Digital Photography for Busy Clinicians: Part 1 - Why should busy clinicians take photos?

The rapid evolution of digital photography technology in the past decade has greatly changed the dynamics and efficiency of its use for documentation of clinical information. A digital camera is now an affordable tool to capture high quality images for many different clinical purposes, however not many doctors use one in their daily work despite the growing use of computerized medical record systems which can now readily incorporate digital photographs.

In addition, the increasing cost of medical litigation has placed greater burdens on clinicians to accurately document their dealings with patients in order to minimize future risks. There is now a very strong case to add photographic evidence of our clinical observations in certain circumstances in order to improve the quality of documentation for legal protection when things don’t quite go the way we wish.

This article has been written to encourage readers to consider using digital photography to enhance the quality of care they provide as well as improving their medical records, and will argue that the benefits greatly outweigh the costs in time and financial outlay.

Further articles planned for forthcoming editions of Pulse IT will cover practical issues such as selecting a digital camera and accessories for clinical work, how to take excellent closeup photos, and how to make the best use of one’s digital photographs.

Why should busy clinicians use photography in their clinical work?

The old adage that “a picture is worth a thousand words” is just as true in clinical medicine as in every other professional field. Much of the information we gain from patients is visual and in some fields of medicine such as dermatology, ophthalmology, radiology and cardiology visual clinical information is of vital importance for diagnosis and management. In general practice a significant proportion of consultations (about 15%) involve skin conditions or cutaneous manifestations of systemic disease. Skin cancers will affect 50% of Australians and a growing level of paranoia about skin cancers especially malignant melanomas propels many patients to their GPs, to dermatologists and to Skin Cancer clinics for “mole checks”. Most trauma will cause visible signs on the skin or visible deformities.

What better way is there to accurately document visual information of diseases such as skin cancer than photographs? Clinical photographs are an excellent aide memoire when one wants to review a suspicious lesion in the future – our memories are very fallible and without photographs it’s virtually impossible to recall the exact appearance of a skin lesion or, worse still, of a number of skin lesions weeks or months after they were originally examined.

Clinical photographs can be a wonderful teaching resource for junior colleagues who, without such resources, may take many years to gain sufficient experience to accurately diagnose skin lesions. Dermatology is one of the most neglected specialties in undergraduate medicine and most medical students have very few opportunities to see common rashes or skin cancers. Apart from a very few training positions for those doctors destined to become dermatologists, there is virtually no training about common skin problems for junior hospital doctors before they switch to vocational training positions and therefore most specialists excluding dermatologists have had virtually no experience with common skin conditions.

Training for general practice is still crying out for adequate resources specifically designed to improve diagnostic skills in dermatology even though every experienced GP knows that patients commonly present with rashes and skin lesions. So there is a need for more doctors to take clinical photographs in their daily work to help teach future generations of clinicians of all types.

Good photographs can also provide excellent legal evidence and may provide sufficient support to minimize or eliminate the risk of successful medical litigation in many circumstances whereas the lack of photographs may undermine the chances of successfully defending a charge of negligence! Even psychiatrists may find value in documenting visual evidence of trauma or perhaps video evidence of patient behaviour for legal reports in the future.

Why not continue using conventional film cameras?

There is now little argument that digital photography has come of age. Digital cameras are now very affordable and can take excellent pictures with stunning detail and accurate colour saturation and contrast as the electronic light sensors are now produced with many millions of light-sensitive pixels. The automatic focus and control of exposure make it relatively easy for the least experienced to take sharp and well exposed pictures even with cheap digital cameras.

While there are still many diehard traditionalists who cling to the extremely high definition and colour accuracy of film-based photography, the economy and convenience of digital photography as well as the control one can have over the finished product has convinced most people to make the switch. One only has to walk into a photography shop to see how few film cameras are left on the shelves gathering cobwebs while the large array of digital cameras attracts the attention of most buyers.

Newspapers all over the world now equip their photojournalists with digital cameras and paraphenalia and have reaped huge financial savings by eliminating developing and printing costs as well as being able to receive digital photographs as files over the Internet within minutes of the pictures being taken.

