Medical Teacher

ISSN: 0142-159X (Print) 1466-187X (Online) Journal homepage: http://www.tandfonline.com/loi/imte20

Cartoon versus traditional self-study handouts

for medical students: CARTOON randomized
controlled trial

Detajin Junhasavasdikul, Kanokporn Sukhato, Suthan Srisangkaew,

Nawanan Theera-Ampornpunt, Thunyarat Anothaisintawee, Alan Dellow &
for the T-REX group

To cite this article: Detajin Junhasavasdikul, Kanokporn Sukhato, Suthan Srisangkaew, Nawanan
Theera-Ampornpunt, Thunyarat Anothaisintawee, Alan Dellow & for the T-REX group (2017)
Cartoon versus traditional self-study handouts for medical students: CARTOON randomized
controlled trial, Medical Teacher, 39:8, 836-843, DOI: 10.1080/0142159X.2017.1324137

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MEDICAL TEACHER, 2017
VOL. 39, NO. 8, 836–843
https://doi.org/10.1080/0142159X.2017.1324137

Cartoon versus traditional self-study handouts for medical students: CARTOON

randomized controlled trial
Detajin Junhasavasdikula , Kanokporn Sukhatob , Suthan Srisangkaewc, Nawanan Theera-Ampornpuntd ,
Thunyarat Anothaisintaweeb and Alan Dellowe: for the T-REX group
a
Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; bDepartment of Family
Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; cDepartment of Pathology, Faculty of
Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; dDepartment of Community Medicine, Faculty of Medicine
Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; eMedical Education Section, Faculty of Medicine Ramathibodi Hospital,
Mahidol University, Bangkok, Thailand

ABSTRACT
Objective: The objective of this study is to compare the effectiveness of a “cartoon-style” handout with a “traditional-style”
handout in a self-study assignment for preclinical medical students.
Methods: Third-year medical students (n ¼ 93) at the Faculty of Medicine Ramathibodi Hospital, Mahidol University, took a
pre-learning assessment of their knowledge of intercostal chest drainage. They were then randomly allocated to receive
either a “cartoon-style” or a “traditional-style” handout on the same topic. After studying these over a 2-week period,
students completed a post-learning assessment and estimated their levels of reading completion.
Results: Of the 79 participants completing the post-learning test, those in the cartoon-style group achieved a score
13.8% higher than the traditional-style group (p ¼ 0.018). A higher proportion of students in the cartoon-style group
reported reading 75% of the handout content (70.7% versus 42.1%). In post-hoc analyses, students whose cumulative
grade point averages (GPA) from previous academic assessments were in the middle and lower range achieved higher
scores with the cartoon-style handout than with the traditional one. In the lower-GPA group, the use of a cartoon-style
handout was independently associated with a higher score.
Conclusions: Students given a cartoon-style handout reported reading more of the material and achieved higher post-
learning test scores than students given a traditional handout.

