A little over a year ago, our electronic medical record started to include photographs of patients along with their medical information.
These thumbnail images, which appear at the top left-hand corner of the computer screen next to a name, age and birthdate, are intended as a safety measure, to help ensure that clinicians are placing orders and entering documentation for the correct patient when multiple patient records might be open simultaneously.
As I was scanning through my day’s clinic schedule recently, I was struck by the different ways my patients approached taking the picture. All of them had been given a diagnosis of cancer, and many were dealing with a range of health issues. I found myself wondering whether these snapshots might give me further insight into how they viewed their medical conditions.
The standard photo is taken from a camera located at the registration desk, by the cancer center’s main entrance. The photos are always taken at an upward angle, usually capturing my patients slightly off-center, with the lobby’s drop ceiling and a couple of LED canister lights as an unflattering backdrop. Most don’t smile — no fun fighting traffic into downtown Cleveland, searching for a parking spot, walking to our building and then having a doctor’s appointment, often many times per week.
No fun having cancer.
Many people have an aversion to posing for a photograph. For years I avoided having my own picture taken in social situations, embarrassed at how unflattering the image always seemed to appear, and maybe in denial at how accurate it actually was. Some of my patients similarly refuse, perhaps because they may feel they aren’t looking their best in our waiting area, preparing for chemotherapy; and perhaps worried that the photo might make their cancer diagnosis that much more concrete. In these cases, the upper left corner of the computer screen contains a white box with the message “Patient Declined Photo.”
I probably would decline too.
When prompted to have their picture taken, some of my patients do manage to summon a smile, though I can’t tell whether it is genuine or “habit being so strong,” as Raymond Carver described the thanks he gave to the doctor who told him he had lung cancer in his poem “What the Doctor Said.” For some of my millennial patients in particular, I am convinced the smile is ironic, reflecting the paradox of expressing joy before a checkup with a cancer doctor.
Patients can also upload their own photos to the electronic medical record, providing a glimpse of what their lives look like outside my clinic. One 21-year-old stares winsomely at me from her bedroom, her dresser and a small picture in the background, from a time that preceded her cancer diagnosis.
If she only knew what was coming.
Another woman in her 40s cheekily uploaded a picture in which she’s flanked by two dogs in her yard, all three facing the camera and grinning ear-to-ear on a beautiful, sunny day. It’s as if she’s thumbing her nose at cancer, using the photo to say that it won’t define who she is. Now that I know she has dogs, they have become a frequent topic of conversation during our visits.
That image brings me joy every time I open her medical record.
The photos are a snapshot in time, capturing a truth that may no longer be accurate: patients bundled up in a scarf and hat when I see them in August, or wearing a tank top in the dead of winter; patients who appear gaunt and bald, their photos taken during the throes of chemotherapy, now greet me in clinic with rounded cheeks and a full head of hair, in remission from their cancer.
Those images remind me of how far my patients have come in recovering their health; they also bring me joy.
Some pictures are unsettling. The photo of one elderly man, whom I treated for years, has a waxy countenance. His neck is arched and head thrown back, as if anticipating a future rigor mortis. Another, a farmer, smiles hesitantly in his photo, appearing to acknowledge the uncertainty of his future. Both are now dead. Their photos remain a part of their medical record, becoming a modern day, electronic equivalent of a death mask.
The images I have in my mind of those patients differ significantly from those on the computer screen. The elderly man lived in my town and used to regale me with stories of restoring his century-old house. I see him leaning in toward me, earnestly discussing the secret to fixing frayed ropes on old window sashes. The farmer was usually ebullient during our frequent meetings, delighting, for example, in the yield from his apple trees. I see him closing his eyes from laughing so hard.
To me, that’s the real purpose of these electronic photos — as a reminder of how the people we care for in the hospital are so much more than how they appear during a visit, in their medical records, or in any snapshot in time.
Dr. Mikkael Sekeres (@MikkaelSekeres) is director of the leukemia program at the Cleveland Clinic and author of the forthcoming book “When Blood Breaks Down: Lessons From Leukemia” (The MIT Press, 2020).