Description of a new education method or tool
Open Access

Integration of Graphic medicine in teaching Pharmacology to Optometry students

Faraz Khurshid[1], Babu Noushad[2]

Institution: 1. College of Health Sciences, University of Buraimi, 2. College of Health Sciences, University of Buraimi,
Corresponding Author: Dr Faraz Khurshid docfarz@gmail.com
Categories: Educational Strategies, Medical Education (General), Teaching and Learning

Abstract

Objective: The study was undertaken to establish student perception and interest in a graphic medicine approach to the teaching and learning of pharmacology in optometry.

Methods: The Graphic-oriented approach to the teaching of pharmacology was introduced periodically to undergraduate students of optometry in semesters five and six. The methodology was accompanied by ‘concept animation’ to translate difficult concepts into comprehensible ideas using handmade diagrams and comic strips. Furthermore, the process was accompanied by learning difficult terminology and definitions of the subject using ‘keywords and phrases’. A questionnaire-based survey was conducted towards the end of the semester to determine student aptitude for and interest in this approach to teaching and learning.

Results: A total of seventy-five students studying pharmacology across two semesters participated in the survey. Survey findings established the effectiveness of the diagrammatic approach to learning the names of drugs among 68% of the students. An overwhelming response of 85% students expressed their propensity for ‘concept animation’ to comprehend the difficult concepts in an easy way.

Conclusion: Graphic medicine has been acknowledged as an important pedagogical instrument for the effective teaching and learning of subjects like pharmacology to allied health sciences students of optometry.

Keywords: Graphic Medicine, Concept Animation

Summary

Basic science courses are non-comfort zones for many allied health science students. An environment nurtured early in the curriculum can facilitate student learning of the fundamental principles of human biosciences. However, failure to promote this will make basic science subjects disinteresting for most of the students in the later part of their study (McVicar, Andrew & Kemble, 2017). A similar situation was observed among Optometry students studying at the College of Health Sciences, University of Buraimi, Oman.  The students are taught General and Ocular Pharmacology in semester I and II of academic year 3.  Although some students managed to obtain good scores, in general, the learning experience of the students influenced the perception of the novice registering for the course. This situation persuaded the teacher to initiate the concepts of Graphic medicine and animation for the Pharmacology course to make students more accustomed to and comfortable with the subject requirements.  Graphics and comics can be instrumental in delivering the course content in a coherent manner and improves the attitudes of non-science majors toward biology (Hosler & Boomer, 2011). 

Introduction

Learning can be an effective, long-lasting experience if it is driven by fun-loving approaches and worth-memorizing experiences. Strategies have been developed to refine the metacognitive skills of the students to optimise their independent learning. Teachers may contribute to improving a student’s metacognitive expertise in addition of attributing towards the cognitive and affective domain (Ten Cate, Snell, Mann & Vermunt, 2004). Still, a popular visual approach of learning is Graphic medicine which is expressed with the idiom ‘a picture is worth a thousand words’. It is a valuable tool in medicine that uses graphic stories of patient care and education (Green & Myers, 2010). Though it is not widely incorporated in medical education, it has an engaging style to support learning in different contexts. 

Methods

The critical concepts of pharmacology were taught to students registered in semesters I and II in year 3, using handmade diagrams and comic strips. The graphic elements were periodically introduced during the lectures to communicate challenging concepts as simpler ideas. Furthermore, special emphasis was given to articulating difficult definitions in simple ‘keywords and phrases’; in addition, efforts were made to spell out the names of the commonly used drugs into ‘prefix’, ‘roots’ and ‘suffix’ and graphically relate them to the comic or story. In general, carefully designed text diagrams improve learners’ efficiency in a range of text-determined cognitive outcomes (Carney & Levin, 2002).

For instance, the drug ‘Cyclopentolate’ is a commonly used ‘cycloplegic’ in diagnostic optometry. The name of the drug is divided into three component (Cyclo- indicating a bicycle), (Pento- the student riding the bicycle) and (late- means delayed). The story said that Pento will reach school late as his bicycle tyre has been punctured. The narration was shown by a handmade diagram (Figure 1). Moreover, the end of the story facilitated the learning of an important aspect of the drug’s pharmacokinetics i.e. the late onset of drug action which is linked with the late arrival of Pento at school as shown in Figure 1.  

