Clinical Necessity or Physician Malfeasance?

"So now you're saying sensitive -- sometimes very sensitive pictures of other people's bodies are on your [cell]phone, and half the time they could be accessed by your kids. That is not a good situation."
Dr. Matthew Bromswich, Clearwater Clinical, Calgary

"Imagine this on the consent form ... 'Do you agree to your photograph -- the photograph of your newly reconstructed face, for example -- being in the phone beside your physician's baby photos?"
"How many would say 'Yes'?"
Juliet Guichon, bioethicist, University of Calgary

Dave Chan for National Post     Smartphone photos can help good doctors like Dr. Matthew Bromwich better their practice, but there are concerns about doctors who break the rules or exploit patients' most intimate moments.

Perhaps a printed consent form is beside the point. Of the 147 surgeons who took part in the Calgary study that Dr. Bromwich was responsible for, fully 75 percent of respondents felt that a simple verbal consent is more than adequate permission for doctors to take patient photos and do with them what they would. Cellphone cameras are increasingly used in surgery, dermatology and wound care. The primary purpose for those photos is to  help with diagnosis, to monitor an illness course, and for teaching.

Dr. Bromwich, whose study has been published in the journal Plastic Surgery, points out his own experience with patient photos taken by attending physicians. One doctor at a hospital other than Dr. Bromwich's was of the firm opinion that a patient had a coin embedded in his esophagus, and the situation could await being addressed the following day. But to be certain the Ottawa ear, nose and throat specialist asked a colleague to text a smartphone photo of the X-ray.

Just as well that happened, since as it turned out the child had swallowed not a coin, but a watch battery. If that battery hadn't been urgently removed, its presence in the child's throat could have led to what the doctor characterized as a "horrible death". Another case that Dr. Bromwich recalled was one where a patient's peculiar skin lesions perplexed him to the extent that he texted a photo of the patient to a dermatologist.

That expert in skin care alerted Dr. Bromwich to the fact that the patient was suffering from Von Zumbusch psoriasis, a rare skin condition capable of causing death if it is not promptly attended to. Clinical photography has become so ubiquitous that there is a Canadian mobile-phone app, Figure 1, which is a photo-sharing program for health professionals, which boasts over a million users worldwide. Medical images on Figure 1 have been viewed 1.5-billion times.

It is the problematical, ethical aspect of the situation that caused Dr. Bromwich to undertake his study. In Maryland, as an example, a doctor was investigated by police for drug trafficking. But in the course of their investigation police found photographs of female patients' genitalia on the doctor's cellphone. While he maintained the pictures were being used for clinical reasons -- documenting a novel vaginal-reconstruction procedure, he was given the benefit of the doubt and never prosecuted.

Figure 1 has an automatic feature that blanks out faces to completely anonymize photographs, so that practise photos of patients are personally unidentifiable. Dr. Guichon points out that a 2009 British study found most patients were actually opposed to doctors using personal cellphones to capture their images, even while those same patients found nothing suspicious about general medical photography.

Likely their sense of caution had been heightened by stories going the rounds in medical circles. As an example, a Victoria, B.C. urologist photographed a patient where he'd just attached a urinary catheter. That doctor considered it a harmless "joke" to send the photograph of his patient's genitals to a number of friends and acquaintances. When it was revealed, the specialist was fined $20,000  and given a six-month medical practice suspension.

In an Alberta survey of plastic surgeons across Canada it was ascertained that about three-quarters of those surgeons maintain patient photos on their cellphones, along with vacation snapshots, pet pictures and various personal images on their phones. Some of these doctors have inadvertently shown patient shots to friends or family members. A similar survey of 258 members of ear, nose and throat specialty by an Ottawa doctor revealed that over 50 percent said they were aware family members could find patient photos on their phones.

There appears to be an absence of professional guidelines to instruct doctors how to proceed when taking photographs of patients. Guidelines to ensure that no photographs can be taken without a patient's informed and specific consent, and that once taken, those photos be stored  as clinical photographs in an encrypted cloud service which includes a consent form completed on screen by the patients themselves could provide that framework. Dr. Bromwich is working toward that end.

Joe Raedle/Getty Images files   Can you imagine a world in which you'll be able to attach a device to your smartphone and send a detailed picture of your child's inner ear to their doctor? You don't need to imagine: that world is here.