The Clinical Excellence Podcast

MK Czerwiec, a nurse, cartoonist, educator, and co-founder of the field of Graphic Medicine, discusses her work and the utility of graphic medicine.

What is The Clinical Excellence Podcast?

The Clinical Excellent Podcast, sponsored by the Bucksbaum Institute for Clinical Excellence is a biweekly podcast hosted by Drs. Adam Cifu and Matthew Sorrentino. The podcast has three formats: discussions between doctors and patients, discussions with authors of research pertinent to improving clinical care and the doctor-patient relationship and discussions with physicians about challenges in the doctor-patient relationship or in the life of a physician.

[00:00:00] Dr. Cifu: On today's episode of The Clinical Excellence Podcast, we have MK Czerwiec talking about graphic medicine.

[00:00:09] MK Czerwiec: The ones I'm focused on when I teach about it is four roles, like as an educational intervention, as a tool for reflection, as you mentioned, and you know, as a tool for research, which actually is a whole interesting area, like, comics have an interesting place to play in drawing, having people draw in research, and then advocacy, kind of putting all those together to advocate for whether it's better care or better maternal outcomes or whatever, you know, a comic can tell a story, bring a narrative and also bring data and actually like, do really interesting work in advocacy.

[00:00:48] Dr. Cifu: We're back with another episode of The Clinical Excellence Podcast sponsored by the Bucksbaum Institute. On this podcast, we speak to patients and doctors and today a nurse, about all aspects of excellence in clinical medicine. I'm Adam Cifu, and today I'm joined by MK Czerwiec. Ms. Czerwiec is a nurse, cartoonist, educator, and co-founder of the field of graphic medicine.

Her work attempts to use the medium of comics to help make challenging situations easier to navigate. She is the creator of Taking Turns: Stories from HIV/AIDS Care Unit 371, which for me is up there with Can't We Talk About Something More Pleasant? And Fun Home as graphic masterpieces. She's also co-author of Graphic Medicine Manifesto, editor of the two-time Eisner Award-winning Menopause: A Comic Treatment, which I actually gave to my wife as a birthday present, so we'll see how that goes, and the comic editor for the journal Literature and Medicine.

MK regularly teaches graphic medicine at Northwestern Medical School, the University of Illinois, and the University of Chicago. She has served as a Will Eisner fellow in Applied Cartooning at The Center for Cartoon Studies in White River Junction, Vermont, and as the inaugural fellow of the Kingfisher Institute at Creighton University.

MK, thanks so much for joining me today. Really appreciate it.

So you seem like you have a very interesting history. So before we sort of talk about anything else, I just wanted to kind of hear a little bit about, you know, how you ended up in nursing, how you ended up in graphic medicine, how those things all work together for you.

[00:02:22] MK Czerwiec: Yeah, it's funny 'cause you look back on it and it feels like a straight line but of course, it was a lot of jumping around. And it starts with like, I was raised to be a nurse by a nurse and my father had had strokes when I was growing up. In fact, my senior year of high school, a real debilitating stroke. So we were full-time caregivers. And so I had all those skills but the last thing in the world I wanted to be was a nurse. I wanted to study the humanities. I wanted to study the arts and literature. And so I did that. I went to my undergraduate education and got my degree in English and philosophy. And then I was like, "Oh, I have to work, outside of the home." So yeah, so then I sort of realized like, well, I have all these skills, you know, there's going to be... I mean, I was so focused on stories, like I wanted to write stories and then I realized I actually just liked having written stories rather than writing stories. So I thought, well, healthcare, you're close to a lot of amazing stories and I can be helping people in the process. And I have these... So that's my indirect route to nursing. So nursing was a second.

[00:03:28] Dr. Cifu: And did you feel like when you started in nursing, I mean, I think all the fields in medicine, right? And for us, both nursing and doctoring, you know, so many of the people in the field are people who've thought about it forever, right? Been exposed to it at home, whatever. It's like, "Ah, yeah, I decided in sixth grade I was going to be a nurse." With your background, when you got into nursing, did you sort of feel like you had, you know, I don't know, a shared calling to your colleagues or did you feel kind of different to begin with?

[00:03:57] MK Czerwiec: I think I felt different in that I'd been on the other side of the equation, right? As a family member. And I think that informs the care and the approach all through my career.

[00:04:09] Dr. Cifu: Right, right. Made you better or made you worse?

[00:04:11] MK Czerwiec: Made me more sensitive, I think. Yeah, sensitive to just what we weren't hearing when we ask questions, with questions we weren't asking. What is, you know... Thinking about that person in the bed or in the clinic as part of a system rather than just a person standing there because I know there, you know, there's a family and all that. So it makes me sound more noble than I intend to be but yeah, it was more like understanding more of the complexity, I think.

