Standing L-R, MScBMC Class of ‘25 graduate students Yu-wen Jan, Bonnie Wang and Ashton Goebel show their palettes of professional body paints. The medical illustrators painted the lumbar anatomy onto the backs of the nine patient models seated in front of them. Photo credit: Danielle Dilkes for the Health Education Media Library, Western University.
On a recent Saturday in February, three Biomedical Communications graduate students traveled to Western University in London, Ont., to paint the internal anatomy of the lower back onto nine patient models.
Photos and videos of the painted models will be used in the creation of new educational materials that represent a diverse patient population. The inclusive curriculum will be used in training medical residents to perform lumbar punctures.
Courtney Casserly, an assistant professor of neurology in the Department of Clinical Neurology at Western, is leading the medical curriculum development team.
She contacted the Master of Science in Biomedical Communications at the University of Toronto in December 2023 with an inquiry about anatomical body painting.
“I responded to Dr. Casserly that not only did we have the expertise, but we also had the tools and some experience with this kind of thing,” says Shelley Wall, associate professor in the biomedical communications program.
Écorché is a technique in art where the human body’s underlying anatomy is depicted without the skin. Écorché can be represented in painting or sculpture, but it can also be created on a model’s body.
Wall taught the anatomical illustration component of the BMC program’s first-year human anatomy course in fall 2023.
“The knowledge was fresh, so I approached the top three students who were having the most success with anatomy,” Wall says.
Ashton Goebel, Yu-wen Jan and Bonnie Wang all said yes. “No hesitation,” says Goebel.
L-R, Bonnie Wang, Yu-Wen Jan and Ashton Goebel review an illustration of the lumbar anatomy created by Jan. The students used the illustration as a template for reference to expedite painting the models. Credit: Maeve Doyle
To help the students prepare for the opportunity, Wall organized an écorché workshop. All BMC graduate students were invited to participate.
John Tran, anatomist and assistant professor (teaching stream) in the division of anatomy, department of surgery at U of T, teaches the gross anatomy component of the human anatomy course. He delivered refresher lectures to the students on the lumbar spine, and hand and forearm anatomy.
Tran worked with Goebel, Jan and Wang to show them how to identify landmarks on the model that are relevant to lumbar puncture. The students worked for the first time with professional body paint to visualize the bony structure of the lumbar spine onto the living human model.
Other graduate students painted hand and forearm anatomy onto BMC faculty volunteers.
BMC graduate students practice painting the hand and forearm anatomy onto skin. Photo submitted by Shelley Wall
TEACHING LUMBAR PUNCTURE
Casserly teaches the lumbar puncture or LP procedure to medical students and residents in neurology.
“One of the challenges we faced in teaching the LP was that the educational materials focused on young, able-bodied, white men when, in reality, the patients we’re seeing are all sizes, all ages,” says Casserly.
L-R, Courtney Casserly and Yu-wen Jan identify bony landmarks on a model’s back. Credit: Maeve Doyle
Casserly and her team deliberately focussed on the inclusion of different body types and ages. They selected models from Western’s standardized patient program who had different skin tones, different amounts of body fat, different degrees of skin elasticity, and with the presence of body art. “We've also looked at spinal curvature to see how that impacts our procedure.”
Casserly says that by painting the underlying anatomy onto the skin’s surface, “learners will be able to visualize what they are doing and also be able to visualize it on different body types. Visual cues for the learners that might help them to see both the horizontal and vertical landmarks and to really envision what's going on under the skin.”
She says that that is where the biomedical communications program came in. “We needed people who had training in the scientific medical background, but also people who had those artistic skills to be able to execute that vision in a way that was both beautiful and informative for our learners,” says Casserly.
Examples of the lumbar anatomy illustrations at various stages and on a variety of models. Credits: Maeve Doyle
Over five-and-a-half-hours in a Western University nursing simulation suite, Goebel, Jan and Wang painted the lumbar anatomy onto three models each. They painted from the lower rib cage and T12 vertebra down to the tailbone, and the pelvic bones and iliac crests.
Wang says that they used their training from Tran to identify and paint landmarks onto the seated models’ backs as they leaned forward. After landmarking, the medical illustrators created outlines and painted them in.
As prepared as the medical illustrators were, they still experienced some challenges.
“Not every standardized patient could be landmarked the same way because of individual variation in body size and muscle mass in their back. In those cases, I did the best I could and relied on the experts there to make informed approximations,” says Wang.
Bonnie Wang, MScBMC ‘25. Credit: Maeve Doyle
One of the models was a former gymnast. Jan says that “her back muscles were so strong that it was difficult to identify the bony landmark from her muscle. Also, because she was short-waisted, the landmarks were in a different location from where we expected at first.”
Jan, Casserly and anatomist Charys Martin, an assistant professor in Western’s medical school, worked for several minutes to identify the landmarks. Casserly said that this was representative of the real-world experience.
After spending much of the last semester creating only digital visualizations, Goebel says it was good to return to a traditional medium and have a new kind of experience. “Painting on skin is completely different from painting on canvas or paper,” they say.
L-R, Charys Martin and Ashton Goebel, MScBMC ‘25. Credit: Maeve Doyle
“We also had to take into consideration the patient’s comfort. And unlike digital art, there’s no undo button,” says Wang.
REPRESENTATION IN MEDICAL CURRICULUM
“Learners are going to encounter all different patients. They need to know how to approach a person who is young or old. How skin elasticity will impact things. How different spines, curvatures, spaces, levels of degenerative change and even tattoos impact things. If we focus on one specific body type when we teach these medical students, then they’re not ready to approach a lumbar puncture in clinical practice,” says Casserly.
Goebel says that medical illustrators have a responsibility to create materials for not only medical professionals, but patients too, so that they see themselves represented in medical media.
Wall agrees. “Medical illustrators and medical educators are important partners in developing learning materials that represent the broad range of patients that new doctors will meet in their practice.”
The newly created educational tools will be available by the end of summer 2024 through Western University’s Health Education Media Library. The resource is available to anyone around the world who has access to a computer and the internet.
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Web sites referenced.
Ashton Goebel’s Instagram https://www.instagram.com/ashton.arts.sometimes/
Bonnie Wang’s Instagram https://www.instagram.com/visualsbywang/
Charys Martin’s profile https://www.schulich.uwo.ca/anatomy//people/faculty/faculty_members/martin_charys.html
Courtney Casserly’s profile https://www.schulich.uwo.ca/cns//people/faculty/neurologists/bio-Casserly.html
Health Education Media Library, Western University https://ir.lib.uwo.ca/healthedu/
John Tran’s profile https://surgery.utoronto.ca/faculty/john-tran
Living anatomy workshop 2015 https://bmc.med.utoronto.ca/news-events/2015/04/20/living-anatomy-workshop?rq=living%20anatomy
Shelley Wall’s profile https://bmc.med.utoronto.ca/faculty-staff/#wall
Yu-wen Jan’s Instagram https://www.instagram.com/dinosaur.visuals/