Manga: An Underutilized Resource in Medical Education

Abstract

Manga, a popular form of Japanese comics, is an underexplored resource in medical education. Though meant as entertainment, manga has the potential to enhance learning through its application of illustrations, compelling narratives, and relatable characters. Manga may be particularly well-suited for conveying complex medical concepts and developing the empathy and communication skills of learners through patient experiences. This commentary offers a recommended reading list of manga titles that can serve as a starting point for educators interested in integrating manga into their curricula. However, additional empirical research is needed to evaluate the effectiveness of manga in medical education.

Introduction

The Japanese term “manga,” derived from the kanji 漫 (man) meaning “whimsical or impromptu” and 画 (ga) meaning “pictures,” refers to a popular form of comics and graphic novels [1]. Much like Western-style comics, manga feature panels with stylized art, speech bubbles, captions, and sound effects linked together by a narrative. However, manga differs in that it is typically printed in grayscale and read from right to left, the reverse of English language books [2]. Manga can appeal to readers of all ages and interests, including adult readers interested in more mature themes [3]. Available genres include action, adventure, science fiction, romance, comedy, education, drama, sports, horror, historical, and beyond [3, 4]. In recent years, the popularity of manga has boomed worldwide [2]. In 2024, the global manga market was valued at US $15.78 billion and is projected to continue increasing over time [5]. According to NPD BookScan, a point-of-sale tracking system used by the book industry, US manga sales even outpaced those of American comics, with over 24.4 million units of manga sold in 2021, a 160% increase compared to 2020 [6]. Despite its mass appeal and popularity, the potential applications for manga in medical education have not been fully explored.

Manga can be more accessible compared to American comics and graphic novels due to their lower cost and wider availability [7]. Printing in grayscale rather than full color reduces printing costs, a financial savings that is passed on to the purchaser [2]. In the USA, a typical manga volume (tankōbon) consists of 160 to 180 pages and costs about US $10 [7]. Conversely, single issues of serialized American comics are generally 22 pages in length and cost US $5 per issue [7]. On the lower end, American graphic novels are about 100 pages in length and cost about US $10, but page length and price can both vary significantly [7]. While both manga and graphic novels can now be found at popular booksellers such as Barnes and Noble, single or special issues of serialized comics are less widely available and must be purchased from specialty comic stores [7]. As such, manga can offer greater value and may be easier to procure if included as a required course text.

Though originally meant as entertainment, comics as a medium can be well-suited for medical education purposes. Comics rely heavily on illustrations to convey narrative and message, and as the old saying goes, “a picture can be worth a thousand words.” The characteristics of each illustration, such as shape, size, perspective, complexity, and relationship with other illustrations, can convey a plethora of details to the reader, including complex concepts [8–11]. This heavy use of images can build the reader’s observation and communication skills. As readers view each comic panel, they must interpret the non-verbal cues portrayed in the images and use the available images and texts to fill in the blanks of the story [10, 12]. Any text that is included in a comic is restricted to speech bubbles, captions, and sound effects, thereby limiting its length and complexity. Together, these characteristics make comics easier to read and digest, while still conveying complex, powerful messages [10]. The narrative and characters depicted within comics can also promote learning. In addition to making learning more enjoyable, a compelling narrative can drive readers to continue reading and link course content to memorable, emotionally charged events, supporting long-term retention [13, 14]. The inclusion of characters can also support learning by providing readers with someone they can identify with and emotionally invest in [14]. Narratives and characters can allow readers to immerse themselves in the perspective of another person, which can be particularly useful when discussing topics like patient and caregiver experiences [15]. From a practical standpoint, comics can be read and digested much more quickly than a novel of comparative length, making them appealing for both learners and educators. Educators can dedicate less curricular time to comics, allowing them to be more easily integrated into existing curricula and leaving more time for other activities [10]. Learners, particularly those who are busy, stressed, or burnt-out, can also benefit from the use of comics in medical education, as they are less burdensome than other forms of literature and academic writing. Since comics can be humorous and entertaining, they can also add some much-needed levity to didactic sessions for these learners [16].

