Thursday 4th October 2018

by Geraldine Thompson, Head of Services, Manchester University NHS Foundation Trust.

Our annual professional conference in 2018 took place in the lovely Spa town of Harrogate in North Yorkshire, at the Old Swan Hotel, surrounded by picturesque lawns and gardens, The Old Swan was once the famous retreat of Agatha Christie.  As it was the 50th Anniversary of the Institute of Medical Illustrators it was fitting to revisit this historic location for a second time to celebrate our profession and the people within. Filled with ‘old’ and ‘new’ faces, this conference ran from Thursday 4th October to Saturday 6th, three packed days of workshops, plenary sessions (concurrent in the three disciplines of graphics, photography and ophthalmic) and social events.  

Registration opened early on the first day by our conference team volunteers whose hard work has to be acknowledged, without them, we simply wouldn’t have a conference. After checking in on arrival, I secured the conference pack, which this year, comprised of a special document holder embossed with the institutes emblem, note book, paper and pens, therefore, suitably armed with fresh stationary, I set off to plan my day’s activity.  

The conference officially opened at 10.30am with the Chairman’s Official opening expertly crafted run through by Carol Fleming on the history of our institute. As usual, Carol gave us a very polished and accurate account of our profession to date – a walk through our archives. This was followed on by the keynote speaker, Jonathan Lord, a Consultant and Anaesthesiologist at Moorfields Hospital London, who regaled us with his work for ‘The Orbis Flying Eye Hospital’ with World Vision.

The ‘Orbis’, he explained is a flying eye hospital, once a cargo plane (a DC8), it is now an incredibly sophisticated aircraft (DC10 MD10) that flies teams of elite eye care specialists to developing countries where they share skills and techniques with local medical teams. The aircraft is a ‘state-of-the-art’ teaching facility complete with operating room, classroom and recovery room – this aircraft and its team of specialists have been flying since 1982 and have 400 members, 100 nurses and 100 technicians, with a medical licence to practice in 58 countries. Jonathan describes the fight against avoidable blindness in those countries he visits, in that, the longer someone waits to be treated, the higher their chance of becoming permanently blind. There are currently 36 million people across the world who are blind from preventable disease and another 217 million people who suffer from low vision impacting their ability to carry out every day activities we take for granted. Jonathan walked the audience through images of the aircraft, the dedicated teams, and a virtual walk through of the facilities but the talk ended on a sober note, with the question of building sustainable health care systems in developing countries for the future and under often unstable social economic and political challenges.  

Personally, I had a difficult time deciding on my own itinerary since there were three plenary sessions, ‘Photography & Video’, Art & Graphics’ and Ophthalmic Imaging running concurrently until the lunch break at 12.20pm. I stayed with photography and sat in to listen to Jane Tovey, who spoke about ‘Major Incident Preparedness for Clinical Photographers’. Jane began with a brief overview of the facilities at Birmingham Hospital’s and described the context behind encouraging photography departments to engage with their corporate services in regards to becoming involved in a Trusts ‘Major Incident Planning’.  With example’s given such as the Manchester M.E.N bombing and the London attacks, the UK’s current international threat level is ‘severe’ which means healthcare sectors have been planning for ‘imminent attacks’ and ‘business continuity’ for a few years. Jane walks the audience through how in Birmingham they engaged with their respective ‘emergency preparedness’ teams to be included in the ‘major incident policy’ and to define the way clinical photographers could be of assistance as responders. It was emphasized that an emergency preparedness plan is ‘be-spoke’ to a specific organisation, it is not a plan that fits all, and as such, before entering discussions with emergency planning teams, activities such as the ‘role’ of the clinical photographer in major incidents, developing staff competencies, testing procedures with table top exercises is highly recommended. Consideration to the consent and upload of ‘traumatic’ images taken in these scenes, was discussed, as well as the creation of ‘action cards’ which describes the category of responder, the command centre and activity expected of those responders in the event of an incident. Understanding that in these situations clinical photographers work solely for the NHS and not the investigating authorities, was something Jane emphasised as requiring clarity when engaging with the incident teams. A clear definition of our job roles in major incidents will avoid ‘confusion’ with investigating authorities who would also want images of casualties and incidental additional imagery on arrival. To conclude this very informative session, the importance of providing ‘psychological’ after care for responders in major incidents was emphasised, it is high on NHS England’s agenda and therefore an important consideration to begin thinking of the ways that can be integrated within the aspects of major incident planning.  

