Table of Contents  
REVIEW ARTICLE
Year : 2017  |  Volume : 13  |  Issue : 2  |  Page : 35-39

Clinical photography and video recordings in plastic surgery: Patient autonomy and informed consent in an era of smartphone technology and social media in sub-Saharan Africa


Division of Plastic Surgery, Department of Surgery, Ahmadu Bello University Teaching Hospital, Zaria, Kaduna State, Nigeria

Date of Web Publication20-Apr-2018

Correspondence Address:
Dr. Abdulrasheed Ibrahim
Division of Plastic Surgery, Department of Surgery, ABUTH, PMB 06, Shika, Zaria, Kaduna State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njps.njps_3_18

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  Abstract 

Clinical photographs and video recordings in plastic surgery are indispensable in clinical practice, training, and research. Historically, clinical photography and video recordings were confined to the stringent control of the medical illustration units of hospitals. However, the evolution of social media platforms and smartphone technology has facilitated the rapid exchange of images with a virtual audience of potentially limitless size. The risk to patients is that more people have access to their images, which may be used in ways not authorized or anticipated. We reviewed current literature including original and review articles obtained through a search of PubMed database, Medline, Google Scholar, and the bibliographies of published articles, which was by hand searching, using the following keywords: clinical photography, video recordings, social media, smartphone, consent, autonomy, and plastic surgery. This review fills an important gap in the plastic surgery literature by providing ethical guidelines in clinical photography and video recordings.

Keywords: Autonomy, clinical photography, consent, smartphone, social media, video recordings


How to cite this article:
Ibrahim A, Abubakar LM, Maina DJ, Adebayo WO, Kabir AM. Clinical photography and video recordings in plastic surgery: Patient autonomy and informed consent in an era of smartphone technology and social media in sub-Saharan Africa. Nigerian J Plast Surg 2017;13:35-9

How to cite this URL:
Ibrahim A, Abubakar LM, Maina DJ, Adebayo WO, Kabir AM. Clinical photography and video recordings in plastic surgery: Patient autonomy and informed consent in an era of smartphone technology and social media in sub-Saharan Africa. Nigerian J Plast Surg [serial online] 2017 [cited 2018 Jul 21];13:35-9. Available from: http://www.njps.org/text.asp?2017/13/2/35/230804


  Introduction Top


Clinical photographs and video recordings in plastic surgery are a valuable adjunct in clinical practice, training, and research. Preoperative photographs are an essential complement to a good clinical evaluation including communication with patients to clarify their treatment plan.[1],[2] They create models for preoperative planning and provide visual references during surgery.[3],[4] Minor asymmetries and subtle contour changes can be highlighted and are indispensable in the postoperative assessment of surgical outcome.[4]

The value of video recordings in didactic lectures, seminars, and workshops is well established.[1],[5],[6] It is a suitable tool to focus a discussion, illustrate clinical cases, and analyze operative performance.[5],[7] In addition, many teaching units may not be doing pediatric craniofacial surgery, esthetic breast surgery, and laser therapy, but the training of residents can be augmented by video sessions demonstrating reconstructive techniques.[1] Thesis, dissertations, and journal publications may require photographs and video clips to substantiate their research value.[1],[4]

In the past, clinical photography and video recordings were confined to the stringent control of plastic surgeons and the medical illustration units of hospitals.[8] However, the evolution of social media platforms and smartphone technology has facilitated the rapid exchange of high-quality images that are easily stored and downloaded with a virtual audience of potentially limitless size.[9] Facebook, YouTube, Twitter, Whatsapp, and Instagram offer interaction in the form of text, sound files, pictures, and videos.[3],[6],[9] The ability to share images comfortably and at a low cost has revealed fallibility in one of the truest of truisms: a picture is no longer “worth a thousand words,” a picture and a video have replaced a thousand words.[6]

Despite its clear benefits, the globalized digital era also brings a myriad of ethical issues, which plastic surgeons in sub-Saharan Africa must be aware of to avoid potential legal pitfalls.[3],[9],[10],[11] Clinical photographs and videos shared by plastic surgeons on social media have blurred the line between entertainment and patient care.[12],[13],[14],[15] The added risk to patients is that more people have access to their images, which may be used in ways not authorized or anticipated. These risks are widely acknowledged, and steps must be been taken to protect the patients.[3],[14],[16] This review fills an important gap in the plastic surgery literature by providing ethical guidelines in clinical photography and video recordings.


