Visual Data in Education and Health Research: Historical Reflections and Current Prognostications

Abstract

This commentary serves to explore the relationship between photography and medicine since the 1800s, in order to establish a contemporary link between the two, and thus to act as a renewed invitation for pedagogical consideration for educators and researchers. Three themes are developed: first, there is a strong link between the advancement of photography as a technical field and the advancement of medical practices and education since the 1800s in a way which invites renewed consideration. Second, there is a strong mandate to consider the explosion of visual images in our everyday and global virtual landscapes vis a vis social media for the ongoing purpose of excellent standards for education and research. And finally, the field of narrative medicine has gained significant recognition, bringing the arts into clinical practice and training of clinicians, further suggesting the value and importance of visual data in the field of education and research. These 3 themes are the building blocks for an exploration of the value of visual data, here to stay in virtual and public educational domains. Educators in health sciences and health-related studies are invited to consider the value and strategies of visual data towards curriculum development, as transformative tools, and in regards to their potential not only for education, but also for clinical practice and research.

Photovoice ¹ and photo-elicitation ² are seen as valuable methodologies engaging visual data. Existing work by well-known ethnographers ³ and other visual methodologists^4,5 further underpin the foundations of visual methodology. As Banks and Zeitlyn ⁶ have said, “seeing and knowing are mutually constitutive,” and thus, this commentary explores the benefit of considering visual data as a resource in the context of education and health research. As this paper explores, photography and medicine have developed hand in hand since the 1800s. Today, we also see prolific engagement in the virtual landscape for the general public, available at a fingertip's notice through social media; and, we note the recognized role of arts and humanities through narrative medicine in training clinicians. We ask whether this triad requires educators and researchers in health to better integrate and recognize strategies that incorporate and include visual images in their work. Since there is a strong link between the advancement of photography as a technical field and the advancement of medical practices since the 1800s, there are solid reasons to consider the explosion of visual images in our virtual landscapes as relevant for educators and health.

The History of Photography and Medical Advances

We live in and with the body, yet as many images [show], we need to constantly re-imagine it…. Mapping the body and recognizing its ever-emerging complexity is also a way of mapping our minds: a job that will never be finished. ^{7 (p#)}

Two hundred years ago, we see the development of the first photos in the example of the dageurreotype, moving soon to gelatin wet/dry glass plate negatives, the polaroid, and eventually to digital photography. ⁸ Over time, the use of photography progressed through the aid of technical developments, and in order to produce “digital photography, telemedicine, 3D imaging, mole mapping, … high resolution digital files…coming a long way from the [original] flash.” ⁹ Photography in the 1800s was quickly accepted as a visual medium in which the photographer could represent “reality,” as oil paintings and drawings before had solely tried to do. Pasquali ⁸ states that in fact, physicians and scientists were among the first to take photographs, alongside police and crime detection units. For example, early phrenologists began to create visual profiles of the typical criminal^10,11 and interest in depictions of the dead developed. In the mid-1800s, Boulogne ¹² made efforts to photograph people considered mentally ill (retrieved May 30, 2022), historic examples that the education and study of health was mirrored in some ways through the progress of photography in the 1800s. One benefit, alongside the mechanical development of picture-taking, was that photos could be reproduced as many times as the photographer wanted. This no doubt was useful for training clinicians as they studied and met in teams to discuss illness and disease.

The first medical prints in 1840 ¹³ allowed for the idea that photography could create accurate visual evidence of specific facts. A subject could be asked to sit for a photograph prior to a treatment for the purposes of diagnosis and for record keeping; and, for an “after” picture, demonstrating the failure or success of a treatment in pictures. The photograph acted as a kind of documentation, a form of data if you will, contributing towards the study of disease and the focus of any given research question. Milam ⁹ references the first medical photography department, created at Bellevue Hospital in NYC in the 1860s. As Milam ⁹ describes, Mason, a head radiographer at Bellevue Hospital, encouraged physicians to have their “landmark medical cases photographed instead of drawn,” ^{9 (p1)} a move away from drawing and painting. Lynteris and Prince, ¹⁰ Milam, ⁹ and O’Connor ¹¹ among others, describe the many purposes photography served early in its development for the field of medicine: wounds could be depicted for size and shape for students and clinicians alike, a person's facial features or body type could be depicted for a variety of educative purposes, levels of hygiene could provide a foundation for other health related arguments and study, and external growths could be described and named. It was not long after the first photographic examples emerged, that photography became capable of “seeing” bacteria through microscopes (a visual image in any case), or to “see” the internal body in the example of broken limbs through x-rays or CT scans. ¹² Alongside the development of medical photography, a sign that this new tool was taken seriously and seen to have potential for medicine by way of departments on this topic, we see that photography grew into a deepening service for a wide range of medical needs. This was not without the ambitions and merits of photographers, and so a mutual relationship between photography and medicine, photographers and medical experts, developed.

