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Opinions on Practice Management

Steven Emmet, MD

Digi-Cams for Dermatologists

Steven Emmet

Wednesday, October 15, 2008

Film is dead, it has gone the way of the daguerreotype and calotype. As DVDs have replaced VHS, digital cameras have replaced film cameras and for pretty much the same reason; digital cameras are easier to use.

But why would dermatologists want a camera, even a "digi-cam" in their office?  If, like many dermatologists, you are doing any cosmetic procedures, including Botox and fillers, then you will have a record of what the patients looked like before the procedures. This can be not only medico-legally useful but also show patients how improved they are and encourage them to consider more procedures.

If you need to schedule an extirpative procedure for a skin cancer some weeks in the future, rather than trying to find the original biopsy site from memory, or a hastily drawn diagram in the chart, a photo will help you pinpoint it exactly.  Sometimes you or the patient may be concerned about a given lesion but not enough to warrant a biopsy; the ability to compare the lesion now with photos taken in the past may reassure you both or suggest that a biopsy is indeed now necessary.

Some dermatologists have teaching collections of interesting photos; digital photos can, with some forethought, be easier to store, retrieve and even share with residents or colleagues. 

As with every therapy and procedure there are of course some potential negative aspects. You have to buy a digital camera (see below), and either learn how to use it or assign one of your staff to do so. The photos will then need to be transferred to a computer using a storage system that will enable you to easily retrieve them in the future. In addition, there is always the risk that if you take a picture of a potential skin cancer that someone in the future might review your photo and say that given this picture you should have biopsied it immediately rather than use the photo to see if it has changed at a future date.

While there are a plethora of digi-cams available, I think dermatologists should consider basically two types for office use: "point and shoot" and D-SLRs (digital single lens reflex).  Don't worry about megapixels, CMOS or CCD chips, or chip size, as any of the newer cameras will take adequate pictures for office and teaching use. However, while almost all cameras have a "close-up" function (usually indicated by a button with the outline of a tulip on it), some are clearly better than others. Many dermatologists use cameras from Sony, Canon, Nikon and Casio; as new ones are coming out every 3 to 6 months if I recommend one or the other now, it may be replaced by the time you read this.  In general, top of the line point-and-shoot cameras from any of these companies are less than $500 (€370) and are excellent for both office and general use. I am personally using a G9 by Canon but only because it also takes "raw" images which are easier for me to work with in Adobe's Photoshop; almost every other small camera defaults to "jpg" images which are both compressed and "enhanced" by the computer program in the camera. I also have a 5-year-old Sony T-1 which is also excellent for office use.

Image stabilization is also a feature you may want to look for in a pocket sized camera, as without practice, they can move as you mash the shutter button. Another useful feature is "optical zoom"; digital zooms give impressive numbers but are basically worthless. Another benefit of the smaller cameras is that they can be used with derm-lights and even with microscopes without too much difficulty. Aiming with the smaller cameras of course has to be done by viewing the screen on the back of the camera because when you get closer, what you see through range finder on top is not what the lens is actually seeing. Another consideration is battery type: many cameras require you to use their own rechargeable batteries. If that is the case, buy two, as the one in the camera will always be totally discharged just when you have to take an important picture. A few cameras still use AA type batteries and these are readily available no matter where you are.

For pictures with better lighting than either the room lights or the tiny flash built into the point-and-shoot cameras you may want to consider D-SLRs. While new ones are coming into the market at a record pace, the established leaders are Canon and Nikon. Both companies make excellent macro lens and I encourage you to purchase a macro lens for office use. You will not need the top of the line "heavy metal" cameras for excellent photos but you will need to consider the size of the chip as cameras with less than 35 mm sized chips will effectively multiply the focal length of the lens. For example, if you have a chip that has a 1.6 multiplier factor, your 100 mm macro lens is now effectively 160 mm, which means you may have to stand outside the exam room to get even an upper body picture. In general, for all but the most expensive (full chip sized) D-SLRs, consider a 60 mm lens. 

Lighting is very important. How many times have you opened a dermatology magazine and seen before and after photos that had different lighting and even different colors? These photos are not useful to say the least. While a dedicated room with carefully placed lights and neutral color walls is ideal, most of us use electronic flashes and if used with some practice can give excellent repeatable quality. The flashes built into some D-SLRs are useful for general photos but when you get very close they may over light one part of the lesion and leave another part in the dark. Small external flashes are inexpensive and can be either hand held or placed to the side or above a camera, either wired or wirelessly, with inexpensive supports. Both Canon and Nikon also offer close-up flash units that sit in front of the lens and whose lighting can be altered to be evenly distributed or slightly stronger on one side than the other, offering some shadows and a more 3 dimensional picture.  This function is highly recommended.  Note that there are "ring flashes" for point-and-shoot cameras: Marumi and Digi-Slave among others make them. They are not as controllable but are inexpensive and may be useful with some practice. 

D-SLRs with macro lenses and external flashes are not small so while you can potentially get better photos you (or your staff) will have to retrieve the camera for each photo session; you would do well not to simply leave it on a counter top as they can occasionally fall or somehow disappear.

Note that there are "all in one" products by companies such as Canfield and MoleMax that are complete systems for dermatological photography and if you are interested you might want to investigate them.

I encourage you all to at least purchase and use a small pocket sized point-and-shoot camera but before you purchase one, try taking a picture of a small area on your own arm and see if you are happy with both the ease of use and quality of image.

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