It's time next to dive into the clinical images. And I show this image on the title slide because it's the most famous image I've ever taken, as this is the first case of monkeypox in the Western Hemisphere. And that was a clinical photo of a child that I took when I was in my very first year as a faculty member, just finished residency a few months prior. And I was in the patient room and really knew, you know, I didn't know exactly what it was, but I knew it was something odd. And I searched the room to look for the best background I could possibly find, put the child's hand on it and took what was then, you know, once we knew what it was, very widely distributed to newspapers across the country. And it was really an image I was very proud of. And I can only think that if I hadn't taken the time to capture the image or to compose the photo or whatever, it would have been a very different story. And we'd have had a very difficult time getting the same kind of publicity and to getting the word out about, you know, educating what was this very unusual disease, which, you know, obviously isn't so unusual now, but what looked like, you know, it was the I believe it was the photo that really got the news out to people around the country and around the world. So, it can be very valuable to take the time to compose a good image. And this is the anatomy that we're talking about. And this is a quote that I heard at our ABD test writing orientation session in 2010, a great DERM picture is worth a thousand words and a lousy DERM picture is worth a thousand complaints. This is especially true in a testing scenario. You really want the photo to be crisp and clear and high quality and you don't want there to be an issue for the examinee. You want it to be, you know, the question that's at the forefront of the mind and not the quality of the photo. So, incorporating photos can really aid and elevate the Bloom taxonomy level of assessment because without saying words or without being given a diagnosis, people are having to apply the knowledge of a variety of things like the persona and the morphology and the distribution and the configuration. All of those things are unspoken, untold to the person. They're assessing that on their own by looking at the photo. That really elevates the Bloom taxonomy level of assessment. Now, there are many key tips to preparing great clinical photos and I'm going to run through a few of these. The first is really important that you have good lighting. You can have the best picture in the world, but if you have poor lighting, as these two images demonstrate poor lighting, it can really be distracting and it can make a difference in the focus of the learner or the test taker when they're taking their exam. And the last thing you want is for someone to be angry in the middle of an exam because the picture is lousy. You want them to be able to see everything there is. So make sure that light is appropriate for what it is you're trying to light. Like on this example on the left, you have a lower lash line lesion that happens to be a basal cell carcinoma, but it's really hard to tell that because it's in the dark. Similarly, from a patient with rosacea being very poorly cross-lit with a fluorescent or incandescent light in the office, it's very distracting and casts a very unusual color that aren't natural on the skin surface. So you want there to be a front lighting if you're not trying to show texture or cross-lighting if you're trying to show texture. So keep in mind the lighting, and sometimes it's as simple as, you know, I get it. You don't always have control over all the lights. We don't have all these wonderful photo labs where you say, oh, I'll just go down to our photo lab and they'll take a nice picture of this lesion that I will order. You have an office and you have exam rooms and you have medical assistants. So sometimes it's just as simple as having a patient slightly point their head upward to get the above overhead lighting to not cast shadows. Next, we talk about focus, and this is a very important thing, too, particularly these days where a lot of point-and-shoot cameras where you don't have the manual focus are being taken. You're relying on the machine to do the focusing. Here are examples of two very worthwhile conditions to photograph, but it's very out of focus and blurry, and that hurts the quality of the image, and they're never going to show up on a test like this. On the left, you can see that there's a lot of stuff in focus, but it's all actually stuff that isn't important. It's the stuff on the collar, and the lesion that was meant to be the testing point, which is in the conchal bowl of the ear, isn't at all in focus, which is really the point of the question. Then on the right, you can see that the whole picture is just plain out of focus. It's not sharp. It's very blurry. You can't tell, and that's unfortunate because this is a little bit, you know, more of an unusual condition of Crest syndrome, and it would have been nice to have all of those features in a nice, sharp focus. So only submit photos that are in focus. I can tell you that at the American Board of Dermatology that they try very, very hard to only keep photos that are very crisp and in focus. Those are some of the first questions that get tossed if there's any question of the focus of the image that's being tested. Next, be mindful of the background. Frame the photo. Here we have a little baby with the epidermolysis bullosa, but it looks like we might be in the 1970s psychedelic circus because there's so much going on here that really is distracting from patterns and colors and whatnot. Had you simply had the baby's leg cropped in the photo, you would have still been able to tell it's a baby's leg and that you wouldn't have all this loud noise of distraction all around it. So be mindful of the background and frame the photo. Sometimes you can help it a little, like I did in the monkeypox photo, rather than having a sterile white bedding or a washed out, you know, color in the background. I threw down a little darker colored Afghan to contrast. Try to have solid colors in the background when you can, but when it's not possible, just work the cropping to frame the photo a little better, a little less loudly, like the loudness that we see in this picture. Similarly, be mindful of the photos you submit. Here, if the purpose was to show an elevated cystic nodule on the scalp, which is being cross-lit from a nearby window, that might be the purpose of the photo, but geez, we don't need all the mirror and the glove boxes and the different clock in the background. That's not important and it's rather distracting. What does that mean? This was almost 20 