Examples include “The Art of Medicine: Over 2000 Years of Images and Imagination,” ¹³ and, “Medicine in Art” ¹⁴ as marvelous collections that demonstrate the development of mechanics of photography supported the innovation and science of medicine. In one example, Anderson et al ¹³ describe Curtis’ now historic photographs around 1904 of First Nations Peoples,^(p97) including some Navajo-based medical practices, which contemporary Indigenous researchers are critiquing further with the lens of understanding colonization. Another example in this collection includes an early photograph of normal red blood cells^(p72), never before seen in this way. As images became more valuable to clinicians in their research, helping to push training, treatment, and prevention forward, there was a greater need to expand on the utility of image whether this was through the microscope or through photography. The visual image began to take on a life of its own—and so we come to understand that as educators, clinicians, and physicians, or as researchers, a photograph is worth a thousand words. ¹⁵ Social scientists began to examine the content of photos, seeking and finding that social norms and values of the day were also being expressed, and while photos could be used specifically for medical diagnosis, in fact in their view, that which was social as well as medical was brought to light.

The work within medicine was led predominantly and increasingly into the early 1900s by a biomedical mindset and overall approach to health and well-being. However, as scientists engaged with images in a multitude of ways and settings, the opportunity increasingly existed for them to interpret the content and meaning of photos in the context of health. With continued use, the role of the photographer, and the importance of “seeing” the subject as socially valued and driven by cultural norms, foregrounded that “seeing” was revitalized beyond primarily a biomedical view (by way of example, McClintock ¹⁶ ). Images in medicine, about health and the body, emerged as valuable beyond simply their representation of a body, an illness or a disease. Visual data as an educational tool became transformative—and this transformative nature had potential for education.

The World of Social Media and Images

Today, we see undoubtedly an era of exponential growth and innovation in all that is virtual and visual. It is undeniable. Over the past 5 years, the use of Facebook and Youtube has remained fairly stable, with 7 out of 10 Americans reporting social media use on any platform including Facebook or Youtube. ¹⁷ Instagram, SnapChat, and TikTok are more popular among those under 30, while Youtube appears to be the most popular, and growing in use, of any age group. According to the same study, Facebook and Youtube are the most commonly used platforms for folks over 65, an interesting fact given our increasing older population globally. LinkedIn is more commonly used by those with higher level incomes. A significant number of users of the most popular platforms will access them several times a day, with a slighter lower number of users accessing the most popular platforms only once a day, and attrition documented for use less than once a day. ¹⁷ According to this study, women are more likely to use Pinterest than men by a large margin, and Hispanics are more likely to use WhatsApp than other communities. These statistics are pertinent, in that each of these platforms depends heavily on the influence of imagery in initially capturing (inviting) the viewer's eye as they scroll through and scan social media platforms—their attention is drawn in by a visual image—and evoking a visual moment in daily life as the focal point for garnering their focus to whatever content follows. This initial visual invitation is then followed by a few written words, or, an article, only if the user chooses to follow-up. The image precedes the word. Social media illustrates that a method of communication predominantly guided by a visual invitation to engage, inviting the user in with the use of pictures, is appealing to a large majority of the world's population. Individuals speaking many languages, with a variety of levels of literacy, and different social demographics, can be invited into further discussions through the initial invitation of a visual image, regardless of what their background. According to Norman, ¹⁸ pictures are invitations that make a quick impact, they invite a fast scroll, they are designed to be pleasing to the new viewer in a way that captures their attention in competition with many other images.

COVID-19 has only increased the reality of being online daily and people's regular social media use, and it is unclear that this will change. Gruzd and Mai ¹⁹ state that 94% of Canadian adults are registered with at least one social media platform, making Canada one of the most connected countries in the world. According to Gruzd and Mai, ¹⁹ Facebook, messaging apps (for communication), Youtube, and Instagram—in that order—were reported with the highest number of users in Canada in 2020 (during the pandemic), with growth in all except for Facebook falling by 1% between 2017 and 2020. Each of these platforms are guided by the presentation of images first and foremost, and Gruzd and Mai ¹⁹ report that daily use went up per person during 2020, as well as the increase in the number of users. Unavoidable questions emerge about the where this use of imagery as an invitation to engage will lead us in light of communications into the future.

