The aim of an informed consent procedure is to ensure that patients can make an autonomous decision. This involves the provision of details about the procedure, including the associated risks and benefits. Due to the complex nature of certain treatments, as well as the anxiety associated with them, patients often struggle to fully understand the steps involved.

Researchers from Charite – Universitatsmedizin Berlin, one of the largest university hospitals in Europe, were inspired by the idea that a picture is worth a thousand words and wanted to test whether comic-style information might be more easily digested by patients. The team focused on cardiac catheterisation, the most common procedure in the field of cardiology.

The provision of medical information within a comic format is seemingly an unusual choice but was a carefully considered decision by researchers. A key factor was the realisation of the ineffectiveness of the current method of informing patients about cardiac catheterisation.

“We realised that patients were not as well prepared as we would wish them to be, even though the physician was communicating all aspects of the investigation and they were receiving a standard written consent form,” says Anna Brand, lead investigator and cardiologist at Charite – Universitatsmedizin Berlin. “They still had several questions at the beginning of the procedure.”

Better by design

Researchers looked for alternative approaches to presenting the information. They stumbled upon graphic medicine – a growing field in the US and France, in particular – which uses comics to communicate information to patients and their families, as well as educating students.

“We thought that comics might help in the informed-consent procedure because text is too complex for patients who lack knowledge of their disease and its treatment,” says Brand.

Together with Alexandra Hamann, a science communication specialist, Brand and Professor Verena Stangl from the medical department, division of cardiology and angiology on Campus Charite Mitte, developed a storyboard based on the standard consent form for cardiac catheterisation. The team went to great lengths to optimise the likelihood of it being effective for patients.

“We didn’t only want to have the comic but we really wanted to test its effects,” says Brand. “Is it useful? Do patients understand more? Does the comic help them to feel less anxious?”

As cardiac catheterisation is so routine within cardiology, Brand was acutely aware of how patients felt about it.

“A lot of patients are very worried about the procedure and they expect a larger operation than just an invasive coronary angiography,” she explains.

Researchers hoped that the comic-style information might be a useful way of reducing anxiety as well as informing them about the treatment.

In order to put the comic-style booklet to the test, the team recruited 121 individuals scheduled to undergo cardiac catheterisation. Patients received either the standard informed consent procedure or the standard informed consent with additional comic-style information. Using a range of questionnaires administered before and after the provision of the information, researchers assessed levels of comprehension and anxiety in addition to the satisfaction with the consent process.

The comic-style booklet was found to be significantly superior to the standard information.

“Patients who read the comic before the procedure could answer 12 of 13 questions correctly on the multiple-choice test that was assessing comprehension.”

“Patients who read the comic before the procedure could answer 12 of 13 questions correctly on the multiple-choice test that was assessing comprehension.”

“Patients who read the comic before the procedure could answer 12 of 13 questions correctly on the multiple-choice test that was assessing comprehension,” explains Brand. “We were even more surprised by the limited value of the standard information because patients who read a text which contained all the information for the test only answered 9 of those 13 questions.”

There were also positive emotional effects of the comic-style information for participants.

“Patients in the comic-style information group also reported feeling less anxious after their informed consent procedure,” says Brand. “Patients even expressed more anxiety following the standard informed consent, which was something that was really surprising to us.”

Perhaps most surprising was the high level of acceptance of this format in light of it being relatively novel.

“Approximately 72% of participants were satisfied with the comic-based information booklet and reported feeling well-prepared for cardiac catheterisation. This is compared with only 41% in the standard informed consent group.”

“Approximately 72% of participants were satisfied with the comic-based information booklet and reported feeling well-prepared for cardiac catheterisation,” explains Brand. “This is compared with only 41% in the standard informed consent group.”

Comic-style information is clearly effective but are there certain types of patients who stand to benefit the most from this format?

“What we saw was that patients without any professional education had poorer results on the multiple-choice test that was assessing patient comprehension than those with more education,” says Brand. “Given that the official standard form is very complex and beyond the literacy level of many patients, I could imagine these individuals maybe benefit the most from comic-style information.”

That doesn’t mean that comic-style information is not suitable for those with high educational levels.

“On the other hand, the patients that had a higher university degree were also happy to receive the comic because, although they were educated, they didn’t have knowledge of this particular medical field,” notes Brand. “They also said that they really liked this form of patient information, so comic-style information can be used for all different types of patients.”

Researchers were surprised by this as they expected that more highly educated patients might find it too simplistic.

“More than 95% said that this was not the case; they felt better informed and were happy with the comic-style consent form,” says Brand. “The high levels of acceptance of this format is beneficial because it means that all patients can be provided with this style of consent form, rather than singling out patients based upon their educational level.

Standard procedure

There are a number of benefits of using comics for both patients and healthcare professionals.

“Sometimes patients do not want to ask, or they forget what they have been told,” explains Brand. “It is also very useful for us medical doctors because it allows you to convey very complex aspects of the disease or of the procedure in an easy manner.”

As a result of the research findings, cardiologists working at Charite – Universitatsmedizin Berlin have already changed their informed consent procedure.

“We now use the comic-style information form as standard procedure for patients receiving a coronary angiography,” says Brand.

The team are also very keen to take their work forward.

“We see elderly or foreign patients that may struggle more with the standard informed consent procedure,” explains Brand. “We would like to test comic-style information for these types of patients, as well as for other procedures within the cardiovascular field.”

Types of health-focused comics

In recent years, a growing body of research has demonstrated the potential effectiveness of comics in order to educate patients. Broadly, there are two categories of health-focused comics that appear in this graphic medicine literature: memoirs about a personal health, medical or illness experience; and instructional content designed to educate patients.

Personal memoir comics

The first category – personal memoir comics – is sometimes called graphic pathography and is often created by an individual writer-illustrator who tells the story of his or her own healthcare experience. These comics can range from a realistic, documentary-like style to more metaphorical representations. By definition, this genre of comics focuses on the experience of a particular person, which might factually differ from that of other patients or caregivers. Therefore, clinicians should keep in mind that the value for patient education may be more in the author’s depictions of relevant concepts and accurate representations of potentially relevant emotions than in the author communicating detailed and comprehensive medical information.

Health education comics

The second category – health educational comics – is more like the type of patient education format that straightforwardly explains medical information. However, instructional comics are very different from handouts that use bullet-point lists, or brochures that use photographs. Comics have a unique grammar that Scott McCloud defines as “juxtaposed pictorial and other images in a deliberate sequence, intended to convey information and/or to produce an aesthetic response in the viewer”.

Comics have been used to communicate accurate and relevant information on serious and technical topics over many decades and across cultures. Instructional comics can use narrative or be more didactic. The grammar of comics might be able to facilitate comprehension to a greater degree than other patient-education formats. One well-known feature of comics is the carefully designed interplay of words and pictures, which can help improve health literacy. For example, sequences of action can be depicted visually that might otherwise take many paragraphs of written text to explain in equivalent detail, and the sequence itself could contain concise speech bubbles or captions that complement or clarify the visual information.

In addition, spatial relationships between illustrations can create a dynamic depiction of time, which could be used to help explain cause-and-effect information related to certain medications or health behaviours. Another graphic technique of comics is the juxtaposition of differing images on the page. This technique can be useful to contrast healthy and unhealthy or disease states, or to compare observable external symptoms and internal physiological processes. Taken together, these features give comic readers a multi-layered experience, encouraging repeated reading that could continue to reinforce educational concepts long after the patient visit.

Source: AMA Journal of Ethics