Introduction
Recent years have witnessed a trend towards supplement-
Practical points
 Students given a cartoon-style handout for self-
ing traditional text formats with creative educational mate-
study reported reading more of the material and
rials. Cartoons, also known as graphic stories or comics,
achieved higher post-learning test scores than
appear prominently (Negrete & Lartigue 2004; Williams
those given a traditional handout.
2012; McNicol 2014) as they can serve an educational pur-
 Compared with traditional handouts, the use
pose by combining sequential images or pictures to give
of cartoon-style material for self-directed out-
visual clues to accompanying text (Mayer & Sims 1994;
of-classroom learning was associated with higher
Dalacosta et al. 2009; Cohn 2014). The “dual-coding model
post-learning test scores. However, this result was
of multimedia learning”, a combination of verbal and visual
not seen in a self-directed but time-limited class-
explanation, has been proposed as a way of improving
room session.
cognitive processes, especially when the materials are pre-
 A cartoon-style handout appeared particularly
sented in a coordinated way (Mayer & Sims 1994; Mayer
helpful to medical students whose previous
2010). Cartoons not only have a remarkable capacity to
assessments of performance were below average.
convey information but their use of symbols and pictures
can also attract their reader’s interest and provide a pleas-
urable reading experience (Gonz
alez-Espada 2003; Green &
Myers 2010; Branscum et al. 2013; Green 2013; Matsuzono for laypeople and patients (Delp & Jones 1996; Houts et al.
et al. 2015). 2006; Green & Myers 2010; Kennedy et al. 2014; McNicol
Cartoons have been used widely in education at many 2014; Matsuzono et al. 2015) is often termed “graphic
levels and in many areas, including literacy, science, and eth- medicine” (Green & Myers 2010; McNicol 2014; Williams
ics, with growing evidence of their effectiveness (Hutchinson 2016). Medical education has shown growing interest in
1949; Gonz
alez-Espada 2003; Gomez 2014; Hosler 2010; Mayer’s principles of focused multimedia presentation
Tuncel & Ayva 2010). Their use in health-related education (Mayer &Sims 1994), advocating the use of evidence-based

CONTACT Kanokporn Sukhato kanokporn.suk@mahidol.ac.th Department of Family Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol
University, 270 Rama VI Rd., Ratchathewi, Bangkok 10400, Thailand
Supplemental data for this article can be accessed here.
ß 2017 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License (http://creativecommons.org/licenses/by-nc-
nd/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or built
upon in any way.

