Robert J. Demarest - 1989 AMI Presidential Address



Editor's Note

Bob Demarest's Presidential Address is reprinted from the AMI News, Vol. 30, No. 7, 1989. This was his second AMI Presidential Address. Bob's address identifies those timeless fundamentals that help us create memorable medical illustrations.


Gary Schnitz, JBC Board Chair and Co-editor



Background Twenty years ago in my Presidential Address before this Association, I said that we need not be intimidated if, in the future, all of our pencils should become electronic. I believed, then as now, that it is the mind behind the pencil, electronic or otherwise, that makes all the difference.

Today with many of you working on monitors, with computer images part of your daily life, I am going back to the fundamentals. The fundamental strengths, which will ensure our future. If we neglect these fundamentals, we will quietly, but surely, turn our future over to outsiders, some of whom are already producing images that they do not understand. Our strength is in our knowledge, our skills, and our ability to communicate medical and scientific information. We must not hide or neglect these strengths. Underlying all of the accomplishments of our Association is the vitality of the profession itself, and behind the vitality is the quality of the product that we produce. Whether we work with pen and ink, brush, or computer, there are certain fundamentals that must perfuse our output.


There are, if you will, fundamental truths with which we must not lose touch. We need to articulate them on occasions. So, I will be talking about fundamental things today. You need not agree with all that I say. You may argue with my definitions. You may want to substitute, or add, retract, or even object to some of my thoughts. But think about them you must. For what I will be talking about is the very fiber and substance of our field. I started preparing this talk many times before I realized that I have only one speech, one message. Those of you have heard me speak through the years, have heard bits here and parts there. Sometimes more, sometimes less. But really only one message. It is my best message. So for those of you who have heard it, there is new packaging today. For those of you who have not, well I look forward to saying it anew. I think that you'll not be bored; I hope that you'll find it meaningful.




Our world is changing. Visual methods of presenting information are gaining legitimacy and acceptance. The medical illustrator is riding the crest of the information wave. Our pictures are seducing even the most sophisticated audience. Our work is starting to grab the legs of the physician, and even the most verbal of all professions, the lawyer, is being affected. This is fairly recent. I think that most of you were born before the first piece of demonstrative evidence was ever introduced into the courtroom. But visual illiteracy is still the norm with many of our clients. They have little or no idea of what an illustrator can do to help them communicate information.


The average client comes to an illustrator to buy a pair of talented hands and to do what he tells those hands to do. Seldom does he or she come to buy the intelligence behind those hands. But that's OK. We don't have to parade our minds before our clients. That spectacle would be unbearable.


But I am tired of hearing one or another variation of, "It must be nice to get paid to paint pictures." Implicit in this is the assumption that what we do is easy, that the results flow from the brush without effort, or that the results just happen. That we were simply told what to do. Indeed, this concept is behind much of the work-made-for-hire problem. Fortunately, clients are changing. Truly, if that was all there was to it… just taking directions, I wouldn't be here today, and you wouldn't be here today. I wouldn't have had such an exciting life, nor would I feel that I've spent my life in such a worthwhile way.




What is unique about what we do as medical illustrators, and what separates us from other illustrators? Unlike most artists or general illustrators, we must be subject matter experts, amassing an ever-increasing body of knowledge – a bank of information - which grows throughout our lives. We develop motor skills, learn painting techniques, and then, when an assignment comes in, we draw on all of this. We tap into our knowledge pool, which includes content experts, resource books, and data banks to create medical illustrations…. illustrations that teach, illustrations that communicate information.


How do we do it?


Let's follow an assignment through its familiar route. While doing this, let's look behind those talented hands. The client comes in with a request; he wants to show how he clips an aneurysm, or perhaps he wants to show his technique for a total hip arthroplasty, or any one of the hundreds of requests that we all get.