The next speaker in the photography plenary, was Jonathan Brett, an Ophthalmic Research Photographer based in Oxford Eye Hospital, working in Virtual Reality (VR) for e-learning in health applications. Jonathan began with taking the audience through the history of the development of virtual reality. What was really interesting, was that the first virtual reality head set was created as early as 1968 by Ivan Sutherland and his student Bob Sproull. The first VR / AR (augmented reality) head mounted display (the Sword of Damocles) was connected to a computer and not a camera. From its first appearance in 1968 VR then developed to became the main attraction of immersive arcade games with ‘real-time’ stereoscopic visuals finally finding a ‘home’ in a device called ‘Oculus Thrift’ ( a ‘Kick Starter’ funded headset bought by Mark Zuckerberg). Since then, VR has been further developed by tech giants such as, Google, Samsung and HGL. 

Jonathan then went on to describe the many uses for VR in healthcare such as in the fields of Cognitive and Clinical Neurosciences treating gambling, alcohol, drug dependency, OCD or Dementia  as it has been found that VR affects the parts of the brain associated with these specific disorders. Interestingly, VR has also been successfully used in apps designed for children with specific needs that require assistance in accessing clinical services as a part of their ‘journey’ through the hospital environment. The speaker then highlights the work and the use of VR in the training of clinicians in ophthalmic imaging, specifically in ‘Retinopathy of prematurity’ (ROP).

ROP is an eye disease that can happens in premature babies, causing abnormal blood vessels to grow in the retina, and can lead to blindness. The ‘Optomap’ is created by Optos a camera and imagining system founded in 1992 by Douglas Anderson after his young son went blind in one eye after a retinal detachment was detected too late. Anderson set out to commercialize a patient-friendly retinal image product that encompassed a digital wide field image of the retina in a single capture for pre-mature babies less than 27 weeks. VR is used to train ophthalmologists in this type of image capture. Jonathan ends the session by highlighting that the future of VR is an exciting one, the National Institute of Health Research (NIHR) has stated that VR and AR technology VR play an important part in healthcare education and treatment. 

After lunch the ‘New Voices’ session took place and as in past conferences, is a highlight event welcoming new speakers. The venue was full to welcome our first speaker, Jessica Leonard who spoke to us about ‘Wound Photography’.  Jessica discussed the challenges of wound care photography and the acceptance of ‘average’ images taken by non-clinical photographers in a healthcare setting that ‘do not fit’ our perception of what a standardized, controlled ‘clinical photograph’ should be. Jessica discussed how she set out to create a questionnaire aimed at healthcare professionals taking images, this questionnaire asked the questions around the uses of the images and what quality was acceptable to a health professional. The outcome, whilst not what we in the profession would want to hear, was that our standards are not necessarily what a clinician would require for an initial wound assessment at a subjective level. Jessica discussed, the assessment method used and questioned whether using clinical images taken by clinical photographers should have been used to assess quality against amateur photographers? Why not compare images taken by the non-profession with another non-professional? And how about clinical photographers becoming involved in the teaching of ‘how to take’ a better quality image to match the standards we set?  