materials and modes of delivery. Cartoons have proved to
be effective in teaching topics that range from ethical issues
to improving skills and attitudes such as empathy, communi-
cating with patients and colleagues, and clinical reasoning
(Green & Myers 2010; Lo-Fo-Wong et al. 2014; Green 2015;
McDonald et al. 2015). Less research has been undertaken
into the effectiveness of cartoons for transferring core med-
ical knowledge. Two studies suggested that preclinical stu-
dents achieved higher grades by reading recommended
learning materials in the form of comic strips containing
anatomical knowledge (Shin et al. 2013; Kim et al. 2016).
Another study reported improvements in the post-learning
scores of healthcare professionals and medical students after
using an online cartoon-based learning tool about the inter-
pretation of hepatitis B serology (Sim et al. 2014). However,
there has been no randomized controlled trial (RCT) to com-
pare cartoons with traditional text materials and to assess
relevant outcomes.
In many countries, cartoons are popular not only with
children but also with young adults (Fusanosuke 2003;
Wong 2006; Kishi et al. 2011; Sakamoto et al. 2014;
Shigehatake et al. 2014), suggesting that cartoons may be
a suitable medium for promoting medical student learning.
We wanted to know how cartoons (referring in this article
only to non-animated materials) perform when used as
tools to teach core medical knowledge to undergraduate
medical students. We, therefore, designed a study to com-
pare a “cartoon-style” handout with a “traditional-style” or
text-based handout used by pre-clinical medical students in
a self-study assignment. Our aim was to evaluate the effect-
iveness of these two approaches using a post-learning
knowledge assessment test.
Materials and methods
Study settings and participants
The cartoon versus traditional self-study handouts for med-
ical students (CARTOON) trial was a parallel-group RCT
Figure 1. Sample pages from the “Cartoon-style” handout (left) and the “Traditional-style” handout (right).
MEDICAL TEACHER 837
undertaken at the Faculty of Medicine Ramathibodi
Hospital, Mahidol University in Bangkok, Thailand. All third-
year medical students in 2015, in their final year of
pre-clinical placements, were eligible for the study.
Although not previously given any learning exercise con-
cerning intercostal drainage, they had studied the physi-
ology necessary to understand the topic. Students
volunteered to participate after receiving an explanation of
the study in class. The study was approved by the Ethics
Committee of the Faculty of Medicine Ramathibodi
Hospital, Mahidol University.
Intervention and comparison
The two types of handout on the topic “Basics of intercos-
tal chest drain (ICD) system: one and two-bottle ICD” were
developed by the first author (D. J.). These handouts
described the basic anatomy and physiology of the pleurae,
the causes of pneumothorax, the working principles of
intercostal drains, and the basic circuits of one and two
bottle ICD systems. Sample pages from both handouts can
be seen in Figure 1 and full versions can be accessed via
the following link: http://tiny.cc/cartoon_trial (available in
Thai and English).
The study intervention was the “cartoon-style” handout.
This was a series of hand-drawn pictures, 23 pages in
length. These represented anthropomorphic animal charac-
ters which interacted with each other following a storyline.
In the story, the characters encountered a pneumothorax,
developed a solution using basic physiologic principles,
and managed additional problems occurring afterwards.
Physiological aspects were described by using cartoon pic-
tures with metaphors, e.g. using a stream and a length of
tube to illustrate the principle of an underwater seal and
comparing the fluctuation of water in a tube with a straw
sucking water from a glass. The knowledge content was
conveyed through diagrams, narrative, conversations
between the characters (speech balloons) and by using
838 D. JUNHASAVASDIKUL ET AL.
additional text beneath each picture. The artwork was cre-
ated on paper and scanned into a computer for coloring
with Adobe Photoshop CC (Adobe Systems, Inc., San Jose,
CA). The language and fonts were of informal style, some
being hand-written, to match the nature of the cartoon.
Thai was used as the main language, except for specific
medical terms which were in English.
For comparison, a “traditional-style” handout was cre-
ated as a 10-page text-based document with computer-
generated color figures using Word 2013 and PowerPoint
2013 (Microsoft, Corp., Redmond, WA). Content was pre-
sented by mainly using text and diagrams. Unlike the car-
toon-style version, no metaphoric images were used and
comparisons were described in the text. Formal language
and fonts were used throughout this form of the handout.
Quality and comparability of handouts
To confirm face and content validity of the two handouts
and to verify that they were comparable, an independent
