Quirky, squirmy x-rays: Where to draw the line?

This week a radiologist's campaign to become a US senator was thrown into controversy by reportedly 'gruesome' x-rays he posted on Facebook. In a filmed interview, journalist Tim Carpenter confronted Milton Wolf with x-rays and comments he posted on Facebook several years ago. Despite claiming the x-rays were shared for educational purposes, it seems clear that the images, including one of a gunshot decapitation, were mainly intended as entertainment. 

I'll leave you to judge the specifics of Wolf's actions for yourself (some aspects I personally don't condone), but my interest in this issue is more broad.

As a website built upon collaborative contributions, Radiopaedia.org contains many 'entertaining', 'confronting', 'gruesome' and downright 'WTF' medical images that serve little educational purpose. And yet these images contain no patient identifiers and abide by HIPAA guidelines. I myself have contributed medical images of such nature to this site and as social media editor i have overseen the sharing of some of these images across our social media network - and yes, they usually prove very popular! 

Just yesterday, journalist Caleb Garling published a piece about Radiopaedia in the San Francisco Chronicle, clearly inspired by the 'bizarre' nature of some of our images. With the Radiopaedia site and social media network rapidly expanding, I expect mainstream media exposure like this will only increase, placing the site's content more and more in the realm of the general public. 

And so for a site that primarily aims to educate health professionals, is the publication of occasional images of 'questionable' clinical value appropriate? Is it just a little harmless fun? Is it right for the public to be shown or have access to these images? Or should we as radiologists and other health professionals enforce upon ourselves a degree of professionalism beyond that of simply maintaining patient confidentiality? 

I'd be very interested to hear your thoughts on the issue. My personal philosophy has always been that as long as what I am sharing or saying brings no harm, then exposing others to the quirkier or squirmier sides of radiology is not a terrible thing. But perhaps with the new popularity of Radiopaedia, a more considered approach is required on my part. 



Dr Andrew Dixon is a Radiologist at the Alfred Hospital in Melbourne, Australia. He is social media editor for Radiopaedia.org, and among other things, has founded the successful Radiology Signs project on Facebook, Tumblr and Twitter and the Radiology Channel on YouTube.  

NB: Opinions expressed are those of the author alone, and are not those of his employer, or of Radiopaedia.org

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    Chad 1st Mar 2014 16:55 UTC

    As an educator myself, I depend on sites like Radiopaedia to offer new/interesting cases that I share with my students. Some are for "entertainment" purposes, but a majority are used to help the students "open" their eyes to the pathology being presented.

    Some of the "entertaining" cases are used with the junior students to help them think "outside the box" on how they would achieve the image; especially on trauma patients. I feel the general public does not truly understand our field/profession. We're just button pushers, right? That's why the ASRT has started their new campaign in educating the public about radiology.

    You have provided a disclaimer. Maybe make it bigger, bolder, or even the only thing on your home page to enter the website (just a thought). Whatever you decide to do, I will continue using and sharing the information. Keep up the good work.

    Moving Forward,

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      Andrew Dixon1st Mar 2014 21:04 UTC

      Good point Chad - such images definitely help capture the attention and imagination of our students. Thanks for commenting.

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    Giovanni Battaglia1st Mar 2014 23:24 UTC

    In Italia queste persone le chiamiamo teste di cazzo. Se vuoi posso fare la traduzione. ..

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      Andrew Dixon1st Mar 2014 23:37 UTC

      Giovanni' comment according to google translate: "In Italy we call these people morons. If you want I can do the translation. .."

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    Andrew Murphy1st Mar 2014 23:39 UTC

    At my hospital there has been a huge push against the sharing of any images out side of the work site. Everything reached an almighty halt, when an image of a FB in a penis ended up on social media.
    This resulted in an all out phone ban during work hours, with hospital policy quoted to staff members regarding the use of mobile phones and sharing of images.
    The general idea that was voiced to me was, " if you asked the patient, do you think they would be happy with you sharing that image?" .
    I don't fully agree with this, as I too am in the same mind about de-identified images. Just some food for thought.

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      Andrew Dixon2nd Mar 2014 02:45 UTC

      Thanks Andrew. The "if you asked the patient do you think they would be happy" approach is not an unreasonable thought process, but unfortunately it is subjective. What I think a patient would be happy about might be signifcantly different to what someone else thinks. What I worry about is when this kind of thought process is used to justify a blanket ban on sharing any medical images online, which I am in doubt would stifle education if adopted globally, to the great detriment of patient care.

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      Matt Skalski2nd Mar 2014 04:42 UTC

      I second the opinion that although this makes sense, it is dangerous to apply as a blanket thought process. If this were the case, patients should also have to approve the use of their imaging in textbooks and journals as well (like is required for photographs of them), as those are also available to the public. Should that information not be available to teach doctors and others because a patient might be uncomfortable with the use of their images? I think the public benefit outweighs the nearly non-existent risk of someone identifying the images and associating them with someone specific.

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    Maria Elena Misu2nd Mar 2014 20:03 UTC

    I think we have to differentiate between imaging shown to med students/doctors/medical professionals for educational purposes, especially those meant to be humourous (or "humerous" in this case?), and those posted simply to shock/surprise people (whom I see mostly as laymen).

    Radiopaedia posts images of rare diseases or disfigurements or even of (gruesome) injuries on FB and Tumblr, but for us medical professionals you're a source of information and education and everyone contributing is very careful to conceal and protect the privacy of the patient whose imaging they use. For me, this site is like a database for common and rare diseases/cases and often my no 1 source if I have to look up something at work quickly and don't want to hit the books.

    However, posting gruesome images on your private FB for the world to see - and maybe even write a "haha, look at that guy's all but severed head" kind of comment, is not only unethical, it can also be deeply disturbing for non-medical people stumbling over your posts. Such images could even be considered triggering for some people. And what is the poster's gain apart from receiving horrified comments or comments making fun of the patient shown? And it's not only radiology images that are being posted online. I recently saw close-ups of PAD limbs with mummified feet and disgusting open and infected sores posted on FB. I'm not squeamish, but those pictures still made me lose my appetite. Why is there such a need to expose other people to gore like that?

    Btw, I told my fellow SpRs about this site and now everyone is using it and talking about your cases of the day/the week. Even our consultants are impressed.

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    Gerry Gardner 11th May 2014 10:10 UTC

    Last year I had to endure a talk during Clinical Governance from our Caldicott guardian who suggested that we should not be using images, even if all identifying information is removed, that may be likely to identify a patient by pathology! The example given was we should not use X-rays ,in teaching, of a person who had one leg amputated as this may identify them!
    At this point I walked out as they are obviously taking things way too far and have no real conception of how they are potentially endangering the learning process.
    I do cringe when coming across awful images on social media sites (but it doesn't stop me viewing them) and feel some level of 'moderation' should be used by site owners if the images are for shock value only. I have 2 young children who now have internet access and it is a constant worry what kind of 'education' they will stumble across when my back is turned.

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