[00:04:40] Dr. Cifu: Right. Now, it's interesting I feel like I got there, but I got there much later in my career as, you know, really, my close family members inevitably got sick. And that's when all of a sudden I realized like, boy, that look I see on that, you know, person's adult child's face, I know what that means, but I was kind of lacking that for, I don't know, the first, you know, 15-20 years of my career.

[00:05:04] MK Czerwiec: Right, right. And you know, as I say that maybe that's okay, right? Because you can focus on what needs to happen. Yeah, and so I think there's ways in which it was a little bit of a detriment, but I hope to think there's ways, especially during the AIDS crisis when there wasn't much we could do that I think that was helpful.

[00:05:23] Dr. Cifu: And then the cartooning, it sounds like maybe that was not like an undergraduate thing, but something that came later?

[00:05:27] MK Czerwiec: No, not at all. I really, you know, I was not the kid at school who could draw. I was told, put those crayons away, put the markers away. You're making your pages all fancy, but the content's not there, right? So, yeah, I was told to leave that behind and use words, and I was pretty good with words, and so, okay, I'll do that but when I was working during the height of the AIDS crisis here in Chicago, certainly, I really just struggled, like I didn't get in my nursing education how do we deal with everything we bear witness to, right? Like Rachel Naomi Remen has said to expect that you can bear witness to so much suffering and not suffer is like thinking you can walk through water without getting wet.

[00:06:10] Dr. Cifu: Absolutely.

[00:06:11] MK Czerwiec: Right? And so that's what I was looking for. And I had that handy, original kind of grounding in literature and art and so out of desperation, you know, I had been writing in journals. And then that was just too hard and I think too soon and too traumatizing and then I had been painting with literally no training just these screens I would make to like memorialize people I really cared about, but then I felt like those images alone didn't tell the whole story but then the thing about like one day I just sat down and made a little drawing of myself and put over it like I feel miserable and then put a box around it. And I put another box and then I just kept going and it... And I mean literally, it was I worked three to eleven shifts, this is around ten o'clock in the morning I had a terrible night the night before and I needed to figure out a way to like be present to my patients that day. And that's what I was struggling for and I found it because there was something about in mix of image and text in sequential fashion that took me to a place of hope. And it was exactly what I needed, so I just kept going.

[00:07:12] Dr. Cifu: It's interesting, so my next sort of scripted question for you was going to be about, you know, having seen a lot of your work, it seems like it combines both, you know, reflection, sort of education of people, and maybe even a way to kind of transmit true information that people need in their healthcare. So listening to you talk, it's interesting that it sort of came almost naturally from reflection, but I assume you see graphic medicine as potentially having many more roles, is that...?

[00:07:45] MK Czerwiec: Well, I've been teaching this for about 15 years, and lately I've really focused on, and I know there are more, but the ones I'm focusing on when I teach about it is four roles, like as an educational intervention, as a tool for reflection, as you mentioned, and I, you know... As a tool for research, which actually is a whole interesting area, like comics have an interesting place to play in drawing, having people draw in research, and then advocacy, kind of putting all those together to advocate for whether it's better care or better maternal outcomes or whatever, you know, a comic can tell a story, bring a narrative and also bring data and actually like do really interesting work in advocacy.

[00:08:23] Dr. Cifu: When you talk about research, the thing that immediately comes to mind in my critical appraisal course, we always read this pediatric neurology migraine article where the kids draw their headaches and it's like, how diagnostic is that? Is that sort of the kind of thing you think about or how do you think of using them?

[00:08:42] MK Czerwiec: Yeah, I've seen those kinds of articles. There's one about heart attack like if the person draws the heart attack, right? They've got poor outcomes, right? Right. So yeah, I actually in teaching this over the years have moved away from those. That's not so much what I'm interested in. I'm interested in, um, so I'll give an example.

I was invited to be a part of a festival, believe it or not, in New York, that was looking at getting people to talk about dying and death, right? This kind of advanced directives conversation when they're perfectly healthy, right? When they should be having it, and could drawing be a way into it. So I have this prompt where I just asked people to hold paper in a landscape orientation and I say, "Draw a good death."

I don't say 'your' death. I say draw 'a' good death but a lot of times people pivot to theirs, right? And then we can have this conversation around that. And if they're there, it would be fantastic if they were there with their child or whatever but, and then we sort of joked and someone at the table said like, "Well, I'm just going to give him this drawing and tell him, get me as close to this as you can." You know?

[00:09:43] Dr. Cifu: This is my living will, right?

[00:09:44] MK Czerwiec: It is, exactly because what they draw... Like, who's there? Who's not there? Where are you? Outdoors? Indoor? Is there music? Is there, like... And basically, you're creating this tableau that you feel is ideal. And yeah, it's hard. It's hard to get to that but at least knowing what those wishes are. People don't draw themselves necessarily, like, on a ventilator with a lot of medical intervention. And that's not to say those aren't good things. Those are great things but it's a way to get that conversation. Now, I haven't done this, but say I could gather up all those and we could just pull some data out of there, right?