expert panel (consisting of two respiratory physicians, a car-
diothoracic surgeon, an emergency medicine physician and
a family physician) checked that both handouts were
equivalent in terms of information accuracy and compar-
ability of contents. This included ensuring that all content
presented in the cartoon version was also present either in
the text or as figures or diagrams in the traditional version.
Each of the experts qualitatively assessed the equivalence
of both versions, resulting only in minor suggestions about
formatting e.g. choice of coloring and clarity of the lines
drawn. We also asked a group of third year medical stu-
dents (n ¼ 21) from the Praboromarajchanok Medicine
Programme, Mahidol University, who were not involved in
the study phase, to give qualitative feedback on the clarity
of the handouts in conveying key concepts and on any
issues raised from reading them. This feedback was used to
improve the final version of both handouts. Additionally,
we conducted a pilot RCT with 152 second-year medical
students in a controlled-environment self-study assignment.
There were no significant differences in post-learning
assessment scores between the two groups using different
handouts (see eMethods in Supplemental material).
Study procedure
After giving written informed and signed consent, partici-
pants took a pre-learning multiple-choice question (MCQ)
test. All participants were advised that no part of the test
would be used for their formal academic assessment. A
lapse period of 2 weeks was then allowed to minimize any
carry-over effect. Students were then allocated to two
groups using a computer-generated simple randomization
program and were given either a cartoon-style or trad-
itional-style handout in a sealed envelope. Participants
were told they had two weeks to study the material indi-
vidually, whenever it suited them. The use of other learning
materials was discouraged and was to be reported. After
the learning period, students returned to take a post-learn-
ing test using the same MCQ used in the pre-learning test.
Data collection
We collected baseline characteristics of the study partici-
pants i.e. age, sex, and cumulative grade point average
(GPA). Student preferences for reading cartoons in daily life
were rated using a 5-point Likert scale (strongly unfavored,
unfavored, neutral, favored, strongly favored).
Outcome measurements
Primary outcome
The primary outcome was the post-learning MCQ test
scores. The pre-test and post-test scores from the newly
created 20-question MCQ were used to assess participants’
recall of knowledge, their understanding of the information,
and their ability to apply knowledge about ICD (stated as
learning objectives on the first page of both handouts).
The expert panel were asked how well our MCQs sampled
the range of content knowledge and the various cognitive
levels that students were supposed to acquire. They were
also directed to ensure that the multiple choice questions
were related to topics included in our handouts or could
be answered by applying concepts stated or implied in the
learning materials. The MCQ paper was then tested by the
group of students from the Praboromarajchanok Medicine
Programme previously described. After further adjustments,
the MCQs were piloted in a study with second-year medical
students (see eMethods in Supplemental material) before
being used in the current RCT. Cronbach’s alpha was calcu-
lated from post-learning test scores as a measure of the
internal consistency reliability of the test. An English ver-
sion of the MCQ can be seen in eMaterials (Supplemental
material).
Secondary outcome
We wanted to compare the attention given to the study
materials by assessing levels of reading completion in the
two groups of students. Each participant was asked to self-
report his or her level of reading completion using a 5-
point Likert scale (0%, <25%, <50%, <75%, and 75% of
all handout content). Attention differences between the
two arms of the trial were measured by comparing the pro-
portion of students who reported having read 75% of the
assigned handout contents.
Sample size calculation
We calculated the sample size from the mean post-learning
test score of the control group in the pilot trial, i.e. 15.69
(SD 2.26). To detect a 10% difference between the post-
learning test scores of the groups, with a 2-sided type I
error rate of 0.05 and power of 80%, we needed 72 partici-
pants (i.e. at least 90 students, allowing for an estimated
loss-to-follow-up rate of 20%).
Data analysis
Continuous parameters were presented by mean (with
standard deviation) and categorical data were presented by
frequency (percentage). For primary outcomes, we used the
unpaired T-test to compare the differences between the
post-learning test scores of the groups. For secondary out-
comes, attention differences were analyzed with Chi-square.
A two-sided test with p value <0.05 was considered to
 MEDICAL TEACHER 839

