Family & Community Medicine

Why use Digital Photography in Medicine?
Digital photography is a wonderfully creative method for teaching and learning medicine. Even before digital photography was available, the 35mm camera was a great tool for capturing images to teach medicine. However, the cost and inconvenience of developing slide film meant only the most avid photographer and teacher would engage in this method.

The advent of digital photography makes the recording of photographic images less expensive, easier to do, and easier to maintain. Also digital photography gives you immediate feedback and a sense of immediate gratification. No longer do you have to wait for a role of film to be completed and processed before finding out the results of your photography. Not only does this give you immediate gratification to see your image displayed instantaneously in the camera, but alerts you to poor quality photographs that can be repeated while the patient is still in the office. This speeds up the learning curve of the beginning photographer in a way that could not happen with film photography.

Most good quality digital cameras already create images with resolutions (dots per inch) and numbers of pixels (points of light and color) adequate to fill a standard computer monitor or a full slide in a PowerPoint presentation. Digital cameras will continue to come down in cost and improve in quality.

Digital photography can be used to improve the development of visual pattern recognition. An astute clinician is a careful observer of visual details. Many of the signs of disease are collected using our visual senses. We collect data through sight, sound, touch and smell. While doctors of days gone by may have used taste to collect data, such as tasting the sweet urine of a diabetic patient, this sense is rarely used in modern medicine. We listen to heart sounds, lung sounds, bruits and percussion notes to collect information for diagnosis. We touch our patients to feel lumps, bumps and masses. We occasionally use smell for diagnosis when we have no choice. Unfortunately the smells of disease are rarely pleasant. Of course we also use the patient's history, laboratory data and more advanced imaging techniques to diagnose and manage patients illnesses.

We all know that a picture is worth a thousand words. Visual images are often used to diagnosis problems of the skin, the joints, the upper respiratory system and the eyes. Changes in the normal body habitus can give us clues to diseases of almost any organ system. We use clues such as changes of skin color and areas of body swelling to help us diagnose our patients. Some of the more common changes that we see are erythema, jaundice, edema, joint swelling, petechiae, purpura, pus, and all the primary and secondary lesions associated with dermatology. We process these images with our eyes and our central nervous system. We also benefit when we can keep these images in our memories as references to go back to for future diagnostic investigations. The larger our image bank becomes, the better clinicians and diagnosticians we are. The expert clinician has a very large image bank stored in memory to call upon for rapid pattern recognition. Hypothesis testing may then be used through the comparison of one image against many. Our image banks begin to develop in medical school when we view pictures in lectures and textbooks. We then begin to develop our own clinical image bank by our clinical experiences. Our references were printed color atlases but now we have new color atlases available on the Internet and on CD-ROMs. Studying and learning the patterns from any atlas can enhance your expertise by enlarging the image bank stored in your memory. One of the problems of this technique is that all the images you see are not retained and retrievable in your memory. Grotesque and disturbing images are better retained because they are processed along with an emotional reaction. I contend that images taken by you with your own camera of your own patients with their own stories are more likely to be retained and retrievable in your memory because they have a broader context and story to go with them rather than something you might find in a printed or electronic atlas. «Back to top

Asking permission to take a picture & getting written consent
It is important to know how to ask a patient for permission to take a picture and to get written consent. You MUST have the patient's written consent for all pictures. A long-term trusting relationship between the doctor and patient makes this issue easier. If it is a new patient for you, it is recommended that you completely care for the patient's needs before even bringing up the idea of taking a photograph. If the patient has much shame over his or her condition, it may not be a good idea to ask to take a photograph at all. Do not keep the camera in the exam room and only ask for permission to take a picture when you sense the patient is pleased with his or her care and is willing to be photographed. Then explain to the patient why you want to take the photograph and that the photograph will be anonymous when used outside the chart. Reasons for taking these photographs include: self-learning, teaching, publishing and medical documentation.Clearly explain that you will not attach the name of the patient to the photograph for others to see unless it is going in the patient's chart. Printed photographs in paper charts and electronic files in electronic medical records can be used for documenting and following a patient's acute and/or chronic conditions. Asking to take photographs of breasts or private areas is more difficult. You must very carefully explain how the photograph will be used for teaching medical students, residents, physicians or other health professionals in training. Explain how valuable such a photograph will be to help future doctors learn to not miss this diagnosis. The good news is that most patients will respond favorably to your request and feel like they are special because their physician wants to photograph them. See the FORMS section of this page for the required consent form.

Permission for patients under age 18
If the patient is under age 18, you MUST ask permission from the parents or guardian and the patient. When taking pictures of children with skin lesions you can take a picture of the child's face, as long as the child and parents are willing. Be sure to show the child his or her picture on the LCD panel of the camera. Most children are delighted to see their face on the camera and this makes the photographic experience a pleasant one for all involved. Remember, you MUST have the written consent of the child's guardian. «Back to top

How to take the best photographs
The content and composition of the image is the most important aspect of a good clinical photograph. With virtually no cost to each photograph, I recommend that you take photographs liberally as long as your patient approves of this practice. This means if your patient has multiple skin lesions on different parts of the body, ask the patient whether he or she will allow you to take pictures of these multiple sites. This provides a more comprehensive view of the clinical story than a single photograph. You may want to take a total body shot and then focus on more specific smaller areas of detail.

The lighting in photography is absolutely crucial. Fortunately digital photographs can be easily improved upon using digital editing software. Photographs that are slightly too dark or too light can often be fixed using software like Photoshop. However when photograph is much too dark or too light important information has been lost. In photographs that are too dark, detail that was not visible to the camera is lost. In photographs that are too light, the extra light will wash out the details. Therefore, optimal lighting should be the goal of every photograph. The beauty of the digital camera is that you get to see your photograph immediately on the LCD screen of the camera. If you see your photograph is not well lit, then make an adjustment to the camera or the ambient light in the room and shoot the photograph again. The best photographers will try different lighting situations to get the best photograph. In the clinical exam room this might involve using the clinical exam light available or opening up the blinds of the window if privacy is not an issue.Many of the digital cameras may also be used for photomicroscopy. When you have an interesting image in the microscope field, you need only place the lens of the camera up to one lens of the microscope and shoot the picture. You may need to play with settings on the microscope and camera to get the best image. «Back to top