It is an admirable attempt by Bradshaw, Gergar, and Holko ("Collaboration in Wound Photography Competency Development: A Unique Approach," February 2011) to try to standardize medical photography. The checklist they published certainly has merits. However, I believe that the article forgets a number of technical aspects of actually making a good photograph, as illustrated by some of the photographs that accompanied the article. In one photograph, the label is in focus, but the actual ulcer is not; a second picture is shown with a distracting background, and a third photograph is underexposed.
In my opinion, technical aspects that should be part of the checklist include the following:
* Make sure that the entire wound is in focus (several cameras allow different areas to be the focal point [or to fix a focal point after which the orientation of the picture can be changed]).
* Make sure that the depth of field covers the entire depth of the lesion (use a small aperture, particularly in close-up or macro mode).
* Correct the white balance, if necessary (fluorescent light gives a greenish hue).
* In contrast to what the checklist states, use a flash:
[white circle] A regular flash may cause shadows or uneven lighting, but a ring flash (granted, a bit expensive) is ideal.
[white circle] With a ring flash, shadows and glare are avoided, and crevices show up more clearly.
[white circle] The influence of background light (fluorescent light) is virtually avoided, guaranteeing good color representation.
[white circle] Because the light source is close to the wound, there is enough light to allow for a small aperture, thus allowing for a good depth of field (small aperture).
In addition, a label should have a color chart on it for reproduction purposes (eg, printing the picture as part of a poster), and lastly, the authors are not specific about the file format they use (which determines to a large extent the compression and thus the accuracy of the reproduction).
I do realize that Advances in Skin & Wound Care is not a photography journal, but despite of all the sophistication available in even simple cameras, some technical background is still necessary to make good medical photographs.
-Michel H. E. Hermans, MD
Newtown, Pennsylvania
Author Reply:
We thank Dr Hermans for taking the time to read our article on wound photography and appreciate his insightful comments. His points are all well taken, and we are in agreement that the technical aspects he mentions are all essential when taking photographs for purposes of research and/or publication. However, we would like to point out that the aim of our article was to demonstrate the educational process and format utilized to ensure basic competency of frontline clinical staff with varying levels of photographic expertise in order to "level the playing field" of our multidisciplinary team. The authors' intent was to share our process and in doing so to assist other clinicians confronted with similar challenges in the clinical setting. Because most frontline clinicians are not at all skilled in photography, we believe mastering the basics in a consistent manner is the first step in taking a good photograph.
The focus of our article was to highlight the educational process used to achieve this goal. In addition, the photographs included in our article were intended to depict the label content only and were not representative of the desired quality of a wound photograph. We are pleased at the attention to our article and the discussion generated, and we look forward to future articles related to this important topic within the wound care community. Dr Hermans' comments will be helpful as we take the next step toward developing a process by which the quality of our clinical photographs can be enhanced. Thank you.*
-Leah M. Bradshaw, MSN, RN, CWS
Allentown, Pennsylvania
-Ginger A. Holko, MBA, BSN, RN, CWS
-Margaret E. Gergar, MSN, RN, CWON
Bethlehem, Pennsylvania