“Take Two Photos and Call Me in the Morning”

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“Take Two Photos and Call Me in the Morning”

Until medical school, I never knew there were so many words for a rash. During our dermatology training, we were continually tested on the differences between “macule” and “papule,” “patch” or “plaque,” “wheal” versus “vesicle.” On rounds in the hospital, we were quizzed on the detailed descriptors of skin problems: erythematous, blanching, targetoid, confluent, punctate. “Words matter in medicine” was a mantra I carried near to my heart.

Yet as I noticed almost immediately on my clinical rotations, patients speak a different language. Ask a patient about a rash, and he will typically say: “It was kinda red and itchy. I can’t remember when it started.”

So during a busy clinic in my first year as a pediatrics resident, when I saw that my next patient’s chief complaint was listed on the chart as “rash,” I mentally readied myself for the frustration that accompanies a mismatch of medical terms.

My patient, a 15-month-old boy, was clambering about the furniture as I entered. His mother explained that recently they were visiting friends out of town when the child suddenly spiked a high temperature. Since he had been eating and drinking normally, she just treated it with Tylenol. “His fever went away, but then he developed a terrible rash,” she explained.

I opened my mouth to start the laundry list of questions, but then the mother did something unexpected: She pulled out her smartphone.

She opened a photo app and showed me a series of pictures of her son displaying the characteristic red, blanching discolorations on the face and torso that are classic for the post-viral rash of roseola, which can be common in young children. I finished the physical exam, showed the mother some similar roseola photos online, and she was able to walk out of the room reassured.

In studying the history of medicine, physicians honor major turning points in medical technology, such as Laennec’s stethoscope in 1816 and Röntgen’s radiograph X-ray in 1895. What goes unmentioned is that we are enjoying a golden age of palm-size iWonders.

My own smartphone is stocked with apps that include complex pediatric dosing, advanced life-support algorithms for optimal resuscitation and specialized textbooks for late-night reading. Now there is even an app that lets doctors transform their cellphones into ultrasound machines.

But the simple camera phone is epochal in that it puts the power—literally—into the hands of patients. The photographic possibilities extend far beyond the skin. In the pediatric gastroenterology clinic, many concerned parents bring in photos of their kids’ dirty diapers, which all parties agree is vastly preferable to bringing in the real thing. Some neurologists recommend that parents make videos of children who have a known history of seizures to help the team fine-tune medication doses. In developmental and behavioral clinics, parents can show videos of their children at home demonstrating milestones like a mature pincer grasp or pulling to stand, even if the kids get shy about showing off their skills to a room full of doctors.

With regard to taking photographs or videos of patients, health-care providers are bound by the privacy rules of the Health Insurance Portability and Accountability Act. But parents are free to capture such pictures. Especially in pediatrics, parents are encouraged to be advocates, and phones can be their close allies.

But even at its best, a snapshot cannot replace a thorough history and physical examination. Had the mother of the 15-month-old patient with roseola told me a different story, the photo she showed me could have been the rash of contagious measles. Instead of expecting a picture to replace a thousand words, we should take the more prudent step of welcoming this new tool into the ever-growing digital inventory available in the fight against disease.

One of my tech-savvy supervisors recently found a way to upload daily photos of a patient’s resolving cellulitis to the patient’s permanent medical chart so that his outpatient primary-care doctor could track the infection’s improvement. Electronic medical records already are becoming more patient-friendly, allowing patients to view their lab results and electronic notes. As smartphones increase in prevalence, we’ll need to foster more and better ways for patients to upload pertinent photos and videos as part of their medical history.
In medical school, OLD CARTS is a popular mnemonic for helping students remember all the pertinent questions in a patient interview: Onset, Location, Duration, Character, Aggravating/Alleviating factors, Relieving factors, Timing and Severity. It might be time to make it GOLD CARTS, adding a “G” for “Got a photo?”