In Part 2 of her interview with Katie Grogan, Emily Milam discusses how photography is used in medicine today. For Part I, click here.
As a second component to your project, you surveyed dermatologists nationwide about their use and opinion of medical photography. What did you discover about current practices?
Current practices vary depending on the clinical setting and the specialty. I restricted my survey to dermatologists because it is a population that relies on regular use of medical photography. I also chose this group because I do clinical dermatology research, so I have greater access to that population. But plastic surgery and other subspecialties that are particularly visually-oriented also rely on medical photography. To be honest, most fields use medical photography or images in some capacity, whether it's CT scans, MRIs, endoscopic images during a colonoscopy, intraoperative images of a patient's abdomen - these are all forms of photography to some extent.
The goal of the study is to better characterize the use of medical photography, including issues of technology, image storage, consent, and patient privacy. Despite its ubiquitous use, little is known about how photography is employed in the clinical setting.
Is there any formal training for medical professionals to encourage universal responsible photography practices?
To my knowledge, there are very few formal training opportunities. There are courses at national meetings, and some residency programs teach basic photography skills. There are also a handful of review articles in academic journals and CME courses that guide readers on how to focus a camera and things to keep in mind while taking photographs. Some medical centers are fortunate enough to have a professional medical photographer on hand who can take that expertise and apply it to patients throughout the hospital instead of having to rely on physicians. Also, with the advent of telemedicine, there is a focus on training physicians to be skillful photographers so that the images are clear and accurate representations of the disease that they are trying to transmit. I think there is still room for improvement. Medical photography tutorials should be a required component of training for many specialties, especially within the visually-oriented fields such as dermatology and plastic surgery. Beyond teaching students how to use digital cameras and take images that are in focus and with adequate light, it is also important to teach them how to drape a patient properly, what should and should not be included in the image, to remember to remove identifying jewelry and to cover tattoos and avoid the face if it is not the subject of the photo. I think that this is a benefit to everyone because oftentimes you can't publish photos that don't meet those criteria anyway. Other important tips are to place a ruler next to the lesion of interest for scale or to take follow up images at similar distances and angles so that they are more comparable. You'd be surprised how few photographs fulfill these criteria, including images published in some of the best academic journals.
Today, when a medical photograph does feature a patient's face, are there steps taken to protect that person's identity?
That's changed in recent years. At the end of the 20th century - the 70s, 80s, 90s - it was very common to put a black bar over the patient's eyes after the picture had been taken, using a computer to pixelate the image, or some other post hoc editing changes. It was later determined to be kind of silly - you can still tell who's who in a photograph with the eyes covered. So the focus now is on gaining consent, making sure the patient is informed about how their photograph is being used, doing the necessary paperwork, and if the area of interest is the face, including the face - eyes and all. There is greater emphasis placed on making sure the patient is fully aware and on board with how their photos are being used.
Medical photography can really come to bear on patient-physician trust then, right? How do you think it shapes this relationship?
I think that the relationship between patient and physician can go either way. In the modern age of technology, in some sense, patients expect their photographs to be taken, especially if it's for a procedure where they're looking to have before and after differences, or tracking their disease over time. But in the end, to maintain trust, it's important for the physician to fully communicate what they intend to do with the photograph, why they need it, and where it's going to be stored. Otherwise patients may be skeptical or distrustful, and it might make them nervous to come back. There is actually a study by dermatologists at Bellevue and NYULMC clinics, where patients were surveyed on their perspective of medical photography. In that survey, a majority of patients agreed that photography enhanced their quality of care, and they were okay with it. And they were okay with their photograph being used for medical purposes, for their continuity of care, teaching and research purposes, but particularly when the photographs were not identifiable. The study also found that patients preferred the use of clinic-owned cameras above personal cameras or smartphones. They preferred physicians to take the photos and not nurses or medical students. While patients are open to medical photography, there are some things that we need to be mindful of to make it comfortable and to continue that trust and even empower that relationship.
What do you think patients should be aware of when they are asked to be photographed?
I think they should know what their images are being used for, whether that's education, publications, part of their historical medical chart, or medico-legal purposes. This communication should be part of the informed consent process prior to taking the photograph. But obviously in the rushed world of clinical medicine this doesn't always happen. I think if patients understood that their photographs are a benefit to their clinical care as well as a useful instructional tool to trainees and journal audiences, they would feel more comfortable with the process and perhaps even take pride in their involvement. In fact, I've written a few case reports as part of my medical research, and I've found that a couple of patients were very excited to be a part of a journal and to be helping in some way, even if it showed them with a strange rash.
And when a patient consents to have their photograph taken in a clinical context, what does that mean for ownership of the image? Whose property is it?
That's a good question. It is very hard to say because when a patient agrees to have their image published in a journal, it is very difficult to take it back down the road. So you can argue that a patient no longer has control of the image, especially on the Internet. Once it's on the Internet, it's very hard to extract.
