Duke Hospitals doctor turns to graphic medicine to educate

Dr. Nathan Gray does some of the most notoriously difficult work in the field of medicine.

Gray specializes in palliative care at Duke University Hospital, helping support patients and their families as they navigate all of the daunting concerns that come with a serious illness, including end-of-life issues. It requires a very specific skill set — deep empathy and an ability to communicate complex, sometimes hard truths. This is even more crucial as the coronavirus pandemic sparks concerns and fears about the unknown, and people are having emotionally taxing conversations they didn’t expect to have.

That’s where Gray’s second line of expertise comes in. Gray, a lifelong artist and doodler, has developed a side specialty in comics — specifically, deeply empathetic comics that communicate those complex and hard truths.

Gray, who has no formal art training, has published several comics in the past three or so years on a wide range of complicated subjects: palliative care in the time of pandemic; the crippling cost of cancer care in America; the ethics of resuscitation medicine.

His work has been published in mainstream publications — The Los Angeles Times, Medium.com and Topic magazine — as well as peer-reviewed professional journals, including the AMA Journal of Ethics and the Annals of Internal Medicine

Gray’s work fits into a relatively recent but rapidly expanding area of work known as graphic medicine, which refers to the use of graphic novels, comics and visual storytelling in medical education and patient care. In the broadest sense, it’s about using images and words together to impart medical information.

“It’s about looking at the intersection of comics and medicine, and trying to figure out ways to use comics as a tool to communicate,” says Gray, also an assistant professor at Duke University School of Medicine, calling in via Zoom from his home in Durham.

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Nathan Gray

Telling a story through words and images

Fans of Bill Watterson’s “Calvin & Hobbes” newspaper comic will notice certain similarities with Gray’s work. They’re both artists who put a premium on careful compositions, emotive flourishes and expressive characters. The biggest similarity? They’re really good. Lots of doctors might doodle on the side. Very few have chops like Dr. Nathan Gray.

“I loved to draw growing up, though I came to comics pretty late,” says Gray. “But eventually I had tons of Calvin & Hobbes books and, like, just devoured them. They had this awesome range of color palettes and styles that I found really captivating.”

Gray’s love of the comics form never went away, but he was forced to put art on the back burner as he went through college, medical school and residency.

“If I still had my lecture notes, you’d see the margins covered with doodles,” he says.

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Nathan Gray

Toward the end of his medical residency at the University of Texas Southwestern Medical Center, Gray lost a patient in heartbreaking fashion. The young man was an undocumented immigrant living with kidney failure and had no option for getting regularly scheduled dialysis care. He would come into the ER near death, get a session or two of dialysis, then try to survive with crippling symptoms until he was forced to return to the ER again a week later.

“His life in that last year was horrific,” Gray says. “As one of his doctors, I felt helpless and complicit in this system of care.”

Gray began drawing a few panels reflecting on the experience, and it quickly grew into an extended comic sequence about his young patient — a sobering graphic representation that could tell the story through both words and images.

“When I put the comic together and looked at it, at the end, I broke down,” he says. “I had never stepped back and admitted how much his situation affected me. That was the first moment it really dawned on me how useful comics could be as a medium for processing these kinds of stories.”

Gray submitted his series to the American Medical Association’s Journal of Ethics, where it went through scholarly review and eventual publication in 2018.

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Dr. Nathan Gray is a professor at Duke University School of Medicine and doctor of palliative care whose work fits in graphic medicine. He draws comics on medical topics like COVID-19 and end-of-life issues. Courtesy of Nathan Gray

Dealing with current health issues

Earlier this year, as the coronavirus pandemic stretched on, Gray collaborated with the non-profit organization VitalTalk on an illustrated COVID-19 communication guide for clinicians. That one ended up in the prestigious British Medical Journal. He did another series in November 2019 on an early pioneer of palliative medical care, English doctor Dr. Cicely Saunders. It was published in the Annals of Internal Medicine.

Last year, Gray collaborated with Dr. Fumiko Chino, a former Duke colleague, to publish a comic-style op-ed in the L.A. Times concerning the crippling cost of cancer care. The comic is based on Chino’s real-life experience of losing her husband to cancer, and it’s an emotionally powerful piece of work.

“It was amazing to see a full page of newsprint dedicated to telling her story in visual form,” Gray says. He has now published four Op-Eds in the L.A. Times, dealing with different issues of medical ethics and the effects of the pandemic on the nation’s hospital systems.

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Nathan Gray

When doodling for himself, Gray used to do all of his artwork by hand, using pencils and ink. But he’s since migrated to the digital realm.

“Now I’m exclusively on the tablet,” he says. “The Apple Pencil is so great. It’s gotten to where it feels almost like the real experience of pen and paper.”

Working digitally also makes it easier to submit his work for publication.

“If this were 15 or 20 years ago, I never would have been able to get into publishing comics at this point in my life,” he says of the new technology. “I would have needed more formal art instruction to be able to go and learn the ins and outs of prints and hand inking, sketching and color washes.”

Gray says the comics medium has an intrinsic power as a mode of communication. Because it uses both words and images, comics can generate an effect that’s more than the sum of its parts.

“I feel like comics actually provide a really wonderful way to make even difficult topics feel a little bit more accessible,” he says. “Some things are really hard to put into words, and sometimes having a picture that demonstrates that emotion or that feeling goes a really long way. I think we all bring our own experiences into the space between the panels.”

Glenn McDonald is a Chapel Hill-based writer.


Dr. Nathan Gray’s work can be found on his website at inkvessel.com. Follow him on Twitter @NathanAGray or on Instagram at instagram.com/inkvessel.

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