Images of another kind are also used to present data in a variety of other forms: graphs, Venn Diagrams, visually pleasing charts (consider “Information is Beautiful,” https://informationisbeautiful.net/; and other examples by Webster ²⁰ ). In this context, the developing field of “anthropographics” emerges. ²⁰ Morais et al ²¹ state, “when communicating data about people, [professionals] regularly create visualizations meant to foster an emotional connection with the persons whose data are represented.”^(p1) The concept is one of promoting visual strategies which create or invite an emotional connection between the numbers being represented in data, the daily lives of people those numbers represent, and their view of themselves in the data. Lupi ²² speaks of data humanism, in which design practices and data presentation are intended to promote prosocial values, empathy, and a connection to the persons within the data. Interestingly enough, Morais et al ²¹ suggest that “there has been considerable interest in visualization research in trying to map strategies for telling stories with visualization.”^(p3) This idea of narrative media, and visualizations that foster empathy in the viewer, map well onto the next section of this paper in which we discuss the value of narrative medicine—an approach within medicine which supports the use of stories (arts and humanities) through the patient's narratives.

The visual world is a medium for communication, engagement, and learning, and we are “seeing” this more and more through social media. Social media, with the help of images, reflect social issues, social determinants of health, social application of treatment plans, social realities around illness and disease, social contexts leading to disease, healthy practices, and more. The pandemic has shown us that social media has an immediate role to play in whether people will or will not take up the vaccine for the COVID-19 pandemic ²³ and earlier historic examples of visual education (eg, posters of the value of washing hands during the Spanish flu) are the same. A new generation has already developed strong habits on the top 3 platforms (Facebook, Youtube, Instagram) as mentioned. The mechanics of digitization and live streaming images has certainly far outpaced any expectations the early photographers in 1840 would have had for their innovation and work. Changes have occurred already as well, regarding how researchers can use images in other examples within academia: for example, copyright issues are much stricter than 10 years ago, vis a vis the use of images from the Creative Commons (see https://creativecommons.org/). These examples circumscribe an essential new way of using the image, and act as an invitation to educators of health to consider the power of the image.

Narrative Medicine

Through the formalization of narrative medicine, clinicians have been invited to listen to and “think with stories” ²⁴ in order to better understand their patients’ illnesses. Values of this approach include creating an “affiliation” ^{24 (p1267)} between doctor and patient, but also as Charon states, a “sustained habit of clinical reflection” for clinicians to assist in countering the claims that medicine has come to inhabit a decline of empathy, and an increased lack of altruism. Examples of sustained clinical reflection in Charon's view might include the use of art but also “prose paragraphs, a poem, a scenic dialogue, an obituary, …. a love letter.” ^{24 (p1266)} It is a pedagogy that might include philosophy or film. As Charon has noted, the principal tenets of narrative medicine include: relationality and emotion, the philosophies of embodiment, ethicality, participatory pedagogy, close reading, creativity, and clinical practice. Of course, the overall goal has always been to improve the effectiveness of healthcare by examining how clinicians are educated, in favor of broadening the curriculum and pedagogy of those doing the educating through these other media. Narrative medicine suggests that stories are not only an acceptable form of presentation of illness, but an essential one, and the clinician can benefit and learn to better listen to and understand a patient's stories in order to better serve the patient. ²⁵ In this way, the power of the image is a natural fit for consideration in the education of clinicians, the purpose of health studies and research.

Discussion

As Mitchell ⁵ has suggested, the “idea of treating “word and image” as a distinct theoretical problem {…} requires not only a semiotic, formal analysis, but a historical and ideological contextualization, [and] has been highly productive in a number of fields.”^(p20) As this discussion has shown, there is an historic precedence for the use of photography in education and research on health and wellness—and there is a need for continuing innovation as our world changes: our technologies, our methods of communication, and our global health concerns. Historical reflection and contemporary prognostication create a fertile ground for further work in the use of visual images in pedagogical innovation. The pandemic if anything has outlined how quickly communication modes might be altered around the globe (everyone leapt into Zoom meetings within weeks of lockdown in 2020), so having seen that global health concerns can change at a very fast pace, people and their approaches to communication need to change alongside. If we understand Timmermans ²⁶ correctly, guidelines for the practice of health-related professions (objectification, standardization, and operationalization in health care) are blueprints only, and even here for the best of practitioners (or educators), guidelines for practice are to act as blueprints, teaching practitioners to listen with a third ear (or “see” with our third eye) an encounter with a patient. Reading a patient, hearing a story in a clinical encounter, cannot always be a direct exchange of factual medical information when it includes non-medically trained patients, and so it is always the clinician's job to sort out the chaff from the wheat in order for the most accurate diagnosis or treatment to emerge.