Following on, our next speaker was Philippa Stiff, who presented on the emotional challenges clinical photographers face on a daily basis and how this led to Philippa’s research into trying to understand what the mental health impact is on our profession and how emotional and psychological distress is managed. The design of the questionnaire was discussed and how it was circulated out to 380 professions members with 261 completed questionnaire’s returned. The results were discussed in detail such as facts as the time spent in the profession increases the emotional response as life experience correlates with the photographic experience. Out of those returns, 46 participants over the age of 31 have experienced challenging situations and half of the photographers that returned the questionnaire are involved in paediatric bereavement, safeguarding and trauma situations where ‘direct’ personal life experience can allow you to be more sympathetic and vulnerable to emotional responses. The techniques to help balance the emotional response were then discussed at the closing of this informative presentation. Some of those were, focusing on taking the image as a priority for the patients benefit for example, or the support of your colleagues (in that you are not alone) and openly discussing with the team and managers your experience.

A change of pace to the photography driven session was delivered by Megan Williams and her presentation on ‘Virtual Embodiment’ – Understanding Mental Health. Megan describes the difficulties in successfully treating mental health conditions and how the use of new technologies can have extraordinary positive effects. Megan discusses the various technologies now used in the treatment of mental health conditions, such as VR and specifically TILT Brush by Google, where patients can use the immersive technology to draw around themselves when experiencing a challenging mental health episode. Immersive technologies using VR and AR have had a huge impact in many areas of where social anxiety disorder, pain management where the usual psychiatric treatment has failed. 

Following from Megan, Vanessa Shepard took us on a journey through British Sign Language (BSL) and ‘non-verbal’ communication skills, including how powerful facial expressions and body language can be in a healthcare environment. Megan illustrated how a simple BSL hand gesture, can improve the patient experience, explained the differences between BSL and Makaton and lastly how good eye contact, good lighting for lip reading can make a difference to a deaf patient. A video was then shown demonstrating some common phrases and the audience learnt how to sign in BSL ‘hello my name is.’  

Next, Nicolas Gray spoke about ‘Trans Awareness in the Workplace’ and the work undertaken with the Gender Identity Clinic to inform IMI guidelines on improving the patient experience for transgender patients. Nicolas informed the attendees on the high levels of mental health conditions in the transgender community, such as self-harming and depression and that small changes in how we address a patient by using the correct ‘pronoun’ assists in nurturing a ‘safe’ environment for patients. Nicolas then discusses his work with gender re-assignment patients and the steps every photographer and department should consider when working in this environment. Last but certainly not least, was Amy Shorter presenting on the outcomes of the audit of consent and referrals for clinical photography. A brief overview of audit reporting structures of the organisation, details of how to conduct an audit and the National Clinical Audit standards were presented. Amy then goes on to explain that the reason for the audit, was so the outcomes could inform the development of a new electronic referral system. Around 100 consent forms were randomly selected over 3 months in conjunction with 50 patients independently surveyed over a two week period.  When the results of the patient survey were collected, it was clear that patients attending for clinical photography were generally ‘unclear’ on the reasons for the referral and had not understood the ‘informed consent’ process, or the difference between images for publication versus clinical record. The audit results on the consent forms, demonstrated that out of the 100 consent cards sampled, 81% of that sample, had missing patient or clinical data.
To conclude the audit ensured that any developing electronic referral system of the future would have mandatory fields such as patient data and consent information with a handy leaflet that can be downloaded and handed to the patient as a part of the process.

The ‘New Voices’ segment was closed by our current Chairman Kathy McFall, who emphasised that this is a platform for speakers to highlight current ‘good practice’ and research. It is also an opportunity for ‘new faces’ to engage with their peers and proudly showcase their experiences, with an audience that will always meet the individuals with enthusiasm and encouragement. The winner of the New Voices session Vanessa Shepard was awarded free IMI conference registration and a year’s IMI subscription.   