Let's go into the O.R. with him. Here we are with a camera and sketchpad, and what we do we do? We ask questions! That's what we do! We ask, "What is this? Why are you doing that? Explain what you just did. Why did you remove that? What's the nerve?" So many questions that the surgeon wonders why we aren't taking pictures or sketching. And if he knew what I was taking my pictures for, when I did take them, he might be surprised. It's only for the position of the hands, the instruments, the pull of the skin, or the way the towel is folded. The main reason I'm there is to ask questions and understand what he's doing. The photos and sketches are only peripheral. My illustrations of the surgery emanate from understanding the procedure, not from my sketches. We draw what we know, and we can only draw well if we know the subject and know it well. This is an axiom in our field, "We can only communicate what we understand." Everyone of you can look at a drawing of a femur by a pair of talented hands that belong to a general art student and recognize it for what it is - an interesting study of a bone. But it's almost totally useless as a medical illustration. No matter how good of an observer, if you don't understand the "why" of the femur, you have simply created a "study."


We can only communicate what we understand. That should be inculcated in every medical illustration student and whispered to ourselves whenever we start a new assignment.


Illustrating what we know is easy to say, but let's look at what's involved. We can't understand surgery unless we understand the anatomy and the physiology. Often embryology makes everything clear, as is the case in many congenital heart defects. This knowledge, which many of our younger members are just starting to acquire now, is the base upon which they will build their careers. We should never stop adding to that base.


This business of illustrating what we know concerns me a great deal. I like to turn it around so it doesn't become too familiar of a cliché. What it really means is that we must know what we don't know! If you put down a line, that line is a statement of fact. If you don't know why you are putting it down, you better look it up! Unfortunately, I work with too many professionals who don't heed that advice.


As we start to prepare our illustrations, we ask ourselves, "Who is going to learn from them, who will be the audience?" And that questionnaturally leads us to the next topic - know your audience.

Know Your Audience

Sounds easy… "know your audience," but it means knowing what the audience knows and what it doesn't know. That means putting yourself in the audience.


And we must give each audience enough familiar material so that the "new" fits in and they understand it. As we move through a book, from chapter to chapter, the audience's understanding grows. Likewise, just as a child or a student moves up the educational ladder, his knowledge base grows with him or her. With any audience, what we include in our illustrations must change with our knowledge of our audience and with our audience's knowledge.


You'll note in my neuroanatomy book that I start with an illustration of the brain in the head. Included is a nose, which visually indicates the front of the head (and brain) for orientation. The head shape provides a recognizable reference for size and situation. I can soon drop the nose and the head shape, for very quickly the brain cortex alone becomes orientation enough. Later, the thalamus alone may be sufficient orientation for the groups of nuclei that we're illustrating. Here, however, I would certainly not change the direction of view, or change the front to back, or switch from the right hemisphere to the left. I don't want my audience to stop and ask themselves, "Where am I?"


This leads naturally to how much we should include in an illustration. How much information is enough? There is very real temptation to overload an illustration or a surgical plate with many separate pictures all crowed together. The day when the cost of reproduction was a major consideration in an illustrated book, has now evolved into an era where a profusely illustrated book is a major selling point. Today we can, and should, use more illustrations, each making a single point. Each with just enough orientation to guide the viewer, using accent and highlighting for the message – then move on to the next point to be made. The illustrations should pace the text or pace the lecture.


In a era of fast moving television shows and commercials, a great many images are essential. A lecturer can no longer get away with a few slides overloaded with information. Here, I'm reminded of a seasoned lecturer, who uses one overloaded slide, filled with information, with text much too small to see. He keeps referring to it line-by-line, point-by-point. Soon you start to notice the dust webs in the corner of the screen. You watch them wiggle from the slide projector's fanned air. This becomes the most interesting thing on the screen.


How do I avoid overload? I reduce my thoughts on paper, to thumbnail sketches. This becomes my visual plan to see how much information that I should include in each illustration. If the thumbnail sketches progress well and "read" OK, I feel confident to proceed with detailed sketches. I always resist the temptation too add in more information or to try to show too many steps in one figure.


