Using Graphic Medicine to Explore Perceptions of Professionalism in Early Medical Education: A Pilot Study

Abstract

Background

Lapses in professionalism remain a critical concern in medical education, with early unprofessional behaviors linked to adverse outcomes in clinical practice. Traditional interventions focus on reflection and mentorship, but alternative approaches such as graphic medicine may provide new opportunities for awareness and discussion.

Objective

This pilot study sought to evaluate comics depicting professional and unprofessional behaviors as a tool for measuring medical student awareness of professionalism, and assess perceptual discrepancies between students and supervising faculty.

Methods

Faculty at the University of Louisville School of Medicine provided examples of professional and unprofessional student behaviors. These examples were transformed into comics using ChatGPT, each depicting both classroom and clinical contexts. M2/M3 medical students and supervising faculty were then asked to rate the professionalism depicted in each comic using a Qualtrics-based survey and to provide qualitative feedback on the graphic medicine approach.

Results

Faculty (N=14) and students (N=20) differed in their perception of professionalism, with students rating unprofessional behaviors as less extreme in comparison. Conversely, professional behaviors were rated more positively by faculty than by students. While both groups considered the comics realistic and engaging, participants questioned their effectiveness as a learning tool in the survey format. Students also completed the survey more quickly than faculty on average, suggesting less engagement with the material in its existing survey format.

Conclusion

Discrepancies in perceptions of professionalism between students and faculty may explain lapses in medical professionalism exhibited by M2/M3 students at the University of Louisville. Though provided in survey format, graphic medicine may serve as an engaging entry point for discussion, through integration into small-group or reflective learning environments, for effective prevention of medical professional decline.

Plain Language Summary

Lapses in professionalism remain a critical concern among medical students, with early unprofessional behaviors linked to undesired outcomes in clinical practice. This study sought to evaluate the use of comics as a way to measure medical professional awareness among students and the gap in professional perception between students and their supervising faculty. Specifically, students and faculty were provided with comics depicting professional or unprofessional behavior in the classroom that were considered to have clear translation to clinical practice. Recipients of these comics were then asked to simply rank each behavior on a numeric scale in an online survey platform, permitting statistical evaluation of responses. Results pointed to a trending gap in perception between students and faculty, with unprofessional behaviors deemed less extreme (toward the middle of the numeric scale) by students than their supervising faculty. While both groups deemed the comics realistic and engaging, participants questioned their effectiveness as a learning tool in the existing survey format, suggesting comics may serve as an effective prevention of medical professional decline when presented in small-group discussion among the students and faculty.

Introduction

Medical professionalism is a cornerstone of safe, effective, and compassionate patient care. Lapses in professionalism have been directly associated with adverse outcomes, medical errors, and poor patient safety^1,2 Alarmingly, national reports indicate that these lapses may emerge as early as medical school,³ with behaviors observed in the classroom and training environment predicting later professional conduct in clinical practice.⁴ Previous studies suggest that interventions aimed at fostering self-reflection can mitigate this decline³ by increasing medical professional awareness, or the capacity to consciously recognize, reflect upon, and regulate how one’s values, behaviors, emotions, biases, responsibilities, and interactions influence team dynamics and patient care. In response, medical education has increasingly emphasized reflective practice and professional identity formation, including written narratives or discussion-based exercises. However, these reflective practices may not fully capture the emotional complexity, ambiguity, and interpersonal tensions that shape professional development.