Graphic medicine, a term originally coined by comic artist and physician, Dr. Ian Williams, refers to the use of the comics medium (e.g., comic books, graphic novels, manga) in the field of healthcare [17, 18]. As noted by Dr. Williams, the definition of graphic medicine is left intentionally broad to be inclusive of all potential applications of comics in the medical field [19]. In the case of public health, graphic medicine has aided in educating the public on topics such as skin cancer [20], HIV and AIDs [21], smoking [22], and mental health [23]. Manga specifically has also been successfully used to combat obesity by promoting healthy snack selection in youth populations [24].

Several graphic medicine studies have also demonstrated how comics can support learners and professionals in learning both the psychosocial and scientific aspects of medicine [16, 25–28]. When surveyed, the majority of medical and nursing students believed that comics could support their learning by aiding them in understanding and memorizing course content [27]. Similarly, medical residents considered a comics-based curriculum to be a high-value and enjoyable method for developing empathy and communication skills, particularly for individuals who are already busy and stressed [16]. In another study by Lesińska-Sawicka, nursing students who explored multicultural issues using comics demonstrated significantly greater cultural competence compared to their peers who learned using traditional methods [26]. The production of comics can even be beneficial for medical students and residents by providing them with a creative outlet for emotions such as frustration, helplessness, and inadequacy [28]. Though explored to a lesser extent than psychosocial and humanistic applications, some evidence suggests that comics can also enhance the learning of basic science content. Although comics are unlikely to cover basic science content to the depth needed for clinical practice, they can serve as a good starting point for foundational concepts that will be built upon later. For example, elementary school students who closely studied the educational comic series “Anna and Tommy” scored significantly higher on an anatomy knowledge quiz compared to their peers [25]. These studies demonstrate the great potential of graphic medicine in enhancing medical education, but there still remains significant room for further exploration.

As a cultural export of Japan, manga can further add to the educational benefits of graphic medicine by providing learners with insight into a different healthcare system and how another culture views health and healthcare. In the USA, the healthcare system is built upon both publicly and privately funded insurance and healthcare providers [29]. Most coverage is provided through private insurance funded by employers, with benefits packages and copayment rates determined by the insurance company [29]. State and federally funded programs, such as Medicare and Medicaid, focus on providing coverage for adults over the age of 65, people with disabilities, veterans, and low-income people [29]. This structure leaves 8.5% of the population uninsured [29]. Conversely, Japan’s healthcare system provides universal healthcare coverage for nearly the entire population, excluding undocumented immigrants and visitors [30]. Citizens and non-citizen residents are expected to pay a 30% copayment for most services, though out-of-pocket maximums and lower coinsurance rates are also available to reduce patient expenses [30]. While private insurance is available, it serves as supplemental coverage rather than the primary source of coverage [30]. In medically focused manga, these systemic differences often come to the forefront as the characters must navigate their country’s healthcare system. Exposure to these different healthcare systems and perspectives on health through manga can provide readers with insight into both the advantages and disadvantages of each system, giving them a more global perspective on healthcare and greater appreciation for different cultures.

Given the unique educational benefits that manga can contribute to medical education, its potential should be further explored. However, it may be daunting to dive into such a vast genre to identify specific works that may be applicable to medical education. To that end, the following is a recommended reading list of manga titles that can serve as a starting point for those interested in graphic medicine and in integrating manga into their curricula.

Reading Recommendations

Cells at Work!

Summary

Written and illustrated by Akane Shimizu, this manga series follows the daily lives of anthropomorphized cells as they perform their biological functions in the human body [31–36]. In each chapter, the main protagonists, an erythrocyte (AE-3083) and a neutrophil (U-1146), encounter a variety of maladies and injuries ranging from common and benign (e.g., the common cold, scrapes, allergies) to life-threatening (e.g., cancer, COVID-19, hypovolemic shock) [31–36]. These pathologies are crafted into memorable narratives with visually striking illustrations that capture the reader’s attention. Along their adventures, the protagonists meet a plethora of other anthropomorphized cells such as macrophages, platelets, eosinophils, basophils, T-cells, and B-cells, often resulting in humorous or dramatic interactions [31–36]. As new cells, organs, and physiological processes are depicted in the manga, brief captions also provide the reader with accurate details about their real-life counterparts [31–36].

