The art of medicine

Daniel Carvalho Muller was originally a trained biologist but veered into medical and biological illustration. He is now one of the medical illustrators at the New England Journal of Medicine having formed his own medical illustration company. Tiago Villanueva caught up with him

How did you become medical illustrator at the New England Journal of Medicine

I've always had a passion for art and science. After I finished my biology degree at the University of Lisbon, I received a Fulbright grant to do a two year Master's degree in medical and biological illustration at Johns Hopkins University School of Medicine in Baltimore. On graduation, I returned to Portugal with my classmate (and now my wife), Joanne Haderer Muller, and together we opened the first medical illustration studio in the country. In late 2003, the New England Journal of Medicine (NEJM) was seeking a new medical illustrator. I thought this was an amazing opportunity and decided to apply. In early 2004 I was offered a full time position as an illustrator, and we moved to Boston.

How do you juggle your work on the NEJM with that in your company?

Since I am now full time staff at NEJM, I am less involved in the day to day operations of our studio, Haderer & Muller Biomedical Art, LLC, as I used to be. Joanne continues with the studio full time, and I keep myself busy in the evenings and at weekends, helping her with some of the projects that come to the studio. Of course, my work at NEJM all revolves around the journal-either illustrations for the print version or interactive media for the online version-but the topics and audience are always similar. In my freelance work, I find myself doing more varied work, from surgical illustrations to biological illustrations for patient education and illustration of basic anatomy or conditions.

Describe a working day at the NEJM

Working at NEJM is always extremely exciting because not only do I get to do illustrations for some of the most important medical articles published today, but I am also helping to develop the interactive graphics and videos for the web version of the journal. A typical illustration starts when I choose an article needing illustrations from a database. Usually the author has included some kind of illustration concept along with the manuscript and figure legend. After carefully reading the article and understanding all the information, I make a preliminary sketch, which I sometimes ask the editor to review and approve before moving to the final illustration. This is usually done directly on the computer and then sent to the editor and the author for their final approval.

How do you balance your creativity with the demands of editors and clients?

The purpose of a medical illustration is not just to make a piece of art, but very accurately to explain a medical concept or topic visually. To do this, medical illustrators manipulate artistic skills and techniques but always remain focused on the scientific material, on the intended audience, and on the delivery method for the illustration (printed in a book or viewed on the web). Professionally trained illustrators use their creativity to organise and explain complex scientific information in a logical and visually intuitive way.

How do you judge your work?

As an artist I tend to be one of the harshest critics of my work, perhaps. But as a medical illustrator, I have to consider a successful piece to be one that is scientifically accurate, in the first place, and that clearly communicates a given message to the appropriate audience. Secondarily, the work should be engaging and visually pleasing. That is part of what distinguishes the work of a medical illustrator. The aesthetics, although important, give way to the scientific information.

Have you worked with doctors, medical students, or faculty before?

I have worked with all types of clients in the academic, business, and government fields. For me, each project is exciting. I enjoy the opportunity to be in touch with cutting edge techniques and discoveries. And I like the fact that one day I may be in an operating theatre, sketching a new surgical technique for a doctor writing an article for a medical journal, and the next day I may be illustrating DNA for a general biology textbook. I also like doing illustrations for conference posters, PowerPoint presentations, or pharmaceutical advertising.

Courtesy of NEJM
Linking cigarettes to the cell-Muller illustrates the power of medical art

What do doctors and medical students think about your work?

We have always received very positive feedback from students and doctors. Many of them had never considered who created the illustrations and posters that they used to study or to educate their patients.

Medical illustration is clearly an art. Is it also a tool for teaching and training doctors?

Absolutely. The essence of medical illustration lies in thoroughly understanding the scientific topic and then using artistic techniques to explain it visually. This sets our work apart from pretty pictures or "art for art's sake." The key is in the accuracy and didactic value of the message.

We learn anatomy in dissection classes. But will dissection become outdated as a teaching tool?

There is no doubt that computers have led to amazing medical advancements and opportunities. However, as a student who benefited from the opportunity to dissect and study cadavers, I can only say that I hope that dissection will remain a part of medical school training. Working with real tissue and understanding the complex spatial interactions of organs and tissues is key to a solid knowledge of the human body. In my opinion, it would be hard to completely replace that tactile experience with any software program.

You must have excellent visuospatial skills. Would medical illustration be good training for potential surgeons?

Certainly both specialties require an ability to think spatially, use eye-hand coordination, and understand the complex spatial relationships between organs, bones, vessels, and nerves, but I don't believe that one field would prepare a person for the other. Training for medical illustration also includes studying traditional and digital rendering techniques (watercolor, carbon dust, airbrush, pen and ink, and software programs for digital rendering, animation, and modelling) and mastering concepts of information design and graphic design.

You must need a sound knowledge of anatomy. Did you have any medical training?

My masters degree studies at Johns Hopkins had a very strong scientific component. This training included anatomy class with the medical students, which meant doing exactly the same dissections, oral presentations, and written exams which were required of them. We were also required to take a course in general pathology and another in histology in addition to our time spent in the operating rooms and autopsy lab.

Medicine is becoming increasingly molecular. Will this trend towards nanomedicine affect your work?

Today medicine is definitely moving to the molecular level, and a sign of this is that about 50% of the illustrations I do for NEJM are of molecular subjects, like an interaction of a specific drug or a molecular pathway inside a cell. The process for creating these microscopic illustrations follows the same process as a macroscopic illustration. After all it is just scientific information that needs to be explained in a visual way.