be statistically significant. Data were analyzed using SPSS
version 16.0 for Windows (SPSS, Inc., Chicago, IL).
Analysis was performed on an intention-to-treat basis.
We also asked participants about “cross-group” reading of
un-assigned handouts (contamination), measured as the
amount of read content using a self-reported 5-point Likert
scale similar to the one used to assess the secondary out-
come. If any participant reported having read >25% of
unauthorized content, additional per-protocol analysis
would be performed with the exclusion of the participant.
To discover whether or not our handouts were equally
effective among students with different levels of academic
achievement, we categorized students into three groups
based on quartiles of their previous GPAs, namely an
upper-GPA group (GPA above the third quartile), lower-GPA
group (GPA below the first quartile), and middle group
(GPA within the interquartile range). Post-hoc analyses
were undertaken to compare post-learning test scores and
attention differences between students in the same GPA
group.

Figure 2. Participant flow and randomization of the trial.

Figure 3. Pre-learning test and post-learning test scores of students receiving cartoon-style and traditional-style handouts. The numbers shown are mean
(± SD) and the error bars demarcate the range of ± 1SD (Total test score: 20 marks).

Table 1. Baseline characteristics of the students.

By group
Characteristics Overall (n ¼ 79) Cartoon-style (n ¼ 41) Traditional-style (n ¼ 38)
Sex: female, n (%) 33 (41.8) 18 (43.9) 15 (39.5)
Age (year): mean (SD) 21.3 (1.5) 21.1 (0.6) 21.4 (2.1)
GPA: mean (SD) 3.20 (0.36) 3.23 (0.36) 3.17 (0.36)
Cartoon preference, n (%)
Favored and strongly favored 57 (72.2) 29 (70.7) 28 (73.7)
Neutral 20 (25.3) 11 (26.8) 9 (23.7)
Unfavored and strongly unfavored 2 (2.5) 1 (2.4) 1 (2.6)
840 D. JUNHASAVASDIKUL ET AL.
Figure 4. A histogram showing detailed levels of reading completion in each
group.
Figure 5. Correlation between level of reading completion for all participants
and the post-learning test score (Spearman’s rho ¼ 0.553, p < 0.001).
Results
Baseline characteristics
We recruited 93 volunteers from 179 eligible students.
Seventy-nine participants attended the post-learning test
session and were included in the analysis (Figure 2). There
was no statistically significant difference in baseline charac-
teristics between the two groups (Table 1).
Primary outcome: the post-learning test score
Before the self-learning session, there was no significant dif-
ference between the test scores of either group. After their
learning sessions, all students had significant score
improvements (paired T-test p values of <0.001 and 0.002
for the cartoon-style and traditional-style groups respect-
ively). For the primary outcome, students using the car-
toon-style handout performed better than those using the
traditional-style handout, with a mean post-learning test
score of 1.69 marks (13.8%) higher (p ¼ 0.018) (Figure 3).
Cronbach’s alpha for post-learning test scores was 0.663.
One participant in the traditional-style group declared also
reading the cartoon-style handout but only to an extent
<25% of total content, lower than our predefined threshold
for contamination. None of the students reported using
additional learning materials related to our topic.
Secondary outcomes: students’ attention and level of
reading completion
More students in the cartoon-style group (70.7%) reported
having read 75% of the assigned handout content
Figure 6. The post-learning test score of the students who read the cartoon-
style and the traditional materials, categorized by the quartile of their GPAs.
The numbers shown are mean (± SD) and the error bars demarcate the range
of ± 1SD.
compared with the traditional-style group (42.1%); p ¼ 0.01
by Chi-square (Figure 4). The level of reading completion
correlated significantly with the post-learning test score, i.e.
the more content read, the higher the score achieved
(Spearman’s rho ¼ 0.553, p < 0.001) (Figure 5). This was true
for students receiving either type of material.
Multivariate linear regression analysis of two factors
associated with the post-learning test score (i.e. the type of
handout being cartoon-style and the level of reading com-
pletion) showed only the level of reading completion to be
independently associated with the post-learning test score
with beta-coefficient of 1.07 (95% CI: 0.65, 1.50) (eTable 1
in Supplemental material).
Outcomes for students with different previous
academic achievements
There were no significant differences in baseline characteris-
tic or pre-learning test scores for any of the student groups
categorized by quartiles of GPAs (eTable 2 in Supplemental
material). However, students in the lower and middle GPA
groups who had been given the cartoon handout achieved
significantly higher post-learning test scores than those who
had used the traditional handout (Figure 6). Moreover, in
these two groups, the number of students who reported
having read 75% of the handout content tended to be
higher for the cartoon material. The level of reading comple-
tion also correlated with the post-learning test score
(eFigures 1 and 2 in Supplemental material).
After adjusting for the level of reading completion by
multiple linear regression, the use of the cartoon-style
material by students in the lower-GPA group was inde-
pendently associated with higher post-learning test scores
(beta coefficient 2.47, 95% CI: 0.69-4.24). For the same level
of reading completion, the use of cartoon-style material in
this group of students would result in a post-learning test
score 2.47 marks higher than would be achieved using the
traditional handout. However, this result was not observed
for students in the middle and upper-GPA groups, in which,
the level of reading completion was solely an independent
factor for the post-learning test score (eTable 3 in
Supplemental material).
Discussion
Our study found that students given a cartoon-style handout
for self-study achieved higher post-learning test scores and

