Apart from archival value and documentation, Photography inside workplace always hold a special position. That type of photography is artistic in nature and not considered in this article. We thought to write a guide on Clinical Digital Photography for Surgeons, Doctors & Dentists on our website for the advanced users. One can read this article along with the hyperlinked articles to avoid any overpriced course. Author of this article has paperback on Portrait Digital Photography, at $10 price tag that is more than sufficient for learning the basics with DSLR camera. Standards have not been established for medical photography in orthopedics. The usual artistic matters like Rule of Thirds, Golden Section is not very important in composition of Clinical Digital Photography. Half stripped human and artistic photography with nice composition will become erotic photography. Photographs or illustration are made bland with Anatomy style of illustration. The Photographs shown in Bailey & Love is the Standard. The historical reason is that, Henry Hamilton Bailey’s wife was photographer and she took them under Hamilton Bailey’s observation. The standard clinical books, Atlas have standard images.
Clinical Digital Photography for Surgeons, Doctors & Dentists : Choice of Cameras
We have varied options of cameras – Digital Rangefinder, Digital SLR, Mirrorless Camera, Point & Shoot, Mobile Phone Camera, Head Mounted Camera like Google Glass, Film Rangefinder Camera, Film Point and Shoot camera and Film DSLR Camera. As we always say – Film Rangefinder Camera is the Gold Standard as Film itself a physical documentation, costs lesser than Digital Rangefinder Camera.
We suggest to use Leica M9 or Leica M series or Leica Monochrom for natural photographs. If Leica is out of budget, but any Point & Shoot. DSLR shutter makes sound which may make patient looking uneasy. Canon and Nikon is consumer grade cameras, unlike Leica or Hasselblad, which are professional grade. Most good photographs on this earth taken by Leica or Hasselblad with Kodak’s film. That Kodak’s film is not Leica’s sensor manufactured by Kodak. Leica M9 is of pocketable size.
At next position, we will keep the advanced Point and Shoot cameras, Head Mounted Camera like Google Glass and Mobile Phone Camera. DSLR Camera is never our favorite because of bad metering, low quality optics and complex shutter mechanism. Digital SLR is practical in one situation – making photographs from microscope and microphotography.
Unless otherwise specified, we are taking Leica M9 as Standard Camera. Digital SLR may not be suitable for higher reproduction quality in Orthopedics. Leica M9 does not need post-processing to convert RAW to JPEG. On the fly, it does enough good work. Leica M9 uses sensor manufactured by Kodak. Leica has dedicated B&W camera – Leica Monochrom. I expect that an Orthopedic Surgeon will use devices manufactured by the Standard company. Our photographs started with Hugh Owen Thomas’s pose of smoking while doing regular work. People says that Hugh Owen Thomas applied force to check the mechanism on injury. That photograph has non-co-operative patient whose arms are held by Hugh Owen Thomas’s assistants. Free treatment. I hugely like Hugh Owen Thomas and is like before I knew him for the sake of passing theory exam.
Converting Clinical Digital Photography to Line Diagrams and Image Editing
We can convert raster image to vector image. Previously we wrote about raster to vector conversation softwares. They are great for creating/writing operative steps. That process factually makes the outline like image in one color (usually black).
Adobe Photoshop on Mac with calibrated display is ideal for post processing of photographs. Adobe has excellent learning resources. GIMP is Free Software and a Standard Alternative to Adobe Photoshop.
Clinical Digital Photography for Surgeons, Doctors & Dentists : Choice of Lens & Accessories
All lenses which are used for portrait photography should work great. It is obvious that adding photographic beauty like bokeh must be avoided. We suggest to use the Prime Lens for better quality. Canon EF 50mm f/1.8 is the cheapest lens. We expect that a professional will use a good Tripod and Tripod Head. The total setup should be like a home studio. Usage of reflectors, lens hood, external flash, light meter, ring flash and remote control shutter are other probable needed components. Electronic strobes are near ideal light sources for medical photography studio. Overhead fluorescent lighting may tend to produce inaccuracies in color tones. Backdrop is an important part of most clinical photography. Any good clean, thick, non reflective cloth is good for the purpose. Black and White are the standard color backdrops in all photography except medical photography. Why green and blue colored backdrops are used in medical photography, that is unknown. Any colored backdrop other than black will reflect some light working as a type of filter. Additionally, metering and autofocus may go bad.
Video Photography is fully different topic. Orthopedics use IEEE, ISO certified or specified Standard instruments for video photography specially for Live Surgery. New users can read which camera mode to use in which situation and manual mode of DSLR camera. Whole Digital Photography section is a good guide for any type of photography.
Basic Setting using studio lights with the camera is :
- White Balance : Auto or Florescent daylight (daylight for strobes)
- ISO 200 to 800
- Focus set to center spot
- Manual Mode
- Shutter Speed : 1/125 Sec
- Lens opening (f-stop) : Approx. 5.6
Clinical Digital Photography and Standardization
Plastic Surgery Educational Foundation has some standards. They give importance to the pertinent anatomy of the patient without distraction ensuring comparisons of pre-op and post-op images for a meaningful observations. Having a total setup like a home studio is practical. The magnification factor of clinical photographs should always be controlled and standardized like Xray films. Westminster Scale is a table of standardized scales for recording the commonest views of the human anatomy, which is used by the medical photographers and allows different workers to achieve closely matching magnifications. The scales refer to primary magnification on the film itself, and apply to photography with a 35mm camera. So for digital SLR photography with cropped sensor, calculation must be made – sensor size is important. In forensic or medicolegal photographs a two dimensional right-angle scale is used. Depth of field is especially narrow in macro or close-up photography with 1:1 to 1:4 reproduction ratio. Writing the magnification in ratio over the image during post processing should work fine. Any kind of imaging – MR Imaging, Xray, CT Scan etc. must not be “photographed” unless avoidable but should be scanned on normal flatbed scanners if the digital format is not available. IEEE Medical Standard for 3D stuffs is chaired by Dr. Young Lae Moon, MD (Orthopedics), PhD et all.