years ago that this photo was taken. It means I'm an old educator, but what we want to say is we don't need this in our picture. Crop it out. Crop out the date. That's distracting. Be aware of the digital era and the errors that occur in photo distortion. There's a lot of digital distortion that happens. Does this man have microfingers? No, it's just that the angle is all wrong. Does the guy in the middle have some sort of major bodybuilding disorder? No, it's just the angle at which he's being photographed. Does this woman have a humongous nose? No, it's just the warping that happens from the digital camera era that we're now living in. Be aware of the digital distortion that can occur and adjust your photo taking accordingly. Usually it means back up. One of the beauties of the digital era is that you can instantly see what your photo looks like. Take a look before you say that enough is enough. I always like to take more than what I think I need. Avoid photo over compression. This is where you take a photo at a certain quality, but then when you save it or upload it, it gets compressed. You have to understand that there are different levels of compression. Sometimes your institution's settings for your electronic medical record auto-compress the photo. So many times if the only photos you're taking are in your electronic medical record, that may not be good for Borg style questions. You may want to supplement and take some compliant raw photo file sizes. Sometimes it's as simple as getting the institution's setting to be a little bit higher. You can advocate for quality purposes and for tracking purposes that your institution should adjust the photo quality in your DERM photos. I've worked with certain medical record systems that were able to tweak that. It's simply a setting they can adjust. It just costs them more storage, that's all. They were already dealing in terabytes and terabytes and terabytes of information. And so, you know, you're talking about a couple of megabytes. So just realize this is really making a lot of great photos very worthless. If you're just snagging photos out of your electronic medical record system, realize that can also incur some compression. Avoid the over compression when you can. It's the same picture that you're looking for, just under a bigger file size, because when it gets compressed and over compressed, it really gets pixelated. And as you can see here, I mean, it's just like you can't do anything with that. It's never going to work. Next, we talk about Jurassic photos. Jean Bologna was one of my favorite people on the American Board of Dermatology in my time. Our times overlapped there. She was a great mentor as a question writer. She had a phrase that she continually reminded us all to avoid the Jurassic photos. And what that means is photos from a very old era. And you know, you say, well, what difference does it make what era the photo was taken? If it's a great photo, it's a great photo, and that might be true. Here are a couple of photos. The one on the left may be not so good of a squamous cell carcinoma of the hand, and the other is Gunther's disease, one of the porphyrias. But the point is, the older or more ancient the photo is, it's obviously an older photo because of the clothing or the style of hair or the yellowing of the photo, whatever it might be. But the overall photo, you can tell just looking at it, this is an old era photo. Sometimes you can actually see the hairs or the fuzz on a scan slide, for instance. It actually will cue the learner about what diagnosis we might be talking about. So you're not going to put a 45-year-old photo of acne, because acne you can see every day and snap a picture of in the new digital era. So you're going to cue the learner that it's probably something rare and unusual, something that's less common to experience. So always try and use modern photos, even when you're testing rare conditions. You don't want to give a false cue to someone and let them know that this is some form of trickier question or more rare disease simply by the age of the photo you're submitting. So now it's your turn. You were writing a question about a mild to moderate inflammatory acne, and you want to use a clinical photo to illustrate your findings rather than describe them. And I think, first of all, that's a great idea. Always try and show a picture rather than describing the finding. It's so much better to give a photo. The question was written with this patient's findings in mind. So rather than describing the findings, you wanted the test takers to see the findings. How would you assess this photo? Is this photo of this guy good as is, or do you think edits are needed? So I say that the answer is that edits are needed. And when we look at where we are here, there's too much happening. I don't need to know about the lungs, and I don't need to know about the patient's rights on the back of the wall. What I'm interested in is that this guy's findings are acne-related. Now I know that down here, he doesn't have a whole heck of a lot going on. And maybe what I need to do is first see, you know, can I just crop this and get the effect that I need by cropping at the neck? And that's what this does. So when I go into that, here's what cropping does. Now this is a much better picture, okay? Now I got a pretty good idea just by cropping it that we've got inflammatory mild to moderate acne. We've got some ice pick scarring and things of that nature. Now I'm going to tell you that if I were on the test writing committee, I would still try and kill this question or this photo for this question because I don't like all this washout on the nose. And you know, the scrutiny at the American Board of Dermatology would probably kill this photo too because of that washout on the nose. This is a much more poor quality photo to have that sort of finding. So I would vote to ax it. But this is certainly a much better photo than the previous photo with the lungs and the patient right. So remember about the cropping and use it to your advantage. Here's the next one. So assess this photo. You're writing a question to assess a differential diagnosis for a blistering condition. The question was written with this patient's findings in mind. So rather than describing the findings, you want the test taker to see the findings. So how would you assess the quality of this clinical photo? Good as is or edits needed? So again, I would say edits are needed. And what you can do is just simply crop it. Cropping it can make a big difference in eliminating the distracting information. Think about these tips as you're creating your photo submissions for your test questions.

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