Nature Medicine - Vol. 4 (1998)
http://www.nature.com/nm/web_specials/comics/กก
Global Health Network Contributors
Superman (U.S.), Beezer (England), Manga (Japan), Patoruzu (Argentina). As kids most of us read comic books. Many of us have gone back to our parents' home, and opened a comic book not read in 30 years. Amazingly, upon seeing the first page, the story and images spill forth from memory. We know what happened to Superman, where the Kryptonite brings Superman to his knees, and what Jimmy Olson and Lois Lane will say. Why is the recall over 3 decades of our comic books so good, yet we barely recall the contents of Nature Medicine, BMJ, Lancet, or Science from 3 months ago? What can comic books tell us about improving journals?
The much better recall of the comic book can be explained by "a picture tells a thousand words". Our perceptions and memories are sensory grounded and organized through our senses so that what can been seen, heard, felt, tasted and smelt are best remembered. Scientifically, in terms of cognitive theory, Pavio has described this as Iconic Memory (1). We remember pictures better than words. As we walk through our universities or hospitals we recognize and say hello to hundreds of people, recalling the names of but a few. In the Lancet (2) this was demonstrated where house doctors were asked questions about journal articles they read two months previously. The recall on most articles was near chance. Disappointingly we remember little of what we read in medical journals. Perhaps it is time to reconstruct journal format in light of the Internet.
A second reason that we recall comic books is that the pictures are perfectly woven into the story as our eyes dart from picture to picture. In fact, the icons are the story. In journals there are figures and pictures, but they are separate and adjunct to the story. This is extremely important as the famous English cognitive psychologist from the 1930s, Professor Bartlett argued. As we read we create schemata where we "hang" new knowledge (3). The creation of the schemata is very powerful as one ignores information that does not fit, and adds to the construction of the schemata in our minds. Humans have a very limited information processing capacity, and thus have to be selective. Schematas allow us to encode the important information while rejecting that does not "fit" with the schema. Comic books have the best of all worlds in that the iconic learning is maximized and integrated into the construction of the schemata. There is little wonder, that recall of information from comic books can be made over 30 years, whereas medical information from journals cannot be recalled over 30 days.
What can the lessons of comic books provide to enhance the retention of medical information? One may think that it is rather absurd to consider publishing journals in a comic book format. But is it? We did not give up comic books because our mothers were yelling at us; rather it was because we could not obtain sufficient information from a comic book format. As seen in the pages of the comic book, obviously, there is much less information than a scientific journal. Comic books are not information dense; we recall very simple messages and story lines, as this is the nature of comic books. This is just right for children who have little verbal repertoire but inadequate for mature information processors as we adults. With aging we cannot absorb sufficient information from comic books, and thus headed to prose, which consists of considerably more information.
With the advent of the computer, there is a solution to the lack of recall of journal information. When many of us learned about computers we used the almost unfathomable Fortran language, and DOS based commands. These were very difficult, with a strict grammar where a comma out of place would blow up our communication. Fortran and DOS commands are pure text and serial in comprehension and use, in many ways like how we learn from medical journals. Two events changed our ability to comprehend and use the power of the computer, Windows and the Mac. Examine your computer screen, isn't Windows but a comic book? Viewing Windows one sees icons with minimalist text. But it is much more powerful than a comic book as one can click onto an icon to dig deeper and deeper for more knowledge and to skitter in any information direction our minds wants to take us. This icon driven systems on the computer changed our abilities to use and learn from the computers, and changed the world. Just 20 years ago there were only 50,000 computers in the world, now there are over 140 million, because people can easily comprehend and learn from computers, using Windows as a means to reach information in ones computer and to the information of the world through the Internet.
What if we had a comic book and could point to Superman and find out more about the rocket from Krypton, the aerodynamics of Superman flying, see and hear Superman "leaping a tall building with a single bound" and what Jimmy Olson thinks about Metropolis, etc.? What if we could "jump" back to the previous issue to see how Superman fell into this predicament? In a situation like this one could obtain considerable information. One would not be constrained by the picture and the small balloons of information above the pictures. One could also point to an author of a medical communication, and hear his/her voice. One could click to read the article in Japanese. It would be possible to indicate your years of schooling, and be provided an information trail that would be most comprehensible based upon reading level and background. It would also be possible to have something like a global game of medical Sleuth where one could obtain advice from a thousand experts playing the "game" of medicine in chat rooms to unmask a microbe killer.