reported higher levels of reading completion of the material
compared with students given a traditional handout. The
level of reading completion was positively associated with
post-learning test scores. Interestingly, in the post-hoc analy-
ses, students with previous GPAs in the lower and middle
range achieved significantly higher post-learning test scores
using the cartoon-style handout than those assigned to read
the traditional-style handout. This effect was strongest in
students in the lower-GPA group and independent of the
reported level of reading completion.
The results of our RCT support the findings of previous
observation and quasi-experimental studies showing that
cartoon-style handouts can help learners to understand
complex medical content (Shin et al. 2013; Sim et al. 2014;
Joshi et al. 2015; Kim et al. 2016). This suggests that using
carefully designed cartoons can equal or better the results
achieved with traditional materials. There could be two
explanations for our observed outcomes. First, cartoons may
be better able to attract and sustain a reader’s attention
throughout a reading session. In our research, students who
received a cartoon handout reported higher levels of read-
ing completion than students using traditional materials.
Furthermore, linear regression analysis showed an associ-
ation between levels of reading completion and higher
post-learning test scores. This supports the results of previ-
ous studies demonstrating an increase in motivation and
interest when cartoon-based educational materials
were used (Houts et al. 2006; Sim et al. 2014). Second, a car-
toon-style handout may be better able to aid student under-
standing and retention of complex medical concepts
through three mechanisms. (1) “Combining pictures with
text messages”. One of the principles of the dual coding the-
ory of multimedia learning is that the concurrent presenta-
tion of verbal and visual descriptions enhances
understanding of a topic by helping students to build men-
tal connections between both channels (Mayer & Sims 1994;
Mayer 2001, 2010; Issa et al. 2011). (2) “Metaphors and ana-
logy”. These help students to connect the concrete with the
abstract, prior knowledge with unfamiliar concepts, and lan-
guage with images (Wormeli 2009; Niebert et al. 2012).
Metaphors can also promote assimilation and “structurizing”
(Evans & Evans 1989). (3) “Story telling”. This provides a scaf-
fold to aid memorization of content, with cartoon characters
making the material more concrete (Green 2004). Stories not
only stimulate cognition but also engage the readers’ emo-
tions, including imagination and the recall of past experien-
ces (Clark & Rossiter 2008). Emotions provoked during
academic sessions have been shown to be related to motiv-
ation, self-regulation, and achievement of learning (Pekrun
et al. 2002; Dirkx 2006). Cartoon characters and a storyline
may help students to engage emotionally with educational
content, motivating them to continue reading and perhaps
aiding memorization.
The benefits of the cartoon handout seen in our main
RCT were not duplicated in our pilot study, which used the
same set of handouts but resulted in similar post-learning
test scores for both groups. However, the two studies had
important differences. The pilot study was performed in a
classroom setting with a fixed period of learning time
whereas our main study allowed students to use the mate-
rials out-of-class and in their own time. We conclude that
cartoons may be more effective when used for flexible
home study than in time-limited classroom settings.
MEDICAL TEACHER 841
When exploring how different handout styles affected
students with different levels of academic achievement, we
found that students in the lower and middle GPA levels
learned significantly more when reading a cartoon-style
handout while students in the upper GPA group performed
equally well with cartoons or traditional material. Our
results imply that the cartoon-style handout particularly
helped students in the lower academic achievement group.
Some students in this group may have difficulties dealing
with the complexity and quantity of information taught in
medical school when this is presented only in a traditional
way. As mentioned previously, a well-designed cartoon-
style handout may be able to aid understanding in ways
that a traditional text handout cannot.
To the best of our knowledge, this is the first RCT to
comprehensively address the effectiveness of a cartoon-
style handout in the area of medical education. Students
