Medical illustration in the 21st century and beyond

Caroline Erolin It is the role of the medical illustrator continuing professional development (CPD), Centre for Anatomy and Human Identification, to communicate often complex scientific which is essential to those wishing to join a University of Dundee, Dundee, Scotland information and concepts to a broad range of register such as that held by the AHCS. The audiences through visual media. To this end, the registration of medical illustrators has been modern medical illustrator should be educated welcomed within the profession as it recognises Correspondence to: to an advanced level in both anatomy and visual and promotes the specialist skills required and Dr Caroline Erolin communication. While some train first as artists thus helps to raise professional standards. In Centre for Anatomy and Human and illustrators, others come from backgrounds addition, such registers help to safeguard the Identification in and , with each typically public by allowing anyone to search them and University of Dundee learning the other when they go on to specialise check that practitioners are registered and meet Dow Street in medical illustration. While there is no legal the required standards. It is also possible for Dundee, DD1 5EH requirement in the UK or elsewhere to undertake concerns to be raised against a registrant and [email protected] specialist or accredited programmes, it is ultimately for actions and sanctions to be taken generally regarded as best practice. In the UK, where necessary. Most professional bodies also medical illustrators are encouraged to join the produce guidelines in terms of professional Abstract Academy for Healthcare Science (AHCS) practice and ethics. The IMI, for example, This paper provides an overview of Medical Illustrator Register, which requires the provides a large number of guidelines to their contemporary medical illustration; the role of completion of an accredited degree programme. membership on topics as diverse as; patient the modern medical illustrator is examined, Similarly, in the US, the Commission on Accred - confidentiality, working with transgender including who they are likely to work for itation of Allied Health Education Programs patients, cultural diversity, and the ethical use of and with, as well as the range of media (CAAHEP) accredits a number of medical social media (to name just a few). These are of and technology employed. The various illustration programmes in North America. utmost importance as this is a profession whose applications of medical illustration are It should be noted that in the UK, medical members often have direct access to patients described with a focus on looking at how illustration is an umbrella term for both medical and/or their data. An understanding of the these are likely to change and develop in the photography and artistic illustration, which is responsibilities and laws around subjects such as near future. also referred to as medical art. For the purposes data protection and anatomy legislation are of this article, the terms medical illustration and therefore essential. medical illustrator will be used in place of art and Medical illustrators work for a variety of The modern medical artist. employers including organisations such as illustrator There are several professional bodies that various governmental health services, private “As art reflects culture, scientific illustration medical illustrators can join, such as the hospitals, medical schools, research institutions, reflects the findings of science and tech nol - Association of Medical Illustrators (AMI) in the publishers, as well as specialised medical illus - ogy. Science illustrators are artists in the service US and the Institute of Medical Illustrators (IMI) tration companies. More recently, medical of science. They use scientifically informed and Medical Artists Association (MAA) in the illustrators are also being employed by e-learning observation, combined with technical and UK. There are many advantages to joining a companies, software and app developers, and aesthetic skills to accurately portray a subject. professional organisation, including the sense of even VR developers. In addition, a sizeable Accuracy and communication are essential.” community and networking that comes about proportion of the profession is self-employed, Guild Handbook of Science Illustration, through conferences and regional meetings. Such working with clients such as medical profes - ©GNSI 1989, 2003 face-to-face events also provide opportunities for sionals and publishers directly.

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Media and technology Traditional media Despite the proliferation of digital media, many medical illustrators still incorporate traditional media into their work. Those who use traditional media for all or a part of their work, often cite a preference for it because of the tactile feedback it can provide along with certain effects that can be difficult if not impossible to replicate with digital media. In addition, using a medium such as watercolours can be beneficial when depicting partic - ularly graphic or sensitive material as it can “soften” the image and make it less disturbing, especially for a lay or patient audience. Medical illustrator Joanna Culley frequently uses both watercolour and pencil media in addition to digital. Figure 1 shows an example where the client requested the illustration be created in pencil so it could be used within an animation to “reflect a softer look and ‘feel’ to the illus trations… Graphite pencil was the preferred choice to depict the properties of the intrauterine birth control device and the insertion procedure along with the female anatomy so that it would seem more appealing to the Figure 1. Illustration by Joanna Culley, demonstrating the use of graphite pencil to depict the IUD and its patients watching the animation.” 1 insertion procedure along with the female anatomy in a style that would be more appealing to patients watching the animation 2D digital illustration and animation Two-dimensional digital illus tra - tions are the staple work for many medical aid in highlighting important features. e-books and iBooks, as well as in interactive PDF illustrators. They can be produced in a variety of documents. In addition, they can be used as styles and at different levels of realism for various 3D digital modelling and animation ‘assets’ (i.e., individual components that can be target audiences. They can range from simple Over the past two decades, there has been a re-purposed) when creating animations or black and white line illustrations to full-colour proliferation of 3D software enabling the creation educational games and applications. They can be realistic depictions, or even cartoons and “graphic of complex 3D models and animations. 3D viewed and interreacted within virtual reality medicine” comics. 2 models can either be based on scan data, such as (VR) and even 3D printed. In addition to 2D illustrations, 2D animations magnetic resonance imaging (MRI), computed 3D animations are very popular and, when are also useful for conveying information that tomography (CT), and surface scans or created done well, have the potential to convey a large does not require 3D spatial relationships, or for from scratch within the software itself. 3D digital amount of information in a short space of time. conveying complex concepts in a simpler models have a range of uses; they can be They are particularly useful for topics that require manner. Animations (both 2D and 3D) are best embedded as interactive models (that allow the an understanding of 3D spatial relationships and combined with a voice-over (as opposed to user to rotate, zoom, and read annotations) in for which a narrative or a sequence of events is subtitles) as this can help guide the narrative and webpages, virtual learning environments, important.