Finally, camera manufacturers such as Nikon are one by one abandoning traditional film technology and even manufacturers of film are going bankrupt or diversifying into digital technology to survive as the use of film continues to dwindle.

Digital photography offers many advantages over traditional film-based photography.

Firstly, the speed with which one can see images after they’ve been taken with a digital camera cannot be rivalled by any film technology, even Polaroid photography. Within a second of taking a digital photograph the image can be seen in a screen, admittedly rather small, on the back of the digital camera. Using this screen one can zoom in on the image as well as scroll up and down and from side to side to see it in more detail. Images which are poorly focussed, illuminated or composed can be immediately deleted from the camera’s memory card and if necessary the photo can be taken again within a very short time before the opportunity is lost forever! In the case of film photography, it will be at the very least an hour‘s wait for the fully exposed roll of to be developed and printed at the photo shop.

However the longest delay is waiting until the roll of film has been entirely used up. In the case of clinical photography it would be quite unusual to take an entire roll of film within one patient consultation. Usually a number of separate consutations over the course of several days or even weeks would be necessary before a roll of film is used up and can be sent off for developing and printing. By the time the pictures are back the skin lesion may have already been excised or the rash may well have resolved (hopefully) and if the pictures proved inadequate for some reason, the opportunity to take the pictures again will have been lost.

Patients love to see the pictures of their skin lesions especially when they are in hard to see places such as on the back. Grotesque as some lesions can be, especially when the photos are taken close up, patients still have a morbid curiosity about the appearance of their skin lesions! Digital photography allows clinicians to show patients exactly what makes their lesions look suspicious thereby warranting biopsy or prompt removal. Using traditional film cameras creates delays which make this stimulating visual experience for patients impossible, at least within the initial consultation.

Digital photographs can be stored or archived either directly within electronic medical records or externally but linked to specific fields within the medical record database. Both methods allow rapid and easy access to the images from within the patient record without having to do lengthy searches. One can easily make multiple copies of one’s digital photos onto CD or DVD to reduce the risk that they might be lost or destroyed.

Digital photographs occupy virtually no room other than the hard drive within one’s computer or on an external hard drive. By contrast, prints made from films take up space in an album or a box and unless one is diligent in accurately filing them, printed photographs can be hard to find especially when there are large numbers to sift through. And if one has shifted one’s medical records to a computer it seems futile to have to keep a separate filing system for printed photographs when one can simply do it all (patient notes and patient images) on a computer system!

Digital photographs can be examined on a computer screen and if they are of sufficient resolution one can zoom in to see greater detail. This just not posible with printed photographs unless a magnifying glass is used – what you see is what you get!

Digital photographs can be printed using various resources depending upon one’s specific needs:

  1. within the surgery one can use inkjet printers, even very low-priced units, to quickly print high-quality 15x10cm photos using glossy “photo“ papers. For infrequent use, this can be a relatively cheap exercise but may cost slightly more than having pictures taken with film printed out by a photo agency. Nevertheless doing it yourself gives you complete control over the quality of the final output and you may want to experiment till you get the quality you want.
  2. Camera stores and chemists often provide printing services and will print out photos taken directly from a memory card or a CD containing the images. They generally charge competitive prices and will often print out your photos while you wait. However this process may well be less convenient than printing your photos yourself on your own printer when you want them and the quality of printing will vary significantly between operators.
  3. Online printing services are simple to use – you merely upload your images from your computer to the online operator and your prints are sent to you by the post. This is probably the slowest but the cheapest way to do your photographic printing especially if you need to print large numbers of photos. If you only need to print a small number of photos this may prove to be the most expensive option!

Digital photographs cost almost nothing except one’s time. Once the camera and accessories have been purchased (they are tax-deductible if used primarily for clinical purposes) the photos cost nothing to take. Storing them on a computer’s hard drive costs hardly anything given the rapidly declining cost of hard drives and backing them up onto a CD or DVD is very cost-effective. Take one photo or take a hundred – the cost is essentially the same so there’s no disincentive to take as many as are needed. By contrast, every photograph taken with a film camera costs money, initially to buy the film, then more money to develop and print the photos and then even more money for storage of the printed photos and/or negatives in albums.