with no pre-existing knowledge of ICD were randomly allo-
cated to intervention and control groups, thus minimizing
selection and confounding bias. As self-study sessions can
be confounded by multiple and uncontrollable environ-
mental factors, we designed and conducted a pilot RCT in
the controlled environment of a classroom in order to test
the equivalence of efficacy of the two types of handout
before using these in our main study.
Despite these strengths, our study has some important
limitations. First, participants were drawn from a single
medical school, thus limiting generalizability for students at
other levels and in other settings. Second, we were not
able to blind participants to their assigned group and the
novelty of the cartoon handout may have resulted in it
receiving greater student attention. Third, all participants
were Thai and their perceptions of cartoon-based material
may differ from those in other countries and cultures.
According to a survey of the Publishers and Booksellers
Association of Thailand, cartoons and graphic novels are
the most widely read categories of book for Thai adult
reading (PUBAT 2015). Although the relevance of our trial
results to other parts of the world and to different reading
cultures is at present unknown, the potential for suitably
adapted cartoons to be an effective cross-cultural tool
remains. Lastly, our MCQs may have limitations when used
to assess higher learning objectives such as comprehen-
sion, application and analysis. Evaluating the translation of
learning into practice may require a different assessment
tool but this is beyond the design of our present study.
Given that our multiple choice questions tested different
aspects of the topic and different levels of learning, inher-
ent heterogeneity in the test led to relatively low
Cronbach’s alpha internal consistency reliability, especially
with the low sample size of the study. Nevertheless,
Cronbach’s alpha for the main study was sufficient
(Nunnally 1967). In addition, as we had not pre-defined
GPA subgroups at the outset of our study, differences in
the effectiveness of cartoons among students in different
quartiles of GPA should be interpreted with care. However,
our post-hoc analyses raise the possibility that cartoon
material may achieve different responses from students of
varying academic ability. Differences in outcome could also
relate to learning-styles, which were not explored in this
study. These factors should be probed in future research,
with pre-planned subgroup analyses and larger sample
sizes.
842 D. JUNHASAVASDIKUL ET AL.
The traditional academic style currently in use to present
information may not be appropriate for every student. This
study gives a new and positive message for the use of car-
toon materials in teaching and learning. For most medical
students, carefully designed cartoon-style handouts can
transfer core medical knowledge as well as, if not better
than, traditional handouts. Developing innovative
approaches to learning may result in better outcomes,
especially for those deemed previously to have below aver-
age academic ability. Creating high-quality cartoon material
may seem daunting but, in our view, the most important
issue is not necessarily the need for an artist with medical
knowledge. Any medical teacher with the ability to tell a
story can work alongside an artist to produce cartoon les-
sons. Our experience also shows us that talented medical
students with a passion for drawing cartoons represent an
untapped resource. From an academic perspective, future
research is needed to evaluate the use of cartoons for a
variety of learning outcomes and to establish long-term
results. The influence of preferred learning styles and the
impact of geographically different reading cultures should
also be taken into account. Finally, we do not know what
style of cartoon or what sort of characters is likely to
achieve the best results.
Conclusions
Our RCT found that a cartoon-style handout was able to
attract more of a student’s attention and result in a higher
post-learning test score when compared with a traditional
handout. This effect appeared to be most marked in stu-
dents with previously low academic evaluations and was
independent of other factors. We hope that our study will
encourage medical educators to consider using cartoon-
style materials and to undertake further research into their
effectiveness and popularity with students.
Glossary
Graphic medicine: The use of comics or cartoons or graphic
stories in the study and delivery of healthcare. This includes