Graphic medicine, defined as the use of comics and other visual media to explore healthcare experiences—offers a unique medium through which the complex dimensions of professionalism can be examined. By combining text, imagery, metaphor, and narrative structure, graphic medicine can communicate emotional nuance and embodied experience in ways that conventional reflective methods may overlook. The visual format encourages close observation, perspective-taking, and critical self-reflection while also making space for ambiguity and contradiction- features that are central to real-world clinical encounters. Historically, graphic medicine has been employed to promote reflection, empathy, and professional growth, with roots tracing back to visual depictions of illness and caregiving during back to World War I.⁵ It has since emerged as a method of communicating difficult-to-convey medical concepts to patients, such as extravasation that can occur during chemotherapy.⁶ More recently, it has also been deemed a valuable pedagogical tool in medication education, helping learners engage with difficult topics such as moral distress and communication barriers.⁷

As medical educators seek more effective and humanistic approaches to cultivating professionalism, graphic medicine provides a compelling framework for fostering reflective capacity and deeper engagement with the lived realities of healthcare. Yet, despite its success in patient education and narrative medicine, the potential application of graphic medicine to professionalism training in medical education remains underexplored. In this pilot study, we sought to address two questions surrounding graphic medicine in the professionalism arena:

1. Can medical student awareness of professionalism be measured (and potentially improved) using comics depicting realistic examples of professional and unprofessional behavior?

2. Do discrepancies exist between student and faculty perceptions of these behaviors that may help explain the persistence of unprofessional mannerisms exhibited during medical training?

Materials and Methods

Study Design

This cross-sectional survey study was conducted at the University of Louisville School of Medicine and approved by the University Institutional Review Board (#23.0077).

Comic Development

Faculty were asked to provide examples of professional and unprofessional student behaviors encountered in recent years. Four representative examples were selected and adapted into comics using the AI platform ChatGPT.⁸ Each behavior was depicted in two contexts: 1) during the learning process (eg, classroom, panel 1) and 2) its translation to clinical practice (panel 2). For example, the prompt for what is referred to here as “Distraction”, was worded as “Generate a comic illustrating a medical student distracted during class in one panel and then distracted during an interaction with a patient in the second panel”. Comics were intentionally vague in order to provoke thought as to the context surrounding the scenario and to promote discussion during the time of the survey as well as future applications.

Participants and Recruitment

Participants included second-year (M2) and third-year (M3) medical students, as well as faculty who directly supervise these learners (including faculty described above). Students and faculty were invited via institutional Email to participate in a voluntary, anonymous survey.

Survey Instrument

Comics were presented through the Qualtrics survey platform, and participants were permitted as much time as desired to complete the survey and post-survey questionnaire. Participants were asked to rate each comic on a 5-point Likert scale according to perceived professionalism (1 = “Highly Unprofessional”, 5 = “Highly Professional”). A post-survey questionnaire assessed perceived realism, engagement, and effectiveness of the graphic medicine approach on a similar scale of 1–5 (1 = “Not at all”, 5 = “Extremely likely”). Demographic information was also collected.

Data Analysis

Quantitative data from the Likert scale ratings were analyzed for differences between student and faculty responses (Figures 1–4). Qualitative feedback was thematically reviewed to assess perceptions of the graphic medicine approach (Figure 5).

Figure 1.

“Distraction”. Distraction in the form of shopping is depicted in the context of the classroom (left) and in the clinic (right for the same individual at different stages of their career. This comic was presented in a survey (without title) to students and supervising faculty, who were asked to rank the comic according to perceived professionality. Results of this ranking are presented below the illustration. Comic was adapted from ChatGPT.⁶

Figure 2.

“Unconstructive feedback”. Feedback is depicted in the context of a faculty evaluation (left) and communication with an individual patient (right) for the same individual at different stages of their career. This comic was presented in a survey (without title) to students and supervising faculty, who were asked to rank the comic according to perceived professionality. Results of this ranking are presented below the illustration. Comic was adapted from ChatGPT.⁶

Figure 3.

“Unpunctuality”. Late arrival is depicted in the context of a Standardized Patient Encounter (left) and surgical procedure (right) for the same individual at different stages of their career. This comic was presented in a survey (without title) to students and supervising faculty, who were asked to rank the comic according to perceived professionality. Results of this ranking are presented below the illustration. Comic was adapted from ChatGPT.⁶

Figure 4.