Digital photographs are very easily incorporated into documents, slide shows or presentations for lectures, teaching aids or demonstrations for all educational scenarios whereas printed photographs taken with film need to be scanned before the images can be used for these sorts of purposes. Slides can be used for the traditional slide shows but it is far more tedious to load slide carousels than to look through pictures in an image browser on one’s computer. Presentations with Powerpoint or other presentation programs such as Apple’s Keynote can be far more inventive, entertaining and useful than simple slide shows using film transparencies.

Finally it can be very useful and extremely time effective to email clinical photographs to professional colleagues in order to obtain opinions. If the photos are digital they can easily be attached to emails without much bother but printed photographs from film first need to be scanned before they can be sent by email.

Why are so few doctors using digital cameras in their daily work?

With all these advantages there must be some real or perceived disadvantages which deter clinicians from using digital technology or else this article would hardly be necessary.

Obviously not everyone is comfortable with modern technology and it’s fairly obvious that to make the most of digital cameras and digital photographs one needs to use a computer! This issue is hard to get around but with time this problem will just disappear.

New technology is always expensive when it’s introduced but fortunately the cost of digital cameras has plummeted in recent years while at the same time the quality of digital images and the features available on digital cameras have improved dramatically. Nevertheless, there is still an initial outlay needed to buy a digital camera and the essential accessories such as extra memory cards on which the images are stored before being transferred to a computer. Unfortunately the memory cards which come with the cameras are invariably of very low capacity. Unexpected costs arise when extra software is needed to manipulate and improve the images, and when one’s computer needs to be upgraded to cope with the demands of storing all the photos by installing a larger hard drive or by adding more memory (RAM) if the new software needs more memory than is already installed on the computer. Perhaps a new CD or DVD drive needs to be bought for backup purposes.

However important the previous two factors are in causing people to defer their decision to buy a digital camera, the major obstacle facing most busy clinicians is time, or more specifically, the concern that it would take too much during a consultation time to take photographs and then to transfer the images to the computer and to do any subsequent processing of the images to link the photos to the clinical records. Well, it’s certainly true that a complete novice will take quite some time to become both proficient and efficient at taking good closeup photographs with any sort of camera and both interest and enthusiasm to devote this time are necessary to get up the learning curve. However once experience has been gained, using a camera within the context of a consultation doesn’t add very much time to the consultation, although patients often want to spend some time looking at their own skin lesions! If the extra time taken converts a standard consultation to a prolonged consultation it is completely ethical and appropriate to charge a higher fee; patients accept this because they know their clinical needs have been dealt with in a very useful and entertaining way!

The author typically takes about 3-4 minutes to take a few close up photographs of a questionable or interesting skin lesion, then transfer the images to the computer, link them to the patient’s medical record, label the images with the patient’s name and the date, and finally look at them on the computer, usually with the patient glowing with admiration at the new technology and somewhat horrified by the magnified appearance of their skin lesion. This may sound like a lot of extra time but surely it is time worth spending when dealing with skin cancers or lesions which one cannot definitely justify removing and therefore deserve followup in the near future.

Obviouslyly it‘s best to practice with a newly acquired digital camera outside of the rigorous time constraints of the consulting room before trying it out at work. Even photographers with years of experience using film cameras discover that digital cameras are very different, in some important ways, from film cameras and this difference imposes a new approach to taking pictures. Nevertheless it usually doesn’t take very long to learn the basic functions of the camera and how to transfer images from the camera to the computer. And it ALWAYS helps to read the manual!

If you are a novice both to digital photography and to closeup or macro photography, you have a little bit more to learn but it’s not all that difficult. Macrophotography opens up a fascinating world on a very different scale and there are plenty of interesting subjects within every garden or shed just waiting to have their pictures taken at close range. The laws of optics imposes interesting and challenging constraints with macrophotography and it takes time to learn to take good quality closeup images of clinical subjects in a reliable and efficient way. Practice makes perfect but with a digital camera it costs you nothing to practice!

The take home messages are that it can be a lot of fun using a digital camera, it isn’t particularly expensive, it doesn’t dramatically extend consultations, it can contribute significantly to quality patient care, it can reduce the risk of litigation AND patients actually love it when you take photographs of their skin lesions.

Posted in Australian eHealth

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