I decide to the leave the photography plenary after a brief coffee break to squeeze into an art/graphics presentation given by Jack Cheatie who has worked designing NHS workplaces for 9 years, for the firm, Parson Lloyd. Jacks spoke about the ‘processes’ behind designing a better ‘environment’ for Accident and Emergency departments (A&E). ‘Spatial Ergonomics’, Jack explains, is the relationship people have with complex design and the emotions that can manifest, such as ‘negative behaviours’ if a patient is confused whilst navigating through a clinical space in a traumatic situation. ‘Spatial Ergonomics’ is recognised by the Department of Health who often challenges the Design Council UK to come up with innovative ways in which violence and aggression can be reduced by better designing the space’s in healthcare environments. In England 53,000 physical assaults are reported annually, that is equivalent to 1 in10 staff experiencing which in real terms equates to a £69 million bill in sickness absence, high staff turnover and absenteeism.
Jack then goes on to explain the process the Design Council took responding to the Department of Health question and who had specifically undertaken 300 hours of ‘ethnographic’ research on ‘perpetrator characteristics’ (to understand violence behaviour and the triggers). Which was then further divided into the obvious characteristics, known factors, such as a person that is clinically confused (Dementia), intoxicated, drug dependent, angry and frustrated or suffers from poor mental health. He then goes on to explain the ‘triggers’ discovered that drive a person to extreme behaviour, such bad communication, perceived inefficiency, staff fatigue leading to a clash of personalities.

The Design Council then issued the challenge to companies in 2011 to bid for the project on behalf of the Department of Health, and which Parson Lloyd won. Jack then went on to explain the further processes he undertook to design a space that met the Design Council’s brief – to minimise violence. He described the ‘user centred’ process engaging with both staff and patients and a ‘holistic’ approach to the final design where clean lines, safe staff spaces, minimal infographics, clean walls, clear communication on waiting times and versatile spaces interrupted the ‘chain of negative experience’. This highly informative session ended with images from the design successes of the A&E department’s in Southampton General and St. Georges Hospital, London.

I ran back to the photography plenary sessions to listen in on Dr. Carolin Erolin on writing for the ‘Journal of Visual Communication in Medicine’ and after that Norm Baker and his ‘Science 3’ project.
Carolin provided an overview of the Journal, its history, why write and explained that many members do not feel capable of writing a paper, which is the reason few submissions are received. Carolin went onto to describe the various topics that can be accepted and the reasons for writing a paper, such as sharing knowledge, exposure, continuing professional development. Members were encouraged to look at ways of maybe collaborating together and building confidence. Finally, steps in structuring a paper were covered with lots of links to the Taylor & Francis website and an explanation of the ‘peer review’ process.
Norm Baker, our colleague from across the ‘Pond’ is a regular attendee of our conferences and brings 40 years of imaging experience with him. Norm talks about ‘Project Science 3’ – ‘can science be art?’ And his various collaborative works with Michael Pares and the ‘Health Museum’ creating fashion out of some of the science imagery produced by them. Norm put out a call for submissions for his new project accepting all forms of media and showcased his latest publication of stunning images.  

To end this very busy day, I dropped back into the photography plenary session where Jane Tovey, Nigel Beardsmore and Roddy McColl spoke about the NHSi (NHS Improvement) Service Review process that will affect the way future clinical photography and medical illustration services are costed using the ‘model hospital’ exemplar. The current data NHSi have on us as a profession, does not fit the actual activity undertaken and this can cause budget setting errors. The speakers further highlighted the need to capture data that we usually do not – meaning a possible change in consent cards to accommodate that data recording. This ‘extra’ information will enable a fair and accurate assessment on the activities and subsequent ‘real-cost’ of providing a service such as ours.

To illustrate, Jane spoke about their benchmarking exercise, ‘tracking’ the time
it takes for a photographer to leave, arrive, take images, return and process the images taken for each event attending but some, will take longer than others,
so distinctions need to be made between say, a ward visit to an operating theatre.
This is just one given example, the cost of equipment, materials used needs to be added. Jane, Nigel and Roddy have already put in the initial work into this costing process and there is much more to do. The speakers asked that if other departments would like to help in the process, then they encourage you to get in touch.

The presentation ended on a positive note, whilst sobering, NHSi have actively worked and listened to the institute, actively engaging.  

This ends my account for the first day of this historic conference, I am now waiting for the AGM, thoroughly tired but fulfilled – what a day! 


Geraldine Thompson