Conclusion

When determining the appropriateness of a health-focused comic for adult patients, clinicians may need to invest more time than they do with other formats. For example, they might have to do their own evaluation of the accuracy of the content, because comics are less likely to be included in a standardized collection of physician-reviewed patient education materials that practices or hospitals might already use. Similarly, they might need to review each comic for its potential relevance to their own patients in terms of the artwork style, storytelling approach, and emotional content. Finally, clinicians need to be prepared to present this less-common format in a sensitive manner by explaining its potential educational advantages and particular usefulness. In this effort, clinicians do have a growing number of resources, including medical librarians, websites, and journals that are beginning to evaluate and organize graphic medicine titles in a way that could make it easier for clinicians to know which comics to recommend to patients [23, 24].