[00:10:18] Dr. Cifu: Is there a barrier? I mean, people are so self-conscious about, you know, their artwork, whatever it is. I think it's partially, you know, failure of our education, but putting that aside, is that a hard barrier to get over, or mostly if you're like, "Hey, this is just for us," people are willing to express?

[00:10:38] MK Czerwiec: Yeah, it depends on the group I'm working with, but for the most part, there's a book that a couple of colleagues and I put together called the Graphic Medicine Manifesto. My chapter in that book is called the Crayon Revolution. And that's my secret is that I think if, I mean, I have medical students, I have those people in the workshops, all just using crayons because it takes us back to a place when we knew we could draw. We didn't worry. It takes the pressure off. No one's expecting perfection from crayons. And then I kind of, you know, one of the things I'm very influenced by the artist, Linda Berry, who very much was about like, you know... I just used this in class the other day because people will start out with, "Well, I can't draw but..." Right? Or "This is really ugly, but..." And I say, you know what Linda Berry says, it's like, think of the thing you create. It's like, what if this was your child? Treat it well. You wouldn't say that, like, "This is my kid, he's really ugly but here you go." Right? You wouldn't. Treat what you make with respect, because no one else could do exactly what you just did, no matter... And we all have a visual language, right? It may be stick figures, but that's okay. It does the work.

[00:11:41] Dr. Cifu: I also think crayons are good, because crayons, I think, actually bring the best artists down a little bit.

[00:11:47] MK Czerwiec: Oh, that's true. I hadn't thought of that.

[00:11:48] Dr. Cifu: Nobody can do perfection with crayons.

[00:11:50] MK Czerwiec: That's true.

[00:11:50] Dr. Cifu: So it probably works.

[00:11:51] MK Czerwiec: That's actually helpful because I'm teaching medical illustration students now whose skills are like insane. What can I bring to this? But yeah, it actually, part of what I have to get them to do is back it up.

[00:12:02] Dr. Cifu: Exactly, exactly. You do not have to work for three months on this drawing, right? That's wonderful. So I think in the introduction I already tipped my hat to how incredible I thought your book, Taking Turns, was for me. You know, a lot of this was just because it was a great book and I think it's... You know, I recommend it to everybody and I've given away a few copies.

I also found it very personal to me, reading it, I kind of assumed that you and I both entered medicine at the same time, you in Chicago, me in Boston, taking care of kind of similar populations at really like the worst time, death wise, during HIV. And as I read the book, I was struck that you seem to deal with it by, you know, really getting involved with the people in the community.

I think I dealt with it by, you know, protecting myself, hunkering down with the medicine and saying, "God, I got to sort of stay away from getting attached to these people who are all my age and look like me and it's going to kill me." So I wanted to ask like, is that true? And what do you think led you into that and, you know, would you criticize me for my approach?

[00:13:14] MK Czerwiec: No because as I hear you tell that story, I think about the medical residents on our unit at the time. And I mean, I teach medicine, of course, in... I don't teach medicine, but I teach in a medical environment and I get like the role you were in, and the ways in which having that approach served the role and the time in your career that you were in, right?

I was in a very different place. I had graduated, it wasn't like I was a nursing student, like I had graduated, right? I was in my, this would be like if we had nursing residency, like, but I didn't have to go anywhere, I was staying there. And also there's part of it too is the role of the nurse, 24/7, right? But I know you guys were there 24/7 too, but literally at the bedside.

[00:13:53] Dr. Cifu: Totally different, yeah.

[00:13:54] MK Czerwiec: But also we could leave for eight or 12 hours, right? And then come back and do it. So I think the role is very different. And the goals of care, right? So the goal in your situation would be to you know, provide the people who are staying at the bedside with what they need, here's the order for the morphine, okay, we can up them, right? And just kind of providing that to be able to deliver that 24/7 care as best as possible.

[00:14:22] Dr. Cifu: That's neat to hear. And we've talked a little bit before we kind of got on mic about this and that I've been spending a lot of time sort of reflecting on the time. And it's interesting to hear you say that because, you know, yes, I did feel like I was, you know, learning the medicine. And it was interesting that I did really look to the nurses I was working with to, I don't want to say protect the patient, but often, you know, speak for the patient as far as actual needs beyond the medicine. I think I protect myself by saying, I don't have the time for that but it was a great time for me as far as like an alliance, you know, with nursing staff, which I think I've always, you know, I don't long for much out of those years, but it's something that I do long for because I think there was such great both overlap in our roles and kind of distinct callings for us.

