Q&A with Physician-Comic Author: Dr. Omar Mirza

Dr. Omar Mirza is a consultation-liaison psychiatrist based in New York City. He also co-creates the comic series Zindan: The Last Ansaars with his friend and nephrologist Dr. Khurram Mehtabdin (see their interview here). Now, Dr. Mirza is bringing comic books to medical education with his newest comic series published by Roaring Sun Studios, The C-L Psychiatrist. The first installment presents decisional capacity with an antiracist lens by using the ethical principles of autonomy versus beneficence and Dr. Mirza’s F.R.E.E. W.I.L.L. pneumonic that he teaches to trainees. You can purchase the first installment here.

Tell us a little about yourself and the work that you do.

My name is Omar Mirza and I am an academic Consultation-Liaison Psychiatrist based in New York City. I moved out to New York City from Ohio where I grew up about 13 years ago. I went to medical school at Touro College of Osteopathic Medicine New York and then completed my general psychiatry residency training at SUNY Downstate Medical Center. After I completed residency, I went on to do a fellowship in psychosomatic medicine at Mount Sinai West/St. Luke’s, which is now Mt. Sinai West/Morningside. I took on my first attending job at Mt. Sinai where I worked as a transplant psychiatrist and assistant program director for the psychosomatic medicine fellowship at Icahn School of Medicine. I recently joined Harlem Hospital where I am the director of Consultation-Liaison Psychiatry. As an academic psychiatrist, much of the work I do involves clinical service and teaching residents or medical students. 

How did you get into writing in the first place? 

As you recall from my last profile on Student Doctor Network, writing came out of my love for comics as a child. As far back as I can remember I have loved comic books and the intersection between visual and narrative arts. Ironically, writing was not always my strongest subject in school. Coming from a South Asian background I was always nurtured towards math and science (with the hopes of becoming a doctor). Writing, however, was overlooked and became a subject that I really struggled in. I had so much trouble in writing that I needed a few years of tutoring to get my grades up in my writing class. It wasn’t until high school that I realized I could be an ok writer. Writing comics didn’t really manifest until my residency when I decided I needed a creative outlet to offset all the time/effort I spent studying medicine.  I had always dreamed up stories in my head but never actually put them down on paper. At this time, I was also wrestling with the lack of South Asian representation in media, particularly comics. Desiring to see that representation, and to finally stop making excuses for why not to create my own stories, I partnered with my med school roommate to launch a South Asian historical fantasy comic [Zindan: The Last Ansaars]. Since then, I wrote a political satire series [The Incapable Trump] and contributed to a few anthologies. The writing/creating bug has bitten and I can’t stop!

Why graphic medicine? Is there a difference between graphic medicine and graphic novels or comic books?

Looking back, the arts and science were always two distinct and separate interests for me. The psychological boundary between these two passions persisted throughout my life where I saw these two spheres of interest as incompatible with each other. In many ways, this pattern was reinforced through the organization of my education. Art and humanities were rarely represented in my educational path to medicine and thus reinforced the idea that these were divergent interests. As such, I often viewed these two interests as escapes from one another and worked to uphold boundaries between them.  It wasn’t until I picked up the Graphic Medicine Manifesto, that I was introduced to the principles of the field of graphic medicine. Through the reflections of the six pioneers that collaborated to create the text, I became familiar with how graphic medicine employed the graphic novel medium to explore medicine and illness. As such, graphic medicine is simply a genre-specific form of graphic narrative or comics. Like many other useful examples of comics and graphic novels, graphic medicine is an exciting tool for teaching as well as portraying particular experiences. Realizing that the graphic narrative medium can be effectively integrated with the study of medicine, inspired me to dismantle the boundaries I had built between my two interests and fully embrace these dual passions of mine.  

What was the inspiration behind The C-L Psychiatrist comic series?

The C-L Psychiatrist comic series is inspired by my love for consultation-liaison psychiatry and teaching. As an academic psychiatrist, I am always looking for engaging ways to teach psychiatry and foster interest in the subspecialty of consultation-liaison. In The C-L Psychiatrist, I am trying to use the graphic narrative medium to give a glimpse into the world of consultation-liaison psychiatrists and the thought process behind certain clinical scenarios. My hope is that students, trainees and practitioners of all types will find it to be an easily digestible and memorable way to learn complex topics within psychiatry.

What was the process of writing The C-L Psychiatrist comic series like?

Interestingly, this was probably one of the easiest writing experiences I have had in comics even though it is one of my longest by page count. I approached this series by adapting a topic that I have taught and reviewed multiple times in my professional career. Using the framework from grand rounds presentations and didactic lectures I have given, I was able to quickly draft a script.  The script focused on conveying teaching points through a clinical case. What made the graphic narrative medium particularly useful in this case was the ability to simultaneous portray spoken dialogue and the internal thought process of the main character. This allows reader to see how interactions may play out, but also the background decisional process that leads to that particular interaction. I also wanted to include some text that would expand on aspects that were being portrayed in the panels. Using the citations and research that I had collected for the grand rounds presentations, I included various long-form footnotes that assist in the progression of the clinical case.

The front cover portrays a scene where a Black man is being physically restrained on a hospital bed while white medical professionals surround him. The Black man exclaims “Let me go!” while a white man in a green gown says “Call psychiatry! I’m afraid he does not have capacity!” I imagine that the cover art can be provocative to some people. How was it developed?  

