10 Tips for Better Patient Care and Better Business

The Dermatologist’s Guide to Effective Clinical Photography

Photography has become essential to the practice of dermatology and aesthetic surgery. It provides a mechanism to improve patient care, enrich your documentation, aid in patient education/consultation, and allow you to set realistic expectations for your patients through the use of “before and after” images for cosmetic procedures. Despite the power of great photography, most medical practitioners find it difficult to capture high quality images. Consis- tent lighting, as well as camera and subject placement is critical to taking the quality photos that can showcase your skills and expand your practice. We have compiled ten invaluable tips to help you and your office achieve the best photographic results possible.

Put a mark on the floor where the photog- of the distal cheek. This will help your pre- and Stand your ground. ▪ 1 rapher should stand. Try to keep the camera post-treatment images maintain consistency for successful comparisons. Many photographers stand too close to their over this line to maintain the distance. subjects, which may create distortion in the Photographing extreme close-ups Perspective is also important in non-clinical image. Additionally, at a short distance, the For extreme close-ups, special equipment is situations. The effects of laser and cosmetic bright flash from most cameras will overex- often required. The macro mode on a point- treatments can be effectively documented pose or “wash out” the center of the picture. It’s and-shoot camera, or a macro lens on a digital with consistent patient positioning. To reliably much better to maintain a reasonable distance single lens reflex (DSLR) camera, will enable duplicate patient positioning: from the subject—typically around four feet or the proper focus when you are photographing Place or note small marks every 3-4 inches more—and use the camera’s zoom feature to at a distance of less than six inches. ▪ on the wall opposite where the patient will isolate the subject of the picture. Set your camera or lens to macro. On many be standing to have their picture taken. Maintain consistent distances ▪ cameras, this is denoted by a small flower The marks should generally range in height When taking before and after pictures, it is icon. from just under five feet to just over six feet very important to maintain consistent dis- Use a tripod. This is essential for taking ex- to accommodate all patients. tances from the subject. There are some easy ▪ treme close-ups with the macro mode. Label the marks on the wall with colors, let- techniques to help with this. Take some test photos to gain a better un- ▪ ters or numbers to correspond with patient Keep your camera on a tripod to keep your ▪ derstanding of the lighting requirements. height. ▪ camera steady. Make sure your patients are photographed Put marks on the floor where the tripod legs ▪ with their shoes off to remove height varia- ▪ stand, as well as marks on the floor where Maintain perspective. tions based on high heels or thick soles. the subject should stand—about two feet 2 It’s important to take all of your photographs Have your patients stand with their toes on from the wall to minimize hard shadows on from a consistent angle, or perspective. This ▪ the spot you’ve marked on the floor. Ask the wall. ensures that you can make useful comparisons them to point their nose to the spot that If a tripod isn’t a viable solution because of between images taken at different times. corresponds to approximately four inches space restrictions, try one of the following below their height. For example, if a 5’10” Establish standard positions techniques: tall woman is standing to be photographed, Establishing a regular set of positions for pho- she should point her nose at the spot at or Attach a piece of string to your camera the tographing each part of the body will make it about 5’6” high on the wall. ▪ length of the distance between the cam- much easier to track the progress of a treat- era and the subject. The string then acts as ment. For example, facial photos should be Note that asking the patient to look at the a convenient measuring device to ensure taken with the patient’s Frankfort horizontal spot does not achieve the same result; con- that the subject will stand the same dis- plane (i.e., the imaginary line from the external sistency in positioning over multiple pho- tance from the camera each time. (To avoid auditory canal to the infraorbital rim) parallel tographs comes from the patient pointing contamination, be careful not to touch the to the ground. For oblique facial views, you their nose at the spot. The color of the dot string to the subject.) should align the tip of the nose with the edge can be noted in her chart.