 

Figure 1. Transformational image depicting the narration of Pento and his bicycle

Figure 1. Transformational image depicting the narration of Pento and his bicycle

 

The same philosophy was used for several drugs to make the students familiar with their names, actions, clinical uses, contraindications, side effects etc. The graphic medicine component supported by concept animation philosophy was presented in the theoretical as well as tutorial classes of general and ocular pharmacology courses across two regular semesters.

Towards the end of the semester, a questionnaire survey was conducted to analyze the qualitative aspects of this approach to effective teaching and learning. The content validity of the questionnaire was established. The students responded to each survey item of the questionnaire on a five-point Likert scale with 1 indicating strongly disagree, 2 disagree, 3 neither agree nor disagree, 4 agree, and 5 strongly agree. 

Methods

A total of seventy-five students enrolled in General & Ocular Pharmacology courses for two consecutive semesters participated in the survey. The scales of ‘strongly disagree/disagree’ and ‘strongly agree/agree were consolidated for the convenience of graphical representation. On a five-point Likert scale, 58% of the students acknowledged their difficulty in memorizing the names of drugs; moreover, 42% students also acknowledged the ease of remembering the generic name of the drug, which is an integral requirement of the course.

The subject-related concerns of the students were addressed by graphics and concept animation approaches. The students responded positively to this, they found the diagrammatic approach of learning the names of drugs effective. Moreover, an overwhelming response of 85% (Figure 2) showed student appreciation for ‘concept animation’ to help them understand the difficult concepts in an easy way. Likewise, 76% of the students expressed their preference for ‘keywords and phrases’ over lengthy definitions.

Figure 2. Graphical representation of the results from the student survey on Graphic medicine and concept animation

Discussion

The effective utilization of the underrated medium of Graphic medicine and pathographies can foster learning and teaching about diseases in an innovatively creative way. However, this medium has not been significantly employed in medical education. A teacher can facilitate it to foster a range of cognitive skills among his/her pupils; moreover, it can trigger the metacognitive abilities of the students for self-regulated learning. Pictures complement the text by serving as ‘adjunct aids’ to perceive, understand and remember the information in the text (Carney & Levin, 2002). The current study explored the interest and perception of students learning pharmacology using graphic medicine. In addition, the ideology of graphic medicine was threaded with the process of ‘Concept animation’- a graphic way of simplifying the complex core concepts of a subject like ‘pharmacology’ using pictures and comics. The notion of ‘concept animation’ reinforced graphic medicine. In addition, this study also demonstrated the ease of learning pharmacology by the use of ‘keywords and phrases’.

Primarily, the hardships that most of the students experienced in learning and memorizing the names of the drugs fuelled the need graphic medicine in pharmacology. This was a key factor in introducing this medium to address the needs of students who found it challenging to memorize the names of the drugs. As the number of drugs taught to them was limited, this encouraged the instructor to use the graphic approach for teaching the most important drugs. The students endorsed this idea and many of them came forward to work with the teacher in developing this innovative approach. Merging visual knowledge with verbal description has positively influenced student reading performance, knowledge retention capacity and creative problem-solving skills (Carney & Levin, 2002; Mayer & Sims, 1994; Gambrell & Jawitz, 1993).

The images used for this purpose were consistent with conventional (representational) and unconventional (transformational) functions of pictures as described by Levin (1981). Representational pictures are the most common type of depiction; they reflect the text in part or whole, whereas transformational pictures have emerged as potent facilitators of student knowledge reconstruction (low cognitive level) and application performance (high cognitive level) (Levin, 1981). Students perform well when the narration is accompanied by animation. Subsequently, the graphic medicine approach was employed to simplify the difficult concepts for consolidation of learning experience via concept animation. Concept animation was well received by the students. The use of comics not only engross students in the knowledge being discussed, it also evolves the analytical and critical thinking skills of the students (Versaci, 2001). Furthermore, the learning process was strengthened by transforming difficult terminologies and definitions into easy to recall key words and phrases.

This study provided a perspective of utilizing graphic medicine to reinforce effective learning. The observational and interpretive capabilities of students are augmented by reading graphic stories and animation (Green & Myers, 2010). Moreover, graphic medicine helped the student to minimize the chance of spelling mistakes while writing the name of the drug. The blending of all the above-mentioned components in the questionnaire was supportive of the idea of honing students cognitive and metacognitive skills toward a positive learning environment, to nurture their interest for the subject and to facilitate an effective independent way of learning.

However, this study has its limitations as the perceptions were not transformed into a quantitative conclusion to measure the impact of this approach on student evaluation. Future studies should be directed to establish ‘How graphic medicine can improve student performance in formative and summative assessment?’ Nevertheless, the effectiveness of graphic medicine could also be explored in other basic sciences subjects with different sets of students in a more structured way. 