  Patient autonomy Top


The creation, use, and protection of medical records have a long and distinguished history. “Whatsoever things I see or hear concerning the life of men, in my attendance, on the sick or even a part there from, which ought not be noised abroad, I will keep silent thereon, counting such things to be as sacred secrets.” This oath of Hippocrates dates to the fourth century B.C. and highlights the confidential nature of a patient’s medical records including digital images.[12],[17],[18]

In contemporary medical practice, all patients are entitled to the fundamental right to determine what happens to their body, which includes a patient’s right to autonomy and privacy.[12],[19] Medical documentation involving the use of clinical photographs and video recordings can present peculiar challenges in maintaining patient autonomy in sub-Saharan Africa.[12],[18],[20] An unequal healthcare provider power imbalance could exist between the plastic surgeon and the patients, especially in busy public hospitals and teaching hospitals. Patients may, thus, feel coerced into consenting to digital photography and video recordings, whether this is overt or camouflaged, in part due to the inherent vulnerability of their position as a patient.[1],[9] Furthermore, in some societies, a sibling, co-wife, or grandparent may accompany the patient to seek medical care and represent the family. It may be deemed that collective decision-making or approval from an elder relative is more important.[14] Moreover, consent when obtained is often verbal and may not include an explanation conveying that clinical photography and video recordings are not only for treatment-related purposes, but also for teaching and research.[9],[12]


  Informed consent Top


The doctrine of informed consent is the cornerstone of the patient–clinician therapeutic partnership.[12] The moral obligation for plastic surgeons toward their patients in sub-Saharan Africa is to obtain first-person voluntary informed consent, while at the same time remaining conscious of the attendant cultural implications.[15] An empathetic perspective of the patient’s apprehension of the use of digital photographs and video recordings represents a good beginning in the professional and ethical management of their care.[9] A sample consent form [Figure 1] and recommended guidelines for obtaining patients’ consent for clinical photography and video recordings are shown in [Table 1].
Figure 1: Sample consent form for clinical photography and video recordings

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Table 1: Guideline for obtaining patients’ consent for clinical photography and video recordings

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It is critical that the patient understands four key elements. First, the patient must have a clear understanding of the purpose of the clinical photographs and videos, including how the images may be disseminated and the intended audience. Consent should be obtained as a distinct question to the patient and should not be implied in the request to make a clinical photograph or video recording.[1],[16] As the second key point, the patient must be competent to make a decision to have a clinical photograph or video recording and decide whether or not to accept it.[21] Third, once children reach the age of consent, they attain the right to withdraw consent at any time. By including the minor in the consent decision, the plastic surgeon can simultaneously promote a positive relationship with the patient and increase the child’s participation in his or her own medical decisions, minimizing the chance that he or she will later withdraw consent.[16],[21],[22] Fourth, the patient must also be informed that their treatment will in no way be affected by their refusal to give consent, and may withdraw their consent for all or any of the clinical photographs and video recordings at any time.[16],[21]

When prior informed consent is not feasible, for example, clinical photographs and video recordings of burn injury resuscitations for quality improvement education. Patient confidentiality must be carefully protected. The subsequent use of such images should be limited to medical record documentation. Once the patient is fully resuscitated and stabilized, consent for the images taken should be obtained retrospectively. If the patient refuses consent, the images should be deleted.[1]

A checklist for clinical photographs and video recordings [Figure 2] is recommended to improve quality assurance during consent. The checklist will increase and improve the awareness of the plastic surgeon and focus attention on the diligent need for consent before, during, and after taking a clinical photograph and video recording. There is a logical concern that increasing requirements for patient consent will lead to greater rates of refusal, and thus result in a loss of valuable digital images for clinical practice, training, and research.[1],[5],[6] However, several authors have found that upholding the patients’ right to choose to have their images published or made available on social media platforms is not associated with an increase in patient refusal.[16],[22] Most patients are still willing to have their clinical photographs and video recordings captured and shared when adequately informed of the intended use.[16],[22]
Figure 2: Checklist for clinical photography and video recordings

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  Smartphone cameras and uniform standards Top