Sound impossible? Well it is not on the Internet. We can have all of this using the capabilities of HTML (Hypertext Markup Language) and the World Wide Web. Smart home pages on the Web now incorporate interactive graphics, text, and audio into formats that are easily pictured in our minds. Hypertext was envisioned in 1945 by the visionary Vannevark Bush (4). Hypertext represents links (associations) between components of texts and figures to other components in the corpus of data on the Internet. An enormous associative web is formed. With hypertext one can jump from idea to idea by clicking on underlined concepts, which takes you to linked concepts. The power of hypertext for changing how we learn information was not apparent until the development of the Internet. The Internet in this new environment affects the way we construct the sense of who we are. With hypertext we can jump from diabetes, to epidemiology, to Japan, to genetic markers; wherever our creative minds takes us. Meshing the iconic presentation of the comic book, with medical knowledge and hypertext provides the solution to the major shortcoming of comic books, the limited information. This produces a highly comprehensible, memorable and enjoyable system as the icons pull us, and at the icons we decide which trail to take, and at any point can dip down to improve comprehension.
The process in which one learns using the Internet further enhances the icons and pictures of the web. On the web, learning is based upon active decisions and choices that the readers select, rather than the authors. With a journal, one is more a passive recipient of knowledge due to the channeling of the information, with "smart" hypertext homepages one interacts and becomes a part the knowledge domain. Moreover, a hypertext iconic journal presents the gestalt of the concept by merely looking at the picture. This brings together pictures and technical language in a coherent work with multiple levels of complexity. In a scientific journal we are lead along by the author as the serial learning format makes deviating difficult, e.g. to look up a concept means going to the library to get a book, etc. With a hypertext comic book the reader drives the destination of his/her information acquisition. The reader can delve further on a key point or go in a completely different direction to find out new information. This brings the acquisition of knowledge squarely under the control of the reader. We can follow trails set up by experts, or we can easily blaze our own trail through medical knowledge. No text need be too difficult as there can always be pathways taking one to an easier form of comprehension.
It is time to consider shaping the information sharing system for medical information in the light of the information superhighway, which is the Internet. Until now the approach has been to take the existing medical journals and put them on the Internet making them look similar to the format of the paper Nature Medicine, BMJ or Lancet, with perhaps a few links to other journal articles. However, the next level down is the traditional text driven, serial learning AIMD (Abstract, Introduction, Methods and Discussion). This does not use the power of the Internet to improve cognition. Perhaps the most potent approach would be to establish medical journals as icon driven information gathering tools, "Windows" into the world of medical knowledge. We think that it is possible to have something better, this is the "hypertext combic book" approach towards medical.
We have created a mock up of a hypertext comic book that includes formats of the information in a web based scientific communication titled: Scientists Assassinate Journals. Presentations such as this can be easily produced using current software programs. The format is similar to the comic books of old in that the figures tell a story unto themselves, they form the schemata of information presentation. The figures are like the slides of an oral presentation. However, the reader can go well beyond the slides as one can "jump up and down" the talk, or one can delve deeper and deeper into the information by linking to other sites on the web. John Patrick from IBM has called this "creative reading". It is you, the learner, who is making the decision at each icon as to if you grasp the meaning, if you need more information to understand it, or if you want to find out more about that topic. The icon is driving your choice, not the serial nature of the text. The beauty of this approach is that the reader, based upon his or her previous knowledge, is building up the schemata. It is an icon based schemata for better learning, and one can find their own level of comprehension, from the lay reader, to the clinician, to the graduate student, to the Nobel Prize winner. The reader will be determining the trail as to what to see not the journals. The journals will provide the icons and potential trails for which individuals can begin their journey through the forest of medical knowledge. A system like this could markedly improve comprehension, memory and potentially creativity. This format for journals can easily be translated into lectures, thus blurring the distinction between scientific articles and training.
Clearly there is the opportunity to greatly enhance the learning from medical sources, should the information be presented in new formats. The Internet can transform not only the quantity of information that can be brought to us, but also, if constructed correctly, can facilitate our ability to learn, and create in a shorter period of time, and remember over a longer period.
In 1945 Vannevark Bush (4) stated "Professionally our methods of transmitting and reviewing the results of research are generations old and by now are totally inadequate for their purpose". Our approaches and format for sharing medical knowledge have not changed since 1945 and in fact are not much different than 1745. There needs to be new approaches developed, if the systems were not adequate at the end of WWII, they most certainly are completely deficient now.
1. Pavio, A. Imagery and Verbal Processes. New York, Holt, Rinehard, and Watson, 1972.
2. Kellett C, Hart A, Price C, Jones G, Bulstrode C. Poor recall performance of journal-browsing doctors. Lancet 1996;348:479.
3. Bartlett, F. Remembering. London, Cambridge University Press, 1932.
4. Bush, V.As we may think. Atlantic Monthly, July 1945.
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