The Story Behind My Viral Interstitium Illustration
Medical illustrator Jill Gregory describes how her simple illustration got swept up in the media buzz over the discovery and debate of a ‘new organ’ — the interstitium.
One of the things I like best about working in the academic setting of the Icahn School of Medicine at Mount Sinai is the diversity of projects I get to illustrate: everything from sub-cellular immune processes to complicated surgical techniques. Back in the spring of 2016, I was contacted by a client I’ve worked with several times, Dr. Neil Theise, a pathologist at Mount Sinai Beth Israel. When he told me, “I’ve discovered a MAJOR new revision to human anatomy!” I was ready to jump on the project! I also knew that the work and his findings would likely evolve, as he and his co-investigators were still investigating exactly what they were seeing. Dr. Theise knew it was best to bring a medical illustrator onto the project early, so that I would have time to develop images as he and his team worked on the science.
The projects I’ve worked on with Dr. Theise in the past have been some of my most creative and fun, as he holds beliefs in both the Eastern and Western medical traditions. For example, I created the figure below to help him explain the interconnectedness of the universe, from subatomic particles to the planetary level.
The irony is that the interstitium illustrations, which have garnered a vast amount of attention, were actually quite simple to create (as opposed to the figure above, which took many, many hours). I illustrated two figures for the paper; the image that has received the most exposure is just one portion of figure 1. At the beginning, I only contributed to one figure. But after feedback, the authors asked me to create an additional illustration that depicts all the organ systems that are surrounded by interstitium because they felt reviewers weren’t “getting” just how extensive the interstitium is (figure 3).
Most of the artwork was adapted from previously created images. I’ve incorporated the male figure with internal anatomy into at least 15 other illustrations. If you look closely, the Caucasian man in the first figure and the African American man in the second are the same illustration, with modified facial features and skin tone. In addition, I had already created the Whipple surgery image for a different project. These re-uses are one of the many reasons retaining copyright is so crucial to my work. Having worked for the same institution for over 18 years, I have a vast library of assets to draw upon, meaning I rarely need to start an illustration from scratch.
One image I did make from scratch is figure 1-I, showing the structure of the interstitium. In fact, it was my suggestion that the paper needed it. Dr. Theise had only planned to use clinical microscopy images of the structures. Given that this is the image most news outlets chose to include in articles about the discovery, I believe this simple depiction of the cellular-level architecture is crucial to understanding — especially for the general public.
Though the illustrations were simple for me to create, the figures themselves required many rounds of revisions, as the authors refined how they wanted to explain their technique, and how to pair the clinical microscopy photos with the illustrations. I was up to version 8 by the time the article went to press in Scientific Reports.
Speaking of Scientific Reports, this is an Open Access journal, which means Mount Sinai needed to provide a Creative Commons (CC) license in order for the journal to be able to publish my work. I have a standard copyright permission form for subscription journals that I draft (this form is adapted from the license template available to Association of Medical Illustrators members), and my department’s Vice President signs. This was the first time I’d been asked to provide a CC license. I therefore had to create a new license for this project. I used the subscription-based license already on file and modified it to fit CC-BY-NC-ND (Creative Commons- Attribution- Non-Commercial- No Derivatives) terms. Once I drafted it, the legal department at Mount Sinai reviewed the form, and I received approval to use it. This process took about 3 weeks. Dr. Theise was very anxious to hear news of the CC license being approved, as he knew that the illustrations were key to this paper being comprehended. In the intervening year, I have had several more requests for CC licenses, so it’s clear protecting my department’s work under this system is going to become part of our standard operating procedure.
To add a further wrinkle, after the article was accepted, the journal informed me they can’t publish with CC-BY-NC-ND terms as they are a commercial journal (thus, the NC (Non-Commercial) clause cannot be used). That required another round of form editing and review by Legal before the we finally supplied a fully usable CC-BY-ND copyright permission form.
On October 10, 2017 — 196 days after submission — the paper Structure and Distribution of an Unrecognized Interstitium in Human Tissues was accepted by Scientific Reports and published online on March 27. While Dr. Theise had expected the paper to have a big impact, I had no idea how much media attention it would generate.
NYU School of Medicine public relations office issued a press release, “Researchers Find New ‘Organ’ Missed by Gold Standard Methods for Visualizing Anatomy & Disease” along with my art. This is when things went into hyperdrive for me! Though I suspect the words “new organ” are bound to get a big reaction by the general public, these claims were not in Dr. Theise’s paper. The news headlines sensationalized the discovery and drew lots of online attention (an Altmetric score of 3907!), but also criticism and debate from the scientific community. This is a reminder to medical illustrators of our ethical role in science communication to provide context and accuracy. Despite the hype, what I’ve found most gratifying is that my illustration is used so prominently to explain the interstitium.
The past week has been a whirlwind of excitement, as my illustration appeared in many prominent publications, including Time, Newsweek, USA Today, and The Daily Beast. It was even incorporated into the monologue of the Late Late Show with James Corden on March 28. And I’m so happy to see my name (embedded within the image itself) and Mount Sinai credited in all the major outlets. There were a couple of hiccups; when the image was first posted on Time.com, they included my name, but not Mount Sinai. So, I found the journalist’s account on Twitter and sent her a tweet asking if she would modify the attribution; she wrote back immediately and fixed the byline. I had a similar experience with the author of the article in the Daily Beast. I was pleasantly surprised by the quick response from both, though in retrospect it makes sense that journalists would want their sources to be credited properly.
I have been so surprised and happy by the impact of this article and my illustration. It has cemented my belief in the power of a clear, didactic image in communicating a complicated concept. The opportunity to communicate science through art is why I became a medical illustrator; the fact that this image has been seen by millions of people is an incredible affirmation!
Author:
Jill Gregory, Associate Director of Instructional Design, Icahn School of Medicine at Mount Sinai
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