Philly Creative Guide

Creative Personality

Birck Cox | M.S.M.I.,CMI

Interview :: Birck Cox
by Juanita Berge, 1 Oct 2009

Birck Cox, M.S.M.I.,CMI, is a Medical Illustrator(Master of Science in Medical Illustration; Certified Medical Illustrator). He lives within the city of Philadelphia, with clientele as far-flung as Southern California to Vienna. Most of his work is drawn flat art, as opposed to 3-D or motion graphics. Most illustrators now work with computers to one degree or another, and he is no exception. Everything he does begins as a sketch at the drawing board, and leaves his studio as a computer file.

You can see more of Birck's work at

PCG: How did you get involved in this field?

BC: I was a late bloomer. I was out of college with a degree in English and working as a low-level computer programmer in a research institute when my boss required some illustrations of the scientific/medical experiments we were all involved in. I did them myself, handed them in, and he was impressed enough to contact a friend of his who was one of only two medical illustrators in town at the time. This was in 1970, in Portland, Oregon, where I'm from. It took another 7 years to make up my mind, figure out how to go about it, and get the coursework necessary to go back to school and get a Master's Degree in the field. So I started as a grad student in 1977 at the Medical College of Georgia, in Augusta, Georgia.

PCG: What does the world of medical illustration encompass?

BC: When I tell someone that I'm a medical illustrator, sometimes it's self-explanatory, but I usually have to add that I illustrate medical books. In my case, that is strictly true, but not limiting. I try to have a book or two in progress all the time, plus interior art for nursing and medical journals, product illustrations for medical hardware manufacturers, work for pharmaceutical companies, and courtroom medical exhibits for attorneys.

Arthritis - closeup on section through a finger joint to illustrate normal condition and two types of arthritis. Done for a patient education booklet on arthritis.

PCG: Who are generally your clients? What types of companies?

BC: I work directly for art directors in publishing houses, journals, advertising agencies, and sometimes big medical centers. Individual doctors occasionally, local hospitals seldom. The client base has changed over the years. When I started, I was working within a medical school as a state employee; 25 years later, there aren't many jobs like that one left. Many of the medical schools have cut their educational resource budgets, and no longer employ in-house illustrators or photographers. More recently, the journals have either folded or stopped buying new art, but I have done a lot of work for a 3-D animation company near here, producing storyboards, and some medical-legal work for lawyers in the Philadelphia area.

PCG: How do you find work?

BC: I advertise in a few key places, both online and via an advertising "book" specifically for medical illustrators and illustration studios, which is sent out to art directors. So the work often seems to find me via various channels. There are medical-art websites that carry my work, and some of them are linked, which helps keep my name out there. Otherwise, I pick a target audience and simply send out packages of tearsheets (full-color examples) of my work.

PCG: Is there any specialized training involved in becoming a medical illustrator?

BC: Yes and no. There are about 700-800 medical illustrators working in North America, and most of them are graduates of five or six currently accredited university (medical school) teaching programs in the States and Canada. On the other hand, there are some very good medical illustrators who are not graduates of any accredited program. In fact, the only medical illustrator most doctors can actually name, Frank Netter, was a physician, but not a medical illustration graduate. We don't like him.

Part of the "specialization" in the training is numbers: there are very few places to get the training, and those few places produce very few graduates. Every degree program is either part of, or closely associated with, a medical school, and the illustration students enter with, and take classes with, the medical students. But as I indicated, out of all the thousands of colleges and universities in this country, only about 130-140 have or are medical schools, and of those, only six offer degrees in medical illustration (there are none in or near Philadelphia). And most of the six programs only accept three to six students each year. So I think the specialization consists of selecting the right students for the program; the program itself is, basically, medical school with a cutting-edge art department and an experienced medical-art faculty.

Battlefield Amputation
Battlefield Amputation - done for the Gettysburg Battlefield Museum to demonstrate the use of surgical instruments and techniques in use at the time of the battle of Gettysburg.

PCG: What's the most difficult part of the body to draw?

BC: Assuming that we can all draw well, the difficulty isn't so much in delineating a particular anatomical area as it is understanding it in the first place. I can't speak for other illustrators, but for me the difficulty prize goes to inguinal hernias. A hernia is a phenomenon or a pathology, rather than an anatomical feature, but it comes about because of the peculiar anatomy of the walls or layers that the hernia penetrates. Keeping track of where those layers begin and end, and which membranes the bulging gut forces out through the muscle layers under the skin - that can be challenging.

PCG: Do you use live models for your illustrations?

BC: In many cases I use myself. Otherwise, it's catch-as-catch-can. I don't have any kids, so pediatric subjects can be difficult, but I do have a computer program that can pose, and then print out, a reasonably accurate, generalized human figure to use as a "frame" for the medical subject matter. If the illustration demands a specific type of person, or a specific activity in progress, I would work from a digital photo of myself or someone else.

PCG: Have there been any difficult or challenging assignments for you?