Conclusion

The sound synchronization of graphics and concept animation facilitated student interest, concentration and learning potential of a bioscience-related subject, pharmacology, in a positive manner. The medium provided a complementary support to the problem faced by most of the students learning pharmacology. The medium has been perceived as an effective pedagogical tool to motivate students towards a life-long, fun loving, independent way of learning. 

Glossary

Graphic Medicine: The use of comics or photographs or graphic stories with the purpose of health care and education is known as Graphic medicine. It has a role in patient care and medical education (Green & Myers, 2010).

Concept animation:  A graphical approach of simplifying complex core concepts with the help of pictures and comics

Representational picture: The literal depiction or overlap of text information in part or whole (Levin, 1981).

Transformational picture: Pictorial representations that facilitate student learning from text by 'keywords illustration';

Moreover, it prompts higher-order cognitive application tasks (Carney & Levin, 2002; Levin, 1981).

Take Home Messages

The sound combination of graphic medicine and concept animation can function as an effective metacognitive strategy to enhance the learning experience of students.

Notes On Contributors

Faraz Khurshid, MBBS, MS Molecular Biology, is Lecturer at College of Health Sciences, University of Buraimi, Sultanate of Oman.

Babu Noushad P, M.Optom, FIACLE, is Lecturer at College of Health Sciences,​University of Buraimi, Sultanate of Oman.

Acknowledgements

I would like to acknowledge all my optometry students for being a constant source of inspiration to make graphic medicine a worthwhile experience for learning pharmacology.

I would like to convey special regards to one of my students Ms. Ghaliya Rashid Said Al Buriki for her endeavors.

Special mention to Professor Graeme Henderson from the University of Bristol, UK for his constructive comments and proofreading.

Bibliography/References

Carney, R., & Levin, J. (2002). Pictorial Illustrations Still Improve Students' Learning From Text. Educational Psychology Review, 14(1).

https://doi.org/10.1023/A:1013176309260

Gambrell, L., & Jawitz, P. (1993). Mental Imagery, Text Illustrations, and Children's Story Comprehension and Recall. Reading Research Quarterly, 28(3), 264.

https://doi.org/10.2307/747998 

Green, M., & Myers, K. (2010). Graphic medicine: use of comics in medical education and patient care. BMJ, 340(mar03 2), c863-c863.

https://doi.org/10.1136/bmj.c863   

Hosler, J., & Boomer, K. (2011). Are Comic Books an Effective Way to Engage Nonmajors in Learning and Appreciating Science?1. Cell Biology Education, 10(3), 309-317.

https://doi.org/10.1187/cbe.10-07-0090  

Levin, J. (1981). On functions of pictures in prose. Neuropsychological and Cognitive Processes in Reading, 203-228.

https://doi.org/10.1016/B978-0-12-185030-2.50013-5   

Mayer, R., & Sims, V. (1994). For whom is a picture worth a thousand words? Extensions of a dual-coding theory of multimedia learning. Journal of Educational Psychology, 86(3), 389-401.

https://doi.org/10.1037//0022-0663.86.3.389  

McNicol, S. (2016). The potential of educational comics as a health information medium. Health Information & Libraries Journal, 34(1), 20-31.

https://doi.org/10.1111/hir.12145  

McVicar, A., Andrew, S., & Kemble, R. (2015). The 'bioscience problem 'for nursing students: an integrative review of published evaluations of Year 1 bioscience, and proposed directions for curriculum development. Nurse education today, 35(3), 500-509.

https://doi.org/10.1016/j.nedt.2014.11.003  

Ten Cate, O., Snell, L., Mann, K., & Vermunt, J. (2004). Orienting Teaching Toward the Learning Process. Academic Medicine, 79(3), 219-228.

https://doi.org/10.1097/00001888-200403000-00005  

Versaci, R. (2001). How Comic Books Can Change the Way Our Students See Literature: One Teacher's Perspective. The English Journal, 91(2), 61.

https://doi.org/10.2307/822347  

Williams, I. (2012). Graphic medicine: comics as medical narrative. Medical Humanities, 38(1), 21-27.

https://doi.org/10.1136/medhum-2011-010093

Appendices

There are no conflicts of interest.