“Learning from mistakes”. Professional growth in the form of learning from past mistakes is depicted in the form of the classroom (left) and clinic (right) for the same individual at different stages of their career. This comic was presented in a survey (without title) to students and supervising faculty, who were asked to rank the comic according to perceived professionality. Results of this ranking are presented below the illustration. Comic was adapted from ChatGPT.⁶

Figure 5.

Post-survey questionnaire gauging effectiveness of graphic medicine approach among students (black) and faculty (red). X-axis depicts ranking from 1–5.

Results

Participant Characteristics

Faculty (N=14) were predominantly female (57.1%), non-Hispanic (100%), of White or Asian descent (100%), aged 35–54 years (78.6%), and most held a graduate or professional degree as the highest achieved educational level (92.9%). Students (N=20) were predominantly female (47.4%), non-Hispanic (84.2%), of White or Asian descent (78.9%), aged 18–34 years (100%), and most reported a Bachelor’s degree as their highest level of education (63.2%). Additional participant characteristics are provided in Table 1.

Table 1.

Faculty and Student Participant Characteristics

	Characteristic	No. (%)		Characteristic	No. (%)
Faculty (N=14)	Age		Students (N=20)	Age
	18–24 years:	1 (7.1%)		18–24 years:	2 (10.5%)
	25–34 years:	0 (0%)		25–34 years:	15 (78.9%)
	35–44 years:	7 (50%)		35–44 years:	0 (0%)
	45–54 years:	4 (28.6%)		45–54 years:	0 (0%)
	55–64 years:	1 (7.1%)		55–64 years:	0 (0%)
	65+ years:	1 (7.1%)		65+ years:	0 (0%)
	Gender			Gender
	Female:	8 (57.1%)		Female:	9 (47.4%)
	Male:	5 (35.7%)		Male:	7 (36.8%)
	Non-binary/third gender:	0 (0%)		Non-binary/third gender:	0 (0%)
	Prefer to self-describe:	0 (0%)		Prefer to self-describe:	1 (5.3%)
	Prefer not to say:	1 (7.1%)		Prefer not to say:	0 (0%)
	Hispanic/Latino origins			Hispanic/Latino origins
	Yes:	0 (0%)		Yes:	1 (5.3%)
	No:	14 (100%)		No:	16 (84.2%)
	Race/Ethnicity			Race/Ethnicity
	Black or African American:	0 (0%)		Black or African American:	2 (10.5%)
	White:	12 (85.7%)		White:	13 (68.4%)
	Asian:	2 (14.3%)		Asian:	2 (10.5%)
	Native Hawaiian or Pacific Islander:	0 (0%)		Native Hawaiian or Pacific Islander:	0 (0%)
	American Indian/Native American or Alaska Native:	0 (0%)		American Indian/Native American or Alaska Native:	0 (0%)
	Other:	0 (0%)		Other:	0 (0%)
	Prefer not to say:	0 (0%)		Prefer not to say:	0 (0%)
	Highest Education			Highest Education
	Bachelor’s degree	0 (0%)		Bachelor’s degree	12 (63.2%)
	Graduate or professional degree	13 (92.9%)		Graduate or professional degree	5 (26.3%)
	Prefer not to say	1 (7.1%)		Prefer not to say	0 (0%)

Perceptions of Professional vs Unprofessional Behaviors

Unprofessional behaviors encountered by faculty in recent years were provided in the following forms: 1) “Distraction” in the classroom, specifically by electronic media (eg, laptop; Figure 1); 2) “Unconstructive feedback” provided to teaching faculty and staff in the form of evaluations (Figure 2); and 3) “Unpunctuality”, specifically pertaining to arrival of students to Standardized Patient Encounters (Figure 3). Additionally, one scenario representing professional behavior in the form of “Learning from mistakes” was provided, depicting a student proactively engaging with teaching faculty to understand incorrect answers (Figure 4). Each of these scenarios occupied one comic panel or set of panels to the left, with a second panel or set of panels to the right illustrating the risk of perpetuating these unprofessional behaviors into the clinic. In the right-hand panels, students were represented as older versions of themselves in the clinical setting, demonstrating related behaviors in that clinical context.

