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Commentary on Boxed In: Lessons From the Margins of Medical Student Comics

Green, Michael J. MD, MS; George, Daniel R. PhD, MSc

doi: 10.1097/01.ACM.0000527353.34595.7b
Medicine and the Arts
Free

M.J. Green is professor and interim chair, Department of Humanities, Penn State College of Medicine, Hershey, Pennsylvania; e-mail: mjg15@psu.edu; Twitter: @mjg15; ORCID: https://orcid.org/0000-0002-4828-4749.

D.R. George is associate professor, Department of Humanities, Penn State College of Medicine, Hershey, Pennsylvania; ORCID: https://orcid.org/0000-0002-8708-3480.

For decades, medical educators have written about medical student mistreatment and abuse.1 While the most egregious of these transgressions (sexual harassment, discrimination, etc.) tend to receive public attention, the day-to-day educational neglect, as illustrated in the comics by Yvonne Y. Tsui, Michael Pitzer, and Jennifer Rice, do not.

Quite simply, many medical students are marginalized in the clinical setting2; that is, they feel superfluous within the very system into which they are being socialized. This sentiment is immortalized as one of the famous laws in the House of God: “SHOW ME A [MEDICAL STUDENT] WHO ONLY TRIPLES MY WORK AND I WILL KISS HIS FEET.”3 Much of what we know about the issue of student abuse is derived from quantitative surveys such as the Association of American Medical Colleges’ Graduation Questionnaire.4 Such surveys describe the frequency and types of mistreatment endured by students, but lack descriptions of students’ lived experiences. Narrative analysis can delve below the numerical surface to unlock meanings that may be missing from quantitative data.

Within medical education, creating narrative through comics is a relatively new way to foster student expression. This medium, which frees students to communicate their thoughts honestly and vividly using visual metaphor and satire, offers a variety of advantages over written and spoken language.5 As the realist painter Edward Hopper once commented, “If you could say it in words, there would be no reason to paint.”6

The comics on the facing page were created by three of the fourth-year medical students who have completed an elective course on comics and medicine at Penn State College of Medicine. In this month-long seminar/workshop, students not only read and discuss book-length comics about medically themed topics but also create their own short comics about formative medical school experiences.7,8 Previously, we noted that almost half of the comics contain themes from the horror genre.9 Additionally, as reflected in the panels here, a more subtle, yet pervasive theme students express is feeling marginalized in a clinical environment bereft of supportive mentorship.

In “Adventures in the O.R.,” Yvonne Y. Tsui shows herself literally and figuratively minimized by an imposing operating room nurse who shouts (among other things) “YOU’RE NOT IMPORTANT!” Whereas the nurse and her words are large and bold, the student is tiny and isolated. The message is sharp and clear: the student, at the bottom of the operating room hierarchy, is not a valued member of the team.

“Medical Student: A Tragic Comedy,” by Michael Pitzer, depicts the student’s interactions with an attending physician portrayed as a horned, white-coated devil. While the drawings of the attending remain largely unchanged, the student shrinks under withering invective by the physician who basically commands him to disappear. Missing the opportunity for positive role modeling, the physician berates the student as being little more than a nuisance—not the mentor Pitzer hoped for or deserved.

“Culture of Compassion,” by Jennifer Rice, depicts an attending physician shredding the student’s history and physical writeup while insouciantly commenting, “Yeah, that patient history looks great.” The student notes that “nothing we did really mattered,” perfectly capturing the disempowerment experienced during clinical rotations. In the adjacent panel, the cross-armed doctor sternly proclaims, “I’m going to call you ‘med student’ until you prove you’re worthy to be called by name,” sending the message that students must prove their value before being granted the basic dignity of their names. Rice’s comic raises the question of how a student can prove worthy when genuine attempts to contribute are not valued.

What can we learn from these comics? The overriding message is that supervisors do not seem to care about students’ learning experiences, or about helping them obtain necessary skills for becoming effective (and caring) physicians. Rather, the students’ job is to stay out of the way and avoid causing trouble.

Such marginalization has important implications for medical education. Short-term, this is clearly damaging; in fact, one of us (D.R.G.) recently polled 23 fourth-year students, and 22 of them said they would not go to medical school again if given the choice. We also worry that mistreated students will perpetuate such practices with future generations or, worse, treat their patients without the care and concern they deserve.

What seems clear is that medical students’ creative expressions provide educators with a window through which to view themselves in new ways. Windows are both transparent and reflective. The comics here allow us to peer into the medical students’ world, while simultaneously reflecting back to us the intricate patterns of mistreatment that exist in our own professional environments. When we look through these windows, what do we see?

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References

1. Cook AF, Arora VM, Rasinski KA, Curlin FA, Yoon JD. The prevalence of medical student mistreatment and its association with burnout. Acad Med. 2014;89:749754.
2. Anyaegbunam JA. Med students are marginalized in the hospital. It’s time for that to stop. KevinMD.com. July 1, 2015. http://www.kevinmd.com/blog/2015/07/med-students-are-marginalized-in-the-hospital-its-time-for-that-to-stop.html. Accessed October 12, 2017.
3. Shem S. The House of God. 1978.New York, NY: Dell.
4. Association of American Medical Colleges. Medical school graduation questionnaire: 2017 all schools summary report. https://www.aamc.org/download/481784/data/2017gqallschoolssummaryreport.pdf. Published July 2017. Accessed August 15, 2017.
5. McNicol S. The potential of educational comics as a health information medium. Health Info Libr J. 2017;34:2031.
6. In Leavy P. Method Meets Art: Arts-Based Research Practice. 2009.New York, NY: Guilford Press.
7. Green MJ. Teaching with comics: A course for fourth-year medical students. J Med Humanit. 2013;34:471476.
8. Green MJ. Comics and medicine: Peering into the process of professional identity formation. Acad Med. 2015;90:774779.
9. George DR, Green MJ. Lessons learned from comics produced by medical students: Art of darkness. JAMA. 2015;314:23452346.
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