Cells at Work! was serialized monthly from 2015 to 2021, with its chapters published in six tankōbon volumes [31–36]. In 2018, the total print run of the first five volumes had already reached 1.5 million copies in Japan alone [37]. Due to its popularity, Cells at Work! also received multiple spin-offs including Cells at Work!: Bacteria, Cells at Work!: Code Black, Cells NOT at Work!, Cells at Work and Friends!, Cells at Work!: Baby, Cells at Work!: Lady, Cells at Work!: White Brigade, Cells at Work!: Platelets, Cells at Work!: Illegal, Cells at Work!: Medicine, and Cells at Work!: Cat [38]. Each spin-off focuses on a specific topic within cell biology, anatomy, and physiology, further increasing the breadth of content covered in the manga series. Additionally, both Cells at Work! and Cells at Work!: Code Black have been adapted as animated television series (anime) [39, 40]. A live-action adaption of the main Cells at Work! series is also currently in development and set for release in December 2024 [41].

Potential Applications in Medical Education

Cells at Work! is a prime example of how manga can enhance learning in medical education. Each character’s design closely reflects the appearance and functions of their real-life cellular counterpart. These details not only make each distinct and visually appealing, but may also aid the reader in recalling the form and function of each cell. For example, the basophil is dressed in heavy blue overcoats and face coverings, which references the dark, basophilic granules that obscure the cell’s nucleus when stained and viewed under microscopy. Throughout the manga, dry medical information is also transformed into exciting narratives, making the information much more memorable for the reader. For example, an eosinophil (portrayed as a young woman in pink coveralls) feels inferior to her childhood friends, the other leukocytes, because she struggles to combat bacterial infections. However, her time to shine comes when the other leukocytes are helpless to defeat a foodborne parasite, which she is specialized to fight against. This plotline highlights the eosinophil’s specialization in destroying parasites and shared lineage with other leukocytes. Learners may find these aspects of Cells at Work! useful in retaining and recalling their knowledge of cells and cellular processes.

I’m a Terminal Cancer Patient, but I’m Fine

Summary

In this autobiographical manga, Hilnama, the author and illustrator, recounts her personal battle with terminal cancer [42]. Within the first few pages, Hilnama establishes her experience with cancer was unlike what she expected from television [42]. She initially suffered ambiguous abdominal pains, which force her to begin navigating the Japanese medical system in search of a definitive diagnosis [42]. After consulting multiple doctors and undergoing several diagnostic procedures, Hilnama eventually receives her diagnosis: stage IV colon cancer [42]. Soon afterward, she is admitted to the hospital and undergoes both surgery and chemotherapy, diminishing both her physical and mental well-being [42]. As new medical concepts and procedures are introduced by her doctors, Hilnama provides readers with additional explanations and illustrations, which were reviewed by physicians for accuracy and supported by citations [42]. Though her circumstances are dire, Hilnama manages to add optimism and levity to her story. During her diagnosis and treatment, the support of her chosen family and friends as well as her medical professionals helps her remain positive and hopeful. She also does not shy away from retelling the more awkward situations she encounters throughout her diagnosis and treatment such as her colonoscopy [42]. These aspects make Hilnama’s memoir a heartfelt, engaging, and informative read for learners interested in the experience of patients with terminal illnesses.

Potential Applications in Medical Education

I’m a Terminal Cancer Patient, but I’m Fine can serve as an excellent resource for providing learners with insight into the patient perspective. Throughout the manga, Hilnama meticulously documents her thoughts and feelings at every stage of her diagnosis and treatment. This includes her frustration with the medical system, uncertainties with her diagnosis, financial stress, confronting past family abuse, and the physical pain from treatment and recovery. On the more positive side, she highlights the invaluable support from chosen family and friends, the compassionate care from healthcare providers, and the encouragement from her social media followers. Hilnama also underscores the importance of maintaining normalcy during such an abnormal time and offers guidance on supporting patients with cancer or terminal illnesses. For learners without firsthand experience of such conditions (either themselves or with a loved one), these authentic accounts may help learners appreciate the struggles of the patients under their care and empathize with them more deeply. Additionally, Hilnama’s advice and warnings throughout her journey can assist medical professionals in better preparing their patients for the challenges ahead during treatment and recovery.