Through the years I've come up with some interesting ideas for projects, and then have sold them to pharmaceutical agencies and companies. Many of them conceived or described during a lunch, and sketched out on a paper napkin. You've got to draw quickly on a paper napkin, particularly when using a felt tipped pen, as the ink bleeds pretty quickly. But if you can communicate the idea successfully on a blurry paper napkin, you know it has merit.


I spoke about the intelligence behind an illustration. I like to describe what goes on in our head when we embark upon an illustration assignment. Let's take a dynamic, moving procedure, a surgical operation, let's say, four hours in length. And you reduce it to maybe just 6 illustrations. You, the illustrator, have witnessed an ongoing surgical procedure for hours while standing on your tiptoes. You make a few notes, ask a lot of questions, and then you go back to your desk and you sketch it out. You make a visual re-creation of the procedure. You take a dynamic, 3-dimensional procedure and now can communicate it to others. A reader or viewer, who has never seen the actual surgical event, is now able to understand it. He or she becomes oriented and informed from just the right amount of surgical detail. While the surgeon-in-training can't touch or feel the tissue, or move their head around the operative field, he or she can reproduce the very actions that you've illustrated. Wow, and to think they come to us only for our talented hands.


I just mentioned the concepts of "touch and feel." That's an important point. Surgery is a tactile as well as visual discipline. We as artists can't put tactility into our illustrations (and that's a real hindrance). So we have to substitute graphic effects (or devices) to depict a surgeon's hand within the surgical field. We can show the bony landmarks, ghost in a structure that's underneath the subject, include a cross-section, etc. These devices make medical illustrations more than mere visual records.


But what about the moving perspective? I referred to this when I reference a surgical procedure as being a "moving perspective." The surgeon is always moving his head around, changing his viewpoint, looking under structures, looking, if you will, at both ends of the barrel – and then he wonders why we can't (or won't) show both ends of the barrel at the same time. After all, he keeps saying that he can see them.


Perspective has been defined as the elimination of everything you can't see from a particular viewpoint. Think about that… the elimination of everything that you can't see from a particular viewpoint.


The camera, and monocular lens, has had an enormous influence on the look of our work. Photography is a field with which I'm familiar, but certainly not accomplished. Obviously indispensable to the world of medicine and in sheer volume, photographic records overwhelm the world of medical illustration. But what's nice is that there is little or no overlap. Only the uninformed may still ask, "Hasn't medical photography put you artists out of business?"


Photography's positive impact on the world needs no review here, but its impact on the medical illustration is real. Like so many great boons, its dangers are little understood. Too many illustrators think that the camera "sees" reality. That a photographic perspective, is the only true perspective. A photographic perspective is confining, sometimes distorted, and good illustrators consciously have to override it. We don't walk around with shutters in front of our eyes. We don't keep our eyes closed most of the time (at least most of us don't), and only open them to "freeze" a moment. We don't look at a subject just from a fixed point of view. No, we're constantly moving, gaining a different viewpoint. And what are we doing with all this visual information? We're building a more complete mental picture, impression, and understanding of what we're viewing. Whether we are illustrating surgery, a cadaver dissection, or sailboat, it doesn't matter at all. We study with our eyes, cascading over the scene, seeing and analyzing by building a mental matrix.


So I say, throw out the limitations of the fixed-point perspective whenever it gets in your way. Let's show both ends of the barrel. If the assignment so dictates, if the need is to show more than the camera can show, move your viewpoint around - you'll be a better medical illustrator because of it.


Certainly the camera is important. It's an aid to our depictions, but it's no more than that for us as illustrators; it's only a tool. An art director once told me that he could usually tell what lens was used and how far from the subject an illustrator was as he or she made reference photos for their illustration. I can see people looking back at the golden age of illustration and denigrating some of our popular and venerated commercial illustrators because of their photographically dependent (and photographically distorted) illustrations.


