by Craig Klugman, Ph.D.

When I was teaching in medical schools I recall a case where a student was reprimanded for breaking patient confidentiality by uploading a picture of surgery to his Facebook profile. This incident led to educational interventions about the appropriate use of social media in medicine. The short guideline was, “Never upload photos of patients onto the internet.” Now, physicians are encouraged to upload patient pictures through a service called Figure1, which has been described as “Instagram for doctors.”

Figure 1 is part of Medicine 2.0, using online technology to enable collaboration and interaction. Rather than simply reading about a medical condition, a user is able to comment, participate and offer advise.

The images are graphic and shocking. A glance through the Figure1 home page and Facebook page showed a foot covered in black spongy masses, a pink femur in a metal pan riddled with cancer, and a woman’s back covered in mushroom-like keloids. This is definitely not something to peruse while eating lunch.

With Figure1, health care professionals can (and do) upload medical images with commentary. These can be unusual teaching cases—the sort of things that rarely come along. Or they can be genuine requests for help—“does anyone know what this is?” A new feature is called “paging” where you can send questions and images to experts around the world for instant feedback.

The service offers education through an image of the week, name this condition, and interviews with experts. Their ambassador program recruits medical and nursing students to be advocates for the service on their campuses.

The first ethical concern that came to my mind upon hearing about this was patient confidentiality. Figure1 does not require patient consent but they do suggest that the person who uploads an image remove any identifying marks. The program automatically blocks any faces in the images. They also claim that since the images lack identifying marks, that it does not fall under HIPAA or other nation’s privacy legislation. However, if your conscience or institution requires consent, Figure1 offers an easy to use consent form that the patient can sign on your mobile devices screen.

Does a patient in the middle of an exam or procedure truly understand what consent means? Do they know that a permanent image of their disease will be made and sent around the world to the more than 150,000 users for education, comment, and curiosity. The comments are insightful but also comedic. There is a lot of the gallows humor for which physicians are known.

One could question whether removal of identifying marks and a blanket consent form are truly informed consent. There is a question also of who owns the images—Figure 1, the physician or student taking the picture, or the patient? If a condition is rare, then even de-identifying an image may still allow someone who knows the patient to re-identify. When doing social science research, the possibility that someone could figure out who you are based on a story or feature must be revealed as a risk in consent forms.

Plus, as Wikileaks and the NSA have taught us, nothing on the internet is truly anonymous or ever forgotten. The records can be tracked to the account of the user who uploaded them and an IP address. If uploaded over the hospital network, then the place of origin can easily be known. And copies of this will exist on devices all over the world, in the cloud, and be forever available.

I then wondered about the people who comment on these images. If you are getting medical advice through an internet program, how do you know that they have the expertise to make an accurate diagnosis. The program allows physicians affiliated with online networking tools or who submit credentials to receive a virtual badge indicated that the user is indeed a real physician. However, anyone can sign up, read, and post.

Launched in 2013 by a Canadian intensive care specialist, a software developer and a journalist, Figure 1 has attracted millions of dollars in funding. As of summer 2014, the program had 150,000 users and was seeing a million posts per day. Thirty percent of medical students are believed to use the program. The Google Play version has had more than 100,000 downloads and their Facebook page has over 6,000 likes.

Some medical schools have already banned the program for their students. Officials in one school with whom I spoke said their ban was based on concerns about patient privacy.

This is not the first time that medical images have made their way into the virtual realm. Surgeries have been tweeted for several years now as a way to educate residents and others who cannot be in the OR or who are not near a particular hospital. This can be especially useful for learning from noted experts or from unusual cases. The SurgeryLive twitter account allows people to interact with surgeons operating live on Channel 4, an independent UK station. Extreme Makeover and The Swan showed viewers plastic surgery that drastically transformed patients on television. E! network show Botched broadcasts images of plastic surgery gone wrong. Even I admit to having caught an episode or two of the show, “The Operation” that broadcast from 1993-2001.

Also consider that taking pictures of patients is not new. A colleague of mine has published several visual textbooks on medicine using pictures taken of medical conditions found in his and others’ patients. The patients do sign a photo release.

Where Figure1 differs is that it is a community built for professionals, not for the general public (though they are certainly welcome to participate). In that way, it is probably more secure and professionally oriented than a Twitter or Facebook post. While Figure1 is a tool for education and for collaboration in ways never possible before. In real time, health care providers can have consults from across the world. Jokes are made about patients which can skirt the border of offensiveness. With the good comes risks. A physician who posts uncouth jokes may risk a bad reputation—especially since potential patients may be watching. The Figure 1 conversation is more like talking about patients in the hospital cafeteria than in a private office.

While a photo may be worth a thousand words, Figure 1 left me speechless.