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Applications of medical resources, medical illustrators work closely with website, etc.) to use for patient information, the illustration subject area specialists in order to understand the medical illustrator needs to consider who the Medical and anatomical education key learning objectives that need to be target audience is, i.e., adults, children, the elderly, Medical and anatomical education is one of the communicated. Medical illustrators working in visually impaired, etc., since this may affect both primary applications of medical illustrations. medical education should also the format and style chosen, as well 6 Traditionally, medical illustrations have featured have a good understanding of the In terms of what the as the level of detail provided. prominently in anatomy and medical textbooks. research surrounding learning styles It could even be argued that some of these books and theories in order to apply these future holds for Other applications (such as Vesalius’s De humani corporis fabrica ) are to their work. medical illustration, In addition to the two primary known more for their artwork than for the New technologies such as one of the major applications described above, other accompanying text. Such textbooks are still a virtual and augmented reality have drivers will be types of applications also use mainstay of medical education, featuring modern also made their way into medical medical illustration. (usually digital) 2D illustrations. However, there education. These are discussed in recent and ongoing is a new wave of educational resources being more detail below. developments in Medico-legal exhibits , such as developed, aimed at engaging students who are technology. Illustrations, 3D models and used to seeking information online and via apps. Patient information animations, can all be used to clarify These include commercially available software The other primary application of often complex information for both programmes, mobile apps, e and iBooks, and medical illustration is patient information. judges and juries. Such exhibits often take the websites, as well as bespoke resources made in Traditionally, this has largely consisted of form of ‘body mapping’ where the injuries house. Such resources tend to be more engaging illustrations and designs for 2D posters and sustained are mapped onto a digital model, both for the user, often featuring 3D interactive leaflets. While these are still used, as with medical to prevent distress to the jury as well as helping models and animations in place of or in addition education, there is a growing demand for them to focus on the cause and impact of the to 2D illustrations. These can be combined information to be accessible in digital formats injury rather than the traumatic image. In with touch-screen technology, “gamification” and online. It is well documented that patients addition, radiographs and medical scans can be principles, 3 and self-testing. E-learning is a often search their symptoms or conditions in enhanced with the addition of colour or the growing field as it can provide students with order to find out more information without the creation of an illustrated interpretation. access to approved learning resources remotely. need for a doctor’s appointment. 4 The results of As such, some medical schools now employ such activities can be varied, largely because of Pharmaceutical and medical device companies e-learning technologists along with the differing quality of information utilise medical illustrations in their brochures, medical illustrators to create visual available online. However, research by websites and promotional materials for trade learning resources for use online; Briggs et al. demonstrated that when shows, etc. These tend to demonstrate, often to a Figure 2 is an example created patients were provided with access to specialised medical audience, what the drug or by the author for the high-quality digital resources (in this device is capable of as well as how to use it. University of Dundee. It is case, a series of three iBooks con - important to note, that taining written information along with Peer to peer science communication can take when creating such interactive diagrams, 3D animations, many forms but typically includes illustrations, and interactive 3D models), they no 3D models, and animations for illustrating longer felt the need to seek scientific reports, journal articles, and conference further information from exter - presentations. In addition, visualisations can be nal sources, such as the useful when trying to engage the public in internet. 5 This demonstrates medical and life science research. the importance of good quality and readily accessible patient The future of medical infor mation. For this reason, many illustration and visualisation organisations such as the NHS and Technology medical charities have their own In terms of what the future holds for medical webpages where they can guarantee the illustration, one of the major drivers will be quality and accuracy of the information recent and ongoing developments in technology. provided. Illustrations, animations, and 3D Imaging technologies such as medical and 3D models can enhance these online resources surface scanners can capture higher resolutions making them easier to understand and more of detail than ever before; likewise, modern 3D accessible to a range of audiences. modelling software packages (such as Pixologic When considering the best format (paper Zbrush, Autodesk Maya, Cinema 4D, etc.) are leaflet, interactive PDF, e-books and iBooks, able to handle ever more complex models and

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Figure 2. An example of a 3D interactive model (of the muscles of the hand), created by the author for use in e-learning, hosted online at Sketchfab.com (https://skfb.ly/6GWXx )

