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When Words Aren’t Enough, Medical Students Go Back to the Drawing Board

julian lejbman and elizabeth lizz card

Julian Lejbman, MD, and Elizabeth (Lizz) Card. (Note: all photos were taken prior to the spread of COVID-19 in the region.)

Breaking down complicated medical concepts into understandable pieces can be a challenge — whether a surgeon is trying to describe what will happen during a patient’s procedure or a pediatrician is trying to explain to parents how their child’s medication works. Stress and anxiety, language barriers, and low health literacy can limit comprehension, breed frustration, and make patients and caregivers feel like they’re incapable of making informed decisions. When facing these obstacles, many physicians turn to a different form of communication: drawing.

A picture is worth a thousand words, but a clear medical illustration can be even more valuable. From simple sketches on scrap paper that help patients visualize their anatomy to handouts with symbols that clarify discharge instructions, visual aids can be enormously helpful in bridging communication gaps and opening dialogues. Plus, patients and caregivers can take these aids home and consult them as needed.

However, while drawing is part of many providers’ clinical repertoires, visual communication and medical illustration generally aren’t covered in medical school curricula. Last year, two Perelman School of Medicine (PSOM) students decided to change that.

Like PSOM’s culinary medicine and COVID-19 courses, the new “Drawing for Visual Communication in Medicine” course is a hands-on, out-of-the-box elective developed by medical students driven to meet a need they recognized among their peers. Julian Lejbman, MD, now a first-year Internal Medicine-Pediatrics resident at UCLA, and Elizabeth (Lizz) Card, a fourth-year student who plans to specialize in Plastic and Reconstructive Surgery, noticed that though they were honing their skills in culturally competent verbal and non-verbal communication, the curriculum offered little emphasis on how to create and utilize drawings, diagrams, and other graphics, despite ample research showing that visual aids can reinforce messages and improve the patient experience.

“I felt like I had a clinical deficit, and I wanted to develop the skill of using visual communication to talk to patients about procedure plans and diagnostic concepts,” Lejbman said. “Something like congestive heart failure can be a really nebulous concept for many people. Telling somebody, ‘Your heart doesn’t pump well, so you have all this excess fluid’ — what does that mean? A patient might nod along as I talk to them, but I’m focused on figuring out how I can use images in a way that’s not overwhelming, but that gives enough accurate information to get their buy-in.”

visual communication course psom

Students learned how to translate the lines, shapes, and proportions of the human body into sketches and explain medical information relevant to their chosen specialty through images and universal symbols.

Knowing that research indicates that art observation classes can improve medical students’ reflective ability and help them approach patient encounters in a more holistic, empathetic way, Lejbman did some digging. However, he found that these educational opportunities generally didn’t extend to actually creating art or to visual communication. He teamed up with Card — “one of the most artistically inclined students in the med school” — and they began drafting a course for third- and fourth-year students to fill this gap.

Luckily, they didn’t need to start from scratch. Card, who paused her medical studies for a year to study medical illustration at Stream Studios at Children’s Hospital of Philadelphia (CHOP) in 2019, discovered that studio co-founder and lead illustrator Eo Trueblood, MA, had created a visual communication class for CHOP surgical residents that had been shelved due to time constraints. His innovative curriculum included many of the topics Lejbman and Card hoped to cover, such as sketching an accurate body from the front and side and using symbols like checkmarks, Xs, and arrows to visually explain procedures.

“Our goal is to advance medicine and medical education, so when Lizz told me about this class, and I saw that she [and Julian] had the time, the drive, and the connections to bring it to fruition, I was happy to partner with them and hand over my curriculum,” Trueblood said. “Most people think they can’t draw, but this course shows them that it’s just a skill, and if they nurture that skill, it will really give them a leg up in the profession.”

In addition to Trueblood, who agreed to co-teach the course, Lejbman and Card also gained the enthusiastic support of Horace DeLisser, MD, associate dean for Diversity and Inclusion, Amanda Swain, MD, a clinical assistant professor of Family Medicine and Community Health, and Brian Dunham, MD, a pediatric ENT surgeon at CHOP and founder of Stream Studios — all of whom recognize that the humanities aren’t adjacent to medicine, but are necessary to shape creative, compassionate physicians.