A dire need for uniform standards in the recording and storage of clinical photographs and videos in sub-Saharan Africa deserves emphasis.[9] While some hospitals employ a medical photographer to capture clinical photographs and videos, a recent survey revealed that an overwhelming majority of plastic surgeons do not believe that the existence of a medical photographer eliminates the need for capturing their clinical images with smartphones and digital cameras.[23] Barriers to the accessibility of the photographer have been raised, including large patient volume that may overwhelm this resource and availability after daytime hours.[23],[24],[25] Additionally, in most public hospitals in sub-Saharan Africa, secure electronic databases are usually not available for image storage.[12] The storage of images on smartphones and digital cameras compromise their protection if extra security measures are not put into place.[12],[26] Several detailed reviews recommend the use of security pin codes to lock smartphones and keeping a record of the smartphone’s unique mobile equipment identification number (IMEI).[12],[25],[26],[27] If a smartphone is lost or stolen, the IMEI can be quoted to the service provider to prevent other parties from accessing any data including stored images.[12] Smartphones can be both encrypted and password protected. Emerging smartphone apps such as PicSafe and cloud storage services generally have stronger security offerings, making them a better choice for protected health information.[25],[27] Most digital cameras do not have the option of a security pin number. To ensure the protection of the images, they should be stored on digital cameras for short periods only. Downloading images onto a computer or data storage device with password or pin protection soon after they have been captured is recommended. Although this may become laborious for plastic surgeons who take numerous images, a routine practice of regular downloading should be initiated.[12]The hallmark of international best practices is the creation and implementation of an effective, evidence-based policy.[25],[28] To comply with ethical standards in the face of an ever-changing smartphone technology and social media, an audit of digital photography and video recording practices in sub-Saharan Africa is important.[15] It will illustrate the frequency and use of digital photography and the presence of policies and guidelines that reflect the current technological climate.[9],[24],[28],[29],[30]


  Conclusion Top


The art of clinical photography and video recordings in plastic surgery must be practiced within the context of professional etiquette. Best practices recognize the need for patient autonomy, informed consent, and the constraints associated with confidentiality. Patients in sub-Saharan Africa must feel more than reassured that their clinical photographs and video recordings are safe in an era of evolving smartphone technology and social media.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Bhattacharya S. Clinical photography and our responsibilities. Indian J Plast Surg 2014;1:277-80.  Back to cited text no. 1
    
2.
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Dorfman RG, Vaca EE, Fine NA, Schierle CF. The ethics of sharing plastic surgery videos on social media: Systematic literature review, ethical analysis, and proposed guidelines. Plast Reconstr Surg 2017;4:825-36.  Back to cited text no. 3
    
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[PUBMED]    
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Franchitto N, Gavarri L, Dédouit F, Telmon N, Rougé D. Photography, patient consent and scientific publications: Medicolegal aspects in France. J Forensic Leg Med 2008;4:210-2.  Back to cited text no. 13
    
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Devakumar D, Brotherton H, Halbert J, Clarke A, Prost A, Hall J. Taking ethical photos of children for medical and research purposes in low-resource settings: An exploratory qualitative study. BMC Med Ethics 2013;1:27.  Back to cited text no. 14
    
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Koch CA, Larrabee WF Jr. Patient privacy, photographs, and publication. JAMA Facial Plast Surg 2013;5:335-6.  Back to cited text no. 20
    
21.
Lakdawala N, Fontanella D, Grant-Kels JM. Ethical considerations in dermatologic photography. Clin Dermatol 2012;5:486-91.  Back to cited text no. 21
    
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Harting MT, Dewees JM, Vela KM, Khirallah RT. Medical photography: Current technology, evolving issues and legal perspectives. Int J Clin Pract 2015;4:401-9.  Back to cited text no. 24
    
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27.
Thomas VA, Rugeley PB, Lau FH. Digital photograph security: What plastic surgeons need to know. Plast Reconstr Surg 2015;5:1120-6.  Back to cited text no. 27
    
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Berle I. The ethical context of clinical photography. J Audiov Media Med 2002;3:106-9.  Back to cited text no. 28
    
29.
Pinsky LE, Wipf JE. A picture is worth a thousand words: Practical use of videotape in teaching. J Gen Intern Med 2000;11:805-10.  Back to cited text no. 29
    
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