As our goal of photography is to maintain consistent magnification, for a given camera, surgeon and patient, this can be achieved by :
- Knowing the crop factor of the sensor and constant
- Knowing the focal length of the lens and constant
- Keeping camera-to- patient distance measurable and constant
This can be automated by using a measuring system from patient’s nose to the sensor. Measuring system can be light/infrared based or simple measuring tape. Obviously, Rangefinder camera are better to handle this part.
Medico-legal aspects of clinical photography
Prior written or verbal consent for photography must be obtained prior to any photography. The consent should be written by a lawyer to avoid future legal fuss. Suddenly if you land to a Lawyer after filing case whom you never knew, how he/she will save you? Original copy must be given to the patient. If you use GNU GPL 3.0, then use patient’s SD/memory card or cheaper blank SD/memory card. You can not apply copyright restriction with GNU GPL 3.0, GNU GPL is powerful and for the hackers. If you add “Copyright Protected, All Rights Reserved”, that is violation of GNU GPL 3.0. Lawyer should be either a software engineer or is used with Free Software development. Copy of original photo is not same as original photo. Read Facebook’s terms.
Face’s photograph is not dangerous, Neck to Mid Thigh pose is quite sensitive matter.
Poses for clinical photography (non-operative)
As I said at the beginning, see the photographs in clinical examination books, Bailey and Love at different Atlas. Basically, we need to show in anatomical position. Otherwise part of thumb may look like part of penis! We will mainly talk about the Orthopedic positions.
Face is common in oculo-facial plastic surgery. There is standard five-view head series.
Frontal view : Framing is either edge-oriented framing and center oriented framing. For close-up of face, reproduction ratio would be: 1:4. Follow the normal stuffs for portrait as written in my $10 paperback. Frontal view is from the upper limit of the head to the suprasternal notch while the patient looking at the camera. Reference plane will be should be horizontal and run from upper edge of the tragus to the Frankfurt plane (lowest point on the lower edge of the orbit).
Oblique view : Oblique view is modified frontal view, face is rotated 45 degrees to align the tip of the nose with the cheek The Frankfurt plane is held horizontal. Eyes will point forward.
Lateral view : Again it is modified frontal view, where the whole body rotated 90 degrees so as to align the tip of nose and chin. Head will be in anatomical position with no lateral inclination, flexion or extension. The Frankfurt plane is held horizontal and opposite eyebrow will be invisible. Eyes will point forward.
Neck to Mid Thigh
Patient should only wear minimum garment, while standing comfortably erect with arms at sides. Feet should be aligned with appropriate tape marks on floor. Clavicles should be at the top of frame. For frontal and oblique views, torso will be horizontally centered. Distal breast should not be visible in lateral views. For oblique views, distal arm should be moved slightly backwards.
Same as Neck to Mid Thigh, only patient showing ass to the camera instead of face. Obviously, thing of interest will be positioned in the center with some reference bony points.
Patient should only wear minimum garment, while standing comfortably erect with arms folded above breasts. Feet should be at approximately shoulder width, aligned with appropriate tape marks on floor. Knees will be at the bottom of frame while hips horizontally centered. What is we say “leg” that means below the knee joint, that part should not be visible in lateral views.
Patient should only wear minimum garment below the waist, may stand on a step stage or stair case with feet at approximately shoulder width. Toes will be at the bottom of frame, feet horizontally centered. Other leg should not be visible in lateral views.
Patient should only wear minimum garment below the knee, rest foot on a step stage or stair case with feet at approximately shoulder width. Lateral malleolus will be at the bottom of frame, feet vertically centered. Other leg or foot should not be visible in lateral views.
Patient should only wear minimum garment above the waist, may sit on a stool with elbow at edge of frame, arm vertically centered. Shoulder joint and arm will have the angle of 90 degrees, elbow joint can be at any angle.
Patient will sit on a stool with elbow at edge of frame, forearm vertically centered. Shoulder joint and arm will have the angle of 90 degrees, elbow joint will be 180 degree.
Extend hand in horizontal plane above, perpendicular to camera axis at center in the frame.
Extend the finger in horizontal plane above, perpendicular to camera axis at center in the frame.
Poses for clinical photography (operative)
All is same but patient may be under anesthesia. We can not make an under GA patient standing. Surgical skin markers should be used. If I am demonstrating Total Knee Replacement with MAKOplasty, I should show the bony points first, planned incision line with different colored skin markers. After dissection photographs will need post processing and marking with Adobe Photoshop.
Storage of clinical photographs
As we always suggest – encrypt data. It is obvious, who will take Digital Photography will know how to maintain Data Security on the Cloud. If no web software is installed on a server, all common ports except port for SSH is closed, how data can be stolen?