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Reviews

Stella Briggs - (20/11/2017)
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The components of pharmacology is many, thereby posing a challenge for students to comprehend and/ or commit to memory. The results of this manuscript show that integration of graphics, animations and comics in teaching definitely improved the cognitive skills of the learner. As often said “a picture is worth a thousand words”, has proven true in this research. The manuscript is well written. I had some questions right after reading the results section but these were cleared in discussion section where supporting explanations were given for the positive effect of the use of graphics, animations and comics in overall student performance.

I have a minor correction the authors should have made. In the methods section of the main manuscript. The total number of years to complete the optometry program should have been indicated. The first sentence should have read… “The critical concepts of pharmacology were taught to students registered in semesters I and II in year 3 of a 4-year program”. This would show that the research was done on seniors of the program. Cognition is somewhat related to stages of growth. Would results differ in other levels of the program?

This manuscript is a valuable contribution to optometric education.. I would recommend it to anyone teaching in higher education.
Ingrid Spanjers - (17/11/2017)
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I think this is an interesting article. My area of interest is strategies to improve memory for instructional material. This article is about such a strategy. So, I liked to read it.

What I also liked is that the focus is on a problem which is not specific to one institute and programme; the issue that ‘basic science courses are non-comfort zones for many allied health science students’ will be an issue which different institutes have to deal with. So, the proposed strategy to deal with the issue can be of interest to teachers all over the world.

Another good aspect of the paper is the use of literature from different theoretical backgrounds. This also makes the article interesting.

By including an example the strategy proposed is described well. However, a few improvements are possible in the description of the strategy. For me as a reader it is not clear what the term concept animation means. I associate animations with moving images (see for example the description of concept animation in this thesis: https://ir.canterbury.ac.nz/handle/10092/9570). I do not see how moving images fit into the story told in this article.
Besides, it can be stated more explicitly and clearly how graphic medicine may improve the students’ metacognitive knowledge and may foster their cognitive skills. The strengths of the paper are the common problem and the use of literature from different theoretical backgrounds. When the authors would have gone in somewhat more detail about how the literature explains the positive effects of the strategy, the strengths of the paper would have been highlighted even more.

Good that attention is given to limitations of the study. This is also a well-written section.
Just for information: It is stated in the limitation section that future studies could use a more structured way and can measure the impact on student evaluation as well as on assessment results in a quantitative way. In such a study, one would probably compare survey results and learning outcomes on a formative or summative assessment for two groups of students: one group which was instructed with the new approach and one group which was instructed with another approach, for example a more traditional approach. In this way, one can study whether students would have evaluated their instruction less favourable, when they would have been taught with another method. By including assessment results, one would, hopefully, be able to examine student performance in a more objective way than with survey results.

It is a minor point but I would see this study as quantitative, because the focus is on the numbers/percentages of students agreeing and disagreeing with statements. For a qualitative study one would interview the students or observe them, and subsequently search for themes in the data which can be used to interpret how the students experienced graphic medicine.

With regard to the data presentation, I wonder why the x-axis is from 0 to 75 rather than to 100%.
sadaf asif - (19/10/2017)
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This article reveals a great depth of information on new teaching teaching techniques that could appeal to visual learners and this mini- research could be developed into a full fledged research to explore in-depth different ways to address the learning needs of students as in academics, we see a dearth of research into teaching techniques which could benefit learners and address their needs on a wider perspective. We have seen the age old lecture technique of keeping learner engaged but in keeping with technology , it's essential to use the technological advances to further education and apply different learning techniques that includes visual learners as their approach to learning is in contrast to other learners.
Krupa Philip - (19/10/2017)
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This paper shows that use of graphics in teaching can be an effective tool in making a course/subject more attractive and appealing to the students. It also demonstrates that if the students are made to illustrate these course related comics, graphics can not only stimulate interest in learning it also persuades the students to actively participate in teaching.

This paper also gives evidence that, contrary to the usual phenomena of forgetting a concept or content after the completion of the course, learning with the aid of graphics can reinforce effective learning.

Hence I strongly recommend this article to the readers especially those in academics as it gives a novel idea to transform the challenging concepts of pharmacology into easily comprehensible graphics.
Michael SH Wan - (15/10/2017) Panel Member Icon
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The paper showed that incorporating graphics in the teaching will improve the understanding and interest in learning. Students could be visual learners and would benefit from this.
The concept is novel and interesting.
The evaluation could be stronger if the authors can look at the retention of the knowledge in a few months time and even look at improvement in the actual performance (knowledge or competence).
Trevor Gibbs - (12/10/2017) Panel Member Icon
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An interesting paper described a novel approach. Any technique that provides accretive learning for the student deserves mention. However for time taken up in novel approaches there is equal time removed from what is probably an overcrowded curriculum.