The cover has certainly invoked a variety of responses. This was definitely the intention. The cover was designed with a specific eye to the potentially racist nature of capacity assessments. This idea is motivated by a manuscript I just finished that examined capacity consults over a two-year period at a tertiary academic center. Unsurprisingly, we found a disproportionate representation of BIPOC [Black, Indigenous, People of Color] in those for which capacity consults were requested (a graphic abstract of this manuscript is included in the book). Understanding the reality and the implications of the capacity assessment, it was important for me to convey this on the cover. As you can see, the BIPOC character is faced with an uncomfortably abusive situation while being surrounded by characters that appear to hold a lot of power. It is my experience that many capacity questions are precipitated by BIPOC expressing emotions around treatment recommendations. As such they are disproportionately placed into coercive or abusive situations in which their autonomy is called into question as depicted on the cover.

Secondly, the cover is a nod to arguably the greatest cover artist of all time, Alex Schomburg. In addition to being a prolific golden age cover artist (Captain America, Human Torch, The Submariner, Black Terror, Fighting Yank, Green Hornet), Schomburg was known for his elaborate “bondage” covers. These covers are highly recognizable for innocent characters centered in dramatic scenes of impending torture by a villain. A hero (for which the comic was often named) was usually off-center, about to spring into action. In trying to capture those themes in this cover, I placed the central character in bondage (restraints) surrounded by healthcare workers attempting to force treatment. The health care professionals are dressed in uniforms reflective of the World War 2 era in which Schomburg was most active. What’s noticeably absent is the hero on the cover. This was in order to reflect the fact that patients are often not “saved” from forced treatments. You might assume the hero is going to be the C-L psychiatrist (given the name of the comic), but the villains in this cover are actually calling for the psychiatrists to help facilitate the impending treatment. This was a conscious choice to explore if the psychiatrist is complicit in these acts, or truly the last chance to save the patient from the horrors of forced treatment. Unfortunately, in the eyes of the patient, the psychiatrist is often not the hero. If there is any discomfort evoked from the cover image, it was my hope that it would cause the reader to reflect on how this routine clinical encounter can be another act of systemic racism for BIPOC and force reflection on how we challenge capacity within our practices

The front cover references the Applebaum Criteria. Could you describe what that is?

[Drs. Paul S. Applebaum, M.D. and Thomas Grisso, Ph.D.] wrote the seminal article on capacity which introduced a model by which clinicians can assess a patient’s capacity to consent to treatment. The model includes four major required skills including communicating a choice, understanding relevant information, appreciating the current situation/consequences, and rationally manipulating information. This model is the standard of practice when it comes to capacity assessment and has been a very helpful way to standardize the approach to capacity assessments.

Tell us more about how your dynamic model for decisional capacity expands on the Applebaum Criteria. Could you give some examples?

While the Appelbaum Criteria is a valuable model for the skills required to demonstrate the capacity to consent, I find that it fails to give a broader structure on how to approach the question of capacity. For this reason, the Applebaum Criteria only provides guidance for a small component of the capacity question. In the model that I propose in the book, I provide a comprehensive guide on how to approach the question from start to finish. This guide is structured around the pneumonic “F.R.E.E. W.I.L.L” which I use to teach this model of capacity to trainees. The elements contained in “F.R.E.E” can all be completed before seeing the patient, while “W.I.L.L” references the approach to seeing the patient. The model also differs in that it is designed to troubleshoot the issue of capacity in a way that does not ultimately lead to a capacity determination. This is based on the fact that concrete applications of the Appelbaum Criteria only further the potential structural racism that patients experience within the healthcare system.

How do social identities, like race and ethnicity, affect decisions around capacity? Do you have examples from the consultation liaison work you’ve done in the hospital? 

As I mentioned earlier, social identities play a significant role in capacity. The manuscript I just finished highlights these findings in which people from Black or Hispanic backgrounds are overrepresented in capacity questions. The bio-essentialist mistake would be to conclude that there is something intrinsic about these populations in which they require higher degrees of capacity interrogation than others, but when you look at it from a structurally competent lens you understand this reflects the bias that is built into structures. Capacity is not immune to the vulnerability to structural racism and this has been something I have observed multiple times throughout my consultation work. Individuals that come from backgrounds of social power or privilege are given greater latitude with respect to their choices in healthcare than patients who are not of those same backgrounds. Being aware of this and working consciously to counteract this reality is one of the main motivations for trying to go beyond the Appelbaum Criteria.

Any words of wisdom for medical students and trainees who want to get involved in graphic medicine?

I would encourage everyone that is interested to pick up a copy of The Graphic Medicine Manifesto. It is full of incredible knowledge and experience from the pioneers of the field! In addition, there is a graphic medicine community on www.graphicmedicine.org that hosts an annual conference where you can connect with others interested in graphic medicine. There are also medical humanities departments at various medical schools around the country that host graphic medicine courses. Outside of that, I would be happy to connect with anyone that is interested or has questions!

What other exciting projects do you have in store for the future? What should we keep an eye out for? 

The next project for me will be to try to tackle the next volume in The C-L Psychiatrist. I am still narrowing down some topics and will rely on the feedback from readers on what I should cover next. I hope to get started on writing in the coming weeks. Aside from this, I hope to continue work on some ongoing comic series like Zindan: The Last Ansaars and The Incapable Trump.

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