Intended for healthcare professionals

Letters

Videos, photographs, and patient consent

BMJ 1998; 317 doi: https://doi.org/10.1136/bmj.317.7171.1522 (Published 28 November 1998) Cite this as: BMJ 1998;317:1522

This article has a correction. Please see:

Medical educationalists can free themselves from constraints of “real world” images

  1. Mark Pallen (m.pallen{at}qmw.ac.uk), Senior lecturer,
  2. Nick Loman, Web resources development officer
  1. Department of Medical Microbiology, St Bartholomew's and the Royal London School of Medicine and Dentistry, London EC1A 7BE
  2. Department of Neurology, Queen Elizabeth Hospital, Birmingham B15 2TH
  3. Department of Physiology, Birmingham University, Birmingham B15 2TT
  4. Department of Radiology, Royal Hospital Haslar, Gosport, Hampshire PO12 2AA
  5. Regional Infectious Diseases Unit, Western General Hospital, Edinburgh EH4 2XU

    EDITOR—Hood et al rightly emphasise that “the internet and electronic publishing are powerful tools for the dissemination of medical information and have created a demand for medical images” and that images of patients should, in most circumstances, not be used without consent.1 In the digital age, however, the links between images and individuals are complex and non-intuitive. With appropriate software it is easy to create images that do not reflect a true likeness of any real individual—cover girl images are commonly touched up, O J Simpson can be turned into a blond,2 and Ronald Reagan can be given AIDS, complete with multiple Kaposi's lesions.3 Thus manipulation of digital images means that the potential of the internet in medical education need not be frustrated by ethical issues.

    Figure1

    MorphMan was used to combine faces of both authors (left and centre) and then Photoshop was used to create a rash on the “combination” face (right)

    We wished to see whether we could, in a single afternoon, create fictional images of near-photographic quality illustrating medical conditions; we are interested amateurs and know that professional illustrators with more time and skill could achieve better results. We began by creating a malar butterfly rash such as one might see in systemic lupus erythematosus on a face that does not exist in the real world. To create the face we used the program MorphMan to combine the faces of both of us and then used Photoshop to create a rash on the “combination” face (figure). When we showed this image to a medical colleague he neither suspected that the rash was fake nor recognised us in the image.

    One could argue that, in doing this, we used images without consent. When multiple images are combined in this way, however, the final image is probably so far removed from any one patient as to obviate the need for consent. Had time permitted, we could have combined dozens rather than just three images. In such cases, use of how much of an image would warrant consent: would use of a single pixel require informed consent?

    We conclude that in the age of Lara Croft (the virtual reality “star” of the Tomb Raider series)4 and Kyoko Date (the “virtual idol” created by engineers and designers of a Japanese model agency),5 medical illustrators and educationalists can begin to free themselves from the constraints of “real world” photographic images; the future is virtual.

    Most patients agree to be videoed for teaching and publication purposes

    1. David Nicholl (d.j.nicholl{at}bham.ac.uk), Registrar,
    2. David Davies (d.a.davies{at}bham.ac.uk), Lecturer
    1. Department of Medical Microbiology, St Bartholomew's and the Royal London School of Medicine and Dentistry, London EC1A 7BE
    2. Department of Neurology, Queen Elizabeth Hospital, Birmingham B15 2TH
    3. Department of Physiology, Birmingham University, Birmingham B15 2TT
    4. Department of Radiology, Royal Hospital Haslar, Gosport, Hampshire PO12 2AA
    5. Regional Infectious Diseases Unit, Western General Hospital, Edinburgh EH4 2XU

      EDITOR—Hood et al write about the electronic publication of images.1 We described similar methodology two years ago,2 and a copy of our consent form is available at http://medweb.bham.ac.uk/http/depts/clin_neuro/teaching/consent.html. We took advice from the General Medical Council, Medical Defence Union, Royal College of Physicians, BMA, local ethics committee, and legal department on the design of the form.

