6 lessons learned on visual representation of patients

Making intentional choices to create images that represent patients

5 min readDec 13, 2018

As an instructional designer, my role is to create a variety of online, interactive content that enhances user-experience and learning. Creating imagery representing patients in medical education without patient involvement may impact patient care as stereotypes may be reinforced. In my previous post, I showed an image that I created before starting my project. Since then, I have:

read artiread articles on diverse imagery (see references below)
led a participatory design workshop analyzing and creating diverse vs. ambiguous images in the context of medical education
moderated 5 user research sessions with learners assessing types of media used and diversity of patient depiction to improve patient case study content

Participatory design workshop — illustrations were compiled from external companies branding that featured diversity or ambiguity. Participants analyzed these images in the medical education context. Participants then ranked them and discussed the pros and cons of each image. Overall, participants preferred diverse images, as they fostered more empathy.

Why should we be critical of images?

Canada is diverse. Therefore, providing meaningful education entails that the content and images we create as Canadian medical educators accurately reflects the patient population. That being said, we need to be critical towards images where patients or societal groups are being stigmatized. Here are two opposing examples of when images of minorities may de-value stereotypes or reinforce stereotypes:

When diversity may de-value stereotypes:
If you were to search ‘trans people’ on a stock photo website, it is likely that you would predominantly see white, and perhaps androgynous images. Alternatively, you may notice that icons appear first and therefore there is a lack of humanizing trans people. These images allude to stereotypes, and do not equate with the diversity of trans, non-binary and gender non-conforming folks. Here, diversity in imagery may offer a more realistic lens compared to ambiguity because it works against stereotypes, and allows us to better educate healthcare professionals about this community.
When diversity may reinforce stereotypes:
In the TED Radio Hour podcast episode, “Getting Better,” Dorothy Roberts discusses how race is not an indicator of our genes, and thus diagnoses. Instead, family history and social determinants can offer healthcare professionals more valuable information. As mentioned in my previous article, we work with medical experts to create case studies. When developing case studies for clinical topics where race has no bearing on diagnosis (i.e. heart disease), how do we assign patient identities? How do we best curate the image and content? For example, if adding an image of a black patient to a case study, it is crucial to discuss social determinants of health and family history as a component of the screening and diagnosis process. We need to reduce race-based medicine. How would the outcome of the case differ if the patient is a non-black person? Is it better? Or does it avoid discussing and disrupting stereotypes?

Some of these conflicts are wicked problems — problems that we cannot find a clear solution to, but are worth considering. I do not have all the answers, but as a medical educator I am committed to working through them on a case-by-case basis.

Tips on creating diverse patient illustrations:

Draw individual people, not averages.
By drawing individuals, people will be represented more authentically.
Diversity goes beyond skin colour and gender.
Think about the age, height, clothing choice and body weight in your patient illustrations. Who is missing? Interestingly, during the user research sessions with family doctors, having a range of age in case studies was highlighted as being very important. Age influences patient care the most, and therefore should be considered in patient treatment.
Randomly assign characters to case studies, then assess to see if any stereotypes are being reinforced.
If stereotypes are being reinforced, think critically.
If stereotypes are being reinforced, consider how the case studies have been curated. Is it better to change the image, or disrupt the stereotype through the written content? To devalue stereotypes, include information about social determinants of health, family history or other features of their identity that may shift the narrative. It is important to note that stereotypes are not confined by race, but also include gender, sexuality, culture, ability, and age.

Creating ethical, diverse images may now sound more complicated than ever before, so creating ambiguous images seems easier — right? I’m not so sure anymore…

Tips on creating ambiguous patient illustrations:

Critique your ambiguous images often, and ask for others’ interpretations.
By excluding skin colour or using blues and purples, one may think that the image produced is ambiguous, but in reality this could potentially have the opposite effect. As white people are disproportionately shown in the media, you may not realize that the features you’ve drawn are that of white people. It doesn’t help that default page colours are also white and by drawing the inverse of black figures on a white background, it may seem like you’re drawing black people. Consider that ambiguity can be interpreted in a multitude of ways making it sometimes challenging to do well.
Focus on emotions to convey an idea.
Focusing on emotions can enable the learner to remember experiences that they have had. Using expressive eyes on your image is a good way of developing empathy.

What would I change about the original image?

Based on my research, I would create these images differently to incorporate the lessons I have learned:

change facial features to represent individuals, not averages
create images that are diverse in size and age
create individual people instead of a base-template. Adjusting hair, skin and eye colour is not best practice
vary size and age of women better
vary the babies more to show personality and age differences

I was hesitant to post these images based on my findings, but ultimately I think that it is important to show what I have learned.