Page 1 Positioning almost frozen. “Too warm” will occur if the red rendering the image useless for its intended There are five commonly used angles for most and yellow tones of the picture are increased, purpose. Alternatively, an overly bright expo- medical photographs: frontal, oblique (45˚ causing the patient to look flushed. sure might minimize wrinkles and other skin left and right), and lateral (90˚ left and right.) features that may need to be highlighted in On some cameras, you can combat this type For each of these, position the same height the photograph. of distortion by adjusting the white balance. markers on the opposite walls. Have the sub- When possible, keep this set to “auto” or “flash” The key to proper lighting is to provide enough ject turn and point their nose to the spot that for closer images. On some point-and-shoot light to illuminate the subject, but to diffuse corresponds with their height. In this manner, cameras and all DSLR cameras, the white bal- the light or provide it from an indirect angle. you can maintain consistent positioning over ance can be manually set. This will remove the harsh shadows without multiple visits. overexposing and washing out all the shad- Consistent settings Camera Height ows in the image. In any case, it’s critical to set up the room with The height of the camera is important. An im- the same type light for each photograph and The two specific factors to consider in light- age taken from below someone’s chin will look keep the setting consistent on the camera. ing a photograph are angle and intensity, very different than one taken from six inches and there are multiple ways to manage their above them. Know the height on the tripod Close the blinds in each room during photog- effects on a picture. Many of the methods are that corresponds to the mark on the wall raphy. Use your flash or hot lights as the pri- camera- and/or light-dependent; a general and the height of the patient. Extend every- mary light source. Each of the light sources— understanding of the factors involved can go thing and make marks on the extension tube fluorescent, exam light, flash, and hot lights— a long way toward understanding the proper corresponding to the proper height. Finally, are different colors of light. If you change the setup. make multiple marks on the floor where the light you use between photographic sessions tripod belongs to enable you to position the of the same patient, their skin will appear to Angle tripod and quickly take the photographs of all be a different color in each session. Light traveling straight from the camera and angles. Be sure to add all of these settings to reflecting from a subject tends to flatten the Clinical images can also be detrimentally in- the patient’s photographic record, so they are features. Conversely, light coming from an fluenced by background, clothing, jewelry, readily reproducible for each visit. extreme angle will drastically increase shad- makeup, and hairstyles. owing. Navigation of these extremes can be Use a plain grey or dark-colored poster fairly simple—provide ample light at moderate Let there be light. ▪ board or wall as a backdrop for all of your angles. 3 photos. Your best results will be obtained by using Consistency in color is also important for good two light sources to illuminate the object from photography. While the color of your photo- For darker-skinned patients, blue or grey ▪ will provide enough contrast. both sides. This will remove the harsh shadows graphs can be influenced by a number of fac- and light “fall-off” often seen on one side of an tors—the paint color on the walls, colors worn Advise your patients to remove any acces- image due to the light coming from the other by a patient, the number of office windows, ▪ sory that may appear distracting or cause side of the subject. and the fluorescent lights on the ceiling—the distortion in any pre- or post-treatment Whether you are using one or multiple light single most important factor in achieving con- photos. sistent color is to provide the exact same light sources, you should diffuse the light or bounce each time you take a photograph. Have your patients wear a collarless gown it off the walls to illuminate the entire room ▪ to maintain neutral and accurate skin tone and create a softer effect. Diffusion is accom- While our eyes automatically adjust from light in your images. plished using the on-flash diffuser, a third-par- source to light source and balance out the col- ty diffuser such as a Lumiquest flash diffuser, or differences, cameras have a more difficult This will ensure a consistent look for accurate or a “soft box” to scatter the light, enabling it time doing this. They simply capture the color comparisons. to reflect off the subject from multiple angles, of the light that enters the lens. resulting in a softer photograph. Consistency in color, like the angle and inten- When film cameras were very popular, people sity of light, is very important. Tight control Alternatively, bounce the light from your flash- would buy “indoor film” and “outdoor film,” over the type of light coming into the lens will es off the ceiling or side walls to flood the room which would compensate for the color chang- have an important positive impact on your with light. For extreme close-ups, use a multi- es in the light. Today, on digital cameras, you photographs. element ring flash or a twin flash such as those can set the “white balance” to make those made by Nikon or Canon, which can be found same adjustments. at most camera stores. These provide light Capturing natural skin tones All light isn’t created equal. that reflects at an angle into the lens, reducing 4 shadows yet providing consistent lighting. The goal is to capture natural skin tones and avoid the color extremes: too cool and too Proper lighting is important in any photo- Notice that all of these solutions accomplish warm. “Too cool” is when your image is dis- graph, and it is especially important for close- the goal of having light illuminate your patient torted in a way that enhances the blues and up images in medical photography. Shadows from multiple angles, removing the hard shad- greens, causing your patient to look pale or can distort the subject of the photograph, ows while still providing the necessary detail.