Created by: Dr Caroline Erolin

render objects with highly realistic material opposed to viewing them on a 2D screen. Models the digital and real world simultaneously. properties. Developments in image capture and can be displayed as life-size replicas or blown up Both technologies demonstrate great promise creation technologies are already to 100x their normal size, which for the future of medical and anatomical being com bined with new and Virtual and can be particularly useful when education in particular and may even find their evolving forms of media (some of augmented reality exploring small structures such as way into other applications such as patient which have been described those of the inner ear. In addition, information and medico-legal exhibits. Currently, above), including e and iBooks, technologies not only can objects be viewed however, most students don’t have access to good interactive PDFs, online 3D demonstrate great from an external per spec tive, but quality VR and AR HMDs at home. This may models, and mobile apps. promise for the future users can view a model, such as a change in the coming years as more affordable, In addition to these, virtual of medical and beating , from within. The standalone VR headsets (such as the recently and augmented reality tech - term augmented reality (AR) is released Oculus Quest) become more readily nologies are being investigated by anatomical education used to describe a range of available. a number of medical schools as a in particular and may experiences, including the use of means of further engaging even find their way QR codes to trigger the launch of Representation students with virtual models. 7–11 into other applications additional web-based information , Finally, it is worth saying something about VR refers to a fully immersive such as images and models, representation in medical illustration. Parker et experience using a head-mounted such as patient usually on mobile devices, as well al. 12 in their 2017 paper “A visual analysis of display (HMD) where the user information and as HMDs such as the Microsoft gender bias in contemporary anatomy textbooks” can interact with a digital object or medico-legal exhibits. HoloLens. Unlike the HMDs used explored the ratio of female and male repre - environment. One of the benefits for VR, AR HMDs show the sentation in contemporary anatomy textbooks of viewing models in VR is that they are truly 3D, virtual scene overlaid with reality. This has the and found that out of the 17 textbooks examined i.e., the user can move around them in space as benefit of allowing the user to interact with both (consisting of a total of 6,004 images), only 36%

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of the images with an identifiable sex were female. https://www.graphicmedicine.org/. imaging, a pilot study in undergraduate In addition, other forms of bias were also found, 3. Ang ET, Chan JM, Gopal V, Li Shia N. medical anatomy education. Clin Anat. including: “the visualization of stereotypical Gamifying anatomy education. Clin Anat. 22018;32:238-43. gendered emotions, roles and settings; the lack of 2018;31:997–1005. 10. Marks S, White D, Singh M. Getting up ethnic, age, and body type diversity; and in the 4. Jutel A. ‘Dr. Google’ and his predecessors. your nose: a virtual reality education tool almost complete adherence to a sex/gender Diagnosis . 2017;4:87–91. for nasal cavity anatomy. In: SIGGRAPH binary”. This is a major problem considering that 5. Briggs M, Wilkinson C, Golash A. Digital Asia 2017 Symposium on Education. these textbooks are used to educate our future multimedia books produced using iBooks ACM: New York, NY, USA; 2017. p. 1–7. healthcare workers. Rather, medical students Author for pre-operative surgical patient 11. Moro C, Štromberga Z, Raikos A, (along with nurses and other allied health information. J Vis Commun Med. Stirling A. The effectiveness of virtual and professionals) need to be prepared for the diverse 2014;37:59–64. augmented reality in health and range of patients they are likely to encounter in 6. Strong J, Erolin C. Preference for detail in medical anatomy. Anat Sci Educ. their working lives. It is the responsibility of medical illustrations amongst professionals 2017;10:549–59. everyone associated with the production of such and laypersons. J Vis Commun Med. 12. Parker R, Larkin T, Cockburn J. A visual material, including medical illustrators, to 2013;36:38–43. analysis of gender bias in contemporary consider how to address this issue in the future. 7. Erolin C, Lamb C, Soames R, Wilkinson C. anatomy textbooks. Soc Sci Med. Does virtual haptic dissection improve 2017;180:106–13. Acknowledgements student learning? A multi-year comparative The author would like to thank Joanne Culley for study. In: Studies in health technology and the kind permission to reproduce her artwork. informatics. IOS Press; 2016, p. 110–7. 8. Maniam P, Schnell P, Dan L, et al. Conflicts of interest Exploration of temporal bone anatomy Author information The author declares no conflicts of interest. using mixed reality (HoloLens): Dr Caroline Erolin is a senior lecturer and development of a mixed reality anatomy programme lead for the MSc in Medical Art References teaching resource prototype. J Vis at the University of Dundee. She is Editor-in- 1. Culley J. medical-artist.com. [cited 2020 Commun Med. 2020:43:17–26. Chief of the Journal of Visual Communication Jan 6]. https://www.medical-artist.com/ 9. Maresky HS, Oikonomou A, Ali I, in Medicine , and a member of the Institute of portfolio/frontera-pencil-medical- Ditkofsky N, Pakkal M, Ballyk B. Virtual Medical Illustrators and Medical Artists illustrations/ reality and cardiac anatomy: Exploring Association of Great Britain. 2. Graphic Medicine. [cited 2020 Jan 6] immersive three-dimensional cardiac

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