Digital Camera System: To Use or Not to Use
INTERNATIONAL JOURNAL OF COSMETIC SURGERY AND AESTHETIC DERMATOLOGY
Volume 3, Number 3, 2001
Letter to the Editor
After hearing over and over again about the benefits of the digital cameras, the issues of whether to use the system or not have come into focus. The reasons not to convert to the digital camera system includes:
- Hardware startup costs are at least $3500 and possibly $5500. Obtaining a fancy printer, to get speed so that the office staff does not have to sit around waiting longer than necessary, costs $2500 (Xerox "wax" printer), while the camera costs $1000. I asked the experts at the camera shop, not the technology infatuated physicians at meetings, what the savings would be and they looked at me as if I were crazy. They said it was more expensive than ordinary camera work because you may not have a proper computer that can be dedicated to this and you need a good backup system. Cost would be an additional $2000.
- Software can range from $1000 to $10,000 or more, but if you buy the cheap system you may find yourself without support later (unless you purchase a Naimtu).
- Staff costs increase. There's time and hassle involved to learn the new system. There is a long learning curve for the staff to photograph and print the images properly. They will have to wait by the printer for the images to come out. Paper costs are high, up to 48 cents per sheet of four images and then add printer cartridges, printer costs, maintenance, and replacement. If you wish to obtain duplicates, which we feel is an important aspect of patient services, then double the costs. Several of our staff have managed to figure out a pen and paper system for labeling the photographs. I am not enthusiastic about spending time training the staff to work on a computer and if you think you can do this all yourself, you are wasting a lot of time.
- The technology buffs may think this is not a concern, but your plaintiff's attorney may find cause to accuse you of photo alterations. They are clever.
- It seems to me that the risk of the office burning down and destroying my film negatives is pretty small, but sometimes, in a fit of paranoia, I think about keeping them in a firebox. I do not want to add to this the risk of a hard drive crashing and/or the backup system becoming messed up by some staff member not understanding the system properly. I do not want to lose my photos because they allow me to sleep better.
The touted advantages of the digital camera seem to be:
- Better "sales closures" with a computer imager.
- Convenient storage.
- You can play with the images.
- Immediately available photos.
- Great slide shows on PowerPoint.
Our opinion is that the compute imager gets in the way of what the consultation patient is really interested in, which is making an emotional contact with the physicians. The practice that has trouble with counseling patients should develop the physician's skills rather than spend the money on technology and think that the problems are solved.
Storage convenience is hampered by the need to go into the room where patients are being counseled to get a print of a photo. On the basis of getting the photos back the same day we have considered computer imaging and digital photos. Now, if necessary, we use a Polaroid.
What is needed is a simple stereotyped system that allows your staff to obtain great photos without your help. We use a single camera on a fixed tripod, with interchangeable 60 and 105-mm lenses (for bodies and faces) respectively that is set on marks on the carpet in a four-foot-wide back hallway. There are marks on the carpet where the patient is to stand. There are slave flashes overhead, one in front and one in back of the patient. The f-stop is 8 to 11 for good depth of field and the shutter speed is 125. The background is blue. Once you are set up, take some photos to be sure every thing is correct. The name and date are recorded in a log and are later marked on the prints and filed.
There is always some technology maven waiting to grab some of your meager income from your hard work. I fell for it 5 years ago when I spent $25,000 for one of the early imaging systems. The lease was finally paid off last year. It was a good lesson each month writing that check. It told me to be more suspicious and analytical about my purchases. I am going to wait until the digital imaging is so cheap and simple that it clearly pays for itself.
Commentary: I have been intimately involved with clinical digital photography since its inception. I respect Dr.Yoho as a highly competent and evidence-based cosmetic surgeon, but he is out of step with the reality of modern technology.
At one time, some argued against Henry Ford's car and how it would never replace the horse. People resist change because they are afraid of it and will find reasons (excuses) to validate their fears. Others will, fortunately, embrace new technology.
Dr.Yoho's comments are a perfect example of what occurs with a paradigm shift (new technology replacing the old model). Cosmetic surgeons are experiencing a paradigm shift in photography. With this shift, all rules change and it takes a period of time to adapt to the new model. One can find excuses to avoid digital photography by citing cost, learning curves and so forth, but these are largely excuses and not limitations.
There are some specific issues in which Dr.Yoho is misinformed. He states that the costs of hardware are exorbitant, but an Olympus C2500L digital camera (Melville, NY) is about $850.00. This camera is a single lens reflex (SLR) with through the lens focusing (TTL) and, for all intents and purposes, feels and acts like a traditional 35-mm camera. The only minor difference is that it may take a second for the auto focus to adjust. This is a small price to pay for having the ability to view your image immediately and know that it is adequate. One million pixels (one megapixel) are more than adequate to view diagnostic detail and are suitable for publication and presentation.