As the third and final component of your project you examined creative portrait projects that feature individuals who have visible diseases aimed at reframing the way we see them. What is different about portrait photography and contemporary medical photography? Why do you think photography is such a powerful medium for raising our consciousness?
Creative portrait projects have provided patients the opportunity to be the subject of art and not just the subject of clinical attention in the medical gaze. It allows them to reclaim their appearance and feel special rather than peculiar. That can be very empowering. These projects are important not only because they empower the portrait subject but also because of their rippling effect in empowering others with similar disfiguring diseases who see the portraits and then can identify with the portrait subjects and say, "There are other people out there like me." It's also important for people who are not disfigured to see the diversity of appearances.
Outside of this project you enjoy photography and documenting your experiences through pictures. Does this inform the way that you see patients? Are you observing your surroundings through multiple lenses, from medical and artistic standpoints?
Absolutely. When I observe clinicians taking photographs of patients or when I'm tasked to do it myself in the medical office, I can't help but consider the principles of perspective and depth of field that I learned in college photography. I can't help but look at the subject and the surroundings as kind of artful in some way. But I also have to remember that medical photographs, when used in clinical medicine, are not intended to be artful. They are supposed to be accurate representations of disease that convey clinical truths. There are two different sides of the coin, and I'd like to think that my interest in photography helps medical photography. I'm able to bring images into clear focus and center the photograph and make sure they are standing appropriately and able to consider the aesthetic elements that are helpful for the clinical needs or the purpose of the photograph. But sometimes it's hard not to want to play around and do creative things.
I hear the distinction you're making, but I wonder if those two things can really be so separate - where a medical photograph is completely objective and doesn't involve the subjective elements of perspective and framing.
I totally agree and in the end you're photographing a human, so you're seeing a human - whether that's through an objective medical gaze or you're peering into what they might be going through because of the malady they have and the reason why they are being photographed. So I don't think they can be separated. I think they go hand-in-hand and are kind of a composite entity.
From this whole process, going through all the photos you studied, do you have a favorite image that really spoke to you and maybe captured the spirit of this project?
It's hard to pick one, but one of my favorites is a photo taken by the medical photographer at Bellevue that I mentioned, Oscar G. Mason. My Rudin fellowship mentor, Dr. Oshinsky, initially told me about the photograph and I think it perfectly encapsulates the purpose of my project, not to mention its historical link to NYU. This photo, nicknamed "The Bellevue Venus," shows a young woman with a debilitating case of elephantitis of the legs. It was published by George Henry Fox in his dermatology atlas, Photographic Illustrations of Skin Diseases in the 1880's. What is striking about this photo is the way the subject has a cloth draped over her head and is covering her exposed chest, perhaps out of modesty or shame, or to protect her privacy or anonymity, yet it is such a clear representation of disease at the same time. You can almost imagine the overlap of the physical and psychosocial distress in this one image.
"Bellevue Venus," photograph by Oscar G. Mason, The Bellevue Photographic Department
The fellowship year is about to end, and I understand that you have a few manuscripts in the works. What are you working on, and what do you imagine to be the future of this project?
I did have a paper accepted for publication, and it should be coming out in JAMA Dermatology in the next few months. It's a historical survey of the first dermatology atlases, after photography was invented. In this era, many of the photos were hand painted by artists to give color to the otherwise black and white images. I also discuss Oscar G. Mason and George Henry Fox's dermatology atlas. I'm working on a few other pieces for publication, including one on the psychosocial implications of one's appearance and society's "beauty biases." I'm also working on a manuscript that discusses, in depth, the legal cases that have shaped medical photography and the current guidelines we have today concerning consent and image security. Finally, I've also compiled a list of portrait projects that exist, showcasing different visible ailments such as alopecia, vitiligo, and craniofacial conditions. I want to have that on a site where people can find them and look through the images and feel empowered.
I want to take photographs of patients at some point. It's been interesting how some of the issues I've researched have been a barrier in my ability to take photographs of patients, such as concerns about image and privacy and anonymity. I still hope to have the opportunity to photograph patients and give them the chance to be the subject of art.
And, finally, you're planning to go into one of the visually-oriented fields of dermatology, so how do you imagine both your interest in photography and the knowledge you've gained from this project will shape the way you integrate photography into your practice?
Well, for one, I definitely hope that photography is a large part of my practice, and that means taking photographs of patients to track their disease progression or to use in educational materials. But I'm going to be very aware of the patient's experience in that process and make sure that I am clear and forward in what the photographs are going to be used for and provide patients the opportunity to opt out. I also want to help create educational tools or teach my future colleagues how to take photographs correctly. I see that on the horizon. Once I'm a physician, I will have built relationships with my patients and may have an easier time taking photographs of them - both clinical and creative - and they won't just come to me for their medical illness.