“This visual communication course represents the type of curricular innovation that has been a hallmark of the Perelman School of Medicine, and it speaks to the increasingly recognized role that Penn is playing in developing pedagogy based on the arts and humanities for medical education,” DeLisser noted, adding that these types of student-led initiatives illustrate the “amazing talents” of PSOM’s students.

visual communication psom brian dunham

“If you have to draw it, you can’t fake your understanding of the anatomy; it forces you to see the 3D relationships and to understand form and structure,” said guest lecturer Brian Dunham, MD.

The three-week elective first ran in February 2020 with 17 students. During the first few classes, Lejbman and Card focused their efforts on helping their peers build confidence, explaining that even if they hadn’t progressed past drawing stick figures as children, they could still build on their existing skills. They also encouraged students to shut down the hyper-analytical side of their brains and just see what they could do — without judging their work, getting hung up on preconceived notions on what something ‘should’ look like, or feeling like drawing is something only meant for artists.

Following Trueblood’s original curriculum, each class included a brief lecture introducing a key principle of drawing. Early classes focused on observing the lines and shapes that make up objects and translating them into drawings. Students then adapted these skills to draw the human face and body. They learned to draw anatomical components proportionally and from various angles, add organs, illustrate tubes and tissue manipulation (cutting, pushing, pulling, etc.), and show complex processes and disease progression. After students expressed interest in caring for pediatric and bariatric patients, Lejbman and Card augmented the original curriculum, adding a session centered on drawing bodies of different sizes. The course also covered universal symbols and visual hierarchy. Students had the opportunity to practice each of these principles individually and get feedback, then they paired up and applied all of the skills they’d learned to a clinical case relevant to their chosen specialty.

“They’re learning to carefully examine how something is built. If you have to draw it, you can’t fake your understanding of the anatomy; it forces you to see the 3D relationships and to understand form and structure. As a physician, that visual analysis is critical,” Dunham said. “When you spend a lot of time looking at things, it uses a different part of your brain, and it has a mildly meditative quality. It changes your relationship with the world — it both demystifies art and helps you to see the beauty.”

The feedback has been excellent. Post-course surveys indicated that students built confidence in their drawing skills and believed they could find ways to integrate visual communication into their work. A follow-up survey for students now in residency supported this, with participants across the board reporting that they had been able to create helpful visual aids that really changed the course of a patient encounter. The biggest suggestion was to make the class longer so students could have more time to practice both basic drawing and advanced visual communication skills. Card is using this encouraging feedback to update the course, which is set to run later this spring with a few additional class periods and a lengthened two-hour runtime.

Lejbman is now on the West Coast, but Card and Trueblood have been hard at work determining how to best adapt the course to a virtual platform during the ongoing pandemic. Card recently finished teaching another drawing course she developed for first-year anatomy students, and she’s confident that she can employ the same multi-camera work for the visual communication class.

visual communication course psom

The class discusses how to draw cleft deformities to help parents understand the operative plan.

“You have to show students what you’re drawing so they can follow along, so I have three computers set up: an iPad pointed down on my sketchbook, a computer for the main meeting room where I can share my screen and bring on guest lecturers, and a separate computer for breakout sessions,” Card explained. “These students are just learning to draw, so it’s a lot of pressure to ask them to point their webcam directly on their work and share it with all of their peers at the same time. Instead, we’ll pull each student into a breakout room and give them time to talk about their drawing and ask questions. It’ll take time, but it worked out [for the first-year class], so I’m optimistic.”

Though the format has changed due to COVID-19, Lejbman, Card, and Trueblood believe this is just the beginning for the visual communication course. They are hopeful that it will be officially added to PSOM’s curriculum, offering more students the chance to appreciate the wide application of visual communication skills in medicine and recognize that even rudimentary drawing skills can help them become better physicians and communicators.

“Instead of leaning on just verbal communication, I want it to be second nature for providers to implement visuals in their patient interactions, especially when facing language, cultural, or health literacy barriers,” Lejbman said.

“By teaching physicians to draw, it empowers them to empower their patients and bolsters the shared decision-making part of medicine,” Card added. “Drawing is a powerful tool all of us can use, regardless of specialty. It just takes practice.”

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