      We were interested to read that Hood et al have found rates of acceptance similar to ours. Out of 169 patients approached prospectively over two years in this department of neurology, 154 agreed to be videoed for teaching and publication purposes (primarily for CD Rom, but also for use on the internet in a minority of cases). Many patients, especially older ones, have little precise knowledge of what a CD Rom and the internet are. We would therefore recommend that a laptop computer is used to allow fully informed consent to be obtained. The process takes time, but we have been encouraged by both our patients' enthusiasm and their help. One woman with dystonia agreed to be filmed for teaching purposes on the internet. Since it had taken nine years for her condition to be diagnosed, she was keen for anything that might help other doctors to learn about dystonia—so keen that she told fellow sufferers at a local meeting of the Dystonia Society about our project. One of them telephoned me the next day to ask if she could be filmed for a dystonia web page. We should not underestimate our patients' altruism.

      References

      Medical images can be transferred by email

      1. P J Buxton, Surgeon commander, Royal Navy,
      2. D J Vasallo, Lieutenant colonel, Royal Army Medical Corps,
      3. J H Kilbey (xray_haslar{at}compuserve.com), Wing commander
      1. Department of Medical Microbiology, St Bartholomew's and the Royal London School of Medicine and Dentistry, London EC1A 7BE
      2. Department of Neurology, Queen Elizabeth Hospital, Birmingham B15 2TH
      3. Department of Physiology, Birmingham University, Birmingham B15 2TT
      4. Department of Radiology, Royal Hospital Haslar, Gosport, Hampshire PO12 2AA
      5. Regional Infectious Diseases Unit, Western General Hospital, Edinburgh EH4 2XU

        EDITOR—We were interested to read of the case report on transferring images on a single patient via the internet1 as we have used email to send various clinical images on over 60 patients from a British field hospital in Bosnia and one of the navy's deployed warships to Royal Hospital Haslar so that a second opinion could be given. We have used a digital camera with a matrix size of 1280£1024 pixels (Olympus C1400L) to acquire good quality images of a wide variety of radiographs, dermatological problems and burns, electrocardiograms, and laboratory slides. Unlike the authors, we have found that a flat bed scanner is unnecessary, and we believe that email is the most suitable method of transmission as it is widely available and does not require a hospital to maintain a web server. We have found the technique neither complex nor time consuming.

        We have reported our initial results,2 and we are currently undertaking a full analysis of the image quality, diagnostic accuracy, and clinical utility of our system. A camera based system is clearly both clinically versatile and suited to military use in remote locations. In one case we were able to provide a second opinion on a blood film when this system was used; other, vastly more expensive, telemedicine systems were unable to capture these images.

        Exciting though the possibilities are for this simple technology, we would recommend some caution. Although the quality of the image is usually excellent, degradation occurs. These camera based systems must be regarded only as second opinions, and the original material must be reviewed. We agree with the authors that patient confidentiality is of paramount importance. We would advise that no information that identifies a patient is included in any email sent via the internet.

        Examples of all types of images that have been transferred can be viewed on our website (http://ourworld.compuserve.com/homepages/xray_haslar).

        References

        Digital disguising techniques need to be improved

        1. Philip D Welsby, Consultant physician
        1. Department of Medical Microbiology, St Bartholomew's and the Royal London School of Medicine and Dentistry, London EC1A 7BE
        2. Department of Neurology, Queen Elizabeth Hospital, Birmingham B15 2TH
        3. Department of Physiology, Birmingham University, Birmingham B15 2TT
        4. Department of Radiology, Royal Hospital Haslar, Gosport, Hampshire PO12 2AA
        5. Regional Infectious Diseases Unit, Western General Hospital, Edinburgh EH4 2XU

          EDITOR—Hood et al show a photograph in which the facial appearance has been disguised.1 This technique, and the use of animated multiple squares for anonymous television interviews, is ineffective. By cutting down the information input by half-closing both eyes the viewer is able to recognise faces without any difficulty. I do not know the neurological explanation for this but presume that the simplification of the visual input enables the brain to retain the input for longer; the brain is able to summate the changes occurring in each square, and the brain can then summate the summations to produce a normal picture. These digital disguising techniques should be abandoned unless they can be improved.

          References

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