I like the technique and its description although I did think that it was a little over-exagerated and complicated. However I do have a problem with the evaluation, given it is self-perception- novelty and being liked by the student can raise internal motivation and it was an active piece of teaching and learning. It really needs a more formal evaluation over a longer period of time to assess its effects
Maria Elizabeth Arlene Ubarra Castel - (12/10/2017)
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“Role of Graphics in Education”

Review of “Integration of Graphic medicine in teaching Pharmacology to Optometry students” by Faraz Khurshid[1], Babu Noushad[2] of 1. College of Health Sciences, University of Buraimi, 2. College of Health Sciences, University of Buraimi under the categories: Educational Strategies, Medical Education (General), Teaching and Learning
“Integration of Graphic medicine in teaching Pharmacology to Optometry students” is an attempt to transform Pharmacology, from a “strange” into a “friendly” course category maintaining its substance but with minor twist on the teaching methodology. Authors have earlier mentioned that experienced wise, students have reiterated difficulty in spelling names of drugs, actions, clinical uses, ‘pharmacokinetics’ and so on. “Primarily, the hardships that most of the students experienced in learning and memorizing the names of the drugs fueled the need for graphic medicine in pharmacology.” Thus, this study came as a pedagogical instrument to facilitate teaching Pharmacology and improve students’ learning outcomes. The authors highlighted that ‘concept animation’ is vital “to translate difficult concepts into comprehensible ideas using handmade diagrams and comic strips.” (Faraz & Noushad, 2017).
The use of graphic stories and comics was used as a teaching tool to medical and allied health students by some researchers from the University of Toronto to expound on the emotional and ethical uniqueness and syndrome of illnesses, injuries and trauma experienced by patients. The authors’ mimics the same teaching path utilizing concept animation to develop cognitive and metacognitive skills. Students were empowered to develop critical thinking and creativity. Emphasis of pictures and visuals to enhance memory can improve learning in the principle of “Picture superiority effect”. The strengths of this article have been well emphasized in objective, methodology and students’ involvement. But as stated earlier, the weakness is in the limitation that they have confessed. Owing to the fact that their findings were based on perception of students, the opportunity was not maximized. Authors could have also associated the effects of Pharmaco-graphic approach to student’s assessment and learning outcomes to address the said week points.
Graphics were introduced to simplify difficult terminologies coupled with the use of simple ‘keywords and phrases’. During the lectures, narrations (as illustrated) and handmade diagrams were supplied to correlate pharmacologic concepts with reality. Graphics and diagrams help learners comprehend abstract concepts using visual language to depict meaning despite the fact that no one can say that visuals are superior compared with words but familiar objects are easily recalled as illustrated. Furthermore, teaching is inspiring students to see and discover, thus pictures have certain aesthetic appeal to enhance learning. As what has been mentioned, “In general, carefully designed text diagrams improve learners’ efficiency in a range of text-determined cognitive outcomes (Carney & Levin, 2002)”. Main points clearly emphasized and supported by the survey findings. Central concepts defined and findings explained. This article inspired by its objective can serve as stimulant for other educators to utilize graphic as a tool in teaching students, for doctors to educate patients and for patients to understand the “what’s and why’s” of their diseases and to realize the importance of health.
This review has evaluated the article, “Integration of Graphic medicine in teaching Pharmacology to Optometry students” by Faraz Khurshid and Babu Noushad. The arguments in the article reveal the positive responses of students towards graphic oriented approach in teaching. A typical example of an idiom, “a picture is worth a thousand words” thus, it is a valuable tool in teaching and in medicine that uses graphic stories of patient care and education (Green & Myers, 2010). I recommend reading this article to educators and anybody who would like to share information in whatever field as well - prepared and educational graphics can be powerful mnemonics to open minds and motivate any target audience. The challenge is for future researchers to delve into the role of graphics towards teaching, learning and its relationship to assessment.

References:
Faraz Khurshid & Babu Noushad. “Integration of Graphic medicine in teaching Pharmacology to Optometry students”. MedEdPublish, October, 2017

Michael J Green & Kimberly R Myers. “Graphic medicine: use of comics in medical education and patient care” BMJ 2010; 340: .c863, March, 2010

Stephanie Findlay. “Comic books have something to teach future doctors” July, 2012