The Medical Illustrator

I am an illustrator, a drawer of pictures, if not by aptitude, then by necessity. Many of the concepts I am required to explain beg for diagrams, for pictures, for some sort of visual representation. It is amazing, for example, how many people do not know what a uterus looks like, what’s attached to it, or what lurks in its vicinity. Its exact locality is often a mystery, its constituent parts as unfathomable as the inside of a computer; even its lunar duty and occasional lapses are frequently misunderstood.

I would have thought that Google and Wikipedia would have solved all that, but they oftentimes provide riddles wrapped in mysteries inside enigmas, to mangle a trope. And besides, you need to know how to spell something before you can research it… Adenomyosis, and submucosal leiomyomata spring to mind.

I used to pride myself on my drawings until a patient that I hadn’t seen in a few years resurfaced in my office the other day. I noticed her looking at one of the drawings I keep on my desk -the standard uterus at the top of a vagina with its Fallopian tubes coming out each side like little arms. I use it to depict the myriad gynaecologic conditions from fibroids (leiomyomata) to polyps, to pregnancies… It looks for all the world like a fat T with drooping crosspieces. She, however, immediately laughed and reminded me that she had always seen it as a cow -the uterus as the body and the tubes as horns. And this from a professionally-created, printed illustration.

It reminded me of the early days when I hadn’t thought of pre-made diagrams and had trusted my skill as an artist to depict whatever I happened to be describing. I would do it on sheets of foolscap that I could tear off and hand to the patient -presumably to remind them of the details later when they were called upon to describe it to a significant other. A patient returned to see me after just such a scholarly pictorial adventure the week before, brandished the drawing and flattened it out carefully on the desk. It was the uterus and tube foray, again; it was my favorite illustration, the organ with which I felt the most artistically at home. I had, of course, over the years refined it sufficiently to feel confidence in its explanatory powers, its verisimilitude.

“My husband wondered why you drew this for me, doctor,” she said with a weak but forced smile on her face.

I glanced at the diagram, inwardly pleased that it was one of my better models, and looked up at her for an explanation.

“He says it was rude to accuse him of something you hadn’t talked to him about.” She looked down at the floor as she said it, obviously embarrassed at having to confront me like this.

I studied the diagram for clues. “I’m sorry, I don’t…”

“We looked up some of the words but we couldn’t find one of them and he was annoyed.”

The paper was crumpled and creased from storage in her pocket, but the words were clear enough: I had been trying to illustrate the reason her cervix bled when she slept with her husband and had labelled the structures and the region quite expertly I thought. I mean, what could be more clear than cervix, glands, and vagina with arrows helpfully indicating each structure? As a bonus -I often include these for further clarity for my most curious patients- I had even drawn an arrow to the top part of the vagina behind the cervix and printed (so there could be no mistaken identity) posterior fornix. Simple, concise, illustrative: a reward for them, redeemable in discussion points with whomever they were describing it to.

She had by now ventured a stare at my face, daring me it seemed, to deny the folly of my words, the error of my drawing. When she noticed my puzzled expression, she immediately withdrew her eyes and pointed to a word. “He didn’t think you should have used that word,” she said, almost afraid to say it. “Fornix,” she whispered.

When I still didn’t seem to understand, she merely shook her head -sadly, I thought- and stood up. She was still shaking her head when she left.

That I have to be more sensitive in my diagrams was the lesson, I suppose. It’s something we should all consider. For a while, I assumed it a one-off -an anomaly. It took one more example, however, to sear the need for examined delicacy onto not only my desk but my walls as well.

I had always prided myself on my examining room. As well as the requisite diplomas and awards in clear and easy view over the sink, and the pictures my kids drew on the ceiling over the examining table, diagrams festooned the walls: illustrations of IUDs, pictures of the stages of pregnancy with actual sizes of the fetal passenger as it matures, pictorial explanations of the uterus in various phases of its menstrual cycle… I even had a picture of the urinary systems of both males and females near the head of the bed -a mural Wikipedia.

The proof of my insensitivity surfaced yet again one day when a patient came storming out of the examining room fully dressed and face tense. “I refuse to lie in there under that.”  She almost spat the words at my face.

I tried to smile at her, but I have to admit I was too traumatized to pull it off successfully. “What..?” I stammered, trying to look over her shoulder at the offense, wondering if there was a tear in the paper sheet I’d given her to cover herself with.

She saw that I was looking at the table and not at the wall. “Not there,” she said impatiently. “There!” And she pointed with a shaking finger at the two urinary systems.

I took them down after she left -they’re still in a drawer along with a few other pictures I thought might offend. I left the one of the IUDs though, but I think I’m only getting away with it because I call it a Pasta Poster (they do kind of look like pasta I’m told) and make a joke of it when a patient first enters the examining room. Anxiety changes perception, I suppose, and I haven’t meant to startle already nervous people.

But I can’t help but think my new, pre-printed diagrams will add a certain veracity to my explanations. I can guide patients through the thornier parts, and steer them clear of the more confusing -and to me hidden- moral aspects of the subjects I am desperately trying to explain. I have avoided inflammatory and suggestive words wherever possible, and limited any free-hand illustrations where trespass might be construed. Autonomy acknowledged…

But I haven’t avoided risk entirely, you understand -retreat is permissible; surrender not: there is still a large black and white photograph of a man holding a baby skin-to-skin on his chest prominently displayed on the wall where the trangressive urinary systems had hung. I’m not sure of the message I’m trying to convey nor its educational value, but it avoids all the urinary pitfalls. So far it has been greeted with smiles and only one raised eyebrow. It’s a statement though, don’t you think?

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