Page 2 Intensity With either one, you can diffuse the light as Blinks and blanks. Intensity, defined as the amount or degree of discussed above, which will help prevent your 5 photograph from being overexposed or too strength of light per unit area, is another criti- Some patients find it difficult to keep from cal element in successful photography. There harsh. Remember to check the image preview blinking when a camera flash goes off. Many are three factors that contribute to controlling on the back of the camera. Your image should of today’s digital cameras use multiple pre- the amount of light coming into your camera be clear and bright. paratory flashes to overcome this problem. It on any given picture, also known as the “expo- Lighting Strategies may also help if you have the patient keep his sure” of the image. They are: The next step towards achieving consistent or their eyes closed while you count to three, Aperture: Adjusting the size of the lens photographs is to understand how to set up and then open them at the moment the pic- ▪ opening, or “aperture” effectively changes the room to maximize the probability of a cor- ture is taken. Always check the image in the the diameter of the hole that the light rect and consistent image. image LCD view on the back of the camera comes through into the camera. The smaller to make sure you captured your subject with The most common scenario is a practice that the lens opening, the less light comes in. their eyes open. uses a point-and-shoot camera with a built- Shutter speed: Controlling the length of time in flash and no external lighting source other If you are photographing a patient’s face, you ▪ that the light is exposed to the digital chip, than the exam room lights. If this is the case, should make sure that the face is expression- or the “shutter speed,” changes the amount you may find that your images look slightly less in both the pre- and post-op photos. The of light that can get in. Shortening the flat. Purchasing a diffuser for your camera and slightest smile can change the shape of the length of time that the camera is “open,” re- making consistent the amount of ambient face and the severity of lines and wrinkles. An duces the amount of light that can get in. light in the room by drawing the shades can obvious benefit of digital cameras is that im- improve consistency in your photographs. ages can be immediately checked for closed External light source: Controlling the amount eyes and correct facial expressions mimicking ▪ of light coming into the camera increases or Previously, we recommended positioning the those from a past picture. decreases the intensity of the external light subject four feet from the camera. However, source. in this case, the built-in flash may not have enough power to run through the diffuser, Balancing black and white Keep it simple. appropriately light your subject, and bounce The combination of the amount and bright- 6 light back at that distance. Therefore, you’ll ness of light coming into the camera and the More features and a higher-priced camera need to test your distances by moving your length of time the camera is open can change don’t necessarily mean better pictures. Actu- camera incrementally closer to your subject, the image from an almost black exposure ally, the opposite can be true: extra features taking a picture, and looking at it in the view (not enough light), to a perfect exposure (the add complexity and can make it harder to take finder. proper combination), to an almost white ex- good pictures quickly. This is especially true in posure (too much light). Once you find the maximum distance where practices where nurses and/or office assistants, your subject is brightly lit, use that as the sub- who are under heavy time pressures, take the While this may all sound complex, camera ject-to-camera distance every time you take bulk of the photos. When choosing a camera, manufacturers have made it very simple to get a photograph. The camera will then set the look for the following basic features. the perfect exposure. The computing power in shutter speed (usually at 1/60 or 1/125 of a today’s cameras is so fast that the camera can Resolution second), and adjust the aperture and flash calculate the amount of light and automatical- Digital camera resolution is measured in intensity. These automatic adjustments on a ly adjust the flash intensity, aperture and shut- megapixels—the more megapixels, the high- consistent setup should result in consistent ter speed while the picture is being taken. er the resolution, and the clearer the photo- images every time. graph. Generally speaking, a 3 megapixel (MP) This is accomplished by ensuring the camera is Lighting strategy is an area of photogra- camera will provide more than adequate reso- set to read the amount of light coming through phy that lends itself to lengthy discussions lution for 8 x 10 prints, PowerPoint presenta- the lens; almost all cameras will automatically of possible options, depending on the par- tions, or most common applications. Many of adjust the exposure accordingly. To do this, set ticular needs of a practice and the facili- today’s cameras capture images at 5 megapix- your camera on Auto or Program (sometimes ties and budget available. For an in-depth els or more. Anything over 3 megapixels is fine. shown as P on the camera dial). discussion of techniques and equipment, Higher resolution images mean larger image Next, make sure that the room has consistent visit the Photography Consultation Room on files. Except in rare cases, the additional infor- lighting each time you take pictures. Draw the the ImageStore for Healthcare web site at: mation provided in images over 5 megapixels blinds to minimize the differences in time of www.ImageStore.md isn’t necessary for medical photography. day. Even though the camera will adjust its Above all, in clinical photography, consistency Zoom own settings, it will do so within a tolerable is critical. Once you find a combination of el- An optical zoom of at least 4:1 will serve well range, which may produce slightly different ements that works—distance, angle, and infor applications ranging from close-ups of le- exposures if the light used for the images is tensity—repeat those elements for each and sions or other conditions, to full body pictures. drastically different. every photograph to eliminate the differences Many digital cameras have “digital zooms;” Finally, use external light sources, such as flash that can cause a series of photographs to be however, these are not true zooms. They re- or continuous lights (known as “hot lights”). unusable. duce the resolution of the image and are not

