Brighton and Sussex Medical School, Brighton, United Kingdom
Comics have long been used as a way of attacking cultural and political hierarchy, as has the art of caricature.1, 2 They can also be used as a way to explore and understand the link between the medical profession and the rest of society.3 My comic is not intended to be a "tool for resistance"2 but simply a way to observe hierarchy amongst health care professionals—from the lowly medical student to the most senior of attending physicians. I have tried to depict the different perspectives and behaviours, such as the nurse, always keen to serve the doctors ("right you are doc!") or the always disgruntled junior doctor, resentful at being landed with patients no one else wants (in this case "the loony and the drunk").
Much of the power of comic art comes from the use of non-verbal communication; so much can remain unsaid, but yet be clearly depicted through graphic means. Comics can distil complex social situations and make simple but important points in ways that are hugely effective. The moral purpose of my comic is to highlight and challenge the still prevailing prejudice and stigma surrounding mental health and the widespread lack of understanding of depression in society.4 Clay highlights the negative attitude towards depression in his comic "Self Harm."5 For me, talking to patients during my psychiatry rotation taught me that clinical depression is not a simple extension of "low mood," but instead a totally debilitating illness.
Unfortunately, there is ample evidence that some doctors continue to show a lack of sympathy for patients attending emergency rooms following self-harm or suicide attempts. Terminology like: "loony," "psych case," "nutter," and "crazy" are repeated throughout the comic in order to highlight how strongly this stereotype is engrained. I also believe that prejudices surrounding mental health are not confined to the hospital but are common throughout our society. For instance, the penultimate frame makes a subtle suggestion that the media may play a role, with the headline in the tabloid paper: "Loony beats death."
I wanted to challenge the idea that one injury was "self-inflicted" by directly comparing suicide with another injury acquired during a road traffic accident. When it emerges that the patient in the accident was alcoholic, the approach to treatment changes and the patient is abandoned to the care of a junior doctors. The implication is that his injuries are now seen as "self-inflicted" too. It is left to the virtuous consultant to remind the reader that all patients should be treated with dignity and respect.
The patient from the psychiatric hospital Millview, a caricature of Jesus, appears unkempt and dishevelled yet turns out to be the most gracious of patients, praising the doctors for their valiant efforts to save him. This is deliberately ironic, prompting possible feelings of guilt, because in reality, the patient was neglected by most of the staff. He is a testimony to the goodwill of the consultant who defied the image-based prejudices to save him.
To underline the message about the inherent susceptibility of everyone to make judgements that reflect their prejudices, I tried to depict the over-worked junior doctor as a character the reader could empathise with: collapsing in front of the television set in the doctor's lounge and commiserating with friends at the bar after a long day. Yet the junior doctor left in charge of the "loony" realises his error and panics. Whether he will learn a life lesson from this or take it as a lucky escape is open to interpretation. Only the attending physician remains morally upright.
Rita Charon argues that comics can be used as a "model for profession."3 I have taken this literally by creating the blonde-haired "Disney prince" as my model of the archetypal professional. Unlike the other characters, who have identifiable elements of relapse in their virtue, he is depicted as "super human" in his unfaltering ability to be honourable. Even the innocent medical student (myself) is preoccupied by her logbook rather than concern for the patient. Stereotyping has been used (often controversially) in comics to emphasise a point over many centuries.6 The hero stereotype in my comic is intentionally exaggerated in order to question whether anyone can be truly righteous or whether this is a trait that only fantasy characters possess. The question is asked but not fully answered.
Challenge your preconceptions, or they will challenge you
Colour and tone are often used in comics to enhance meaning and characterisation.7 In the scene where the consultant is carrying out CPR I have used dark shading to reinforce the contrast between good and bad. I chose to use dark, cold blues around the questioning voices as a metaphor for prejudice. I was inspired by Tom Humberstone's use of dark shading and gloomy colours in his comic about living with Crohn's Disease, emphasising the depth and blackness of his depression.8 Despite Humberstone's remarkable ability to find humour in every situation, his choice of colour and heavy shadowing force the reader to realise the morbid reality of the condition.
Body posture, gesture, and facial expressions can be a powerful tool in comics, conveying far more than words alone. To quote Will Eisner, "Expressive postures are accumulated and stored in the memory."9 This certainly rings true for me. On returning to the wards, I realise I was far more receptive to subtle changes in body language and expressions adopted when addressing or discussing such patients with mental illness. I have attempted to highlight these in my comic, by exaggerating the physical gestures that emphasise the negative attitudes.
Comics in medicine serve many roles: to tell a story, educate, reflect, observe, heal, and perhaps above all to help introduce humour into how we communicate and project an understanding of medical conditions and clinical contexts.4,9,10,11 Although my comic is ethically based, it was never intended to teach a moral lesson. Rather my aim was to make the point that preconceptions are often very entrenched in medicine. I was also intrigued by how producing a comic allowed me to explore my own emotional response to what I have observed in practice. The process of making comics is an effective means of reflecting on professionalism, developing empathy, and understanding one's own personal reactions.3,12,13,14 This was particularly pertinent in my exploration of people's attitudes towards mentally ill patients. Only through drawing the comic did I realise how deeply it affected me.
1 Williams, J. Comics: a tool of subversion? Journal of Criminal Justice and Popular Culture. 1994; 2(6): 129-146.
2 Bergman, S. Fiction as resistance. Annals of Internal Medicine. 2002; 137: 935-937.
3 Charon, R. Narrative medicine: A model for empathy, reflection, profession, and trust. JAMA. 2001; 286:1897-1902.
4Seah, S. The drawn-out battle against stigma: mental health in modern American comics and graphic novels. Third Annual Undergraduate Conference on Health and Society: Health and Illness in the Media, Providence College. March 2012.
5 Clay. Self Harm. Depression comics: A comic about mental illness. 2014.
6 Soper, K. From swarthy ape to sympathetic everyman and subversive trickster: The development of Irish caricature in American comic strips between 1890 and 1920. Journal of American Studies. 2005; 39 (2): 257-96.
7 McCloud, S. Understanding comics: The invisible art. New York: Harper Collins, 1994.
8 Humberstone, Tom. Everything you ever wanted to know about Crohn's Disease. Webcomic, 2007.
9 Eisner, W. Graphic storytelling and visual narrative: Principles and practices from the legendary cartoonist. New York: Norton, 2008.
10 Williams, Ian. Autobiography as auto-therapy: Psychic pain and graphic memoir. Journal of Medical Humanities, 2011; 32: 353-366.
11 Green, M. and Myers, K. Graphic medicine: use of comics in medical education and patient care. BMJ. 2010; 340: 574-577.
12 Al-juwad, M. Comics are research: Graphic narratives as a new way of seeing clinical practice. Journal of Medical Humanities, 2013; s1-6.
13 Dadds, M. Empathetic validity in practitioner research. Educational Action Research. 2008; 16(2): 279-90.
14 Milner, M. On not being able to paint. Second ed. London: Heinemann Educational Books, 1971.
ROSE GLENNERSTER is a fourth year medical student studying at Brighton and Sussex Medical School. She has a keen interest in medical humanities and has just completed an intercalated degree in Medical Ethics and Law.