Visual data, as the literature has shown, has historically been meaningful in training and education in the health sciences through photography and its emergence—and so here, we argue in favor of a more integral encounter with visual images for the purposes of education in health studies. In “Elicitation as a Mind-Set,” Roger and Blomgren ²⁷ argued that the use of participatory visual methods can enhance and promote a mind-set of elicitation for researchers at every stage of the research process. Visual data can be seen to be an additional important tool in research but also education, imbued not only with future potential, but also historic relevance and clinical depth when studying and training in health studies. It is apparent that photography has been part of the history of medical education and advances, and so visual images might require a new kind of literacy for educators, and a form of elicitation or invitation for the trainee as well. Pink ³ has previously argued that there is a need for visual ethnography: “Images are everywhere, … they permeate our academic work and everyday lives.”^(p1) This invitation to “see” acts to open our senses as educators, as clinicians, and as researchers, expanding our options for collecting data from the world around us and learning about it in a visually rich world, and thus, positioning new questions about pedagogy.

Integrating visual data into health-based education is considered by some clinicians to be a new pedagogical field despite what appears to be a long history of its use over time. Certainly, with the explosion of social media, its application going forward requires careful attention. Appeals to ethical use have emerged in literature on photovoice and photo-elicitation in relation to research, which could be well suited for the evolution of its use in health-based education. By way of example, ethics committees in my experience using both photovoice and photo-elicitation in research have communicated important concerns about when and how to show people's faces, what needs to be password protected if i-phones or personal tablets are used by participants, or, in regards to analysis of visual data: the impact of lacking basic information about a health concern or procedure can result in misuse or misinterpretation of visual data on the same. Evolving the use of photos in education and training would be aided by a thorough yet basic knowledge of visual data as it is used in research, the value of thoughtful pedagogies in the classroom and how they might intercept usefully with the use of photos, meaningful peer and supervisory guidelines about the use of visual data, and a general climate that welcomes discussion about visual tools in future education and training.

In conclusion, it is our additional argument that the use of image data can act as a transformative tool, assisting the educator and the researcher not only throughout their work, but in the vital process of bringing the findings back to the community/patients and by way of acting as a tool for the transfer of knowledge. One excellent example includes the “photostory” which can be used as a stepping stone in community engagement. ²⁸ Engaging with images as a form of knowledge transfer is key, for communities and broader constituents invested in the outcomes of health education, and many already literate in reading the visual image in their daily virtual and public lives. Transformation indicates a priori a de-medicalization of definitions of health vis a vis an increasingly global, visual social world in which health is imbued. Transformation as a foundational approach to how we understand education and learning is a uniquely age-old principle, suggesting that not only is health viewed through a medical lens, but it also requires of us to “see” the social, economic, philosophical, and other aspects of the body and the person in a social world. Transformative action in this renewed context of applying visual data in health education depends on encouraging practitioners and researchers to ask questions about who is doing the “seeing,” how pictures are taken and where, which story assists us as continuing learners to encounter health in the images around us. This analytic approach of the image follows a view consistent with Smith's analysis of text—text which needs to be understood in the context in which it was activated. ²⁹ What is “not” in a picture tells a story too, providing depth for what we assume about health or disease, about treatment or medical resources/availability, about the individual seeking help, or even about the values of a society. Visual data becomes not only an outcome valuable for the transfer of knowledge, but it also becomes implicit to changing what we ask and what we might know, revealing its transformative nature. As Mitchell ^{5 (p135)} stated, this “… puts ‘the visual’ at the center of the analytic spotlight rather than treating it as a foundational concept that can be taken for granted.” Visual data, in the form of a more systematic integration of the “image sciences” could be transformative for pedagogy in health training and studies.

Highlight of Key Points: Visual Data in Education and Health Research

1. Visual data engages the general public vis a vis social media and virtual images: it is an essential tool for education of health clinicians as well.

2. The value of a visual ethnography as a field allows for a more systematic approach of the use of the visual image. This can be transferred to education as well.

3. Keeping step with contemporary society's use of images through social media: a general public affinity with visual data already exists. This can be used for transformative action in health research.

Conclusion

This paper has explored the important value of using visual data in a number of health care and related teaching and training contexts, through well-recognized methods such as photovoice and photo-elicitation, demonstrating the ways in which visual information already exists in our every day and daily lives. Training and education of health care professionals, as well as that of researchers, can be supported through the utilization of this resource.