the role in patient care, medical education, and the social cri-
tique of the medical profession.
Notes on contributors
Detajin Junhasavasdikul, MD, is a Lecturer in Pulmonary and
Respiratory Critical Care Medicine at the Department of Medicine,
Faculty of Medicine Ramathibodi Hospital, Mahidol University.
Kanokporn Sukhato, DipMedEd, MD, is an Assistant Professor and
Director of the undergraduate program at the Department of Family
Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol
University.
Suthan Srisangkaew, MD, is a Lecturer at the Department of
Pathology, and an Assistant Dean for Education at the Faculty of
Medicine Ramathibodi Hospital, Mahidol University.
Nawanan Theera-Ampornpunt, MD, PhD, is a Lecturer at the
Department of Community Medicine, Faculty of Medicine Ramathibodi
Hospital, Mahidol University.
Thunyarat Anothaisintawee, MD, PhD, is an Assistant Professor at the
Department of Family Medicine, Faculty of Medicine Ramathibodi
Hospital, Mahidol University.
Alan Dellow, MMedEd, FRCGP, is an educational research advisor at
the Department of Family Medicine, Faculty of Medicine Ramathibodi
Hospital, Mahidol University.
Teamwork for Ramathibodi Educational eXcellence (T-REX) collabora-
tors: Kanokporn Sukhato, DipMedEd, MD (Department of Family
Medicine), Detajin Junhasavasdikul, MD (Department of Medicine),
Suthan Srisangkaew, MD (Department of Pathology), Nawanan Theera-
Ampornpunt, MD, PhD (Department of Community Medicine),
Thunyarat Anothaisintawee, MD, PhD (Department of Family Medicine),
Chathaya Wongrathanandha, MD, MPH, MSc (Department of Family
Medicine), Marut Chantra, MD (Department of Pediatrics), Wisarn
Worasuwannarak, MD (Department of Pathology), Itthipon Wongprom,
MD (Department of Family Medicine), Alan Dellow, MMedEd, FRCGP
(Medical Education Section); Faculty of Medicine Ramathibodi Hospital,
Mahidol University, Bangkok, Thailand.
Acknowledgements
The authors would like to show their gratitude towards the expert
panel who contributed to the revision of the learning materials and
test questions. The panel consisted of Prof. Sumalee Kiatboonsri
(Pulmonary and Pulmonary Critical Care Medicine), Asst. Prof. Saipin
Hathirat (Family Medicine), Dr. Viratch Tangsujaritvijit (Pulmonary and
Pulmonary Critical Care Medicine), Dr. Zyam Kacharoen (Cardiovascular
and Thoracic Surgery) and Dr. Arrug Wibulpolprasert (Emergency
Medicine); Faculty of Medicine Ramathibodi Hospital, Mahidol
University, Bangkok, Thailand. The authors would also like to thank the
volunteer students from Praboromarajchanok Medicine Programme,
the participants from the Faculty of Medicine Ramathibodi Hospital,
and all personnel from the Faculty’s Medical Education Section who
assisted in the study. The authors also thank Dr. Martin Urner
(Interdepartmental Division of Critical Care Medicine, University of
Toronto) for additional opinions regarding statistical analysis.
Disclosure statement
All authors have completed and submitted the ICMJE Form for disclos-
ure of Potential Conflicts of Interest. D. J. declared that the cartoon
characters depicted in the handout in this study are sold for nominal
profit by D. J. as stickers for LINE, an instant messaging and social
media application.
The other authors report no conflicts of interest. The authors alone
are responsible for the content and writing of this article.
Ethical consideration
This study followed the World Medical Association declaration of
Helsinki ethical principles and was approved by the Ethics Committee
of Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.
Trial registration
This trial assigned medical students to intervention and comparison/
control groups with the purpose to examine only the effect on the
knowledge or attitudes. The registration was thus not performed.
Previous presentation
This study was presented in abstract form as a poster presentation at
the 13th Asia Pacific Medical Education Conference (APMEC) 2016; 15
January 2016; Singapore.
Funding
This research received a grant from the Faculty of Medicine
Ramathibodi Hospital, Mahidol University. The funder had no role in
the design and conduct of the study; collection, management, analysis,
and interpretation of the data; preparation, review, or approval of the
manuscript; and decision to submit the manuscript for publication.

ORCID
Detajin Junhasavasdikul http://orcid.org/0000-0002-0300-407X
Kanokporn Sukhato http://orcid.org/0000-0001-8034-8020
Nawanan Theera-Ampornpunt http://orcid.org/0000-0002-3322-
4145
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