Focus, a photographic term, an item of great interest to illustrators and one that overlaps into orientation, emphasis, and viewpoint. Focus is what many of our illustrations are all about. It's a concept that we all too often neglect.


How we direct the viewer's eye to that which is important is what makes an illustration work. How do we direct the eye? We can do it in a number of ways. We can use composition, strong contrasts, and accents on the important features, sloughing off the less important background. Changing from full color to monochrome (or line) within the illustration also focuses the viewer. The camera with its stopped-down lens and increased depth of field often supplies us with pictures in which everything is in sharp focus. As we rely on these images for visual resources, we can end up with fully rendered illustrations in which no one thing is more important than another. We can lose our visual way. Artistic focus and emphasis, call it what you may, is the key to effectiveness, and this focus is often over-looked in our rendering zeal. It is hard for us at times to get beyond the rendering. We spend so many hours mastering the rendering, that we must be careful that it doesn't master us.


Let me tell you a little story about one of my rush projects. It involves the first time any of my work won the "Best of Show" at an AMI meeting. I had seven full color illustrations to do for Abbott Laboratories, and I didn't have a "7 full color" amount of time in which to do them. What could I do? My solution was to first transfer all of my sketches, and then with a light pencil line I circled the central, key areas in each illustration. I painted the circled areas in full color, and when I reached the pencil line perimeter, I segued my technique into line art – simple, quick line that filled the remainder of the board and was essentially the background. The result was a "punchy," focused, effective visual that the client loved. So much so, that they were submitted the illustrations to the Society of Illustrators Annual Show. I also submitted one of the illustrations to the AMI Salon and won a first. All because I was short on time and looked for a solution to complete the visuals in a less-than-ideal time frame. I discovered a way to be a more effective illustrator in the process. So the lesson is to spend your time on the main thrust of the picture. You don't need to render in detail everything in the field. Here's where less time actually led to a more focused, higher quality illustration.




This is the sexy word of the 80s. Everybody wanted to be creative. Creative jobs, creative pictures, creative lives. Prospective students often ask, "Is medical illustration creative?" No one knows what creative means, but everybody wants it. Try to define it, and you lose it. Like love, it is often better left without too close of an examination. But we all know what it is not.


We in the western world have a sentimental view of creativity. We have seemingly detached it from its roots in mastery.


Creativity is not a free wheeling, effortless, rootless flight of fancy. It grows out of discipline and mastery of your craft. It comes from knowledge. The writer, who says the story's idea just happened upon him, or the artist, who says he was simply inspired to create, is only using verbal shortcuts to answer the "how" question. We probably wouldn't listen if he described the labor behind the creation. No mention is made of the countless hours spent perfecting (mastering) the craft, the years of study, the slow evolution from incompetence to mastery.


Creative medical illustration? You bet! The more you know, the more creative you can become. You can bend, you can distort, and you can compose your image for drama, for effect. All with the proviso that you know where the fences are. You must know your audience's limitations. The better you are at your craft, the more creative you can be. The more you know, the more creative you can become.



Memorable Medical IllustrationsThe last major item I will touch on is how do you produce an illustration that jumps off the page? An illustration that sticks in the mind? One that has what I call a "high memory quotient."


We're getting into terrain more difficult to define now. These are more subjective areas. But some medical illustrations have it, while some illustrations are all too forgettable. And if our illustrations are to teach, we surely don't want them to be forgettable. What makes the difference?