Page 3 appropriate for dermatology applications. Dare to be digital. In any of these scenarios, the pictures need Make sure you purchase a camera with at least 9 to be filed and categorized with the appropri- a 3:1 optical zoom and then turn off the digital Many practices attempt to manage their pho- ate information that will allow them to be re- zoom through your camera’s menu system to tographs in a set of folders on their computers trieved easily. You should be able to file images avoid activating it by mistake. or just print photographs and add them to the by patient, cross reference them by diagnosis, procedure or location, and store them in mul- Macro Focus patient’s paper records. In the long run, this tiple reference folders. Most importantly, now Macro focus is required to take sharply focused approach is problematic, as it does not allow that you can find them, use them effectively: close-up images. Be aware that the macro photos to be easily retrieved based on their share them in a HIPAA-compliant manner to function does not always work well with the specific characteristics. provide better care, submit them digitally to existing flash, as many flash set-ups will not il- For example, if you file images by patient, they insurance companies to streamline your oper- luminate the entire area in extreme close up are easy to retrieve as long as you are search- ation, and show before and after shots online situations. However, twin-flashes, multiple ing based on patient name or number. But if or on-screen to ensure realistic patient expec- flashes, or hot lights will provide more than you are looking for images of specific body tations. enough light to take an excellent photograph. sites, conditions, or procedures, you’ll have to On a higher-end camera, a ring flash com- remember which patient had the best result, In conclusion bined with a macro lens will provide the best or you’ll literally need to browse through ev- Digital photography is an essential tool in possible image. ery patient until you find the desired image(s). today’s world of increasingly specialized medi- This is expensive and time consuming. cal care. By following a few basic rules, you can capture excellent pictures to support optimal The name game. With a powerful image management system, patient care and meet essential business re- 7 you can easily retrieve photos by searching quirements. With the right approach, the right Just as consistency is important in taking your on various criteria. You can find photos of a equipment, and the right system, you can im- photographs, it’s also crucial to have a consis- patient taken after a specific date, or all the prove patient care, grow your practice, mini- tent naming convention. This will greatly sim- photos for a specific diagnosis. This increases mize insurance hassles, and achieve the full plify the filing and retrieving of desired images. office efficiency and the utility of your images. potential that digital photography has to offer A typical format might consist of the first few In addition, having the capability to access and your practice. letters of the patient’s last name, followed by retrieve images from multiple locations such as an underscore, followed by a date. For exam- exam rooms, consultation rooms, your office, Through the Lens (TTL) Software provides ple, “smith_2006031506” or “smi_20060315”. your nurse’s station, and home increases effi- state-of-the-art image management and Using a date in the image name enables you ciency and image usability. Although storing sharing solutions for medical professionals to quickly scan through all the photos of a pa- your images on a single computer may seem and healthcare institutions. Using these so- tient and see progress over time. like a simple solution in the short term, over lutions, your staff members can easily store Whatever naming convention you decide time, it may become very limiting. Consider in- and retrieve images based on any and all upon, post a guide explaining the system near vesting in a service that manages your images relevant criteria. Designed for intuitive use the computer so everyone entering data will in a secure, HIPAA-compliant manner. You can and flexible customization, TTL Software’s use the same format. then access your images from any computer photo archiving tools enhance all aspects using the proper login and password. of medical practice including diagnosis, consultation, claims management, regu- Get the 411. latory compliance, professional develop- 8 Build a database. ment, and education. Even the best photographs will have only lim- 10 ited usefulness if they are not accompanied Watch for our upcoming article entitled Your knowledge database of images is an in- by complete labeling of all their relevant at- “Patient Positioning for Effective Medical credible asset to your practice. The images can tributes. Mark each image with the patient Photography.” be used to demonstrate treatment effective- name, date, condition, procedure, and loca- ness and track progression or regression over tion on the body. time. They can be filed with insurance compa- For more information, go to This comprehensive image “tagging,” or label- nies for quicker processing and payment, can www.ImageStore.md ing, helps ensure that every photograph can be added to letters for referring physicians and be fully utilized to support any task for which it are helpful in avoiding mistakes. They can be is appropriate—in effect turning your images used for before and after reference images, into a medical knowledge-base. The use of a for marketing brochures, treatment books, or good image management system that sup- on your website. In difficult cases, they can ports such comprehensive image labeling and be shared with a colleague or specialist for an retrieval is essential. outside opinion.

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