The Hewlett-Packard 970 Cxi printer (Palo Alto, CA) costs about $300 and has amazing photographic quality of cosmetic images. This printer is a workhorse and can be used for all printing needs including documents and 8 x 10 color images. It is true that special paper produces better images, but excellent glossy paper can be obtained at Sam's Club for about 14 cents per sheet. The cost of paper is negligible when compared with all the slides I used to waste trying to obtain a good picture.
As for imaging software, things keep getting better and cheaper. Unfortunately for the imaging companies, technology is progressing so fast that prices are dropping and powerful, inexpensive programs are becoming available. There is no reason that an investment of 1000 to 2000 cannot get a novice doctor set up with quality of software and support. The technology-seasoned doctor can do most imaging needs with an image editor, such as Photoshop (San Jose, CA.) and database software.
Basically, for $2000-3000 you can get everything you need to perform quality imaging. I must admit that it does take time to archive images. I do not recommend naming every image, but rather make a directory with folders for each major cosmetic procedure performed. Then make a subdirectory with the patients' names and dump the pictures into that directory. It is simple to find digital images if you have a basic catalog system and you use basic Windows search functions.
Having my entire "slide collection" on my laptop allows me to use any image at any time with a mouse click. I can prepare presentations on the plane on the way to a conference. I can take my images home, to the hospital, to meetings, and to marketing seminars. In the past, I lived an addiction of constantly shifting slides between rattling carrousels and seemed to always be doing this late at night before a presentation. It is impossible not to see the huge advantage of one or two CDs compared with storing 60 carrousels.
Dr.Yoho minimizes the chance of his office burning down, but I have seen slide collections lost or damaged. Some of my "once in a lifetime" slides taken years ago have begun to fade and discolor. There is no doubt that anyone using digital media must have a backup strategy because Dr.Yoho is correct that a single virus can wipe you out. I recommend a CD writer that can be purchased for $200, which gives you a backup that is stable for at least a century and can be read on any computer. If you are not responsible to backup your images, then keep your slides.
Dr.Yoho feels that digital images depersonalize the cosmetic consult, but I feel that they enhance it. Most physicians are getting away from complex morphing and are using actual images. When a patient comes into my office for consult for the first time, I take a frontal and lateral digital picture and load it into the computer. This takes about 30 seconds. I can now project the patient's image on a large monitor (or the entire wall if I use my digital projector). This is far superior to having a patient look in a mirror. Every time I do this, I am amazed at how people become aware of parts of their face that they look at every day in a mirror. Having the patient's image immediately available and bigger than life helps me get more personal with the patient, not less. I then show the patient PowerPoint slide shows of various procedures that show before and after pictures from my consenting patients. This is far superior to trying to morph a computer cartoon. I will morph the patient is he really wants that, but he will usually get the idea from the preoperative and postoperative pictures.
When I hear people critical of digital imaging and hear them defend their slide film images, I am reminded of the poor photographic quality of images in many well-know journals. Frequently images are different sizes, different and distracting backgrounds, crooked and tipped, out of focus, and many other permutations of normal. Using digital images makes it a snap to achieve consistent high-quality, standardized images. It takes only a few mouse clicks to make a before and after image, add text or names, and enhance color, contrast, hue, and saturation. You cannot convince me that there is anything about slide film photography that warrants not embracing digital technology. As for the ability to "fake" or alter images, people have been doing that since the inception of film photography. As long as there are dishonest people, dishonest pictures will appear.
Having the ability to take an image and email it anywhere in the world in 1 minute is reason enough to change. Sharing images with remote colleagues or using them on the Internet is just the tip of the iceberg of great things to come with digital photography.
Response Joseph Niamtu III, D.D.S.
7113 Three Chopt Road
Richmond, VA 23226
Dr. Niamtu is one of the most passionate individuals I have ever met and I am grateful for his friendship. Of course he is correct, but only about a few of the trees in the forest and not the ecosystem.
The question is not whether digital photography is advancement but whether it is as inexpensive, practical help in the modern medical office for a doctor who is not into photography. I want a system that I can delegate reliably. Even if the hard costs of the system are the same as regular photos (which I do not believe), staff costs are going to be much more unless you do the work yourself (this would be the most costly thing of all). Of course if the lecture circuit or publishing is what you do with your life, you should go digital (or scan your best photos in digital, which I have done). But for consultations, showing photos to the patient is not the hot ticket and morphing the image is not a help. An efficient system should expose the patient to your photos before they even see you and the patient should be convinced of your competence through your literature and photos.
What the patient really desires is to trust the physician. Machinery may help some physicians make an emotional connection but they should understand that this is the issue in the patient's decision to operate, not some abstraction about the service you can demonstrate through technology. In my hands, listening carefully to what the patient's needs are is more important than trying to objectify possible results. These needs may be as simple as expressing why surgery is desired such as fears of aging or problems competing with young people on the job or in their personal life.
Medicine is about bonding with your patient and unless your technology improves this or makes your life simpler or cheaper, it is as worthless as an erbium laser, which I can duplicate with 15 cents worth of sandpaper.