For one thing, a clear concept is necessary. The essence of the subject is presented. How do we find and then show the essence? You certainly are not going to stumble upon it. There is only one way; you must know the subject matter. If you are planning to present a memorable stomach, you must know stomachs – that's plural. You must know the structure, the function, and the curves. What shape it takes when you're standing, and what it looks like when you're lying down. You must be familiar with the look and function of the pylorus, and the ligament of Treitz. You need to be familiar with the stomach… not just one specimen, but dozens. You must bleed your author and your content experts for everything he or she knows (lots of questions again). You build upon their knowledge, and then, and only then, do you start sketching. Looking, searching for that initial line that says "truth." With knowledge, hard work, with talent in depiction and a skilled technique, you'll have a good stomach illustration. And that stomach, or brain, or heart, or whatever, will jump off the screen or page, and click into the memory grid of the viewer. He or she will learn from your illustration; your picture will have a "high memory quotient."


I can think of no more important place to stop and say that if you remember nothing else, remember my beseeching you to work toward creating memorable pictures. They'll jump out at you through the ages. The Max Brödel illustrations, not just well executed, but well drawn…. and you remember them! A Tom Jones stomach and duodenum. The Spalteholtz mid-sagittal female pelvis (probably the most copied picture in medical illustration). The indirect ophthalmoscopy illustrations by Bill Stenstom. The Magic Anatomy Book by Carol Donner, and almost anything by Gerald Hodge. Why are all these memorable? One basic reason… the artist knew the subject matter cold! He or she searched for viewpoint or viewpoints that said it well.


I remember telling Bill Andrews that I loved the way his great vessels arched up from the aorta and disported themselves across the page - playful, realistic. He smiled and said that all he did was not smooth out his crooked lines. What he didn't say was that he works with a heart team, he works with hearts. He knows hearts and the great vessels. As a result of this knowledge, Bill can depict them in ways that most of us know less well, and in ways that we are more constrained from doing.


Implicit in these memorable illustrations is the foundation. This is, given your artistic ability, the base upon which you will build much of your career. Too often it is a neglected foundation, an inadequate base. It is a life-long study. It must be constantly refreshed and added to. I see too many illustrations that tell me that the illustrator doesn't know anatomy. Of course, it is not an all or nothing state. No one will ever know everything anatomical. But unfortunately, every line we put down is a statement of fact, or truth. You can't hide behind a line. A line is clean. It either shouts your ignorance or your incompetence.


A love of this incredible machine that we inhabit must be a precondition for success in our field. That love and understanding leads us in our study. I like the intellectual side of my work as much as I like the artistic side. I like struggling with my assignments, finding effective ways to illustrate and communicate a complex surgical point. I know that I will continue to be hired for my talented hands, and not my mind. However, I take comfort in what John Dewey said in the classic work, "Art as Experience." I found this passage: "The idea that the artist does not think as intently and penetratingly as a scientific inquirer is absurd. An artist must constantly undergo the effect of his every brushstroke, or he will not be aware of what he is doing or where he is going. To apprehend such relations is to think, and is one of the most exacting modes of thought."


Again John Dewey: "A genuine work of art probably demands more intelligence than does most often the so called thinking that goes on among those who pride themselves on being intellectuals."


This pursuit, this journey to be the best medical illustrator that you can be. This is a life long process. But it is what life is all about, always striving. I'm reminded of one of my favorite stories. The true story (at least I hope it's true) that Katsushika Hokusai's daughter tells about her father. (Parenthetically, if you've never seen the Hokusai Iris prints at the Chicago Art Institute, you must go. It remains one of the greatest museum experiences of my life.) Hokusai, then in his 90s, near death, tells his daughter, "If I had ten more years, 5 more, …even 1 more, maybe I could learn to draw." Here we find the consummate artist, maybe Japan's best ever, still striving, still aware that there is more to uncover, more insight to gain, and more skills to develop. In a small way, that's the way I feel. I think that medical illustrators are very fortunate. We have life-long goals and something else - we disseminate information that leaves the world just a little better off. And when something goes right, when something clicks, when a part of an illustration really works, that makes it so worthwhile!


That's why I feel fortunate to have discovered this field. To be on a life-long quest for acquiring a mastery that I will never achieve. But along the way, I can share the joy and adventure with the marvelous people of the AMI.


Thank you.




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