Summary of: Does the use of photography help to prioritise patients when referring to the oral medicine department?

Key Points

• Highlights the importance of photography as a tool in the referral process in addition to a good quality referral letter.

• Encourages dentists to consider photography in all suspicious and potentially sinister oral lesions.

• Promotes the need for further research when referring patients into secondary care using the fast improving and increasingly accessible technology

Abstract

Objective To determine whether the use of referral letters with and without photography will make a difference to prioritising patients to the oral medicine department.

Design Retrospective analysis.

Setting Oral medicine department of Birmingham Dental Hospital.

Method Forty-eight photographs were randomly selected using a database of clinical photographs. This was whittled down to 25 photographs after exclusion criteria were met. Referral letters that corresponded to the photographs were found and anonymised. Ten clinicians of varying experience (from consultant level to house officers) then filled out three separate forms: the first form to prioritise patients with referral letters alone, the second to prioritise patients with both referral letters and their matching photographs and the third to prioritise patients with referral letters, photographs and the final diagnosis of the patient's condition.

Results It was found that photographs made a difference to the appointment prioritisation of a patient in 37% of cases on average. 8.6% of the time, on average, photographs led to an inappropriate appointment prioritisation being selected. On average, 41.1% of the time the most appropriate appointment priority was chosen regardless of whether photography was used or not; on average 21.2% of the time, the most appropriate appointment priority was chosen only as a direct result of the clinician viewing the patient photography. In cases of malignancy, regardless of the experience of the clinician, not a single clinician was misled into making an inappropriate appointment prioritisation by the presence of a photograph. There is evidence to suggest that photographs lead to an increase in patient prioritisation regardless of whether this was appropriate or not.

Conclusion From the results of this study the use of photographs in addition to a referral letter appears to be very useful in helping oral medicine consultants to prioritise new patient appointment for their initial consultation. This seems especially true in cases of oral cancer.

Main

A. Aslam and J. Hamburger British Dental Journal 2010; 208: E16

Editor's summary

It has been suggested that in future, historians attempting to research the time from the advent of the internet may well find it an uphill task as so few records will continue to exist, so many having been deleted or become inaccessible due to obsolescence of the equipment or systems on which they were originally recorded.

The same may be true of digital photographs whose half-life compared to those lovingly pasted in yellowing old photo albums will be somewhat shorter. Be that as it may the convenience of cameras, in phones for example, also means that there is an almost universal opportunity to make use of transmissible visual images. (A carpenter who visited my home recently to quote on some work whipped out his phone and asked if could take a couple of shots to help in his later construction of an estimate – brilliantly simple).

So, the logic of using images of patients and their conditions as part of the initial referral process has to be in the league of 'why didn't we think of that before?' Well, now someone has and this study illustrates with common sense simplicity how the visual advantage of literally being able to see what the problem is instead of having to read a report and make a stab at it, enables far greater efficiency in speed, accuracy and satisfaction of the referral process.

Oral medicine also seems a logical starting point since patients with conditions which might be oral cancer or pre-cancer can be prioritised and seen by appropriate specialists all the sooner; crucial for improved prognosis. The ubiquity of imaging devices and the flexibility of capture, storage and transmission by electronic means enables us as clinicians to better serve our patients as well as make our own jobs and those of our colleagues to whom we refer that much more straightforward. A handy piece of research that could have considerable positive outcomes. Press and click.

The full paper can be accessed from the BDJ website ( http://www.bdj.co.uk ), under 'Research' in the table of contents for Volume 208 issue 8.

Stephen Hancocks Editor-in-Chief

Author questions and answers

1. Why did you undertake this research?

Having heard the concerns of fellow colleagues regarding the poor quality of referral letters to the oral medicine department, I found articles that backed up these views and found that this problem was wider and more prevalent in scope than just isolated to Birmingham Dental School. It was a natural progression to ask how this problem could be overcome and as a result I came across photography as a potential solution. I could not find any research into how and by what degree this could improve the referral process and this ultimately led to the study being carried out.

2. What would you like to do next in this area to follow on from this work?

There are many potential directions in which this research could be taken. Photography may be useful in other specialities such as orthodontics as a tool for referral and this may be an avenue worth exploration. With regards to oral medicine, future studies to examine the quality of the photographs would be useful, for example using different types of camera at the same resolution to see which would be the most useful in capturing soft tissue lesions and to see if this would make a difference to patient prioritisation. Research may also be useful in the primary dental care arena to investigate why photography is not used more regularly when referring patients. More fundamentally, the issues and reasons surrounding poor quality referral letters may be worth exploring with both general dental practitioners and consultants who accept their referrals.

Comment

The use of photography in all areas of dentistry has been increasing over the past year, in particular in dental practice for the illustration of treatments such as 'whitening', veneers, Botox etc. This study looks at the use of photography in the hospital environment to prioritise referred patients.

The authors stated that a triage system had been adopted in Birmingham Dental Hospital, and their aim was to find out what type of effect the addition of photographs would have on oral medicine referral urgency. Twenty-five appropriate patients were found and their referral letters anonymised; 10 clinicians of varying experience were enlisted. Good quality colour photographs were taken of each patient and supplied with the referral letters, and clinicians filled in appropriate forms.

The study found that senior clinicians, with the benefit of photographs, showed the greatest change in referral urgency, with junior staff showing the least change. On average patient photographs made a difference to the referral urgency 37% of the time. The authors did not, however, think it illustrated whether the referral urgency was improved or worsened by the photographs.

Individual clinicians' personal experiences made it possible that two different clinicians could select two different referral categories for the same patient, even having read the same letter and seen the same photographs. In light of this, the referral urgency selected when the clinician has seen the referral letter, photograph and knows the final diagnosis was thought to be the most appropriate.

There were three cases of malignancy, no clinician was misled by the presence of the photograph, and no clinician downgraded the referral urgency. On 14 occasions the presence of the photograph led to an increased suspicion of the malignancy, which would not have been possible with the referral letter alone.

The most significant finding is the use of photography for lesions subsequently found to be oral cancer. All clinicians, regardless of experience, recognised from the photographs that such a lesion should be seen as soon as possible.

There were positive comments from the participating clinicians regarding the additional use of photography. The authors concluded that photographs greatly enhanced diagnosis and referral category, and it would seem appropriate for all referring GDPs to consider including photographs, though photography is not a substitute for a good quality referral letter.