Students consistently ranked the unprofessional behavior examples (distraction, unconstructive feedback, and unpunctuality) as less extreme, or less unprofessional, than faculty (Figures 1–3). Similarly, the single professional behavior example (“learning from mistakes”) was rated as more professional by faculty than by students.

Perceptions of Graphic Medicine

Both students and faculty described the comics as realistic and somewhat engaging (Figure 5). However, effectiveness ratings among all participants were modest (Figure 5), including recommendation for inclusion in educational courses, effectiveness in improving awareness of professional classroom communication, likeliness of applying what was learned, immediate influence on communication behavior (average scores less than 3). Additionally, the clarity of the examples depicted in the comics was considered low (average score less than 3).

Survey Engagement

Students tended to spend less time completing the survey compared to faculty, raising concerns about superficial engagement with the material (Figure 6).

Figure 6.

Duration of time spent on survey by students and faculty. Duration (seconds) included time from initiation to completion of survey.

Discussion

This pilot study highlights a meaningful gap in perceptions of professionalism between medical students and their supervising faculty. Students appeared less attuned than faculty to the severity of unprofessional behaviors, which may act to explain previous findings of professional decline in the medical education setting^3,9 and is in opposition to the notion of complete awareness coupled with refusal to act. However, the less time spent in completing the survey and comments on lack of clarity and understanding of the comics by the students suggests the intentional ambiguity in the comic depictions had the desired effect of ambiguity, but ambiguity in the absence of guided discussion translates to less time spent in understanding and evaluating the nature of the comic. Hence, while the use of graphic medicine as a reflective tool in this study demonstrated its utility in measuring this absence of awareness its potential as an effective intervention may be limited by its survey-based implementation. Rather, comics may function best as a catalyst for discussion within small-group or reflective settings, where learners can process the material more deeply. However, this setting comes with its own set of limitations, as the medical curricula are already densely packed, and professionalism teaching already competes with biomedical content for instructional time. Additionally, facilitating discussions around graphic narratives requires different interpretive and reflective skills than standard lecture-based teaching and discussion, which may require additional faculty development and training. This time may be offset by the reduced time taken for material production, owing to availability of artificial intelligence tools for comic generation. We would like to note that, while less time-consuming than personnel training, comic generation in the OpenAI tool required many iterations for production of multi-panel comics that demonstrated across-panel consistencies in character and language, despite highly specific prompts. Improvement in these AI tools would be ideal for future research and/or curriculum integration aiming to incorporate an increased number of topics of interest.

Lastly, whereas cultural influences on professionalism may be at play,² the study group described herein, particularly faculty, was demographically homogeneous (eg, 84–100% non-Hispanic), limiting the generalizability of the findings to larger faculty bodies. A larger sample size and more diverse demographic representation than provided here is needed for further exploration of cultural influences in professionalism perceptions, as well as for the rigorous assessment of graphic medicine as a tool to measure medical professional awareness and its potential as an educational aid.

Conclusions

Medical professionalism has been described as vulnerable to decline during the formative years of medical school. Discrepancies in perception between students and faculty, characterized by a lack of awareness in the former, may hinder early recognition and correction of unprofessional behavior. Graphic medicine offers an innovative, engaging medium for measuring and, potentially raising, awareness of professionalism, though the latter may require incorporation into interactive learning formats to achieve meaningful impact.

Ethics Approval and Informed Consent

This study was reviewed and approved by the by the University of Louisville Institutional Review Board (#23.0077). Participation in this program was optional, and informed consent was waived for this project because it was part of an educational quality improvement program. Rather than consent documentation, participants received an informational letter describing how data from the activity would be used for evaluation and may be additionally used for research.

Disclosure

The authors report no conflicts of interest in this work.