Mayo Clinic medical illustrators Michael King (left) and Robert Morreale translate what they see in the OR and on MRI and CT images onto paper in their studio.

Photos courtesy of Mayo Clinic

Visual reference. On the wall are several of the posters surgeons used as guides during the separation of conjoined twins Abbigail and Isabelle Carlsen.

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July 2007 | Back to Table of Contents

Pulse

A Sketchy Profession

Medical illustrators help physicians and patients visualize what photos can’t capture.

Robert Morreale still has a hard time explaining how he felt when he walked into the surgical unit where the now-famous Carlsen twins were being surgically separated. The two infant girls, Abbigail and Isabelle, were conjoined at the chest and shared a liver, biliary system, and intestines. A few hours after the surgery, chief surgeon Christopher Moir, M.D., whispered to Morreale and his colleague, Michael King, that what they had come up with was accurate, that what they had visualized was what he was seeing during the surgery, Morreale recounts. “We were thrilled.”

Although they never made one incision, Morreale’s and King’s hands were instrumental to the operation. Having studied literally thousands of images—radiographs, CT scans, and MRI images—to learn the twins’ anomalous anatomy, King produced 4-by-3-foot posters depicting their shared organs and vasculature. The images were hung on the walls of the OR to guide the surgeons through the girls’ separation. “We called them roadmaps,” says Morreale, the director of Mayo Clinic’s Medical Illustration Unit, which with eight medical illustrators, four medical animators, and two scientific illustrators is one of the largest medical illustration teams at an academic medical center in North America. “We were painting a picture in the surgeon’s mind as to how they were going to do this incredibly complex, life-altering task,” Morreale says.

The Art of Deletion
Morreale and King’s role in the twins’ separation is one example of the ways illustrators have made a mark on medicine over the centuries. Medical illustration can be traced back to the time of Leonardo da Vinci, when artists often studied cadavers and rendered images through woodcuts and copper engravings. The Johns Hopkins School of Medicine employed Max Brödel, America’s first medical illustrator, in the 1890s, and in 1907, Mayo hired its first full-time clinical artist.

Today, medical illustration remains a relatively rare niche within the worlds of medicine and art. According to membership data from the Association of Medical Illustrators, an international organization, more than 700 professionals are actively engaged in the field. The work they create is used in everything from journals to textbooks to television programs and advertisements.

Sometimes, an illustration ends up serving multiple needs. Minneapolis freelance medical illustrator Daphne Orlando recently completed a guache (opaque watercolor) image depicting how the kidneys help regulate calcium in the body that was to appear on the cover of a catalog. “The image was also very educational,” Orlando says, and it ended up on a poster that now hangs in physicians’ offices.

The key to creating an effective medical illustration is being able to distinguish the trees from the forest. David Herman, M.D., an ophthalmologist at Mayo Clinic, often turns to the medical illustration team to zero in on a surgical step or anatomical area—something that a video or still photograph cannot effectively capture—that he’s describing in a book chapter or journal article. “Unless you are knowledgeable about the specific procedure, those types of images don’t allow you to focus on what’s important,” Herman explains. “When a medical artist draws the illustration, the focus that the eye is drawn to ends up being exactly what we want the image to depict, nothing more and nothing less.”

Morreale says a colleague calls it the “fine art of deletion.” “When you really boil it down, what we don’t draw is sometimes more important than what we do draw.”

Training the Mind’s Eye
The ability to translate what’s important into an image demands training as well as talent. Currently, the United States has half a dozen degree programs in medical illustration. Aspiring medical and biological artists take gross anatomy and histology courses alongside medical students and study other sciences that are basic to medicine. They also study anatomical sketching and drawing using specific media such as pen and ink and watercolor.

Fueling a pre-teen dream that was inspired by a National Geographic article, Orlando enrolled in the medical illustration program at Johns Hopkins and received her master of arts degree in 1995. A New York native who loved art and excelled in science, Morreale attended the Rochester Institute of Technology’s undergraduate medical illustration program, then completed a master of science in fine arts education. He has worked as a medical illustrator for 17 years.

“People who know that there is such a thing as training in this field do look for people who specifically have it,” Orlando says. “I have clients tell me that they find it easier to work with me because I know the anatomy and medical terms and have some of that medical education.”

Physicians’ Assistants
For decades, carbon dust and pen and ink were the preferred media for medical illustrations (the latter is still Herman’s favorite). Color-rendered images, while engaging and vibrant, were rarely done because of the cost of reproducing them. Technology has allowed for more use of color and made it easier for illustrators to render what Morreale calls “the glitzier stuff.” “Color is absolutely an essential element to describe texture and variance between and within organs,” he explains.

Although technology allows illustrators to produce 3-D and animated images, the information-gathering process hasn’t changed. Illustrators still meet one on one with medical professionals to learn what a drawing must depict. “The relationship between the physician and illustrator is not like that of a speaker and stenographer,” Herman says. “It’s truly a partnership, where the physician shares an expertise and then the artist uses his or her additional knowledge to bring ideas to life in a visual form.”

Morreale appreciates the fact that Mayo physicians consider him integral to the team. But what most inspires him is his ability to use his talents to help patients such as Abbigail and Isabelle Carlsen. “It was so inspiring and validating to know that I made a difference in terms of their surgical outcome and perhaps even their lives,” Morreale says. “Those two little girls are doing great, and we were part of making that happen. I get emotional every time I think about it.”—Jeanne Mettner

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