[00:15:20] MK Czerwiec: Yeah, yeah, and I think that's a part of why I wanted to do this book, Taking Turns, because what I was really looking at was two things. One, I was very fortunate to come up in a very multidisciplinary, interdisciplinary environment, right? So we had these weekly meetings and often, you know, the person who was emptying the garbage cans, the housekeeper for the unit would be in the meetings because maybe they developed a relationship with that family being in the room when there weren't any official medical people there.

And so there was this great respect for, and it's down to the founders of this unit because they set that tone, great respect for what every profession contributes. And part of why I created the book was to memorialize that, but much more to think about like what could be exported. Why do we have to be in a crisis to be all... And also like part of why it was like, what does everybody else have to think is because nobody had the answers, right? I mean, Ross, the art therapist says, you know, medicine with their pants down and nothing we can do except try to make you comfortable. And so, I mean, obviously, eventually we were treating all the opportunistic infections, but we knew that's where we were headed, right? And so everyone had something to contribute.

[00:16:29] Dr. Cifu: Yeah, it's interesting because we have adopted, you know, as part of actually, you know, the medical and the graduate medical curriculum, the kind of, you know, interdisciplinary experiences, which absolutely did not exist in my medical training but came to be necessary because you were always talking to, you know, family, partners, community members, and then in the hospital, right, whoever had something to add and whoever could sort of point out a crisis or something that was missing. So I feel like I do, I use that but I use that mostly because of the experience of, wow, you sort of have to, right?

[00:17:09] MK Czerwiec: Right, right. If you're seeing this as, you know, not just a person isolated in that bed, but part of a system, whether it's a family and a community and, you know.

[00:17:19] Dr. Cifu: Totally off-topic, or maybe not completely off-topic. I've found it interesting that my career in a way, I feel like it's been bracketed by, you know, one epidemic to another with COVID recently. Did you feel like living through what you lived through at the beginning of your career, did that affect at all the way you sort of looked at COVID, dealt with COVID, how much anxiety it created for you?

[00:17:44] MK Czerwiec: Right. Absolutely. The book was reissued during COVID. And so I had the opportunity to write an introduction where I could sort of crystallize some of those thoughts. And I've actually put part of it into a comic, which is on my website.

[00:17:57] Dr. Cifu: Oh, I can look at that. I didn't know that.

[00:17:58] MK Czerwiec: Yeah. Yeah.

[00:17:59] Dr. Cifu: That's a great question.

[00:18:01] MK Czerwiec: Thank you. But yeah, so I've thought a lot, like, part of it was echoes, right? Echoes of, "Oh God, look, caregivers who are taking care of their own." Right? The nurses and doctors who became sick. That was familiar to us. People in full, just the full PPE. That was familiar to us, right? So many echoes. And then it turned to, of course, the differences, right? The airborne. Yeah, that's huge, right? And you know, you mentioned like how you were informed as a caregiver. I've been thinking a lot about like how HIV/AIDS changed healthcare as we provide it. And one of the things I end this comic with on my website is like, how are we going to resist that? Right? For example, we didn't wear gloves before AIDS, right? And we learned that's a good idea. And maybe, I don't know if it was more for self-protection, other protection, it's good for everyone but how have we resisted that with masks, right? We learned that masks, there's all kinds of things that could be transmitted, not just COVID, right?

So, you know, maybe it's a facial thing, maybe it's... But I think about like, how is... And I'm even thinking teaching a course on dying and death right now, like, how has COVID changed thinking about dying and death? Maybe for the next generation of young people who had to think about losing loved ones or experience losing loved ones, right?

[00:19:25] Dr. Cifu: Yeah, the universal precautions, masking parallel was something, boy, I have, you know, thought about over and over again. And I've also thought about, you know, the sort of othering of a patient population that you know, was a little bit easier at the time with AIDS than with COVID but it was surprising even with COVID, how much it was like, "These are the people who get sick." And it just seems to be as bad as it is, almost like a natural human defense.

[00:19:56] MK Czerwiec: It is, look at every era of history and, like, even the plague, right? It was the people who... We've always done it. That echoes through all of the history of medicine, which is fascinating.

[00:20:08] Dr. Cifu: Is that true? MK, I wanted to thank you very much for this conversation and for taking the time to join me with all of the things you're involved with. So I really appreciate your time.

[00:20:18] MK Czerwiec: Thank you.

[00:20:19] Dr. Cifu: Thanks for joining us for this episode of The Clinical Excellence Podcast. We're sponsored by the Bucksbaum Institute for Clinical Excellence at the University of Chicago. Please feel free to reach out to us with your thoughts and ideas via the Bucksbaum Institute webpage or on Twitter, X, whatever you want to call it.

The music for The Clinical Excellence Podcast is courtesy of Dr. Maylyn Martinez.