BC: It's story time. Ten years ago I did a series of panels for a legal case demonstrating the injuries suffered by a girl who had been thrown from a van with a defective door latch. She had been thrown 50 feet and hit the trunk of a tree pretty hard. I collected all the information for the job from EMT reports, ER reports, and pathology photos of the body. She looked completely unharmed. No broken bones, just one minor head laceration and no other visible injuries. She was still alive when the ambulance reached her, breathing, but comatose and unresponsive, and the EMT noted that she was starting to assume a peculiar posture. When the ambulance got her to the hospital, the ER team worked heroically on her for two hours, trying to get a response, but eventually someone recognized the posture: she was decerebrate. At autopsy, they found that the violence of her collision with the tree had twisted her brain, inside her skull, off her brainstem and torn the two cerebral hemispheres apart. She would never have awakened, and all that was keeping her going was her brainstem. It wasn't difficult to understand or to draw, just sad, disappointing, and uncomfortable to think about. Like seeing death disguised as life.

Brain in situ
Brain in situ - done to demonstrate the way in which the human brain fits into the hollows and recesses of the cranial base and the posterior fossa of the brainpan.

PCG: Of what job are you the most proud?

BC: Another story. I was working at a medical school in Virginia, across the street from the state Medical Examiner's office, and one day the ME herself showed up with some photos of a little boy who was the alleged victim in a child-abuse case. The photos showed a boy about three years old, lying on his stomach in bed, with a strange, scalloped pattern of burns across his legs and lower body. The mother had been giving the child a bath, but claimed that it was all an accident - she had no idea the water was so hot until the damage was already done. The ME made a point of handing over the photos to me without offering an explanation - she referred to it as a child abuse case, but told me only what the mother had claimed, and asked me to draw my own conclusions about the pattern of burns, and then illustrate the probable situation.

It didn’t take long to figure it out. When I imagined the little boy held off the ground with his knees drawn up, the edges of his burns described a straight horizontal line from mid-ankle to the base of his spine. The boy had been lowered into a sink full of water that was close to the boiling point, probably held under the arms by someone standing behind him, and as his feet approached the surface of the hot water, he had - of course - drawn his knees up to his chest. Thus, he contacted the water with his buttocks, backs of his thighs, feet and ankles, leaving his knees untouched.

In this case, the combination of medical photography and illustration succeeded in making the point. No one in the courtroom believed that the mother could have “bathed” her child without hearing strenuous objections from him before his feet touched the water.

It was better than jury duty.

PCG: Do you draw internal parts of the body? If so, what do you use as models?

BC: Yes, and I rely on an array of plastic models to supplement my own knowledge and what I can look up in numerous anatomy books. For example, I've done a fair amount of work detailing central nervous system anatomy and surgery, using some fairly detailed models of skull, brain and brainstem. The best ones can be assembled and disassembled. I have a full-size skeleton as well, and boxes of spare bones, spines, assembled feet and hands. Head and neck anatomy is probably the trickiest, but there are little anatomical surprises all over the body – like those darn hernias.

Tendons of the foot
Tendons of the foot - dramatizes the tendons of the extrinsic muscles that control foot movements from outside the foot itself. The muscles themselves originate in the lower leg and the knee joint.

PCG: Why go with illustrations instead of photos?

BC: Ah, yes, the old "why not use a photo?" question. OK, Ms. Smarty-pants photographer, get this: the client, a pediatric cardiothoracic surgeon, just walked into your photo studio and stated the assignment: She's giving a lecture on Friday and needs a full-color Powerpoint slide that demonstrates the differences between a Patent Ductus Arteriosus, a Patent Foramen Ovale, and a VSD. With labels. By Friday. Go photograph that.

Seriously, that scenario is valid, but the subject is more complicated. Some subject matter actually makes more sense as a photo than as an illustration, for example, dermatology and pathology. In this country, medical photography is important for documenting visible facts like child or spouse abuse, and pathological conditions. The Brits have taken it further toward illustration - a lot of British surgical atlases have been done with sequences of cleaned-up photos rather than illustrations. One real value of medical illustration lies in our artistic license to zero in on a specific site, or process, or anatomy, while leaving out everything extraneous, and including only what is necessary to make our point.

I've worked with some good medical photographers. They have plenty of skills that I don't, and it's worth noting that no qualified medical photographer has ever asked me "Why not just use a photo?".

PCG: Where do you see the field of medical illustration going?

BC: It's unclear. I've watched the field change, and there are now fewer people like me, sitting at a drawing board doing line art or watercolor drawings than in, say, 1990. The computer and desktop publishing came along in the mid-eighties, after I was out of school and working, so I got up to speed through on-the-job training. Once I became self-employed, keeping up with the changes became more difficult.

Obviously, as long as there are medical books being published, there will be conventional illustration work for us. If books are replaced by computer-based learning, e.g., cloud computing or online tutorials, the medical illustration training programs will have to adjust to that - and they are adjusting already. The public is familiar by now with 3-D modeling and animation, that computer technology that makes it possible for the Terminator to walk through walls and Wall-E the robot to make friends with a cockroach. Those computer skills are being taught now in medical illustration programs.

Medical illustration as a field of study got started in the early 20th century, at Johns Hopkins Medical School. Through the 60-odd years between WWI and desktop publishing, the job of a medical illustrator was predictably pencil, ink, watercolor, drawing and painting, then shipping off the finished art to the publisher, or sending it over to the photographer. The development of the personal computer has changed everything, and the rate of change is accelerating. Will books be the primary means of medical education in 2029? Possibly not. If not, there will still be a need for the kind of work we do. We all have computers (we have to), and if the client wants his work delivered not as flat art to be included in a book, but as a web-safe interactive Adobe Flash file with lap dissolves, a sound track and some animation, that's what we need to come up with. We are part and parcel of the changes.

You can see more of Birck's work at

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