My Alcoholic Escape from Reality; My Pancreas Broke but My Life Got Better

Summary

In these two installments of Kabi Nagata’s autobiographical manga series, the award-winning author and illustrator candidly recounts her battle with alcoholism and how it resulted in acute pancreatitis and extended hospitalization [43, 44]. Nagata begins by explaining her history of mental illness and how she progressed from completely abstaining from alcohol to consuming liters of alcohol daily [43, 44]. For her, alcohol had become inextricably interwoven with her adult identity and served as a coping mechanism for stress, guilt, and social anxiety [43, 44]. After years of unchecked alcohol consumption, she suddenly experienced severe abdominal pains and was rushed to the hospital where she was diagnosed with acute pancreatitis [43, 44]. Following stabilization, Nagata learned she would need weeks of hospitalization and was warned that without significant lifestyle changes—including quitting alcohol and avoiding high-fat foods—her health would continue to deteriorate [43, 44]. Throughout her hospital stay, Nagata vividly describes the physical agony of her pancreatitis, the toll of the treatment on her physical and mental well-being, and her frustrations with the medical system [43, 44]. Once discharged, Nagata continues to grapple with her addiction, oscillating between adopting a healthy lifestyle and relapsing into alcoholism [43, 44]. After multiple unsuccessful attempts and another bout of pancreatitis, she eventually achieves lasting progress with the support of her family and addresses the root causes of her alcoholism. Rather than relying on alcohol to make life bearable, she finds purpose in her life through her parents [44]. Abstaining from alcohol remains an ongoing process with benefits and drawbacks, but she resolves to continue working on herself [44].

Nagata’s other autobiographical manga include My Lesbian Experience with Loneliness (winner of the Harvey Award for Best Manga), My Solo Exchange Diary, My Wandering Warrior Existence, and My Wandering Warrior Eating Disorder [45]. These installments detail other aspects of her life such as her experiences with loneliness, eating disorders, and mental health, and as a lesbian, which may be useful for discussion of other topics beyond those addressed in My Alcoholic Escape from Reality and My Pancreas Broke but My Life Got Better.

Potential Applications in Medical Education

As Nagata comes to realize, “If pain has a value, it’s in the experience. The lesson” [43]. Much like Hilnama’s memoir, Nagata’s autobiographical manga offers learners insight into the patient perspective and imparts the lessons she learned while grappling with addiction and other mental illnesses. For one, Nagata’s candid narrative humanizes addiction, helping learners view it as a behavioral disorder rather than a character flaw. Despite her awareness of her addiction and the problems it caused for both her and her loved ones, breaking free proved incredibly challenging. On several occasions, she finds temporary success with quitting or limiting alcohol consumption but relapses due to various life stressors. Even as she is hospitalized and faces lifelong medical complications, she withholds details about her alcohol consumption and continues to drink, albeit with great reluctance and guilt. After confessing the true extent of her alcoholism to the reader, Nagata admits, “I can’t just tell the doctor all that.” [43]. Like many substance abuse issues, she conceals the truth about her addiction out of fear of judgment, scolding, or embarrassment [43, 44]. Reading Nagata’s memoirs may help learners appreciate the extent of what patients with addictions or other mental illnesses contend with beyond their brief hospital encounters. This understanding may enable learners to empathize more fully and offer more non-judgmental care. Nagata’s works illustrate the importance of holistic patient treatment, and developing a treatment plan that considers both the patient’s physical and mental health.

Manga, as a form of graphic medicine, holds great promise for enhancing medical education. By leveraging its compelling visual narratives and memorable characters, manga can captivate readers while effectively imparting them with valuable lessons that encourage empathetic medical care. With manga’s growing global popularity comes an expanding catalog of relevant material that educators can and should harness to enrich medical training programs.

Declarations

Competing Interests

The author declares no competing interests.