Images Of Health

“I recognise myself in that situation…” Using photographs to encourage reflection in general practitioners

BMJ 2004; 329 doi: (Published 16 December 2004) Cite this as: BMJ 2004;329:1488

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  1. Torgeir Gilje Lid, general practitioner (giljelid{at},
  2. Rune Eraker, photographer2,
  3. Kirsti Malterud, professor3
  1. 1 Eiganes Legekontor, St Olavsgt 9B, N-4005 Stavanger, Norway
  2. 2 Nedre Movei 35, N-1450 Nesoddtangen, Norway
  3. 3 Section for General Practice, Department of Public Health and Primary Health Care, University of Bergen, Kalfarveien 31, N-5018 Bergen, Norway
  1. Correspondence to: T G Lid

    Photographs can elicit strong emotions and encourage reflection, but what effect can such self reflection have on a general practitioner's identity?

    Photography is a tool for dealing with things everybody knows about but isn't attending to.

    Emmet Brown, photographer1

    Doctors' skills in communication have received much attention lately, yet there is still a need for general practitioners to develop a more profound self awareness, not just of their clinical skills but of their professional identity as a doctor.2 3 Images can help elicit memories, feelings, and conflicts forgotten or perhaps never acknowledged.4 We developed a photography based strategy to facilitate and stimulate reflections on clinical practice and on what it means to be a general practitioner.

    Materials and methods

    The photography

    We chose four general practitioners as models to cover both sexes and different nationalities, ages, and practice location. The photographer spent five to eight days with each doctor, capturing encounters with patients in the practice, on call, in nursing homes, and at a child health centre. He was given few instructions but was briefed to focus on the doctor and on the interaction with patients. No artificial light was used, and the photographer never attempted to rearrange a situation. The patients were informed of the study in writing and gave their oral consent to the doctor before their consultation. They were shown the images, and their permission was obtained to have them reprinted.

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    “That you can learn something… especially when it comes to those enclosed settings, where usually no one sees the hand you've been dealt”

    The reflective strategy

    The reflective strategy was developed on the basis of experiences and discussions in three groups.5 To test the strategy, one researcher (TGL) selected photographs on the basis of his judgment of the tension in the situation portrayed and on the ambiguity of the image. The photographs were then presented in the groups, acting as triggers for reflection and discussion. The three groups were all local; two groups were tutored trainee groups for general practitioners, one with younger participants than the other, and the third group comprised experienced general practitioners. Since our main target group was trainee general practitioners, the group containing experienced general practitioners served as a validation point. TGL was present at all the meetings, acting primarily as observer. He initially told the groups to focus on spontaneous recollections, thoughts, and feelings evoked by the photographs. The discussions were audiotaped.


    Photographs stimulate talk

    The participants stated that the photographs had stimulated many thoughts and memories. Some said that the images had also encouraged them to reflect on situations never experienced.

    Emergent themes

    Feelings of insecurity

    Young doctors may struggle to rely on their own decisions to a larger extent than more experienced doctors. The discussion raised by one picture showed that such feelings of insecurity seemed to be non-existent in the control group and prominent in the youngest of the two trainee groups.


    One of the trainee groups had several doctors from other countries. It became evident that in a cross cultural setting it is not unimportant whether it is the doctor or the patient who sees himself or herself as the stranger.

    Seeing the other

    Sometimes the narrative about the patient was as prominent as the narrative about the clinical interaction:

    You see the way she's laying… the way I see it this patient, she's not extremely ill, but she's not used to being ill and she feels insecure as a patient the way she has covered herself. And I also see it in the eyes of the woman, perhaps the daughter, that she too is insecure in this situation and she's not used to seeing how she's changed in behaviour

    Moments of relief or joy

    Photographs from on-call situations were powerful in eliciting troublesome feelings and experiences, but even in these settings there were bright spots:

    “To have been in similar situations, and the lonely role you have as a doctor… and then recognising it in these images; I feel it does something to me now, just having seen these different images, it's a bit… and then we share it, more than we normally do.”


    Photographs have the ability to elicit stories and reflections from observers. We therefore developed a strategy for self reflection by doctors, using photographs of commonplace clinical situations to act as triggers.4 6 We aimed mainly to stimulate general practitioners to develop self awareness of their professional and personal identity and to reflect on their practice, rather than to improve their clinical skills.2 710

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    “Yes, a combination, I think, a bit like, relieved, you see, because okay; then the patient is taken care of in a way, but at the same time a bit doubtful about what is really the matter… or if something serious happens on the way in; should I join the ambulance? Am I really in control after all? I don't know”

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    “For me at least, I struggle with being… with finding the right place in a home visit, where people have their positions, they've sat down, they've furnished a room… there's not much time to sit down and think and meditate about where to sit. I've very seldom asked a patient to move over in his own home”

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    “That I can relate to, actually, I mean, if I feel that communication is not as good as I want it, it is very stressful, and then in a way at the same time the language issue in a way; how shall I explain that everything is completely normal; is something wrong or isn't something wrong… if you don't create that communication, then I feel very stressful anyhow” (non-Norwegian doctor)

    Summary points

    Working in general practice can be a solitary activity

    Photographs can be used to address memories, thoughts, and reflections

    Photographs are especially suitable for addressing emotional issues related to being a doctor

    Based on this reflective strategy we have produced a package of 16 of the photographs. To avoid the need to have technical equipment to view the photographs, we opted for prints (20 cm×30 cm). Three copies of each image were produced to accommodate being used in groups of 6-12 participants. The package has now been made available by the Norwegian Medical Association for the tutors of specialisation groups in general practice.

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    “Where the problem is presented and where you're supposed to talk for five minutes with the relatives and then come to a reasonable conclusion, like ‘That's it, conclude and get it over with’”

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    “It's very good to get behind there and not the least even further behind where you can get a cup of coffee and stand there for a few minutes and just enjoy that the coffee is warm and recover one's strength again”

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    “When I see him, he's got an assistant who we don't see there, but who I see as a helper and that's time, so time can work against you and with you, but you get some time to reflect, on your way in the boat, in the car or anywhere, and that's a helper we don't see. And you don't have that in the city, normally it's right on, at least if it's something urgent it's right on and you have everything straight in your lap immediately”

    Narrative based reflection in groups is a powerful method for teaching empathy. In our group meetings everyone was encouraged to give their views on several photographs. The photographs themselves did not tell a story, but provided a prompt for new stories. Photographs may capture a moment in time and are open to interpretation, but everyone's story is equally valid.


    • We thank the participants and their tutors Rhaman Dhawan and Ole Jøssang; Geir Sverre Braut (former county medical officer of Rogaland, Norway); and Richard Gwyn and Glyn Elwyn and the staff of the School of English, Communication, and Philosophy at University of Cardiff in 2001.

    • Contributors TGL conceived the project. He was responsible for planning and running the photographic procedure and the implementation groups and did most of the writing. RE created the photographs, guided by a few principles from TGL. KM gave advice on academic issues such as the design, methods, and formal questions, and participated in evaluation, analysis, and writing the manuscript.

    • Funding This study was supported by funding from the Norwegian Medical Association, including the local chapter in Rogaland county and its fund for general practice research.

    • Competing interests None declared.

    • Ethical approval Regional committee for medical research ethics, Bergen.


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